The Knights of the Round Table

Charge Given to the Knights by King Google*

God make you a good men and women and fail not of beauty. The Round Table was founded in patience, humility, and meekness. Thou art never to do outrageousity, nor murder, and always to flee treason, by no means to be cruel, and always to do patients, the elderly, and gentle children succour. Also, to take no battles in a wrongful quarrel for no law nor for no world's goods, except for fee for clicks.

Thous shouldst be for all nurses, doctors and patients and fight for their quarrels, and ever be courteous and never refuse mercy to them that asketh mercy, for a knight that is courteous and kind and gentle has favor in every place. Thou shouldst never hold a medical record, patient, nurse or gentle caregiver against their will.

Thou must keep thy word to all and not be feeble of good believeth and faith. Right (and privacy) must be defended against might and distress must be protected. Thou must know good from evil and the vain glory and profit motives of the world, because great pride and bobance maketh great sorrow. Should anyone require ye of any quest so that it is not to thy shame, thou shouldst fulfil the desire by asking medical bloggers and patients themselves.

Ever it is a worshipful knight’s deed to help another worshipful patient with search engines when he seeth him a great danger, for ever a worshipful man should loath to see a patient misinformed, for it is only he that is of no knowledge and who faireth with cowardice that shall never show gentleness or no manner of goodness where he seeth a patient in any danger, but always a good man will do another man as he would have done to himself.

Do not, nor slay not, anything that will in any way dishonor the fair name of the US Healthcare System for only by stainless and honorable lives and not by prowess, conflicts of interest, and courage shall the final goal be reached. Therefore be a good knight and so I pray to God so ye may be, and if ye be of prowess and of worthiness then ye shall be a Knight of the Table Round.

-Wes

* With apologies to kingauthursknights.com.

Hat tip: Kevin, MD.

Dr. Charles Bids Farewell

Without doubt one of the most eloquent writers in the medical blog-o-sphere, Dr. Charles is taking an extended break to pursue his passion.

-Wes

Do Residency Restrictions Limit Clinical Competencies?

“Good judgment comes from experience. Experience comes from bad judgment.”
-- Anonymous

“I have missed more than 9,000 shots in my career. I have lost almost 300 games. On 26 occasions I have been entrusted to take the game winning shot, and I missed. And I have failed over and over and over again in my life. And that is precisely why I succeed.”
-- Michael Jordan

Ask any doctor in practice today what they think about residency programs, and most will tell you they do not represent medical reality. But then, residency should not represent independent practice, should it? This week, the New England Journal of Medicine has two articles describing the dilemma faced by the residency training programs: residents’ work hours and continuity of care. Residents want shorter work hours by sharing care of patients with other residents, but frequent handoffs of care may result in as many medical errors as created by an exhausted resident.

Kevin Volpp, an assistant professor of medicine and health care systems at the University of Pennsylvania, is conducting a large national study of patient outcomes that attempts to examine the impact of the (Accreditation Council for Graduate Medical Education) rules, using data on millions of patients in the Medicare and Veterans Affairs systems. "We're basically looking at the net effect of reduction in sleep deprivation versus reduction in continuity of care," he said. "One of the big challenges is figuring out how to tease this apart and examine the tradeoffs." Volpp said the evidence is compelling that assigning residents to shorter shifts reduces errors caused by fatigue. However, shortening residents' shifts requires adding staff such as physician assistants, nurse practitioners, and hospitalists, and he noted that despite receiving Medicare subsidies for residency training, teaching hospitals operate on slim financial margins and have recently seen substantial reductions in Medicare funding. Considering the cost of further reducing duty hours, Volpp asked, "Is this the best use of resources that could be targeted to reducing medical errors?"

But is reducing errors really what we should be striving for in residency programs? Will further reducing work hours limit exposure to eduational experiences? Will residents have enough opportunities to stumble, trip and fall in a protected environment like residency so they can later succeed as attending physicians? Or is achieving a residency utopia in training with no medical errors more important than later clinical competency as an attending physician?

Certainly worth pondering…

...especially when good judgment comes from lots of experience.

-Wes

MedBlog Power

Thanks to Kevin, MD, with his amazing ability to stay abreast of the latest news and commentary in medicine while working as a practicing internist, for his mention as a member of the his weekly MedBlog Power 8.

-Wes

Who Needs Minute Clinics?

...especially when you can order your own blood tests for heart screening online yourself?

HeathCheckUSA is proud to offer a heart check profile, which is essential for anyone concerned about their cardiovascular health. Even if you have no immediate concerns, a heart check profile is a good way to gauge your baseline levels for future comparisons. Our heart check profile combines many different of the following tests, which combined give you a good measure of your overall heart health. The combination of homocysteine, highly sensitive C-reactive protein, Chem-26, and the revolutionary VAP (Vertical Auto Profile) cholesterol profile makes our Heart Check Profile the most comprehensive cardiovascular disease assessment HealthCheckUSA offers.

Yee hah! Can't wait to see all those people who've gotten false positive results in my clinic! I mean with over 30 blood tests being performed, what are the odds someone will have one abnormal test if we estimate there's is a 2% false positive or false negative rate? About 60%!!! Yee hah! Better than even odds!

But their "comprehensive cardiovascular disease assessment" misses what's really needed - a good history and physical. From the Third report of the National Cholesterol Education Program Expert Panel's report (ATP-III):

"The identification of cholesterol disorders in the setting of a medical examination has the advantage that other cardiovascular risk factors—including prior CHD, PVD (peripheral vascular disease), stroke, age, gender, family history, cigarette smoking, high blood pressure, diabetes mellitus, obesity, physical inactivity—co-morbidities, and other factors can be assessed and considered prior to treatment. At the time of physician evaluation, the person’s overall risk status is assessed. Thus, detection and evaluation of cholesterol and lipoprotein problems should proceed in parallel with risk assessment for CHD."

And the "VAP®" test they claim is so superior for detecting cholesterol? It's not recommended as a screening test for the general population. Period. From Atherotech's own website:

When used judiciously, the improved LDL-C accuracy and additional ATP III information provided by the VAP cholesterol test can be used to better identify and manage individuals at elevated risk for CHD. (i.e., not as a screening test) The conventional Friedewald calculated profile is recommended for patient screening.

So save your money. And if you're really concerned about your health, see your doctor.

-Wes

It's Sicko, Alright

Michael Moore, health care policy expert, hit Washington DC yesterday to the applause of many of our nations' politicians. But his morning's Tribune commentary from Helen Evans, discusses what he may have left on the cutting room floor.

-Wes

World Record Treadmill Runner

Shouldn't this guy be promoting heart health rather than prostate cancer research?

Ultramarathoner Dean Karnazes will attempt to break the world record by running more than 153.76 miles in 24 hours on a treadmill in Times Square. He'll start running at midnight Thursday and be suspended between two billboards. One billboard will run live video for viewers, along with a clock and mileage counter.

Karnazes plans to raise $1 million for the Athletes for a Cure Foundation, with the money going to prostate cancer research.

Sheesh! But who's going to follow his EKG?

-Wes

Clipboards or Care?

It seems health care is going from bad to worse.

Now we have "lean manufacturing" from the manufacturing industry on which to improve healthcare:

Michael Roberto, an associate professor of management at Bryant University, says the trend will continue as hospitals face increasing pressure to control costs while improving patients' safety and satisfaction.

Much of the demand for factory veterans stems from hospitals' embrace of lean manufacturing techniques. Pioneered by Toyota Motor Corp., lean manufacturing aims to cut waste and reduce defects by speeding up the production cycle, shrinking inventories and implementing just-in-time supply delivery. On hospital wards, lean tactics are used to reduce patient waiting times or prepare operating rooms faster. ThedaCare was among the first to adopt these techniques in 2002.

Ted Stiles, whose recruiting firm specializes in placing managers with backgrounds in lean manufacturing techniques, says demand among health-care providers is up tenfold this year from last year.

Once again, "health-care providers" is a term confused with doctors. Sorry, this doctor does not agree.

"Lean manufacturing" seems to me to be nothing but a euphemism for "lean staffing." Do more with less. Once again, it appears that hospital administrators would rather turn to non-medical auto-industry "efficiency" and "safety" experts, rather than asking health care professionals to recommend the best way to improve care. Instead, they turn to these "experts" to squeeze any amount of remaining professionalism from their medical staff in order to squeeze every health care dime out of the staff they have.

Why? Because nurses and doctors are "expensive" to hospitals.

But what, exactly, is the cost of these hired-gun administrators? Do we really need yet another company or administrator to tell us how to do our job? Is it all about safety and efficacy? Or might providing a better nurse-to-patient ratio be far better at improving care?

And regarding "patient satisfaction?" Ask any patient - is sitting in a dirty bed after soiling yourself and not being able to get a nurse to help you in a time of need what patients want because they've cut back on nursing staff to become more "efficient" and "safe" or "satisfying." Will these clib-board carrying types be on call at 3AM to help answer a call button?

Certainly it is important to provide a safe environment for our patients. No doctor or nurse would argue that fact. But using "safety" and "efficacy" and "patient satisfaction" as a ruse to provide less frontline care in the name of "improving efficiency" is not only potentially dangerous, but expensive too.

-Wes

Addendum: NHS Blog Doctor adds his not-so-subtle pithy bit about this trend as well.

ACLS Recertification Issues

I recently recertified in Advanced Cardiac Life Support, and really wasn't doing to say much, but then, I blog.

Sooooo, I thought it might be informative to discuss a few issues I had with my ACLS recertification process this year.

The American Heart Association provides a course for health care professionals to learn the latest techniques for Advanced Cardiac Life Support in the event an individual collapses of cardiac or respiratory arrest. The certification process is partially performed by company called CardioConcepts (although now it looks like its called 'Scitent') based in Virginia. The recertification process demands a fee for their course and includes an online registration where doctors must now surrender their most personal information (address, phone number, e-mail) to their website on an electronic registration form. You can bet this information is sold, but I digress...

I have some constructive (I hope) criticisms.

If a company is going to teach ACLS instead of doctors, then either the members of this company must first learn EKG's - especially is I have to PAY for the priviledge of undertaking this experience every two years - or else the American Heart Association needs to do a better job proofing the work for hire for which they have contracted.

For the student's pre-test (available on a CD within the ACLS provider book), we find this tracing:

Click to enlarge

So what is this rhythm? The publishers of the student pre-test for ACLS would have you believe it was "Reentry Supraventricular Tachycardia." I wonder if these guys know basic medical terminology. The correct term should be "reentrant supraventricular tachycardia." *Sigh*

But that's not the real problem with this tracing. My guess this tracing is not even reentrant. (I'm open to what other cardiology and EP docs think, here). Look carefully at how this arrhythmia initiates - a slightly premature beat that looks quite similar to the sinus beat - followed in rapid succession by other P waves with a sudden onset with a "warm-up" phenomenon. See the small indentations in the T wave? These suggest a superimposed P wave. I have placed lines above the P waves below:


These findings seem most consistent with an atrial tachycardia to me. Atrial tachycardias usually have an automatic mechanism, not a reentrant one.

And don't get be started about this tracing of Torsade de Pointes which appears on the Student pre-test:


The correct answer (according to their student pre-test) was "Coarse Ventricular Fibrillation." Wrong again. Most texts and online resources I've seen have classified this as arrhythmia as one form of "Polymorphic Ventricular Tachycardia," not coarse ventricular fibrillation. Certainly the treatment for Torsades is very different (consider magnesium, pacing, isuprel, lidocaine, etc.) than for "coarse ventricular fibrillation" (shock, drugs and shock again) and should be recognized by everyone who cares for heart patients.

And I was surprised procainamide was removed from the Tachycardia with Pulses algorithm, especially for irregular, wide tachycardia algorithms as well. I've already discussed my preference for this drug (and why) in an earlier post (See Part I and Part II). Instead, they've decided a "Phone a Friend" option (actually, it says, "expert consultation advised") works best. But sometimes experts aren't there right away...

I do appreciate the folks at the American Heart Association's efforts. I can't imagine what an undertaking organizing the training of the nation's doctors must be like. But we must assure that we train folks correctly and give good examples.

After all, people's lives are at stake.

-Wes

Image credit.

One Expensive Domain Name

Man, they paid $550,000 at auction for Cardiology.com. I mean, I guess it's a good subspecialty name, but it seems the be a high price to me.

But then then again, it might pay for itself if it helps sell about 28 defibrillators or 275 drug-eluting stents...

-Wes

Proving Our Worth

I just don’t get it.

Here’s how we attempt to control the costs of healthcare in America.

First, we must prove to the medical consumer that we have good healthcare in the US and that Medicare is getting their money’s worth, so we assemble TONS of people in the form of associations including: the American Hospital Association (AHA), Federation of American Hospitals (FAH), Association of American Medical Colleges (AAMC), Centers for Medicare and Medicaid Services (CMS), the Joint Commission, the American Medical Association, the American Nurses Association, the National Association of Children’s Hospitals and Related Organizations, American Association of Retired People, American Federation of Labor and Council of Industrial Organizations, the Consumer-Purchaser Disclosure Project, the Agency for Healthcare Research and Quality, the National Quality Forum, the Blue Cross and Blue Shield Association, the National Business Coalition on Health, General Electric, and the U.S. Chamber of Commerce.

Next, we give them a nice marketing name like the “Hospital Quality Alliance.”

Then, they then make sure the hospitals and care providers know the “74 answers” to the tests that they’ll be tested on.

Next, they collect scads of information on every patient admitted to nearly 5000 hospitals across the country.

They spend countless hours of personnel time, intellectual energy, and human resources.

Then they crunch the data.

They spit this data out on a website paid for by the consumer by tax dollars on yet another government department database owned by the Department of Health and Human Services.

And when they reviewed heart disease care statistics, they only find that 17 centers (0.4%) provided exceptional care and 35 (0.8%) provided “substandard” care. Gratefully, they can now justify to those lackluster performers that they will withhold some of their Medicare reimbursements to them and save the government (and taxpayers) a bit of money.

After all, 99.2% of hospitals, they found, are doing a “good” job (at least when it comes to heart disease) by upholding their measures of “good” care.

So what have we learned?

We have now learned that there are millions and millions and millions of dollars of health care and association resources being expended to collect data that might mean something to 0.8% of the hospitals in America and to a tiny fraction of the medical consumers out there.

And will these data really effect care outcomes? For instance, should the ambulance carrying a person with chest pain bypass a hospital with a poor door-to-balloon time in favor of one that meets the standard? Or might this delay care further? Who will decide?

The real outcome question I’d pose is this: Is all of this retrospective review of health care delivery in America worth its cost to gather and process the data when we find it changes how only 0.8% of the hospitals in America will be reimbursed?

Or might our time, energy, and efforts be better expended improving health care facilities, providing programs for the poor, and taking care of patients?

But then, think of all the administrators who might become unemployed, eh?

-Wes

Thankless Dummies

I just saved three people's lives - but I never heard a word from them.

The NERVE!

Could the fact that they were plastic have had anything to do with it?

Ah well, at least I passed ACLS. I'm set for another two years...

-Wes

The MRI-Safe Pacemaker

Magnetic resonance imaging (MRI) scanners are one of the most effective ways to follow soft-tissue and vascular diseases in the body. Unfortunately, sometimes these patients also have heart disease that requires that a permanent pacemaker or implantable defibrillator be installed for control of heart rhythm abnormalities. For these patients, follow-up of their soft tissue tumors is impaired because MRI-safe pacemakers and defibrillators are not available on the market, especially for patients who are dependent on their pacemaker for their heart to beat at all. Fortunately, some investigators (in the US and Europe) have devised special protocols for non-pacemaker dependent patients to undergo MRI scans when they are clinically required. The FDA still frowns on this practice, however.

Studies presented by Sommer et al and Nazarian et al in this issue of Circulation offer further promising evidence in this regard. As with the previous studies, however, the authors acknowledge a multitude of limitations that prevent broad applicability of the results. Furthermore, one of these studies was not entirely free from concerning outcomes with the potential for serious clinical events. We view these results as consistent with our previous message that, on a case-by-case basis, the diagnostic benefit from MRI outweighs the presumed risks for some pacemaker and ICD patients. However, the FDA remains firm in its belief that those risks have not yet been characterized and mitigated sufficiently to justify the routine use of MRI in those populations.

In February of this year, Medtronic began a trial overseas with a new MRI-safe pacemaker called Enrhythm MRI. The was trial recently announced in Canada as well. It will probably be a bit longer before we see the trial spread to the United States, although it looks like the centers have been selected that will participate.

There are several issues with MRI's that can cause problems with conventional pacemaker and defibrillator systems:

• Usually the most common is interference with sensing the patient's underlying rhythm (oversensing, usually of noise, causes the pacemaker to inhibit its output, or undersensing causes the pacemaker or defibrillator to not be able to see the underlying rhythm and may cause pacing at inappropriate times)


• Alteration in programming (like reverting to a power-on reset mode of pacing or actual damage to the circuitry)


• Changes in pacing thresholds, perhaps due to lead movement (torque) or local heating.

A short review of these issues (with references) can be found from this piece from the University of Utah.

Medgadget also has a an even better overview of Medtronic's study and the technology in place to counteract these issues.

I just hope that someday MRI-safe capabilities will eventually become a standard feature in all cardiac devices marketed. After all, patients may have their pacemakers for years before the need for an MRI arises.

-Wes

Taking the Fall With Reduced Risk Cigarettes

Try this experiment some time. It was shown to me in medical school.

Take a brand new box of pristine sticks of chalk - you know - the kind your teachers always used on a blackboard in school. Open the top and be sure all of the pieces of chalk are in one piece but do not remove them from the box. Close the top of the box again.

Now, hold the box of chalk really high over a solid concrete surface (a tile floor usually works well, too).

Now, drop the box and observe it hitting the floor.

Open the box and examine the contents. No doubt you will find many, many shattered sticks of chalk. But almost as certainly, there will be one or two sticks that are still pristine, whole pieces of chalk that survived the fall.

Now why would this have been shown to our medical school class?

Because the speaker was explaining how to counteract this excuse posed to doctors when they attempt to ask a patient to stop moking: "But my mother smoked all her life and she never got cancer!" Statistically, you see, some survive even after they were subjected to the risks of smoking. Just like some pieces of chalk survive when their box is dropped to the floor.

So when I read that Phillip Morris wants to produce a "reduced risk" cigarette or new tobacco products with a "reduced risk" of cancer, I can't help but think that their efforts will be just like dropping a box of chalk from a little lower altitude, hoping that a few more sticks of chalk will survive.

Wouldn't it be better not to drop the box at all?

-Wes

Another Great Grand Rounds

Codeblog does a great job hosting this week's medical blogging grand rounds. Her creativity is remarkable. Be sure to check it out.

-Wes

Another Example of HIPAA Futility

Todd Stroger, the elected Cook County Commissioner here in Chicago, never wanted the public to know that he needed surgery for prostate cancer. He made it clear his health issues were a "personal matter." But the public wanted to know, so the public found out.

Is there any backbone to HIPAA? Does holding public office imply that individuals forfeit their rights to protection under this law?

Interesting questions, eh? What do you think?

-Wes

The Price of Safety

Don't look for drug and medical device prices to come down anytime soon.

(WSJ) Showing that legislation to overhaul drug-safety laws has strong bipartisan support, members of the House Energy and Commerce health subcommittee approved the nine bills on voice votes. The legislation, which also would renew programs that let the FDA charge fees to drug and medical-device companies that help fund the agency, is similar to many provisions contained in a single FDA bill that swept the Senate last month 93-1. The full House Energy and Commerce Committee takes up the legislation tomorrow, and a full House vote is likely in July.

Who do we think is going to pay these fees?

The FDA had proposed collecting $393 million from drug companies next year. Drug companies would pay an additional $50 million under the Senate bill and an additional $225 under the House bill over five years. Much of the extra money would be used to fund drug-safety monitoring programs. Both the House and Senate bills would also authorize the FDA to collect about $287 million in fees over the next five years from medical-device firms.

I assure you, with profit incentives, it won't be the drug and device companies.

-Wes

On Radiation Risks and What's Appropriate

Although I've commented on this before, it's good to see that others are taking notice about the potential problems with excessive use of diagnostic imaging.

But I take issue with this part of the article:

There are several steps patients can take to protect themselves, and they should not be shy about asking questions, doctors and other experts say.

“They can always inquire of the referring physician, ‘Is this test necessary?’ ” said Richard Morin, chairman of the radiology college’s quality and safety committee, adding that “exams are often done for reasons that are not quite appropriate.”

Doctors should be familiar with the radiology college index of appropriateness criteria, which rates the imaging procedures for some 200 medical conditions. Dr. Morin suggests asking the doctor ordering the test about its rating for a given condition.

Scores range from 1 to 9, he said, and “if the number turns out to be 1 or 2, you should look for some other exam.”

Whaaa? Wow, I learned something new... I now have to remember the contents of a 22-page document to see if a test is appropriate or not. I even learned there's a downloadable PDA version of the software, just to make it easy! So watch out docs, patients now might be asking you to consult your PDA while writhing in pain from an acute abdomen: "Gosh, is it acute appendicitis or a kidney stone? Let me check my handy PDA to see if I need to order this CT scan. Gee, there it is! Hot damn, he's a 9 on my handy-dandy xray scale! Okay, Wilma, take him away!"

But "appropriateness" for a test is in the eyes of the beholder. Just ask any emergency room doctor versus the obstetrician selecting a screening test for a preganant mother - each have a different take on the short- and long-term liability risks of such tests. And just for the record, I've never seen an ER doctor whip out his PDA to make such a decision about the "appropriateness" of a radiological test - especially when he's under an ever-mounting pressure to see more patients in less time while trying to never miss a diagnosis for fears of significant liability retribution.

-Wes

Alli's Treatment Effects

The new diet drug, Alli, has some interesting "treatment effects." Here they are:

• You may feel an urgent need to go to the bathroom. Until you have a sense of any treatment effects, it's probably a smart idea to wear dark pants, and bring a change of clothes with you to work
• You may not usually get gassy, but it's a possibility when you take alli. The bathroom is really the best place to go when that happens
• You can use a food journal to recognize what foods can lead to treatment effects. For example, writing down what you eat may help you learn that marinara sauce is a better option than Alfredo sauce

Amazing how the pharmaceutical industry spins side effects as "treatment effects." Bada bing bada boom.

-Wes

Patient-Laundered Direct-to-Consumer Advertising

Direct-to-consumer advertising took a new turn today.

I received this press release for a new website, called StopAfib.org. I follow atrial fibrillation therapies and developments pretty closely, I think, for obvious reason: it's what I do. So when I saw this site I decided to check it out.

The website is nicely executed. It seems to have been sponsored by a patient who experienced what sounds like a transient ischemic attack, or stroke, seven months after having emergency heart surgery. She was, the site says, "intrigued by the potential of pulmonary vein isolation to eliminate her atrial fibrillation, and especially fascinated that the removal of the left atrial appendage could eliminate her stroke risk." Really? Would Ms. Hill even know what a left atrial appendage is?

A closer inspection to the press release confirms that the site is being marketed by a website developer and marketer to the elective healthcare industry:

Founded in 2002, and based in San Luis Obispo, California, Etna Interactive provides Web marketing services to the elective healthcare industry (including medical device manufacturers, plastic surgeons, cosmetic surgeons, surgeons and medical day spas); to physicians and surgeons offering new or novel treatments; and to professional service providers including lawyers, architects and builders. Etna Interactive services clients from Hawaii to upstate New York.

What is interesting is that this company recognized the need to skirt the provisions of Section 650 of the Medical Board of California Business and Professions Code that forbids "fees for referrals."

And yet, close inspection of the one and only advertiser on this website is Atricure, Inc., the company interested in marketing their equipment for open-chest pulmonary vein isolation for atrial fibrillation. Further more, look at Ms. Mellanie Hill's story carefully.

On September 13, 2005, Mellanie had Mini-Maze surgery with the AtriCure bipolar (RF) device and says, "Though it was surgery, with risks and anesthesia, and was in an area that is very delicate for women, I have no regrets." She had been grounded from flying for two years, and was now able to fly again and travel by herself. She says, "You can't put a price on getting your freedom back."

Would a patient really know (or care) that her surgery was performed with the "Atricure bipolar (RF) device?" Does the patient know what "bipolar" means? Or what "(RF)" means?

It is clear this site has been developed by a marketing department of a medical device company. Like industry-paid ghost writers in medical journals, this new tactic is disturbing. Has Atricure has used a website developer and gullible patient to ghost write the marketing of their medical devices? Worse still, could this patient who has had a stroke (or transient ischemic attack) and might be at high risk of recurrent stroke, even after her ablation, be making potenially dangerous recommendations (that stopping warfarin is OK), all in the interest of marketing? And when does a patient testimonial platform that is funded by a company become a "fee for referral" for that company's devices?

While I have nothing against patients standing up for a cause they believe in, I just wish they'd do it themselves. If the StopAfib.org site wants to accomplish this goal:

We're not pushing products or services, or selling anything. We want this site to be as unbiased and informational as possible.

...then they'd better develop their site themselves.

-Wes

15:15PM CST Addendum: I contacted Ms. Hill regarding this post and she was very nice to respond. She did confirm that Atricure contacted her first and had a particular interest in her skills as an "author, writer, and speaker," and they shared ideas and it was her idea to provide a forum for patients to explain options for atrial fibrillation therapies and ways to prevent strokes. Hence they provided a grant to her. She states Atricure was "very careful" to remain detached from the project. She also noted the "EP's had a vested interest" in performing catheter-based afib ablation procedures and often refused to refer patients for surgical procedures. She is continuing to seek other sponsors for her website.

Micropractices: A Normal Rockwell Thing?

It seems some think so:

Savard, 36, a graduate of the Stony Brook University School of Medicine, is in the vanguard of physicians who are experimenting with a new family practice business model.

It's called a micropractice.

Savard has no nurse but shares a receptionist with several other solo practitioners; she does her own paperwork. Mostly, she runs her office electronically, lowering her overhead because she has no salaries to pay.

She keeps patients' files on her laptop and soon will be billing electronically too. She uses software to process insurance claims. One more thing: Savard estimates her income will remain about 10 percent less than if she were in a group practice with a full staff -- and that's fine with her. She makes her own schedule and works four half-days a week for now, although she plans to start working a fifth.

"I'm not being controlled and being told when I'm on call," Savard said.

Savard began establishing her practice last fall and has 200 patients. She had been working as a salaried doctor at a group practice.

How did she come up with this system? She read an article by Gordon Moore, a physician in Rochester, N.Y., and an advocate for micropractices. Moore says micropractices give patients "unfettered access" to doctors at a time when some physicians have overloaded their practices.

"There's nothing new under the sun here," Moore said, calling it "the Norman Rockwell thing ... plus the software."

With the price of gas these days, I'm not sure I can afford to earn 10% less, as this model suggests.

-Wes

Non-Profit Hospitals Get New Tax Form

In 2009, non-profit hospitals will have to file a new tax Form 990 which promises more transparency regarding executive compensation, charity care, contributions to the community, and calculation of bad dedt expenses. The IRS is seeking public comment on the new Form 990 until September 14th.

Review of the proposed changes to a new schedule H specifically for hospitals can he found here.

-Wes

Pfizer: Coming Clean on Lipitor

Seems Pfizer admitted to the SEC that its superiority data regarding Lipitor (atorvastatin) over Zocor (simvastatin) was overstated. They might have the same efficacy rate. It seems they were forced to reconsider their claims:

The error was discovered while researchers were re-analyzing the data at the request of an expert who was reviewing the manuscript, which had been submitted for publication in a journal. (Pfizer senior vice president Michael) Berelowitz declined to name the publication.

Hmmm. I'm intrigued. There must me something going on here. Why would Pfizer suddenly decide to come clean and surrender their profits to generic simvastatin? Could people be on to their techniques?

-Wes

Reference: Wall Street Journal's Health Blog

Doctors' Scarlet Letter: The Big Blue Dot

Today the New York Times reported that there is a wide discrepancy in reimbursement rates of private insurers from hospital to hospital for patients in need of open heart surgery in Pennsylvania. (Medicare rates are relatively fixed and only vary slightly based on geographic location). They based their report on Pennsylvania’s Health Care Cost Containment Council’s report published today.

While the information is interesting and serves as a reasonable overview, it has no “drill down feature” to look a specifics of the data collected. Instead a complicated, obfuscating, and proprietary weighting scheme (see the last page of these technical notes) was used to determine measures such as expected mortality rates. Cardinal Health claims the trademarked Atlas Outcomes™ methodology has been verified, but then they stand to profit from the data, don’t they?

But what was not discussed in the Times report was that physican mortality data was also presented in the Pennylvania report. Simply. Graphically. You see, rather than reporting an actual number or percentage mortality with details to view, various graphics analogous to Consumer Reports methodology were printed representing mortality data: an open circle (better than expected), dotted circle (expected), or Big Blue Dot (higher than expected).

For Pennylvania physicians that performed with in-hospital mortalities higher than their colleagues in 2005, they are branded with this scarlet letter of health care on the report: the Big Blue Dot. It becomes clear that even one of these Blue Dots might spell disaster for future referrals for a physician. But administrators, insurers, and likely patients will praise the simple graphic.

But health care is anything but simple. Just look at the letter one surgeon in Pennsylvania sent in to the Health Care Cost Containment Council in an attempt to explain his higher mortality rate (looks like three of 43 patients put him at the Blue Dot level). These folks were sick! But his explanation, while posted on Pennylvania’s website, did nothing to change his label.

His Big Blue Dot still stands for eternity for the world to view.

So what will happen with this doctor next year? Surely he will hope to avoid the Big Blue Dot again.

And so, this surgeon might hesitate just a bit before offering surgery to complicated patients with multiple medical problems. It’s not because he wants to be mean-spirited. No, it’s just that now he has to manage the risk to his reputation in concert with the risks of the procedure to the patient. Hopefully, by caring for patients who are less sick, his Blue Dot will be revoked next year and his name cleared. And the sick patients? They’ll either be left to fend for themselves medically, or referred to higher volume centers where, perhaps, the risk will be better absorbed.

And if every surgeon does this, there will be no more Blue Dots. Health care will be better, right?

Well, at least the report will look better.

But for the sickest of patients, they may stand to lose.

-Wes

Waist of a $246 Billion Tobacco Settlement

Overlawered has the story.

Sick. Just sick.

-Wes

Boston Scientific to Face the Music

Unfortunately, the tune is likely to be a dirge.

Hundreds of patients who then had their Model 1861s (defibrillators) removed are now suing the company for emotional distress and punitive damages and for failing to warn them of the flaw. Three patients died because of the flaw, but the plaintiffs at issue in the ruling didn't experience a malfunction themselves.

The ruling, by Judge Donovan Frank of the U.S. District Court in Minneapolis, means the cases will proceed to trial. The first case is scheduled to start in July.

Last month, Boston Scientific argued in court that Guidant didn't need to inform doctors because the rate of failure was extremely small -- about one in 500 over a three-year period. Lawyers for the company said it had already informed doctors that the devices were imperfect, and had told the Food and Drug Administration that the rate of failure could be as much as one in 20.

The company argued that patients whose devices weren't faulty shouldn't be able to sue the company for punitive damages. In yesterday's ruling, the court rejected those arguments, stating "the law is not furthered by allowing a manufacturer to escape liability for a defective product simply because a plaintiff elected to remove a medical device."

Was the rate of failure one in 500 (as Guidant told us doctors), or one in 20 (as the plantiff's lawyers contend Guidant reported to the FDA)?

Here's what Guidant's "Dear Doctor" letter said:

There have been 28 reports of this failure worldwide, in 26,000 devices built prior to the April 2002 change. This includes an event reported in March of 2005 in which a device was returned after a patient death. The device was found to have experienced this failure in conjunction with attempted delivery of at least one high-voltage therapy. To date, no such failures have been observed in the
devices built after the April 2002 change (including the approximately 11,000 devices built after the April 2002 change and before the November 2002 change). Approximately 13,900 devices built before the April 2002 change remain in service in the United States.

This would put the failure rate at 28/26000 = 0.1% (or 1 in a 1000 devices). If we double that (to pick up some that might not have failed), then 1 in 500 seems reasonable. But the "one-in-20" incidence, as the plantiff's lawyers contend, seems a bit grandiose given the data...

This ruling makes things more difficult for Boston Scientific, since there is less likelihood that the cases can be dismissed before going to trial on the basis that the claims could be preempted by a federal regulatory scheme (e.g., the FDA cleared our device, so it's not our fault). Further, and perhaps just as importantly, it permits the punitive damages portion of the trials (where big cash judgements to be levied against the device manufacturer) to also be brought forward. Boston Scientific's lawyers might be looking more seriously at settling given this turn of events.

This ruling may also have implications for the other device manufacturers (Medtronic and St. Jude) since now they may also have a hard time keeping their cases from going to trial for similar reasons.

-Wes

Grand Rounds XR

Dr. Val hosts this extended release version of medical blogging's best this week.

-Wes

How Hospital Administrators Think

Here's an inside glimpse:

Compensation as a strategic tool has been gaining traction for a number of years in healthcare. But seeing compensation as a competitive tool, not for recruitment, but for market share, is just starting to be discussed. Hospitals are spending resources and energy competing with their neighboring care providers for physician referrals and community support. But could the real battleground be in recruiting away talent – with the main goal to severely curtail an institution’s ability to provide a service, thus limiting their ability to gain market share?

All's fair in love and war, I guess.

-Wes

Current Data on Risk Stratification for Sudden Cardiac Death

Some interesting results of an industry-sponsored expert conference on risk stratification of sudden death appeared in this month's American Heart Journal. The experts reviewed left ventricular ejection fraction (LVEF), New York Heart Association Class, the presence of nonsustained ventricular tachycardia, microwave T wave alternans, measures of cardiac autonomic modilation (like heart rate variability), QT interval variability, signal averaged EKG, electrophysiology study, genetic testing, imaging studies and serum markers (like brain naturetic peptide or c-reactive protein).

Their take? Only ejection fraction seems worthy for risk stratification so far.

Here's what they said about ejection fraction:

The LVEF has been recognized as a predictor of all-cause mortality in patients with coronary artery disease (CAD) for >30 years. One early study by the Multicenter Postinfarction Research Group showed in 866 post–myocardial infarction (MI) patients that the strongest predictor of 1-year cardiac mortality was the LVEF. This finding has withstood the test of time. In the VALIANT (trial), a randomized comparison of captopril, valsartan, and their combination in post-MI patients (n = 14 609) with left ventricular dysfunction, CHF, or both, LVEF was a strong predictor of SCD or cardiac arrest. The risk of SCD or cardiac arrest increased by 21% for every 5% decrease in LVEF.

Left ventricular ejection fraction is also a strong predictor of all-cause mortality in patients with nonischemic cardiomyopathy. The MACAS (trial) was a prospective cohort study of 343 patients with nonischemic cardiomyopathy and an LVEF ≤45% who were followed for a mean of 52 months. Left ventricular ejection fraction was the only significant predictor of major arrhythmic events with a relative risk (RR) of 2.3 per 10% decrease in LVEF (95% CI 1.5-3.3, P < .0001) in patients with sinus rhythm and 4.5 per 10% decrease in LVEF (95% CI 1.5-13.2, P = .0008) in patients with atrial fibrillation.

Participants at the meeting were as follows:

Participants from the Academia: Sana M Al-Khatib, MD, MHS (co-Director), J Thomas Bigger, MD, Alfred Buxton, MD, Robert M Califf, MD, Anne Curtis, MD, Jeptha Curtis, MD, Bernard J. Gersh, MB, ChB, DPhil, Michael R. Gold, MD, PhD, Jeff Goldberger, MD, Stephen C. Hammill, MD, Jeff Healey, MD, MS, Mark Hlatky, MD, Stefan Hohnloser, MD, Raymond J Kim, MD, Kerry Lee, PhD, Daniel Mark, MD, MPH, L. Brent Mitchell, MD, Eric Prystowsky, MD, Gillian Sanders, PhD (co-Director), and Wojciech Zareba, MD, PhD

Participants from the Centers for Medicare and Medicaid Services: Steve Phurrough, MD, MPA

Participants from the US Food and Drug Administration: Norman Stockbridge, MD, PhD, Robert Temple, MD, Bram Zuckerman, MD

Participant from the National Institutes of Health: Robin Boineau, MD, Michael Domanski, MD

Participant from Agency for Healthcare Research and Quality: Elise Berliner, PhD

Participant from the Heart Rhythm Society staff: Joel Harder

Participants from Industry: Mark Carlson, MD, Eric Fain, MD, Ali Haghighi-Mood, PhD, Steve Ketchum, PhD, Steve McQuillan MS, Marcus Mianulli MA, Philip Sager, MD, Dan Schaber, PharmD, Robert Shalwitz, MD, Joseph Smith, MD, PhD, Michael A Stein, MD, David Steinhaus, MD

Coordinating Staff: Marelle Molbert and Cass Finley from the Duke Clinical Research Institute.

The conference was funded by AstraZeneca, Bayer, Boston Scientific, Cambridge Heart Inc, Medtronic, Reliant Pharmaceuticals, St Jude Medical.

-Wes

Atrial Fibrillation Ablation: Wider is Better

Today a single-center prospective, randomized trial studying the efficacy of wider area catheter ablation around the pulmonary veins for treatment of atrial fibrillation compared to a more localized pulmonary vein isolation was published online before print in Circulation. In this study of 110 patients with paroxysmal or persistent atrial fibrillation, the wider-area catheter ablation procedure proved superior.

This study joins an earlier study from the University of Michigan which demonstrated similar findings in 80 patients. The newer study confirmed, however, that even with wide area ablation procedures, long-term success after a single catheter ablation procedure for atrial fibrillation was 67%.

We've still got a lot to learn since a 20-30% re-do rate (to attempt to achieve success) remains just too high, in my view.

Other investigators have been studying the importance of autonomic ganglia to the initiation and maintenance of atrial fibrillation. Unfortunately, ablating in areas thought to have high density of neural inputs to the heart has also had a high recurrence rate of atrial fibrillation.

Perhaps improvement in atrial fibrillation ablation can be achieved by a combination of the two approaches. But how much ablation is enough? Where should be ablate? Is there an endpoint that always determines success? Or is there a point of diminishing return? Is ablating a significant portion of the left atrial tissue helping or hurting atrial transport if repeated ablations are undertaken?

These and many other questions remain, but one thing is certain...

,,, my day job is secure.

-Wes

Overcoming Barriers to Early Heart Attack Treatment

Image of a 12-lead EKG of an Acute Inferior Myocardial Infarction

One of the biggest factors influencing survival during a heart attack (also known as myocardial infarction) is the time it takes to open the occluded coronary artery. Cardiologists in Oregon have worked together to provide a plan that secures an earlier reperfusion time and published their remarkable observational results in the American Journal of Cardiology. Unfortunately, their approach has not been universally applied across the country. Municipalities should look carefully at these requirments for improved survival in heart attack victims as they plan upgrades to their Emergency Medical Services. These include the following:

• Equip all ambulances with 12-lead EKG-capable defibrillator systems. These facilitate the early administration of life-saving medications in the field for patients suffering a heart attack. Use of 12-lead EKG, particularly a wireless system capable of transmitting the information to a hospital during transport, is also supported by the 2004 American College of Cardiology guidelines.
• Development of policies that permit patients to be transported directly to a hospital capable of acute coronary intervention (not just the closest hospital). While understandable, this requirement might be difficult for more rural communities remote from hospitals equipped with an interventional cardiac catheterization laboratory.

Additionally, as an electrophysiologist, I would like to assure that the recordings of the heart rhythms obtained by these machines in the field are carefully archived to permit later review by specialists. These tracings can be invaluable for diagnosing the cause and best treatment options for the patient after their preliminary treatment in the Emergency Room and cath lab.

-Wes

Therapy Dog

My daughter and wife just left for Therapy Dog International testing. Therapy dogs, for those not familiar, are the dogs that visit hospitals or have served in disasters to provide companionship and support to people in times of need. I know our hospital has such a program. It is remarkable the changes in people when they can pet a friendly dog while in the hospital: it's as if their ailments melt away, if for a moment.

There's only one problem, though. Our cocker spaniel is blind in her right eye (congenital cataract). While she is fantastic around humans, if a dog approaches her from the right ride it might startle her causing her to go into a limbic storm. If this happens, she'll be disqualified on the basis of failing Test #8.

I hope she gets to wear one of these cool scarfs...

-Wes

References: Using a therapy dog to alleviate agitation and desocialization of people with Alzheimer's disease. J PsychoSoc Nurs Ment Health Serv 1999 Apr; 37(4):16-22.

The Effects of Animal-Assisted Therapy on Anxiety Ratings of Hospitalized Psychiatric Patients. Psychiatr Serv June 1998; 49: 797-801.

Reduction of Aniety by Petting Animals in a Controlled Laboratory Experiment. Anxiety, Stress & Coping, Dec 2003; 16(4): 387-395.

05:00 11 Jun 2007 Addendum: Remarkably, she passed her test. She never saw the other dog they placed to her right. Sometimes there's a benefit to having a limited visual field. :)

Cheney to Have Routine Defibrillator Change

Vice President Dick Cheney is to have his implantable cardiac defibrillator (ICD) battery changed. Actually, he'll have the whole device changed, with the exception of the leads - those will likely be re-used. It is a common misconception by patients needing an ICD battery change that only the battery is changed. The battery is housed with the capacitors and computer logic circuitry in one hermetically-sealed titanium can, to which the leads that extend to the heart are attached with small fixation screws. As such, the whole defibrillator can will be exchanged in a smae-say procedure.

It has not been publically discussed if Vice President Cheney has had some heart failure, or how much he uses his device to pace his heart. No doubt his doctors have considered if his device should be upgraded to a biventricular pacing defibrillator which can "resynchronize" and re-coordinate the heart's muscular contraction to improve symptoms of heart failure, since this would be an ideal time to do so while his device is exposed.

But usually with politicians eager to make light of the circumstances at hand, they usually opt for as little as possible (i.e., get in and get out) to minimize possible risks and media exposure. Hopefully, this will be the right decision.

As to which device he'll receive? Since he's had Medtronic devices previously, it's likely he'll receive a Virtuoso ICD this time around (which is a dual-chamber ICD that can be interrogated wirelessly). If his doctors should decide to upgrade his device to a biventricular ICD, then it would likely be with a Concerto ICD.

-Wes

Chowing on Bugs

Seems there are others that like to eat bugs out there. Monica Eng from the Chicago Tribune demonstrates on video what it's like to eat silkworm pupa, and describes the experience:

"Mmmm. Mmmm. Crunchy exoskeleton, and soft, creamy chicken-like inside with a sort of a smokey, nutty, dirt-ish finish."

Maybe I'll pass on cicadas.

-Wes

The 5-Second Rule Tested

And now comes this word that the "5-second rule" has merit. You know, the opps-I-dropped-something-I-want-to-eat-on-the-floor-and-as-long-as-it-sits-there-less-than-5-seconds-it-will-still-be-safe-to-eat rule. It seems the rule has now been tested and you might even have more time than that:

A college professor and her students have challenged the prevailing wisdom of the so-called 5-second rule, which for generations has governed how long little morsels can remain on floors uncontaminated.

The window, the Connecticut team has concluded, is really 30 seconds.

"We wanted to look at a real-world situation," said Anne Bernhard, assistant professor of biology at Connecticut College in New London, noting the difference between her team's work and that of an earlier researcher.

Funny, I always thought it was the "ten-second rule." Glad to hear I can take my time bending over.

I wonder what our infectious disease department will say...

-Wes

Chernobyl - 20 Years Later

Sarah Wallace, a senior at Duke University majoring in public policy and global health, is traveling to Chernobyl, Ukraine this summer and has a blog to document her travels and foray into the Ukrainian language. She links to this powerful photo essay by Paul Fusco who traveled to Belarus for two months to document the horrific health consequences, especially to the children, of the nuclear disaster ongoing some twenty years later. I was struck by the incredible courage and love shown by the health care providers and families struggling to cope in such challenging circumstances. Although the images are difficult to view, the courage they portray is inspiring. I encourage you to wish Sarah well on her travels.

For many, the Chernobyl disaster is long forgotten or even unknown.

May we never forget.

-Wes

Photo credit.

Chernobyl Children's Project International website.

Conquering Heart Disease is Multifaceted

An interesting question comes to mind when reading this study from the New England Journal of Medicine about how far we've come in twenty years treating heart disease: If we're doing such a good job with all of our public health initiatives and evidence-based treatment strategies, then why do we need more cardiologists? Why are we experiencing such a dearth of general cardiologists now and in the foreseeable future?

I think there's a lot of merit in this statement:

The looming critical shortage of cardiologists is due to a confluence of factors. The number of U.S. medical school graduates matching in internal medicine residencies has declined dramatically over the last 20 years. Fewer cardiologists are being trained today than a decade ago. An estimated 10% of cardiologists will retire in the coming decade. The baby boomers are reaching the age when cardiovascular disease rates climb sharply. The average patient load in cardiovascular medicine is declining, and maintaining those lower patient loads requires a greater number of physicians, Dr. Williams continued.

The road to cardiology requires a path through internal medicine, and where internal medicine training goes, so go budding cardiologists.

But I do not think this is the only reason the general cardiologists' numbers are declining.

I am aware of many, many residents who have completed their internal medicine residencies and are eager to enter cardiology fellowships but are unable to "match" in any cardiology fellowship position. I have seen graduating residents submit 50 to 70 letters to programs across the country without a single interview granted. This is where the REAL pruning of potential cardiology trainees occurs.

Fellowships are expensive for hospitals and academic programs. Funding sources have become limited as the squeeze to pare expenses continues in healthcare. So fellowship positions are often one of the first things reduced as a cost-cutting measure. Fellowships have historically also been partially funded by industry grants at times, but as the closer scrutiny of industry perks to medicine increase, these funds are more difficult for training programs to acquire. Competition for fellowship slots, then, becomes keen.

The training programs themselves are sometimes to blame. Some programs freely recognize that there may be some danger to "training their competition." Most trainees often like the city they're training in, so they look to stay nearby, making competition for patients near the training center higher if the new cardiologists chooses to practice outside the training center's immediate patient catchment area. Rural locations have fewer patients to treat, so geography may also limit the spread of cardiologists to more rural areas.

Training the new cardiologist also requires commitment from the academic faculty. As pay-for-performance initiatives drive productivity interests and are coupled with declining Medicare and insurer reimbursements, academician-teachers are being driven to become clinical revenue producers with less time to teach. It is hard to have a training program if there is no incentive to teach. Where's the Medicare reimbursement for this?

So if you want more cardiologists, not only must we make more fellowship positions, but we must also figure out how to compensate the folks doing the teaching so they're not penalized for doing so.

-Wes

Heros All

The Chicago Tribune tells the story of those that were lost yesterday in this morning's edition:

Amid all the unanswered questions, University of Michigan President Mary Sue Coleman said the six victims will be remembered for their heroic work.

"Every day, the doctors, nurses and flight personnel of Survival Flight do heroic work in saving the lives of others, and that is how we will remember those who perished in Monday's tragedy –as selfless heroes," Coleman said.

-Wes

Twenty Questions

I while ago, I had a friend show me this little electronic ball called "20 Questions" that promised to guess what I was thinking with only twenty questions. I thought a bit, decided on an inanimate object for the gizmo to guess, and then answered the questions one by one that the device posed to me. For each question I pushed the buttons corresponding to "Yes,"No," "Sometimes," and "Unknown" in response. I was astonished at the depth of answers the device could conceive based on my answers, but soon realized I could "beat" it by thinking about something fairly obscure or unusual.

Now it seems "20 questions" has come to diagnostic medicine.

iVillage.com has introduced a beta version of its "Symptom Solver" in conjunction with GE Healthcare that helps patients determine possible causes for the symptoms they are experiencing. It seems that medicine can really be reduced to 20 questions!

So I decided to take the system for a test drive.

My case?

I pretended to be a 24 year-old 34-week pregnant woman who has had two hours of chest pain associated with abdominal cramping from a dissection of a coronary artery with an associated heart attack that also induced labor (I had a case like this). This was on the Women's Wellness section of their website after all... Let's see how it does....

First question: My age? 18-29. Check.

Second question: Which symptoms (about 20 were shown)? I clicked on "Abdominal pain or discomfort" and "Chest Pain." Check.

Third question: "Tell us more about your abdominal pain?" I clicked "Abdominal Pain extends to the back and other areas." Check.

Fourth question: "Tell us more about your chest pain?" I clicked "Chest pain extends to arms, shoulders, neck, back or jaw" and "Chest pain for longer than 20 minutes." Check.

With the next screen, I received an "Emergency Notification" in small red letters at the top of the question box suggesting I seek immediate medical attention for my chest pain extending to my arms, shoulders, neck and jaw and chest pain for over 20 minutes. But I ignored this and continued... after all I'm only 24 years old!

Fifth question: "Additional symptoms?" I checked "Chest tightness," "Abdominal tenderness," "Sudden sharp chest pain," and "Heartburn." Check.

The next screen gave be my most likely diagnoses so far in the following order: (1) collapsed lung, (2) gastroesophageal reflux (What's that, I wonder as a non-medical person?), (3) pancreatitis (huh?), (4) cardiac ischemia (sounds interesting...but they expect me to know what this is?, and (5) heart attack (I know what that is, only old people have one of those...). Oh, and this little disclaimer appears:

The Symptom Solver service is designed for educational purposes only. You should not rely on this information as a substitute for personal medical attention, diagnosis or hands-on treatment. If you are concerned about your health, please consult your family’s health provider or go to the emergency room.

So I answer the next question:

Sixth question: "Tell us more about your heartburn?" I click "Frequent heartburn." Check. (Hey, things must be better! That little red warning box went away...)

With the next screen, GE reflux springs to the top of the likely diagnoses! Whew! I'm feeling reassured already! Glad it's not my lung! So I continue...

Seventh question: "Select additional symptoms:" I checked "indigestion." Check.

Eighth question: "Select additional symptoms:" I checked "Cramps" here. Check.

Of course, it wants to know more about the cramps. I noticed now the diagnosis of Irritable Bowel Syndrome is now in the mix of possibilities. (Hello, would anyone think about pregnancy??? But maybe the "Symptom Solver" needs more information...)

Ninth question: "Tell us more about the cramps:" I checked "Abdominal cramps" and "Sudden, severe abdominal cramps." Check.

Tenth question: "Additional symptoms?" This time I didn't see anything that correlated, so I said "None of these. Show me more." (Ugh... Hmmm, I'm feeling this sudden incredible sense I need to have a bowel movement...)

Eleventh question: "Select additional symptoms:" Hmmmm. My eyes don't look yellow, I'm not dehydrated (am I?), my heart is not pounding... I just have to have a bowel movement. So once again I click "None of these. Show me more."

The next screen got closer when it again asked for additional symptoms:

Twelveth question: "Select additional symptoms:" Oh my goodness! Although I feel like I needed to have a "bulky or foul-smelling stool" but I hadn't had this yet, so I again checked "None of these. Show me more." By now, I'm becoming weary...but I persist!

This time some interesting things popped up to select:

Thirteenth question: "Select additonal symptoms:" I checked "Loss of interest in sex" and "bloating." Check. (By the way, I have been at this for an hour now. It seems the website loads its ads too slowly...) Wow, that chest pain sure is burning... The order of diagnoses right now? #1: Gastroesophageal Reflux, #2 Collapsed Lung, #3 Heart Attack, #4 Irritable Bowel Syndrome, #5 Pancreatitis.

Fourteenth question: "Select additional symptoms:" Hey look, there's "Pregnancy!" So I click it!

Sadly. I'm asked again to select an "Additional Symptoms:" So for Question Fifteen, I answer "Pain all over."

Question sixteen appears: "More symptoms!" So I pick "Lump or mass in the pelvis or abdominal area."

Again, adding more symptoms is what is needed it seems: But for question seventeen's questions, I pick "None of these. Show me more." (I'm feel a bit masochistic now...) And now, my top five diagnoses do not include heart disease: #1 Gastroesophageal reflux, #2 Irritable Bowel syndrome, #3 Esophagitis, #4 Ovarian Cancer, #5 Collapsed Lung. And yes, it wants more symptoms for question seventeen.

Question seventeen: More symptoms: I pick "Severe lower abdominal pain or pelvic pain."

And again: It wants more symptoms but I've run out. 10 more answers to the additional symptoms questions with "None of these. Show me more." makes clear that the program will continue to ask symptoms until the person clicks "Skip to Results." At which time I see an explantation of Gastroesophageal reflux disease, Esophagitis, Irritable bowel syndrome, Collapsed Lung, Ovarian Cancer, Misscarriage, Stomach Cancer, an then finally, Heart Attack (#8).

I think I beat the game, but probably sacrificed my fictional heart and baby...

What is clear is that more and more of these tools will soon surface on the internet, especially with similar efforts underway by Steve Case, former co-founder of AOL (RevolutionHealth), or by other corporate efforts like the Continua Health Alliance. It is clear that patients are turning to the internet more frequently to identify a cause of ailments before seeking the advice of a health care professional. While there is great information out there, there is a moral to today's post:

Take these symptom-related questionnaires with a grain of salt... you might just beat them at your expense.

-Wes

Transplant Team's Plane Crashes

More sad news today from Milwaukee where a University of Michigan transplant team's jet crashed yesterday afternoon into Lake Michigan shortly after takeoff from Milwaukee en route to Willow Run airport near Detroit, a 42-minute flight.

Our prayers go out to the families involved.

-Wes

California Chiropractors: Anesthesia Without CPR Training

Amazing that California's Board of Chiropractic Examiners recently adopted a resolution (supported by a defensive news release) stating that "manipulation under anesthesia" falls under a chiropractic's scope of service, while also recently abandoning the requirement for doctors of Chiropractic in California to train in CPR:

“Repeal of Section 356.1, Cardiopulmonary Resuscitation (CPR) Requirement For Doctors of Chiropractic: The Board of Chiropractic Examiners repealed section 356.1, which required Doctors of Chiropractic to maintain current certification in Cardiopulmonary Resuscitation (CPR)/Basic Life Support (BLS) from the American Red Cross, American Heart Association, or “other associations approved by the Board.” The Board no longer requires CPR/BLS certification for applicants and renewals beginning May 1, 2007.”

Anesthesia without CPR training?

"Houston, we have a problem."

If I was Governor Schwartzenegger, I'd think twice about leaving a link to my website on their home page!

-Wes

Hat tip: a faithful reader.

More On Fishing

I started my previous post, and it quickly morphed into a statement regarding the loss of a fellow medical blogger, Flea. So in the interest of re-living an all-too-short respite from healthcare, I thought I'd talk about something really important (at least while you're on vacation): fish.

Fortunately, our first day in Florida was a great day of fishing, but then came Tropical Storm Barry. With it's sustained 45-50 MPH winds, we were prevented from venturing out in the deeper water near the Gulf of Mexico over the remainder of the trip. But all was not lost. We still have fun on our first day there on the Gulf and the third day in the back waters closer to mainland Florida.

Our quarry on Day One? Atlantic Tarpon.

Tarpon, I soon learned, are a fantastic sport fish. They move to the passes between the islands between mainland Florida and the Gulf of Mexico to feed on the crab and small fish that float with the tidal currents between the islands. Weighing typically 90-200 pounds (40-90 kilos), they can put up an incredible fight, often surfacing right after consuming your bait. Landing them next to your boat often takes 45 minutes or longer (it was all catch and release). And catching them takes tenacity and determination...

... and a good guide - especially when you're a "Yankee" from Chicago.

So we set out eager to make a catch, trying for hours to catch these devils. We learned there are two ways to catch a Tarpon: jigs or live bait. Live bait was what they were biting, we were told.

Our guide was quite adept at throwing a net to catch a slew of bait fish. He stored them in the live bait wells near the stern of the boat. We would motor to the inland aspect of an island, drop our bait in the water, then ride the tidal currents out to Gulf. But despite many passes, we were skunked.

But our guide decided on another tact: catch some of those crabs floating by the boat.

So as we motored back inland, we netted several nice-sized crabs. Our guide then placed a hook through the side edge of the crab's shell, and threw them out into the current. Before long, we had our first strike! And soon each of us on the boat had the chance to fight one of these incredible fish. Here I am with one on my line:


Now, if you look real close, you can see the fish leaping out of the water. I've blown up the image a bit here (you can click to enlarge, if you're so moved):



Unfortunately, after 45 minutes of fighting, a huge roiling in the water was seen at the site of my fish. A brown, smooth-skinned fish about twice its size was seen attempting to eat it: a shark. And just as quickly as I had caught it, my line was severed, and neither fish nor shark was seen again. The lack of blood in the water gave us hope my fighting fish escaped unharmed. I hope so. It was quite a spectacle to behold.

We fished in to the early evening, but then had to call it quits. Three tarpon in all were hooked. Only one shark joined in (with my fish), thankfully, and we all returned home exhausted but ready to return again for more fun.

But the next morning brought the winds and rain of Tropical Storm Barry, (the media called it "Beneficial Barry" since there was so little rain in Florida before this weekend - it figures!...) so we resigned ourselves to a few good card games, a good book, and a nice long nap. By the next afternoon, the winds were still up on the Gulf with 6-8 foot waves, so we decided to fish the backwaters. Our luck wasn't bad there either, as we caught some pretty nice snook.



It's going to be hard to get back to work tomorrow...

-Wes

On Flea and Fishing

I learned several things this weekend about fishing in Florida: (1) never book a fishing trip around the opening day of hurricane season and (2) lots of big blogging news occurs when you're away from a computer, even for a little while.

What I have derived from this whole Flea malpractice blogging debacle was that it was a mess: for him, for the family of the child involved in the personal injury lawsuit, and for the medical blog-o-sphere. Medical bloggers the world over have learned a great deal at Flea's expense. Life's lessons, unfortunately, are not always pretty.

But I have faith that the medical blogging community today will not wither from public writing for fear of litigious retribution. Doctor- and nurse-bloggers remain a potent voice of reason in the healthcare and healthcare delivery debate. Their opinions and insights coupled with timely and insightful commentary by others can quickly question the status quo, offer constructive criticism of poor research or medical technologies, support or defile federal or state healthcare policies, or clarify health care topics for the very patients we treat.

Who will serve as the best advocate for patients: hospital administration, lawyers, politicians, insurance providers, or doctors and nurses?

-Wes