Wednesday, August 31, 2016
Should doctors lie for patients?
Even the most honest among us do not tell the truth all of the time. We are flawed human beings. We covet, we gossip, we steal, we lie and we stand idly by. You don't think you steal? Have you ever “borrowed” someone else's idea and represented it as your own?
A few weeks before I penned this, I was presented with 2 opportunities to lie in order to save a patients a few bucks. The first patient wanted a refill for her heartburn medicine, which she takes once daily. She asked if I would refill the medicine to take twice daily, so she could get double the supply for the same price. The second patient asked me to write a note that he was at risk for Hepatitis B so that he could get the vaccine for free. Writing the note would be easy, but claiming that he faced risk of Hepatitis B infection would require some prevarication.
I'll assume that Whistleblower readers know how I responded to the above 2 issues. However, many patients, and perhaps some physicians, who are so harassed by insurance companies and an uncaring medical bureaucracy are looking for any measure of relief when they can grab it. Many of them have risked rising blood pressures and panic attacks trying to talk common sense with insurance company “customer service” representatives, who have less medical training than hospital housekeepers, about getting their medications approved. I've been down that tortured road more times than I can count, and I feel their pain.
I routinely receive disability forms for patients who are seeking this benefit. I advocate zealously for every patient who has a legitimate claim for any benefit they are entitled to, often making the phone calls with the patient seated beside me. There are occasions; however, where no matter how hard I squint at the patient's chart, I just can't discern any medical evidence of a disability. Sometimes, I haven't seen the patient for years. (Often, disability forms are sent to every physician the patient has seen, so some of these physicians are not appropriate targets.)
Ethical quandaries can be tormenting. Let's say a patient is sent to me to evaluate constipation. A colonoscopy is scheduled. Since the procedure is diagnostic to evaluate his symptom, he will have to pay much more out of pocket than if the procedure is coded as a routine screening colonoscopy. Should I slightly adjust my coding to help the guy out?
It doesn't take much effort to rationalize siphoning a few bucks from insurance companies that many of us think deserve it. Somehow, we don't regard this theft as we would shoplifting or stealing a neighbor's TV.
I could state here that I respect medical insurance companies because of their unwavering devotion to protecting our health and serving the greater good. But, I'd be lying.
This post by Michael Kirsch, MD, FACP, appeared at MD Whistleblower. Dr. Kirsch is a full time practicing physician and writer who addresses the joys and challenges of medical practice, including controversies in the doctor-patient relationship, medical ethics and measuring medical quality. When he's not writing, he's performing colonoscopies.
Tuesday, August 30, 2016
danger of loss, harm, or failure.
Two weeks ago, I did something that I have never done in my entire medical career. Had I come close to it before? Yes. And is it something I probably should have done a few times in the past? Definitely.
So, what was it that happened, you ask? Well, I'll tell you. Um, yeah, I'll tell you even though, after 20 full years of not doing this, it's pretty hard to actually confess. I, I, sigh. Okay. I, I, I, whew.
I. Called. In. Sick. *squeezes eyes closed and turns head so you won't look at me*
It was the week of our interns' orientation in the hospital. Those first few days had gone just fine and at the end of the hustle-bustle of a particularly crazy afternoon, I popped by a casual eatery to grab a late lunch. And that part was fine, too.
It wasn't until about an hour and a half later that I began feeling this cramping sensation in my midsection. My tumbly became rumbly and before I knew it, I was in and out of the restroom doing what the Grady elders (and my daddy) refer to as “running off.” Somehow I managed to get a long enough window to get over to get the kids from their camps but admit that I sprinted from my car to the front door.
Thank goodness I did.
And you know? The running off part I could mostly deal with. I mean, I was hydrating and such and told myself that if there wasn't anything in my gut, the “running off” would eventually “run out.” But then came the nausea. And then came the vomiting.
And so. I pretty much spent the next several hours trying to decide which end of my body to aim at the commode. I tried all those home remedies like ginger ale and the non-home remedies, too, like antiemetics and antidiarrheals. But mostly, this was something that was just going to have to run its course. Literally.
I didn't catch a wink of sleep until about 4:30 that next morning. My alarm went off at 6 a.m. and I just sort of stared at it for a few beats before silencing it. Finally, I sat up on the end of the bed and prepared to treat the day like any other Thursday. I grabbed a t-shirt and a pair of sweats, pulled on some socks and shoes and prepared to walk Willow. And that was fine, too.
Well, I take that back. It actually would have been fine if I wasn't lightheaded from my certain dehydration and on the verge of vomiting the remains of the Canada Dry ginger ale and the electrolyte drink that I'd carefully sipped all night. After only two steps toward the door, I felt my belly churning again. But still, I grabbed the leash (and my tummy at the same time) and took Willow for what I am sure was the least gratifying dog walk ever.
You know? I didn't even think to wake Harry and ask him to take the dog out instead. Even though I knew he would have, I didn't. Then, when I came back inside, I stood staring at the medicine cabinet and trying to decide which concoction would allow me the best chance at not barfing all over a patient. Or passing out on them.
But somewhere in the middle of all of that, I spoke out loud even though no one but me was awake. “I really, really feel like shit.” Which, I am sure, is exactly what I said. Followed by a dry heave.
And right then and there, I had an ah hah moment. I recalled all of the times I've told countless residents that self-care is essential. Even though, particularly when it has come to personal illness, I've never given my health priority over going to work.
It dawned on me that if I were advising any of my students or residents, I would tell them to immediately contact a supervisor in order to afford that supervisor as much time as possible to cover the clinical duties. And then I'd tell them to drink, drink, drink fluids like crazy and get in bed under the covers and get some legit rest. And/or seek medical attention if it is even more serious.
But for myself? Chile please.
So with my dog at my feet wagging his tail and me hunched over the kitchen sink on one elbow out of fear of projectile vomit, I made up my mind to do the unthinkable. Yes. I decided to call in sick.
Um, because I was. Sick, that is.
Now. I tried as hard as I could to recall a time ever in my career that I'd done that but came up with nothing. And I think I came up with nothing because that adequately represents how many times I've decided to stay in my household infirmary versus crappily do my job while ill. And how many times I acknowledged that I was too unwell to work.
I blame jeopardy. Confused? Okay. Let me explain.
At nearly every residency training program, there is this back up schedule that is designed precisely for moments such as these. And you know? Nearly every residency training program calls it by the same name: JEOPARDY.
So when one is sick, they call the chief resident or schedulers or whomever, and that individual refers to the “jeopardy schedule” and notifies some unlucky soul who, up until that moment, was basking in an awesomely easy assignment. Only to be thrust into the firing line of some essential patient care situation such as the intensive care unit, hospital service, or something else even more hellacious. And yeah, it's exactly as sucky as it sounds when you get called.
Similar to, say, jury duty, everyone knows that the jeopardy schedule is everybody's necessary civic duty. That is, in the resident community. But, just like jury duty, it isn't one of those things anybody is particularly pumped up about getting notified about. But physician jeopardy is more complicated than that.
When I was a resident, we had this longstanding culture of bravado when it came to toughing it out through illness on the job. And I can't say that it was because our program leadership wasn't supportive of our personal needs. It was just this thing that sort of happened, you know? Most of the time they had no idea.
Well, I take that back. They were supportive when a person actually endorsed being ill as a reason to call off. But because they came up in the same system, I can't ever remember anyone insisting that someone leave back then. Go lie down for a few moments? Sure. But full on leave and cause another resident to be called in? Never.
Oh, and before I go further, I will say that there is always this teeny, tiny subset of individuals that call jeopardy 200% more than anyone else in their entire program. Most notable was this girl who had taken 2 Benadryl on accident and called in because she was afraid she'd be drowsy. (Me countering her with the half life of Benadryl, which she'd consumed 4 hours before, didn't seem to make a difference.)
Anyways. The vast majority of my resident colleagues worked when ill. Furthermore, there was this esprit de corps between us that caused us to rally around the sick guy and fill in the gaps. (Forget the fact that everyone was getting exposed to whatever illness the person had.)
A few times stand out in particular. One was my junior year when I was taking call in the cardiac care unit (CCU.) I came down with fever, chills and a terrible headache. My neck was tight and I had some nausea and diarrhea, too. It was the summer and I had just come off of the pediatric inpatient service where kids with aseptic meningitis from enteroviruses was rampant. I even had a tell-tale viral exanthem (rash) to go with my constellation of symptoms. And you know? I was 99.9% sure that viral meningitis was exactly what was going on with me.
Maybe even surer than that.
I called one of my classmates (who was also on call) and asked him to come examine me in the nurses station which he did. “Dude. You probably got viral meninge. You gonna go to the ER and let a second month intern do a spinal tap on you?” He bit into the room temperature honey bun he was eating and laughed at his own joke.
“No way, dude. Did you see my rash?” I asked while pulling up my sleeve.
“Cool,” he replied. “So what are you gonna do?”
“I think if I take some Motrin, I can make it through the night.”
“Yeah, probably so.”
And I am not kidding you. This is what happened. I took the call, fever, stiff neck and all.
Super stupid. Especially since it could have been something far more serious.
That same friend called me the following year (when we were both on call again) to check him out in a call room. He'd developed some shaking chills and a nasty, rattly cough rather suddenly. When I got there, he was breathing super-fast. “Dude! Holy shit. You look like you're about to code.”
“I feel like I'm about to code.”
I listened to his lungs. “Yikes. You've got signs of consolidation. This looks like a bad pneumonia. And that history, man! You might have pneumococcus, I think.”
“Hmmm. Cool. Think I can tough it out?”
“You're breathing pretty fast, bud. Let's go to the PICU nurses station and pop a pulse oximiter on you to see if you're hypoxic.” Which is exactly what we did.
Guess what his oxygen saturation was? 82% (96-100% is normal.) Craziness.
Let me tell you. This guy? He looked sick-sick. It was NOT a soft call. At all. That said, I am convinced that were it not for the whole needing oxygen thing, he would have slugged it out through that call with his pneumonia.
Would you believe that he got admitted to the hospital that very night? And you know? We were so entrenched in that culture that I can remember like yesterday cracking jokes in his room about him spreading TB to the interns and telling him that I was totally going to present him in morning report the next day.
Which he found funny, too. That is, when he wasn't nearly about to code.
I blame this word “jeopardy.” The actual definition means “danger of loss, harm or failure.” I can't think of anyone who has ever wanted to be the one responsible for putting someone in that situation--that is, one involving jeopardy. Especially another overtired resident who finally, finally, finally is on a lighter work assignment.
But see, that word just underscores the culture. It sounds heinous, punitive even. And to tap into it literally puts another person in peril, if you follow the definition. And I think that's a part of the problem, frankly.
The one time I called jeopardy as a resident was when my father had a massive heart attack requiring emergency surgery. And you know what? I actually took call all night before taking a flight out, now that I think about it. We also have a jeopardy schedule (also called “jeopardy”) in my current faculty position and you know what? The one time I called jeopardy with this group then was on November 15, 2012--the night my sister Deanna passed away.
So yeah. I am reflecting on all of this and realizing that doctors who neglect themselves really aren't the best physicians at all. Coming to work while truly ill puts patients in danger, can make things worse and it probably increases the chance of an error happening.
Now. Do I think folks should be calling off for sniffles or allergies? No. Do I think taking two benadryl should allow a rain delay at best but not a full on call off? Damn right. But do I believe that a vomiting, diarrhea-ing, teeth-chattering person should have another able physician working in their place? Definitely.
If you ask me (though no one did) the first step is changing the name. Instead of calling it “JEOPARDY” it might be better to refer to it as “FAMLY EMERGENCY/ILLNESS PATIENT CARE BACK UP.” This way, those who need it will understand when it is to be called. And those who get called will feel okay with being called in.
We could even call it “FEIBU” (pronouced FAY-BOO?) for short. As a reminder that this is for FAMILY EMERGENCIES and ILLNESS when back up is needed. And that FAMILY EMERGENCIES and ILLNESS happen and aren't a sign of weakness at all.
Oh, and the times that folks get pulled in because of human scheduling glitches NOT due to the needs of a colleague dealing with a FAMILY EMERGENCY or ILLNESS? Well. Keep right on calling those times ”jeopardy.”
So yeah. I acknowledged that I was ill and called off the other day. My colleague Stacie S. was great and made sure I didn't have to feel guilty. And my other colleague Alanna S. was super kind about picking up my slack in the resident clinic that morning. And you know? I think if my patients knew of my decision, they would have appreciated my choice to call off, too.
And so. I drank fluids and rested in my bed all day. That photo is proof that I was exactly where I was supposed to be, too. I went through a whole lot of hand sanitizer and considered going to get a bolus of IV fluids at one point. But the next morning, I felt a thousand percent better which taught me a mighty lesson.
And you know the best part? Not a single patient was harmed or put in jeopardy, thanks to my decision to first put the oxygen on myself.
Kimberly Manning, MD, FACP, FAAP is an associate professor of medicine at Emory University School of Medicine in Atlanta, Georgia where she teaches medical students and residents at Grady Hospital. This post is adapted from Reflections of a Grady Doctor, Dr. Manning’s blog about teaching, learning, caring and growing in medicine and life. It has been adapted and reprinted with permission. Identifying information has been changed to protect individuals’ privacy.
Monday, August 29, 2016
The yearly physical
“I'm going to the doctor next week for my yearly physical.”
So normal. Of course you are. Everyone should do that.
But the concept of a yearly examination of one's whole body to see if everything checks out fine is a relatively new invention and whether or not it is necessary is a very controversial question.
I just read an article by Abraham Verghese, an internist and champion of physical diagnosis, professor at Stanford University, and inspired writer, about the history of the physical exam. The idea that physicians could know more about a person than he or she could know about him or herself has only gained traction in the last century and comes partly from the invention of gadgets such as the stethoscope, the reflex hammer and the blood pressure cuff which reveal truths only to those of us skilled in their use. Enthusiasm for these has waned a bit as we have become enamored of our ability to see the shadows made by bones and such during an onslaught of electrons (X-rays), or the ability to check the levels of molecules and minerals in the fluids of our bodies, among other technological miracles. This evolution which takes us away from the bedside has also made us less confident in and also less dependent on the information we get by physically examining our patients.
We love what we can measure and correlate, and the physical exam is part of that process. If we can feel an enlarged spleen or liver, that is correlated with certain disease states, but certainly not always. If we can feel lumps in the breasts, testicles or thyroid, there may be something life threatening going on. Or not.
As doctors, we are trained in the nuances of the physical exam. I learned how to examine every orifice and surface, looking for specific abnormalities, and then developed skills over many years in understanding the wide variation in normal people. My physical exam is a conversation with my patient's body which happens simultaneously with a verbal conversation, which in itself is a kind of physical examination. How a person speaks, what interests them, how they follow the conversation are part of the neurological and psychiatric examination. As the physical exam unfolds, my understanding of a patient and my relationship with him or her deepens.
Does a physical exam save lives? I'm not sure. The definitive study will never be done. Only a small subset of what we do at the time of a physical exam has been rigorously studied and found to be of benefit. What a physical exam should entail has never been adequately worked out and there is no consensus. A pelvic and rectal exam, synonymous for some people with a “complete physical” have not been shown to have value in a patient with no symptoms in those areas. These and other parts of a “routine physical” may lead to overdiagnosis: finding something wrong that leads to more testing or treatment that does not improve or lengthen life. Nevertheless, it seems likely that a physical exam, done well and mindfully, is substantially valuable.
If it is valuable, shouldn't we all be getting one, yearly at least? Not necessarily. Plenty of people are healthy and will remain healthy without a doctor doing anything at all to them. “Health checks” were studied by the Cochrane Collaboration and found not to improve morbidity or mortality. There are a few things that would be good to check if you are feeling healthy, just to make sure all is well, though. It would be good to measure blood pressure or screen for HIV or hepatitis C for people at risk. If a patient somehow hasn't heard that it is unhealthy to smoke and be inactive and morbidly obese, ride a motorcycle without a helmet or drink and drive, it may make sense to impart this wisdom.
Medicare does not cover a general physical in the sense that most people think of it. What it does cover is a “Welcome to Medicare Physical” right after becoming insured under Medicare, which involves some screening that is important for determining risks and needs, and a yearly “Wellness Visit” which involves only vital signs and some screening tests along with advice on what is presently being recommended, stuff like mammograms, pap smears and colonoscopies. Patients are often put off by this because they don't like scripted interactions with their doctors, and doctors are put off by it because we have usually not memorized the script and some of us are not sure we agree with it.
Is a physical exam a good idea then? And should it be performed yearly on everyone? I, personally, would prefer that I have a chance to have unstructured time to physically examine and interview my patients yearly, in other words to do a physical. I would like them also to get information about what the evidence says about various screening tests and I would like that to be easily accessible in the medical record, but I don't necessarily feel strongly about being the person to offer that information. Perhaps a nurse or a health educator could do that better. I recognize that insurance companies may not cover a complete exam for a person who is healthy. For this reason, a physical exam may need to be scheduled as a prolonged visit to discuss multiple health issues. Taken as a whole, and not because it is based in scientific evidence, I favor the physical exam. I also would completely forgive anyone who preferred to skip it.
Janice Boughton, MD, ACP Member, practiced in the Seattle area for four years and in rural Idaho for 17 years before deciding to take a few years off to see more places, learn more about medicine and increase her knowledge base and perspective by practicing hospital and primary care medicine as a locum tenens physician. She lives in Idaho when not traveling. Disturbed by various aspects of the practice of medicine that make no sense and concerned about the cost of providing health care to every American, she blogs at Why is American Health Care So Expensive?, where this post originally appeared.
Friday, August 26, 2016
Who decides if medical marijuana is safe and effective?
Medical marijuana is a smokin’ hot issue in Ohio. Marijuana enthusiasts targeted our state constitution again this year with another amendment attempt, which failed. Instead, our legislature passed House Bill 523, which will legalize medical marijuana use.
As a physician, with some training and experience in prescribing medicines to patients, these marijuana machinations are medical madness. Is this how we want to bring new medicines to market?
I think it is absurd that a specific medical treatment—or any medical treatment—should become a constitutional issue. Do we want to establish a constitutional right to a specific medicine? Why stop at marijuana? Why not start circulating petitions for constitutional amendments for screening colonoscopies, mammographies, and MRIs for back pain? Patients with chronic lumbar disk issues have rights too!
The Ohio bill specifies an array of medical conditions that could be treated with marijuana, including AIDS, hepatitis C, inflammatory bowel disease, Parkinson's disease, post-traumatic stress disorder, and many other illnesses. Is it the legislature's responsibility to decide that a medicine should be approved for a medical illness? Do legislators have medical expertise? Do we want the state's Senate or House weighing in on approving a new chemotherapy agent or artificial hip?
Might I suggest with just a tincture of cynicism that medical marijuana mania has become a mite politicized? Do we want folks who stand to make money or enhance their political power from a new medicine and who have no medical expertise to be the ones with a major role in approving its use? Are cannabis con artists using a political pathway because they fear that the medical avenue will less hospitable to their objective?
Once marijuana becomes a legal product, an inevitable outcome, will enthusiasts for its medical use support vigorous testing of its therapeutic value?
I am deeply skeptical that the medical claims of medical marijuana adherents are supported by persuasive medical evidence. I remain open, however, to submitting marijuana to the same Food and Drug Administration (FDA) testing that all new medicines are subjected to. Let the scientific method with appropriate clinical studies and peer review judge the product for safety and efficacy. If approved, then the public and the medical profession can be confident that the approval was on the basis of science and not smoke. Shouldn't those who champion medical marijuana use demand this level of independent scrutiny? If not, then why not?
Yes, I have heard powerful individual vignettes describing great benefits of medical marijuana. Every physician has similar anecdotes of patients who have achieved significant benefits from unconventional and unapproved medical treatments. But, anecdotes are not science. If medical marijuana is the healing elixir its proponents promise, then prove it.
Let our politicians do what they do well, whatever that is, and leave medicine to the professionals.
This post by Michael Kirsch, MD, FACP, appeared at MD Whistleblower. Dr. Kirsch is a full time practicing physician and writer who addresses the joys and challenges of medical practice, including controversies in the doctor-patient relationship, medical ethics and measuring medical quality. When he's not writing, he's performing colonoscopies.
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Why is American Health Care So Expensive?
Janice Boughton, MD, FACP, practiced internal medicine for 20 years before adopting a career in hospital and primary care medicine as a locum tenens physician. She lives in Idaho when not traveling.
World's Best Site
Daniel Ginsberg, MD, FACP, is an internal medicine physician who has avidly applied computers to medicine since 1986, when he first wrote medically oriented computer programs. He is in practice in Tacoma, Washington.
Other blogs of note:
American Journal of
Also known as the Green Journal, the American Journal of Medicine publishes original clinical articles of interest to physicians in internal medicine and its subspecialities, both in academia and community-based practice.
A collaborative medical blog started by Neil Shapiro, MD, ACP Member, associate program director at New York University Medical Center's internal medicine residency program. Faculty, residents and students contribute case studies, mystery quizzes, news, commentary and more.
Michael Benjamin, MD, ACP member, doesn't accept industry money so he can create an independent, clinician-reviewed space on the Internet for physicians to report and comment on the medical news of the day.
The Public Library of Science's open access materials include a blog.
One of the most popular anonymous blogs written by an emergency room physician.