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?


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