Sunday, September 27, 2015

Heroes Behind the Counter & In Other Places

The Marvelettes in 1963

Patients are cool.   I did a colonoscopy on a hospitalized man who was saddled with the ravages of obesity, diabetes, sleep apnea and respiratory disease.  My partner had performed the initial consultation, and it was my task to bring light into a dark place by performing a colonoscopy.  I engaged in some conversation prior to the procedure, not simply to acquire relevant medical facts, but also to establish some rapport with a man I hadn’t met before, who I was poised to violate.  I learned that he was a navy SEAL decades ago during the Vietnam war, and enjoyed some leisure time in Cambodia then.  He mentioned that he was waterboarded during his training repeatedly and described it as a routine exercise.  Yikes.  When I was his age, I was dissecting a cadaver in medical school.  The most risk I faced was crossing a New York City street.

Fast food workers are cool.  I stop often in the morning at a McDonalds near one of the community hospitals we serve.   This is where I can spread out a few newspapers and sip a carbonated beverage that has zero nutritive value.  I love the older music that is piped in there from the 50s and 60s.  (Don’t tell me you haven’t heard of the Marvelettes,  the Platters or Wayne Fontana and the Mindbenders?)  Denny serves me up when I arrive with courtesy and a smile.  He’s entered the senior phase of life, similar to many other workers at fast food establishments.  Although the food may be fast, Denny isn’t.  He has one speed which is between neutral and first gear.  He’s the kind of guy who just can’t be rushed, despite whatever pressure might be exerted upon him.   We all know folks like this.  Sometimes, I felt myself becoming impatient with this avuncular man who moved at the pace of a loris.  Patience is a lost virtue in a world that demands instantaneous data retrieval and communication.  In my parent’s day, I don’t think they would suffer apoplexy if the person in front of them in the supermarket check-out line was counting out some change.  It took months before I discovered that Denny was an intelligence officer who flew on combat missions during the Vietnam war.  What was I doing then?   Trying out for Little League or participating in some equally perilous activity.  Denny has earned the right to move a little slower than the instagram generation demands.  We can learn a lot from Denny.

Teachers are cool.  I recall a patient who was a science teacher.  I have enormous respect for educators and their profession.   I am partial to science teachers, not only because of my own love of the subject, but also because this country needs to cultivate science and math excellence for our self-preservation.   While I admired him for his career choice, I was in awe of his prior profession.  He was the commander on a nuclear submarine.  While he was circumnavigating the planet, I was writing college application essays. 
I am regularly amazed an awed to learn of the heroic and extraordinary acts of seemingly ordinary individuals.   I am also so impressed with their modesty and understatement.  Over the years, I have learned about their accomplishments because I have asked, not because they have volunteered their heroics, which they often shrug off.

Who’s serving you French fries and a burger?  If you’re not in too much of a rush, you might learn that the man who is giving you change, might have changed the world.  

Sunday, September 20, 2015

Is Your Hospital Crooked?

I read an interesting piece this morning about a medical renegade who turned his back on one of the most powerful health care systems in the world.  It’s not easy to push back against a leviathan.  If I give you an oar, I doubt that you could change the direction of a cruise ship.  But sometimes, a single person can make a wall fall down.  Remember, the brave Chinese man who faced down an approaching tank in Tiananmen Square, which was captured on an iconic video?  On a lesser scale, an orthopedist, formerly employed by The Cleveland Clinic Foundation, decided that his Clinic bosses were preventing him from offering his patient’s the best medical care possible.  He fired them.

"Let's blow this joint!"

The Clinic, in a cost cutting move, restricted orthopedists to using artificial joints from only two device companies.  The surgeon had been using artificial joints from another company for nearly 3 decades, and he reported excellent results.  This orthopedic surgeon had a bone to pick with his bosses, but their edict was as rigid as a steely plaster cast.  There would be no exceptions.

Usually, when stuff like this becomes public, we are greeted by nauseating and sanitized statements from the PR office that generally seek to distract and deflect.  That’s when the PR Prism is so useful.  Consider some examples.

Facts: A sneaker company is discovered to be using child laborers in Southeast Asia for 10 years.
PR Prism: Our company never knowingly hires underage works and always strives to adhere to the highest corporate ethical standards.  We have started a full investigation and promise transparency and accountability.
Translation:  We got caught.

Facts: A presidential candidate deletes tens of thousands of e-mails that were housed on a personal server that was kept in her basement.
PR Prism: I never violated my well known stratospheric standards for probity and integrity.  To the best of my recollection, I never knowingly sent or received any e-mails that any reasonable Secretary of State would have regarded as Confidential, Top Secret or even Semi-Secret in accordance with written Policies and Procedures.  I wish I could share these P & P manuals with you, but of course, they are classified. 
Translation:  Ha! Ha! Ha!

In what I suspect was PR lapse, the statements from The Cleveland Clinic contained some glimmers of actual truth.  I would have expected some doublespeak about how the Clinic is ‘always striving to provide World Class Care…”, but here’s what the Chief of Staff said after acknowledging that their corporate and coercive decisions can give individual practitioners vexing choices

“It doesn’t make everyone happy.  There is a tremendous amount of change going on in health care as we work to drive quality, but do it in a more affordable way.”

I congratulate the Clinic on at least admitting that they trying to save money, and not disguising the cost-cutting under the veil of medical quality.   I support practicing cost-effective medicine, as I have expressed repeatedly in this blog.   However, I suspect there is an important part of this story that was not reported in 9/10/15 Plain Dealer article.

How did these 2 orthopedic device companies get the Cleveland Clinic gig?  Was it based on cost?  Did the Clinic or any of their physicians have financial ties to the companies?  While the Clinic claims that physicians had input into the choices of these two vendors, was the process in truth a preordained corporate decision?  Did artificial joint competitors have a fair shot to bid for the business?  If a competitor sold artificial joints to a Clinic competitor, would this company be shut out? 

This issue goes well beyond artificial joints.  Every hospital in the nation makes deals for artificial joints, heart valves, intravenous catheters, medications, surgical instruments and radiology equipment.  Increasingly, these are as much business decisions as they are medical decisions.  If a product or service can be delivered more cheaply with no loss of quality, than we all support it.  Who do patients trust to make these judgments?  Your doctor or the hospital’s accounting department?

I’m not suggesting that the Clinic, or the hospitals where I practice are crooked.  But, the medical industrial complex has many tense conflicts of interests that are sequestered far beyond the view of the public.  I’m sure there are troves of hospital e-mails that would be fascinating to review, unless the servers have been wiped clean.

Sunday, September 13, 2015

Is the Medical Profession a 'Special Interest'?

Don’t expect this humble blogger to explain Donald Trump’s broad and sustained GOP support, if our most seasoned political pundits are flummoxed.   Why is this man with no prior political or governmental experience trumping all of his competitors?

Is he ahead because he is right on, or is he leading because the competitors are way off?

Like most folks, the conventional politicians are by and large an uninspiring lot who offer scripted screeds that are canned and calculated.  Indeed, most political junkees like me can almost orate their stump speeches, since they vary little from speech to speech.

Trump Appears to have no 'Special Interests'

The conventional candidates often rail against ‘special interests’, a pejorative term that conjures up an evil group that is possessed by greed that tramples over the public good to serve themselves.  I challenge you to identify a candidate who has not spewed vitriol against these nefarious ‘special interests’.   When they do so, the audience reliably responds with loud applause.

Of course, this is pure political pandering.  Here’s why.  Special interests are not a dark and ominous cloud hovering over us ready to thrust a bolt of lightning impaling us.  We all are ‘special interests’. Every one of us either belongs to or supports one of them.  
  • My beloved first grade teacher Mrs. White belonged to a teacher’s union.  Is she a ‘special interest’?
  • Is the letter carrier who delivers mail to my house a ‘special interest’?
  • My accountant prepares my taxes.  I pay him for this service.   Does he have a ‘special interest’ to resist tax reform?
  • Are NRA members and gun control advocates ‘special interests’ who are trying to further their agendas?
  • Is Emily’s List a ‘special interest’?
  • Is the Sierra Club a ‘special interest’?
  • Are trial attorneys who donate millions of dollars to politicians to pursue good government or are they a ‘special interest’?
  • Aren’t corporations allowed to advocate for their ‘special interests’ like the rest of us?
If you carve out all of the 'special interests', who's left?

When politicians speak of 'special interests', they identify them specifically.  If they were to name them, they would alienate many voters who support them.  Politicians want voters to believe that the special interests being targeted are other voters’ interests, not theirs.

Is the medical profession a special interest?  You’d better believe it.  We are gluttons feeding at the ‘special interest’ trough.  Physicians, pharmacists, pharmaceutical companies, hospital administrators, medical device companies, nursing home owners, home care companies and medical insurance companies all have their own interests which may collide against the public interest.  For example, there may be many reasons why a particular artificial hip is used in a hospital.  Why are only certain heartburn medicines available on hospital formularies?  Similar questions can be asked of every medical specialty or hospital.  Get my point?

Who’s looking out for the patients?  What ‘special interest’ is advocating for them?

Sunday, September 6, 2015

Labor Day Honors All

It’s Labor Day tomorrow when we pause to honor those whose labor has laid down the scaffolding of this nation.  Are we all in agreement who the honoree is on this federal holiday? 

Labor Day - A Sad Day for Cows

Originally, the holiday was to honor the labor unions, organizations that emerged over a century ago as a response to unfair and unsafe labor practices.  I certainly honor the working man for their contributions.

There are carpenters and electricians who work for themselves, not for  labor unions.  Is the holiday for them also?

What about the rest of us?  I’m a physician.  I work hard and hope that I am making some contribution toward the public good.  Is this holiday for me also?

Business owners and management work long hours, often beyond traditional shifts, to maintain the success of their companies.  Is this holiday for them?

Artists labor long hours coloring canvases or sculpting provocative creations.  Should they work tomorrow or are they entitled to a day off?

Entrepreneurs risk capital to create new or improved products and services.  While they don’t use hammers or wire cutters, it sounds like work to me.  Are they allowed to picnic tomorrow?

How about pregnant women who are about to deliver their offspring?  If they go into labor tomorrow, I say that Labor Day is for them.  Care to argue with me?

All work is honorable and deserving of honor.  Whatever you do for a living, fire up the grill tomorrow.  Make it a labor of love.

Sunday, August 30, 2015

Patient Survives Death Sentence - Medical Negligence?

Doctors do not know everything.    We make mistakes and mistakes in judgment.  Sometimes we make the mistake of speaking when we should keep silent.  At times, patients ask us questions that we can’t or shouldn’t answer; and yet we do.  It shouldn’t be our objective to force certainty into an issue which is amorphous and murky. 

Here’s a response that I recommend in situations where certainty is elusive.

“I don’t know.”

I saw a patient for the first time when he was sent to me for a colonoscopy.  Prior to the procedure, we interviewed him to be acquainted with his medical history.  We are always particularly interested in the cardiac and pulmonary history, as these conditions impact on the risk of the procedures and the anesthesia.   This patient had a lung resection.   He related the details which left my staff and me aghast.

“The doctors told me that I had cancer and would be dead in 3 months.”

Of course, it is not possible for a spectator to imagine the horror of this pronouncement.  To know the date of your upcoming demise, a fate that is only known to those on death row, is cruel torture.   In this case, the doctors were wrong on two counts.  This man wasn’t going to die.  And, he didn’t have cancer.

What a horrible error that didn’t need to happen. While I didn’t have the medical details, here’s what I think happened.   He had a CAT scan of the chest because he was having respiratory symptoms.  A mass was found.  The physicians then followed up with a PET scan, which is a special radiographic test used to determine if a mass is cancerous.   While this result isn’t as definitive as a biopsy, a positive result usually portends unfavorable news.   Oncologists use PET scans routinely.  My guess is that this patient’s PET scan result was on fire and the patient was told that his days were numbered.   Surgery was scheduled.   When the final pathology of the resected lung specimen was issued, not a cancer cell was in site.  This patient had a fungal infection and completely recovered.

This was a colossal error, even though the outcome was a blessing.   If a patient is wrongly told that his condition is benign, and he has cancer, then the same error assumes a very tragic proportion.  My patient lived to relate his saga to the world.

An Error of Colossal Magnitude

Could he have successfully sued his treating physicians?  I think he had a reasonable case for pain and suffering damages, including perhaps, unnecessary surgery.   No case was ever filed.    I would hope that an unexpected gift of life would render a lawsuit to be a trivial pursuit, even if the case had legal merit.  He feels perfectly well now.  The damages diminished and faded while his life endured.  

I recognize that others may have a different view of what transpired here.  They may focus on what was taken from him and that he deserves to be made whole.  They may not feel that he has been given life, as his life was never truly in jeopardy. 

I’ve done about 25,000 colonoscopies and I’ve confronted scores of colon cancer.  I know it when I see it.   When I see a lesion that concerns me, I share this concern with the patient and his family after the procedure.   But, I still wait for my biopsy specimen results before issuing an authoritative declaration.  Shouldn’t I wait until I have 100% of the data before speaking with 100% certainty?

Sunday, August 23, 2015

Is Your Doctor a Spin Doctor?

We are in the Age of Spin as the presidential campaigns percolate along.  So much fun to watch!  It’s a performance in doublespeak, deflection and distraction that is so obvious, that even a person who knows no English can spot it.  I used to get exasperated when I would watch a politician dodge the question posed, but now I view it as pure entertainment.   I’m glad I made this transition, particularly since I live in Ohio where we will see more spinning than anywhere else.

Spinning is an old profession.

To those who are unschooled in spinning recognition, keep your ear out for these phrases which are classic spin initiators.

‘…what I will say…’

‘The question we should be asking…’

‘I have always said…’

Let me illustrate.

Reporter:  Do you support the president’s Iran deal?
Spinner:    The question we should be asking is why are we caving to the Ayatollahs?

Reporter:  Do you support a path to citizenship for the 12 million undocumented immigrants?
Spinner:   I have always said that this nation must have border security to protect our nation.

Reporter: Do you accept the Supreme Court’s decision legalizing gay marriage as settled law?
Spinner:   I am a champion for liberty and  I have always said that I believe that this issue should be addressed by the states.

Reporter: Will you say now on national television that you recommend American boots on the ground in Iraq?
Spinner: What I will say, is that if it weren’t for Obama’s leading from behind, we’d never be in this position.

The political spinmeisters are weaving a tapestry that is stretching across the country.

While the medical profession cannot rival the political class in spinning competence, we’ve been known to massage a phrase or two.  Have a look.

Medical Truth:  Regular exercise has a modest effect on weight loss.
Patient Spin:  Once I resume my exercise routine, the pounds will melt off.

Patient Truth:  Hey, where’s my doctor hiding?
Administration Spin:  If you like your doctor, you can keep your doctor.

Medical Truth: Proof of efficacy of probiotics for gastrointestinal diseases is lacking.
Health Food Store Spin:  After you swallow zillions of good and great bacteria, they become your personal warriors against digestive evil. 

PhysicianTruth:  The placebo effect is a real phenomenon.
Physician Spin: I think this pill has a good chance to deliver some relief to you.

What's your profession?  What yarns have you spun lately?

Sunday, August 16, 2015

Who Deserves Quality Medical Care?

We all should know the difference between a slogan and real substance.   One of these has size and shape while the other is just a shadow.   Why then, is the slogan so powerful?

A slogan is one of the weapons wielded by the Guardians of Political Correctness.  They will point toward the slogan du jour, and then, with cameras rolling, demand to know if you support it.  Even a moment’s hesitancy will be taken as weakness.   Expect to see your waffling go viral for all to see, edited down and sans context. 

Politicians Advised to Avoid Waffles.

During a presidential election, this practice is omnipresent. 

Mr. Bush, do you support fair trade?
Mrs. Clinton, is your immigration policy to give amnesty to all illegal aliens?
Mr. Cruz, do you believe in the rule of law?

These questions cannot be adequately answered with a reflexive yes or no.   The slogans contained within these 'gotcha' questions point to complex and nuanced issues that need layered responses.  Of course, if a politician were to begin his response with, ‘Yes, but…’, he will be tossed aside as a spineless waffler.  

I hear the slogan ‘equal pay for equal work’ bandied about.  If a reporter shoved a microphone in your face and demanded to know if you support this slogan, would you scream ‘Yes!’ while you pumped your fist in the air for emphasis?   After all, who could oppose equal pay for equal work?  Shouldn't a man or woman receive the same wages for the same job?

Try this example.  A new teacher who has just completed his training becomes a 3rd grade teacher.  He is qualified and brings youthful enthusiasm into the classroom.  His colleague across the hall, has been teaching 3rd grade for 15 years.  This teacher is a seasoned professional whose students benefit from a career of experience during which she has honed her craft to higher level of performance.  Both are 3rd grade teachers.  Should each be paid the same salary?   I don't think so.  Does this mean that I do not  support equal pay for equal work?

Slogans are rife in the medical world.  How often do we read or hear about ‘quality health care’?  Not a day passes that I don't confront this slogan.  It’s an empty phrase that masquerades as something real.  It’s a phantom, a cloud, a ghost.  It falls apart if you try to hold it.  

I think every American deserves quality health care from quality physicians who prescribe quality medications dispensed by quality pharmacists purchased by quality patients.

My point?  Try to define quality medicine.  It’s not as easy as it seems.  Could you do it as a quality reporter with a mic and a camera demands a quality definition in 5 seconds?

Context anyone?

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