Sunday, August 20, 2017

Yikes! There's Food Stuck in My Throat! The Steakhouse Syndrome Explained

While I typically offer readers thoughts and commentary on the medical universe, or musings on politics, I am serving up some lighter fare today.  Hopefully, unlike the patient highlighted below, you will be able to chew on, swallow and digest this post.  If this blog had a category entitled, A Day in the Life of a Gastroenterologist, this piece would reside there.

I was called to the emergency room yesterday to attend to an elderly woman who had steak lodged in her esophagus.  While this sounds life threatening to ordinary folks, it poses no mortal danger.  The airway is uninvolved and normal respirations proceed without interruption.

These patients, while fully alive, are rather uncomfortable. 

This is one of the tasks that gastroenterologists are routinely called to undertake, often at inhospitable hours.

Sometimes, these folks have known esophageal narrowed regions where food that is not masticated with enthusiasm can hold up.  On other occasions, a person with a totally normal esophagus tears into a steak like a famished wolf and forces down a mass of meat that has no chance of passing through.  Bar patrons who are inebriated and then grab a handful of chicken wings are prime candidates for an emergency room visit with a gastroenterologist when the wings just won't fly through.  And, if granny forgot to put in her dentures before biting into a chicken sandwich…


Don't bite off more than you can chew.


No one involved enjoys the experience, and the procedure has more risk that our routine scope examinations of the stomach and esophagus.   Usually, these episodes can be prevented with proper attention to making wise food choices and chewing well. 

How do we get the job done?  Basically, we serve as plumbers and use our usual scope instrument to unclog your food pipe.  (Reminds me of a joke when a customer complained to a plumber over his bill.  "I'm a doctor, " the customer said, "and I don't charge that much!"  The plumber replied, "I used to be a doctor also, but I wasn't earning enough money."

The curious aspect of this case is I asked the woman prior to the procedure if she has difficulty swallowing foods with regularity.  She responded that the only food that she has consistent difficulty swallowing is the type of meat she ate that day.

Can you guess my next question?

Sunday, August 13, 2017

The Heartbreak of Psoriais - Guilt by Association

I was asked this week for an informal opinion by someone who was advised by his dermatologist to take a biologic medicine for psoriasis.   Now, my knowledge of this disorder is barely skin deep, yet knowledge alone will not set you free in the murky world of medicine.  Knowing something is not as significant as knowing when to do something.


Can guacamole really cause cancer?  Read on.


Biologic medicines, which have surpassed in frequency the nearly omnipresent TV ads for erectile dysfunction, are expensive medications that have risks of serious, albeit uncommon, side effects.  And, unlike chemotherapy for cancer, which has a finite course, biologic medicines are administered forever, that is without a clear stopping point. 

The individual who questioned me was not suffering from insufferable psoriasis and was satisfied with the conventional topical treatments he has been using for years.  His dermatologist offered the biologic in an effort to reduce his risk of heart disease.  Let me try to explain.

If you GOOGLE psoriasis and heart disease, you will find a surfeit of hits claiming some kind of connection between the two conditions. However, if you GOOGLE any two items on any subject, you are likely to hit upon some ‘connection’.   I just randomly GOOGLED guacamole and cancer and sure enough, there is a 'connection'!  Presumably, the dermatologist accepted the psoriasis-cardiac connection to be one of causality, meaning that psoriais can cause heart disease.  Extrapolating beyond this FAKE NEWS, he assumed that treating the psoriasis would mitigate the risk of an adverse cardiac event.   It is exactly this false reasoning that so often gets patients into trouble.  The logic of the intervention seems sound, but it is entirely specious.

The facts are here that there is no proof that psoriasis causes heart disease.  Clearly then, it makes no sense to treat the skin condition hoping to prevent a complication for which there is no proof that psoriasis causes.  Psoriasis may be associated with or linked to heart disease, which understandably suggests to an ordinary patient that there is a strong connection where Condition A causes Condition B.  I address this fallacy several times each week when I am asked if heartburn medications cause hip fractures or dementia.  They are associated with these complications in a statistical sense, but have not been shown to cause the complications.

Say I publish a study showing that tall individuals are associated with high blood pressure.  This does not mean that height is responsible or that we should hope that our children remain short.


Do you think that this blog is associated with astute and discerning readers?   If so, can I write next week that reading the Whistleblower blog is powerful brain food?

Sunday, August 6, 2017

Will Genetic Engineering Save or Sink Humanity?

We cannot let the anecdote rule over us.   We don’t make sound policy if we are swayed by isolated emotional vignettes.  Of course, a vignette describes a living, breathing human being, but we must consider the greater good, the overall context and the risk of letting our hearts triumph over our heads when making general policy.  Consider these examples.

If an expensive drug treatment program keeps 5 addicts clean for 6 months, do we champion this success in asking for funding to be renewed while omitting that 400 enrolled addicts failed?

If an experimental medical treatment seems to be effective in one patient with a stubborn disease, should physicians lurch toward it leaving aside standard treatments which have been subjected to Food and Drug Administration approval and years of clinical experience?

If a high school student attends an SAT prep course and achieves a near perfect score, do we conclude that every student should enroll in this course?

It is natural to be drawn to a shiny object, but on closer review, the shine often tarnishes quickly.

Earlier this week, we learned of an astonishing scientific breakthrough that seems utterly fantastic and futuristic, even though it has actually occurred. Scientists amended the DNA of human embryos to correct a mutation - a genetic defect - that causes a very serious medical disease.   This suggests that with additional research and testing that embryos who otherwise might be destined for misery could be rescued. 

We will hear heartwarming and breathtaking anecdotes that, if considered in isolation, will generate excitement and support. 

Would you argue against the following headlines?

Embryo with fatal cystic fibrosis mutation saved.

Tay-Sachs embryo rescued from fatal outcome.

Hemophiliac embryo expected to live normal life.

As is always the case, there will be ethical mission creep, despite the usual bromides that “scientists and research institutions will conform to the highest ethical standards”.   The fact that there is a fortune to be made in the genetics industry can be expected to alter the direction of our ethical compass.  And, while the initial rollout will be discussing how genetic intervention can reverse the course of devastating and fatal diseases, does anyone believe it will stop there?  Once the concept has been normalized, other medical conditions will be targeted.   The creep will be inexorable.  Boundaries will be shattered.


Einstein said 'God does not play dice with the universe.'

Should we?


Who doesn’t want a perfect child?  Over time, how will all of us regard the disabled community or even folks of average intellect and ability?  Will a disabled person be defined as anyone who is imperfect?

Beyond medical mission creep, I believe there is a very serious risk that genetic engineering will be used to achieve non-medical results. 

Imagine that you are new parents.  If medical science could perform a procedure that would add 20 IQ points to your child, would you pursue it?  Would you submit to a minor DNA tinker that would produce an excellent athlete or a musician?  See where I'm going with this?

Are you really ready for the curtain to rise on the Genetic Engineering Show?  I'm not.  To me, all this sounds like coming attractions of a horror show.






Sunday, July 30, 2017

Is America Ready for a Single Payer Health Care System?

Each morning, as I read the newspapers in view of 3 birdfeeders, I send excerpts of news morsels to various individuals in an effort to stimulate a dialogue on issues of the day.  I am mindful how deluged we all are with a tsunami of unsolicited material.  I will not contribute to the cyber pile-on.  First, I’ll never forward an article that I have not read in full.  Secondly, I will send an item to an individual only if I have judged beyond a reasonable doubt that this person will feel that the time investment in the material will be judged to be time well spent. 

I engage in an active colloquy with one of my good pals, who is among the millions of Whistleblower readers who ponder these posts each week.  To my knowledge, he has never left a comment on the blog, which is somewhat unexpected of this rather voluble individual.   As he has opted to remain anonymous, I will not ‘out’ him here, although perhaps this post may be the catalyst to morph him from spectator to participant.

More than once this past week, my pal has importuned me for my view on a single payer health care system.  I shall do so now, in this very public forum.

Readers are aware of my views on our current health care system.  For those yet unacquainted with my insider’s view of the health care reform, I refer you to the Health Care Reform Quality category on the right side of the screen where you can digest several edifying entries. 

We already have a single payer model in this country.  It’s called Medicare and it is wildly popular with enrollees.  A single payer system can be regarded as a Medicare-for-All program.

I have written many times that I believe that Obamacare was designed to be an interim measure until a full and complete government nationalization of our health care system could be accomplished. How ironic it would be if single payer emerges because the GOP majority who favor private sector solutions can't bring a bill to the president's desk. 


Single Payer Health Care Will be a Heavy Lift

I will support a single payer system, if the following features can be guaranteed.

  • Universal access for every American.
  • Fair and reasonable compensation for physicians and health care professionals.
  • Pays physicians and health care institutions in a reasonable time period.
  • Adequate number and distribution of primary care physicians.
  • Eliminate the dreaded ‘prior-auth’ for prescriptions which tortures physicians and our patients.
  • Reforms an unfair medical practice tort system.
  • Reforms medical education so that students are not routinely saddled with 6 figure debts.
  • Incorporates innovations to reduce over-diagnosis and overtreatment which bleeds the system and harms patients. Both patients and the medical profession are culpable here.
  • Affordable medications understanding that the pharmaceutical industry needs a profit motive to spend hundreds of millions of dollars of research to develop treatments for cancer, arthritis, dementia, diabetes and various chronic illnesses.
  • Defines clearly what medical care is not covered by the plan.  Everyone wants coverage for experimental treatment regardless of the cost for an afflicted family member, but this is beyond possible.  We cannot pay for every conceivable medical test or treatment, even if some experts regard it to be ‘promising’.  What should the standard be?  Perhaps, FDA approval might be a starting point for this discussion.
  • An impartial appeals process that is fair to all parties and issues a decision in a timely manner must exist.  Fund promising clinical trials so that patients who have exhausted conventional treatment, can altruistically help to generate new medical knowledge.
  • Ensures that patients, physicians and hospitals who contact SinglePayerCare can reliably and promptly reach a living, breathing human being who can answer the question or solve the problem without dropping the caller into a labyrinth of horrors.
  • While the costs to patients must be reasonable, they need to have some ‘skin in the game’ in order to serve as a break in what is now a runaway train of unnecessary medical care.
  • Medical quality must be championed and fairly measured, which would be a departure from current sham and scam ‘quality metrics’ that are in place.
  • Futile medical care should not be provided even if demanded by patients and their families, although I recognize that this is a sensitive issue.  Families understandably ‘want everything done’ as they cling to vain hopes.  And, while I don’t mean this to be callous, it’s easier to request a service when someone else is paying for it.
  • Has proper incentives and access to primary care so that routine medical issues are not clogging up our emergency rooms. 
  • Separate medical institutions’ economic interests from the public interest.  I surmise that the United States has the highest per capita of CAT scan machines on the planet.  Would private hospitals and nursing homes willingly surrender control or even ownership to the federal government to serve the greater good?  (You may laugh now.)
Single payer?  Bring it on!   I think, however, that this would be a very heavy lift.  We have a Medical Industrial Complex (MIC) riddled with waste and conflicts of interest and very powerful players who are making a fortune off the system.  Perhaps, if we were designing our health care system de novo, we would establish a single payer system, as other nations have done. 

Think of the health care reform issue as we do term limits for our senators and congressmen.  We all know that it’s a good idea, but it will never happen.  Legislators, like those in the MIC, do not seem capable or willing to place our interest over theirs. 


Sunday, July 23, 2017

After Hours and Weekend Medical Care - The Doctor's Perspective

Today's patients must adjust to seeing many physicians, many of whom are strangers.   If you need a doctor on the weekend, at night or just need a ‘same day appointment’, you may very well not be seen by your physician.  This is not your father’s medical practice.  The days of the physician house call have vanished.   There are many reasons responsible for this evolution (?devolution) in medical care.  Patients have by and large adjusted to this new reality.

Housecall with some Old Fashioned Bloodletting

We physicians have had to adjust as well.  Formerly, we took care of our patients exclusively, with rare exceptions when we were out of town.  If you went to the hospital, we were there.  Same day appointment needed?  We squeezed you in.   There was no nurse practitioner to pick up the slack.  While I’m not making a judgment on the mediical merits, physicians of yesteryear were more devoted to their patients and their profession than they were to their own lifestyles, a fact that their families would attest.  Times have changed.

Nowadays, physicians regularly see patients whom we do not know.  Consider that for a moment.  On a regular basis, doctors treat patients whom they have never seen.  While this challenge is obvious from the patient’s perspective, it’s not easy for us either.  In my own practice, this experience usually occurs on the weekends when I am covering my partner's hospitalized patients. This is much more complex than if I were seeing my own patients whom I know well.  Here’s why.
  • I have no personal relationship or rapport with the patient or the family.  If I have a serious recommendation, such as surgery, will I have sufficient credibility?
  • I may be reluctant to aggressively intervene on a Sunday morning, opting instead to tide the patient over until Monday, when my partner who knows the patient will be back on the case.  This phenomenon of a benevolent stall is commonplace when a doctor is temporarily on the case.  
  • Although I may be ‘in charge’ of the patient on the weekend, I am not as knowledgeable of the nuances of the medical situation as would be the doctor of record.  For example, if I palpate a patient’s abdomen on Saturday morning, and it is tender, it may be very difficult to ascertain if it is worse or better, as it was someone else’s hands that were on the belly on Friday.  Additionally, doctors who are active on the case have knowledge of the patient that can never be recorded in the medical record.
When a patient meets me for the first time, he may be wary as I have not yet earned his trust.  I understand this.  Similarly, when I see another doctor’s patient for the first time, it is harder for me as the covering physician.  How could it not be?   I'm not sure that patients reliably recognize this, assuming that the covering doctor can cover it all.

We covering doctors do our best on the weekends, but it’s not ideal.  In a perfect world, every physician who sees a patient would know all.  But, the medical world must operate in an imperfect system and with imperfect professionals.  If patients and physicians both accept this, then our doctor-patient relationships will be more robust.  Let's all keep our expectations in the real world.  

Sunday, July 16, 2017

Obamacare Nearly Repealed & Replaced! 2+2 =7!

Everyone likes R & R.  In fact, I’m enjoying some R & R right now as I sit lounging on the backyard deck.  I have a full frontal of 3 birdfeeders who are all being attacked by avian assaulters.  It’s a microcosm of society – Lord of the Flyers, if you will.  The hummingbirds are working their wings off for a sip of nectar.  The finches politely share space on the feeder.  The male and female cardinals hang together – true love birds. The blue jays bully all the other birds away.  And, the lazy squirrels simply hang out below capturing seeds that the birds above spill to the ground.



The Bully


Senate Majority Leader Mitch McConnell is trying hard to get some R & R also.  Doesn’t he look like he needs it?  Poor guy.  The R & R on his agenda is not exactly like my backyard, bird gazing Rest and Relaxation.  The senator from Kentucky’s R &  R is Repeal and Replace!

The senator is a trained lawyer and must be skilled in logic, reasoning and interrogation techniques.  I have a sense that mathematics was not one of the senator’s stellar academic disciplines.

Here’s the situation:
  • There are 52 Republican senators
  • Two Republican senators are on the record as unwilling even to let the bill proceed for consideration. (52 – 2 = 50)
  • Within the past week, 10 Republican senators have raised serious concerns about the senate’s health care bill.  (50 – 10 = 40)
  • None of the 48 Democratic senators will support the bill.
  • Any Democratic senator who uses the word ‘repeal’ even by mistake will be sent to GITMO by Senator Chuck Schumer.
  • The bill’s public approval rating is a whopping 17%.  Great political cover for legislators who vote Aye!
  • Senator McConnell needs 50 GOP votes so Vice President Pence can push the bill into the end zone.
Can any of my brainiac readers with mathematical acumen show us simpletons a pathway to 51 votes?


Sunday, July 9, 2017

McConnell Needs Magic to Repeal and Replace Obamacare

To this observer of the political scene, it does not quite seem that the Repeal & Replace effort has yet been clinched.  I have already opined on the House of Representative’s passage of their repeal legislation, which was passed for reasons unrelated to healthcare.  Remember, how smoothly that process went?  I wonder what ‘techniques’ were utilized to convince a few wavering House reps to choose wisely?  Hopefully, these methods do not constitute torture, at least as defined by the Army Field Manual.

The world’s most deliberate body, The United States Senate, has not distinguished itself with the same task these past few weeks.  Majority Leader Mitch McConnell was attempting to defy gravity by promising passage, let alone a vote, on a horrendous bill that was rejected by factions within his own party.  Hence, he delayed the vote until after the July 4th recess hoping that there will be a providential act in the coming days that will cause the legislative lions to lie down the lambs.  In other words, prayer may be McConnell’s only recourse and hope for success.   So far, the Almighty has remained silent.


Can McConnell Pull a Rabbit Out of a Hat?


It’s hard to fathom how the calculus could change over the coming days and weeks.  It’s a tough math problem when he has only a bare GOP majority to rely on.  If he seduces a Republican moderate by changing a punctuation mark in the bill, then he may lose a conservative who demands that the semicolon be reinstated.  What a fun time to be the leader!

The fundamental failing is that the House and Senate bills fail the country.   While many GOP politicians disagree with me, I don’t measure success by the mere passage of a bill.  Shouldn’t the content of the bill determine its value and not simply its passage?   Most of our legislators and most of us do not believe that these bills would deliver on their promises of better health care, increased access and lower costs.

As readers know, I have penned at least a dozen posts opposing Obamacare.  I wondered then, and still surmise, that its true purpose was to transition us to a single payer system – a model that the Sanderites and Warrenites now unabashedly champion.   Many folks want ‘Medicare-for-All’ where the government controls all.  I have more faith and confidence with the private market playing a role, admitting that much reform of the system is still needed.   Which business model and performance do you admire more, Google or the Division of Motor Vehicles?

Can McConnell pull a rabbit out of a hat next week?  Or, will he shift blame elsewhere?  Will his threat to bring in a few Democrats into the process spook wavering GOP senators into submission?

Or, should we repeal the repeal effort and start over?

Sunday, July 2, 2017

Whistleblower Wishes All a Happy Fourth of July 2017





How's our sacred Honor doing?


"And for the support of this Declaration, 
with a firm reliance on the protection of Divine Providence,
we mutually pledge to each other our Lives, our Fortunes,
and our sacred Honor."



Sunday, June 25, 2017

Why I Don't Prescribe Pain Medicines

It may seem strange that a gastroenterologist like me does not prescribe pain medicines.  Let me rephrase that.  I don’t prescribe opioids or narcotics.   I write prescriptions for so few controlled substances that I do not even know my own DEA number.  You might think that a gastroenterologist who cares for thousands of patients with abdominal pains would have a heavy foot on the opioid accelerator.  But, I don’t.  Here’s why.


I truly do not know my DEA number.


I believe that one person on the health care team should manage the pain control.  In my view, this should be the attending hospital physician or the primary care physician in the out-patient setting.  There should not be several consultants who are prescribing pain medicines or changing doses of medicine prescribed by another physician.   With one physician in charge, the patient’s pain is more likely to be managed skillfully while the risk of fostering drug dependency and addiction is lessened.  We all know addicted patients who obtain medicines from various physicians and emergency rooms.  It’s cleaner when a patient on pain medicines knows that a single physician is in charge of managing this issue. 

While my argument of single physician authority can be applied to other medical conditions, this is even more important with narcotic agents.  For example, if a patient has an internist a cardiologist and a kidney specialist, only one of them should be managing the patient’s high blood pressure, at least in my view.   Since narcotics and related medications have addictive potential, it is even more important to have a limited prescribing source for patients. 

When I am seeing patients with abdominal pain, particularly in the hospital, I’m often asked for narcotics or to increase the dose or frequency of pain medicines that were already prescribed.  I counsel these patient that the attending physician is in charge of this and that the patient should discuss the request with this doctor. 

Other gastroenterologists and medical consultants may approach this issue differently.  I’d love to hear from them or from patients who have faced this issue. 

We can all agree that pain is the enemy.  But, the medical profession in its zeal to eliminate it, has contributed to the ravages and suffering of drug addiction.  In my state of Ohio, we lose thousands of our people every year to drug overdoses.  For many of them, their tortured path toward agony started with a medical prescription prescribed by a doctor like me.


Sunday, June 18, 2017

Yikes! When Your Doctor's Computer Crashes!

Earlier this week, as I write this, our office lost a skirmish against technology.  It was my procedure day, where lucky patients file in awaiting the pleasures of scope examinations of their alimentary canals.  A few will swallow the scope (under anesthesia), but most will have back end work done.  We are a small private practice equipped with an outstanding staff.  We do our best every day to provide them with the close personal attention they deserve.

The first patient of the day is on the table surrounded by the medical team.  The nurse anesthetist and I have already briefed the patient on what is about to transpire.  Propofol, the finest drug in the universe, is introduced into her circulatory system, and her mind drifts into another galaxy.  I pick up the colonoscope, which is locked & loaded for action, and the screen goes dark.  Our nurse goes through a few steps of messing around with plugs and doing a quick reboot, but we are still in the dark.  I glance at the back of the scope cart and have an eye-popping moment when I see dozens of wires and connectors coursing off the cart in a collage of chaos. 


Ready, Willing, but not Able!


After 5 minutes, when it is clear that the Almighty has not declared, Let There Be Light, we transport the patient into the recovery area where she is awakened.  Patients in the recovery area never remember their procedure.  This time, there was no procedure to remember.

There was tension in our office as we contemplated our options for colonoscopy patients who took the day off, arranged for a driver and swallowed the required liquid dynamite to cleanse their bodies and souls.  We called the hospital who could not accommodate on short notice request for multiple procedures.  I was not willing to cancel anyone and told my staff that I would stay until midnight to get the work done.

Our IT professional was in our office in 30 minutes.  I think he was the youngest person in the building.  When your IT guy is sweating and stumped, you know you’re in trouble.

So, here we were with an able gastroenterologist, a crack staff, patients ready for probing, but we were paralyzed because a computer monitor was in a coma.  It’s a reminder that we have all had of how totally dependent we are on our technology.  Even at home when the modem goes out, we feel that our oxygen supply has been compromised. 

Here’s the denouement of the drama.  About 2 hours after the first case was to have started, we concocted a ‘work around’, which allowed our cases to proceed.  So, we won this skirmish against Technology.  But, I fear they are regrouping, lying in wait for their next strike.

Sunday, June 11, 2017

Obamacare - Repealed and Replaced!

The House of Representatives enjoyed success weeks ago, depending on how one defines success.  Unquestionably, the passage of TrumpCare was a great political success that was not easily achieved.  I can’t fathom the intensity of threats and pressure that was utilized to convert a few ‘no votes’ into TrumpCare supporters.  The president and his team desperately needed a win after so many setbacks domestically and internationally.  And, this is a clear win, at least in the short term.  We will see if this vote becomes one that GOP House members can run on or will try to run from in 2018. 

Indeed, the GOP high-fiving and Rose Garden ceremony seemed premature considering that they have ascended only about 20% of their upward trek on an icy mountain as they hope to slog to the summit.  They may never get there.  The Senate, who have been quietly working on their own reform bill, are unlikely to endorse the House bill which contains antagonistic policies toward Medicaid expansion and pre-existing condition coverage.


The White House Rose Garden


Like Obamacare, this bill was passed without a single supporting vote from the opposition party.  Like Obamacare, this means that the effort is unlikely to attract the nation’s support, which is so critical for an issue that affects every American.  Imagine if Congress passed a declaration of war with votes from only one political party.  Would this be good for the country?   Could such a war be maintained when half the country opposed it initially?

The GOP’s mission was to achieve a win at any cost.  The Democrat’s response is to hope the reform effort soars over a cliff so they can benefit politically.  Does any reasonable person challenge me on these assertions?   

Leaving your own partisanship aside, do you feel that our legislators from either party care about our medical health or their political health?   Which institution – the Congress or the Health Care System – needs reform more?   Guess which one I’d like to repeal and replace?

Sunday, June 4, 2017

Are You A Victim of Abuse or Neglect?

Words matter.  Patients can get spooked by the words we use.  All of us have heard vignettes of how some inadvertent harsh words from a physician have caused injury.  I know there were times that I wish I could rewind and erase some errant words. 

Sometimes, an innocent remark from the doctor doesn’t land innocently.   When I ask as a matter of routine, ‘is there a family history of colon cancer’, as I do with every patient, this may provoke anxiety in a patient who is seeing me for a bowel disturbance.

Words Matter

We ask every patient who arrives at our ambulatory surgery center if they have a living will.  This often causes the patient to utter a nervous joke.  We then go on to ask if the patient has ever been ‘a victim of abuse or neglect’.   We are required to ask this..  It would seem rather unlikely that a patient who has just purged themselves for the pleasure of a colonoscopy, would confess to a nurse that (s)he is meeting for the first time that (s)he has been victimized.  Keep in mind that this a question follows a barrage of very routine medical inquiries.
  • Did you complete the laxative prep?
  • When did you last eat or drink?
  • Did you take any medications this morning?
  • Have you ever been a victim of abuse or neglect?
  • Who will be driving you home after the procedure?
Let me state unequivocally, that I am dead against all forms of abuse and neglect, both foreign and domestic.  I acknowledge that this is a serious problem that is clearly under-reported, particularly among the elderly.  I am skeptical, however, that querying our patients who are poised for an endoscopic adventure about a personal abuse history is likely to be enlightening.  A better case could be made for having these conversations in our office practices after we have developed rapport.

Who makes up these silly rules?   This is but one example of the documentation abuse that has been foisted upon the medical profession by the government and others.  I wish we could simply neglect to comply, but this boldness would only generate more government abuse on us.  

Sunday, May 28, 2017

Memorial Day 2017



Freedom is not Free.


Expressing profound gratitude to all those who served our nation and serve today, and to their families who share their sacrifice.

Sunday, May 21, 2017

Why My Patient Will Quit the Military

I had an interesting conversation with a patient in the office some time ago.  He was sent to me to evaluate abnormal liver blood tests, a common issue for gastroenterologists to unravel.  I did not think that these laboratory abnormalities portended an unfavorable medical outcome.  Beyond the medical issue he confided to me a harrowing personal tribulation.  Often, I find that a person’s personal story is more interesting and significant than the medical issue that led him to see me.

I am taking care to de-identify him here, and I did secure his permission to chronicle this vignette.  He is active duty military and is suffering from attention deficit disorder (ADD).  He likes his job.  He was treated with several medications, which were either not effective or well tolerated.  Finally, he was prescribed Vyvanse, which was a wonder drug for him.  The ADD symptoms melted away.  This is when military madness kicked in.  He met with military medical officials who concurred that this medicine was appropriate for him.  This decision, however, was overruled by a superior, since Vyvanse, is a controlled drug, which was prohibited.  My patient was told that he could choose between taking this drug or keeping his job.  In other words, if he opted for the one drug that worked for him, that he would have to quit. Who wins here?

Scales Tipped Against Him

While I do not know all of the relevant facts , this seemed absurd to me.  My guess is that the decision came right out of a Policy & Procedure Manual, which so often contains one-size-fits-all directives that override any measure of common sense.  It is this mentality that expels a first grader who kisses a classmate because the school has a rigid zero-tolerance policy against sexual harassment. 

When the patient was in my office, he had been off Vyvanse as required by his military superiors.  He was not feeling mentally well.  Not only was he off of his medication, but he was facing a profound professional decision that would change his life. 

And here’s the most ludicrous aspect of the situation.  The patient told me that other branches of the military had no issue with their servicemen taking VyVanse.  These branches apparently use  different Policy & Procedure Manuals. 

If this vignette is representative of the how decisions are made in his military branch, then they have a deeper issue to address.  Is there a medication that can combat rigid and robotic thinking?  If so, let’s hope it’s not a controlled substance.  

Sunday, May 14, 2017

Patients Who Drink Too Much

When I am facing an alcoholic in the office, I do not advise him to stop drinking.  Other physicians may advocate a different approach.  We live in a free society and individuals are free to make their own choices.  I have decided, for example, not to own a firearm, ride a motorcycle or bungee jump as these activities are not only beyond my risk tolerance threshold, but are also activities that I have decided would not enrich my life.  Many smokers, though addicted, enjoy the experience and are aware of the risks of this activity. 

Preparing One for the Road

My responsibility as a physician is to inform and counsel, not to lecture or preach.  I tell alcoholics with clear candor the medical risks they face if they decide to maintain this lifestyle.  I advise them that if they wish to aspire to sobriety, that I will refer them to appropriate professionals for treatment.  I further inform them that in my decades of experience, very few alcohol addicts can quit on their own, despite their vigorous declarations that they can do so.  Finally, I tell them that if they decide to venture on the difficult journey away from wine and spirits, that I will be there at every step to assist and encourage them.  However, there is no hectoring or finger-wagging from me.  No threats or intimidation – which never work anyway - just cold facts and honest predictions.  The patient is then free to make his decision, as he is with any medical proposal.

Patients aren't obligated to accept my advice.  Indeed, the bedrock concept of informed consent places the authority of the decision where it properly resides, with the patient.  

Alcoholsim is an insidious disease whose tentacles slowly suffocate the addict and causes many friendly fire casualties.  Yes, I am aware that there may be a genetic predisposition to the illness, but at some point the decision to drink was still a choice.  Ultimately, only the afflicted one can cast off the chains. 

What do you think?  Am I derelict by not delivering an energetic exhortation, “You’ve got to stop your drinking!”  Is it my job to tell patients what to do, or to give them a fair presentation of their options so that they can choose for themselves?  

Sunday, May 7, 2017

Should Physicians Provide Futile Care?

I was covering for my partner over the weekend and saw his patient with end stage liver disease, a consequence of decades of alcohol abuse.  He was one of the most deeply jaundiced individuals I have ever seen.  His mental status was still preserved.  He could converse and responded appropriately to my routine inquiries, although he was somewhat sluggish in his thinking.  It’s amazing that even after the majority of a liver is dead, that a person can still live.

The Liver - Alcohol's Enemy

When I do my hospital rounds, it is rare that one of my patients is not suffering some complication of chronic alcoholism.  In the hospital, the disease is rampant.  In my office, this addiction is much more easily disguised.  I know that many of the high functioning alcoholics whom I see there have kept their addiction a secret.  Some lie and others deny. 

There was a dispute with regard to the jaundiced patient referenced above.  There was no disagreement among the medical professionals on treatment options.  At this point, there was no medical treatment to offer beyond his current medications.  A palliative care specialist advised that hospice care was the most appropriate option.  The physicians and nurses concurred.  Why didn’t it happen?

The patient’s wife, who lived out of town, insisted that all medical measures be pursued.  Hospice care was a non-starter. While the patient and his wife were separated, she was still the legal spouse and next of kin.  The patient had not prepared a living will.  It was not felt that the patient possessed sufficient mental capacity to make this profound medical decision.  So, the wife's view prevailed.

My task was easy as I was only responsible for his gastro care over the weekend.  But, there was a huge ethical task that demanded to be confronted.  Physicians were continuing to provide futile care because a wife demanded it.  Such care, in my view, is unethical and need not be provided, despite the insistence of a family member.

Physicians are under no professional obligation to provide care that is futile, oris  extremely unlikely to offer benefit, even if patients and families demand it.  The fact that a third party is usually paying for this treatment only deepens the ethical infraction.  Physicians should not feel obligated to accede to futile care requests, or feel that they need a court order to protect them against such requests.  In my experience, surgeons are more comfortable than are medical specialists and internists in declining to provide care that won’t help.  I have often heard surgeons tell patients and their families that an operation simply won’t help and shouldn’t be done.  For some reason, this issue seems to be murkier for non-surgeons. 

Of course, physicians must be sensitive when discussing these issues with patients and families who understandably want anything and everything done to save their loved one.  But, giving care that won’t work is wrong. 

Over the weekend that I saw this patient, I was not in a position to set the patient free.  It seemed surreal that everyone on the case knew the right thing to do, but none of us were doing it.


Sunday, April 30, 2017

Does the Patient Need a Feeding Tube?

What should a medical consultant do when the referring physician wants a procedure that the consultant does not favor?

Of course, this sounds like a lay up.  The consultant, readers would surmise, should have a conversation with the referring colleague to explain why the procedure is not in the patient’s interest.  The colleague then thanks the consultant for his thoughtful input, and for sparing the patient from the risks and expense of an unneeded medical procedure.  Then, a rainbow appears, songbirds tweet in harmony and the lion lies down with the lamb.

When Physicians Dialogue, the Heavens Open and Music Plays!

This is not how it works in real world of medical practice.  I wish it did.  Indeed, this issue has tormented me more than, perhaps, any other in my decades of work as a gastroenterologist.  Many referring physicians request procedures from us – not our opinions – and expect that their requests will be complied with.  This is the same mentality that all physicians, including me, have when we order a CAT scan.  We generally do not consult with the radiologist in advance soliciting their opinion.  We simply click ‘CAT Scan’ on the computer and then the magic happens. 

On the morning that I write this, a physician has consulted a gastroenterologist to place a feeding tube in a patient hospitalized for this purpose.  The patient is not only demented, but speaks no English.  I called the son to acquire more understanding of his dad’s condition.  The patient has lived with the son for 7 years and knows his feeding habits intimately,   From time to time, he will have some coughing spells during meals, but this pattern has not accelerated.  This is his normal pattern.  The son related that his dad ate sufficiently and has not lost weight.

While I am able to connect the dots here that would lead to a feeding tube, for me this would require a lengthy caravan of dots to reach the referring physician’s request.  While I acknowledge that the patient likely has an impaired swallowing mechanism, it does not seem to pose a medical threat.  Today is Sunday and the physician expects that the tube will be placed tomorrow.

I am covering over the weekend for the gastroenterologist who will assume the patient’s care tomorrow.  I did not schedule placement of a feeding tube.  I requested instead that a speech pathologist, who is an expert in swallowing, offer an opinion.  I think that was the right answer here.

Consultants know that all referring physicians are not created equal.  Some welcome our opinions and others don’t.  Still others will punish us by cutting us out of their referral stream if we push back against their requests.  This is a sad reality that I wish I could remedy.

I’ve certainly complied with procedure requests for tests that I might not have personally favored.  This is not unethical, as long as there is a rational basis for the test, and the referring physician will use the information gained to adjust a treatment plan.  Additionally, we consultants may be wrong.  Perhaps, the referring physician’s request for a colonoscopy is the proper test, even if we may not think so.  No one knows it all.

Oftentimes, when folks are offered a ‘peek behind the curtain’, they are surprised to see what is happening behind the scenes.  Anyone shocked here?


Sunday, April 23, 2017

Is My On-call Doctor Any Good?

Physicians spend a lot of time counseling patients on the phone.  Often, these conversations occur at night with patients we have never met before. When I am on-call in the evenings or on the weekends, these are some typical phone calls I receive from patients I have never met.
  • I have a very bad stomach ache for the last hour.
  • I started having rectal bleeding an hour ago.
  • My wife tells me that my eyes are yellow.
  • My chest is hurting.  It feels different from my usual heartburn.
How do we manage patients with issues like those above?  We get hundreds of calls like this every year.  Do we send every patient to the emergency room just to play it safe?  Do we tell them to hang in there and to call their regular doctor when office hours open?   How can we be sure that a simple stomach ache isn’t the first warning of appendicitis or some other severe abdominal condition?

My After Hours Medical Equipment

Phone medicine relies on an entirely different skill set than physicians use in the office or in the hospital.  Consider these obstacles:
  • We often don’t know the patient.  The doctor who does know him may readily recognize that the complaint is benign.
  • On a phone call, we cannot read body language to gauge a patient’s level of distress.  Seasoned physicians get a gestalt feeling about a patient’s intensity of illness from simple observation.
  • There is no opportunity to perform a physical examination.
  • Prior medical records may not be available, although many electronic medical record systems to do permit remote access.
During my 3 years of internal medicine training and my 2 years of gastroenterology fellowship, I received not a whit of training in phone medicine.  This was a gaping oversight in medical education considering how important these skills are to practicing physicians.  I use them every day.   I confess that during my first several months on the job, there were many anxious moments for me as I fielded phone calls from anxious and sick patients.   It would have been easier had my educators given me a few pointers.

Understandably, patients who are calling physicians off hours are not aware of the handicaps that these doctors face.  Patients often seem to feel that even on a phone call, we somehow have our full toolboxes available and can make diagnoses or prescribe treatments.  Consider the following scenarios.

  • Driving at night wearing sunglasses.
  • Playing guitar with a broken string.
  • Enjoying a movie without sound.
  • Preparing a dinner party with only a saucepan available.
  • Providing medical care to a stranger on the phone.
Want to discuss this further?  Give me a call after hours.

Sunday, April 16, 2017

Overcoming Drug Addiction Solo - A Mother FInds Strength

Recently, I saw a young woman referred to me for an opinion on her hepatitis C infection.

In the latter part of 2013 she made an unwise decision and started using intravenous drugs.  She also made a more unwise decision and shared needles.  She is fortunate that the only virus she contracted was hepatitis C, now curable.  I do not know the details of her life then which led her to lean over the edge of a cliff. It would seem to most spectators that her new lifestyle would portend an inexorable slide into an abyss.  Young addicts, for example, often cannot fund their addictions, and resort to criminal activities to generate necessary revenue.  Employment status and personal relationships become jeopardized.  The tapestry of a person’s life can rapidly unravel. 

But, none of this happened.  About two years after the first shared needle pierced her vein, she quit and she’s been clean since. It was nearly a year later that she first saw me in the office accompanied by her young, spirited son.  I asked her how she molted and emerged from a grim and dangerous world of self-destruction.  “Who helped her?” I inquired.   “No one,” she said.   She had thrown the devil off her back herself, and had dispatched him to a place so distant that he would never find her again.

Devil, Be Gone!

Consider how extraordinary this life-preserving act was.  Only someone who has overcome a true addiction can understand the magnitude of this act.  That she succeeded alone only magnifies the accomplishment.  I admired her grit and devotion, but I couldn’t feel it on a visceral level since I have never suffered from an addiction.

She told me that she her two young kids gave her the motivation she needed to put her needles aside.  She owes them a great debt.  They gave her a gift that she can never repay.  But, I have a sense that she will spend the rest of her life giving back to them. 


Sunday, April 9, 2017

Health Care Reform 2017 Solved!

Have you noticed over the past several weeks that reforming the health care system must be slightly more complicated that we were told?  The promise that Obamacare would be repealed and replaced on Day 1 seems to have been met with a few minor obstacles.  In other words, it’s dead in the water.

Whose fault is it?  It’s like Agathe Christie’s Murder on the Orient Express [Spoiler alert!] – everyone is guilty!

The Freedom Caucus stiff-armed the Speaker of the House.  The GOP House moderates dissed the Freedom Caucus.  President Trump learned that being the leader of the free world is not quite the same as being a CEO of a private company.  If the repeal plan was adjusted to capture a few more hard line GOP members, then moderate GOPers jumped ship.  The Democrats gloated at the GOP’s failure, although their smiles became slightly more taut once Judge Neil Gosruch was confirmed to occupy the GOP’s 'stolen' Supreme Court seat. 

Remember John Boehner?   He’s the happiest man on the planet!

Now, I don’t pretend that the Whistleblower can reform the health care system in a blog post, although I don’t think my results could be worse than the GOP controlled House of Representatives.


Health Care Reform - Searching for Low Hanging Fruit

As a medical insider, consider a few issues listed below that would save zillions and improve our health.  They are not controversial.  Why then, aren’t we pursuing ideas that every medical professional supports?  Perhaps, one of my erudite readers can enlighten us, as I am stumped.   
  • Tens of millions of dollars are wasted on unnecessary antibiotics, which result in serious side effects and are creating superbugs. 
  • We are spending too much money on end-of-life and futile medical care.
  • Every physician who is breathing orders CAT scans, stress tests and colonoscopies that are not truly necessary.
  • Patients are punctured much too often for blood tests, particularly in the hospital when multiple specialists (like me) are on the prowl.  Most patients need only occasional blood tests.
  • Patients, particularly our elderly, are overmedicated.  The length of some of their medication lists are staggering.  Any wonder they are routinely sent to gastroenterologist to explain their nausea and other side-effects?
  • Whatever happened to watchful waiting?  Does every complaint that a patient brings to the office have to result in test or a prescription?   How often does a patient’s medical issue simply resolve on its own?
  • The PSA, prostate specific antigen has single handedly harmed more men and wasted more money than perhaps any other screening test.  Despite mountains of evidence supporting my contention, the diehards are still hanging on.
That was a quick list of some very low hanging fruit.  I’ll wager that if all of them were implemented, that we could reform the entire system and have enough money left over to subsidize obscenely high drug prices.   The absurdity is that the above bullet items would be supported, if not championed, by every reasonable physician, informed patient and health care policy pro.  Here’s the riddle.  Why do we persist in behaviors that we all agree are destructive?   Why do we keep furiously digging in the same hole that leads nowhere?






Sunday, April 2, 2017

Is My Doctor Up to Date?

Professional training and development are critical.  Police officers, educators, orthodontists, painters, chief executives, musicians and chefs all need ongoing training to remain current.  Job requirements evolve, and we must adapt.  An accountant who hasn’t kept up with new or anticipated tax law changes might not account for much when computing your tax obligation or refund.

Physicians need to be dedicated to ongoing professional development as much as any other occupation.  Patients often wonder if their doctor is up to date.  Does your primary care physician know about new medications for your condition?  Does your orthopedist use the latest medical hardware when replacing your hip joint?  Is your anesthesiologist using the same old laughing gas to put you asleep?  Is your dermatologist’s knowledge of his field only skin deep?

In the medical profession, there has been a paradoxical emphasis on reducing professional training.  Here’s what I mean.  In hospitals, it is no longer true that every patient relies upon a registered nurse, or R.N., for nursing care.  Now, lower level personnel such as nurses aides and other care assistants are frequently utilized.  I’ll let the reader surmise what motivated this hospital ‘reform’.  Nurse practitioners now roam the hospital wards, technically under the authority of a physician who is seeing his own patients in an office miles away.  Why see your own primary care physician, when the ‘minute clinic’ on the street corner is open for business.  These clinics are conveniently housed in pharmacies so that any antibiotics prescribed, which we hope and pray are truly necessary, can be purchased on site. 

Who should be doing your colonoscopy?  Do you prefer a trained gastroenterologist, or would you be satisfied with a nurse who has been trained in how to technically use the instrument, as some cost cutters have advocated?    Even a casual reader might appreciate that competency in a colonoscopy, heart catheterization or knee arthroscopy extends far beyond the technical requirements of the procedures. 

Gastroenterologists are similar to Navy SEALS.  We both train to a knife’s edge and do all that we can to stay razor sharp.  To my patients, I want to reassure you that staying current in colonoscopy is my life’s mission.  The training manual pictured below is never out of reach.  Feel better?


Sunday, March 26, 2017

Beware of Joining a Clinical Trial - Medical Research Must Come Clean

From time to time, friends, patients and relatives ask my advice on participating in a medical experiment.  My response has been no.  More accurately, once I explain to them the realities of research, they don’t need to be persuaded.  They back away.

Here’s the key point.   When an individual volunteers to join a research project, the medical study is not designed to benefit the individual patient.  This point is sorely misunderstood by patients and their families who understandably will pursue any opportunity to achieve some measure of healing for an ailing individual.  I get this.  In addition, I believe that these research proposals are often slanted in a way to suggest that there may direct benefit that the patient will receive.  I am not accusing the medical establishment of uttering outright falsehoods to prospective study patients, but there are two powerful forces that may incentivize investigators to recruit patients with undue influence.
  • The Medical Research Industrial Complex is a voracious beast that needs a steady diet of new recruits.  In other words, the beast must be fed.
  • Investigators have bias favoring their research and truly believe that the new drug has a real chance of helping study patients.
The truth is this.  In general, research projects are designed to generate new knowledge that will be used to help patients down the road, not those in the study.  Of course, I cannot state with absolute certainty that a study patient won’t realize a favorable result, but this serendipitous outcome is not the study’s planned yield. It should be viewed as a happy accident.  This is why the study is properly called a research experiement.

Napoleon Has Stomach Pain.
Should He Join a Study?

Beware of the packaging.  If your mom or dad has Alzheimer’s disease, of course, you would be susceptible to the following hypothetical pitch.

Is someone you love struggling against Alzheimer’s disease?  Our Neurological Institute is fighting hard against this disease and is now testing a new drug to help conserve memory.  Call for confidential information. 

Recently, in France, 90 volunteers took a study medicine testing the safety of a psychiatric medication.  One volunteer is now dead and others have suffered irreversible brain damage.  We don’t know the underlying facts yet.  While a horrible outcome is not tantamount to guilt, this is a terribly troubling event that must be sorted out. We will find out soon enough if the French study subjects were given all the information they were entitled to, and if the investigators and others behaved properly.  The investigation that must be full and fair.  A conclusion of c’est la vie won’t be enough.

If you want to join a medical study to serve humanity – and not yourself – then you are free to make an informed choice.  Be mindful of the risks including those that are not known. 

Helping others is a praiseworthy act.  So is telling the truth.


Sunday, March 19, 2017

Medical Marijuana Use - Ready, Fire, Aim!

Promoting medical marijuana use is hot – smokin’ hot.  States are racing to legalize this product, both for recreational and medical use.  In my view, there’s a stronger case to be made for the former than the latter. 

Presently, marijuana is a Schedule I drug, along with heroin, LSD and Ecstasy.  The Food and Drug Administration (FDA) defines this category as drugs with no acceptable medical use and a high potential risk of addiction.  Schedule I contains drugs that the FDA deems to be the least useful and most dangerous.  Schedule V includes cough medicine containing codeine.

On its face, it is absurd that marijuana and heroin are Schedule I soulmates.  I expect that the FDA will demote marijuana to a more benign category where it belongs.  It will certainly have to if marijuana is going to be approved as a medicine. 

There is no question that some advocates favoring medicalization of marijuana were using this as a more palatable route to legitimize recreational use.  The strategy was to move incrementally with the hope that over time the ball would cross the goal line.  We have seen this same approach with so many other reforms, legal decisions and societal acceptances, many of which we take for granted.  Consider gay marriage and women’s role in the military as two examples of goals that required a long journey to reach.

Marijuana has had no personal or professional role in my life.  I do not object to responsible recreational use and would support such a measure.  To criminalize marijuana use while cigarettes, chewing tobacco and alcohol are entirely legal seems inconsistent and hypocritical.  Is smoking marijuana more dangerous than riding a motorcycle?

Paradoxically, I have hesitancy at this point to endorse medical marijuana use based on the fragmentary data that supports its efficacy.  If you ‘Google’ this subject, and you believe what you read, you will conclude that marijuana is the panacea we’ve been waiting for.   It helps nausea, neuropathic (nerve) pain, glaucoma, muscle spasms, Crohn’s disease, multiple sclerosis, epilepsy, Hepatitis C, migraines, arthritis, Alzheimer’s disease, cancer and numerous other ailments.  Do we accept so readily that one agent can effectively attack such a broad range of unrelated illnesses?  It sounds more like snake oil than science. 

Cure is Just a Puff Away!

Shouldn’t high quality medical studies demonstrate benefit before we sanction medical marijuana use?

The medical profession and our patients should demand that all our medicines be rigorously tested for safety and efficacy.   I realize that there is huge public acceptance that marijuana is real medicine.  Not so fast.  Let the FDA evaluate marijuana as it does for all medications and treatments.  I do not think we should relax our professional standards just because the public is willing to inhale without evidence and entrepreneurs want to cash in.

If you had a chronic disease, would you expect your doctor to offer you a medicine with definite risks but no proven benefit?  Why would you accept it and why would he prescribe it?  

Sunday, March 12, 2017

Why Are Drug Prices So High?

Why are the costs of prescription drugs so high?  While I have prescribed thousands of them, I can’t offer an intelligent answer to this inquiry.  Of course, all the players in this game – the pharmaceutical companies, Pharmacy Benefit Managers, insurance companies, consumer activists and the government- offer their respective bromides, where does the truth lie? 

While I don’t fully understand it, and I don’t know how to fix it, we all know that the system is broken.  More than ever before in my career, I am seeing patients who cannot afford the medicines I prescribe for them.  In the last few weeks of this writing, 3 patients with colitis, a condition where the large bowel is inflamed, called me to complain about the cost of their new medicine.  The annual cost was in the $2,500 - $3,000 range, which is way out of range for normal folks.  While I was only focused on the colitis drug, many of these patients face prohibitive costs over multiple medicines.  All of these patients had medical insurance, thought it didn’t feel like it to them. 

Medicine or Retirement?

Should sick patients be given the added burden of price gouging?

I'm not an attack dog against PhRMA.  I've expressed sympathy on this blog and elsewhere that it costs pharmaceutical companies a fortune to design, test and market new medicine.  R & D is not cheap.  If we want this industry to take risks developing tomorrow's drugs, then they deserve a profit high enough to justify the investment.  Nevertheless, from the prescribers and the consumers points of view, the system is out of balance and needs to be recalibrated.  

I reviewed my colitis patients' formularies, which is the list of medicines that patients' insurance companies cover.  If a drug is labeled as a ‘Tier 1’ drug, then the cost to the patient is the lowest.  The higher the Tier #, the more the patient will pay.  This is how the insurance company ‘guides’ physicians to prescribe cheap drugs.  Of course, the insurance company will never say that the patient can’t receive an expensive drug.  That’s a decision, they claim with a straight face, that’s between a patient and the doctor.  Give me a break.  Ordinary folks, especially retired people on fixed incomes, are confined to lower Tier medicines.

I have no issue with the Tier system as long as there is at least one Tier 1 drug that can do the job.  If there are half a dozen heartburn medicines that are equally effective, I understand if an insurance company makes one of them Tier 1, their preferred choice.  This happens when the insurance company gets a special discount on this particular medicine.  

With regard to my 3 colitis patients, the only Tier 1 drug was one that came on the scene decades before I was born.  The standard colitis medicines that every gastroenterologist would have prescribed were all upper Tier. My patients had no choice but to accept an inferior drug. 

If any reader can explain why our drug prices are the highest in the world, can you also explain why insurance companies are not practicing medicine?



Sunday, March 5, 2017

Should Attorney General Jeff Sessions Resign?


For me, the test of fairness, which many of us fail, is if we would have the same view of events if the situation were reversed. 

An employee approaches his boss requesting a raise, pointing out that he has not had a raise in 2 years, while other colleagues have received pay increases.  The boss responds that while his performance was highly satisfactory, the colleagues who did receive pay raises demonstrated sterling reviews.  The employee believes this decision is unfair, and suggests there may have been some favoritism at play.   The fairness test here is what would the employee do if he were the manager.

A nursing supervisor is told that two nurses on a hospital ward are unable to report to their shift.  Each nurse has to carry a heavier patient load for that shift.  These nurses believe that they are entitled to additional compensation as their already heavy work load has been increased.  This request is denied by the hospital’s administration.  I wonder if the hospital administrators would agree with their edict if they were the overworked nurses on that shift.  Would they still agree that no additional pay for additional work is downright fair?  Can't you just hear them saying that if they were these nurses that they would welcome the opportunity to be saddled with extra work and would refuse any offer for additional comp.  (Readers are invited to laugh at this point.)

Events always look a little different when we swap places. 

The Attorney General of the United States, Jeff Sessions, is the newest star performer on CNN and other networks this week.  He gave misleading responses during his confirmation hearings when asked if he had any contact with Russian officials during the campaign.  In addition, he did not correct his misstatements afterwards until his 2 meetings with the Russian ambassador were disclosed.  He has been accused of lying and deceiving congress, an allegation that he denies.  He claims that he misunderstood the question and had no intent to mislead anyone.


Public Enemy #1?

Personally, I am not satisfied with his inaccurate testimony and subsequent silence    Did he lie?  I’m not sure.  If so, it would seem to be a poor choice since telling the truth of the two meetings could have been justified and explained.  

Many Democrats are screaming for his resignation and for a special counsel to be brought in to assess the situation independently.   I suggest that the reasons behind these two Democrat requests have nothing to do with Sessions’ behavior, but deserve a larger context, which I’m sure my readers will acknowledge.

We all know that when there is an independent counsel that the investigation always morphs into a mega-mission creep that extends far beyond the initial target.  That’s why political partisans always zealously request this measure when the other party is under attack, but push back hard when they are in the crosshairs.  

Now for the fairness test.   Remember when the Democrats were screaming and whining when independent counsel Ken Starr was on the attack?  His mission started with Whitewater but was incrementally expanded and extended to the Monica Lewinsky affair.  I think the Democrats had a valid point that his investigation became untethered.  However, is an independent counsel only fair when your opponents are being targeted?

As for Jeff Sessions resigning, I think this is transparent partisanship.  How would the Dems react if the situation were reversed?  The experiment has already been done.  Remember when Loretta Lynch, the Attorney General had a near hour long meeting with Bill Clinton on the tarmac while Mrs. Clinton was the target of an FBI investigation?  Quite a long time to be discussing golf and grandchildren.  

How many Democrats called upon her to resign or face a special prosecutor?   Have they passed the fairness test?

Of course, many partisan Democrats will point out the the Lynch affair is 'completely different' from the Sessions matter.  How stupid do they think we are?

I'm taking aim at the Democrats here, but I fully acknowledge that the GOP also fails the fairness test regularly.  


Sunday, February 26, 2017

Do Doctors have a Right to Free Speech? Hippocrates Weighs In.

Free speech is one of our bedrock constitutional rights.  The debate and battle of what constitutes lawful free speech is ongoing.  The issue is more complex than I can grasp with legal distinctions separating political speech, commercial speech and non-commercial speech.  And, of course the right of speech does not permit the free expression of obscenity or ‘fighting words’, along with some other exclusions.  And, there is no right to free speech in a private work place, where an employee can be fired for speaking his or her mind.  While worker in a private shop may claim that he had a right to call his boss a flippin’ jerk, he would likely find that he suddenly has an abundance of free time to contemplate his prior utterance.

Leaving aside the First Amendment, physicians have always enjoyed free speech in our offices.  We ask our patients questions of the most private and intimate nature.  And, they answer us.  We ask such questions because, under appropriate circumstances, we need the information in order to provide our best medical advice.   We ask about specific sexual practices.  We ask about prior or current substance abuse.  We ask if patients are alcoholics.  We ask if patients are suffering from abuse or neglect. 

While we may not invariably receive truthful responses from these inquires, often we do.  Patients trust us to respect their confidentiality, which has been embedded into medical culture and practice since the time of Hippocrates.

And whatsoever I shall see or hear in the course of my profession, as well as outside my profession in my intercourse with men, if it be what should not be published abroad, I will never divulge, holding such things to be holy secrets.

Hippocrates -2500 years before HIPAA!


His admonition holds true nearly 2500 years later.  How’s that for meeting the test of time?

In 2011, the Florida Republican legislature, with the approval of the governor, passed a law that restricted physicians from inquiring of their patients about gun ownership and safety.  Physicians found to be in violation risked loss of their professional licenses or fines.  Nearly two weeks ago, an appeals court struck this silly law down.  Not only was such a law an obvious encroachment on physicians’ First Amendment rights, but also posed a barrier preventing doctors from doing their jobs.  Should a pediatrician, for example, be prevented from asking a parent if firearms in the home are properly secured?  This is not a political or partisan issue – it’s a medical and safety issue.

Of course, the appeals court got it right in a case that I regard as a judicial lay-up.  But, how did such a ridiculous law get passed in the first place?



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