PATIENT PORTALS — Unintended Consequences

Everything new brings with its introduction unintended consequences.

Patient advocacy, access to our own medical records, the concept that we need to take ownership of our health care–all resonates as true and laudable.  What happens in the real world, however, is often chaos and unnecessary suffering.

Please allow me to offter real world examples of this notion.  Patients are able to access their radiology reports, blood work, endoscopy and surgical reports with their associated pathology reports even before their attending physicians.  Sounds great?  Not really. What immediately occurs is a frantic Google search for any medical terms which are unfamilar to the patient.  What often follows is sheer panic and misery when uncertainty and confusion ensue.  This is understandable.  Even the most intellectually gifted layman (my patients, of course) do not understand the  clinical significance or relevance of what occurs on a lab, XRay or pathology report.  

Traditionally (in past days) the patient would receive the initial information while in the presence of their doctors.  Immediate discussions would occur. Analysis of the real consequences of a radiology report which might recommend a follow-up procedure based upon some vague and usually benign finding could be quickly and easily placed in perspective. ” Yes, let’s order another study just to confirm that these findings are probably nothing.”  That would often assuage the patient’s fears and avoid unnecessary panic.

The situations is quite different now.  I find myself dealing with borderline hysterical (or nearly) patients who have convinced themselves via the internet that they are absolutely dying from what may be a totally innocuous condition.  

My plea to my patients and to the patients of other physicians is to bring your reports to your doctors and, in persons, review every line of the report itself.  Frankly, most of this interaction cannot adequately be performed over the telephone (sorry about that).  Often the emotional content of the discussion can only be dealt with on a person to person basis.  Often I rely on diagrams to elucidate the results.  That is the way to promote the best in doctor/patient connections and to alleviate unnecessary chaos and distress.

The system is assuredly changing. Let’s all take a deep breath and try to make it work to everyone’s benefit.


Read another article today from Science Daily selections regarding the status of happiness in ‘old age’.  This one contradicted some earlier studies which implied that we generally become happier as we get older.

 Such confusion exists among claims made on the internet on a daily basis. There are outrageous  assertions made continuously about the benefits of this treatmenet versus another. Recently I’ve seen postings regarding the old claims of the health benefits of coffee enemas. On their face, many might seem reasonable to some, ridiculous to others.

What willl ultimately determine “truth” is the scientific method. Now we all understand that science is imperfect. Its liability, its weakness is that not all science is ultimately accurate. Because scientists are human they may be prone to falsifying data for a variety of personal reasons. Of course this is reprehensible. But what makes science invaluable as a tool for ascertaining truth is its ability to correct itself over time. This is crucial. Studies need to be repeated, over and over. In this way what we deem to be truth is essentially a consensus of scientific studies (which need to be examined as to their own reliability) which is always open to revision. In this sense, scientific truth ( as opposed to religious truth) is always uncertain.  But it is in this uncertainty, this insistence that results be confirmed over and over that we can rely on its veracity.

 Is science ALL we need to understand the nature of reality?  I would submit the answer is NO.  We need the humanities– philosophy, literature, the study of consciousness, spirituality. Some of these aspects of human experience may NOT be open to scientific study.  But when it comes to understanding the physical universe and its manifestations, we absolutely need it.


Before relating the following anecdote I should offer some caveats.

 If you are convinced that consciousness ends at the time of physical death then you shouldn’t bother reading further.  If you are totally convinced that those who claim to communicate with souls who have crossed-over are complete and utter frauds, read no further.  If you are brainwashed by certain religious dogmas and doctrines and believe that alternative experiences are the work of the devil, read no further.

 But……if you are open minded, curious or have had your own intuitive experiences that lead you to seek more, then stay tuned.  The initial “twirling ring” anecdote was described in my book META-PHYSICIAN ON CALL… (p 77)

 The key to what I refer to as the credibility quotient regarding these anecdotes is knowing the individual who has had them.  There must be no question of their credibility, reliability and honesty.  What helps is their unattachment financially or professionally to the content of their story.  In other words, they have nothing to gain (and perhaps much to lose if someone regards them as a bit “off” by telling what they know.)  

In the book I refer to Marilyn (all names changed) who was gifted with medium/psychic ability since childhool.  She never charged for her services and actually desired them to vanish, which they did not.  She recalled learning of a nurse I called Janet whose daughter Sue died tragically in a car accident.  She knew Janet from working together at the hospital at which I was an Attending physician.  She had never met Sue but when she entered the family home for the wake she saw a picture of Sue and her sister Barbara.  Scanning the crowded room she saw Sue present there. She was translucent in appearance and she noted what she was wearing. It was clear that no one else in the room could perceive her.  She appeared anxious and confused and was vigorously twirling a ring on her finger. 

Months later she felt it was safe to approach Janet and describe the events of the wake.  Janet broke down in tears when she confirmed that, indeed, Sue would twirl the ring on her finger when upset.

 I have always considered this anecdote one of the most powerful I have ever heard and, quite frankly, highly suggestive of survival of consciousness after death.  But just the other day, nearly ten years later,  I had an amazing follow up.

 Janet brought her husband to me for a screening colonoscopy.  She then related a recent occurrence in the family.  They were on vacation and her remaining daughter Barbara describe having an extremely vivid dream in which her dead sister Sue appeared in specific clothing and affectionately stroked her face.  It was so realistic that she truly felt her presence.  But the next morning as she told her mother Janet, she felt almost foolish.  She rationalized that it must have been wishful thinking.

 The family returned home and Janet returned to work at the hospital.  To her surprise Marilyn greeted her and pulled her aside. “Your daughter Sue will not let me rest until I tell you and your daughter Barbara that she was really there– it was not a dream!”  Of course Janet was floored. How could Marilyn have known about the dream in the first place?  When Janet described the clothes that Barbara  had described, Marilyn stated– “Those were the exact clothes I saw her in at her wake.  She must have been wearing them at the time of her death.”  Janet confirmed the fact of the clothing, also that she was not wearing them when she was laid out at her wake.

 Now as Janet related this story to me she had a gently smile on her face.  This had been a powerful validation that Barbara’s experience with Sue was not a hallucination or dream.

 It gave her some small comfort to know that her daughter was gone from the physical realm but that her soul connection lives on.



I have been enamored of the relationship between a physician and metaphysician for years now.  My book is titled META-PHYSICIAN ON CALL.  My blog is PHYSICIAN TO META-PHYSICIAN.  I continue to believe deeply that the awareness of human beings as a composite being of body, mind and spirit is essential in the healing process.  

It was particularly gratifying to find a quote from Anatole Broyard, writer, literary critic and editor who stated Also, I would like a doctor who is not only a talented physician, but a bit of a metaphysician, too. Someone who can treat body and soul.  It would be presumptious of me to believe that I have reached that level of awareness. I do believe it is an ideal, one that I am striving to reach.

 I would point out that I have used the term METAPHYSICIAN and META-PHYSICIAN.  They are clearly related but not identical.  A metaphysican is someone who seeks to understand the nature of reality.  Metaphysics is a subcategory of philosophy. Using meta  hyphenated with physician also introduces the notion of meta as change or transformation.

  It represents a level of awareness among physicians that we need to transcend the weight of frustration, annoyance, outright rage that we experience from insurance companies and governmental bureacracy  that threatens our best efforts to appreciate the role we can play in our patients lives.  I must continuously remind myself that my better self can move beyond these hinderances and be the meta-physician I seek to be.

CAN TMI (too much information) BE A BAD THING FOR HEALTHCARE?

I can “hear” the groans right now wafting through cyberspace.  Here is an old school doctor bemoaning the “new patient” who is internet savvy and has done their homework. I must be one of those physicians who fears patient awareness and  their ability to come armed with reams of information by which they can mold and control their own healthcare decisions.  I am probably one of those who decry patient self-determination and their ability to possess ALL of their medical records.  

Well actually that is not entirely true. I do recommend my patients do their homework, their “due diligence” so to speak when it comes to their own health.  They are their own best advocate. But what has become a difficulty for me and my patients is exactly how to deal with the enormous volume of information which patients can obtain. I am concerned by what seems to be an almost adversarial approach that some patients now take towards physicans.

 One particular source of information has been generated by big Pharma in an attempt to bypass physicians go directly to consumers.  Ironically, I find that this practice has actually backfired to some extent.  Let me share one particular situation which I am attempting to deal with at the moment.  I am a gastroenterologist and I treat (among other conditions) Crohn’s disease.  This can be a very difficult, disabling condition with a variety of very unpleasant manifestations.  One of most horrific are fistulas.  They are “tracts” that can drain a mucus/pus like material from openings in the skin.  Unfortunately they often occur around the anus and genitourinary tract.  

One of the breakthrough treatments are drugs known as anti-TNFs.  Now I don’t want to expand in detail about exactly how they work and the brand names which many of you would recognize from TV and magazine ads.  Essentially they are very powerful with “potentially” serious side effects effecting the immune system.  On the other hand they can be tremendously beneficial for some patients with Crohn’s and other autoimmune diseases.  They problem is that the TV commercials are SO explicit in the risks and potential devasting consequences of bad reactions that even I would be loathe to try them.

 This has happened with my one young female patient with Crohn’s disease and perianal fistua who is reluctant to try this medication.  Ironically, she is willing to try an alternative drug which is chemically almost identical to the first but which does not advertize on TV and for which she is unaware of the same potential side effects.  And by the way, her insurance company will only pay for the one she is afraid to take.  So now my difficulty is to try to “sell” her on the necessity of trying the drug she is afraid to take.  And she is afraid because of TMI and her unwillingness (so far) to trust the experience and opinion of a physician.  I desperately want her to try the drug and have tried to communicate to her that thousands of patients have used it without difficulty or complication. And we can closely monitor in case issues arise.

In effect what I am calling for is a reasonable balance between information gleaned from a wide variety of sources, some of which are of questionable veracity, and guidance from a physician who really does have the patient’s best interest at heart as well as decades of experience and hopefully some wisdom as well.  An informed patient and a wise physician can, indeed, be on the same page. 


Is the notion that your physician is a salesman inherently disturbing? It is a question I have asked myself over the more than 35 years that I have been in practice.  I come from a family of salesmen.  My father and son are in fields traditionally viewed as sales. 

Yet I had never viewed what I did as sales–until I thought about it.  The truth is that we all salesmen but hopefully in the best sense of the word. In any field of endeavor, from businessman to artist to physician we are continuously “selling” ourselves to our clients, our colleagues, our patrons, our social contacts.

I am not talking about the stereotypical ” used car”  guy who uses high pressure, fast talk and disengenuous techniques to push you into a choice which may not be in your best interest. To my way of thinking sales is essentially demonstrating your best self.  It is about educating the client/patient about a product or service which will cost them financial resources but which will benefit them in someway (or not)  in the future. 

We all need to be good communicators, educators in effect.  A good salesman can explain the risks/benefits of that product/ssrvice is such a way as to make the decision easier.  If it is not a mutual consensus on what to do the, quite frankly, it should not be done. And yet there remains a strong element of uncertainty in any sales situation. Will the product or service be beneficial in the long run? Is there risk in consummating the sale or in not doing so? Of course.

 Is there an element of trust involved in such an interaction? Certainly.  The salesman almost always has the advantage in knowledge and experience regarding the product/service that are being negotiated. But that has been true and will always be true.  Ultimately, the leap of faith will prove to be mutually beneficial or not.  There will always be the element of uncertainty and risk that is inherent in any human interaction.Time will be the ultimate arbiter.

A “good” salesman, whether selling a dishwasher, car, insurance product or the need for a colonoscopy, will be vindicated in the long run.  Their client/patient will return to them, time and again.  They will recommend them to their friends and neighbors. It is as simple and complex as that.


American Psychological Association (APA). “Falling off the wagon with Facebook.” ScienceDaily. ScienceDaily, 6 August 2015. <>.

The American Psychological Association’s piece cited above points to an important phenomenon of which we should all be aware–namely technology has its limits. Of course this is not to demean or diminish the incredible benefits that computers and access to instantaneous information and communication has brought to society as we know it.  It is virtually impossible to recall just a few years back when we did not possess smart phones, or any portable means of communication for that matter.

The point of this study is to remind us that technology still has its limitations.  We are still inherently social beings who have evolved to interact with each other in close proximity. Body language, facial expressions, subtle emotional responses to close in dialogue represent a dance between who individuals. The give and take often occurs on a subliminal level. Our ability to “read” others is a gift that some of us possess to a higher degree than others.  Face to face encounters are different from computer based and I will openly  risk the wrath of my more technologically savvy colleagues to propose that they always will be so.

So will telemedicine ever replace the office visit? Will it be used as a less satisfying but potentially helpful supplement to the patient-doctor encounter?

 Perhaps I only fantasize that my personal encounter with patients within the sanctity of the closed exam room cannot be adequately duplicated by technology. Perhaps it is only withful thinking that some of my success in the practice of medicine is related as much to those interpersonal skills as to raw medical knowledge.

Perhaps I remain the Luddite in the white coat.  Or at least I remain skeptical of its ability to replace the personal encounter.  Only time will tell.

Doctor On Call — Past/Present/Future

This will be a short version of the story, of an aspect of being a physician that most readers are aware of but which has an enormous impact on their own health care, the personal lives of their own doctors and the future of health care in this country.

Being “on call” begins with a young physician’s first clinical experience as an intern/resident and ends when their either retire or arrange for another physician to assume that responsibility.  It reflects the 24/7 nature of what we do.  As I begin to wind down my medical practice, the first element to jettison is, you guessed it, the on call.

I cannot enumerate the numerous times that I would be awakened by a blaring phone call at 3AM, or a vibrating smart phone in later years to bring my attention from some deep, undisturbed REM state to immediate awareness. The “Service” would be calling. The adrenaline rush became instantaneous and that mili second a barage of thoughts filled my sleep deprived brain.  As a gastroenterologist I knew that the problem I would be facing as I responded would center around a few specific disease states. Had they swallowed a piece of meat, now lodged in their esophagus. Or was it a relatively minor issue– Mrs Jones was ‘bloated’ or called at 3 AM to report her two week history of diarrhea.  Even those minor calls were quite frankly major to me.  I had to shake loose the cobwebs of my cognitive self and make a decision– to come in to the hospital, to defer for a few hours or have the patient call the office in the AM.  At least these calls and decisions could be made over the phone.  I could be half-asleep, grubby and disheveled.  I could be wearing pjs or nothing at all. The consequence of such a call is the inability to quickly fall back to sleep.  The adrenaline is still flowing.  The self-questioning begins.  Did I make the correct decision? Should I call back and change my opinion?

But it is 2015 and it is the dawn of a new era in medicine–Telemedicine.  We are told that the future is rushing up to great us regardless of how we feel. The future will mandate a visual exchange between physician and ER, physician and patient. Telemedicine will require a Skype kind of communication.  After all it will be far cheaper to connect patient with physician this way. And it won’t just be for the emergency on call interaction. Why go to the trouble of having a “hands on” visit when it is so much more convenient to do it via a computer screen.

 So I do not envy my younger colleagues one bit.  They will not have to sound competent at 3 AM, they may have to look the part as well.


Now don’t be alarmed by the title of this piece. The term ambivert is not in anyway connected with the term pervert.

In fact I first became aware of the term via The Wall Street Journal article on the subject by Elizabeth Bernstein. It described a combination of personality traits that did not fit the definition of either an extrovert nor an introvert but something of a hybrid.  

In truth this description sounds very much like me.  Like most of us I often embarked on the journey towards self-discovery.  Who am I, really? How do I relate to the world, really? I have come to the conclusion that I am not a “people person”.  On occasion, when the discussion arises, I will confess this quality to others.  Those who have witnessed me in the course of performing my professional duties as a physician/gastroenterologist are often baffled by my confession.  “No way” they might state.” You can be charming and warm with your patients, particularly the nervous ones.” Of course I thank them for that assessment but admit that this is an act I put on.

 I am always been around extroverts.  My Father was comfortable speaking with anyone and everyone. My wife and daughter-in-law are very comfortable engaging in conversation with total strangers. My Mother was quieter.  I must have inherited her genetic makeup when it comes to speaking with strangers. 

I have always wondered if my approach to dealing with patients is an act, a bit of a charade.  Am I just faking my outward persona?  I know many of my patients would be shocked by my admission.  I often observe myself in the role I play.  But am I being inauthentic? I don’t think so.  I believe we are all capable of being different people under different circumstances.  Years ago I learned the behavior that allowed me to relate better to my patients, to win their trust and to maximize the therapeutic encounter I have with them. I am now comfortable in that role.  I don the white coat of the physician and become that doctor. I believe it contributes to the healing process itself.

 I have observed that I do actually relate well to one individual at a time.  I value time spent with one person in which I can cut through the superficial banter that passes for being “social”.   I am comfortable discussing the deepest metaphysical issues with anyone.  I find those topics holds my interest and I lose any sense of being self-conscious.  I find that actually quite rewarding.  On the other hand, I find “small talk” about personal preferences, other people’s families whom I don’t actually know, rather boring.

 But at least I now know what I am— an ambivert.  I just need to explain the term to anyone who hears it for the first time.

WISDOM FROM THE SAGES — “This Too Shall Pass”

The origin of the phrase “this too shall pass” is clouded in antquity. Whether the pronouncement of a Sufi mystic or derived from the wisdom of King Solomon is frankly irrelevant.  The term resonates with meaning to anyone who seriously considers it.  It is essentially life’s great equalizer.  

It was utilized to make sense of the challenge given to a wise man– derive an expression which will bring joy to those who suffer and sadness to those who are experiencing life’s bounty.

Those who are joyful will acknowledge the transient nature of life’s positive experiences.  Likewise those in the midst of unbearable suffering would be wise to remember it as well.

It can function as an amendment to the Serenity Prayer which prays for the acceptance of that which we cannot change, the courage to chagne what  can be changed and the wisdom to know the difference.

This phrase parallels the Buddhist notion of “nonattachment”.  This does not compel us to distance ourselves from all emotional connection, or to avoid loving relationships.  It merely reminds us of the transient nature of physical existence. By recognizing that “this too shall pass” we are mentally and emotionally better prepared for what comes our way.

“This too shall pass”. Meditate on its meaning and find a path for healing.