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."



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