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?

Sunday, March 29, 2015

Should Hospitals Ban Workers from Smoking at Home?

I practice gastroenterology in Cleveland in the dark shadow of a large medical institution whose name contains the name of our city.  They are a world class medical institution whose reputation is largely derived from its cardiovascular department.   Presumably, these practitioners, like all doctors, advise patients who smoke that cigarettes have deleterious health effects.    The entire campus is smoke-free, as are all hospitals today.   This is a relatively new development.  A few years ago, nurses and other hospital staff would huddle at the entrance puffing away.   No more.  Now, there is no smoking anywhere on the hospital property.  Hospital puffers now have to wait until quitting time, when they are behind the wheel and leaving the grounds before they light up. 

I’m okay with all this.  The hospital should set an example to promote better health.  Patients and families who enter the hospital who must pass through a smoky fog might wonder about the hospital’s commitment to health and healing.   Of course, one could make the same argument about overweight nurses and physicians, but obesity apparently cannot be legally outlawed on hospital wards. 

The mega-medical-mall here in Cleveland has put in place a no smoking policy on steroids.  Not only can’t you smoke on the job, but you can’t smoke anywhere on this planet or any other extraterrestrial location.  In fact, workers there will be tested periodically for nicotine to verify compliance with the edict.

Touch These and You're Fired!

I’m not okay with this policy.  If medical personnel smoke on their own time, but refrain from doing so on the job, I do not believe this should disqualify them from their jobs.  Folks are entitled to smoke, drink, curse, watch adult movies, gain weight, eat deep fried onion rings and forego aerobic exercise when they are on their own time.  Of course, the hospital should encourage personnel to quit and offer treatment programs to assist them in doing so.  But, mandating this as a job requirement is wrong. 

We have staff in our office who smoke.  I wish they didn’t, and they know it.  But, we’re not about to fire them for this addiction which does not impact on their job performance.

While our office is smoke-free, we do permit staff smokers to take a break outside when they feel they need inhalation therapy.  These sessions occur out of view of our patients.  Some of our non-smoking staff have muttered that this is unfair as the puffers are in effect rewarded with a breaks during the day that they do not receive.   While this argument is valid, we have left the status quo in effect.   I’m not sure the greater good in our small practice would be served by enforcing a no smoking policy, although admittedly, this is arguable.
Outlawing Camels and Marlboros at both work and play is beyond Big Brother.  It’s an intrusive violation of personal freedom that should be extinguished. 

To those who support it, why stop with cigarettes?  What other activities and behaviors should be prohibited off the job? I have a personal interest here. If sarcasm were on the list, then I’d be fired. 

Monday, March 23, 2015

Safety first? Not with my patients!

'Safety first' is a mantra of today's hovering parents.  It's the default explanation that a parent invokes when an edict has been issued that cannot be challenged or reversed.

"Mommy, can I pleeeeeeze have a water pistol?"

"I'm sorry, honey.  You know how Daddy and I feel about guns.  This is a safety issue.  Now go and practice your violin and afterwards help yourself to some kale chips."

Caution! Water Pistol Zone Ahead

The safety concept has crept into the medical arena.  In many cases, safety concerns about our patients are justified.  I see many of our elderly hospitalized patients approaching hospital discharge who face safety concerns at home with respect to falls, understanding complex and new medication lists and monitoring active medical issues.  Hospitals today have a staff of capable and compassionate professionals who do excellent work protecting patients poised for discharge.  This effort saves patients suffering and saves the system cash -  a medical win/win.

It's no victory for a cardiologist to rescue a patient from congestive heart failure if the patient goes home and doesn't take her medicines or veers widely off the recommended diet.

But sometimes safety should not be first.  How safe would you want to be if your quality of life would suffer?  To those who argue that safety is paramount, would you support the following proposals?

  • Outlawing motorcycles
  • Decreasing the speed limit by 10 mph on every road
  • Prohibit high school and college competitive athletics
  • No swimming - anywhere
  • Avoid gluten - the silent killer
Don't take the above too seriously, since I don't.  But, here's my point.  I am often asked to place feeding tubes in elderly individual after they are tested and told that it is not safe for them to take food or drink by mouth.  These patients are found to have imperfect swallowing function. The fear by those who make these recommendations is that the patient will choke while eating with some food dropping into the lungs causing a pneumonia.
These concerns are real, but we need some context.  First, if all 80 year old folks were subjected to the conventional swallowing test, many would be found to have swallowing dysfunction, and yet they are eating and drinking without significant difficulty.  So, we have to be cautious about placing a feeding tube just because a swallowing test is abnormal.  Secondly, many elderly patients have few pleasures remaining in their lives.  Are we comfortable convincing them or their guardians to take food away when this may be a singular pleasure for them?   Even if oral feeding has risks, for many of these folks I suggest that it may be the better choice.   I think that we talk many of them and their families into the tube, which has it's own medical risks in addition to its effect on human dignity and quality of life.

Do feeding tubes make sense for some patients?  Definitely.  But, it shouldn't be for everyone,  We can devise a series of rules to live by that would make us much safer than we are now.  Would you want to live like that?

Sunday, March 15, 2015

Futuristic Medicine

I just deposited a check into my bank account by photographing the check with my iPhone and zapping it through cyberspace.  I realize this is a yawn to the under 35 crowd.  Soon, there won’t be any paper checks as the entire transaction will occur electronically.  As a member of the over 35 crowd (plus 20 years), I am wowed by this process.  I remember being astonished when my kids told me how they performed this same process a year ago.   It’s the same amazement I experienced when I first read about a new piece of technology called a ‘fax machine’.

"You mean you slide a document into a machine and an exact copy emerges elsewhere?"

In my younger days, depositing a check into a bank account meant waiting in line with my bank book in hand waiting for a living, breathing human to count and record my allowance and snow shoveling earnings.   The bank that my kids use today has no physical offices.  It is entirely in the Twilight Zone.

Medicine will not be left behind here.  The manner in which medical care will be administered will be beyond what we can imagine.  We are seeing glimpses of it already, but our vision of its trajectory is limited.  There will be huge advances, but as with all technology, there will be a cost.  The traditional doctor-patient relationship will fade out and will no longer be the bedrock of medical care.  There will be nostalgia for it from those who experienced it, much as I have warm memories of bank books, rotary phones, ice cream sodas and playing basketball after school in the school yard.

Find this phone in the Twilight Zone

I’m sure there is technomedicine going on today that I’m not aware of and would amazed me.  Smart phones and their derivatives will become medical routine diagnostic tools.

Easy stuff

  • Tell Siri your history and send a photo of your rash to DERM APP and prescription will arrive at your door in 1 hour.
  • Place phone on your chest and cardiopulmonary data will be forwarded to your cardiologist who will transmit medication adjustments to you electronically.
  • Shine beam of light through a urine specimen which will confirm if urinary tract infection present.
Hard stuff

  • Coronary bypass surgery performed robotically by a surgeon in New York City on a patient in Abu Dhabi.
  • Artificial organs created in 3-D printers.
  • Miniature cameras journeying through the digestive tract, circulatory system and major organs delivering customized treatment for various diseases.
  • Smart phone analysis of saliva sample which will screen for risk factors for 20 common chronic diseases that will have effective preventive strategies.
  • Satellite delivery of yet to be discovered form of radiation to the developing world which will decimate food borne illness.
  • Patient will place his palm on a glass and an electronic signal will be transmitted to internal organs whose function needs adjustment to treat disease or preserve health.
I still use a stethoscope.  It's not a collector's item yet, but I don't think it will be much longer. 

Sunday, March 8, 2015

Musings and Memories from Manila

I have a good memory, which has often been a great asset for me. Medical school in the 1980’s required massive memorization of arcane facts, formulas and anatomical structures. The philosophy then was that it was better to spend hours memorizing stuff every night then it would be to simply look them up when the information is needed.  My tone here conveys my view of this approach.

I can remember the phone number in the house I lived in until I was 8 years old.  Impressive? Perhaps.Useful? I doubt it.

Some folks have long memories, which is not always a gift.  There are events and painful moments that while they will always be stitched within our personal tapestries, they may be better placed beyond easy reach.

Nations also have long memories.  I am writing now from Manila on the other side of the globe. Yesterday, I was snorkeling and witnessed a shipwrecked Japanese warship sunk in WW II by the Americans.  The war in the Pacific theater between the Japanese and the Americans was brutal and protracted.  The Philippines was one of the the staging grounds of this contest, and they bore an enormous cost of collateral damage.  I asked a Filipino citizen, the manager of our hotel in Coron, if Filipinos had any residual anger against the Japanese.  He said no, as enough time had passed to heal the wounds inflicted in the middle of the last century.

Was this the truth or merely a sanitized answer for an American tourist?  On this very morning, I read that President Park of South Korea again asked the Japanese government to assume deeper responsibility over the Korean ‘comfort women’ that Japanese soldiers coerced and abused during the Second World War. South Korean hasn’t quite forgotten.

In Manila, there is a cemetery of just Americans who died in the Philippines.  It’s a vast field of crosses, and an occasional Star of David, that stretches beyond view.  I doubt that their families have forgotten.

Manila American Cemetery and Memorial

Later today, I fly to Tokyo, the capital of a country that started a war against us, killed many thousands of our men and committed atrocities.  Of course, the Japanese have their own narrative, which they regard as legitimate.  They have a memory of atomic weapons that no other nation can share.  I am traveling to Japan with excitement and enthusiasm. It's a new century now.  Time does dull our collective memory.  People and nations can change.

I’m still figuring out what’s really worth remembering.  An old phone number or the names of the body’s tiny bones and muscles do not seem like memories I need to hold on to.

If I were able to clean out my cerebral crevices of of all those faded facts and dusty data, I wonder how much room there would be for stuff that really matters.  The first to go should be that rotary dial phone number from 50 years ago.  (201) 731-7561 begone!

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