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What's the Cause of Chronic Abdominal Pain?

I see patients with abdominal pain every day.  Over my career, I’ve sat across the desk facing thousands of folks with every variety of stomach ache imaginable.   I’ve listened to them, palpated them, scanned them, scoped them and at times referred them elsewhere for another opinion.  With this level of experience, one would suspect that I have become a virtual sleuth at determining the obvious and stealth causes of abdominal distress.   I wish it were the case. Some Cases Defy Sleuthing The majority of cases of chronic abdominal pain that I – and every gastroenterologist – see will not be explained by a concrete diagnosis.   Sure, I’ve seen my share of sick gall bladders, stomach ulcers, diverticulitis, bowel obstructions, appendicitis and abdominal infections, but these represent a minority of my afflicted patients.  Patients with acute abdominal pain are more likely to receive a specific diagnosis, such as those listed above.  However, patients who have abdominal

Whistleblower Holiday Cheer 2014!

T’was the week before Christmas And all through the House, Boehner was stirring No longer a mouse The Senate as well In GOP hands Girding for battle With toothless demands. No government shutdown That never played well. Impeachment would surely Damn them to hell. Executive orders, No self-deport. Why diss the Congress? He does it for sport! In 2016, Are Repubs aware, That they need a candidate With Romney’s hair? GOP are no saints They carp and complain, Blaming Obama With dripping disdain. “He’s a king or a czar. It’s all been a ruse.” We know this is true It was on Fox News. So will there be progress? Will they join hands? Can we have hope? As we watch from the stands? Or can we expect, More of the same, Bickering, sniping And pointing the blame? Will Jeb give the nod? Can Hillary lose? Or Dancer or Prancer, Or maybe Ted Cruz? Sit back and relax, For the start of the show,

Does Quality of Colonoscopy Depend on Time of Day?

Over the past decade, there has been renewed effort to increase the quality of colonoscopy. New data has demonstrated that colonoscopy quality is less than gastroenterologists had previously thought. Interestingly, colonoscopy is less effective in preventing colon cancers in the right side of the colon compared to the left side. Explanations include that some pre-cancerous polyps in the right side of the colon are more subtle to recognize and that the right side of the colon has many hidden areas that are difficult to visualize. New examination techniques and equipment are addressing these issues. The goal of colonoscopy is not to detect cancer; it is to remove benign polyps before they have an opportunity to become malignant. A new measure of medical ‘quality’ is to record how often gastroenterologists (GIs) remove polyps from their patients. For example, if a GI only detects polyps in 5% of patients, which is under the quality threshold, then someone will conclude that this physici

Should Your Doctor Consider Medical Costs?

This blog is devoted to an examination of medical quality.  Cost-effectiveness is woven into many of the posts as this is integral to quality.  Most of us reject the rational argument that better medical quality costs more money.   Conversely, I have argued that spending less money could improve medical outcomes.  Developing incentives to reduce unnecessary medical tests and treatments should be our fundamental strategy.  Not a day passes that I don’t confront excessive and unnecessary medical care – some of it mine - being foisted on patients.  At one point in my career, I would have argued that physicians and hospitals were motivated only to protect and preserve the health of their patients, but I now know differently.  Payment reform changes behavior. As an example, it is impossible for a patient with a stomach ache who is seen in an emergency room to escape a CAT scan, even if one was done for the same reason months ago.  I saw a patient this past week with chronic and unexp

Thanksgiving - A Chance to Spread Sunlight

This is the only Thanksgiving holiday in my memory that I was not on call for hospital work.   Physicians, like many other folks, are not automatically off on holidays and weekends.  I’m not complaining here, but there are times that I am envious of individuals who are home on every weekend and holiday.  Americans need health care, law enforcement, and various emergency services even on days of national leisure.  When I am driving to the hospital on one of those days, I remind myself that the sick person I am headed to see has a much worse deal than I have. I have been bestowed with many blessings, and I am grateful for all of them.  Some of them, I may have earned, while others just fell my way.   Similarly, life’s travails can result from a bad decision or just bad luck.  Life isn’t fair. Spread Sunlight I admire folks who always spy a rainbow through a storm, and I want to be like them. Appreciating one’s lot in life, especially a midst dark days, brings much light in

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 similar to the first-aid kit in your new car, which contains a few BandAids, adhesive tape and, hopefully, the phone number of local doctor.  My home tool box has an item that can practically fix anything – the phone number of a local handyman. Nothing for Hemorrhoids Here.      Photo credit 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

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 k

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 cl

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 Afr

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

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

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 Photo Credit 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. Alert

Which Medical Specialty Should Medical Students Choose?

A medical student recently asked my advice on her decision to pursue a career in dermatology.  It was about 25 years ago when my own parents encouraged me to pursue this specialty.   What was their deal?  Perhaps, they anticipated future developments in the field and were hoping for free Botox treatments?   As readers know, I rejected the rarefied world of pustules and itchy skin rashes for the glamor of hemorrhoids, diarrhea and vomit.  My parents were making a lifestyle recommendation.     Dermatologists are doctors who sleep through the night.  Spying one in a hospital is a rarer sighting than spotting a liberal Democrat at a Michelle Bachmann rally (unless a planted heckler).  Nocturnal acne medical emergencies are uncommon.   And anyone who has had cosmetic work done understands painfully that this is a cash business. Diagram of Skin Luckily, the Whistleblower is thick-skinned Here’s where some readers or Dermophiles will accuse me of skin envy.  Not true.  Some d

Medical Complications Torture Doctors Too

If you are a physician like me who performs procedures, then rarely you will cause a medical complication.  This is a reality of medical life.  If perforation of the colon with colonoscopy occurs at a rate of 1 in 1500, and you do 3000 colonoscopies each year, then you can do the math. Remember that a complication is a blameless event, in contrast to a negligent act when the physician is culpable.  These days, for many reasons, an actual complication is confused or misconstrued as an error. Some complications are more difficult on physicians than others.  For example, if I prescribe a medication and the patient develops a severe rash, I do not feel personally responsible.  It’s the drug’s fault.  However, when I perforate someone’s colon as a medical complication, I feel responsible even if this act was a blameless event which will occur at a very low but finite rate.  (Of course, there are perforations of the colon which result from medical negligence, but I am leaving these as

Should You Trust Your Doctor's Advice?

Is your doctor a hammer and you're a nail?  Here's some insider's advice coaxing patients to be more wary and skeptical of medical advice.  Should you trust your doctor?  Absolutely.  But you need to serve as a spirited advocate for your own health or bring one with you.  Ask your physician for the evidence.  Sometimes, his medical advice may result more from judgement and experience as there may not be available medical evidence to guide him.  Make sure you have realistic expectations of the medical out me.  And most importantly, try as best you can to verify that the proposed solution is targeted to your problem. Is Your Doctor a Hammer? Consider a few hypothetical scenarios. A 66-year-old patient has chronic right lower back pain.  Physical therapy has not been helpful.  Radiological studies show a moderate amount of hip arthritis.  A hip replacement is flawlessly performed.  The orthopedist discharges the patient from his practice.  The pain is unchanged.

Bariatric Surgery: Pulling the Gastric Bypass Trigger Too Soon

If losing weight were easy, we'd all be skinny.  If exercise were fun, we'd all be doing it.  If quitting cigarettes were effortless... What should our response be toward rising societal tonnage? A Weighty Issue Photo Credit Pass laws restricting access to the wrong type of food.  Former Mayor Bloomberg got stiff-armed on this approach by the courts.  It's also always fun to watch folks argue over the definition of a 'wrong food'.  The debate on which foods warrant prohibition at least brings some entertainment into the public square.  Imagine trying to achieve consensus over 20 or so food items that should be banned.  If this task were actually accomplished, cigarettes and alcohol would still be legal.  Make sense? Initiate a massive public education campaign to scare us skinny. Show ads of scary pictures with scary music reminiscent of an iconic anti-drug ad (This is your brain on drugs...) from a few decades ago.          "This is yo

The Meaning of Labor Day

Labor Day is here.  Like many of our National Holidays, we have forgotten the meaning of the day.  Is Memorial Day a time to reflect upon those who sacrificed so we would be free, or a time to grill burgers on the barbecue?   Same with the Fourth of July.  Martin Luther King Day is just a day off for many of us.  If greater participation and reflection on MLK is the objective, then why would this day be on a Monday when most of the country is at work?  Even Christmas, a holiday season that I enjoy but do not celebrate, has shed its deep religious significance having become a commercial enterprise.  This reality, I suspect, must sadden and disturb many believing Christians. Labor Day, when many of us will be laboring over charcoal-broiled ribs and chicken, was created to remember and honor this country’s labor unions.  Triangle Shirtwaist Factory Fire 1911 While I am hostile the politics of unions today, I readily acknowledge that they were a necessary response to egregio

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.   Alw

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 the

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

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 a