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.

CHRISTMAS 2014 — Why This Year is Different for Me

To me Christmas was always the “other” holiday of winter. As a Jew we celebrated Hanukah. But I knew that Christmas was an extremely important holiday for Christians for many reasons. Certainly there were the theological implications of the Messiah becoming fully human as well as divine. That was always a mystery for me as well as devout Christians as well. Then, of course, there were the commercial aspects, Christmas music and time off from school.  All good. We celebrated the gift giving and the beauty of the Christmas tree with our friends and neighbors. But it was always someone else’s holiday.

While becoming officially less observant of Jewish religious traditions, my identity as a Jew is indeliable since being Jewish transcends religion.  It is a cultural, historical as well as genetic (as can be determined by testing) tradition.

The past year 2014 has witnesssed an alarming upswell of anti-semitism in the world, now fostered by radical Islam. This has been deeply painful to the Jewish community. We cannot help but feel its chill in the deepest recesses of our souls.  It rekindles age old fears. The Shoah was only the most horrific and most devastating of a several thousand years tradition.  Now it appears once again.

 That contrast between what is happening around the world  and what I have seen in my personal life is particularly striking. My friends and patients have wished me a joyous Hanukah from the bottom of their heart.  Their sincerity is palpable.  And I am deeply grateful for it.

 It brings home the power and beauty of this great country of ours.  America may stand alone in the world as the bastion of tolerance for diversity.  Tolerance was once understood as the basis of who we are as a nation.  It still remains.  I have been deeply touched by its presence.  

Christmas 2014 is different for me because I will never again take this country for granted.

May we continue to be a light to the nations.  Merry Christmas and my hopes for a peaceful and happy New Year for those of good will.

WHY THIS LIFE ? — It’s a Novel with Many Chapters

I hope what I’m about to write resonates with some of you.

 Most of us look at our own lives as some unexplained mystery.  Why do we experience what we do? Why do we encounter people who seem either loving or toxic to us? Why do some individuals seemed bound to us by proximity or kinship and seem to different from us?  Why is life just so impossible to figure out?

Perhaps we need to enlarge our perspective on life itself.  Let me offer a few thoughts and see if they even remotely make sense.

 Let us suppose, for the point of this exercise, that reincarnation is a real force in the universe.  If that is so then certain aspects of our life here begin to make some sense.  If our true nature is that of a spiritual being having a human experience, then we return to each lifetime with a mission, or at least a goal.  Overcoming adversity, embracing relationships, working on our faults, connecting to the planet, encouraging other beings to become their best selves, etc. etc.

 In the context of rebirth, each lifetime could be regarded as one chapter in our soul’s journey, the ultimate novel.  If our soul, the immortal self, requires multiple lifetimes to evolve, and that we forget the details of our last one, we find ourselves living this life confused and bewildered.  The analogy would hold because if we came upon a novel we have never read, picked one chapter in the middle and begin reading, we would most likely remain confused.  Who are these characters? Where did they come from? Why they interacting with each other? Where are they all going anyway?

 I suspect that our soul’s journey is like that.  If we had the benefit of a greater perspective, many of life’s mysteries and conundrums might make sense.  Since we don’t, this is all mere speculation.  But if reincarnation is real… might just make sense.

Stay tuned.

ALTERNATIVE MEDICINE BREAKTHROUGH–acknowledgement of its Influence

The highly regarded American Journal of Gastroenterology (aka Red Journal) published an article in November’s issue Volume 109 Number 11 pp1705-1711 regarding the use of CAM (complementary and alternative) treatments by US adults with gastrointestinal conditions from 2012 interview of over 13000 individuals. Nearly 42% utilizes CAM modalities.  

This is an impressive number. Even more impressive is the attention from one of the most widely read and respected traditional GI journals. Recognition of the appeal and effectiveness of some of these treatments.  

This is a welcome trend. We need the scientific establishment to be open to these approaches and to apply their analytic skills to their study.

JOAN RIVERS– Revisited

The latest revelations from the Joan Rivers tragedy seems to indict her treatment at the Yorkville Endoscopy clinic.  The importance of these latest findings which appeared in the NYTimes and are based upon a “federal report” seems to point to a variety of avoidable errors and omissions.

The importance to me on a personal level  ( in addition to the Ms Rivers tragic death) is that I participate in an ambulatory surgicenter where upper endoscopies are performed on a daily basis.

I do hear from some of my patients who have expressed concern regarding their own fate. 

To summarize:  there seems to have been a failure to notice her deteriorating vital signs.  To me this points to a dereliction of duties by the anesthesiologist involved in the case.  Their job is to administer the drugs and closely monitor the patient’s vital signs.  That is their responsibility.  The anesthesiologists I work for are compulsively monitoring our patients on a continuous basis.

Again there was notation of the unauthorized ENT doctor Korovin who performed two laryngoscopies.  Even without performing a biopsy, this procedure is known to potentially result in spasm of the larynx and trachea, the result leading to bronchospasm and inability to oxygenate the patient.  This was clearly an inappropriate procedure for an ambulatory surgicenter and may have directly led to the anoxia (lack of oxygen) that resulted in “brain death”.

 The taking of “selfies” was an act of poor judgment and unprofessionalism but not directly contributory to Ms.River’s death.

So in summary, her death was most likely avoidable.  Poor medical judgment and perhaps an anesthesiologists lack of attention contributed to it. 

Obviously I am not responding to sworn testimony for this assessment, merely the NY Times article. But at least I can offer my own patients some assurance that their experience will be much different at our center.