Sunday, November 23, 2014

Are Doctors Good Businessmen? Get a Second Opinion!

We’ve all heard or used the phrase, ‘leave it to the professionals’.   It certainly applies to me as the only tools that I can use with competence are the scopes that I pass through either end of the digestive tunnel.  Yeah, I have a ‘toolbox’ at home, but it is stocked similarly to the first aid kit that your new car is equipped with.   It contains a few BandAids, adhesive tape and, hopefully, the phone number of a local doctor.  My home tool box has an item that can practically fix anything – the phone number of a handyman.

Nothing for Hemorrhoids Here.   

It is essential to know one’s limitations, regardless of one’s profession. 


  • Politicians shouldn’t speak authoritatively as if they are climatologists.
  • Gastroenterologists should not prescribe chemotherapy, even though we are permitted to do so.
  • Bloviating blowhards on cable news shows are likely not military experts.
  • The guy who fixed your toilet might not be a top flight kitchen remodeler even though his business card includes home remodeler, along with railroad engineer, IT professional, seamstress and stand up comic.
Some of us are good at a lot of stuff.  Some of us have a narrower, but deeper range of competence.  Yes, we’re all good at something, as our moms and teachers taught us during our early years.   Without doubt, most of us are not good at lots of stuff, and it’s important to know where our comfort zone approaches the chaos zone.   In my own profession, it is absolutely critical that physicians readily solicit assistance from a colleague when additional knowledge, experience or judgment is needed.   Asking for help to help a patient is evidence that the physician is focused on his patient’s welfare.  Every doctor has witnessed circumstances when a physician is reaching too far beyond his tool box, and it’s not pretty. 

  • Should a surgeon perform a complex operation that he only seldom performs?
  • Should a local oncologist treat a patient’s rare cancer or refer the patient to the expert downtown?
  • How long should an internist struggle with a patient’s hypertension before recruiting an expert?
  • If an allergist’s patient keeps losing weight, is it time to consider a cause beyond the scourge of gluten?
Last year, our practice needed some restructuring.  We met with our accountants for advice on streamlining and managing our practice.  I was impressed how quickly these pros looked over our financial statements and readily understood the state of our practice.  Of course, these guys see the world through Excel spread sheets, just like we GI physicians do through our colonoscopes.  To us physician clods, these reams of number filled pages containing every permutation of various financial reports were encrypted codes that would require NSA cryptographers to decipher.  Most physicians are not good businessmen, although many feel otherwise.  Luckily, my partner and I know the truth about ourselves.   We didn’t ask the accountants for a ‘second opinion’.   We came to them first, and we’re glad we did.   I presume that when they need a colonoscopy, they won’t try it themselves.


Sunday, November 16, 2014

High Drama in an Ambulatory Surgery Center

A few days before I wrote this, a patient had a complication in my office.  I have discussed on this blog the distinction between a complication, which is a blameless event, and a negligent act.  In my experience, most lawsuits are initiated against complications or adverse medical outcomes, neither of which are the result of medical negligence.   This is the basis for my strong belief that the current medical malpractice system is unfair.  It ensnares the innocent much more often that it targets the negligent.

I performed a scope examination through one of the two orifices that gastroenterologists routinely probe.  In this instance, the scope was destined to travel inside a patient’s esophagus on route to her stomach and into the first portion of the small intestine.  Sedation was expertly administered by our nurse anesthetist (CRNA).   The procedure was quickly and successfully performed.  The patient’s breathing became very impaired and her oxygen level decreased markedly, a known and uncommon complication of sedation medications.   We took the appropriate measures, but her low oxygen level did not respond.

At that point, our experienced and calm CRNA decided to intubate the patient by passing a breathing tube into her lungs, in the same manner as is routinely performed prior to surgery.   The RN on the case, an ICU veteran, showed how quickly and superbly her medical skills and judgment could be recalled.  In decades of medical practice, I had never had a patient whose scoping test and sedation led to a breathing tube insertion.   Moreover, this procedure was performed in our outpatient ambulatory surgery center, not in the hospital, so drama like this is exceedingly rare.

Physicians prefer to see drama in the theater.

The patient’s oxygen level immediately returned to normal and she was transferred to the hospital in stable condition.  She was appropriately treated and discharged after a few days. 

I was so grateful to have a team in place that had the skills to rescue a patient who was in a dire situation.   I told this to them directly and they seemed to regard the matter in a more routine manner than I did.  They saved her life.   Nothing routine about this, as I see it. 

For nearly all of the patients we see in the office, our staff is overqualified.  But, once or twice a year, we need these folks on site, locked and loaded.

Physicians and the rest of us need back up.  Do you have a contingency plan in your job if a crisis befalls you?  Will you wait for a catastrophe before implementing one?  We’ve all heard vignettes about cities who were warned about a dangerous intersection, but failed to ask until a tragedy occurred.

Finally, if someone helps you out of the abyss, give the credit to whom it is deserved.   Conversely, if something goes wrong and it’s your fault, do the right thing.  

Sunday, November 2, 2014

Ebola Hysteria in Ohio

The Ebola hysteria continues.  True, we might have a greater chance of being struck twice by lightning, but the press would have us think we need to purchase Hazmat suits for our families just to be prepared.  I’m surprised that an entrepreneur hasn’t at least constructed prototypes for Hazmat suies for newborns, popular dog breeds, pet rodents and heirloom tomatoes.

Tomatoes?

Yes, tomatoes.   I have not heard any authoritative official from either the NIH, the CDC the WHO or Medicins Sans Frontieres (Doctors Without Borders) who have stated unequivocally that you cannot contract Ebola from an heirloom tomato.  To me, the hypothesis is entirely plausible as the sneaky virus  can hide in the heirloom’s surface crevices just waiting and hoping to gain access into an unsuspecting mucous membrane. 

Smooth Skin Tomatoes Probably Safe

As of this writing, there are 159 contacts in Ohio who have had contact with an Ebola infected nurse who for reasons known but to God was cleared by the CDC to board a commercial airplane with a fever after she had treated an Ebola patient in Texas.   Each day, the number of Ohio contacts grows, so by the time these words are posted on Sunday, I expect that there will be more contacts.

Gerbils Need Ebola Protection

The definition of what constitutes contact with an Ebola patient is evolving.  As of today, the new and improved definition of contact is being an enclosed space with the patient for any length of time.  Hmm, if I am watching the Cleveland Cavaliers in our downtown stadium from the last row, and an Ebola patient is in the first row on the opposite side, am I now considered a contact?  Would all 10,000 fans be forced to enter into a 21 day period of quarantine? 

Does it matter that medical experts have consistently explained that you cannot catch this virus unless the infected individual is symptomatic and you are within reach of that individual’s bodily secretions?
An Ohio school was closed as a staff member was on the Frontier airplane that the nurse had traveled on although on a different flight.  Two hospitals in Cleveland sent nurses home with pay and admitted publicly that this was for PR protection, not for patient protection.   What hope is there when our medical institutions are lubricating our hysteria instead of battling it?

This past Monday, I noticed a new procedure had been implemented in our office.  On the advice of local and state medical authorities, we were asking every patient who enters our office, if they have in to West Africa or had contact with an individual who has been there.   This nonsensical policy would protect no one.  There are zero known Ebola patients in Ohio at present.   This is a difficult disease to contract as contracting this virus requires that one is in direct contact with bodily fluids of an infected person.  Querying every patient about recent travels from West Africa only feeds the hysteria, while it burns up our staff’s time.   Asking Granny who comes to see us from her assisted living facility if she’s been to Sierra Leone recently, doesn’t seem to be sound preventive medical policy.

I think that our moratorium on heirloom tomato ingestion makes more sense than the Ebolaphobia policy. Can this post go viral?

Sunday, October 26, 2014

Governors Mandate Ebola Quarantine

Who says that bipartisanship is dead?  Just recently, Governors Cuomo and Christie – a Democrat and a Republican – were shoulder to shoulder as they announced a new and improved Ebola policy to protect their voters,  I mean citizens.  Now, every individual who was arriving at Newark and Kennedy International Airports from Liberia, Guinea and Sierra Leone who had direct contact with an Ebola patient, would face a mandatory 21 day quarantine. 

This policy exceeds restrictions advocated by the Center for Disease Control and Doctors Without Borders, two organizations who presumably are better qualified in infection control than politicians are.
Might this policy discourage our health experts from traveling to West Africa to help to control the Ebola epidemic as they would face a 3 week quarantine upon their return home?

Might some folks who are returning home who don’t agree with this new policy lie about their Ebola contacts?

What if travelers returning home from West Africa didn’t touch down in New York or Newark?  Don't the other 48 states deserve to be safe?

Does this policy seem more political than medical?

Future CDC Director?

Future NIH Director?

Maybe the governors’ new edict doesn’t go far enough?  I'm surprised they did not consider the following scenarios.
  • If an Ebola patient in Sierra Leone sends an email to a New Yorker, should the American be required to take his temperature twice a day?
  • If a Rutgers University student looks up Ebola information on an iPad, and used the touch screen without two sets of surgical gloves, should the student be quarantined and the iPad confiscated?
  • If a Manhattan commuter enters a cab driven by a Liberian…
Why stop at Ebola?  Why not force returning passengers who have been exposed to influenza, which unlike Ebola, is extremely contagious via air, to be quarantined?   

There is a reason that politicians should not make health care policy.  Let them do what it is that they do best – saying and doing anything to get elected.  Will other governors now compete to establish the strictest guidelines?   

Scientists are testing an Ebola vaccine. We pray for their success.  I hope that the NIH is working on a vaccine against hysteria.  I know two politicians who need it desperately.  

Sunday, October 19, 2014

Ebola Virus Outbreak Goes Viral!

While I haven’t devoted significant space on this blog to the news media, it is not because I do not have strong opinions on the current state of journalism.  Indeed, I could write an entire blog on the subject, and many have.

News acquisition and analysis have always been important facets of my adult life.  I spend many hours every week reading various newspapers and other materials to gain new perspectives on the issues of the day.  Nearly every morning, I send items of interest to a close circle of friends and family.  I read news and opinion, although sometimes it’s hard to tell one from the other.  I am always drawn to opinions that differ from my own. While there is excellent journalism today, the profession is deeply flawed by a blow-dried approach that appeals to our tabloid lust and their desire for increased ratings. 

Just because it’s above the fold on Page 1, doesn’t mean it truly deserves this prime real estate.  Pick up your own newspaper and see what the leading articles are.  It’s likely to be some local crime outbreak, while news that really matters is either a small item pages later, or may not appear at all.

TV News - If It Bleeds, It Leads!

Turn on CNN.   Set your stopwatch to measure how many minutes it will take before the bright banner of BREAKING NEWS flashes across the screen.  All that’s left is for Wolf Blitzer to announce:

BREAKING NEWS! 
 HERE’S A COMMERCIAL THAT YOU CAN'T MISS!!

How has the media performed with the Ebola issue?  Poorly, in my judgment.  First, the coverage has been absolutely suffocating on major TV stations and has been on Page 1 of newspapers for days now.  Is this an important issue?  Of course.  Are there public health ramifications?  Definitely.  Has the media heightened public fear beyond the science?  Without question.

When the media, particularly television, sinks their fangs into an issue, they will feed upon it until either the ratings start to ebb or some new fresh meat draws them away.  Remember how CNN covered the Malaysian airplane disappearance?  

While Ebola is clearly newsworthy, the number of infections and fatalities that have occurred here in the U.S. can be counted on one hand, with a few fingers to spare.  My point is that the coverage has been disproportionate to other issues that have been sidelined, as the media routinely does.
  • 30,000 Americans will die of flu this year
  • 11,000 expected U.S. deaths by firearms this year.
  • About 100 U.S. highway fatalities daily with a yearly estimate of 30,000 victims
Where’s the proportionality?   While every life is sacred, why are big stories buried and much smaller ones sensationalized?   Last night, I came home and declared that my domicile would be an Ebola-free zone for the evening.   This meant there would be no TV news for us.  I feared that even turning on a random TV channel could violate my edict as Ebola coverage is omnipresent.  To make sure that we were in compliance, we pursued a safe entertainment alternative.  Netflix!

Ebola, a deadly virus, has gone viral in the press.  The media, as always, perpetuates journalistic contagion.  Maybe they should be quarantined?

Sunday, October 12, 2014

Is Hepatitis C Treatment Cost-effective?

One catch phrase in health care reform is cost-effectiveness.  To paraphrase, this label means that a medical treatment is worth the price.  For example, influenza vaccine, or ‘flu shot’, is effective in reducing the risk of influenza infection.  If the price of each vaccine were $1,000, it would still be medically effective, but it would no longer be cost-effective considering that over 100 million Americans need the vaccine.  Society could not bear this cost as it would drain too many resources from other worthy health endeavors.  Economists argue as to which price point determines cost-effectiveness for specific medical treatments.  As you might expect, insurance companies and pharmaceutical companies might reach different conclusions when the each perform a cost-benefit analysis. 

Remember, it’s not just cost we’re focusing on here, but also effectiveness.  If a medicine is dirt cheap, but it doesn’t work, it’s not cost-effective.  Get it?

Pharmaceutical companies who are launching extremely expensive medicines often boast about the medical benefits while they ignore the cost factor entirely.  We see this phenomenon regularly when the pharm reps come to our office or we are listening to a paid speaker.

Understandably, when expensive medical care is being paid for by a third party, patients and their families are not considering cost-effectiveness.  They are focused on their own health and welfare.  If the doctor advises that our mom needs chemo, we’re not wondering if the cost would be a fair allocation of societal resources. 

A new hepatitis C (HCV) drug, Sovaldi, has recently been launched.  The 12 week course of treatment costs $84,000, or $1,000 a pill.  This bargain doesn’t include the costs of other drugs that are taken with Sovaldi as part of the treatment program.   The cost of curing HCV, a worthy objective, approaches $200,000 including the costs of medicines, physician services and laboratory and radiology testing.  Assuming that there are over 3 million Americans who are infected with HCV, the costs for curing them all approaches $300 billion.   That’s billion with a ‘B’.

Electron Micrograph of HCV

Consider these facts before deciding if hepatitis C treatment is cost-effective.
  • Most patients with HCV feel well.
  • Most patients with HCV are not aware that they are infected.
  • The majority of patients with HCV will not develop cirrhosis or other serious complications of the disease.
  • Many HCV patients who are ‘cured’ of the virus would never have developed any health issues.  They were silently infected.
Here’s what’s needed.
  • Identifying HCV patients who are destined to develop severe complications.
  • Proof that treating these patients changes the course of their disease.
  • HCV treatment that is cost-effective.
TV or print ads about HCV treatment suggest that you ‘talk with your doctor to see if the drug is right for you’,   When you do so, ask for the evidence that the treatment will allow you to live longer or live better.  Clearing your body of HCV sounds like a triumph and is marketed as such, but this might not change your life at all.

Information is power.  I wish there was some way this post could go viral.



Sunday, October 5, 2014

Why I Won't Refill Your Prescription

Giving prescription refills is not quite as fun as it used to be.  Years ago, we doctors would whip out our prescription pads – often sooner than we should have – and we’d scribble some coded language that pharmacists were trained to decipher.  I’m surprised there were not more errors owing to doctors’ horrendous penmanship.  On occasion, the Food and Drug Administration (FDA) would require a pharmaceutical company to change the name of a drug so it wouldn’t be confused with another medicine with a similar name.   The name of the heartburn drug Losec was too similar to congestive heart failure drug Lasix, so the former drug name was changed to the familiar Prilosec. 

Pharmacists Used the Rosetta Stone to Decode Prescriptions

Nowadays, we physicians refill medicines with point and click techniques within our electronic medical record (EMR) system.  When this works, it’s a breeze.  Three clicks and the refill has been transmitted to the patient’s pharmacy. Alerts notify the physician of any potential drug interactions with a patient’s other medicines.   A record of all prescriptions and refills becomes a part of the EMR system for all time.

Often, the drug interaction alerts are too sensitive.  More than once, an alert has appeared warning me that if I hit the ‘prescribe’ button, that my patient will suffer the same fate as did the Wicked Witch of the West when Dorothy doused her with water.  When I can’t verify this doomsday scenario using old fashioned techniques, I call the pharmacist directly who may reassure me that the drug is safe to use.  So, I prescribe the drug knowing that my EMR system will document that I have been duly warned and have chosen to cavalierly override the admonition.  Guess which profession likes this EMR function?

Patients contact us nearly every day for prescription refills.  Of course, we beg them to do so when they are in the office, but life doesn’t work this way and I understand this.   Here are some instances when I will not refill the requested medicine.

  • One of my partner’s patients calls after hours for a refill on narcotics
  • A patient wants a refill beyond my expertise.  I won’t be refilling your cardiac medicines as this should be done by the prescribing physician for several self-evident reasons.
  • I haven’t seen the patient recently.

It is a common scenario for a patient whom I have not seen for a year or two to request a refill on their GERD or heartburn medicine.  When this occurs, I politely request that the patient see me in the office first.   The patient may not grasp any urgency as he is feeling well and only wants another year’s worth of acid-busting pills.  However, the moment I refill it, I am in effect accepting responsibility for this action and any resultant consequences.  Here are some pitfalls with refilling a patient’s heartburn medicine who has been AWOL.
  • Does this specific drug still make sense?
  • Can the dosage be lowered?
  • Have any new symptoms developed that might require diagnostic investigation?  Suppose the patient has been losing weight, for example?  What if the ‘hearturn’ has worsened and a new disease is responsible?
  • Is the patient experiencing side-effects from the medicine that he or his primary care physician might not appreciate?
  • Could the heartburn medicine interfere with new drugs that the patient is now taking?
  • Is the patient up to date on other issues within a gastroenterologist’s responsibility such as colon cancer screening?

Refilling routine medicines may not be routine and should be done with care and caution.   The patient from 2 years back who has GERD might think he needs Nexium for his 'heartburn'.  What if his symptom is actually angina?  Get my point?


So, when we ask you to stop in for a brief visit, it’s not because we delight in hassling you or are hungry for your copay.  We’re trying to protect you and to keep you well.   Doesn’t this seem like the right prescription?

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