Serenity Prayer Can Ease Chronic Pain

One of the toughest parts of treating patients is managing their expectations.  We wish that everyone could enjoy a perfect recovery with complete healing, but the medical profession is imperfect and life is unfair.  Some folks cruise by decade after decade without a scratch, while others sag under the weight of chronic illnesses.   Accepting reasonable expectations can change the game for patients and their families.  If the patient’s expectations exceed what is possible, then the patient will never be satisfied and the dissatisfaction may assume a life of its own, which can torment with virulence equal to the disease.   Second and third opinions may be sought, which usually lead to more testing and frustration.  Learning to accept what is possible – though enormously challenging – creates a path toward leading a fuller and more satisfying life.   While I haven’t been burdened with a chronic disease, I do personally understand that acceptance of a situation opens a path toward healing. 

You have just experienced the joy and delight of a colonoscopy.   The physician approaches you afterwards to inform you of the results.  Which of the following  hypothetical responses would you prefer?

We found a lesion in the large intestine that we are very concerned about.  The biopsies will be available in 48 hours. 

The colonoscopy was completely normal.

Of course, I am not entirely serious here.  We all hope and pray for the second response.  Yet, often, when I reassure patients that their colons are pristine, many react with frustration and disappointment.  This usually occurs with patients who are suffering chronic abdominal pain and distress and are desperately seeking a concrete explanation for their symptoms.  They enter the colonoscopy suite with stratospheric expectations that my scope will crack the code of what has stymied other physicians for years.  These expectations are fueled when other doctors they have seen advised that their pain is clearly coming from their stomach and intestines.  So, when the CAT scans and ultrasounds and blood tests and emergency room visits are all non-diagnostic, they want to believe that the light of the colonoscope will illuminate the diagnosis.

The light of my scope is really quite limited.  It’s an accurate tool for many conditions, but is a clumsy diagnostician for chronic pain.  Of course, the pain is real.  But, our tools to identify its cause are often crude and inaccurate.  In some instances, of course, there may be an occult diagnosis that the physician has overlooked.  In most cases, however, the pain has no identifiable medical explanation. 

At some point, a patient with chronic, unexplained pain must veer away from the quest to find its cause and onto the journey of living as full a life as possible with the condition.  The choice may be ruling over the disease or being ruled by it. 

Blogging about this is easy and comfortable, particularly when your humble scrivener is not suffering chronic pain.  But I have seen patients who summon grit and moxie to stay in charge of their symptoms and their lives.  They might not reach the end zone in one play or two, but they are steadily moving the ball downfield.  Their efforts and successes are inspiring.  I hope I have learned something from them.

Life is unfair and unpredictable.  Which path do we choose when we are challenged?

God grant me the serenity 

to accept the things I cannot change; 

courage to change the things I can;

and wisdom to know the difference.

Medical Malpractice, Tort Reform and James Bond? Let Me Explain.

Sometimes, I feel like I belong in law enforcement.   There was a time in my life that I seriously considered a career where I would haul in the bad guys and make society a better place.   Of course, every American male youngster fantasized that he would one day drive the Aston Martin, get the girl, defuse the bomb, and sip on a martini that was shaken, not stirred.  I was no different.  I was 10 years old then when my pal Lewis and I were secret agents with the requisite weapons, invisible ink and secret codes.   At the risk of disclosing that I have a tincture of obsessive compulsiveness, I still retain the files of our secret organization.  While Lewis has expressed concern that these files in the wrong hands could threaten international order, I have reassured him that the enemies of mankind will be unable conquer our layers of sophisticated encryption.  At risk of being accused of hyperbole, Israeli and American intelligence agencies studied our secret files as a template for the Stuxnet worm.   

I have had many patients who are law enforcement professionals.  I respect them and the work they do.  I have had patients who served in the FBI, the Secret Service and all levels of local law enforcement. I feel a kinship with these folks.  Like a community gastroenterologist, much of what they do is routine.  We both endure endless paperwork that often seems to serve no useful function.  We both are exposed to extremes of the human condition.  We both get scared.  We both serve a public that is sometimes skeptical of our biases and motivations.  We both may need to make urgent decisions relying upon our training, experience and instincts.   We both deeply understand that sometimes the right decision leads to a dark result.

Last November in Cleveland, 2 people were killed by police after a harrowing high-speed chase.  It was a tragic finale that left many painful and raw questions.  Thirteen officers fired 137 rounds that killed two citizens who were ultimately found to be unarmed.  Understandably, there was outrage in the communities, and the matter continues to be under investigation.  As expected, the initial facts were murky and in dispute.  Anger and haste are poor catalysts to develop the truth. 

I have no opinion at this time if law enforcement personnel should have held their fire and pursued a non-lethal strategy of capturing these two individuals who were fleeing from them at high velocity.  A dispassionate investigation will determine this.

But, while it absolutely necessary to investigate this tragic episode, as a doctor, I am very sensitive about being judged after the fact by investigators who have endless manpower, resources, audio and video evidence and months of time to evaluate the propriety of a split second decision.   A catastrophic outcome is not evidence of negligence, despite the ease of reaching this conclusion, particularly by those who have been injured and their families.  In addition, a fair judgment on what transpired must consider the context of one who had to make an immediate decision to act.  If an investigation requires a 4 month inquiry involving dozens of professionals to conclude that an officer erred, could the policeman be expected to reach the same conclusion in 2 seconds in the field? 

When football referees review a call on the field, sometimes the call is reversed.  Of course, the review offers instant replay in slow motion at various angles, none of which were available to the official who first made the call.  Get the point?

None of us envies a cop who faces a situation where he must discharge his weapon.  Sure, there is training, but as every professional knows, one can’t train for every contingency.  This is not a board exam; this is real life with lethal consequences and no time to ponder the alternatives.   Was the suspect reaching for a weapon or an innocuous item?  I can’t imagine the lifelong trauma one would endure after killing another person, even if this was a necessary act.  I suspect it would be a greater trauma if a policeman didn’t pull the trigger when he should have, and missed the opportunity to save innocent lives. 

I was raised to respect law enforcement, and I do.   While their job is tougher than mine, I can personally relate to their profession.   We both serve and protect the public.  We both make decisions based on what we know at the time, which is often less than we want to know.  We agonize when something awful happens and wonder if we contributed to the outcome.

There’s something else that binds our professions.  We both are often judged retrospectively by those who weren’t there when we were blinded by white heat and couldn’t see then what later seems to be in such clear focus. 

We learn from our errors and misadventures.   As readers know, I believe that the negligent must be accountable for their actions and resultant consequences.  The process to determine this, however, must operate at the highest level of fairness and integrity.   Too often, this standard is not achieved or even reached for. 

And now, my thoughts wander back to Miss Moneypenny, ‘Q’, boat chases and ejector seats, when I contemplated a profession that I know now is better left to other others.

Is Colonoscopy the Best Colon Cancer Screening Test?

The medical arena, like society at large, is permeated with self-interest. This reality makes me very skeptical that comparative effectiveness research, which I support, will get airborne. In medicine, every heath care reform, new medicine, new medical device or revised medical guideline is at some constituency’s expense.  Recognizing and dismantling conflicts of interests is one of our greatest challenges and threats. 

When I was a gastroenterology fellow over 20 years, our department was active in new technologies to crush and dissolve gallstones and stones that had wandered from the gallbladder into the liver pipes. Millions of dollars of R & D were spent and the procedures were done in specialized centers in the U.S and abroad. The treatments were cumbersome and only modestly effective, but the treatments continued year after year. Then, laparoscopic cholecystectomy arrived, a new operation that could remove gallbladders with much less pain and recovery time. At that moment, the gallstone dissolving business dissolved. As endoscopic techniques improved, gastroenterologists could safely and easily remove stones from the liver pipes, which became the preferred method for accomplishing this objective.  These outcomes served the public good, but this is not always the case. .

New medical developments are often pursued for both marketing and medical reasons. Large medical institutions will spend mightily for the latest high-tech robotic laser shooting burger-flipping tumor ray gun, even if (especially if) the competitor across the street already has one. Here in Cleveland, I suspect we have a mind numbing duplication of medical services in a very tight geographic reason. Since availability correlates with usage, I surmise that we are a model of overtesting and overtreatment. I am not assigning blame. Indeed, I need to be reeducated as much as anyone since we all practice medicine in a culture of excess.

The prism that should be used to view new medical development is if it serves the greater good. Many folks, however, define the greater good to be any outcome that coincides with their own parochial concerns. Conversely, if a particularly group is threatened by a medical advance, then it will be alleged that the greater good will surely suffer.

To a gastroenterologist, 50 is a milestone year. This is the age that we pounce upon you to scour your colon to remove cancers-in-waiting. While we champion this test, and sincerely believe in its worth, it is not ideal. Here are some drawbacks.

• The pre-colonoscopy cathartic cocktail
• Anxiety
• Discomfort (no it’s not always painless)
• Cost
• Risk of complications
• High rate of negative results
• Loss of a day’s wages or personal enjoyment
• Need for a driver

What will gastroenterologists' reaction be when a better test threatens to retire our colonoscopes? Will we defend colonoscopy against a simple analysis of a person's stool which is just as effective? Will we claim that the research behind the new development is flawed? Gastroenterologists have successfully prevailed against CAT colonography, a competing test which examines the entire colon for polyps using a CAT scan. We have the edge in this duel since patients who pursue the CAT scan option must still take a vigorous laxative and, if polyps are discovered, they cannot be removed. Colonoscopy’s unrivaled advantage is that it can remove nearly all polyps discovered. It’s one stop shopping.  If radiologists perfect the technique of performing a CAT colonography without any required laxatives, then the scales may tip in their favor. 

The above vignette is not a futuristic hypothetical creation. I suspect that colonoscopy and CAT colonography will be properly forced out during my own career as colon cancer screening techniques. Colonoscopy will still be performed, but only when some kinder and gentler screening test indicates that an individual has a high probability of harboring polyps. It will no longer be wielded in a buckshot fashion.  The number of colonoscopies being performed will be decimated.

When that happens, it will not be good news for the Kirsch family. But, it will be greater good news for everyone else’s family.

Medical Quality: Myth or Science?

On the morning that I began this post, I read in our local newspaper that Tennessee is soon expected to have a law that would permit public school teachers to offer views on climate change and evolution that are counter to orthodox doctrine on these subjects.

No, I don’t think that creationism is science and it should not be disguised as such. Global warming, or climate change, however, is more nuanced. While it is inarguable that temperatures have been rising, it is not certain and to what extent human activities are responsible for this. Clearly, this issue has been contaminated by politically correct warriors and those who have an agenda against fossil fuel use. Science, like all scholarship, should be a pursuit of the truth, without a destination in sight. Believing or wanting to believe that man is turning the world’s heat up may sound plausible, but it may not be true.

Just because something sounds true and logical, doesn’t make it so. In addition, repeating an opinion like a mantra isn’t sufficient to confer legitimacy on a view. Zealots and partisans gainsay these inconvenient truths.

In the medical universe, much is presented as true, which may be either false or unproved. Consider how many established medical procedures and practices have no underlying science to buttress them. Consider the following examples and decide if you agree that each is a good idea that makes sense.  Do they sound right or are they truly sound?

• Patients should have regular physical examinations as an integral part of preventive medicine.
• Patients should undergo a CAT scan of the chest and abdomen at age 50 in order to detect any silent lesions that may be present, before they have an opportunity to grow and threaten the patient.
• Medical care is superior in large medical centers because physicians there have access to the best minds and technology.
• If you have fever and a cough, it’s best to begin antibiotics early before pneumonia can develop.
• Everyone should restrict their salt intake.
• Probiotics facilitate good digestion and should be part of a healthful diet.
• Placing stents in narrowed arteries helps patients live longer by allowing for increased blood flow.
• Cardiologists are more skilled at managing high blood pressure than general internists because of additional training and experience.
• A back x-ray is important to evaluate new back pain to exclude a fracture or other serious condition.
• Everyone should receive medication to lower their cholesterol levels, even if the levels are ‘normal’, as this will reduce risks of developing heart disease.
• Alternative and complementary medicine are safe and effective and should be incorporated into mainstream medical practice.
• Colonoscopy is a fun and exciting event that everyone should enjoy often.
• Medical bloggers who spew forth sarcasm need to be chastised and publicly humiliated.

So, let’s not label the backwoods Tennessee folks as backwards too quickly. Medicine and climate change have common elements. Both are suffused with politics, to their detriment. Remember Mammogate? Proponents of both make spirited claims without scientific basis, and attack principled dissenters as outlying heretics. Count me as one of them. Someone has to blow the whistle here.

I have something in common with climate change myself. When I read about myth masquerading as fact, I find that my own temperature starts rising.

Why Doctors Should Write

Sharpening a quill.

I am a physician who writes and I think that more of my colleagues should do so. Not because, we are such skilled wordsmiths or understand plot and characterization. We don’t. But, we confront the human condition every day. We see pain and struggle and fear and rebirth. We have much to share.

Beyond my own profession, I think everyone should write, because everyone has something important to say and to share.

To paraphrase an old Pete Seeger song, where has all the writing gone? Long time past seen. I long for longhand. I plead for paper. I pine for a pen.

Sadly, there has been steady erosion in the craft of writing, which I attribute to the ’new & improved’ forms of communication that have supplanted the written word. In addition, folks don’t simply regard writing as a worthy pursuit. Writing today means tweeting, emailing, texting and various other keyboard or voice activated techniques. This progress, like many other technological advances, has exacted a cost that may be difficult to measure, but is real and it matters. Today’s communications are either robotic directives, such as ‘board meeting cancelled’, or ‘you’r e fired’, or are coded messages that require cryptographers to decipher, such as TTYL and C U L8R!

Writing is intimate. It’s real and it’s raw. It angers and soothes.

I am so struck when I read letters written by ordinary folks in the 18th and 19th centuries, many without any formal education, who write with such grace and poignancy. Yes, they were somewhat flowery, but they conveyed warmth and feelings that can never be transmitted on Twitter. That they were written in longhand, only adds to their authenticity and intimacy.

Today, on those rare occasions when I receive a signed note in longhand, it is a singular experience. I picture the writer at his desk, pen in hand, composing a personal message just for me. The writer might be delighting in the scene that will follow, when I am holding the envelope and imagining its contents. After I open the letter, I hold it in my hands and absorb its words. Afterwards, I can stash it in a drawer to join with other companions that I have received in the past. Unlike the ethereal iCloud, the desk drawer is a real, live treasure chest that I can see and touch.

Master writers from the past created their opuses in long hand and in ink. How did they do it and get it right? Today, this would be an unfathomable task. Today, students and the rest of us write and research in a very different way, cutting and pasting our way to the final draft. I recall as a high school student learning that Hemingway would tell his wife that when he was staring out the window, he was working.

I love words and respect those who use them well. When I am writing, I often wrestle to find the precise word. Is the right word stubborn or tenacious? Bossy or assertive? Timid or reserved?

While we physicians confront an enormous dose of life experiences every day, every one of us has something worth writing about. I’m sure that on any given day, we could send someone a note of love, a letter of apology, a prayer for healing or a description of an experience that moved us.

Why don’t we do this? IMHO, I think I know why.

Whistleblower Holiday Cheer 2012!

Jingle Frost

Romney Lost

Obamacare is here

Brought to us by the Dems

With promises and fear.

Fiscal Cliff

Might be teriff!

Sailing through the air

Watching Boehner and the Pres

Pretending that they care.

Susan Rice

Playing Nice

Charging in reverse

Kissing up to GOP

Who now say she is worse.

Taxes Rise

Before your eyes

While the masses cheer

Will Medicare go on the block?

Let’s punt this 'til next year!

Obama plan

Kick the can

And claim that it's progress.

Who's to blame? You know his name.

George Bush has caused this mess!

Wishing You Joy and Peace!

Should Drug Reps be Mute on Off Label Drug Use?

Am I an apologist for the pharmaceutical companies?  I don’t think so, but others may disagree based on some sympathetic Whistleblower posts that have appeared in this blog.  It is without question that the drug companies have been demonized and portrayed as rapacious gangs of greed who seek profit over all.  Haven’t you come across the pejorative term, Big Pharma?  Linguistical note:  The adjective ‘Big’ means evil. Consider:

Big Oil

Big Government

Big Tobacco

Get the point?

 Big Elephant!

I’m not suggesting that the pharm guys and gals are all Eagle Scouts.  These companies operate to make money, just like car companies, the cosmetic industry, the airlines, banks and financial institutions, hospitals, manufacturers, the hospitality industry and retailers throughout the land. 

Here’s a bold Whistleblower pronouncement.

There is nothing evil about making money.

Of course, I want our drugs to be safe and effective.  We need the Food and Drug Administration (FDA) to provide oversight to protect the public interest.  I acknowledge that the industry needs external review and enforcement powers to keep the industry responsible and accountable.   There’s a reason that professional football games need referees.  Somehow, I don’t think that the honor system on the gridiron would be sufficient.  Players cannot police themselves.

But some of the constraints that drug companies face constitute unnecessary harassment that does not protect the public interest.   Pharmaceutical representatives, or drug reps, are prohibited from discussing ‘off label’ use of their drugs with physicians.  (Off label refers to a medicine being used for a purpose not officially approved by the FDA.) I’ve always felt that this edict was silly and stifled communication between physicians and reps.   Yes, some drug reps have aggressively marketed their products for off label use. GlaxoSmithKline and Johnson & Johnson paid handsomely for committing this offense. 

But, there is a clear difference between misleading promotion and honest communication.  If I question a drug rep about off label indications of a drug, a straightforward response  harms no one.  In fact, it may give me new knowledge that I could use to help a living and breathing patient.  Relax, patients.  I am well aware that pharm reps are sales folks and are not my primary resource for pharmaceutical education.  But good reps have deep knowledge of a very narrow medical issue – their products – and often know stuff that I don’t.   They may, for example, know of side effects of their medicines that are not widely known.

Keep in mind that most of the medicines that we physicians prescribe are off label, which is entirely proper and is acceptable to the FDA.  At present, the only folks in the country who can't discuss off label use of drugs with me are the reps.  

Recently, a federal appeals court set aside the conviction of a drug rep concluding that his marketing a drug for off label use was permissible under the freedom of speech doctrine. This ruling only applies to the region under the jurisdiction of the Second Circuit, but this will not be the last legal word on this issue.   More details appear in the New York Times piece that reported the decision.
 

Where should the line be set here?  I’m not sure, but I think the current FDA boundary is overly restrictive.   We need a dose of leniency and a tincture of common sense from Big FDA.