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Showing posts with the label Medical Quality

Analyzing the Risks and Benefits of Medical Treatment

A fundamental skill that physicians rely on is calculating risk/benefit analyses when we advise patients.  My use of the word ‘calculating’ is a misnomer as there is no reliable scientific method to quantify risk and benefit.  Indeed, different physicians might ‘calculate’ such an analysis differently.  Similarly, different patients in the same medical circumstances might gauge the potential medical benefit differently.  This is not hard science.  Some folks might feel that a 5% risk of a major complication is acceptable, while others would balk at this statistic.   And on the benefit side, is it worth taking a medication that has some risk with the hope that it might shave 1 day off of a 7 day illness?   Despite that risk/benefit analyses are not easily quantified, physicians and patients must enter into a dialogue on this issue when a treatment or a test is being proposed.   The participants have to do their best to tease through the issues. If a 25-year-old athlete develops ac

Do Doctors Talk to Each Other?

 I will share with readers a recent occurrence between me and another doctor that was both rare and refreshing.  I was serving as the gastrointestinal consultant on one of the doctor’s patients.  I performed a scope examination of the stomach and obtained some routine biopsy specimens.  The pathology results were abnormal, but benign.  No urgent action was needed, but a full airing of the significance of the results would require a conversation between me and the patient in an office visit.  I notified the patient that there was no medical threat at all and we would unpack it all during his next visit. The referring physician wondered about this delay, which perhaps is a different style from other gastroenterologists (GI’s) who he works with.   (My guess is that other GI’s may opt to handle the issue with the patient on the phone or via the portal. I think, however, that there’s too much complexity to fully address this issue in this manner.) So, here’s what the referring doctor did.

Measuring Medical Quality - What Really Counts

I have written how challenging it is for ordinary folks, let alone medical professionals, to assess the quality and competence of physicians. There are no easily measurable and reliable parameters.  Industries have emerged that specialize in assessing the competencies of practitioners and organizations in fields beyond medicine.  It is typical for those who are targeted for assessment to howl in protest claiming that the testing methods are irreparably flawed and should be abandoned.  Sometimes, these folks have a point. But other times, they are simply trying to avoid accountability. And just because an evaluation process hasn’t been perfected, doesn’t mean it offers no value.  For example, teachers have recoiled against using student test scores as an element in assessing their pedagogical skills.  I think that both the teachers and the testers have legitimate arguments. Professionals and tradesmen and their leadership advocates will reject processes that will disparage their members

Does Diverticulitis Need Antibiotics?

Over the past several years, there has been an important change in how diverticulitis is treated.  This topic sentence may seem out of place on this blog which is largely a site for commentary.  This is not a site that discusses medical breakthroughs on the treatment of constipation or heartburn.  But diverticulitis does offer a commentary angle, if you will read further. Decades of teaching and dogma have informed the medical profession that diverticulitis is a localized infection of the colon.   Diverticula, or pouches, are weak points in the large bowel.   If a tiny puncture develops at one of these sites, some stool can leak out contaminating the sterile abdominal cavity.   A n infection develops which, of course, needs to be treated with antibiotics. Indeed, for most of my medical career, every case of diverticulitis I encountered was treated with antibiotics.   In most cases, these patients recovered fully.   This observation may be Truth #1.   Just because a patient recove

Uncertainty in Medicine - Ask Your Lawyer for Advice

My great pal Lewis, with whom I have shared a friendship for over half a century, have much in common professionally.   Is he also a gastroenterologist?    A physician?   A nurse?   Actually, he is a tax attorney.   So, where’s the commonality?   Could it be that my patients and his adversaries both feel that they are being ‘instrumented’?    While I suspect that this may be true, it is a different aspect of our respective professions that binds us. Lewis’s clients and my patients need to grapple with and accept uncertainty.   I find the parallels here to be striking and I’ll do my best to illustrate. Legal Uncertainty The client brings an issue to his attorney seeking a legal remedy or an opinion.    Let us assume a corporation wants to know if a particular expense can be legally considered a tax deduction.   The experienced tax attorney responds, after careful thought and deliberation (yes, the time clock is ticking!), that he is 75% certain that the proposed de

Measuring Medical Quality - Let the Games Begin!

There are two ways to increase a quality rating of a process.  The old-fashioned way to work and study and practice and seek assistance and practice again and fail and regroup and ultimately objectively increase performance. Here are a few examples of this technique. A basketball player works with a coach and increases his foul shot success rate by 15%. A new medicine increases the cure rate of a disease by 40%. An engineering team invents a cell phone battery that has 5x the storage of current batteries. There is another way to increase quality ratings that has become quite common.  Lower the standards or game the system.  Here are some examples to illustrate. Lower academic standards in order to increase a high school's can graduation rate. Lower the income threshold of poverty so we can boast that there are fewer impoverished people in our communities. A surgeon's outcome stats rise markedly when he declines to accept very ill patients. So, if you are trying

Hospital Discharge Planning - Is the Hospital Sending You Home Too Soon?

In 1990, Desert Storm was initiated by President George H.W. Bush, along with coalition partners to reverse Saddam Hussein’s aggression with respect to Kuwait.   As American and allied forces moved into Iraq, many hawks wanted these forces to advance to Baghdad, and drive out Saddam Hussein.   As we all know, President Bush pulled us out as he did not feel this objective was part of the mission.   He knew when to get out. Now, physicians are not military strategists, but there are parallels between military strategy and patient care, particularly when a patient is hospitalized.   Consider the following schema.   The Conflict:   A patient arrives in the emergency room with a cough and a fever.   The Mission: Disease eradication The Tactics:   Hospitalization Exit Strategy:   Getting the patient out. Physicians, just like the generals in the Situation Room in the White House, need a sound battle plan.   The plan must be flexible enough to adapt to changing contingencies an

Deaths From Medical Errors: Hell or Hype?

Doctors make mistakes.  There, I’ve said it.  More than having said it, I wrote it.  This confession has now been memorialized in cyberspace, where no piece of data can ever be truly deleted.  We have all seen how seemingly erased data has been resurrected by forensic experts to the horror and dismay of the eraser wannabees. Doctors work on seriously ill patients.  They do their best to help heal them; or when this is not possible, to comfort them.  Some patients get worse under our care.  Some die.  This sober slice of the human condition impacts deeply on physicians and all health care professionals. I acknowledge that medical errors have worsened patients’ condition or have even contributed or caused their demise, a tragic but unavoidable result of a noble endeavor that is imperfect.  I remind readers that physicians are members of the human species and have all of the flaws and frailties that every other homo sapiens creature possesses.   Every aspect of the profession is

New Study Questions Screening Colonoscopy - Doctors Push Back

Colonoscopy became ‘breaking news’ about a week ago.  The preeminent medical journal, The New England Journal of Medicine (NEJM) published a randomized trial assessing the effectiveness of screening colonoscopy in reducing the risk of contracting colon cancer and dying from it.  The results were lackluster. While there is accumulated evidence that colonoscopy can reduce colon cancer risk, the bulk of this data has not been the results of randomized controlled trials, the gold standard in medical research.    In the NEJM study, there was a group who was offered a screening colonoscopy and a separate control group who was not. Gastroenterologists, along with the medical community at large, have been preaching the lifesaving benefits of screening colonoscopy for decades.   The simple strategy is to remove ‘pre-cancerous’ polyps that are lurking silently in the colon and to remove them before they have an opportunity to transform into cancer.   What makes colonoscopy such an attractive

Why Do I Have Abdominal Pain?

I am a gastroenterologist who has been practicing for decades.  One would think that with my diagnostic cunning and length of service that I would be able to identify the cause of your stomach distress from across the room.  Alas, abdominal distress is often more cunning than the medical sleuths who aim to unmask its identity.  A reality of gastroenterology is that abdominal pain – an issue I confront every day  – is often unexplained and unexplainable, a frustrating reality for patients. Here’s another frustrating aspect of the experience that patients must often deal with. A patient with months or years of abdominal distress is seen in an emergency room.   In some instances, there have been more than one ER visit for the same issue.   Despite repeated laboratory data, a CAT scan or two, other imaging studies of the abdomen, a thorough review of the patient’s history and physical examinations which may be repeated over the course of hours in an ER, no diagnosis is made.    The pat

Was the Alec Baldwin Shooting Accidental?

Even casual followers of the news are aware that actor Alec Baldwin killed one associate and wounded another during a film rehearsal.  It was a horrible tragedy that captured the nation’s attention.  How could such a thing happen? This is the same question we ask when we learn that a surgeon has removed the wrong kidney.   I’ll leave aside how much attention this tragedy has received in comparison to the intentional killings that occur daily in cities throughout the country.   While all lives are equal, it does not seem that every life receives the same attention. Based on what is now known, it does not seem to me that this shooting was a mere accident that occurred from pure happenstance.   Of course, the shooting was not intentional, but it appears that there was a reckless disregard of established firearm safety protocols.   Investigators will surely discover how a live bullet ended up in Alec Baldwin’s gun.   More facts are emerging daily that indicate a laxity of gun safety an

Why I Cancelled a Colonoscopy

This morning, as I wrote this some time ago, a patient came to my office for a colonoscopy.  I sent her packing.  Here’s what happened. In our Ambulatory Surgery Center (ASC), in my prior private practice, we introduce light into dark spaces every day.  This is where we perform colonoscopies and upper endoscopies.  We have a program in place where referring physicians can have their patients contact our ASC and schedule a procedure without seeing us first in the office for a consultation.  Obviously, we have to have a vigorous screening process in place  We do not want to meet a person for the first time for a colonoscopy and discover that he has complicated medical issues and is dragging an oxygen tank behind him. Our screening system works extremely well, but it is not perfect.  On occasion, it misfires  The patient arrived at our office at 7:00 a.m. after a 45 minute drive.   She had ingested the required purge,  often the highlight of the experience.  I hadn’t seen her for

Tolerating Uncertainty in Medicine

Uncertainty makes everyone anxious, although each of us has a unique threshold for uncertainty tolerance.  In other words, different folks may react quite differently if they are confronted with the same set of facts.  Consider this hypothetical.   Two patients who are of similar age and enjoy excellent health undergo a CAT scan for a stomach ache.   By the time they follow-up with their physicians to review the results, their symptoms have resolved and they feel perfectly well.   A small spot is seen in the liver which the radiologist suspects is an innocent cyst, but he cannot state this definitively.   Each of the patient’s physicians explain that minor accidental findings like this are common and are very unlikely to pose any health threat. Patient #1:   “Ok, doc. I feel great and if you’re not worried, neither am I.” Patient #2:   “Are you sure it couldn’t be serious, like a cancer?   Should I have it cut out just to be safe?” First of all, let me give readers an inside ti

Do You Need a Patient Advocate?

I wish I could write that medical care today is an optimal, cost-effective and efficient system that consistently provides appropriate and sterling medical care.  I wish I could write that pharmaceutical companies, hospitals and extended care facilities all view patient care as their primary and overriding mission.  I wish I could write that physicians all share the highest ethos of patient advocacy. It is not possible to achieve these idealistic goals as the individual professionals, corporate entities and the government that comprise the medical profession are imperfect and face numerous conflicts of interests.  Indeed, this blog as devoted considerable space to highlighting these issues. Here’s a representative vignette from my world.  I was asked to see a hospitalized patient for an opinion on her low blood count, or anemia.  This is a common request for gastroenterologists as internal bleeding is a frequent explanation for anemia.  This is when we gastroenterologists

There is Too Much Technology in Medicine

As promised, here is the continuation of last week's post where I discussed the loss of physicians' diagnostic skills which have been largely replaced by technology. Of course, the medical community celebrates the miracles that technology has brought us.  Innovation has improved our lives and will continue to do.  On this issue, there is no debate. But, as with many advances, there is a cost.  Here's my take on the downsides of the technologization of the practice of medicine.   Could a CAT Scan Do Damage? Readers, Scan Below! Overreliance on technology has cost zillions of dollars. Much of the overdiagnosis and overtreatment in our health care system – which I have decried on this blog – is caused by medical technology. Technology has strained the doctor-patient relationship.  It is often easier to order a scan than to have a deeper conversation with patient who needs advice and counsel, particularly when physicians’ schedules are jammed. CAT scan

Treatment for Diverticulitis Revisited

Is there stuff that you do just because that’s the way you’ve always done it?    I’ll answer for you – yes. In many circumstances, this makes sense.   For example, I stop my car at red lights just as I have always done.   I recommend that readers do the same as there is an underlying logic for this recommendation.   It is not simply a rote routine that has no rationale.    However, the particular order that we pour ingredients into a pot when making soup, may be more random than rational.    We follow the same order we always have, never pausing to wonder why or if there might be a better way. And, so it is with many practices and procedures in the medical profession. Let’s return to the medical condition of diverticulitis, which I presented on this blog recently.  Follow the link , if interested. For the last several decades, this disease has been treated in the same way – with antibiotics.   This means that physicians believe this to be an infectious disease – like st

Do I Have Diverticulitis?

I have been treating diverticulitis for 30 years the same way.   When I suspect that a patient has this diagnosis, I prescribe antibiotics.   This has been the standard treatment for this disorder for decades. I have found that diverticulitis is a slippery entity that has two trap doors waiting for physicians to fall through.   It is an easy task to miss the diagnosis.   Every physician has done this. The diagnosis can be erroneously assigned to a patient.   Every physician has done this. Recognize that the phrase ‘every physician has done this’ includes me. The diagnosis can be elusive as there is no diagnostic test that secures the diagnosis.   The technology tsunami has covered the medical landscape, as it has run over so many other spheres in our society.   Doctors and patients increasingly rely upon ‘the numbers’.    Want proof?   Do you think there are many physicians today who can actually plug a stethoscope into their ears and hear, let aloneunderstand all of

Should High Blood Pressure be Treated?

In last week's post, I promised an explanation why many screening and medical treatments offer so little benefit to individual patients.    If you invest the time to digest last week's post and the post before you now, then you will be equipped with new understanding that will enable you to make much better medical decisions.  In accordance with this blog's mission, this is truly a 'peek behind the curtain'.  I grant you that these 2 posts are a little wonky, but try to stay focused.   Here is the main reason that ordinary people – and even some medical personnel – become confused on this issue.   Studies that assess screening tests and medical treatments are often performed on very large groups of patients.   The reason for this is that smaller studies, for reasons I cannot fully explain here, are simply not felt to be sufficiently reliable.    This is why the Food and Drug Administration would never grant approval of a new medicine based on favorable resu

Does Mammography Save Lives?

I find that the public often exaggerates the benefits of many preventive health measures.   I don’t blame the public for this.   There are several forces conspiring to deceive the average patient into accepting exaggerated claims of various medical tests and strategies.    Of course, the Medical Industrial Complex is a gluttonous beast that must be fed massive quantities of medical testing and treatment if it is to survive. Most of the public thinks that medical interventions, including mammography, lowering cholesterol levels, blood pressure reduction and even colonoscopy are downright lifesaving. Recognize that I am in favor of all of these measures, but that the actual benefit to the individual is much smaller than most folks believe.   In the case of mammography, there is uncertainty as to whether it saves lives at all, a view readers can easily find with a rudimentary internet search.   Mammography experts all agree that any benefit of this screening test to the individu