Sunday, October 15, 2017

I'm Taking a Knee on Journalism

Thanks to NFL players, our national anthem is getting more attention than ever.  Keep in mind that many of us could not recite its words without error, and fewer of us have the range to sing it.  Even fewer can cite the historical event being described.  This is the latest, but not the last, example of a solvable issue that is being exploited to divide us.  I lament that so many of controversial issues ricocheting in the public square are similarly solvable, and yet remain combustible.

The media stokes these conflicts, in my view.  Listen critically to how CNN and other networks packages and delivers the news.   Not only is the reportage suffused with editorial content and slant, but it sows overt division and partisanship by design.  

Consider the following two questions from a TV reporter.  Which one would the network be likely to air?

“Senator, what is your plan for tax reform?”

“Senator, the leader of the opposing party attacked your tax policy as a cruel attack on working families.  Is he right?”

The 2nd example, in my opinion, improves television ratings at the expense of journalistic professionalism.   

Many cable ‘news’ broadcasts have become extended panel discussions where folks along the political spectrum talk over one another spewing forth predictable drivel in a rhetorical food fight.   Again, these performances may be spirited and entertaining, but they are actually a demonstration by the networks that conflict sells. 


Knees in the News!

The ‘take a knee’ issue has been morphed from its original intent to protest against racial injustice in the criminal justice system to venerating the anthem and the flag.  Of course, there was a pathway forward had calmer minds and listening ears prevailed.  Why solve a problem when conflict can advance your agenda?   Peoples’ positions can harden despite that they have lost sight of the actual issue before them.

Are NFL players who are ‘on the clock’ in uniform permitted to protest on the sidelines?  Although I am not an attorney, I am not certain that sideline player protesting is constitutionally protected, as would speech be in the public square.   Would owners be entitled to issue a restraining directive if the players' actions were driving away fans and profits?  Would a racist player be permitted to engage in a hateful gesture while in uniform on the sidelines?  Lawyers reading this post can enlighten us if an owner can lawfully require that all players stand respectfully during the anthem. 

 In our medical practice, if our staff all wore shirts with a message that stated, ‘I SUPPORT EUTHANASIA’, would the physician owners have a right to limit this speech?

Regardless of one’s view on the legality or propriety of taking a knee, this issue did not have to have sliced the country apart.   I am not hopeful in the short run. As long as our leaders profit from our divisions, and with the public’s insatiable appetite for conflict,  the end zone will remain far out of reach.

Sunday, October 8, 2017

Why Are You Seeing A Gastroenterologist?

I write to you now from the west side of Cleveland in a coffee shop with my legs perched upon a chair.  Just finished the last Op-Ed of interest in today’s New York Times.  Do I sound relaxed?

I rounded this morning at both of the community hospitals that we serve.  There is not a day that goes by that doesn’t have blogworthy moments.  If I had the time and the talent, I would post daily instead of weekly.   Read on for yet another true medical insider’s disclosure.

Gastroenterologists, as specialists, are called upon by other doctors to address digestive issues in their patients.  For example, our daily office schedule is filled with patients sent by primary care physicians who want our advice or our technical testing skills to evaluate individuals with abdominal pain, bowel issues, heartburn, rectal bleeding and various other symptoms.  The same process occurs when we are called to see hospital patients.   If a hospital admitting physician, who is usually a hospitalist, wants an opinion or a test that is beyond his knowledge or skill level, then we are called in to assist. 

The highest quality referring physicians are those who ask us a specific question after they have given the issue considerable thought.  Contrast the following 3 scenarios and decide which referring physician you would select as your own doctor.
  • “Dr. Gastro.  Just met this patient for the first time with a month of stomach aches.  Please evaluate.”
  • “Why did your doctor send you here?” queried Dr. Gastro to the patient.  “No idea,” responded the patient.
  • “Dr. Gastro, please evaluate my patient with upper abdominal pain. I thought it might be an ulcer, but the pain has not changed after a month of ulcer medication.  The pain is not typical of the usual abdominal conditions we see.  Do you think a CAT scan of the abdomen or a scope exam of the stomach would be the next step?  Open to your suggestions.”
Sometimes, we have to deduce the reason the patient is seeing us!
As readers can surmise, I favor primary care and referring physicians who give thought prior to consulting me.   There are many reasons today why primary care physicians pull the specialty consult trigger quickly.  Sometimes, busy internists simply don’t have the time available to deeply contemplate patients’ symptoms.   Physicians have also referred patients to specialists with the hope of gaining litigation protection by passing the patient up the chain, although the medical malpractice crusade has eased over the past few years.  Oftentimes, patients drive the specialty consultation process by asking to be sent to specialists. 

More often than you would think, we see patients in our office or in the hospital when neither the patient nor I have a clue why they are there.  This adds excitement to our task.  In addition to being diagnosticians, we must also serve as detectives, divining the reason that the patient is before us!



Sunday, October 1, 2017

Does Secretary Tom Price Deserve Forgiveness?

What is the explanation for Tom Price, a physician and current Secretary of Health and Human Services, taking private charter flights costing taxpayers hundreds of thousands of dollars?  Keep in mind that when Price was a conservative congressman from Georgia, he would have railed against such fiscal profligacy.  Is it hubris?  Entitlement?  Or, do folks who ascend to positions of power simply rationalize that such excesses are absolute necessities for getting the job done?

By the time this piece is posted, Dr. Price, an orthopedic surgeon, may have been surgically excised from the government without anesthesia. 

While his behavior is not quite Watergate, it was wrong.  And, if it was not wrong, it demonstrated impaired judgment.  And, if was not simply a repeated exercise of misjudgments, then it exhibited bad optics.  And, if it somehow passed the optics test, it was just dumb. 

Would Price have been able to explain these expensive charter flights to average folks, half of whom elected the president to drain the swamp?

I watched Price’s reaction to all of this in several interviews.  Yes, he agreed to pay ‘his share’ of the flight costs, which represented a small fraction of the total costs incurred.  He stated that his department would desist from private charter flights in the future.  He admitted that the ‘optics were bad’ and that previous cabinet secretaries have engaged in similar behavior without suffering repercussions.  He didn’t appear to me to be a man consumed with guilt. 

Sounding the shofar, a call to repentence.  

Personally, I don’t think that Price thinks that he did anything improper.  He never clearly states that he was wrong.  Admitting that he had an ‘optics issue’ is not the same as a confession.   Pointing out that prior government officials committed similar acts with impunity doesn’t sound like a man who knows he has done wrong. 

If he did feel that his flights were proper, then why would he pay back the government anything or stop future charters?    He could have resigned simply because the president was angry and displeased, without offering a pseudo-confession to a transgression he did not believe he had committed. 

Yesterday at sundown, ended the Jewish Day of Atonement, Yom Kippur.  This culminates a 10 day period of reflection and penitence.   We are instructed to beseech forgiveness from the people in our lives before petitioning the Almighty for absolution.  We cannot receive atonement unless we have first admitted our errors, repented for them and strive not to repeat them.  While I am not a rabbi, I doubt that the Almighty would grant us a pardon if we looked skyward and cried out:  “My Lord, forgive me for demonstrating bad optics!”

Sunday, September 24, 2017

Why Graham-Cassidy Bill to Replace Obamacare Should Fail

The Graham-Cassidy bill – the latest Repeal and Replace iteration - still has a pulse, but its prognosis is grave.   While we physicians generally avoid predicting outcomes, my sense is that this bill will be buried in the coming days.  I presume that once its passage becomes mathematically impossible, that the bill will be pulled.

Of course, failure to Repeal and Replace is a horrendous embarrassment and exposure of the Republicans who have been campaigning and crusading against Obamacare with religious zeal these past 7 years.   These patriots knew they could safely rail against the Affordable Care Act (ACA) – throwing red meat to their base – knowing that the bills would never pass while a Democratic president occupied the White House.   How ironic it is that now that the GOP have congressional majorities that they couldn’t get it done.  Not only could they not run the ball into the end zone, but they repeatedly fumbled at every opportunity into the hands of waiting Democrats. 

It seems to me that the GOP efforts to ram though a New & Improved health care program was all politics and very little policy.   The objective was to get a 'win'. Numbers were massaged.  Special deals were offered.  The non-partisan Congressional Budget Office was bypassed.  False promises were made.  Doomsday predictions were declared.  All this is public knowledge.  Imagine what was happening beyond our view. 

I have been consistently hostile to Obamacare, which I have regarded as a waystation on the path toward full government takeover.  Readers are referred to various rants on this subject in the Health Care Reform Quality category along the right margin of your screen.  But my animus toward the ACA doesn’t mean that I’ll support anything offered up as a replacement.


Someone deserves a thumbs up here.  

I didn’t like it when the Democrats passed the ACA without a single Republican vote.   This partisan victory created a chasm that divided the parties and the country which lives still.  While the Democrats will claim that no Republican would work with them then (really?), they could have made some compromises to draw in some GOP legislators and still pass the bill.  Was it simply beyond the Democrats’ ability or willingness to include tort reform in the bill, for example?  How different would our political landscape be now if both sides had contributed to health care reform?

I don’t have a firm opinion on the merits of Graham-Cassidy, but I do not like the process of trying to jam it through before the end of the month so the GOP can utilize the reconciliation process, where only 51 votes are needed, rather than 60 votes.   A decent bill should be able to withstand congressional vetting and inquiry and should be able to draw 10 or so Democrats on board, assuming naively that they would be permitted to vote their conscience. 

I think that Lindsey Graham knew in his heart that his closest friend in the Senate, John McCain was going to give the thumbs down again.   I give him a thumbs up for being the principled and heroic statesman that we so desperately need.  

Sunday, September 17, 2017

Why Are Drug Prices So High? Explanations Welcome

Most of us do not know the basics of economics, although we should.  It impacts every one of us every day that we are alive.  Yet, for most of us, once we get beyond the law of supply and demand, our knowledge of the subject starts to vaporize.  I can't explain fiscal or monetary policy.  While I regard economics as a science, it seems that experts routinely interpret data differently, which confuses beginners like me.  What are novices to think when one expert hails our continued job gains while another laments our anemic recovery?

The Puppeteers

I have a general feel for market forces.  If consumer demand for an item rises, then I will expect to pay more.  If I want to make a purchase at an independent appliance store, then I will expect to pay more in return for superior customer service.  If the item is manufactured in China, it will likely cost me less as this factory is not burdened with worker protections, environmental regulation and union wages.

The above common sense realizations do not compute in the medical universe.  My fees, which I do not control, are unrelated to supply, demand or quality of the product.  Moreover, medical costs are a mysterious enigma which confound physicians and our patients.  Why does the cost of a simple bandage for a hospital patient remind us of the defense department’s $400 hammer?  Why can’t I, a gastroenterologist, give a straight answer to the question, ‘how much does a colonoscopy cost?’

Reimbursement strategies in medicine are changing to a system that will pay physicians and hospitals for the ‘value’ of their service, rather than the quantity.  Like any slogan, it will sound appealing but will bring forth a bevy of burdens that will create foreseeable controversies and challenges.  Stay tuned.

Let me share an absurd medical economic observation that occurred a few days prior to this writing.  I received a phone call over the weekend from one of my patients who was suffering from a recurrence of C difficile (C. diff) infection and needed antibiotic treatment for this as soon as possible.  The drug of choice was Vancomycin (Vanco).  Physicians know that the cost of this medicine is often prohibitive.  The patient and I made phone calls to area pharmacies in an effort to find the most affordable option.  Let me juxtapose below results from two different pharmacies.

Pharmacy #1                  Pharmacy #2

Vanco Cost                        $110                             $2,500

Okay, my economist friends, explain this discrepancy to me, if you can.  Good luck.   

Would it make sense to you if a Big Mac costs $3 at one McDonalds and $500 at another? 






Sunday, September 10, 2017

Hospital Acquired Infections and C. diff. Is My Hospital Safe?

If any reader has heard of C. difficile, affectionately known as C. diff, than I presume you have had closer contact with this germ than you would have liked.  It’s an infection of the colon that can be serious, or even fatal.  There isn’t a hospital in the country that isn’t battling against the infection.  

We are not winning the war against this crafty and cunning adversary. 

We Need Better Weapons Against C. diff

While the infection is not new, the strength and seriousness of current strains of the germ have tilted the odds against doctors and our patients.  The infection usually is a ‘side-effect’ of antibiotic treatment, but it can also be contracted from infected surfaces and people that reside in hospitals and extended care facilities and nursing homes.  For example, nowadays a patient can be admitted to a hospital and pick up the germ from hospital personnel who are contaminated from contact with an actual C. diff patient.  For this reason, C diff patients are kept in a form of isolation to protect against spreading the disease.  When a C. diff patient is discharged, the room must be scrupulously cleaned.  Hospital housekeepers today have an incredibly important job for reasons that need not be explained.  While my intent is not to frighten readers, every room in your hospital has likely housed a C diff patient at one time or another. 
  • Imagine the consequences if hospital rooms are not cleaned fastidiously every time?
  • Imagine the risk to patients if personnel do not observe proper handwashing techniques?
  • Imagine the hazard from overuse of antibiotics which are a known risk of C. difficile?
C. diff is not a simple infection like a urinary tract infection that can be easily wiped out. It can be severe and stubborn. The germ has a spore form where it stays protected within a type of armor and can survive on surfaces for months.  This is why it is so tough for hospitals who are striving every day to destroy these millions of microscopic germs who resist attack and hide in waiting.  It’s not really a fair fight.

Some patients carry the infection for life.  Many have died from it.  It’s especially tragic when a patient battles against C. diff which resulted from antibiotics that were not necessary in the first place.  Think of this when your dentist insists on giving you antibiotics because you have a heart murmur of have an artificial joint, neither of which is supported by medical evidence.

There’s a new treatment called fecal transplantation, where healthy donor stool is introduced into the C diff patient’s digestive system and cures an infection that seemed to be chronic and incurable.  In my view, this is a game changer and I predict that every hospital in America will offer it in the forseeable future.
 
My advice?  Refuse any antibiotics advised by any physician, including me, unless the doctor makes a case for them beyond a reasonable doubt. 


Sunday, September 3, 2017

Labor Day 2017

Couldn't cover every tool or trade here, but a shout out to all.   All work is honorable.

Warm wishes from the Whistelblower.














Sunday, August 27, 2017

Jury Blames Talcum Powder for Ovarian Cancer - No Evidence Needed!

I have written about talcum powder previously.  Indeed, I have not only opined on the slippery substance, but I am also a regular consumer of the product.  Talcum powder has become magic legal dust that brings forth zillions of dollars to those who have been attacked by the poisonous toxin. 

Just last year, I informed readers of $55 million and $72 million judgments to cancer victims who used powder against the manufacturer Johnson & Johnson.  Earlier this year a Missouri woman was awarded $110 in damages. 

Recently, a jury in California, where the cost of everything is stratospheric, ordered J & J to pay damages to a victim of ovarian cancer.   The jury clearly wanted to send the company and corporate America a monetary message that went beyond the pinprick judgements that were issued against J & J last year. 

Readers at this point are invited to consider what would constitute reasonable damages if it were proven true that the product caused the cancer and the company knew of this risk and did not provide adequate warning to the public.   Make your guess before reading on.

Here are some price comparisons to test your sanity

Private Gulfstream Jet                     $70 million
Penthouse in NYC’s Plaza Hotel    $40 million
Alexander Hamilton Autograph             $1,000
Bentley Automobile                            $230,000
100 meter Superyacht                    $275 million
California Jury Award                    $417 million

You may resume breathing now.  Of course, the plaintiff’s attorneys were able to string  a circuitous array of dots that connected talcum powder to cancer in front of a jury who was likely more sympathetic to a dying victim than to a megacorporation.  But, sympathy is not evidence and being a successful company does not define negligence.   


Few strands of GW's hair is a bargain at $22,800!

This mega-judgment is rendered beyond absurd when one accepts that there is no convincing and consistent scientific conclusion that talcum powder is the responsible agent.  The studies have largely demonstrated an association, which are not designed to determine cause and effect.

What should product manufacturers do?  Should every package include a boxed warning that the product can cause misery and death just to cover themselves?   Perhaps, not. This would only give customers anxiety, pain and suffering.  Guess what would happen next?

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?


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