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So many lawyers, so little time...

"The prospect of hanging focuses the mind wonderfully"--Samuel Johnson

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Location: Louisville, KY, United States

Gastroenterologist, cyclist, cellist, Christian, husband, father, grandfather.

Wednesday, February 22, 2006

March is Colon Cancer Awareness Month

(The following is an article being published in our local health and fitness magazine, with the tacit approval of my editor.)

Why should I care?
The risk of colon cancer goes steadily up once you hit fifty. Unless you've figured out how not to age at all as you get older, you better be aware of this disease's potential threat to you health. The disease does not care whether you are male or female, black or white. For it is the third most common type of cancer for both sexes, and altogether causes more deaths than either breast cancer or prostate cancer.

But hasn't everyone heard of Katie Couric, colon cancer, and colonoscopy?
Evidently not in Kentucky, We have the second lowest rate of colon cancer screening in the country. Sadly, Louisville/Jefferson County is bringing up the rear, having one of the highest rates of colon cancer deaths in Kentucky and the nation.

OK, I'm aware. Now what?
"Ask for IT!" as in Information and Testing. Our screening guidelines have changed dramatically over the last ten years, and they are not seared into our medical consciousness the way Pap smears and mammography are. Even conscientious physicians may overlook colorectal cancer screening in all their patients. As in all health-related issues, a knowledgeable patient is her own best advocate.

Give IT to me, then.
Because 90% of cases are diagnosed in patients over 50, we recommend that screening begin at that age. Studies have shown that ANY form of screening is better than no screening at all. The forms of screening include the following:
True colonoscopy.
Barium enema, preferably air-contrast.
Flexible sigmoidoscopy
Fecal occult blood testing
Less common forms include the following:
CT colography ("virtual colonoscopy")
Chromosome analysis of cells shed in the stool.
There are patients who should undergo testing at an earlier age. Patients with family histories of colon polyps or cancer should start their testing at the age of 40, or possibly even earlier. Patients with inflammatory bowel disease are often advised to begin screening earlier, too.

You make your living performing colonoscopy. Which test, by chance, do you recommend?
Colonoscopy, of course. It has major advantages over the other forms of screening. It is more accurate, in most hands, at detecting polyps and cancer than barium enema. It allows us to see the entire colon, instead just the third that is seen with sigmoidoscopy. It is more accurate than stool testing and, at least for now, virtual colonoscopy. It allows us to sedate patients, which is not routinely done for virtual colonoscopy. Most importantly, it allows us to spot and remove precancerous growths called polyps. In these cases we are actually preventing, not just detecting, colon cancer.

Sounds like a big hassle to me. And the clean-out for it doesn't seem inviting, either.
It is a hassle, but most folks only have to go through it only every ten years. It's not like getting yearly prostate checks or Pap smears, thank goodness! Every year we get cleverer with administering the clean-out. There are several different preparations you can take for colonoscopy. Discuss them with your doctor. Who knows, maybe some day we'llhave a prep that people actually enjoy.
The hassle is well worth it. Since 1985, coincident with the growth of colonoscopy, we have seen a 2% drop in colon cancer deaths each year, and nationally deaths from cancer are actually falling! Not all colon cancer deaths are preventable, but we think the vast majority of them are in patients who undergo proper testing.

Colonoscopy is expensive, isn't it?
The up-front costs can be a little daunting, but it is a whole lot cheaper than the costs of treating advanced colon cancer. It is so much cheaper that the Federal government is underwriting colonoscopy screening in Medicare beneficiaries.
In the long run it also saves the health insurance companies money. Recently I received a card from my health insurer reminding me that I was over 50 (thanks for the reminder!) and that I should be thinking about undergoing colonoscopy. This is proactive behavior on the part of the health insurer at its best.
By comparison, it is actually less expensive to save a life from colon cancer than it is to save a life from breast cancer.

You promise you'll sedate me for this?
We got more sedation than you have anxiety. I didn't feel a thing when I had mine, and I was glad I could check off colon cancer from my list of worries!

Sunday, February 19, 2006

About that death wish

Yesterday was a fine day, of a sort: 20 degrees F, 3 inches of snow on the ground, and gray, overcast skies. After struggling to get my morning rounds performed, I took my son's bike out to the local trail for my first ever snow ride. My wife had lobbied vigorously against this endeavor: "You'll kill yourself out there", she said matter of factly, and reminded me that the Fate of Western Civilization rested on whether I was able to emerge from the trails unscathed.

Taking my son's bike was a good idea. His has disc brakes, and besides looking cooler than V brakes, they work well regardless of how much ice and grunge builds up on the wheel rims. Yesterday there was a lot of ice and grunge, and salt, and even mud, I'm embarrassed to say. More about that soon.

Riding at noontime in overcast skies, I was surprised at the abrupt changes of trail conditions I would encounter. I loved the "frozen tundra", where the snow was hard-packed and made crunchy Rice Krispy sounds as you rode over it. The grip was firm and reliable, except for one spot were there was some mud just below the surface. Down I went, but it wasn't painful; it just left a huge mess on my clothes.

The trail would then change into the "snow-mosquito infested swamplands" which are the bane of all responsible mountain bikers. Riding in mud is irresponsible because it tears up the trails and accelerates erosion, and everytime someone does it, God kills a kitten out of frustration. I'd find my way to the nearest road as quickly as possible. I was not going to have some innocent kitten's death on my conscience.

Riding on a snowy trail is a rush. Riding on an icy road is not. Losing control on a mountain trail and plummeting hundreds of feet to my demise would be cool in it's own way. Falling on icy pavement and breaking a hip would only be very painful and very stupid. I'm riding the icy road trying to save the life of a kitten and I'm fearful of my own life the entire time. My fear is accentuated as I hear a sickening metallic crunch behind me. A van has skidded out of control on the icy road and taken out a road sign. Was it the sign that said "Road freezes because of global warming, and its Bush's fault"? I was too frightened to go back and check it out. That metallic crunch could have been my bike.

I got back on the trail and spent more time alternating between frozen tundra and swampland. I was able to work my way back to my starting place without rutting up the trail in too many places, although my bike (or rather, my son's) is now covered with multiple layers of snow, mud, and salt. It looks nasty. Did a kitten die at the hands of an Angry God on my account? I don't know. I do know that I felt great for the rest of the day, and fell into an Ambien-less sleep in a matter of minutes. I felt more alive this day than I had in a long time.

I will feel even more alive when my son sees what a mess I've left his bike in. At that moment I will face death, especially if I by chance messed up the rotors to his disc brakes. Pray for me, now and at the hour of my death.

Friday, February 17, 2006

Death's not my first choice but...

This is one of my favorite doctor jokes:
Q: Why do doctors go into psychiatry?

A: To get free advise.

Psychiatrists didn't find that joke very amusing 25 years ago, but now they're having the last laugh. Stress disorders, depression, ADD, ADHD, and general gloominess are so rampant in our culture that knowledge of psychopharmacology comes in handy. I know how to treat Crohns disease. I don't really know how to treat Hashimoto's thyroiditis anymore, and that doesn't bother me much. But I really wish I were a bit sharper on the treatment of lawyer-induced chronic depression (a recognized medical entity, by the way).

When I was younger I wanted to go into psychiatry, until I was seduced by the dark side of the Force, that aspect of medicine dominated by Pathways and Mechanisms, by Techniques and Procedures.

I enjoyed "fixing things" or at least sharing the illusion of it. Surgery and cardiology were a bit too intense so I opted for the more laid-back field of gastroenterology. It's been a good fit, and I'm glad I chose it. These days I've been ready for a change, and for a specialty that I never would have dreamed of being drawn to.

When I turned 40 I was chunky and sluggish and determined that I wouldn't be that way for much longer. Fueled with the energy that comes with Mid-Life Hypomania, I lost forty pounds, built up muscle, took up skiing and horseback riding, and subtracted 15 years from my physiology. I felt great.

When I turned 50 I was chunky and sluggish and determined that I wouldn't be that way for much longer. At 50 I had no more mid-life energy; I had "matured", which meant that I was just tired. What excited me the most was the prospect of catching a cat-nap. I'm 53 now, but I won't be for long, and the leaves that are green turn to brown, and I'm still chunky and sluggish and have reason to believe that I'll stay that way until I get chunkier and sluggishier and so on and so on until I die some day.

I'm not being morbid. That's just the way it is.

So I could use some free advise facing these end-of-life issues. For the first time in my life I wish I had gone into Oncology, because in facing death we face life. When we face total loss we realize which things we are carrying that are worth the weight, and which ones are not. If I knew as a fact that I had pancreatic cancer with metastasis to the liver, I would not be wondering if it were worth upgrading my TV to high-def and getting TiVo installed in my cable box. I would want to tell my wife and my daughters and my son how much I love them and how I wish I'd bother to tell them that a lot more that I ever had when I thought that I would live forever. I'd tell my friends that I consider them friends. I just assume they know that. I never come out and tell them.

Last week I was discussing with a family the outlook for a man with pancreatic cancer that had spread to the liver, and almost surely by sound of things to a few other places as well. On a physiological basis there is not a lot of good news to share; there is no good news to share, other than to discuss the advances that we've made lately in palliative care.

"But Doctor, is it right to take all hope away from him?"

Baring divine intervention, do we take away all hope by sharing with families that the 5 year survival rate for advanced pancreatic cancer is essentially 0?

What survival rate do any of us have? 40%? 80%? Last I checked the same fate awaits every single one of us. Our collective survival rate is 0. Have we no hope? Shall we delude ourselves and tell ourselves something different? Would we really want it to be different?

What hope does my patient have? He knows he's going to die, like all of us, but he knows that his time will come very soon. Does he have relationships that need to be mended? Does he have people that need to hear about his love for them? Does he need to reconcile himself to whatever his belief is concerning Eternity? Does he find comfort in the fact that his thirty year mortgage and his 1040 and his zero coupon bonds are no longer of any importance to him? Is there no hope in this?

"There's something to be said about having 'the big one' and getting it over with in a hurry", I hear people say all the time. I don't think so. I think I'd have too many regrets dying suddenly, if I were capable of having any regrets at all.

My career is being prolonged because I have the priviledge of telling the vast majority of the patients that I see that they do not have colon cancer, and that has become a great source of joy to me. I hope to be able to continue to deliver this good news to people for years to come. But it is with the unfortunate ones, the ones that I must share the unthinkable, the unhearable and the unimaginable, that I am learning the most about myself and my life.

Friday, February 10, 2006

Free advise and worth every penny

It was a mistake to drink that third cup of Starbucks.

I knew it as soon as the vile brown teeth-staining fluid sullied my lips. This week I have hovered in the nether-region between illness and good health, too tired and sullen to exercise but too healthy to have anyone or anything to blame for it. When I'm in that mood, a third cup of coffee is not in my best interest. Now I feel like I have two hundred rabid parakeets clawing and fluttering in my brain, threatening to explode out my sinuses at any moment.

The parakeet simile is overwrought, of course, but it is not soothing at all to walk into my office after a pleasant and tranquil morning at the endoscopy center and be faced with lots and lots of the usual: "Mr. Jones is furious that you said he drank too much", "Mr. Smith wants you to say its OK for him to skip his colonoscopy because he hasn't seen anymore bleeding for a while", "the Blessed Fields of Dreams insurance wants you to rewrite all your prescriptions to some other drug that they get for less this month", "a patient is suing somebody who hit her with a car and wants you to say that her irritable bowel syndrome is all the plaintiff's fault" and so on and so on.

As I said, that third cup was not wise. I drank it anyway because I have an addictive personality and I just couldn't help it, but I knew it was a mistake.

"Hey Doc, I know of a blogger you would really enjoy. She's brilliant, writes well, and has read every book in the English literature. She's a little to the left of center but I'm sure you'll enjoy her anyway", says a nurse at the endoscopy department. Fine then, I'll check it out. I need something to relax me a little.

The website is nothing more than tired recycled unimaginative Bush-bashing liberal tripe. There are two things that this world just doesn't need anymore of, yes, even three things: No more pseudo-elitist producing liberal tripe, no more pseudo-rednecks producing more conservative tripe, and no more foul cranky doctors kvetching to the world because he's tired, a little peevish, and overdosing on caffeine.

Now that I've cleared the air, let me offer some suggestions on what I think an enjoyable blog would include:

1) Straight party lines are BORING!!! Try to mix it up a little. That was what was so endearing about Hunter Thompson: he was a liberal who enjoyed a huge armory of weapons and loved to shoot animals and blow things up. Imagine, a liberal who is a gun nut, or a conservative who is terrified of them (such as myself). Good stuff.

2) Open yourself to the possibility that people who think or feel differently on things than you might actually have good reasons for doing so. Well-reasoned political writers of any stripe are in short supply, but they are out there. If you're a liberal, for example, make yourself read one David Brooks column a week. It won't hurt that much. Honest.

3) If you rant about how much you hate the hatemongers, it makes you look like a total idiot. Rethink your strategy.

4) Try poking some fun at yourself for a change. Never rag on someone with criticism that you couldn't possibly think would ever apply to you. Admit that you can be hypocritical, self-serving, mean-spirited, or just plain wrong. You'll feel better about yourself, and everyone else knows it anyway.

5) Never post when you are caffeine-toxic.

Sunday, February 05, 2006

The principle of paradoxical risk

One of our "throw-away" journals recently ran an article with this startling conclusion: 'defensive medicine' is a huge problem in America, resulting in an enormous economic drain on our healthcare system.

Practicing physicians have known this for years. Out of narrow self-interest, the trial lawyers have been misrepresenting the magnitude of this problem. If they gave two hoots and a holler about the welfare of patients, they would at least acknowledge that this problem exists and perhaps come up with some constructive suggestions on how to fix it. But they don't, and they won't.

There are many thoughtful reviews about this problem, and I won't burden the Thinking Public with yet another one. I will suggest that among the forces behind the Defensive Medicine Crisis is the Principle of Paradoxical Risk. I have no idea whether anyone else has described this. I've never read it, so I'm happy to take full credit for the concept.

If I see an 80 year old who is complaining about passing blood in the stool, there is a reasonable chance that the patient has colon cancer based on their age alone. If I blow the diagnosis, then Ill be liable for economic damages which are going to be limited to the extend that the patient's "earning potential" is likely limited. If I live in a state with some sort of limitation on "pain and suffering" damages, then my liability will be further limited unless the court can prove that I was willful and malicious in my malpractice, and I get nailed with punitive damages.

Will the threat of malpractice influence my behavior in this case? Of course not. I get paid to make the diagnosis of colon cancer, and, knowing the odds, I'm not about to pat a patient on the back and tell him to take some Preparation H. I'll schedule the colonoscopy.

How about a 60 year old with the some complaint? The patient is less likely to have colon cancer, but the economic damages will be higher, assuming that the patient is still working. The "cost" of blowing the diagnosis of colon cancer will be higher, although the risk of the patient having colon cancer is lower. Again, this isn't going to influence my decision-making. The right thing to do is to proceed with colonoscopy, and I get paid for doing the right thing.

But what about the 20 year old who presents with the same complaint? If I blow the diagnosis of colon cancer I'll have the Devil to pay. The plaintiff will claim 45 years of high economic productivity that I'll be denying him. Unless I live in a tort-reform state, the plaintiff will also parade a steady stream of friends and family who point out how a beautiful young life was snuffed out because of my negligence. I'd be thrilled to settle within the limits of my malpractice insurance. No one would be happy about this.

What are the odds of a 20 year old having colon cancer (I'm assuming the patient has no risk factors such as chronic colitis or a family history syndrome)? What are the odds of complications from colonoscopy vis-a-vis the risk of colon cancer? What is the cost-effectiveness of putting 20 year olds with rectal bleeding through the mill over what is almost always hemorrhoidal bleeding?

The Principle of Paradoxical Risk states that "the less likely a serious medical condition is, the more likely you are to get your butt sued off if you don't diagnosis it".

The Principle of Paradoxical Risk states that these questions have no relevance to the discussion. If you miss the diagnosis of colon cancer in a 20 year old, you will be savaged in every conceivable way. You'll have to look at yourself in the mirror every day realizing that you could have saved the life of a person younger than your own children. You'll be financially ruined. The ordeal of a malpractice suit would drag on for at least 4 to 5 years (plaintiff attorneys do this because it is in their financial best interest).

Fifteen years ago, a gastroenterologist who performed colonoscopy routinely on 20 year olds with rectal bleeding would have been accused of churning. Do you think they would be accused of it now? What would you do? Saying you would just retire from medicine because operating in such an evil atmosphere would take too high an emotional toll is an acceptable answer.