Why Doctors Don’t Like to Send You Test Results.

 Recently I  read an article in the NY Times by Elisabeth Rosenthal. She’s the same author of the enlightening article “My doctor charged me $117,000 and all I got was this lousy hospital gown” That may not have been the exact title of the article.

Following that article she wrote a follow-up about the long and difficult ordeal it was to obtain medical records for the original article,  and how silly this seems in this modern technology age. Indeed, if Netflix can beam movies directly to your google glasses, why wouldn’t healthcare providers and facilities be able get  them to you nearly as quickly.

In this she asks a profound and important question that requires a nuanced, intelligent, well researched answer. This she did not not provide.  Instead she, in my opinion,  callously and cynically took the low road in positing that physicians are money grubbing, greedy bastards who hoard the medical records of their patients in order to keep them coming back. Furthermore, she states, we do so while hiding behind a feigned wall of privacy concerns.

Ms. Rosenthal  makes these bold statements on the basis that they must be factual because a Harvard Law professor told her so.

And who knows more about medicine than lawyers, right?

I can’t speak for all physicians, but I do know that in every profession there are bad, greedy people who do things for the wrong reasons. I also know that most of the physicians I know don’t wake up in the morning thinking about how they can make money by not giving people their test results. And while transparency is a good thing, simply giving results to patients without any context can be fraught with risk.

I have seen cases where patients have gotten their test results directly and lead to unnecessary tests. One individual had benign lymph node enlargements, which were confirmed by a biopsy. However  the person had a follow up scan ordered by another physician, which was interpreted by a different radiologist  who interpreted the follow up scan as “malignancy can not be excluded”.  They eventually went to another physician and demanded another biopsy which was unnecessary, and of course, still benign.

Beyond the practical argument for not directly providing people with their medical test results there are financial reasons as well. And while some may refer to this as greed, remember that physicians are businesses, who expect fair or even less than fair payment for rendered services. While there are a few insurance companies who will pay a physician for their time in making phone calls to their patients, the vast majority (including Medicare) reimburse physicians on a “fee for service” basis. Thus they will only pay for face to face services on insured patients.  In effect, by relaying results over the phone, I would not only be providing a free service, I would in fact be coming out behind. This is because of the fact that in the time it takes me give out sage medical advice for free, I could have been seeing another patient.

If and when test results are to be provided to patients, it’s important that they be provided in the proper context. Test results should be discussed before they are ordered so that patients know what to expect. In my practice simple blood test results can be viewed by patients through an electronic portal. If somebody wants their entire medical history at my practice, this can usually be provided to them within 1-2 business days.

While providing routine blood work tests don’t require much context, other test results are more complicated. How I handle biopsy and scan results is a different process that has evolved over time. Most people who have just been diagnosed with lung cancer, for example need to have a face to face conversation. Following the news of a new diagnosis of lung cancer  there are tears, anger, and questions. What’s the next step? Chemo? Radiation? Surgery? Am I going to die? This takes the time and skill of a practitioner who knows and understands not just the science of the diagnosis, but an understanding of how to navigate the complicated medical maze that comes afterwards.

In her article Ms. Rosenthal refers to the case of a man who had to return  to their doctors office to get results of an MRI which turned out to be negative (apparently the good news that he did not need surgery did not offset the anger at having to pay for another office visit)

If I were to take this approach I would then be calling all people with negative biopsies. It wouldn’t be long before people found out that no call from the doctor  means that  something really really bad is happening.  It is simply more expedient to say that any testing with  potentially far reaching implications (like surgery) should come in for a follow up visit. This is one of the the reasons why patients with certain medical tests are asked to come in for results, and this is what I try to explain to them when I ask the question of why tests simply can not be sent to them.

That’s not to say that people don’t try to circumvent the system. After explaining my policy to a patient who was undergoing a lung  biopsy, her family called and demanded the results without an office visit. They finally called their primary physician’s office and found a sympathetic receptionist who agreed to forward a copy of a “lung biopsy” report. They were relieved to find that the biopsy report showed benign tissue.

She did not come in for her office follow up with me, which was concerning, because while one of her lung biopsy samples was negative, there were other parts of the procedure which the pathologist took longer to report.

I called the family and spoke with the daughter and family and explained how sorry I was that they had received results which were incomplete. Their mother did indeed  have cancer. She yelled in disbelief “but I got the results, they were negative! How can you now tell me that she has cancer?” I explained that the pathologist wanted to perform additional stains and cell typing on other samples that we took. This meant that these results took longer to report than the initial tissue results which were negative.  Her disbelief turned to sorrow and shock, as it often does when one learns of this diagnosis. She began to cry, as I heard other family members  who were listening around the room on speaker do the same.

Transparency is good, and as both a  purveyor of medical technology and as a preacher of the merits of social media, I look forward to the increasing openness of medical information. But there are lots of ways to save money, lots of things to cheap out on, and lots of middlemen that can be removed from medicine. Your doctor is not one of them.

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Doctors’ Prescription to Reduce Gun Violence

Like a lot of people, I get pretty numbed to gun violence on television. I stopped watching the local news because all they seem to show is news about shootings. The general public’s perception about gun violence is that it’s always somebody else, that the person  who was shot had somehow been involved in crime. The numbness we feel to gun violence often ends for most of us when things hit close to home, when you or someone you know is affected.

That happened for me 15 years ago,  as I was off in medical school in another country. I got a call that a childhood friend had been killed, shot in the head while driving to his job in Danbury, Connecticut. We had been best friends since the moment we met in first grade at St. Rose elementary school in Newtown. We were buddies through grade school, his house was my first sleepover. He taught me some of his karate moves. But while he probably could have beat up any of us, he never fought with anyone except for the time some kid in class started calling me the “N” word.  We remained best friends until I switched schools in 6th grade. After I heard the news, I was immediately ashamed that I had not really kept in touch with him since high school. There was no known motive for Mark’s shooting, his life and everything he would have been was just erased from the earth, without reason. To this day, his crime has not been solved.

Things rang close to home again more recently, as I was making rounds in the hospital. I was aghast to see, on a patient’s television screen, an aerial view of people running out of my hometown’s other elementary school, Sandy Hook elementary, which my brothers and sister had attended years ago. Continue reading

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Stem Cells and COPD: What You Need to Know.

I enjoy fielding questions from patients. Yes, I sense you’re rolling your eyes, but really, anything that I can answer that helps keep them out of the hospital is, I feel, time well spent. Recently though,  I’ve been fielding a number of questions that have me concerned. These questions often have a leading tenor about them like, “are you using stem cells for COPD yet?” The questions imply that stem cells are the de rigeur treatment for COPD. Now I may not be at the leading edge of any fashion, but being unfashionable in my treatment regimens? Never!

I can’t blame anyone for wanting to seek out treatments for COPD. It is after all, a leading cause of death and illness in the U.S. And it’s widely regarded that the changes caused by COPD/emphysema in the lungs are permanent. While there are now several different treatment options for emphysema/COPD, very few can prolong life. So if I had a family member with emphysema, I might naturally seek out treatments for COPD that go beyond the usual treatments, and with all the hype surrounding stem cells, why not take a look?

What people find when they google “stem cells and COPD” is in a word, distressing. It’s a fantasy world full of promises of health, healing, and better breathing. Equally distressing are the things that people who visit these sites aren’t recognizing: the greed, lies, lack of ethics, illusions, and misleading claims. Continue reading

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Top 5 Ways That Television is Ruining Your Sleep.

As a sleep physician, I spend a lot of time educating patients about what sleep is and how it works. Sleep, as I often explain, is not simply the lack of being awake; anymore than landing a plane is simply the lack of flying. It’s becoming increasingly understood that sleep is an actively generated state, created by a series of neuro-hormonal changes which work in concert to nudge the brain into the sleep state. To stretch the plane analogy further, if being asleep were like the plane being on the ground, then falling asleep is like the act of landing the plane. And just like when you land a plane, there are a lot of variables that are involved. There are numerous events that must happen in succession, each affecting and triggering other events which ultimately induce the brain to sleep. A recent study demonstrates just how watching too much television can wreak havoc in this delicate process. Here’s just a few of the ways that television can ruin your sleep.

     5. Watching television makes you go to bed later.

Television watching has steadily increased in our society, and its migration into our bedrooms marked a time when it began to disrupt our collective sleep and sleep habits. The most obvious effect that this might have is the most simple; we stay up later watching a program that has our attention. This few minutes a night may seem innocent enough. But our brains have a pre-determined amount of sleep they need to function well. When we miss that sleep we build up a “sleep debt” that can make us tired all of the time. Even if we catch up on a bit of sleep the next day, unless that sleep debt is paid back, the brain will still be fatigued.

     4. Watching television alters your brain’s bedtime habits. Continue reading

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The Shocking Truth Behind “Shocking” Healthcare Social Media Statistics

As a regular follower of social media, I am keenly aware of changes in the healthcare landscape as it relates to social media. While there’s much talk about the impact of social media in healthcare, most of the action sits on the consumer side of the equation. Much of the medical world has to yet to tap into its potential. For most healthcare providers social media engagement amounts to little more than watching as others dip their feet, testing  the waters. A few watch as they anticipate their own entry into the arena. Still many others watch with the expectation that the water would soon become bloody.

So its with a burlap full  of salt that I read various healthcare social media stats promulgated in various infographics, twitter feeds, and blog posts celebrating Medicine 2.0 powered by social media. Collectively they hash and rehash a series of surprising statistics that aren’t exactly bogus, but aren’t exactly completely factual either.

A recent one caught my eye with the claim was that “53% of physicians practices have a facebook page”. This was curious to me, because as I read this in the physician lounge and  took my own poll, the results was much closer to 5% than 50%. Continue reading

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Top 5 CPAP Travel Tips from a Sleep Doctor and CPAP User.

Sleep Apnea is a condition that aflicts millions of people.  There are 2 types of sleep apnea, central, and obstructive. Obstructive is by far the most common, and is usually what is referred to when people talk about “sleep apnea”. Obstructive sleep apnea occurs when, during sleep, the airway passages in the throat close and block the movement of air. Common symptoms are snoring, gasping during sleep, sleepiness during the day, and the overall feeling that your sleep was not restful. While we all may have a laugh recalling that uncle or grandpa that was “sawing logs” all night when they slept over, the truth is that sleep apnea can have profound negative effects on overall health. Sleep apnea has been linked with stroke, cardiovascular disease, hypertension, and is an important contributor to deaths and injuries due to traffic accidents. The most common and effective treatment for sleep apnea is the use of a CPAP (Continuous Positive Airway Pressure) device. As a sleep physician, and a CPAP user myself I know the importance of using your CPAP whenever you sleep, that includes during travel.

Whether I’m travelling across a state line or an equatorial line, whether the destination is medical education, or a mediterranean beach, my CPAP is along for the ride. Because of this, I’ve also run into pretty  much every complication, problem, pitfall, morass, and quagmire that you can have when travelling with your CPAP. Thus I present to you, gleaned from both my experiences and those of my patients, my Top 5 tips for travelling with your CPAP.

  1. Bring Your CPAP With You!

This would seem obvious, but it’s not. Alot of people see their CPAP as an assistive  device which they only need to use when they need it. But they really need to look at it for what it is: therapy. You take your hypertension and diabetes medicines with you when you travel, think of your CPAP the same way. Besides, if you’re travelling for business, you need to be sharp and focused. If you’re travelling for pleasure, well who wants to spend their hard earned vacation being tired and irritable? CPAP will help you get the most out your travels! Continue reading

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Me and My A.E.D.

“Everyone should have BLS training. . . we’ll all be better off because of it”     -Me.

I arrived at my designated gate at Chicago’s O’Hare Airport.  The run there kept the adrenaline level up in my system, though the hubbub was now well behind. I pulled the crumpled boarding pass out of my pocket as I caught my breath. No that’s a hotel receipt. Check the other pocket, there it is, Zone 3, that can’t be that bad; I thought,  there’s gotta be, what maybe 6 or 7 zones, right? “Welcome aboard American Airlines flight to Flint, Michigan” the gate attendant announced. We welcome our platinum medallion, gold medallion, silver medallion, bronze high-flyers, copper star club, as well as plastic fantastic, and purple star members, followed by zones one and two” The last of the passengers was already through the jetway. “Now boarding zone three, welcome aboard”.

After handing over my crumpled boarding pass for scanning, I made my  down the jetway and onto what appeared to be a small but fairly packed little jet. Passengers on each side of the aisle eyed me as I walked past, a few noticed that my jeans were soaked from the knees down. Some caught the odor that  trailed behind, a light of recognition igniting in their eyes as they realized what it was. Does he really smell like that? Is he the one that’s dragging that awful scent through this cabin?

6 hours earlier things had been going very differently for me. My colleagues and I had just given a well received talk at the annual Chest convention. I had reconnected with old friends that I hadn’t seen since training.  I had just personally  thanked Kevin Pho (of KevinMD fame) in the hotel coffee shop for giving our keynote address and getting our membership fired up about the future of medicine and social media. It was with this sense of excitement and renewed enthusiasm that I boarded my plane to catch a connection at O’Hare.

I also distinctly recall that, at the time, my pants were absolutely one-hundred percent completely dry. Continue reading

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Happy New Year from Caduceusblog!

Don’t worry, Caduceusblog is still here! I thought it best to take break through the rigmarole that was ABIM recertification.  I decided to extend my break through Chest2014 and the holidays. Now I’ve that I haven’t vented in a while, I’ve got a whole lot to holler about. The whining will return next week, see you then, and Happy New Year!

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September is Pulmonary Fibrosis Awareness Month, Learn More About This Deadly Disease.

Idiopathic Pulmonary Fibrosis  is a disease which involves progressive scarring of the lungs of unknown cause (hence the term idiopathic).  The median survival from the time of diagnosis is 2 to 3 years, though the course is variable and many patients deteriorate rapidly.

There is little in the way of effective treatment and no cure other than lung transplantation.

There are excellent resources available to learn about this disease.

For Patients: The Pulmonary Fibrosis Foundation and Coalition for Pulmonary Fibrosis. Both resources provide information regarding patient support groups,  fund raising, and advocacy.

For Physicians: The CHEST Foundation website includes information for patients and physicians. I have found this helpful in answering many common questions for patients with newly diagnosed IPF. The author is a pulmonologist whose father died from IPF.

In addition, the Pulmonary Fibrosis Foundation conducts numerous activities throughout the year and is a great resource for information about the disease.

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The Ones that Emory Didn’t Save

It was with much fan-fare that 2 American aid workers were airlifted from across the world and brought to Emory University Medical Center where they began experimental treatment for Ebola. We hope for a full and speedy recovery for them and others like them who do God’s work.

But it appears to me that lost in this conversation are myriad others who need help but never get it. Right now, humanitarian work is being done all over the world, and in very dangerous places. These people  knowingly put their life on the line for others. Yet  tragically, some of them are injured or sickened in the service of others. But for them, the call from the CDC offering to med-evac them out never came. There was a girl, who died of malaria while in Kenya. Or the young man who was serving in Egypt. Or a myriad other aid workers who die while serving their fellow human beings.

Also at issue, and it needs to be asked, at what cost are we saving lives? Who decides who gets what may have been, all told, a hundred thousand dollar medical evacuation? Susan Grant, the Chief Nurse for Emory Healthcare, in an article for The Washington Post rightly downplayed the infection risk posed by bringing these patients here. She went on to say:

“The purpose of any hospital is to care for the ill and advance knowledge about human health. . . As human beings, we all hope that if we were in need of superior health care, our country and its top doctors would help us get better”

This statement brings to mind others that need saving. They don’t work in far away lands, they live here in the U.S, right across town, in fact. They don’t have fancy, exotic diseases.  Their conditions have names like diabetes, heart disease, hypertension, and lung cancer. Right now many of them are getting collection notices for their inability to pay from medical centers like Emory University. Others have been trying to get appointments at tertiary centers  like Emory. Only they’re told that their insurance is not accepted there, or their co-pays and deductibles will be more than they can afford.

How would Ms. Grant justify the incredible expense spent on this endeavor to those people? What would she say about the necessity of this experiment, a clinical trial with an N = 2? Could she really  tell those sweating in the Atlanta heat after their electricity got shut off that this was all really for their benefit?

I don’t know how to solve the ethical dilemma here. While I am hope for a cure on the one hand, I cringe at the highlight this places on those at the bottom end of America’s healthcare disparity gap. Perhaps someday in the distant future they can take solace in knowing that they didn’t suffer for naught. Because if they ever contract ebola, there will be a cure waiting for them.

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