Perfecting Social Graces

He was the most respected man in our training program. The oldest cardiologist at our institution, gruff, never afraid to shy away from a four-letter word to make his point, and with the uncanny ability to diagnose critical aortic stenosis (pulsus tardus et parvus) or insufficiency (bisferiens pulse) by placing his hands on his patient’s pulse. No echocardiogram was necessary. His incredible knack for inductive reasoning of associated diagnoses was unparalleled. His breadth of clinical experience and expertise unequalled. I had always held him in my highest esteem – a real model to follow.

So after returning to that institution of higher learning after fellowship training and getting settled in my new routine as a young staff physician, I headed to lunch with an entourage of medical students and residents. It was then that I saw him, my medical idol, in line with a burger and fries, and a tall Coke.

“Hello, Dr. B., how have you been?”

“Hell, just fine, Wes.” It was then I noticed his tray.

Smiling, I quipped, “Dr. B., aren’t those things bad for you?”

“Well, shit, Wes,” he smiled with a twinkle in his eye, “... I look at this way. I have a 50-50 chance of dying of cancer or heart disease... and I’d much rather die of something I understand!”

Brilliant, as always.

So now when I have a burger or steak with friends at a social gathering and am confronted by the competitive guest eager to restate to me the risk factors for heart disease ad nauseam, my response is simple: “I’d much rather die of something I understand.”

Thanks, Dr. B.

--Wes

FDA Warns Against Some Online Canadian Drugs

If you've thought about getting your drugs online from Canada, beware of counterfeit drugs that have appeared in the market:

The U.S. Food and Drug Administration (FDA) is advising consumers not to purchase prescription drugs from websites that have orders filled by Mediplan Prescription Plus Pharmacy or Mediplan Global Health in Manitoba, Canada following reports of counterfeit versions of prescription drug products being sold by these companies to U.S. consumers. FDA is investigating these reports and is coordinating with international law enforcement authorities on this matter.

The link above includes some of the websites using Mediplan drugs. Several cardiovascular drugs were found to be counterfeit, including Lipitor, Crestor, Zetia, Diovan and Hyzaar, among others.

--Wes

Primary Care: The 'Brewing Storm'

An outstanding job of depicting the current crisis for primary care physicians in America today is nicely described by Thomas Bodenheimer, M.D. in tomorrow's New England Journal of Medicine. The full text is here. Take a minute and read this. It will help you understand why folks are becoming so dissatisfied with their primary care physicians, why young doctors are fleeing from this field of medicine, and where the impediments to correcting the problem lie. In effect, it is a perfect "brewing storm."

--Wes

Celebrex Stops Recurrent Adenomas

Two new studies (one here and the other here) from tomorrow's New England Journal of Medicine have demonstrated a reduction in the recurrence of colonic adenomas following polypectomy in folks treated with celecoxib (Celebrex), a COX-2 anti-inflammatory medication manufactured by Pfizer. Unfortunately in both reported studies, the incidence of cardiovascular events in the two studies were increased in the celecoxib-treated groups in a dose-dependent way (Relative risk 1.3-3.4). Bottom line:

"These findings indicate that celecoxib is an effective agent for the prevention of colorectal adenomas but, because of potential cardiovascular events, cannot be routinely recommended for this indication."

--Wes

Another Problem With Pay for Performance

Pay for performance initiatives are likely to generate the wrong incentives, as this attempt to measure "quality measures" by Medicare has demonstrated. If you make money collecting data, expect financial incentives to exceed health care incentives.

I wish our government officials at CMS made the New York Times bestseller, Freakonomics, required reading. This is a classic example of the wrong incentive being supplied...

--Wes

Medtronic Introduces New Pacer Line

Medtronic announced a new pacemaker line publically. From what I can tell, the new feature on these devices is "atrial capture management (ACM)." ACM is where the device can auto-adjust the output of the atrial lead voltage output to assure capture. The devices do have the cool AAI (atrial or upper chamber-only pacing) to DDD mode(upper and lower pacing as needed pacing) switching capability available in their former Enrhythm line of pacemakers to avoid excessive ventricular pacing. I'll see if I can find out other features soon to share them with the blog-o-sphere. I haven't heard of any REALLY new features that will make me switch to these pacemakers... but even Medtronic's website still does not have info on these devices quite yet.

Although the names of the devices are a bit fluffy in my view (I mean Adapta, Versa and Sensia?!? - these sound like some cologne or sex aid, perhaps!), ", at least they avoided the "sound-alike" problem I commented upon regarding their last product line. I guess I was looking for some of the macho names like stents get to have: like "Cobra", "Cypher", "Taxus", "Multilink Ultra", for instance.

:)

Now, the cost? I'm sure they'll be at the top of the spectrum for now....

-Wes

11:03 AM CST Addendum: For the non-EP folks, sorry about the technical speak, but here's what I've learned about the new line of pacers: the Sensia line will replace the old Sigma and Kappa pacemaker product lines, the Versa will replace the Enpulse product line (it will have the "Search AV" feature but NOT the "mimimum ventricular pacing (MVP)" feature), and the Adapta product line will become their "top-of-the-line" pacemaker similar to the Enrhythm pacemaker (i.e. will have the MVP feature) but will NOT have the anti-atrial tachycardia features of the Enrhythm pacemaker. Also the Adapta pacemakers will be capable of accomodating unipolar leads as well as bipolar leads (the Enrhythm device MUST use bipolar leads). Hope this helps!

--Wes

My New Wedding Song

When I was married many, many moons ago, we had Pachelbel's Canon in D Major played for our wedding. Ah, such a lovely song.

But with the years and more of reality stepping on my idealism, I think I'll have this version played when I renew my vows. It speaks volumes.

--Wes

It's Tuesday - Must Be Grand Rounds

Vol 2, No 49 of (Medical Blogger) Grand Rounds is up at Protect The Airway.

"WELCOME TO THE ED …

From here, a patient could end up just about anywhere in the hospital, and besides the frontline healthcare workers in the ED, it seems there is never a shortage of supporting healthcare personnel passing through. All of this makes for a hectic and confusing environment, so let PTA show you the way."

Check it out.

--Wes

Red Cross One Year Later

On the anniversary of the Katrina, Rita and Wilma hurricane disasters, I was sent the one-year progress report from the Red Cross after our t-shirt website, MedTees.com donated a dollar a shirt over three months (almost $500 dollars total) to the Katrina relief effort. Although the Red Cross has been rocked by significant scandal at its local chapters, they still remain an important US-based relief organization and have done remarkable good for millions of victims of these (and other) natural disasters. Hopefully now they can spend some of that money to clean up their own disasters to continue serving the millions of needy individuals during such crises.

--Wes

Medtronic: Could Direct-to-Consumer Advertising Backfire?

For the past week, there have been reports about Medtronic's direct-to-consumer (DTC) advertising campaign to promote automatic implantable defibrillators, devices costing about $20,000-$30,000 that detect and treat rapid, abnormal heart rhythms that can be potentially fatal in people with abnormal heart function.

The company announced plans to spend $75 million to $100 million to improve sales of implantable defibrillators, which have been hurt by doctors concerned about recalls and by worries about proposed sharp cuts in Medicare reimbursement for the devices.

The campaign will include Medtronic's first large-scale advertising aimed directly at patients. Such ads are common for prescription drugs but have been a rarity in the medical device business.

But could such a DTC campaign backfire? Physicians have typically been the individuals to recommend such expensive, life-saving technology to their patients based on recent studies demonstrating a survival benefit to many patients with significantly compromised heart muscle function. Will doctors become frustrated by every patient with normal heart function or no heart diease at all (and hence are not appropriate candidates) calling their clinic to see if they might be candidates for expensive ICD's or who demand immediate appointments because they might fear "sudden unexpected death?" Are doctors' offices prepared for the emotionally-charged ads of people whose lives have been saved by these devices that then ask: "Are you protected?" (or something like this?). Will doctors feel coerced to act, especially when the implication of not acting might be perceived by their patients as not doing enough to protect them, at all costs? Doctors are not oblivious to these marketing tactics, especially in lieu of the "ask your doctor" pharmaceutical campaigns that have preceeded the medical device industry's proposed campaign.

The indications for appropriate referral for ICD's are complicated. Not all patients need them. But some do. The real question is separating the wheat from the chaff - and no advertising campaign can do this. Such a campaign might raise unnecessary fears in our patient population and subsequently cross an important line that shouldn't be crossed: recommending health care for financial incentive rather than by actual need. Oh sure, it might pay off on the short run (some doctors might enjoy the increased volume of patient visits) and their actions with this ad campaign couched in the "feel good" guise of "saving lives." But it might also alientate the very physicians in whom Medtronic relies to recommend their devices, tacitly implying they are incapable of appropriately recommending such therapy to their patients.

But Medtronic is savvy. No doubt this upcoming campaign has been thoroughly vetted by consumer focus groups. But were doctors part of those focus groups? I doubt it.

--Wes

Could Bioengineered Pacemakers Become Reality?

With this report, bioengineered pacemakers might soon become reality.

"In the current study, the researchers delivered a gene encoding a bioengineered cell-surface protein to heart muscle cells of pigs. This protein mimics the combined action of several proteins called HCN ion channels, which play a critical role in maintaining a normal, evenly paced heartbeat. These channels control the flow of sodium and potassium ions in and out of cells that regulate the electrical impulses of the heart."

Many barriers remain before applicable to man, but with the improved understanding of the inner workings of the heart and genetics, who knows?

--Wes

Atrial Fibrillation Ablation Update

One of the better reviews of atrial fibrillation ablation's current state of the art was recently reviewed by John D. Fisher (no relation) and colleagues from Montefiore Medical Center's section of Cardiology in PACE (Pacing Clin Electrophysiol. 2006;29(5):523-537). A link to the online version of the article can be found via Medscape (registration required). It's a worthwhile read full of good basic information and an objective compillation of the reported studies to date.

--Wes

Heparin vs. Enoxaparin for Venous Thrombosis

Perhaps the biggest piece of news in cardiovascular circles this week was the JAMA article demonstrating the equivalency of unfractionated heparin to low-molecular-weight heparins, like enoxaparin (Lovenox) in treating patients with deep venous thrombosis (blood clots in the legs). This study spells trouble for Sanofi Aventis, the maker of Lovenox. Why? Because of hospitals' concerns over pharmaceutical costs. One dose of 5000 units of heparin costs $1.15, where one dose of a 40mg syringe of Lovenox costs hospitals about $24. Granted the usual starting dose of heparin in this study was about 26,000 units (320 U/kg), with 20,000 units (250U/kg) given twice a day, whereas the average daily dose of Lovenox was 8290 units, but this still represents a significant cost savings for hospitals if this drug substitution is widely adopted by the medical community. And since this study was performed without the requirement for follow-up assessment of the partial thromboplastin time (or PTT) blood levels and demonstated an equal safety record, it likely will be adopted in future guidelines for anticoagulation therapy for deep venous thrombosis.

It would be interesting to re-run all of the retrospective studies funded and eventually marketed by Sanofi Aventis with the newer, more aggressive heparin dosing guidelines adopted by the authors of the currrent JAMA article to re-evaluate costs.

Look for more studies comparing plain ol' heparin at higher doses to enoxaparin for other indications (like pulmonary embolus, acute coronary syndromes and the like) in the future.

--Wes

A New Medical Blogger

Please take a moment to welcome Dr. Kannan, a new contributor to the medical blog-o-sphere, with whom I have had the priviledge to mentor and from whom I continue to gain insights on this complicated field called medicine. His thoughtful prose and insights will be most welcomed.

But I'm afraid he's an internet nerd like me.

--Wes

08:20 AM CST Addendum: The link was fixed. Sorry. --Wes

The Cost of Health Care Education

From the Wall Street Journal today via FinAid.org: the average cumulative debt of doctors after Medical school in 2003-2004 dollars was $113,661 with 95% of medical students borrowing money to fund their education. Compare this to law grad students (LLB or JD) whose average debt was $70,933 (87.7% borrowing) or doctorate degree students($49,007 with 51% of students borrowing) and you get an appreciation for yet another financial pressure our young physicians experience when they complete school. Given these price pressures, how on earth can we justify decreasing reimbursements to physicians? But it's likely to happen. Fortunately, it appears the expected cut in reimbursement to doctors of 4.4% will been repealed this year and reimbursements will be held at 2005 levels, but realize with inflation, this "freeze" still represents a pay cut. So it adds insult to injury when one finds that Medicare has decided to roll over reimbursement to the next fiscal year as a budget-balancing tactic and delay reimbursements to doctors by nearly two weeks this September. From the American Academy of Neurology's website:

A brief hold will be placed on Medicare payments for all claims for the last nine days of the Federal fiscal year, September 22, 2006 - September 30, 2006. These dates do not refer to the dates of service, but to the dates that you would have normally received the actual payments if you filed a clean claim. Claims held as a result of this one-time policy will be paid on October 2, 2006, with no interest or late penalty paid to an entity or individual for any delay in a payment by reason of this one-time hold on payments.

This delay of payments will cause a deferment of $1.3 billion to be paid beginning in October 2006 which marks the beginning of government’s 2007 fiscal budget year. The policy applies only to claims subject to payment and does not apply to full denials and no-pay claims. These payment delays are mandated by section 5203 of the Deficit Reduction Act of 2006.

Times are gettin' tough in medicine on everyone, but especially young doctors. And you can bet these young physicians' bankers will still expect payment on their loans without a 9-day lag.

--Wes

Quackery Gone Wild: Laser and Smoking Cessation

I was driving to clinic yesterday and heard an advertisement by Laser Associates of Chicago to promote their laser therapy for smoking cessation. I nearly crashed my car. "What the heck is that," I thought. So I did some research.

Low-level laser light (the stuff coming out of laser pointers) is red light that when reportedly applied to "acupuncture" sites, stimulates the release of endorphins - specialized neuroreceptors in the brain, that by some incredible circumstance, this helps you stop smoking! Wow! It's Star Trek in real life!!!

But closer inspection demonstrates the sinister plot developing. You see, this "clinic" is a "doctor-directed" clinic, so the web site says. I have no clue who is really running it or the exertise of the "therapists." Closer review demonstrates that the "clinical director" is a chiropractor named Thomas E. Newell. According to the Illinois Department of Professional Regulation's license look-up web page, Dr. Newell had an active chiropractor license from 12/20/1960 through 7/31/1996 and failed to renew the license since that time. It seems Dr. Tom has decided to promote a form of smoking cessation that is not based in fact and aims to defraud people out of $299-$399 per "treatment." Similar clinics have popped up in Las Vegas and Detroit. The citizens' action group Public Citizen has made efforts to petition the FDA to stop fraudulent advertising by these clinics. But one of the firms, Freedom Laser Therapy has offered a weak retort to Public Citizen's claims citing their "IRB" (or Investigational Review Board) is on top of the data-gathering. But who sits on their Investigational Review Board? Are they all stock-holders in Freeedom Laser Therapy? Do they REALLY have the patients' best interests at heart? Are patients given informed consent BEFORE therapy? Is that consent signed and dated by the treating unlicensed doctor?

So please, beware. Avoid this scam. Save your money, or if you must spend your hard-earned $299 in cash somewhere, send it to the American Cancer Society to find a cure for cancer, or to Public Citizen to shut these guys down.

--Wes

100th Medical Blogger Grand Rounds

In case you missed it, Dr. Charles did a wonderful job "reporting" on the state of the 100th Grand Rounds yesterday while I was away. Thank you, Dr.C.

--Wes

Time Out

Ah, our quiet respite from the hussle and bussle of everyday life was refreshing. Although not truly "primitive" by purists standards, the time away from electronics and cell phones to camp with fire and tents was a welcome invitation to slow down and discover that conversations can still occur without the aide of technology, and the world is indeed a beautiful place. Our first night was a lovely bed and breakfast where we had our own cabin and woke to a lovely foggy morning in the mountains on a busy dairy farm.

Next we went 26 miles on the Elroy-Sparta Bike trail with the kids.

We followed this with a 12-mile canoe ride down the Kickapoo River the following day.

And managed to stop and enjoy the small things along the way.

-Wes

Time Well Spent

I won't be blogging for the next four days. For the first time in many months, all of the kids are here at home. We've decided to take some time together in the boonies. No cell phone, no computer, no electricity. (What will the kids do?... heh, heh).

This "back-to-school" season reminds me of the frenetic pace the squirrels exhibit as they prepare for the upcoming winter months. But kids grow so quickly. Before you know it they're up and gone. So although short, I know our time together will be time well spent.

--Wes

Sterile Technique in the Cath Lab

A New York Times article today discusses high rates of coronary stenting noted in doctors in Elyria, Ohio realative to the rest of the US. What was more interesting to me was the article's picture: a cardiologist performing a heart catheterization procedure without a hat or mask, while the radiographic technologist at least has a protective face shield. While I am aware of the low incidence of infection from these procedures, potential risk to the operator and patient still exists. Universal Precautions to eliminate infections to the operator from blood borne pathogens are needed, especially in bloody procedures like this. Also, I remain concerned about the potential for infection risk to our patients with indwelling prosthetic valves or who receive implanted devices like stents, vascular closure plugs, and PFO closure devices. Policy is clear on this:

Since the incidence of infections related to procedures in the cardiac catheterization laboratories is low, it is unlikely an adequately powered randomized study of caps and masks will ever be performed. However, the consequences from such infections are significant while the risk of using these precautions is nonexistent. Therefore, it is the recommendation of these guidelines that the use by the operator(s) of a cap, mask, and eye protection be strongly considered, if not mandatory, for all procedures performed in the cardiac catheterization laboratory for the protection of the operator.

If an operator does not use a cap and mask routinely, they should at least be used for procedures in patients who are at increased risk for both an infection as well as for a serious complication, should one develop. Such patients include those with native valve disease or intracardiac prostheses, arterial access performed through a femoral arterial graft, prolonged catheter or procedure times, prolonged use of an in-dwelling sheath following the procedure, intra-aortic balloon pump insertion, per-Infection Control Guidelines cutaneous valvular procedures, and the use of implantable devices such as stents, septal closure devices, and/or VCDs. It may not always be known at the start of the procedure if one of these higher-risk situations will occur. Accordingly, each facility should consider the best policy for their laboratory, with patient safety given the highest priority.

Issues related to blood-borne pathogens are real, especially in today's highly-interventional cath labs, and proper sterile technique improves safety for the patient AND cardiologist. After all, most of our technicians follow the physicians' lead.

--Wes

FDA Approves Plavix for Acute MI

Today the FDA approved clopidogrel (Plavix) for acute myocardial infarction when the patient is NOT a candidate for revascularization with angioplasty (opening the artery directly) and instead receives the thrombolytic (clot-busting drug) therapy.

Two studies support the effectiveness of Plavix in treating STEMI heart attack patients. A large trial, the Clopidogrel and Metoprolol in Myocardial Infarction Trial (COMMIT) study, demonstrated that Plavix, when combined with other standard treatments including thrombolysis, a procedure to dissolve clots, reduced mortality and also reduced the combined number of recurrent heart attacks, strokes and deaths. COMMIT was a randomized, double-blind, placebo-controlled trial of 46,000 patients conducted in China.

The findings in COMMIT in China are supported by the results of the Clopidogrel as Adjunctive Reperfusion Therapy (CLARITY) study. CLARITY was a clinical trial of 3,500 patients undergoing thrombolysis for STEMI heart attacks. CLARITY showed that the coronary artery blood flow was better with clopidogrel treatment compared to placebo.

For folks without easy access to a heart catheterization laboratory during a heart attack, this might help their outcome.

Given the recent release of generic forms of clopidogrel, it might not help Bristol-Meyers Squibb(BMS)/Sanofi Aventis overcome its lost market share to cardiologists, though.

--Wes

Stop Dissin' my Coffee

Sorry, I can't buy the "just one cup of coffee can kill you" crud coming from the journal Epidemiology (the accompanying editorial can be viewed here). No placebo control group was used and there's just too many covariates to make any meaning of the data. It's particularly bad when such crud is picked up by the mainstream media. The study flies in the face of any "dose-response" theory as we know it. Why would 4 cups not hurt you but one would? The authors offer no plausable explanation. If this was true, I know lots of folks who would have died long ago.

"For people with multiple risk factors for a heart attack and those who have a sedentary lifestyle, a cup of coffee could be the final straw," says Ahmed El-Sohemy, Ph.D., an assistant professor of nutrition at the University of Toronto. "One should aim to remove some of these known risk factors and have a more active lifestyle."

Coffee as a trigger? Doubt it. Why do we now see the benefits of coffee to prevent Type II diabetes or prevent cirrhosis or improve the health (and lower heart attack risk) in postmenopausal women. Since this latest study came from Costa Rica - could it me a back-handed ploy to get people to drink more than one cup of coffee?

I think the most damaging part of coffee for your heart is the transmogrification of a good cup of Joe into these nuclear fat balls (like frappachinos) dispensed at Starbucks.

I'll still have my coffee black, thank you. And if I'm not here tomorrow, oh well...

--Wes

Grand Rounds: A Letter From a Father to His Son

From a father to son: all the nuances of health care today are outlined in Medical Grand Rounds this week at Hospital Impact.

--Wes

Health Care Pricing Challenge

Interesting piece from last Sunday's Chicago Tribune regarding how difficult it is to find accurate negotiated costs regarding health care services rendered here in Chicago (and I suspect other places, too). But the real culprits here are not the hospitals, in my view, but the insurers.

Why? Remember that hospitals do not sell patients their insurance, insurers do. To 'help' people reduce their premiums, we now have high-deductible insurance plans offered to employees. But insurers won't disclose the pre-negotiated costs they have arranged with hospitals, and hospitals don't want these pre-negotiated reimbursements disclosed so they can negotiate an even better reimbursement rate with another insuring competitor (call it the "business of healthcare)."

And for a litle more irony? The insurers determine which hospitals you can go to anyway! So "patient's chosing where they receive care" is nothing more than a marketing ploy to entice patients into thinking they're empowered in this process.

I wonder where things will be in another 10-20 years when I really need health care services?

--Wes

Recipe For the World's Greatest Hospital

It's simple, really.

Warm room to 76 degrees farenheit.
Take 1 part patient, add a teaspoon of doctors with exceptional skills,
add 1 tablespoon receptionist, a dash of facility, 3 teaspoons lab staff,
and a radiology tech. Set aside.

In a separate room, place the other patient.
Prepare the existing room by making the bed.
Keep the water container full. Chill.
Puree the incapable technicians who argue with the patient.
Carefully fold in nurses who smile, are attentive and communicative (and not understaffed).
Mix well. Repeat the last step and add patience.

Permit all ingredients to sit undisturbed overnight.
Each morning, carefully measure all vital signs - report accurately.
Smile often and listen.
Fold in ingredients previously set aside.
Review all studies - plan approach.
Seek divine intervention and begin ambulation as soon as possible.
Add stool softener.

Replace any remaining nursing technicians with RN's and LPN's - allow no substitution here. (Realize the cost is worth it).
Assure nurses' efforts are appreciated and validated.
Engender teamwork and foster professionalism amongst staff members.
Delete all unnecessary verbage from the electronic medical record.
Sprinkle with social work services liberally.

When completed, bake slowly and do not permit administration to open oven.
When center of patient springs back to soft touch - remove.
Garnish with a well-formulated discharge instruction sheet.

Serving size: One patient.

Enjoy!

--Wes

P.S.: This recipe can have many variations - feel free to add your own!

This Little Piggy

I couldn't help myself. I guess you could say I have a sick sense of humor. I thought about the second surgery my father was to have today, and smiled.

"Dad, I have to do this. Call me sick, but you've had a rough week."

My mother seemed puzzled. I stood at the foot of his bed.

This little piggy went to the market.
This little piggy stayed home.
This little piggy will be history.
And this little piggy will have none.
And hopefully, this little piggy will go "wee, wee, wee," all the way home soon.

They both laughed. What else could you do?

And off to the OR he went.

--Wes

FDA Clarifies Points from JAMA Article on AED Recalls

A worthwhile clarification by the FDA was published today regarding the JAMA article on automatic external defibrillator (AED) recalls recently published. Hopefully this will quell some of the hype regarding the authors' findings.

-Wes

Coronary Bypass Best for Severe Coronary Disease?

Today a Reuters news release discussed a study from the July 2006 European Heart Journal that coronary bypass surgery improved quality of life for the elderly better than conventional medical therapy. While this may be true, the study was conducted from 1995 to 1998, well before the advent of drug-eluting stents. Certainly, the upfront risks of such major surgery are of concern for anyone with severe diffuse coronary disease. Recently, the technology to approach complex coronary artery disease by minimally-invasive means has become available. But to really ascertain which therapeutic approach is safest and most effective to recommend to our patients, a multi-center, prospective, randomized trial should be undertaken. Enter the SYNTAX Trial. The SYNTAX Trial is a large multicenter trial comparing the efficancy of three-vessel percutaneous revascularization (with stents) head-to-head to coronary bypass grafting for patients with severe three-vessel coronary disease (including left main coronary disease). It promises to shake up the field of cardiology IF percutaneous revascularization is found to be as safe as bypass, but the results won't be known for some time.

If you know someone who would be a good candidate and would consider having a 50% chance at less invasive surgery for severe coronary artery disease, consider contacting a center performing the Syntax Trial.

--Wes

November-3-5-Uniform-Papa

It was gold and hand-made. It was one-of a kind. Small, cherished, and crafted carefully to have details that would be important to the recipient, but attractive enough to wear for most occasions. It was a unique metallic miniature Beechcraft Bonanza airplane in a three-dimensional relief on a gold background. November-3-5-Uniform-Papa. Heavily instrumented with storm scope, multiple transponders that permitted calculation of speed, arrival time, and the full instrument flight rating or IFR. He'd mastered the skies and loved to fly. It was his passion. He received one of the highest scores ever on the written portion of his pilot's license exam. Every inch of that plane would be checked and rechecked before each outing. Obsessive cleanups occurred after each landing. His baby. In a testament to his passion, the entire wall of his office was covered by green flight charts of the entire airspace surrounding our house. Every airport, runway, IFR transponder for hundreds of miles graphically portrayed on the wall. Never did I see him so happy as the days he flew. And never did I see him so anxious as when bad weather threatened his trips. Life each day was determined by the weather report. November-3-5-Uniform-Papa emblazoned on the craft's tail. Can't land to pee! Use a urinal! Ah, to fly!

So to see that necklace lying in a plastic bag, next to a pair of glasses and a watch, I couldn't help but flash back to a scene I had encountered while working as the Head of the Emergency Department in the United States Navy many years before: twisted wires that used to be a pair of glasses, articles from a wallet, a torn picture of a family I didn't know, Navy dog tags. One of my best friends was asked to deliver these articles to a grieving wife and mother of two young girls. They all knew it could happen. None expected to die. All risks taken were worth it. Only the best flew F-18's in the Navy. So now to look at the carnage represented by these articles I knew the end came quickly. And yet these objects were cherished by the wife, because they were his. They were him, carefully placed in a small container and wrapped in a white cloth. Keepsakes for eternity.

I took the plastic bag that contained my father's necklace, glasses, and watch from the nurses today. They had to be removed before surgery. I never realized how important that necklace was to my father, but they said he surrendered it with great reluctance. It was his contact with years before - of an era of unlimited potential and unlimited freedom. It represented his most cherished hobby - a hobby that had to be surrendered after his health conditions became a concern. And now I held it in my hands. The thought that a day will come when these items would be all I have to remember him by was eerie. I prayed it wouldn't be today.

So when the call came that all went well and he was in the post-anesthesia recovery area I hurried back to see him - call it physician "executive priviledge." And there he was, sleepy, with that grey post-anesthetic look, but arousable.

With that I hurried to replace his necklace, watch, and glasses. "You can't fit it over my head, you know, my ears are too big." I fumbled with the clasp. He smiled. "There, they're on!" They looked really good on him, even with the flowered hospital gown draped over his chest.

And I was happy to have to wait a bit longer before holding these in my hands again.

--Wes

Doctor Cuts Spell Trouble for Medicare Patients

If I asked Americans of all shapes and sizes to take a 5.1 percent cut in their salary in 2007, how many would continue to work in their job? Most would say: "Time to move on."

Doctors are facing just that scenario: a 5.1% cut in reimbursements for Medicare patient services beginning in 2007. Medicare patients, by far the most numerous and vulnerable, will no doubt be refused entry in practices where they once were welcomed.

I fail to understand the logic of Medicare officials cutting physician's reimbursements as a means to control costs. It's like owning a business that writes computer software and deciding to cut the salaries of the programmers that build the software on which your company exists. Will all the bureaucracy and overhead with medical care today, these Medicare officials should consider the following:

• Since 1977 to now, there has been an exponential growth in the number of hospital administrators compared to a near linear growth of physicians during the same period.


• Hospital administration costs represent approximately 25% of the health care dollar spent.


• Physician's Medicare reimbursement rates have consistently failed to keep up with the rate of inflation.


• Malpractice expenses have risen nearly 30% in the past three years for most physicians.

Since admistrators are not on call 24-hours a day and typically work 8 to 12 hours per day based on their salary, I have a suggestion for making rapid, deep cuts in health care spending based on the number of hours worked: remove one half of all admistrative officials at each hospital, insurance agency, collection agency, patient survey company, and the like. Or perhaps more provocatively, cut their salaries by 5.1%.

--Wes

Medical Blog-o-sphere Grand Rounds

This week's Medical Blog-o-sphere Grand Rounds comes from South of the Border.

--Wes

External Defibrillators Also Subject to Recalls?

After seeing this news release regarding the high frequency of external defibrillators being subject to recalls, I'm not sure how we can use automatic external defibrillators to reliably call someone dead, as this article from the New England Journal of Medicine proposes. As I suggested previously, the algorithms for detecting rhythm disturbances in acute emergencies might not be fool-proof enough to make final decisions regarding someone's life.

--Wes

The Talk

My Mom seemed relieved. She returned from the hospital late in the day after staying by my father's side through countless evaluations and assessments, really not comprehending all of the facts, figures, percentages she had heard.

"Your Dad and I talked today, and I really didn't have to bring it up. He did. We were just sitting there after seeing the Nephrologist and I don't know what we were talking about, but all of a sudden he said, 'What ever happens I just don't want an open casket!'"

I listened.

"It was so nice to really talk about these end-of-life issues. We had a wonderful conversation, well, not that it was the greatest thing to talk about, but your father was very open, frank, honest, and I might even say, philosophic, about his final wishes. It was so nice to have such a talk, I can't tell you. We really talked. After over 50 years together... it was so nice to have the time, and such a relief."

It was like a huge burden had been lifted from my mother's heart. She knows now. No question is left unasked, no desire or arrangement to be managed in the end left untended. Not everyone is so lucky to have "the talk" with their loved one. But I was impressed that my mother felt so comforted by it. In my ignorance and with plenty of denial, I'm sure, I reassured her that such a conversation probably isn't needed now.

"You never know," she said.

--Wes

Bill Frist's Health Care Frisk

In an op-ed in the Washingon Times, Senator Bill Frist (R, Tenn.) discussed a new health care bill which strives for interoperability of Electronic Medical Record (EMR) systems to permit secure communication of information between EMR systems while also monitoring the "quality" of health care delivered by today's hospitals and physicians and "rewarding them" accordingly. It seems the Pay for Performance (P4P) model is well on its way to becoming the law of the land:

"The legislation gives the government the responsibility for helping to set standards, establishes a federal structure to oversee federal health information technology efforts, removes barriers in outdated laws, and includes some modest support for new information technology infrastructure. In addition, it will begin monitoring the quality of care so we can reward doctors and hospitals that provide the best care."

I always get scared when the government mandates such "quality" guidelines, especially when they plan to provide a financial incentive for following the rubric. Certainly practices, hospitals, and physician groups that follow the "quality rubrics" imposed by the government by electronically ordering tests and performing rote computer-supplied documentation lock-step with these requirements will be the ones that survive in tomorrow's health care environment. But are we not removing the "art" of medicine in favor of "paint by numbers?" Will such massive guideline-following really improve the quality of care, or the quality of reimbursements? Are we not making yet another bureaucratic convention to serve, rather than serving the patient? And at what cost? Only time will tell.

But what happens to this model if medical errors should occur in the course of treatment? It now seems doctors are not so reliable at self-reporting errors - particularly when the error was a system-based problem and not that of the responsible provider. Will the fear of NOT receiving Frist's "quality" bribes added payments further disincent accurate reporting of errors? You bet.

Worse still for doctors, this documentation requirement will likely become another reason for Medicare to refuse payment for services rendered. I can see it now: "Oops, we didn't see documentation of the pneumovax being administered in the last 10 years on your chart, so we're not paying for last week's gall bladder resection on Mr.Smith," says the insurer. There go your times in accounts receivable. Or perhaps in a best-case scenario, "Sorry, doc, without such documentation we'll only pay 50% of your bill. Our database shows you're a poor-quality provider..." Good luck reversing that designation once you're labeled.

I agree with Frist that the inter-operability and transmissibility of medical records between institutions will improve health-related communication between facilities and will result in improved and more efficient patient care. This needs to happen. But anytime a financial incentive is tied to reimbursement, it welcomes manipulation of the system, especially when such manipulation can occur under the guise of "improved quality of patient care" whether by caregivers or by the government. This is yet another example of the further commoditization of medicine - making medicine a fast food enterprise - and is offered as if this is the only path we can take.

Sadly, it seems such "quality payoffs" will likely benefit everyone except the patient.

--Wes

The Call

After passing through the Black Squirrel Capital of the World (Norwalk, WI) and the city where they make square pies (Gina's Pies R Square Restaurant, Wilton, WI) along the Elroy-Sparta bike trail, the call came.

"Wes?"

"Hi, Mom. What's up?"

"It's not good. Dad saw the podiatrist yesterday and he said that he should see his 'vascular guy.'"

"What's going on?"

"Well he said there's something... I don't know! Can I read you the diagnosis he wrote down for me?"

"Sure."

"Area of blackened necrosis distal aspect of third toe left foot with mottling of other toes and with bilateral dependent rubor. He said we should see a vascular guy, but I told him our vascular guy is in Rochester, Minnesota!"

"What did he say then?"

"He just gave me this paper and told be he'd better get seen soon. What should we do?"

So much for the bike trail. So much for the weekend off. I should have made him see an internist near us! Why now?

We headed home. A call was made to the Emergency Room. I suggested my parents head over to the ER immediately. Six hours later, they arrived ("Had to get the dog a sitter and pick up your father's meds," I was told).

Well, 4 o'clock on a Saturday afternoon is NOT the ideal to hit ANY Emergency Room - it looked like a war-zone after a day of back-to-back patient evaluations - but my colleagues were great, got him seen, normal-sized aorta, found miserable renal function, and he was admitted. The toe, it seems, is the least of his troubles. Frustrated, tired, depressed, resigned to the fact that he knew we'd get him here, somehow, some way, my father seceded to our persuasive onslaught.

But now I must transform from an internist, cardiologist, and doctor, to a son. How does one do this? How to demonstrate empathy while not being too nosey. Should I sit in the room with him? Or will I be too intimidating to the consultants, nurses, and residents who busily do their assigned tasks? Should I review his labs? But this is my father! What do I say? What do I reveal?

"I rode the Elroy-Sparta trail once. Beautiful! Those tunnels are amazing!" he said. "Sorry you guys had to come back."

And suddenly he made it very easy to transition from a doctor to a son. His son.

--Wes

Having Computers Decide We're Dead

Death can come easy now.

Or at least deciding when to say enough is enough. And it seems the computer will help us make that decision. And if it does, about one in three patients would actually qualify for advanced cardiac life support.

This week's New England Journal of Medicine prospectively analyzed a prediction rule using the computer algorithm contained in an automatic external defibrillator (AED) to decide if it was worth transporting a patient found "down" to an Emergency Room. Actually the prediction rule required three things: Emergency Medical Technicians (EMTs) may consider the termination of resuscitation (1) if there is no return of spontaneous circulation before a patient is transported to the emergency department, (2) if the patient received no shocks by the AED before transportation was initiated, and (3) had a cardiac arrest that was not witnessed by EMS personnel responding to the call. Using these three indicators, the prediction rule had a positive predictive value of 99.5 percent and a specificity of 90.2 percent. Among patients whose condition met these three criteria, the survival rate was 0.5 percent. (Yes, there was a very rare circumstance where an individual would survive, even when all three criteria were met). But the prediction rule would have resulted in the transportation of 37.4 percent of patients (464 of 1240), rather than the current rate of 100 percent, and likely saved countless wasted medical resources and perhaps avoided unnecessary risk to the public as the ambulance rushes to the hospital.

AEDs interpret EKG signals from the patches applied to the patient's chest. Using these signals, the device can instruct an early responder whether to apply a shock to a person's chest or not. In effect, these algorithms help decide when not to be overly aggressive at resuscitative efforts.

The authors make clear that these prediction criteria should not be absolute:

"Finally, we consider that our prediction rule offers guidance for clinicians but is not obligatory. In an editorial published more than 20 years ago, Cummins and Eisenberg (Cummins RO, Eisenberg MS. Prehospital cardiopulmonary resuscitation: is it effective? JAMA 1985;253:2408-2412) suggested that prediction rules for the termination of resuscitation efforts should remain advisory and that they should be tempered by the full clinical picture, taking into account the very small possibility of successful resuscitation when the prediction rules suggest termination."

Certainly clinicians are aware of the cerebral-preserving effects of hypothermia. But beyond this, will our ambulance crews accept the clinical decision-making responsibility in our litiginous society? Will the families accept their loss and concur with the EMT's decision in all cases?

Not always. So even with the advances of computer technology and the use of automated schemes, "dead" patients will continue to be transported to Emergency Rooms.

And that's okay.

--Wes

Heading off to the hills of Wisconsin for a bit of much-needed vacation his weekend. See you Monday.

A Brief Reprieve

Thanks to the lobbying efforts of the medical device makers, it looks like I still might have my job next year...

- Wes

George Bush and HIPAA

On a lighter note, isn't all this disclosure of personal health information on President Bush in direct violation of HIPAA privacy laws?

--Wes

Non-Electrophysiologists and Defibrillator Implantation

To appreciate an example of the latest furor between general cardiologists ("plumbers") and cardiac electrophysiologists ("electricians" or heart rhythm specialists), one only needs to read the front page of the New York Times this morning. Non-electrophysiologists implanting defibrillators: it's a mess and a disgrace to us "electricians," but it was bound to happen.

The New York Times points out the questionable ethics of defibrillator companies like Biotronik paying for training of physicians for free and NOT requiring them to have any long-term formal training or testing to perform these implantations. But hungry non-US device companies eager to gain market-share do what is needed to compete. And doctors in their eagerness to increase revenues and isolated geographically from other centers with experienced board-certified electrophysiologists, now use 'patient convenience' as their excuse to perform these procedures locally in their center, despite very little training. Ten cases and a voluntary test is all they need to be certified? Hogwash.

Cardiologists will argue that implantation of these devices is no different than implanting pacemakers. I disagree. Here's an example. These devices are considerably larger than conventional pacemakers. How many of these cardiologists have had experience with a subpectoral (placing the device beneath the breast muscle) implantation in their 10 cases? I would suspect none. But if these devices are implanted subcutaneously (beneath the skin and above the breast muscle) in very skinny individuals, there is a greatly increased long-term risk of the device eroding through the skin and becoming infected. Will these doctors have the judgement to do what's right for the patient during the initial implant? Obviously not, since they would never have gained the surgical skills required and are unlikely to have ever seen a device erosion in their limited experience.

And don't get me started about the follow-up of these devices AFTER they are implanted. How many cardiologists have dealt with repetitive firing of the defibrillator due to improper programming, or upper chamber rhythm disturbances, or malignant lower chamber (ventricular) arrhythmias? Will 10 implants teach them how to troubleshoot correctly or how to revise the system to correct the problem? Hardly.

One more tidbit: the computer programmer to communicate with these devices is specific to the implanted device and must be available at medical centers if you have a problem with your device. In my experience with Biotronik, they have nowhere near the number of technical support staff or market penetration as the other US-based companies to assist physicians with these complicated devices. If you travel, you might want to inquire about this.

But perhaps most disappointing for those of us in this field, is the fact that the Heart Rhythm Society folded to the influence of the device industry to permit the "fast track" option for training of implantation of defibrillators in the first place. It devalues the expertise of those who have acquired the conventional electrophysiology training, and leaves in question why anyone should have to endure the 12-24 months of their subspeciality training in cardiac electrophysiology in the first place.

There is huge financial incentive for Medtronic, St. Jude, Boston Scientific, and Biotronik to capitalize on the expanded indications for defibrillator implantation. These are very expensive devices that represent the majority of revenues to medical device companies. So much so that there was significant political pressure imposed by the industry on our elected officials of the Heart Rhythm Society to address industry's concerns that there were not enough physicians trained capable of implanting these devices relative to industry's perceived number of devices that would be required - and hence the "fast track" implantation training was born.

Yet here we sit. Our lab is NOT to capacity. We have never turned away a consult or been unable to provide a defibrillator implant in a timely fashion to any patient referred to us. Even the business community is rocked by the "slow-down" in the number of devices implanted recently. Real concern exists as well that these minimally-trained cardiologists might not select the best device for their patients. And yet our Heart Rhythm Society made a fast-track despite significant concerns by other colleagues in their field.

As this "get-rich quick" scheme plays out across the country, patients might want to ask several questions of their defibrillator implanter:

1) Are you board certified in cardiac electrophysiology?
2) How did you document your skill at defibrillator implantation?
3) Which manufacturer's device will you be implanting? Why?
3) Have you ever performed a subpectoral implantation?
4) Do you have a defibrillator follow-up clinic or will I be sent to someone else for this? If so, how often do they see patients?
5) How many defibrillator implantations (not just pacemaker implantations) and revisions have you performed?

And if you're still not sure. Get a second opinion, preferably from a board-certified cardiac electrophysiologist.

--Wes

For disclosure and out of fairness, I am a speaker and consultant to Medtronic, Inc.