Sunday, August 24, 2014

Good Riddance to Routine Pelvic Examinations

So much in medicine and in life is done out of habit.   We do stuff simply because that’s the way we always did it.  Repetition leads to the belief that we are doing the right thing.
In this country, we traditionally eat three meals each day.  Why not four or two? 

We prefer soft drinks to be served iced cold.  I’ve never tried a steaming hot Coke.  Maybe this would be a gamechanger in the food industry?

Life gets more interesting when folks question long standing beliefs and practices forcing us to ask ourselves if what we are doing makes any sense.
In the medical profession, a yearly physical examination was dogma.  Now, even traditionalists have backed away from this ritual that had no underlying scientific data to support it.  Yet, patients would present themselves to this annual event believing that this ‘check-up’ was an important health preserver. 
Here were some medical routines that were never questioned.
  • Yearly ear drum examinations with the otoscope.   Always exciting.
  • Palpation of the abdomen.
  • Listening to the lungs with a stethoscope.
  • Testing your reflexes (Sure, this was fun, but did it help anyone?)
Keep in mind that I am referring to components of the physical exam that are performed on asymptomatic individuals who feel well.  Obviously, listening to a patient’s lungs has more value if a patient has fever and a cough.

Yes, I recognize that there may be an intangible value in having a physician make physical contact with his patients, which some argue help to create a bond in the relationship.   This may be true in part as patients have been taught to expect this from their doctors.  Indeed, a ‘hands off’ physician may be construed by patients as being an inattentive or even an incompetent practitioner. 

Recently, the American College of Physicians issued a new guideline published in the Annals of Internal Medicine stating that routine pelvic examinations should not be performed.  Why?  Because there is no persuasive evidence that they do any good.

Hands Off Gynecologists!

Sure, there will be pushback.   In medicine and elsewhere, there is often resistance to change from those whose practices are being challenged.   Review the following complex table that I have prepared.

Procedure Under Review      Resistors
 PSA                                                       Urologists
Mammograms                                   Radiologists
Colonoscopies                                   Gastroenterologists
Term Limits                                        Politicians
Tort Reform                                        Take a guess

If all of the elements of a routine check-up were subjected to scientific scrutiny, we might be shocked at how little of the exam remained.   This might create an unintended benefit.  It would free up time that we physicians could use to talk more with our patients.  So far, no scientific study has deemed this to be a waste of time.   



Sunday, August 17, 2014

Physicians Lose Right of Free Speech

I’m all for free speech and I’m very hostile to censorship.  The response to ugly speech is not censorship, but is rebuttal speech.   Of course, there’s a lot of speech out there that should never be uttered.  Indecent and rude speech is constitutionally protected, but is usually a poor choice.    We have the right to make speech that is wrong.

Does First Amendment Apply to Physicians?

I relish my free speech in the office with patients.   I am interested in their interests and occupations and sometimes even find time to discuss their medical concerns.  I am cautious about having a political discussion with them, but patients often want my thoughts and advice on various aspects of medical politics, and I am willing to share my views with them.   I don’t think they fear that politics or any other issue under discussion will affect their care.  It won’t.

A Federal Appeal Court recently decided in a Florida case that physicians could be sanctioned if they asked patients if they owned firearms if it was not medically necessary to do so.  Entering this information into the medical record could also result professional discipline.  The court was considering such gun inquiries to be ‘treatment’ and not constitutionally protected speech.

I am on the record in this blog more than once that I do not think we should look to the courts to make policy.  Their task is simply to rule on the legality of a particularly claim.  In other words, we should not criticize a legal decision simply because we do not like the outcome.  Nevertheless, this decision is simply beyond wacky and could create a theater of the absurd in every physician’s office

Could the following examples of physician inquires be prohibited?

  • A psychiatrist cannot ask about cigarette smoking as this is not relevant to the patient’s depression.
  • An internist cannot ask what the patient’s hobbies are as this is not germane to the medical encounter.
  • A gastroenterologist asks his patient who is a chef for a recipe and risks professional sanction for crossing a red line.
  • A surgeon asks a patient’s opinion about the town’s new basketball coach and hopes that this patient is not a planted mole recording the conversation.
So for those physicians who practice in the 11th Circuit, no gun inquires unless you can demonstrate with clear evidence that it has direct medical relevance.  The court left open for now asking patients about sling shots, fly fishing and skeet shooting, but medical practitioners are advised to consult with their attorneys regularly.

Apparently, idiotic judicial decisions can still be the law of the land.



Sunday, August 10, 2014

Testing Doctors for Drugs and Alcohol

I read recently that the left coast state of California is contemplating requiring physicians to submit to alcohol and drug testing.   Citizens there will be voting on this proposal this November.I do think that the public is entitled to be treated by physicians who are unimpaired.  Physicians, as members of the human species, have the same vices and frailties as the rest of us.

Traveling leftward

I have no objection to this new requirement, if it passes. This will not be a stand-alone proposal on the ballot, but is a part of the ballot initiative.   Why would trial lawyers in the Golden State want to include it?  The meat of their ballot effort is to reverse effective tort reform that had been in place there for several years.   Click on the Legal Quality category on this blog for a fuller explanation of why the medical malpractice system has been screaming for reform, and is slowing getting it.  Sure, there are always two or more sides to every issue.  But, when the different points of view here are fairly weighed, trial lawyers’ self-serving positions are overtaken.  They offer a different spin, of course.  While I acknowledge the validity of some of their arguments, I believe that the system they advocate helps very few at the expense of many more innocents.

The California ballot initiative aims to increase the financial cap for a medical malpractice award from $250,000 to $1.1 million.   Trial lawyers and other supporters were concerned that the public may reject raising the cap as they have been enjoying the benefits of tort reform.   Focus groups supported the notion that the public would find the drug and alcohol testing proposal appealing, which would raise the probability of passage of the bill.

There’s nothing evil about any of this.  Every player in every issue uses polling and focus groups to create and tailor their message.   (Ever notice how politicians claim they never read polls whenever poll results are against them or their positions?)   I’m sure that the insurance companies who champion tort reform are using the same techniques to manage their message. 

But, voters there and the rest of us should recognize why the drug and alcohol provision is included.  It was just a spoonful of sugar to make the legal medicine go down.  Why not just include the medical malpractice vote on the ballot by itself,?  We’ve seen our politicians use this same technique over and over again.  Add a popular poison-pill provision to an unpopular piece of legislation.  When it’s properly voted down, criticize those who voted against it by pointing out their opposition to the popular add-on provision.  Follow this example.

Legislator A:   I am adding an amendment to the Quadruple the Minimum Wage Bill that would give all veterans and their families free First Class seating on all domestic flights.
Legislator B:  I am voting against the bill because I think that quadrupling the minimum wage is bad economic policy
Legislator A:  Shame on Legislator A for trashing our veterans who have sacrificed so much for this country.

Should other professions be subjected to random drug and alcohol testing?  Which would you suggest?

Will Californians see through the smoke here?   We’ll find out this November?

Sunday, August 3, 2014

Should Doctors be Political in the Office?

Our nation is highly polarized today, and often bitterly so.  Democrats rail against the GOP.  Pro-lifers face down pro-choicers.  FOX News disses MSNBC.  Isolationists push back against expansionists.  Traditionalists disdain the politically correct.  Free marketers duel against government advocates.  Carnivores deride the gluten-free crowd.  Martin Bashir trashes Sarah Palin, two proxies in a culture war.  

There's a philosophical divide among physicians also.  Would you prefer a liberal physician or a conservative practitioner?  I'm not referring here to fiscal policy or legalizing recreational marijuana use.  Consider the following hypothetical scenario and the 2 physicians approach from opposite sides of the medical philosophical spectrum. Which physician would you choose?

Dueling Doctors

The Patient:  She is a 50-year-old female with chronic fatigue syndrome (CFS).  She is only able to work part time because of her condition.  She has consulted with an internist, an infectious disease specialist and a naturopath, but her fatigue persists. 

A new treatment for CFS has just been launched by a reputable herbal supplement company.  Two well-designed studies suggest symptomatic improvement in afflicted patients after 6 months of treatment.  As the product is an herb, there is no formal Food and Drug Administration (FDA) oversight. 

Physician #1: "I'm reluctant to recommend this product, despite the optimistic preliminary results from two medical studies.  These studies were funded by the herb company and there may be bias present.  Moreover, it is very typical in medicine for initial results to be favorable, with unforeseen side effects and complications emerging later when after more widespread use of a drug.  I'm concerned that the FDA had no role in validating that the drug is safe and effective for its intended use.  Additionally, there is evidence that the active ingredient in the product disrupts the immune system, which may have serious future consequences that may not become manifest for several years or longer.  While CFS is decreasing your quality of life, your condition has been stable and will never threaten your life.  I recommend holding off until we have an FDA approved medicine for CFS or the herbal supplement has been used long enough that we have a better sense of its safety and efficacy."

Physician #2: "I recommend that you try this new herbal product.  It is completely natural and showed promising results in two medical studies.  Importantly, no serious side-effects developed in either study.  Of course, we have no long term data on safety, but the vast majority of herbal supplements on the market are safe.  No other treatment thus far has been successful for you, and your condition is adversely affecting your professional and personal lives. The choice is to try something new or to continue suffering as you have been.  Try it for 6 months and then well reassess."

So, that's my herb blurb.  This is a common situation in the medical world where medical advice must pass through the prism of Risks and Benefits.  These analyses are limited when the risks and benefits are unclear or disputed.  Treatment acceptance also depends heavily on the patient's risk tolerance.  What if the herb referenced above had a 5% risk of cancer?  What if the herb needs to be taken indefinitely?  Clearly, when the disease poses a serious medical threat, the patient may be willing to accept greater risk of new or investigational therapies.

So, which of these physicians would you choose for yourself?  Are you a medical liberal or a conservative?

Sunday, July 27, 2014

When Doctors Break the Law

I’m a law abiding blogger.  Laws are meant to be obeyed.  If an individual opposes a law in a free country, then he should operate within the system to modify it.  I recognize that even in free societies, certain laws are so unjust and in violation of natural law that that the citizenry may be justified in relying upon other measures to affect necessary reform.  I’m not suggesting that an unwelcome federal tax on gasoline be greeted with pitchforks in the street.  However, our own democracy is a nation where slavery, ‘separate but equal’, exclusive male suffrage and Jim Crow discrimination were all legal.  In such cases, can we expect a legislature to strike down unjust laws that it enacted?

Law and medicine are increasingly intertwined today, and more than they should be.   Physicians no longer practice unfettered from legal encroachments and regulations.  I am not referring here to the unfair medical malpractice system, a subject that has occupied a substantial portion of real estate on this blog.  Look what Obamacare has wrought and what it threatens to do in the future?  Private practice medicine – my gig - for example, will either be declared illegal or will be deprived of oxygen and put to sleep.

Let's Make Breast Cancer Illegal

The most ludicrous intersections between law and medicine are when legislators try to play doctor for crass political reasons.   This is nonsensical as even trained physicians can’t agree about medical testing and treatment.  Medical experts, for example, are not of one mind on when mammography should be offered and at what intervals.  I don’t fault our profession for failing to achieve a consensus here.  The science behind the issue is not certain and differing and valid interpretations are expected.  I admit here that some of these physician opinions may be politically tainted for reasons of self-interest, but even non-partisan and objective medical experts may simply interpret data differently. 

When there is an important controversy in medicine, it should be addressed by additional medical research or accepting an interim position based on the views of medical professionals.

So do you think that the mammography controversy should be settled by doctors or a legislator submitting a bill that mandates mammography coverage starting at age 40?

If we allowed it, politicians would pass all kinds of medical care treatment and testing laws to curry favor with various interests groups.  This might be good fertilizer to cultivate some votes, but is this how we want the practice of medicine to advance?

Ohio passed a law earlier this year that would require physicians to inform women facing mastectomy about options for breast reconstruction.  The aim of the bill is to assure women that future reconstruction would be a covered insurance benefit so that they would be more likely to accept mastectomy. 


Of course, I want these women to be informed of the reconstruction option.  Indeed, this is the responsibility of the treating physician.  I object, however, to a law that requires it.  For those who support such a law, why only breasts?  Surely, laws could be passed affecting every medical specialist and every organ of the body mandating certain medical advice.    I advise my patients who have reached the 50 year mark that they should pursue colon cancer screening.   I don’t think a law should be passed mandating this conversation, but it’s no stretch to imagine a pontificating populist politician from trying to do so.   I’m not taking any chances.  I’m buying a pitchfork, just in case.

Sunday, July 20, 2014

When Should Doctors Turn Patients Away?

A few days before this writing, a 32-year-old woman came to see me for an opinion on stomach pain.  Why would I refuse to see her again?  Abdominal pain is an everyday occurrence for a gastroenterologist.  She was accompanied by her mother.  I had never met this woman previously. 

She had suffered abdominal pains for as long as she could remember.   She recalled frequent visits with the school nurse when she was a young girl.

Illu stomach.jpg

The Stomach - Usually Not the Source of 'Stomach Pain'

She has abdominal distress of varying severity every single day. Despite this medical history, she was not ill and appeared well. Why did I refuse to take on her case?   She seemed like a very appropriate patient for my practice.  I have expertise in evaluating and treating abdominal pain.  The patient was pleasant and cooperative.   I believe she would have been comfortable with me as her gastroenterologist.

I learned that the patient lived in another state and was only in Cleveland to spend the holidays with her family.  In fact, she was leaving Ohio the day after my visit with her.   I advised her that it was not in her medical interest to have a chronic condition managed by a physician hundreds of miles away. 

Sure, I have some folks in the practice who live in other parts of the country, but I don’t manage their chronic conditions.   These people return to Cleveland with some regularity, and I will do their periodic routine colonoscopies.    Conversely, if one of my patients with active Crohn’s disease is off to Arizona to escape the oppressive Cleveland winter, I insist that he consult with a gastroenterologist there.

I know we are entering the era of telemedicine.   I certainly do a lot of medicine on the phone every day, and many evenings.  But, for many medical issues, there is no substitute – nor should there be – for a face to face visit with a doctor.   Chronic abdominal pain, particularly in a new patient, can’t be solved in a visit or two.   It takes serial office visits over time to deeply grasp the patient’s symptoms and understand the patient as a person.    It needs regular physical examinations, which is a crucial piece of data for the doctor that can’t yet be acquired through cyberspace.

Managing chronic disease is a wandering journey for the patient and physician with unforeseen pitfalls and challenges.  Such a patient may awaken one morning with new symptoms or a flare in his condition and may need to see a doctor on that very day.   Even when the patient’s condition is relatively stable, there may be phone calls in between visits, or phone calls to determine the necessity of an office appointment.

So, I didn’t cure her in a half hour, but I did offer her advice.  I recommended that she select a gastroenterologist where she lived.   I forecasted the conversations  that I anticipated she and the new doctor might have over the ensuing months.   She and her mom understood why local medical care was the proper option for her. 

Maybe eventually, my iPhone will have an app that can palpate an abdomen, discern body language and gauge if a patient ‘looks sick’.   Until then, for most patients I will rely upon my eyes, my hands and my gut. 



Sunday, July 13, 2014

Hobby Lobby vs Obamacare: 1-0

Hobby Lobby, unfairly demonized in various corners of the public square, had their religious beliefs upheld in the highest court of the land in a 5-4 decision this week.   The company’s leaders are deeply believing Christians, which I believe is still a lawful practice in this country.  The company tithes to charity and pays its full time employees at least $14.00 hourly, both evidence of a culture of compassion and fair play.

No, not these Supremes, the other ones.

There is a din of shrill protestations that the company is against contraception and women, which is a complete falsehood.   Hobby Lobby is not the Catholic Church who objects to all forms of artificial birth control as fundamental religious dogma.  The company always intended to cover 16 different forms of contraception, including oral contraceptives, condoms and tubal ligation.  It objects to birth control methods that take action after an embryo has been created.

I don’t grasp the notion that an institution that approves 16 different methods of contraception is against contraception or is posing an undue burden on women, although I admit that I view this issue through the lens of an XY chromosomal organism.   Might the arguments against Hobby Lobby’s beliefs have a political basis that is beyond the substance of the issue?

Although I recognize that the Affordable Care Act mandates coverage of all 20 birth control methods, in the medical universe that I inhabit, insurance companies do not cover every available treatment for every malady.  For example, a particular insurance plan may cover heartburn prescriptions, but not every one of them.

Keep in mind that the Supreme Court decision affects only closely held, for-profit companies, which affects only a small fraction of American working women. 

I personally believe that women who work at Hobby Lobby have a right to the 4 methods of birth control that the company objects to, including intrauterine devices and ‘morning after’ pills.  However, when I weigh the rights of the owners, who have a lifelong and deep Christian belief that forbids these practices, I am persuaded that their religious freedom argument is stronger.   If they had lost the case, they would be complicit in a practice that they find to be sinful and abhorrent.  If they prevailed, as was the case, Hobby Lobby female employees would still have access to numerous forms of birth control.

The Obama administration in its zeal to impose health mandates, has underestimated the resistance from groups and individuals who guard their personal freedoms and liberties with equal zeal.  This governmental myopia has led them to some uncomfortable crossroads, such as their pending litigation against the Little Sisters of the Poor, who will not accept the government’s accommodation to their objection to contraceptive coverage.   I would be reluctant to sue a group of nuns who are respected all over the world for their selfless, charitable endeavors.

I’m not sure I’m right on the Hobby Lobby issue.  Four Supreme Court Justices, all great legal scholars, think I am wrong.   The 5-4 decision is proof that this was no legal slam dunk.   Additionally, a different set of justices may very well have decided the case differently.  Yet, I feel that Hobby Lobby and Conestoga Wood Specialties who joined with them in this case, had more to lose than women had to gain. 

I am neither pro-life nor Christian.  I’m a political moderate who has voted for candidates from both major political parties.   I’ve never even seen a Hobby Lobby store, but I’d like to meet the owners.  Are they warriors in the war against woman or freedom fighters for individual liberty?  I think the Court got it right. 


Add this