This book is dedicated to the hundreds of thousands of physicians, of all degrees and specialties, who adhere to the unconditional commitment to reinforce the importance and significance of our patient’s lives. Thanks to my colleagues, friends and wife Erin for encouraging me to pursue this book. Also a special recognition to my son Greg, a Hollywood film writer and director, for his help and support with the manuscript. Foreword My wife and I, along with another couple, were in attendance at a play at the historic Central City Opera House, Colorado. The leading actor was none other than Don Ameche, famous Hollywood actor and movie star. During the first act, there was a cry from the audience that a man was having a heart attack. The play stopped, and Mr. Ameche asked, “Is there a doctor in the house?” Our friends quickly pointed to me, whereupon Mr. Ameche said thanks, and continued with the performance. However, the play was over for me; after attending to the heart patient, I ended up assisting several other patrons that also fell ill that warm evening. Incidentally, although I only saw one act that evening, hearing Don Ameche ask, “Is there a doctor in the house?” more than made up for it. It certainly wasn’t the first, or last time, I would hear that question. A physician’s education is based on evidence-based medicine. It is rooted in the judicious use of the best information available, while making decisions about the care of an individual patient. It integrates clinical expertise, the best available research, and the values of a patient. Nevertheless, at times, this education can distract the physician from thinking outside the box, along with using a little common sense, which can potentially result in a substantial reduction in health care cost. For example, let’s say a young male complaining of a recent rapid pulse, palpitations and nervousness is seen in the emergency room. He denies taking drugs. By the book he might get an electrocardiogram and blood workup, all of which come back as normal. He is discharged and told to follow up with a physician. Depending on the hospital, his total emergency room bill could total $ 3,813.67: Metabolic panel $ 329.67, Assay of magnesium $ 246.97, CBC $ 219.66, Chest X-ray $ 464.08, Place needle in vein $ 129.35, ER visit $ 1,457.04, Electrocardiogram $ 383.90, and ER doctor $ 583.00. The following week he sees a family physician that his boss recommended. By taking a thorough history and with some common sense, the physician inquires about recent events occurring in his life. It’s found he’s started working for a fast food chain. Further questioning reveals he’s entitled to free food and drinks. He admits to drinking more than a dozen caffeinated drinks a day. Simply by factoring in his age, profession, and recent diet change, he’s advised to gradually wean himself off caffeine over the next 3-4 weeks. A follow up call two weeks later revealed his rapid pulse and nervousness had subsided. Total cost: less than $ 100. Another example involved a stocky middle-aged male who recently had been treated by another health care provider. He’d been complaining of recent lower back pain that radiated down his left leg. He denied any recent lifting or injury to his back. With no improvement after seven office visits, and spending over $ 800, including x-rays, he decided to see a family physician on the recommendation of a friend. With a detailed history, the physician found that as a regional sales representative, the patient was driving up to four hours a day. He’d also recently purchased a new Mercedes with tight-fitting bucket seats. Using a little common sense the physician also noticed a large wallet in his left back pocket. By simply having the patient remove his wallet while driving, the back symptoms quickly subsided. Total cost: less than $ 100. When dealing with their personal health, patients also need to use common sense. In physics, Sir. Isaac Newton’s 3rd law of motion states for every action, there is an equal and opposite reaction. In everyday life, we experience this law. I won’t go to work today. The counter reaction being, I may loose my job. The same type of comparison can also apply to medicine. I won’t take my insulin. The counter reaction is, I not only risk my health, but also my life. Common sense therefore dictates that it’s in my best interest to take my insulin. Any other course of action on my part would be counterproductive, and possibly fatal. Sometimes we make medicine way too complicated. Case in point: an elderly female student complains she’s seeing spots. The practitioner proceeds with a full eye exam, all of which is normal. Had the practitioner quizzed her on recent activities, she would have told him she had just spray painted some of her pottery. By examining her glasses first, he would have graciously cleaned them and returned her clear vision, minus the exam. Prior to a definitive diagnosis, health professionals can increase a patient’s stress and anxiety by giving them the worst-case scenario. A professional bull rider sees a urologist with a painful testicle. Following the exam, the doctor curtly informs the patient that it’s probably cancer, and he may die from it. The bull rider has a syncope reaction and lands on the doctor’s floor—not from the big bad bull, but from an insensitive doctor. If you listen to a patient long enough, the chances are they will give you the diagnoses. A man in this 30’ s shows up at the emergency room with vague chest discomfort. With scant medical history, the staff gets an EKG, chest X-ray, blood panel, all of which are normal. The patient is referred to his family physician for follow-up, without a diagnosis. His family doctor sees him the following day, inquiring in detail what had preceded the days prior to the chest discomfort. Nothing, except that he and his wife went shopping at the local mall. The patient recalls getting a cholesterol test for $ 10, was told his cholesterol was 250, and that probably put him at risk for a heart attack. His dinner that evening was sausage and sauerkraut. Incomplete blood test + invalid suggestion + anxiety + gaseous meal + indigestion and chest discomfort + ER visit + inadequate history = big bill with no diagnoses. Sometimes common sense is lacking even in the ivory towers of medical research. While attending a medical meeting years ago, the speaker announced that a new hypertensive drug (beta blocker), after two years of use, improved the survival rate of patients with heart disease significantly, but didn’t recommend it beyond the two years, even though no adverse side effects were noted. After asking him why not continue with the drug beyond that period, his response was that it needed more time for investigation. With that logic, you’re potentially denying every heart patient the advantage of a better survival outcome because of a technical research requirement. Back in the 60’ s, a pharmaceutical company representative detailed me on a new IUD (intra uterine device utilized for birth control). On examination, common sense told me this device could have potential harmful effects to the patient, because of its design, so I choose not use it on my female patients. The next thing I knew, several gynecologists from the medical school called to inform me I was premature in not using it. I told them to call me back after it was on the market awhile; I didn’t trust their judgment. Without mentioning the product, it was taken off the market years later. It had caused multiple deaths, and the company was sued. By the way, I was never called back from those gynecologists and the pharmaceutical representative never returned to my office. That same common sense utilized in patient-physician interactions is also applicable to how medical care has evolved over the last half century. It can also be applied to lowering medical costs, choosing the right physician, understanding our bodies, and how to respond to our everyday common medical, physical, emotional, and spiritual problems.
Like many other professions, physicians are in the business of providing a service. They are given higher standards to adhere to than perhaps other service providers, because their decisions affect human lives. They rely on a support team of receptionists, nurses, technicians, specialists and therapists. Their training and experience place them in a unique position to predict their patient’s future health needs, based on the patients past history, and present health status, somewhat analogous to Charles Dickens’ stories of past, present, and future tense. For example, a physician sees a 48 year-old male with advanced emphysema (chronic lung disorder, resulting in breathing impairment) and a history of smoking two packs of cigarettes a day in treatment room 1, then sees a 21 year-old male with a history of smoking two packs of cigarettes a day in treatment room 2. It’s reasonable for the physician to predict that he’ll see the 21 year-old in 27 years or less in a similar condition as the 48 year-old patient in room 1, if no lifestyle changes are made. As physicians, we have the opportunity in the present to motivate the 21 year-old to avoid the past mistakes of the 48 year old, and help shape a brighter future in the process. As with all professions, there are the good, the bad and the ugly. No one degree (D.O./ M.D), or specialty, is immune from bad docs. Criteria for a good doc include competency, staying current, having sound ethics, being available to listen, being compassionate, being empathic, and if in doubt, willing to ask for consultation. I’m proud to say that in my four plus decades of practice, I’ve found that the overwhelming majority of physicians are good. They’ve experienced the joy of bringing a new life into this world, and holding the hands of those departing. They’ve shared a family’s hardships, as well as their blessings in life, and been humbled beyond words by patients expressing their gratitude for the care they’ve given, and being called their friend. The bad doc usually lacks several of the above attributes. There are docs who occasionally succumb to the “white-lie scenario” or gray area—“ Hey; I’m not doing anything illegally or grossly wrong.” Case in point: one of my patient’s mothers was visiting from Miami, and was seen by me for a minor medical problem. After the exam, I gave her the discharge form and instructed her to check out at the front office. She then handed me a $ 20 dollar bill, which I said no to; the front office will handle it. She then informed me that her doc back home always accepted a tip. Although it’s completely acceptable at your local restaurant, I find it unethical in medicine. We are placed in a position of responsibility for our patients, and should never be temped to take advantage of their generosity. When I first went into practice in the mid-60s, one of my elderly widowed patients asked if she could add me to her will, because she had no other family to give her assets to. In declining the offer, I suggested she talk it over with her accountant and find a suitable charity to give it to. I thought it a bit strange, and couldn’t believe a physician would ever accept such an offer, until years later when another one of my patients told me her wealthy widowed aunt gave her multi million-dollar estate to her personal physician. The ugly docs are the ones we usually see exposed in the media falsifying visits and charges, practicing with extreme medical incompetence, operating on a wrong part of the body, or prescribing narcotics for profit, like those signing off on the medical marijuana scams. Some have succumbed to the influence of money from their celebrity patients (Elvis Presley and Michael Jackson), resulting in tragedy. In addition to using common sense when dealing with your medical problems, one needs to apply the same common sense when selecting a good physician. Prior to selecting a doc, call the local medical society, medical board or scan the Internet for recommendations. Beware of physicians using excessive advertising. Those costs are usually made up for with high-cost and high-volume practices. Certainly personal references are the strongest and most reliable source for finding a good doc. However, third party medicine today may negate all the above. If your insurance only allows you to see a doc you haven’t researched or know, then you may be on shaky ground until you feel comfortable with that particular doc. Generally your first visit to the office is your first clue to acquiring a level of comfort with the physician. If you get a curt or unfriendly response from the front desk, it may suggest the office staff and doc won’t be any better.