Sunday, May 17, 2015

Is Office Colonoscopy Ethical?

While I consider myself to be an ethical practitioner, I am not perfect, and neither is the medical profession.
I will present a recurrent ethical dilemma to my fair and balanced readers and await their judgment.
Our gastroenterology practice, like all of our competitors, has an open access endoscopy option.  This permits a physician to refer a patient to us for a colonoscopy, without the need for an initial office visit.

Ready, Aim, Fire!

Patients can also schedule procedures themselves, such as a screening colonoscopy, without a physician referral, if allowed by their insurance carriers.  These patients enjoy the convenience of  bypassing an office visit.   We agree that an office consultation should not be required for routine screening procedures or to evaluate minor gastrointestinal symptoms.

Of course, if a patient wants to see us in the office in advance – and some do – we are happy to do so.  I enjoy these pre-op visits which allows me to develop some measure of rapport with the patient and to discuss the upcoming endoscopic adventure, before the patient is naked with an IV dripping into his arm.

When these open access procedures are scheduled, we carefully screen patients on the phone to verify that bypassing an office visit does not pose any safety risks for the patient.   We do not want to meet a patient for the first time for a screening colonoscopy, who is on kidney dialysis and uses an oxygen tank.

Here’s the rub.  There are times when I meet an open access patient who is prepped and primed for a colonoscopy that is not necessary.  In the most recent example, I greeted a patient who was poised to have a colonoscopy because there was a prior history of colon polyps.  However, according to current professional guidelines, the patient didn’t need the exam for a few more years.   I was meeting this patient for the first time.  She had taken a day off of work and had a driver with her.  She had enjoyed the delight of the gentle cathartic agent that colonoscopy patients imbibe with gustatory pleasure on the prior evening.  She believes, of course, that the procedure is necessary as her physician had recommended it.

What should my response, if any, to her be?

One of the pitfalls of open access is that we can never screen patients as carefully as we do during an advance office visit.  Should we halt a procedure that an internist has requested even if we may not believe the procedure is of medical necessity?   Should we be willing to serve as ‘technicians’ for referring doctors in the same manner that radiologists serve their colleagues?  When we order a  CAT scan, for example, the procedure is always done whether it’s needed or not.

I sit in judgment now awaiting your verdict.  May it be as probing and enlightening as a colonoscopy.  

Sunday, May 10, 2015

Is Medical Research Rigged?

Practicing physicians like me rely on scientific medical journals to keep us current on medical developments.  We learn about new treatments for old diseases.  New diagnostic tests are presented as alternatives to existing methods.   Established treatments, which are regarded as dogma, may be shown to be less effective or less safe than originally believed. It’s a confusing intellectual morass to sort among complex and conflicting studies some of which reach opposite conclusions in the same medical journal.  What’s a practicing physician to do?

While the medical journals that physicians read are fundamental to our education, paradoxically most physicians have only rudimentary training in properly analyzing and assessing these studies.  For example, the quality of medical studies often depends upon statistical analysis, a mathematical field that is foreign to most practicing physicians.
Doctors like me hope that our peer-reviewed journal editors have done their due diligence and vetted the studies they publish ensuring that only high quality work reaches readers.  On a regular basis, a study in a prestigious medical journal is challenged by other experts in the field who refute the study’s design or its conclusion.   Medical progress does not proceed linearly.

The Path of Medical Progress

Although I am a neophyte here, I will offer some examples to readers highlight defects in study design that can lead to tantalizing and exaggerated headlines and sound bites.

The Study is Too Small:  If a new treatment is tested on only 5 patients, and one of them happens to get better, is it really accurate to announce that there is a 20% response rate?  Would this hold up if the study had 100 patients?

Where’s the Control Group?:  Doctors know that many patients get better in spite of what we do.  If a new treatment brags a 35% response rate on a group of sick individuals, was there a second group of patients called the control group in the study who were not treated and compared?  In many cases, the control group shows a significant ‘improvement’ without any treatment, for various reasons.  If the treatment group and the control group both show a 25% improvement, then the drug is not quite the magic bullet.

Is the Study Randomized? Ideally, the treatment and the control group should be identical in every respect except for the treatment being tested.  This is why higher quality studies randomly assign patients into each group.  Randomization maximizes the chance that the two groups being compared will be very similar with regard to all kinds of variables including smoking, weight and other risk factors.

Beware the False Assocation!  This is a very common and deceiving practice where investigators try to link events that are much too far apart to be connected.  Newspapers and airwaves love this stuff as they have sizzle.   “Study shows that Gym Membership Reduces Cancer”.  This ‘study’ might be sponsored by the Society of Calisthenics and Aerobic Medicine (S.C.A.M.).  Sure it might be true that gym members have lower cancer rates, but this has nothing to do with pumping iron.  These folks are more health conscious and are likely to be fit, non-smokers who pursue preventive medical care.  Get the point?

These are just a few examples to give readers a glimpse of the issue.  Of course, I just barely peeled the onion here.

Designing medical studies is a profession.  Most physicians have barely a clue on how to properly design a study or to interpret it.  Most of us rely upon others to perform the quality control function.  However, just because it’s a published study, doesn’t mean the study is worthy of publication.  Medical research may contain sleight of hand, confusion, obfuscation, all of which can be hard to recognize.  The fact that our highest quality medical studies are routinely challenged shows how difficult it is for ordinary doctors to make sense of it all.  Medicine can be murky.   Caveat lector!

Sunday, May 3, 2015

Whistleblower Wins Hospital Recognition

Everyone likes to be recognized for a special achievement or accomplishment.   Every career has special awards and commendations for everything.   While there’s no reward that matches cold hard cash, many of these honorable mentions have no tangible value whatsoever.  Pull into a fast food parking lot and you may see a parking space designated with a sign proclaiming, Employee of the Month!  Such an award conveys appreciation but does little to enhance the standard of living of the recipient.

It seems that every other week there is some award show on television for the arts and entertainment industry. 

99.44 Pure!

I’d like an award, or at least a citation, for the work that I do as a gastroenterologist.   Fortunately, there are many awards and honors that I am eligible for.   Here are some of the prestigious honors that would illuminate any curriculum vitae.

  • Fellow of the American College of Flatulence
  • Honorary Doctorate of Hemorrhoidology
  • Election to the Sphincter Preservation Society
  • Light at the End of the Tunnel award
  • 20.000 Scopes Under the Sea Award
Sadly, I wasn’t nominated for any of these prestigious designations, but I have not been left empty handed.  I received a special letter of commendation from my community hospital signed by a physician of authority.  When I say signed, I mean that a living breathing human being applied a real pen to paper.  This was no autopen or stamped signature.  The document is suitable for framing.  In fact, despite my legendary modesty, I posted the letter in the break room of our practice so that my colleagues and staff would confer the measure of respect that was now due me.  After a few days, the letter was taken down, probably by one of my envious partners who was not similarly honored.   As a result of this action, the break room is now monitored by a webcam to deter such acts of vengefulness. 

The letter did not speak to my diagnostic skills or to my rapport with patients.  It said nothing about my cost-effective care or my peer evaluations.   The letter commended me for my consistent hand washing.  I assume that nurses in the hospital are now charged with monitoring physician hand washing practices, which is a task they can easily perform in their abundant free time.   If funds would permit, the hospital might hire professional hand washing monitors who could verify that physicians and everyone are scrubbing up consistently.

Contemplate the notion of a doctor being complimented for washing his hands.   Can we set the bar just a little higher?

Sunday, April 26, 2015

Is My Doctor Thinking of my Best Interest?

Do you think that physicians’ advice should be based on their patients’ best interests? How about lawyers?  Plumbers?  Financial brokers?

An advisor who has what is termed a fiduciary duty is required to use the best interest standard with his client.  For example, an attorney is prohibited from recommending that his client proceed to trial, which would be beneficial financially to the lawyer, if the attorney believes that a settlement serves his client’s interest better.  While it may not always work this way in the real world, this is how it is supposed to happen.

"Toilet's clogged, ma'am.  Better replace the whole thing."

Shockingly, investment brokers, unlike certified financial planners, have no fiduciary responsibility when advising clients on their personal investments.  They are free to make financial recommendations that are ‘suitable’ for a client, even if this would not be in the client’s best interest.  The broker can consider his own financial interest, which clearly may conflict with his client’s welfare, without violating any professional standards.  

I wonder how many clients of brokers are aware of this scam?  The Security and Exchange Commission now has this legalized lapse under review and is expected to issue a regulation later this year, hopefully, raising brokers’ standards to what they should have been all along.  

Imagine if all of society operated under these loose rules.


Broker Standard:  Looks like you need a new fixture.
Fiduciary:  Looks like you need a new light bulb

Auto Mechanic

Broker Standard:  The transmission needs to be replaced.
Fiduciary: I think a new spark plug should do it.

Taxi Driver

Broker Standard:   New in town?  Let me show you the sights on our way to your hotel.
Fiduciary:  Hop in.  We’re only 5 minutes away.


Broker Standard: I think a gastric bypass makes the most sense here.
Fiduciary: I’ve arranged for you to meet with our dietican.

Relax, my patients.  Physicians are fiduciaries and are obligated to consider only your best interest, not ours, when we are offering you medical advice. Even if we weren’t true fiduciaries, I’d like to think we’d do the right thing anyway.  

Sunday, April 19, 2015

Do Doctors Tell the Truth?

I love teachers.  And, I love the teaching profession.  I remember years ago teaching one class to middle-schoolers on a subject that I thought exuded fascination and drama – the Civil War.  It was a long 50 minutes.  Even my daughter was doing her best to feign interest.  While the fault here may have been with the guest instructor, the lesson for me, which I have not forgotten, is how tough the teaching trade is.

Teaching - Leave it to the Professionals

I don’t have the same affection for the teachers’ unions as I do for the profession.  Their unions are advocacy groups to protect the interests of its members.  There is nothing wrong with this.  Many professions and occupations, including mine, have similar societies to whom constituents pay money in  exchange for various job protections.

My issue with these groups is when they torture the truth to disguise the real reason for their positions.  Of course, even the most disinterested spectator can see through this charade.  How many times, for example, have we heard teachers’ unions championing a position claiming that ‘this is for our kids’, when it’s really for the teachers.  Just tell the truth.  If teachers oppose a proposal that threatens their livelihood, then just say so.  Let me illustrate.

A state government facing budgetary challenges floats a proposal to freeze teacher pay for 3 years.

Here’s what the teachers’ union says:

We will oppose any effort that threatens the education of our kids.

Here’s what they should say.

We will oppose any effort that threatens our compensation.  We work hard every day and deserve to be paid fairly for it. We hope the public will support us.

To those educators who are now seething at my holier than thou perspective, calm down.  Physicians are no better.  The American Medical Association, which I have not joined, issues the same bromides about ‘protecting patients’ when they are really aiming to ‘protect doctors’.  Again, nothing wrong with this mission.  Just tell the truth.

Recently, the Texas Medical Board is trying to restrict telemedicine in that state.  Leaving aside the merits and drawbacks of telemedicine, its expansion is inevitable.  Technology vanquishes every obstacle.  Readers here know of my deep concern that medical technology has sacrificed a large measure of our humanity.  Most patients and doctors will agree that electronic medical records, for example, have not burnished the doctor–patient relationship.  The Texas Medical Board’s language suggests that their concern is that telemedicine will threaten the doctor-patient relationship.  Come on folks, fess up.  Just say plainly that you don’t want out-of-town teledocs threatening the incomes of Texas physicians.  While the truth might not set you free, at least your credibility would be preserved.

Why do I write this blog.  It has nothing to do with my ego, of course.  ‘I do it only to serve my readers.’

Sunday, April 12, 2015

Are CT Scans Accurate for Diagnosing Cancer?

A female patient came to see me with some difficulty swallowing, a very routine issue for a gastroenterologist.  I performed an scope examination of her esophagus and confronted a huge cancer occupying the lower portion of her esophagus.

Life changes in an instant.

I expected a benign explanation for her swallowing issue.   She was relatively young and not particularly ill.  She had seen my partner years in the past for a similar complaint, which he effectively treated by stretching her esophagus.  I expected that I my procedure would be a re-run.  I was wrong.

Prior to the procedure, we chatted and I learned that she had recently undergone a CAT scan of the chest ordered in response to some respiratory symptoms, which were not severe.  After I had completed my scope examination of her,  I was amazed that no mention of this tumor was related to the patient, who had told me that only a hiatal hernia was seen.

I requested a fax of the report which confirmed that the radiologist made no mention of an esophageal abnormality.   I assumed that this scan was not interpreted properly by the radiologist who somehow missed this large, consequential mass in the esophagus.   Fortunately, this error caused no harm as I found the cancer just 2 weeks later.

I called the senior radiologist at the hospital as I wanted him to review the scan and to implement whatever internal quality control procedures that existed.  I would want the same effort expended if I had missed a lesion or committed a medical error.   He reviewed the scan he agreed with the original radiologist’s interpretation.  He explained to me how in this case the tumor appeared just like a benign hiatal hernia.  If any reader is suspected that this guy is just covering for her colleague, I verify that this is not the case.  The radiologist I called is irreproachable. 

Usually, we face the opposite scenario from radiologist.  They find lesions everywhere that are benign, but send patients and their doctors on cascade into chaos.

I believe that the cancer, which developed in such a stealth fashion in my patient, also hid from the radiologist.

My point here for patients is that scans are imperfect.  They can miss stuff that matters and uncover stuff that means nothing, the more common outcome.  It’s a reminder that the practice of medicine is imperfect and offers no guarantees even when it is performed well.   This vignette reminds me how important it is to listen carefully to the patient. The scans, labs and even the colonoscopies might be wrong. 
If I’m worried about a patient, but the data all scream that he is healthy, should I relax?   If a patient feels superb, but the scan shows something found by accident, do I sharpen up the scalpel? 

I am gastroenterologist.   I prefer to go with my gut.

Sunday, April 5, 2015

Do Physicians Need a Religious Freedom Restoration Act?

There’s nothing like discrimination – true or imagined – to keep our airwaves humming.  Earlier in the week, Indiana and then Arkansas were media fodder for laws that were proposed to protect religious freedom.   Yes, I know the other side of the argument, that these ‘religious freedom’ protections were veiled attempts to discriminate against the LGBT community.   Both states raced to revise their original laws, although the laws' backers deny any discriminatory intent or effect.

It was likely that these governors feared an economic riposte from large companies who have expressed concern and disapproval over the perceived discriminatory effects of religious freedom laws.  I wonder how many of these companies do business with or remain silent about countries that use child labor, discriminate against women, have no freedom of speech or make homosexuality a crime. 

Realize that the original RFRA proposals do not guarantee an outcome in any dispute, a point that I believe is widely misunderstood.  For example, the law would not make it legal for a florist to deny service to a gay wedding.  It would permit the florist to allege in court that such a service would constitute a significant burden on his religious beliefs.  If I were the sitting judge, I would likely rule against the florist as I do not accept that selling flowers assaults one’s religious tenets.  Just because a person claims his religion is being attacked, doesn’t make it so. 

Everyone deserves flowers.

Some acts of discrimination get a free pass.
  • Ivy League institutions discriminate against students with lower SAT scores
  • NBA teams discriminate against players who can't dribble
  • News executives discriminate against broadcasters with speech impediments
  • The Catholic priesthood will not ordain Muslims as priests.
Of course, I’m not entirely seriously here.  I do not think that anyone should face discrimination for who they are.  Indeed, I wish our society were closer to a meritocracy.  Sometimes, the reason that an individual does not get a job promotion, make the team, get the lead role in a play or get acquitted at trial is because the person doesn’t deserve it. I don’t deny the existence of prejudicial behavior and bigotry, but they should not be invoked by default when a person is denied a desired outcome. Sometimes folks are fired because they should be.

Should a tattoo artist be able to refuse to ink ‘I Hate Jews’ on someone’s chest?  What if an atheist wants body art with bold lettering of ‘I Hate Jesus’?  The Supreme Court decided in the Hobby Lobby case that a private business can deny services for religious reasons under certain circumstances. When can a private business lawfully refuse service to a customer? 

What about physicians?  Do we have to treat every person who makes an appointment to see us?  I don’t know the private beliefs of my patients, but I’m sure they are a cross section of society with all the prejudices that one would expect.  If I knew for certain that a patient was a homophobe or a racist or an anti-Semite, should I discharge this person from my practice?  Could a pro-life physician ethically discharge a pro-choice activist from his practice?  Could this doctor justify this decision by his belief that the patient advocates murder and that a healthful doctor-patient relationship would not be possible?  Or, should doctors see everyone as our mission to heal and comfort transcends personal beliefs and practices?

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