Archive for Medicine

Who are the best Doctors?

As a physician, many of my friends ask me to comment on the doctoring skills of my medical colleagues. Admittedly, a positive testimonial from a physician about your private physician is reassuring, but is it reliable? Outside of my specialty of urology, I found it very challenging to assess the competency of my colleagues other than by the three A’s of medical practice, first Availability, second Affability and finally Ability in that order. Yet, each year both Cincinnati and Cincy magazines glibly put forth a list of the Top or Best doctors in the Greater Cincinnati area.

Currently, statistical measures do not differentiate the best from the average also. Web site such as may crunch the numbers of millions of medical claims from federal and private sources to rate and rank doctors but their parameters that allegedly factor in experience, complication rates and patient satisfaction are grossly incomplete and subject to arbitrary standards of care.

You might think that primary care physicians and pediatricians (PCPs) would be knowledgably about the quality of medical care rendered by the specialists to whom they refer. But today’s PCPs are generally hospital employees and do not follow their patients in the hospital if they are admitted and thus rarely interact professionally or socially with the specialists. Moreover, the hospital systems (Christ, TreHealth, Mercy Healthcare, UC Health and St. Elizabeth Healthcare) have incentives for their ‘owned’ physicians to refer exclusively to other doctors in the network. The advent of the ‘Hospitalist’ and ‘Intensivist’, new breeds of physician that manages hospital care, has added an additional layer of isolation between the PCP and other physicians.

Moreover, insurance plans often change their panel of physicians and enrollees often change health plans. And when you go to see the doctor, you may be seen by a physician assistant (PA), nurse practitioner or anyone of the physicians covering the practice.

Interestingly, patient satisfaction has become a major focus in Medicare and medical insurance reimbursements to hospitals and medical practitioners. Many patients have already received the 3 or 4 page satisfaction surveys after a routine office visit, outpatient surgery or a hospital admission.  The soft data of patient satisfaction does correlate with quality of care, but the response rates to these surveys are much higher in the outliers of either the very satisfied or very dissatisfied. From a physician’s perspective, they do not paint an accurate picture.

So how does one latch onto the best doctors. Probably word of mouth from satisfied patients remains the best method upon which to judge a doctor. In the hospital setting, possibly, the floor nurses and operating room technicians with whom the doctor works day-over-day give the most reliable testimonials about the behaviors and capabilities of individual physicians.  But there is no surefire way to select the very best. In most instances, it is a leap of faith that ends in a good match based upon trust, bedside manner, accessibility and previous treatment outcomes.

And yet the magazine lists of the best doctors, ambulatory care centers, emergency rooms, hospitals, and medical testing facilities goes on and must certainly sell magazines. However, if your doctor or medical facility does not make the cut, don’t get concerned; the lists are very arbitrary and have little correlation with quality of care.


— Richard G. Wendel MD, MBA

Medication Expiration dates… What do they mean?

A medical school friend of mine recently threw out some Nembutal capsules he was given on a tour of Ely Lilly tour while in Medical School in 1959. He now wonders if this was necessary.

If a bottle of Tylenol, for example, says something like “Do not use after June 1998,” and it is August 2002, should you take the Tylenol? Should you discard it? Can you get hurt if you take it? Will it simply have lost its potency and do you no good?

In other words, are drug manufacturers being honest with us when they put an expiration date on their medications, or is the practice of dating just another drug industry scam, to get us to buy new medications when the old ones that purportedly have “expired” are still perfectly good?

These are the pressing questions I investigated after my mother-in-law recently said to me, “It doesn’t mean anything,” when I pointed out that the Tylenol she was about to take had “expired” 4 years and a few months ago. I was a bit mocking in my pronouncement — feeling superior that I had noticed the chemical corpse in her cabinet — but she was equally adamant in her reply, and is generally very sage about medical issues.

So I gave her a glass of water with the purportedly “dead” drug, of which she took 2 capsules for a pain in the upper back.

About a half hour later she reported the pain seemed to have eased up a bit.

I said, “You could be having a placebo effect,” not wanting to simply concede she was right about the drug, and also not actually knowing what I was talking about.

I was just happy to hear that her pain had eased, even before we had our evening cocktails and hot tub dip (we were in “Leisure World,” near Laguna Beach, California , where the hot tub is bigger than most Manhattan apartments, and “Heaven,” as generally portrayed, would be raucous by comparison.

Upon my return to NYC and high-speed connection, I immediately scoured the medical databases and general literature for the answer to my question about drug expiration labeling. And voila, no sooner than I could say “Screwed again by the pharmaceutical industry,” I had my answer.

Here are the simple facts:

First, the expiration date, required by law in the United States, beginning in 1979, specifies only the date the manufacturer guarantees the full potency and safety of the drug — it does not mean how long the drug is actually “good” or safe to use.

Second, medical authorities uniformly say it is safe to take drugs past their expiration date — no matter how “expired” the drugs purportedly are. Except for possibly the rarest of exceptions, you won’t get hurt and you certainly won’t get killed.

Studies show that expired drugs may lose some of their potency over time, from as little as 5% or less to 50% or more (though usually much less than the latter). Even 10 years after the “expiration date,” most drugs have a good deal of their original potency.

One of the largest studies ever conducted that supports the above points about “expired drug” labeling was done by the US military15 years ago, according to a feature story in the Wall Street Journal (March 29, 2000), reported by Laurie P. Cohen.

The military was sitting on a $1 billion stockpile of drugs and facing the daunting process of destroying and replacing its supply every 2 to 3 years, so it began a testing program to see if it could extend the life of its inventory.

The testing, conducted by the US Food and Drug Administration (FDA), ultimately covered more than 100 drugs, prescription and over-the-counter.

The results showed, about 90% of them were safe and effective as far as 15 years past their expiration date.

In light of these results, a former director of the testing program, Francis Flaherty, said he concluded that expiration dates put on by manufacturers typically have no bearing on whether a drug is usable for longer.

Mr. Flaherty noted that a drug maker is required to prove only that a drug is still good on whatever expiration date the company chooses to set. The expiration date doesn’t mean, or even suggest, that the drug will stop being effective after that, nor that it will become harmful.

“Manufacturers put expiration dates on for marketing, rather than scientific, reasons ” said Mr. Flaherty, a pharmacist at the FDA until his retirement in 1999. ” It’s not profitable for them to have products on a shelf for 10 years. They want turnover.”

The FDA cautioned there isn’t enough evidence from the program, which is weighted toward drugs used during combat, to conclude most drugs in consumers’ medicine cabinets are potent beyond the expiration date.

Joel Davis, however, a former FDA expiration-date compliance chief, said that with a handful of exceptions — notably nitroglycerin, insulin, and some liquid antibiotics — most drugs are probably as durable as those the agency has tested for the military. “Most drugs degrade very slowly,” he said. “In all likelihood, you can take a product you have at home and keep it for many years.” Consider aspirin. Bayer AG puts 2-year or 3-year dates on aspirin and says that it should be discarded after that.

However, Chris Allen, a vice president at the Bayer unit that makes aspirin, said the dating is “pretty conservative”; when Bayer has tested 4-year-old aspirin, it remained 100% effective, he said. So why doesn’t Bayer set a 4-year expiration date? Because the company often changes packaging, and it undertakes “continuous improvement programs,”

Mr. Allen said that each change triggers a need for more expiration-date testing, and testing each time for a 4-year life would be impractical. Bayer has never tested aspirin beyond 4 years, Mr. Allen said.

Dr. Carstensen, professor emeritus at the University of Wisconsin’s pharmacy school, who wrote what is considered the main text on drug stability, said,

“I did a study of different aspirins, and after 5 years, Bayer was still excellent. Aspirin, if made correctly, is very stable.

Okay, I concede. My mother-in-law was right, once again. And I was wrong, once again, and with a wiseacre attitude to boot. Sorry mom.

Now I think I’ll take a swig of the 10-year dead package of Alka Seltzer in my medicine chest to ease the nausea I’m feeling from calculating how many billions of dollars the pharmaceutical industry bilks out of unknowing consumers every year who discard perfectly good drugs and buy new ones because they trust the industry’s “expiration date labeling.”

By Richard Altschuler

Why has the C-section rate increased?

The Caesarian Section (C-section) Rate: Why has it doubled in the past 25 years even as this form of delivery increases the risks for mothers and their babies?

In the 1980s, the C-section rate in Greater Cincinnati was 17 percent and Managed Care Organizations such as ChoiceCare and Anthem considered this far too high. At that time, Managed Care considered a 12 percent C-sections rate to be optimally consistent with best medical practices. The current World Health Organization guidelines indicate that C-sections are warranted in only about 10 to 15 percent of deliveries.

The C-section rate across the United States is now higher than a third of all deliveries. With C-sections come higher complications and recovery time from major open surgery as well as risks to the baby including neonatal respiratory problems and possibly medical problems later in life such as asthma, diabetes and allergies. Certainly, emergency C-section in cases of preeclampsia, obstructed labors, fetal distress and abnormal placentas are an absolute necessity to save the life of both the mother and child.

Then why is elective or planned C-section that can complicate future pregnancies so popular? There are many incentives for physicians and their patients to choose elective C-section.

  1. Convenience of elective delivery for both mother and doctor.
  2. Avoidance of painful labor and changes to pelvic support structures
  3. Higher reimbursements for C-section than vaginal deliveries
  4. Threat of malpractice due to fetal trauma with vaginal deliveries


As a general rule, I think most physicians believe that there should be a medical indication to justify the performance of a C-section. A lower C-section rate would be cost and life saving.

-Richard Wendel MD, MBA

New Approaches to the Treatment of Breast Cancer

The appropriate treatment for breast cancer has changed dramatically during the past few decades. At one time, the standard practice was radical mastectomy with an extensive regional lymph node dissection. Current surgical approaches generally involve ultrasound guided biopsy of a suspicious breast lesion that, if positive for malignancy, is followed by surgical removal, irradiation treatment and staging via the excision and microscopic examination of a ‘sentinel’ axillary lymph node draining the tumor. Most patients with invasive cancer have a treatment plan individualized to their particular tumor with regard to stage, tumor pathology and genetic studies. There are many new exciting neoadjuvant treatments for breast cancer.

Early diagnosis through regular self-examination of the breasts for changes in texture, contours or actual lumps and screening mammography are the keys to early diagnosis and treatment that produce better outcomes.

The guidelines for when to start screening mammography are controversial. In general, women ages 40-49 should get screening mammograms every one to two years, if they have an average risk for developing breast cancer. For women 50 years and older, mammograms are recommended every one to two years.

Women at higher than average risk should start mammography before age 40 and this includes:

  1. History of breast cancer
  2. More than one family member with breast cancer
  3. Genetic changes and markers that carry a higher risk of getting breast cancer
  4. Plus many more minor risk factors which are beyond the scope of this editorial.

With newer surgical and neoadjuvant treatments plus earlier diagnosis, the percentages of long term survival from breast cancer has greatly improved.