Wednesday, April 30, 2008

Digitek Recalled

"Foxglove Season" (Digitalis purpurea)

Heard about this from a patient tip after she had a problem getting a refill at the local Walgreens as they scramble to re-stock:
Actavis has issued a nationwide recall of Digitek (digoxin tablets) due to the possibility that tablets with double-thickness, containing twice the approved level of active ingredient, may have been commercially released. The existence of double strength tablets poses a risk of digitalis toxicity in patients with renal failure. Digitalis toxicity can cause nausea, vomiting, dizziness, low blood pressure, cardiac instability, bradycardia, and possible fatality. Several reports of illness and injuries have been received.
Yikes! Check your meds, folks!

-Wes

The Wonders of Radiology Voice Recognition Software

It has become common practice for radiologists to migrate to voice-recognition software to expedite the processing of the myriad of reports that come their way and to save on transcription costs. Here is the actual final report received by one of our cardiologists and delightfully handed to me today:
"HISTORY: CHF.

COMPARISON: 04/20/2008.

Colon pulmonary vascular prominence is again identified, unchanged dirty mediastinal stool is enlarged, but stable. Atherosclerotic disease is present in the aortic arch. Bones are unremarkable.

IMPRESSION: Findings consistent with stable CHF.
XRAY CHEST SINGLE VIEW (Order #95511140) on 4/24/2008"
The radiologist was called and said, "What did I sign off on?"

We read back the report.

"Oh, my God!"

-Wes

Where Have All The Residents Gone?

Last night - a code - complete heart block. I was called it to place a temporary pacing wire in the ICU. Little time. Stress. Need to prepare the field. Gloves, does anyone have gloves? Could we prep the area? You have the central line kit? Could I get another set of hands?

Then I realized something. The residents who had so carefully run the initial code and get the patient to the ICU had vanished. Why? Don't they want to learn how to start a central line, or at least see one placed? Where are they?

After the dust settled, I came to realize what had happened.

So to them and the medical teachers everywhere, I dedicate my parody of Pete Seeger and Joe Hickerson's "Where Have All the Flowers Gone" popularized by Peter, Paul and Mary and Joan Baez:

Where Have All the Residents Gone?

Where have all the residents gone, long time passing?
Where have all the residents gone, long time ago?
Where have all the residents gone?
They’ve gone to the keyboards everyone.
When will they ever learn?
When will they ever learn?

Where have all the keyboards gone, long time passing?
Where have all the keyboards gone, long time ago?
Where have all the keyboards gone?
They’re now in the hospitals everyone.
When will they ever learn?
When will they ever learn?

Where have all the hospitals gone, long time passing?
Where have all the hospitals gone, long time ago?
Where have all the hospitals gone?
They’ve gone to the hospitalists, everyone.
When will they ever learn?
When will they ever learn?

Where have all the hospitalists gone, long time passing?
Where have all the hospitalists gone, long time ago?
Where have all the hospitalists gone?
Consulting the specialists, everyone.
When will they ever learn?
When will they ever learn?

Where have all the specialists gone, long time passing?
Where have all the specialists gone, long time ago.
Where have all the specialists gone?
They’re planning retirement, everyone.
When will they ever learn?
When will they ever learn?

Where have all the retirees gone, long time passing?
Where have all the retirees gone, long time ago?
Where have all the retirees gone?
They’re treated by residents, everyone.
When will they ever learn?
When will they ever learn?


-Wes

Tuesday, April 29, 2008

Grand Rounds Is Up!

Are you ready to ruum-ble? This week here at Doc Gurley is the Grand Rounds Smack Down edition, where the best contenders of the health care blogosphere wrestle down and dirty with tough, scary topics.
Go ahead, jump on in.

-Wes

1984

George Orwell's 1984 struck the Fisher household last night. We received this in the mail:



A government camera caught this traffic "infraction" and the ticket was set to me. But I, you see, was not the driver. My son was.

And so, a tangled conversation ensued, tempers flared, motives questioned, circumstances unknown and impossible to reconstruct - all caught in a series of still-frame photos. After all, there are laws - rules that must never be broken - absolutes - especially when you want to get paid, like the City of Chicago wants to get paid. I felt myself wondering if this is justice or a means to a very monetized end. Worse still, I was not the perpetrator, but the "responsible party."

In a strange way, I saw this ticket as an extreme example of "Pay for Performance (P4P)" - just like we are implementing in healthcare. P4P is another government-mandated endeavor to assure the best quality of healthcare through the use of "absolute truths" agreed upon by a body of experts. There can be no room for negotiation, no original thought involved. Follow the rules and you will get paid. After all, as the ticket says in the upper right corner, it's not about the patient, it's all about this:


Strange.

You see, there was some irony here for I had just run a red light, too.

The police had barricaded the railroad crossing gate near my home in front of the usual road I usually travel yesterday. I saw the railroad gate was malfunctioning: it kept going up and down, up and down repeatedly without pausing in any position. It seemed the stop light mechanism was tied to the gate's action, only turning green would never turn green before the gate lowered again. Without action, traffic would have never moved if each of us at that intersection had not used careful judgment and broken the stoplight law and proceeded with caution.

So I got home without incident, relieved that no one was hurt and that I had creatively problem-solved a predicament and done my part to relieve traffic congestion safely.

Now, though, I guess I'll wait for my ticket in the mail.

And look forward to inflexible Pay for Performance initiatives that make us march lock-step in the name of excellence in medicine.

-Wes

Monday, April 28, 2008

Stand Proud

Stand proud, young doctor, as you no longer get pizza for lunch from drug and industry reps. Medical students, residents, staff physicians and nurses the world over can look forward to the fact that no impropriety can ever be bestowed upon them since they will no longer be coerced by those clueless drug and industry reps. That's right, no more toys.

Clean.

Pristine.

Virginal.

So carry the flag of purity proudly.

Meanwhile, rest assured that others will be wined and dined to discuss the next purchasing contract, and some hospital administrators will continue to rub noses with their existing contract recipients in Las Vegas. Feel good knowing that once their contracts are re-approved, those same contractors will become a Premium Sponsor of the next Hospital Gala to the support the hospital's philanthropy fund...or, maybe a round of golf? After all, we mustn't forget that hospitals ARE the economy!

So hold your head high, dear employees, as you buy your own lunch. Take pride that your integrity can no longer be questioned, your mission pure, and the cause just...

...and revel in the knowledge that others are still making out like bandits.

-Wes

The New Bouncer

Click to enlarge image

-Wes

Reference.

Sunday, April 27, 2008

The Surgeon General on CAM

Dr. Val has been doing a great job interviewing our 17th US Surgeon General, Vice Admiral Richard H. Carmona, M.D (see here, here and here). But today, in regards to a question on Complementary and Alternative Medicine (CAM), I wondered what he was saying... (see the comments).

When one considers that the pharameutical industry has spent more money on marketing recently than R&D, and that those advertising costs are passed down to our patients in the cost of their medications, might removing direct-to-consumer advertising be a better way to lower healthcare costs to our system?

-Wes

Friday, April 25, 2008

The Cause of the Pause

Reading Holters today, I can across this:

A 46 year-old man who drives trucks for a living submitted a Holter with a diary that was blank (no symptoms). Here's his starting rhythm - not too exciting:

Click to enlarge


A bit later, we see this:

Click to enlarge


Then we see this!

Click to enlarge


So you check the rate histogram of all of the beats for 24 hours and find this:

Click to enlarge

So what's the diagnosis? Does he need a pacemaker?

-Wes

Screening ADHD Kids with EKGs

Boy, it didn't take long for UVa Hospital to hop on the EKG bandwagon for kids with Attention Deficit, Hyperactivity Disorder (ADHD) after the AHA released their recommendations for EKG screening in kids on stimulant medications based on retrospective literature review and gut feelings.

Sheesh. I think Dr. Rob had the appropriate amount of skepticism here.

Although I know and respect many of the doctors who were tasked with making the best recommendation they could with little data on the subject, the AHA does a huge disservice to the doctor-specialists' credibility when they cozy up to the pharmaceutical companies with "roundtables" prior to such proclamations. One wonders if the Adderal folks helped with the recommendations before their exclusive patent expires in 2009, eh? Further, as the literature upon which the recommendations are based describe about a 2.3-3.5% false positive rate of EKG's in kids, this recommendation is going to cost more than one family a pretty penny.

-Wes

Publish or Perish


I woke this morning and realized that I had missed the Big Point in my last post.

Last night, I was lamenting over the fact that another EP journal had been born – one of a series of six new journals of the “Circulation” line from the American Heart Association – one more to try to scour to keep current.

But this morning I found myself asking, “Why more journals?"

In the era of the Internet, print media throughout the world is struggling. Readership of newspapers and magazines has plummeted as people migrate to the Internet, where information can be organized quickly specific to the reader’s desires. Print media can’t do that. I suspect medical journals are trying to adapt to this “specialization” of topics in a way as the Internet, but older titles have found themselves, like newspapers, with falling readership and fewer advertisers to support the printed word. But as free online peer-reviewed publishing devoid of commercial interests and vetted by the online-community in real-time takes hold, the threat to printed journals grows.

Moreover, every week, my office is inundated with scores of “free” journals filled with white papers promoting the next great widget or medical technique. There are even journals that summarize each week’s journals. These throw-away journals have become more sophisticated, too, with glossy print and all, as advertisers seek new ways to reach their prey: me, the doctor.

So the print media journal publishers, in their push to instill novelty while finely-tuning a more targeted readership, have created a new product line – something that advertising purchasers want. I mean, who’s going to drive the market for $2 million-dollar robots for catheter ablation other than cardiac electrophysiologists? It isn’t going to be the echo guys. Or how about promoting the next cool, high-tech 3-D echo machine, with latest sophisticated dyssynchrony-evaluating software package? Those echo guys are salivating.

Look at the titles of the new Circulation line of journals: Circulation: Arrhythmia and Electrophysiology, Circulation: Heart Failure, Circulation: Cardiovascular Genetics, Circulation: Cardiovascular Imaging, Circulation: Cardiovascular Quality and Outcomes, and Circulation: Cardiovascular Interventions. These titles no longer dwell on an the pathophysiology of an organ system in a patient any longer (remember "Heart?"). No, like the general internists who proceded the specialist with declining revenues, those broader journals had their day generating revenue and notariety. Now, the new titles reflect the era of specialization.

After all, that's where Medicare still pays and business opportunities lie...

...at least for now.

-Wes

Thursday, April 24, 2008

New EP Journal Premiers

Seems the "Journal Wars" are heating up between the Heart Rhythm Society (which publishes HeartRhythm) and the American Heart Association:
Circulation: Arrhythmia and Electrophysiology is the first of the new "Circulation portfolio" of journals, designed to meet the growing demand for tightly focused information in areas at the cutting edge of cardiology. Circulation: Heart Failure will be the second journal to premier in coming weeks. The remaining four titles - Circulation: Cardiovascular Genetics; Circulation: Cardiovascular Imaging; Circulation: Cardiovascular Quality and Outcomes (Eds note: Can you say CMS and JCAHO??); and Circulation: Cardiovascular Interventions - are scheduled for launch later in 2008.

Each bimonthly issue of Circulation: Arrhythmia and Electrophysiology and the other new journals will be available in both print and online formats. The journal Web site, http://circep.ahajournals.org will also present "Publish Ahead of Print" articles and other online features.
William Stevenson, MD, director of the clinical cardiac electrophysiology program at Brigham and Women's Hospital and professor of medicine at Harvard Medical School, will serve as editor of the AHA's new EP journal.

I look forward to seeing the new issue, but damn, it seems there's just too many journals to keep up with these days!

Can you say "information overload?"

-Wes

Urologic Alignment

I mean, it's like lunar alignment, except for the male urologic system - all in the last 24 hours!

First, we find the penile theft story on Reuters (there was an administrator looking at me strangely today...), then I read about Happy Hospitalist's "boys" being counted (good luck, Happy), then Kevin pipes in on testicular protection devices, and shortly thereafter my wife shows me this video she was sent displaying a guy skydiving who needs one of Kevin's devices (seriously... er this is not a home movie).

Could someone tell me what's going on?

And to think that the "IU" deals with this stuff all the time...

-Wes

Wednesday, April 23, 2008

How the SubPrime Mortgage Mess Is Hitting Hospitals

Bloomberg:
"Patients at the largest hospital in southeastern Georgia are being treated without the latest magnetic resonance imaging and cardiac catheterization technology because of the auction-rate bond market collapse.

The Southeast Georgia Health System delayed spending $3.6 million to upgrade the medical equipment after interest on $94 million of its auction debt tripled to 11 percent in February, said Michael Scherneck, chief financial officer. Hospitals from California to New Hampshire face similar dilemmas because they used the dying auction market to raise at least $50.5 billion, according to data compiled by Bloomberg.

* * *

Auction-rate bonds allowed local governments, hospitals and universities to issue securities maturing in 20 years or longer at short-term rates. Investors fled the market in February on concern the creditworthiness of bond insurers that guaranteed the debt would deteriorate because of losses on securities tied to subprime mortgages.

Rates on some bonds soared to 20 percent after the dealers running the auctions stopped buying securities that failed to sell, triggering a penalty rate for issuers. More than 60 percent of the thousands of auctions conducted each week have failed since Feb. 13, data compiled by Bloomberg show.
And I thought gas prices were bad...

-Wes

Machiavellianism Run Amok

Imagine, such cavalier disregard! Where is the respect for such a caring corporation when workers behave in such a manner?
Whirlpool Corp.'s suspension of 39 production workers at an Indiana plant who were seen smoking after declaring themselves eligible for a $500 annual tobacco-free insurance discount may signal the end of the honor system that rules most corporate wellness programs, experts said Tuesday.

The action also underscores the difficulty of enforcing so-called voluntary programs when fines or incentives grow big enough to encourage cheating and snitching, they said.
How could simple workers look at their company's wellness program with such a jaundiced eye? Don't they realize that their company wants what's best for them? How could these workers so cynically take advantage of the corporation when everybody knows that only the corporation is supposed to take advantage of the workers. Could it be that the simple working man or woman is also capable of acting disingenuously?

Say it ain't so.

If this kind of thinking keeps going on, the "wellness" boys are going to have to fold up their binders and brochures and head back home.

-Wes

Addendum 26 Apr 2008 - A roundup on the issue is offered over at the New York Times.

Tuesday, April 22, 2008

Seidel's Subponea Quashed

Eric Turkowitz over at New York Personal Injury Blog has the good news on blogger Kathleen Seigel's (of Neurodiversity.com) subponea (headlined in my Grand Rounds 8 Apr 2008).

-Wes

Grand Rounds is Up at Dr. Val

Based on my favorite anatomic system:
That's right – I'm taking my inspiration from the limbic system, and have organized the posts according to the dominant emotion they elicit from readers. And because Dr. Val was one of those annoying medical students who brought 10 different colored highlighters to study class, I will also label some of the posts with the following tagging system (in brackets) to offer advanced readers an additional nuance:

[:-)] = A post that demonstrates literary excellence

[{] = Early bird – an author who got his/her submission in early, which is really convenient for the host(ess)

[:-/] = Naughty – an author who forgot to submit an entry to Grand Rounds but who was included nonetheless
Guess which one I was.

-Wes

Doctors vs. Administration

Aggravated DocSurg nails it once again.

Brilliant.

-Wes

EKG Du Jour - #4

Another case from the EKG Hall of Fame:
She was 79 and referred for evaluation of an "aortic valve disorder." She was told of a cardiac murmur 6 or 7 years ago, yet had been asymptomatic, without dizziness, shortness of breath, nor loss of conciousness. She did not feel skipped beats and had never had fevers. Her echo one month prior had demonstrated a very mildly stenosed aortic valve with a mean gradient of 12.2 mm Hg and an aortic valve area of 1.64 square centimeters with mild aortic insufficiency and normal left ventricular function. Her only medication at the time of evlauation was hydrochlorothiazide for hypertension.

As part of her workup, an EKG was ordered and is shown below:

Click to enlarge
What is demonstrated on the EKG and how should it be treated?

-Wes

Having fun? Don't miss these other EKG cases du jour: #1, #2, and #3.

Monday, April 21, 2008

The Electronic Nursing Note

Note #1

"Patient Acceptance Note

Patient Direct Admit from home. Awake, Alert and Oriented. Patient oriented to BR/ER light, bed controls, TV/radio, patient education channel, telephone, bathroom, visiting hours, overnight stay and call light. Vital signs taken and recorded. Pain status assessed. See flow sheet for vital sign assessment.

Documented by: Sally Smith, RN 4/13/2008 at 5:59 PM."


Note #2

Problem: PAIN
Goal: PAIN CONTROLLED TO TOLERABLE LEVEL FOR PATIENT
NO C/O PAIN NOTED.

Problem: HIGH FALL RISK
Goal: FREE FROM ACCIDENTAL PHYSICAL INJURY RELATED TO FALL
BED LOCKED AND IN LOW POSITION. SIDE RAILS UP X 4, CALL LIGHT WITHIN REACH.

Problem: RESPIRATORY
Goal: RESPIRATORY FUNCTION AT PATIENT'S BASELINE
NO REESPIRATORY DISTRESS NOTED.

Problem: HEMODYNAMIC STABILITY
Goal: PATIENT WILL MAINTAIN ADEQUATE TISSUE PERFUSION/HEMODYNAMIC STABILITY
VITAL SIGNS STABLE, AFEBRILE.

Problem: DEHYDRATION (NAUSEA, VOMITING, AND/OR DIARRHEA)
Goal: RESTORE/MAINTAIN FLUID BALANCE
+BS; CARDIAC DIET. NO NAUSEA/VOMITING NOTED.

Problem: EMOTIONAL STRESS
Goal: PATIENT WILL VERBALIZE LESS ANXIETY
PT HAS SOME FINANCIAL AND "HOME" AND FAMILY CONCERNS THAT SHE WOULD LIKE TO DISCUSS WITH SOCIAL WORK.

SOCIAL WORK CONSULTED."
No doubt completing these charting requirements are simplified for today's nurses, but these nursing notes provide lines and lines of very little of substance for doctors to read, read exactly the same from patient to patient (and hence are ignored) and once something is found (like the social issues noted), no description of the issue is provided.

Aspects of the new electronic medical record was not made for doctors or our patients, but clearly for quality assurance administrators.

Thanks, folks.

-Wes

No More Black Box


While I've often wondered about emulating the airline industry, there is one innovation that single-handedly has determined the cause of many airline crashes: the on-board flight recorder, or "black box." Anytime there's a crash, it's what the recovery teams look for on land or the divers seek in the sea. It's the constant stream of retrospective data provided by the flight recorder that allows researchers analyze the conversations, wind conditions, air speed, aileron positions, altimeter recordings, and the like of a flight so the circumstances that lead to the ultimate catastrophe can be recreated. The data from the flight recorder has undeniably improved the airline industry's accident rates.

Regrettably, medicine is losing our black box: the autopsy.

Certainly, with the amazing advances in imaging, we have an unprecedented ability to peer inside the body with remarkable clarity to understand disease processes. Many argue that our understanding of events leading to the death of a patient are better defined than ever before - so why an autopsy?

One only needs to look at the multiple causes of a lung infiltrate on chest x-ray to understand what could be learned: was it caused by infection (bacterial, fungal, viral, worms?), or hemorrhage, or inflammation (bronchoalveolitis obliterans, sarcoid, amyloid, or many other causes), that this person died? Were we treating the correct diagnosis? Would management have been different had we known? Could future lives be saved by a better understanding of the precise cause of death of this one, unfortunate individual?

We will never know. But now we can consistently proclaim, "we did the best we could."

Gone are the days where a third year medical student can hold a heart in his or her hand, smell pseudomonas, see an occluded or anomalous coronary artery or aortic stenosis in person. In effect, medicine has lost the color of human reality in exchange for the black and white images on a monitor screen.

And where are the continuing quality improvement advocates in this debate? They're looking at the living and forgetting about the mistakes that are buried. Yes, Virginia, we do get it wrong sometimes but you'll never know now.

Unfortunately, autopsies are expensive: performed by pathologists who take samples, prepare slides and cultures, write detailed reports scrutinized by lawyers, and occasionally do high-tech tests like electron microscopy to define an answer. In our constant efforts to shave costs, the autopsy's "return" on investment to the education of future physicians is lost since the patient is already dead - another data point chalked up to "mortality." Death, then, has now officially lost its value to the future education of our physicians.

So as the dehumanization of medicine continues, rest in piece, Mr. Autopsy.

Us old farts in medicine will miss you.

-Wes

Image reference.

Sunday, April 20, 2008

At Your Beck and Call

* * * bleep * * * bleep * * * bleep * * * bleep * * *

<07> Sally Smith 847-555-1234 same 65 ENH tecca-cardia attack
4:46AM 20 APR 2008


"Hello, this is Dr. Fisher returning your page."

"Yes doctor, thank you for calling. I'm a patient for Dr. Jones and had surgery in August. I think my heart raced this morning and it woke me from sleep."

"Is it racing now?"

(Pause)

"Uh, I'm not sure."

"Does it feel like your heart beat is regular or irregular?"

(Pause)

"I think it's regular."

"What medicines are you taking?"

"Uh, I'm not sure. I'm not very good at remembering..."

"Do you have a list where they're written down?"

"Yes, but I'm in bed and the list is downstairs."

"Well, now that there's two of up early this morning, you mind retrieving it?"
Please, when you call your doctor about a health concern, have your medication list (complete with names and doses of the drugs) in hand before you make the call.

-Wes

Friday, April 18, 2008

Kickback Quandary

Does a $119,000 kickback from a hospital to a referring cardiologist justify the $2.5 million dollar fine the Feds want to impose?
The federal government yesterday filed a civil lawsuit against an Essex County physician, accusing him of participating in an illegal kickback scheme at the University of Medicine and Dentistry of New Jersey, which has already led to the criminal convictions of two other doctors.

According to the suit filed by the U.S. Attorney's Office, cardiologist Atul Prakash of Cedar Grove violated federal Medicare statutes, committed fraud and submitted false statements by illegally referring more than 30 patients to UMDNJ's University Hospital in Newark in return for $119,000 in payments.

The suit seeks triple reimburse ment of Prakash's salary as well as financial penalties that could exceed $2.5 million.

"There are still others who engaged in the same conduct, and we will use both criminal and civil remedies as needed to achieve justice and the return of money received by fraud," U.S. Attorney Christopher Christie said.
I guess it's justified in the government's eyes if they want to pay for even more investigations.

This issue of "self-referral" is a murky one. If payments for referrals is illegal, then why isn't the profit-sharing amongst members of the same large multi-specialty medical group who refer to each other considered a form of kickback? No, this is okay. But when a separate entity like a hospital dares to "profit-share" in return for referrals, it's illegal.

I guess multiple standards can be imposed when the government needs money.

-Wes

Old Friends

It's happened twice this week. Names, long forgotten, resurfaced. I have noticed that several of my patients need their defibrillator or pacemaker battery replaced - ones I placed seven years ago shortly after I started at my present position.

Being in the Navy and then private practice for several years, my wife and I rarely lived in one place for very long. We've moved eleven times since our marriage. Similarly, the field of electrophysiology is so procedural that patients are usually "returned" to the referring physician for their chronic management, so interactions with your patients can be hard to maintain.

In each case, the patients were relieved as they walked in to my office and saw a familiar face. It seemed almost like yesterday, as we each tacitly noted that the color of our hair was a little gray-er and their stance a bit less certain. Much had happened since I last saw them: many had experienced loss and were dealing with new challenges. Each had taken time with family and friends and seemed all the better for doing it. It was nice to know they've done so well for so long.

I reflected on this while I walked the dog last evening for her nightly constitutional and realized that I really enjoy being in one place for a while.

-Wes

Image reference.

Thursday, April 17, 2008

Grand Rounds: Better Late Than Never

I'm a dog.

After seeing how much work it is to prepare Grand Rounds for the medical blog-o-sphere, I can't believe I forgot to post a link to this week's edition! Head over to Women's Health News to read this week's edition.

-Wes

The Challenges of Biologic Pacing

I worry when business journals report things better placed in medical journals, especially since medicine has become Big Business.

Witness today's article reported in the Wall Street Journal about biologic pacing and it's promise to supplant or supplement permanent pacemakers. Just replace the sick pacemaker cells with biologically engineered ones and the heart will beat, right?

Wrong.

I wish it were so simple.

The heart is a gloriously complex and amazing organ, full of a diverse set of specially designed cells which are carefully interconnected in an almost magical way to provide carefully-timed mechanical propulsion to blood. From the leaky sinus node cells, capable of generating the rhythmic automaticity that begins the cardiac cadence, to the nerves that supply those cells to assure they are bathed in the appropriate balance of neurotransmitters to increase that cadence with exercise or stress, to the gap junction interconnections that permit the spontaneous electrical impulse to be transmitted to neighboring cells in rapid succession, to the remarkable AV node that slows the electrical conduction ever so slightly to allow time for blood to travel from the top to bottom chambers of the heart, to the His-Purkinje system that rapidly speeds that electrical impulse symmetrically to the lower chambers of the heart and distributes the electrical impulse in a lightning-fast way to stimulate the cardiac myocytes to contract in unison, it's a complicated endeavor to get the heart to beat properly. Far be it from me to suggest that the wonder of cardiac electrophysiology and reliable cardiac pacing can be distilled simply to a petri dish of beating stem cells.

Only a tiny fraction of pacemaker patients have a sick sinus node (the pacemaker cells). Many others have interrupted AV nodes, others have cardiomyopathies that need pacemakers to restore mechanical synchrony to improve cardiac output, and many more are on medications that chemically slow the heart's normal cells to such a degree that a pacemaker is required to maintain an acceptable heart rhythm for activity.

Economically, we are left to wonder why we would use such cells as a supplement (rather than as a replacement) for a permanent pacemaker. Would they be used to reduce the amount of pacing required in a chamber just to conserve battery life of the permanent pacemaker? Realistically, there's little cost savings to our health care system in that approach. And if these cells are transfected into a ventricle (the lower pumping chambers), will people develop "pacemaker syndrome" from the loss of AV synchrony?

More likely, in this era of cut-backs for funding for innovative research, such articles in business journals help researchers cast a wide net for funding. The biotech, pharmaceutical and medical device industries have increasingly become vital resources for financial support that permits pioneering research work to continue because they seek one thing: the Pot of Gold at the end of the long research rainbow. So where better to turn to advertise describe your work and the need for more funding than a prominent business journal?

But business speculators should consider the hurdle they're approaching carefully. Although this is fascinating work, realize that the obstacles to overcome for the development of a true biologic pacemaker are considerable.

-Wes

Wednesday, April 16, 2008

The Race is On!


My hospital's faster than your hospital. Let's see you beat a 14-minute door-to-balloon time! I dare you!
A new era of public relations has descended upon us ... one hatched from our wonderful performance initiatives.

No doubt we'll soon have "Performance Olympics 2008" as the ultimate arbiter of the "World's Greatest Hospital."

-Wes

Image reference.

Lost in Space

Monday I traveled to Minneapolis to tour Boston Scientific and learn about the "project Aurora" initiative to clean up their shortcomings that lead to an FDA warning letter which halted their production line. (They devoted some 600 engineers and $140 million to "re-vitalize" their business, they said.)

But along the way, I had the chance to meet with many other electrophysiologists (we call them EP's) from the Chicago area - good guys all - each at the top of their "game," so to speak. We discussed the the future of our field: new ideas and innovations. And naturally, up came the subject of "robots" - specifically robotic assistance for catheter ablation - especially atrial fibrillation. Two main companies are in this space right now, Sterotaxis, that uses some big magnets to move a magnetic catheter in 3D space, and Hansen Medical that uses a motorized robotic sheath system to steer a catheter in 3D space (I blogged on this earlier). Here was the discussion that transpired:
"Yeah, we're going to have two new ones later this year."

"Our center is moving to some new labs and we'll have one, too."

"Is there any data to demonstrate efficacy with these devices?"

"Not in any prospective, randomized, multi-center way, no."

"Do you think these things will help?"

"I don't know. But it'll be cool to play with 'em. I'm looking forward to having an opportunity to really see the potential of this technology. Certainly, the hospital likes the marketing opportunities..."

"But do they work? I mean, for $1.5 million and a special non-magnetic room and all..."

"We'll have to see. Our center got one donated through a grateful patient, so our return on investment will be immediate via marketing. I mean, it's almost like you have to have it to say you're on the 'cutting edge.'"

"Why haven't there been any multi-center studies with these things?"

"Simple. They really don't want to do those studies. They're expensive. Why would a company want to spend the money to study them when centers are buying them anyway? Everyone wants to say they are on the 'forefront' of medicine, right?"
I mean, technology is so sexy, isnt it? Multiple computer screens, 3D graphics, joy sticks with multiple degrees of freedom and pre-designed programs, built on models, that move a stick in 3D space using cool whirring motors or magnets. I mean "pulling" the catheter where you want to go - what could be better?

And I can sit down! No more hemorrhoids! No more swollen legs!

But realistically, each system has its limitations. I have already mentioned some of those seen with earlier iterations of the Sterotaxis system, and Hansen has been plagued by rumors of cardiac perforations.

In the old days of EP, catheter ablation defined itself by number of radiofrequency applications (less was better to minimize injury to the heart), procedure times, acute and long-term procedural success. Are ablation times shorter with robots, hmmm, haven't heard. Better outcomes? Nothing. I have heard about the "learning curve." One novice doctor noted it was hard to even move the catheter to the His bundle position with one of the systems when he tried since this location was not "pre-programmed."

And yet these devices are "approved" by our FDA. Deemed safe, effective by a 510(k) approval process that states:
A 510(k) is a premarket submission made to FDA to demonstrate that the device to be marketed is at least as safe and effective, that is, substantially equivalent, to a legally marketed device (21 CFR 807.92(a)(3)) that is not subject to PMA (pre-market approval). Submitters must compare their device to one or more similar legally marketed devices and make and support their substantial equivalency claims.
Safe and effective perhaps for simple atrial flutter ablation, but atrial fibrillation? Really? How many cases were submitted to the FDA? Twenty?

Now I am no Luddite when it comes to all things technical. I love technology. And I certainly think that studying these devices to determine safety and efficacy should be done.

But I see a trend now where the amount of heart destroyed doesn't matter (some feel if enough ablation is performed, all afib will eventually cease - and they're probably right - but what about atrial transport?) Marketing, marketing, marketing of the latest, yet not necessarily the greatest robot, seems to be the norm. Science and the rigor required to determine efficacy and safety are squeezed by ever-tightening research budgets while companies are permitted to expand without demonstrating superiority, only equivalency.

And it all costs our patients (via the Medicare National Bank) millions and millions of dollars.

-Wes

Image reference.

Monday, April 14, 2008

I'll Get Around to It Later

... really I will...

From USA Today:
Doctors, lawyers, dentists and chiropractors account for a big share of tax delinquents — 10% of California's list, for example. Sometimes, tax trouble isn't the only problem delinquents face.

Neurosurgeon Lorne Houten of Woodland Hills, Calif., owes $440,000 in state income tax and $472,406 in federal taxes, public records show. In 2002, the Medical Board of California accused him of a series of medical errors. A disciplinary hearing is set for September. Houten has not responded publicly to the board.

For most, tax troubles don't signal professional problems.

Madison Richardson, a prominent head and neck specialist in Beverly Hills, owes $1.6 million in state income taxes and $2.1 million in federal income taxes, public records show. He maintains a large practice with two offices.

Neither physician could be reached for comment.

"You'd be surprised how many doctors don't file income tax returns," says David MacKusick, an Atlanta tax lawyer. "They're busy, self-employed and figure they'll get around to it later."
Amazing how doctors from Beverly Hills and Malibu are singled out in this piece by the press. Worse, a tax lawyer gets to slam doctors' fiscal responsibilities but is unable to acknowledge the juicy details of lawyers' taxation delinquencies.

No wonder doctors' salaries are always perceived by the media as excessive.

-Wes

Sunday, April 13, 2008

A Cocktail Conversation

"I have to recertify for boards for the second time on Thursday. My year was the first year they started this every-10-year re-certification game."

"Are you nervous?"

"I think frustrated is a better word - I mean, why does a busy orthopedist in private practice with my experience have to prove his expertise every 10 years? I'm a spine guy. I haven't done club feet in years. I have no intention of doing club feet again - and yet I have to learn not only about club feet, but the whole gamut of orthopedics for this stupid test. And the practice questions - you take them and they give you five answers, none of which are really the right answer - but you have to figure out the "best" answer of the group. Stupid.

Worst of all, no one pays you for taking these tests. I mean, they're expensive. You have to take 50 hours or so of continuing medical education credits per year, just to qualify, at what, four to five thousand dollars a pop? And you're away from your practice losing money all the while… Then you sit for an expensive test that doesn't really cover your knowledge base.

Those regulators should be paying me to take their required tests.

I can tell you one thing...

... I'm not doing it a third time."

My Six Word Memoir

Happy Hospitalist tagged me with a meme to write my six-word memoir.
I really don't like meme's because they're a time sinkhole and tend to burden others. But hey, I found I became haunted by this (see what I mean?). So I guess I can be a good sport and play along, after all, the thought is an intriguing one: you get six words to write your memoir and add a picture if you wish. So here's mine:


Show them kindness, integrity, and love.


'nuf said.

So in keeping with the "rules" of the meme, I get to pick 5 other nice doctor bloggers to torment tag:

TBTAM
Dr. Val
Gruntdoc
Dr. Anonymous
Dr. Deb

But in order to have pity on those I've tagged, I'm gonna change the rules a bit - they don't have to participate if they don't want to...

-Wes

Saturday, April 12, 2008

65,000 New Teen Smokers Every Month

If you get a chance, check out the "Running the Numbers" exhibit by Chris Jordan. Here's an example of his work depicting 65,000 cigarettes, equal to the number of American teenagers under age eighteen who become addicted to cigarettes every month:



Partial Zoom:


Full Zoom:


Street Anatomy (who showed me the way) has another example.

Awesome.

-Wes

Thursday, April 10, 2008

The Industry We're Trying to Emulate

Recently, I had the pleasure of escaping the still-frigid early Spring in Chicago for a warmer climate and flew south for a few days. I found it interesting, to say the least, to observe what happens when price pressures are added on the highly-regulated airline industry - much like what is about to happen in healthcare. You see, many have advocated that we should emulate the airline industry to improve patient safety and healthcare delivery.

Here's what we experienced:
  • The wrong luggage sticker was placed on my wife's luggage. Fortunately, poor "John Doe" was going to the same airport we were.
  • The center bathroom of our packed 757 was sealed shut with a sticker "out of order" and appeared to have been like this for quite some time. Only the forwardmost and aft bathrooms were available.
  • No check of seatbelt fastening occurred at takeoff nor landing.
  • The seat in front of me was unable to stay locked in its upright position
Now it's so easy to criticize, but the implications of what happens to an industry when price pressures mount were certainly plain to see. The "safety checks" and maintenance of our plane had clearly suffered cutbacks.

I remember the days when hot meals were served on planes in coach, not just first-class, leg room was more than an afterthought, and the flight attendants took interest in the passengers and gave their kids those cool little flight wings to wear. Sadly, now we are hearded onboard in "Groups," have to buy a box of carbohydrates called a "snack" for five bucks, and laminate ourselves next to our fellow passenger to improve capacity while the very plane we're flying is poorly maintained.

Is this the industry we're trying to emulate?

-Wes

Wednesday, April 09, 2008

My Pre-Rounds Interview

Thanks to Nicholas Genes, MD, PhD for his nice words over at Medscape.

-Wes

Now Available on E-bay

... a 15-year-old McDonald french fry.

This might make you want to think twice about super-sizing those things...

-Wes

The Money and Marketing in Wellness

Firms’ Health Clinics Cut Costs
- Wall Street Journal, 9 Apr 2008

As a business person interested in improving your bottom line, wouldn’t you want to read this? Such a catchy concept, isn’t it? Especially if you get to build a six million dollar facility to “cut costs.”
"On-site clinics have undergone a huge transformation," said Marne Bell, a senior consultant at Watson Wyatt. "There's much more emphasis on prevention."

Gone are the days when on-site clinics were the sole preserve of manufacturing companies that founded facilities to treat employees' work-related injuries. Some three in 10 large employers -- from financial firms to hair-care companies -- have on-site clinics, offering everything from primary care to travel medicine, pregnancy support and nutrition counseling. Walt Disney Co. just broke ground on a $6 million, 15,000-square-foot health-and-wellness center for employees at Walt Disney World.
Those consultants at Watson Wyatt are so clever. I’m seeing the savings, aren’t you?

I mean, more lunchtime walks and taking the stairs instead of the elevator really makes a difference. Just think, you might burn five more calories taking the stairs rather than an elevator and this surely has been correlated with more days on the job, right? Or maybe the cost savings is because they never have to build any more elevators? (No, the disabilities folks won’t allow that.) And talk about savings, look at what most of these clinics do:
Preventive services, such as health screenings and immunizations, are the most common type at the latest wave of clinics, according to a recent survey by Watson Wyatt and the National Business Group on Health (WWBNGH).
Wow. Thanks for the info, WWBNGH! Screenings. Immunizations. I stand in awe. But I don’t know, don’t screenings require the worker to leave work to get screened? And how much money is saved on those immunizations? I mean, I’ve HAD all of my immunizations when I was a child, and now I just need an annual flu shot or maybe an occasional tetanus shot, so how many immunizations would I need to get in those clinics to break even on the construction costs for one of those six-million-dollar clinics?

Or maybe, just maybe, there’s an ulterior motive at play:
Four in 10 clinics offer pharmacy services, making it easier for those taking medications to fill their prescriptions.

Because of employees' concerns about privacy, clinics typically are run by outside parties. For example, Pepsi Bottling Group Inc. has contracted with Johns Hopkins University School of Medicine to operate clinics at its plants. CHD Meridian Healthcare LLC and Whole Health Management, which recently were purchased by Walgreen Co., and Marathon Health are among the vendors that specialize in providing work-site clinics. Depending on the scope of services, clinics can be staffed by physicians, nurse practitioners, registered nurses in isolation or in teams that can also include specialists, such as nutritionists.
There we go. The money. It’s all in finding the disease, isn’t it? Testing. Testing. Testing. Testing. We’ve gotta be SURE folks don’t get sick, right? And pharmacy services? Oh, baby, now we’re talkin’ dough!

And it needn't stop there.
"We recognized that there was going to come a point where we couldn't pass on the additional cost of providing health care to employees," said Jeff Shovlin, vice president of benefits at Harrah's. "We concluded that the only way to control costs was by helping employees to get and stay healthy."

The clinic, which is open to employees and their family members enrolled in Harrah's medical plan, has extended weekday opening hours and is open half-days on Saturdays. Patients get faster medical attention and longer appointments, for which they pay $10 copays.

A major focus is to delve deeper into patients' medical issues, educate them about healthful lifestyles and direct them to wellness programs.
Ooops.

Mr. Shovlin slipped. He actually said it: “We couldn’t just pass the additional cost of providing health care to employees.”

Oh, sure you can, Mr. Shovlin! Here’s how: by shovin' the concept of your “major focus” to “delve deeper into patient’s medical issues” to your employees! Just find those sick ones so you can remove them from your insurance pool or give them a higher premium! What a deal! You see, that’s how business works, Mr. Shovlin! You scratch my back and I’ll scratch yours. That’s right, Mr. Shovlin, if you find the sick patient’s for your insurer, we’ll give you a lower price on your policy with them.

Money, money, money.

Oh, baby, you gotta love "wellness" and those 12,000-square-foot gyms!

So here's the question: when a patient gets cancer, how exactly does your clinic and gym cut costs?

-Wes

Tuesday, April 08, 2008

Welcome to Grand Rounds - Vol. 4, No. 29

Welcome to the Medical Blog-o-sphere's weekly edition of Grand Rounds! Today we'll take a decidedly (well, what else?) cardiovascular bent. I appreciate all who contributed their talents to this week's edition. Many thanks must be bestowed on Nicholas Genes, MD, PhD, the grandfather of Grand Rounds and the great Keeper of the Schedule, for his patience and guidance during my maiden voyage into the ranks of the truly gullible "grandly" hosts of this weekly event.

All 36 (or so) posts have been included, and have been assembled by their appropriate cardiovascular term.

So grab a cup of coffee, sit back, relax and enjoy this week's Best of the Medical Blog-o-Sphere!


Legal thuggery is sure to make a medical blogger's heart stop. Eric Turkowitz over at New York Personal Injury blog links to the buzz created by New Hampshire blogger Kathleen Seidel of Neurodiversity.com, and her remarkable post entitled "The Commerce in Causation." Ms. Seidel is a level-headed, well-researched citizen-journalist who has tirelessly investigated the pediatric medical research conducted by Rev. Lisa Sykes, Mr. Clifford Shoemaker, and their colleague Dr. Mark Geier; their efforts to compel removal of mercury-containing antimicrobials from FDA-approved vaccines; and their "judicial advocacy" campaign. After sharply criticizing Shoemaker's legal incentives, she received a subpoena within four hours from Mr. Shoemaker, the plantiffs' council, demanding "bank statements, cancelled checks, donation records, tax returns, Freedom of Information Act requests, LexisNexis® and PACER usage records. The subpoena demands copies of all of my communications concerning any issue which is included on my website, including communications with representatives of the federal government, the pharmaceutical industry, advocacy groups, non-governmental organizations, political action groups, profit or non-profit entities, journals, editorial boards, scientific boards, academic boards, medical licensing boards, any 'religious groups (Muslim or otherwise), or individuals with religious affiliations,' and any other 'concerned individuals.'...."

Not intimidated, Ms. Seidel subsequently filed this well-targeted motion to quash the subpoena. It's an incredible story exposes the underbelly of a potential new legal tactic that could be imposed against bloggers anywhere: issuing malicious subpoenas to quell bloggers' free speech.

More likely, as Orac points out in his "important rant," Ms. Seidel will be vindicated by a Streisand effect.


Not Totally Rad reviews the radiologic imaging of sex. It seems it's all about the angle of the dangle. Hey, if this doesn't give you palpitations...

Vitum Medicinus describes his pap smear on a man. Getting lightheaded yet?


It would be laughable if not so true: Dr. Rich at Covert Rationing Blog discusses the implications of the 196-page smoking cessation guidelines (Brady) and their implications for the 7.5-minute outpatient office visit (Tachy).


Really, when it comes down to it, for gay teens "nothing again will matter." (Thanks to Nancy L. Brown, PhD from Teen Health 411 for submitting this lovely poem).

At Med Students Down Under we get a glimpse of a med student's worse nightmare: flunking boards. More importantly, we also learn of the remarkable strength and fortitude it takes to recover from such an event and the lessons learned along the way.

TBTAM over at The Blog That Ate Manhattan demonstrates beautifully what happens when doctors start to think about the tough stuff in healthcare.

Imagine. Finding you could no longer lift your child or swallow. Pearls and Dreams discusses the paradox that lies between the ability of medicine to tackle difficult diseases, like Myasthenia Gravis, and the challenges of ongoing care affter being diagnosed.

The Sterile Eye reflects on the gnosis of diagnosis by biopsy.


Dr. Val notes this is what some orthopedic surgeons sound like during academic lectures. You gotta love those orthopods!


Lisa Emrich at Brass and Ivory outlines the blocks to qualifying for drug-assistance programs when you're a "tweener:" not yet on Medicaid, but struggling with the long-term costs of medications.


Wow, for a minute I thought I was being Rickrolled by Doc Gurley, but it seems the American Heart Association wants us to do CPR to the beat of disco. "Stayin' Alive," to be exact. Another time reentered, indeed. I'm just not sure I want to stay alive to listen to this, but the cadence is catchy...


Sam Solomon over at Canadian Medicine reminds us of the power of doctors' poetry. After losing my father last year, I was struck by this one which appears among the many links he provides.

The Fitness Fixer links to a funny, yet disquieting, video on the sedentary-mindset of our society.


Med Valley High describes food-related references in medicine. Shoot on over and add any he's missed.


Quit coffee? Nah. It's just afib... What's a little coffee among friends? (Kerri - I feel your pain!)

Sandy Szwarc, RN at Junkfoodscience exposes the irregularities of the study design in a recent New England Journal of Medicine study that claimed fat pregnant women outstay their welcome in hospitals compared to their slender counterparts.

Colorado Health Insurance Insider discusses another irregularity: the profit in non-profit hospitals. Well, given that 60% of hospitals are non-profit, maybe this is not so irregular after all.

While on the subject of irregularity: Chronicles from the Middle of Nowhere describes the challenges doctors encounter when they second-guess treating family members.

And if defibrillator hacking wasn't enough, Clinical Cases and Images discusses a new nightmare: hacking blogs.

Did you have an endoscopy in Las Vegas, Nevada between March 2004 and Jan. 11, 2008? Reused syringes and improperly cleaned endoscopy equipment are just of the few irregularities that occurred at the Endoscopy Center of Southern Nevada. Healthline Connect's JC Jones, RN has where to call to get help.

Ian Furst over at Wait Time and Delayed Care looks at his blog stats to suggest an explanation why certain countries (like England) have longer wait times for patients.

Vreni at the Wellness Tips Blog discusses the history of the refined carbohydrate vs. saturated fat debates in the genesis of obesity.


Rita Schwab over at MSSPNexus blog brings us back to normal rhythm as she discusses the real reason doctors should attend educational conferences.

Amy Tenderich of Diabetes Mine makes it easy to teach patients how to count carbs with her handy-dandy mnemonic.

InsureBlog's Henry Stern shares his personal catharsis about caring for aging parents, making often painful decisions, and offers encouragement and suggestions to those in the "sandwich generation."

Who makes the bigger contribution to mankind, an organ donor or a clinical trial participant? The Health Business blog's David Williams thinks he knows.

When Joshua Schwimmer can The Efficient MD, efficiently announce his new book deal with the American College of Physicians and then spin over and tell us about a new bioartifical kidney on the horizon at Tech Medicine. Dude! So efficient! (But normal? Hmmmm... I have enough trouble keeping up one blog...)

Barbara Kivowitz at In Sickness and In Health discusses the fun that can be had by eavesdropping on others in the waiting room. HIPAA? What HIPAA?

Dr. T. over at Fruit of the Womb (great name for an OB blog, by the way) does a nice job explaining how smoking can confound certain prenatal tests for Trisomy 13/18 and Trisomy 21 (Downs Syndrome). Even this cardiologist learned something! Now, where can I apply for CME?

Paul Auerbach, MD at the wilderness medicine blog, Medicine for the Outdoors, reflects on his week working in a hospital in Guatemala where people make due with much less than the US and manage quite nicely, thank you.

Laurie Edwards, a celiac disease patient at A Chronic Dose, discusses why she never ventures to the center of a grocery store.

And finally, How to Cope with Pain proves what I've come to learn preparing all of these posts: computers can be painful. Amen!

Well that wraps up another exciting collection of posts for this week. Thanks again to all who donated a bit of their time, energy and effort to making the field of healthcare just a little bit more accessible to all.

Next week's Grand Rounds will be hosted by Women's Health News.

So now, here's what's left:


May I rest in peace.

-Wes

Monday, April 07, 2008

The Decision's In

Earlier I posted about the challenges of applying and auditioning for college-level study in performance music (cello). The process for selection I would not bestow upon my worst enemy.

But the lessons learned by son and parents were nonetheless important: that hard work and perserverence can sometimes lead to remarkable opportunities and I am happy to say that one young man is now walking on air.

We applied to nine institutions, fearing that the large applicant pool created by the end of the baby boom would limit options for acceptance.

The tally?

4 admissions, 2 wait-lists, 3 rejections.

And the decision is...

... Eastman School of Music - named Newsweek's Hottest Music School in their Aug 20-27, 2007 issue.

Congrats, buddy.

-Dad

PS: Anyone else looking at such a tract? Send me a note: we learned a lot.

Sunday, April 06, 2008

Bad Timing

I don't know about you, but if this story was on the front page of the Chicago Tribune on the 3rd of April, why on earth would your hospital send out this press release about your new $120-million-dollar facility on the 4th of April?
Each of the 64 new private rooms has a large bathroom, flat-screen television, wireless internet access and plenty of natural light through large windows. East-facing rooms offer views of the Chicago skyline and Miller Meadow forest preserve. The rooms have calming colors, and patients have the option of turning down the lighting.

Earth, water and sky themes echo throughout the building. In the atrium lobby, water cascades down an 18-foot waterfall. The lobby, finished in natural materials such as white maple and Egyptian limestone, is named for former LUHS Board Chairman Frank W. Considine and his wife, Nancy S. Considine. Their pledged gift helped to create the welcoming area.
And today, another front-page story appears.

Someone may want to talk to their PR department.

Then again, I guess woo sells.

-Wes

Saturday, April 05, 2008

Affirmation

It happened at least twice a year, after birthdays and Christmas:

"You make sure to write those thank-you notes to the folks that sent you such nice presents, Wes."

"Ah, Mom, do I have to?"

"Yes you do. Just sit down and get it done. Then you can take it off your list of things to do."
* * *

Medicine is a complicated enterprise, with a myriad of talented individuals who work together to achieve a common goal: the care of our patients. While I often rail on this blog about certain aspects of healthcare that frustrate me, I find it is the patients themselves that reaffirm time and time again why I do what I do.

Throughout my career as a doctor, I have always prized thank you notes. They are sincere, gracious acknowledgements of our efforts, and the written word takes just a bit more effort than verbal one and can be cherished for years.

But none of us work in a vacuum. Behind every instance of care that doctors provide, there are a myriad of individuals who have helped sculpt the patient's experience.

So for the secretaries who took the calls,
the nurses who checked and rechecked the particulars,
the nurse practitioners who followed-up,
the technicians who were at the monitors,
the hospital administrators who maintained the facilities,
the phlebotomists who drew the blood,
the engineers who developed the technology,
the companies that made these devices,
and doctors who conceived of the technology,
and the researchers who brought biventricular pacing to fruition...

...this one's for you (used with patient permission):

Click to enlarge


-Wes

Thursday, April 03, 2008

The Hospital Nobody Wanted

From the front page of today's Chicago Tribune:
In a stunning development underscoring the plight of non-profit hospitals struggling with the increase in uninsured patients, the Catholic ownership of St. Francis Hospital & Health Center on Wednesday said it will shutter the hospital because nobody would buy it.

The religious order of nuns that oversees St. Louis-based SSM Health Care said it could not even give the hospital away to other health facilities "for free."

Saddled with tens of millions of dollars in losses from uninsured patients who could not pay their medical bills, St. Francis would be abandoning its core mission of caring "for the people of its communities regardless of their ability to pay." SSM will seek a closing application with the state, a process that could take several months.


"Unfortunately, in spite of St. Francis' outstanding clinical reputation, reimbursement from commercial insurers could not cover the cost of providing care to the growing number of Medicaid and uninsured patients," said Sister Mary Jean Ryan, SSM's chief executive officer.

As health insurance companies and government health insurance programs reduce amounts they pay hospitals, hospital operators increasingly look to consolidate to gain economies of scale in the regions where they operate.

Some operators also try the increasingly controversial route of expanding or relocating to wealthier suburban areas in order to attract a higher number of commercially insured patients who can provide a steadier flow of revenue.

But SSM was stymied in its attempts to expand and does not have other hospitals in the area to rely upon. SSM said it tried to strengthen St. Francis, located in a blue-collar community that has suffered job losses, by expanding to more affluent Orland Park, which is partly in Will County.
But some were skeptical about the decision to shudder the hospital, it seems:
"If you can offset the losses to build a new hospital 10 miles away [in Orland Park] then why can't you offset the losses to keep this unprofitable hospital open with the profits from the parent organization?" asked Joe Novak, an Illinois hospital critic who rails against the non-profit industry on his blog, WhereTheMoneyGoes.com.

In south suburban Will County the building boom has pitted hospital against hospital for the right to build facilities in growth areas. Silver Cross Hospital in Joliet has drawn intense criticism from its city leaders and the community for plans to relocate to New Lenox, which has far fewer uninsured patients just a few miles away in a booming suburb.

North suburban Lake County, too, has been a hotbed of activity, with hospitals engaging in bidding wars to expand.

Lake Forest Hospital this year made an unsolicited offer to acquire Condell Medical Center in Libertyville just one day before Condell executives announced the signing of an exclusive agreement to merge with Advocate Health Care, the area's largest provider of medical care.

SSM said it puts its profits at St. Francis into new medical technology and capital improvements, pointing to $75 million in investments in the Blue Island facility since 2000 that included upgrades to mostly private rooms, new operating rooms and a same-day-surgery facility.

"We could locate this facility about anywhere in the country and it would attract physicians and patients," said Kris Zimmer, SSM's senior vice president of finance
.
It's like Road Warrior - where gasoline was the fuel that people killed for - now, due to the inability for fancy medical technology to attract physicians, the turf war has shifted...

... to the affluent patient.

And the hospital wars continue...

-Wes

Under the Quality Microscope

Uh, pardon me. Will someone tell me which of these groups we should report our healthcare quality statistics to so I can be sure to get my gold stars?
Consumer-Purchaser Disclosure Project
National Quality Forum
Agency for Health Care Research and Quality
American Health Quality Organization
Institute for Healthcare Improvement
The Joint Commission
The National Association of Health Care Quality
Quality Inter-agency Coordination Task Force
American Board of Health Care Specialties
The Leapfrog Group
The Institute of Medicine
The Premier Patient Safety Group
National Patient Safety Foundation
The Illinois Foundation for Quality Healthcare
Just askin'.

-Wes

Wednesday, April 02, 2008

Looking in the Mirror

The left-leaning National Physicians Alliance blog has decided to take on the American College of Cardiology.

Now as a Fellow in the American College of Cardiology, I don't agree with these guys on many things, but I think regarding the above post, they are right on the money as they describe the complicated interplay between the pharmaceutical and medical device industries and those of physicians' need for continuing education.

It was interesting to note that the ACC heavily promoted their "Quality First" initiative at this year's meeting and solicited input from physicians to garner "our feedback" in a survey distributed to the doctor-attendees. I found the survey hidden amongst the multitude of pharmaceutical swag and program outlines residing inside my handy-dandy co-branded Lipitor-ACC.08 shoulder bag. (I regret that I did not get the 1 GB USB drive they promised to the first 500 survey participants as I never saw this survey until I arrived home).

But their list of "key features" embodying the ACC's Quality First Campaign were presented unilaterally, without physician discussion. On the surface, they seem so necessary. What right-minded doctor would not want these things?

Here's what we were asked to rank (from "not important" to "very important") and my initial thoughts as I read these features in italics:
  • "Provide universal access through an expansion of public/private financing" (What? Does this mean "support universal health care?" - a buzz-word of the Dems? Does expanding public/private financing mean promote Health Savings Accounts - a buzz-word of the Repubicans? Hellllloooo, people! What the hay are we talkin' 'bout here?)
  • "Increase patient value through the delivery of evidence-based, high quality care" (Excuse me, isn't that what we're already doing? Are you asking for another 74 "quality measurements" to keep track of (like shorter door-to-balloon times) with even more bureaucracy and documentation so we can pat ourselves on the back and be on the "100-best hospital list" one more time?
  • Manage care by disease state and across sources and sites of care (Huh? I never liked "managed care." Is this what you mean? Or are we promoting the EMR here?)
  • Implement a payment system that rewards quality, value, and coordinated care management (Oh, my God! Pay for Performance! eeeeeeekkkkk! Please, lets call this covert rationing scheme what it is: "Less Pay for Performance," okay?)
  • Involve patients as partners in their own care Uh, excuse me, who has more of a vested interest in their care than the patient with the health problem? What the heck is this supposed to mean?
So what is the ACC's policy direction with these questions? Are they really interested in physician's input and a two-way discussion? Or are such surveys really manipulations of doctors for political intent? How, exactly, will this survey data be used? I can hear it now as our ACC leaders stand before congressional subcommittees and extol: "According to our carefully-conducted (and coerced survey through the use of a 1GB USB storage drive), 65% of surveyed physicians want pay for performance initiatives."

Finally, is our "quality" in cardiology so bad? Haven't we seen a dramatic decline in the incidence of cardiovascular morbidity and mortality over recent years?

Increasingly, large meetings struggle to balance marketing, policy, and educational missions in the backdrop of the medical industry's Big Money. But given the covert and conflicted issues at play, disclosure of these conflicts might no longer be enough: disentanglement of interests might be the better norm.

Maybe first re-evaluating our real priorites regarding the objectives of these meetings should be the "key feature" of the ACC's next Quality First Initiative.

After all, others already have taken the lead and I like the other guys' meeting space better.

-Wes

Tuesday, April 01, 2008

Grand Rounds This Week

Hilarious. Enjoy the ride over at Gruntdoc and...

...well, you'll see.

-Wes

Nothing is Sacred

Wow, the REVERSE Trial studying the benefits of cardiac resynchronization therapy on asymptomatic (New York Heart Association Class I) to minimally-symptomatic (NYHA Class II) are set to be presented at 10:30 today here in Chicago at the ACC Meeting, but this press release of the results is available at 09:00 CST on-line.

This pre-release reporting continues to undermine any reason doctors might want to attend these meetings any longer - it's more efficient to sit at work and surf the 'net.

-Wes

Real Hearts, Remarkable Images

If you've ever wanted to see the heart from within, you must see the work of Paul A. Iaizzo, PhD from the University of Minnesota. On this website are images obtained from actual human hearts removed before organ donation and bathed with perfusate and nutrients in Dr. Iaizzo's lab, permitting the heart to continue beating approximately 4-5 hours after it was removed to obtain these incredible images using tiny fiberoptic cameras placed within the heart chambers. His work was supported by a grant from Medtronic, Inc.
We have created a library of short Video clips to allow you to visualize the beating human heart, all the valve actions, the contractions of atria and ventricles, and the architecture of the heart as it beats. The video clips include those from 14 human hearts that we have reanimated to date, as well as still images from additional human hearts that were perfusion fixed; that is, they were preserved so to maintain their shape at the end stages of filling.

These experimental procedures and research protocols were reviewed and approved by the University of Minnesota Institutional Review Board. Human hearts for this project were obtained both as generous gifts from LifeSource Upper Midwest Organ Procurement Organization, Inc, St. Paul, Minnesota and the Anatomy Bequest Program of the University of Minnesota. This research is made possible due to the generous gifts of individuals whose hearts have been donated for research purposes. Their final act of generosity will enhance understanding of the inner workings of the human heart and contribute to lifesaving advances in cardiac medicine.
Start with the "Website Tutorial" to understand how to use the site. His videos contain truly remarkable images of the incredible inner workings of the human heart.

-Wes