Wednesday, December 31, 2008

Grand Rounds is Up

... over at Moneduloides:
Welcome to Grand Rounds 5.15: At the interface of evolution and medicine, a celebration of blogging on the myriad ways evolutionary biology influences medicine. Why evolution and medicine, you may ask? Why now? Well, in anticipation of the new year, of course; 2009 marks the bicentenary of Darwin’s birth, and the 150th anniversary of the publication of On The Origin of Species, and the one thing that just doesn’t get as much recognition as it should is the role of evolutionary biology in both research and clinical medicine.
Heady stuff and relatively short since the editor was brave to include only pertinent posts.


Tuesday, December 30, 2008

A New Year's Gift

* ding dong *

"Who could that be at the front door? It's dinnertime," I asked.

"I'll get it!" my son said, rushing to the door. ("Strange, he's never moved this fast before, " I thought.)

A few momemnts later...

"Awesome! It came!" He entered the room with a package.

"Dad, do you know where there's some batteries?"

"Uh, I think there's some in the top drawer over there... why?"

A few moments later. He appeared with a new t-shirt on. Not just any t-shirt, mind you, but one upon which he could play the drums. I kid you not. Here, check it out.

File this under "what will they think of next."
(Be sure to play the video on their site to get the whole effect)



Monday, December 29, 2008

More Alphabet Soup

"ACC/AHA/ACR/ASE/ASNC/HRS/NASCI/RSNA/SAIP/SCAI/SCCT/SCMR/SIR 2008 Key Data Elements and Definitions for Cardiac Imaging"

I could not make those initials up. This was the title of the recently published paper in the Journal of the American College of Cardiology from the writing committee organized to develop clinical data standards for cardiac imaging.

ACC = American College of Cardiology
AHA = American Heart Association
ACR = American College of Radiology
ASE = American Society of Echocardiography
ASNC = American Society of Nuclear Cardiology
HRS = Heart Rhythm Society
NASCI = North American Society for Cardiovascular Imaging
RSNA = Radiological Society of North America
SAIP = Society for Atherosclerosis Imaging and Prevention
SCAI = Society for Cardiovascular Angiography and Interventions
SCCT = Society of Cardiovascular Computed Tomography
SCMR = Society for Cardiovascular Magnetic Resonance
SIR = Society of Intervential Radiology

Wow, that's a tour-de-force of cardiac imaging specialists.* These are smart men and women who understand how the Medicare payment game is paid played. They understand that data, lots and lots of data, in fact, so much data that your head will spin, is the way to assure Medicare payment. In short: gather lots and lots of data, any way you can, to assure the folks on the Hill that you are really serious about showing the cost effectiveness of all of this testing:
The ACC and AHA recognize the importance of the use of clinical data standards for patient management, to assess outcomes, and conduct research, and the importance of defining the processes and outcomes of clinical care, whether in randomized trials, observational studies, registries, or quality improvement initiatives. Hence, clinical data standards strive to define and standardize data relevant to clinical topics in cardiology, with the primary goal of assisting data collection by providing a platform of data elements and definitions applicable to various conditions. Broad agreement on a common vocabulary with reliable definitions used by all is vital to pool and/or compare data across studies and assess the applicability of research to clinical practice. The growing adoption of electronic medical records renders an even more imperative and urgent need for such definitions and standards. Therefore, the ACC and AHA have undertaken the task of defining and disseminating clinical data standards—sets of standardized data elements and corresponding definitions to collect data relevant to cardiovascular conditions. The ultimate purpose of clinical data standards is to contribute to the infrastructure necessary for accomplishing the ACC/AHA’s mission of fostering optimal cardiovascular care and disease prevention.
On the surface, these efforts seem like the best way to begin to get a handle on the cost-effectiveness of cardiac testing. No doubt the shear volume of data generated will be heretofore unmatched and a rich source of research grants for academe for years to come.

But tied to each of these data element sets created for every cardiac imaging test, is the requirement to include as an "administrative" data element the patient's insurance information. The writing group explains this data-element necessity as a means to "foster optimal cardiovascular care and disease prevention" because:
The insurance payer element was included to be certain that patients of all payer status were included in studies equitably, especially those funded federally (ed: emphasis mine). The inclusion of this data was not to in any way suggest that cardiac imaging patients should be screened on the basis of ability to pay.
Yep, it's all to justify to the Medicare National Bank that, yes sir, we really DID need this test. While the test might be ordered irrespective of the ability of the patient to pay as the writing committee suggests, for the first time we will be granting insurers direct automated line-item access to clinical information and the test results. The implications of this are concerning.

Imagine, line item data on your renal function, ejection fraction, stress test results, cardiac risk factor analysis - all instantly available to an insurance company's computer database and conveniently entered unwittingly by the echocardiography clerical staff in the hospital of your choice. Imagine the next time you then go to purchase insurance. Best of luck to you.

Or imagine you are a doctor without an electronic medical record and ordering system - best of luck to you as you complete the test-request form that will soon look more formidable than the MCAT bubble answer sheet used to qualify for medical school. Remember to use a number 2 pencil.

Or consider if a clerical error is made during data entry: what recourse will you have? Will you have the option of editing the data entered to assure insurer payment for the test they claim was not appropriate because four data fields were left blank? "Sorry Mr. Jones, on the basis of a creatinine of 1.6, and four empty data fields on the ordering questionnaire, this test should not have been ordered, so * b-o-o-i-i-n-n-g-g *, we're not going to pay for that test after all."

But in this era of "evidenced-based medicine," these convoluted, complicated, and thoughtfully-produced-but-arbitrary data forms (Note: 20 pages were devoted in the article just for the medical history fields alone. And what is an "equivocal" test anyway?) are being feverishly developed by these cardiac imaging societies. They must justify continued testing and Medicare payments on the basis of a promise of future as-yet-undeveloped studies based on retrospective utilization data completed by the non-medical clerks at the time of test ordering. And thanks to hoards of well-meaning academics that are eager to secure more grant funding, this same dubious retrospective data will soon serve as paradigms upon which our treatment and further testing "guidelines" will be based.

But retrospective data collection like this is far easier and less expensive to gather rather than a prospective, randomized trial. Who needs those?

Heck, I guess I should stop complaining.

After all, I am a cardiologist.


* The conflicts of interest of the authors of this document warrant notice. They are not insignificant - so much so that the article reviewers conflicts were also disclosed as an appendix to reassure a more "non-biased" critical review of paper occurred.


"ACC/AHA/ACR/ASE/ASNC/HRS/NASCI/RSNA/SAIP/SCAI/SCCT/SCMR/SIR 2008 Key Data Elements and Definitions for Cardiac Imaging." J Am Coll Cardiol, 2009; 53:91-124, doi:10.1016/j.jacc.2008.09.006 (Published online 8 December 2008).

Heard Over Dinner

"My Dad loves Medicare! Heck, there isn't a test he doesn't like! It seems as he gets older that's he and his wife can think about. Once he had a pain in his butt and his doctor ordered an MRI just to tell him what he already suspected: that he pulled a muscle. And to think he didn't have to pay a thing..."
Yep. No wonder everyone wants government-run health care - it's the bomb!


All-Star JailHouse Rock

Brilliant and courtesy of Parady and Son.


90 is the New 80

A new milestone was recently reached: a man living 112 years.

It used to be eighty-year-olds were the most common people in the hospital. Maybe it's me, but the the ninety-year-olds seem to be supplanting the eighty-year-olds these days in hospitals.

That's because their 70-something-year-old kids can no longer take care of them.


On Young Women, Heart Attacks and Denial

I read this article that appears in the Chicago Tribune today about a 27 year-old woman who reportedly had a "heart attack." I'm not sure what the point of the story really was - perhaps to wake up young women that heart attacks can occur in their demographic - and if so, well, fine.

But there is another, more sinister tone in the article: one that doctors should not be trusted and are mostly interpersonal buffoons. Nowhere is there a thoughtful discussion about the potential causes of why a young woman might have a heart attack, like spontaneous coronary dissection, paradoxical embolis, congenital coronary anomalies or familial hyperlipidemias. Nowhere do we hear from the doctors who interacted with this patient. No, that would require some thought and journalistic background analysis.

Instead we are greeted, once again, to only the patient's perspective: "If your doctor won't listen, fire him and find one who will."

To that, I say, remember the case of Hank Gathers - a young basketball star with exercise-induced ventricular tachycardia and hypertrophic cardiomyopathy who was presribed beta blockers and advised not to play competetive sports. But he didn't like what the first doctors had to say to him. Instead, he "fired" his doctors and shopped around for another doctor who "listened" to him.

The rest, as they say, is history: Hank Gathers ultimately died of sudden cardiac arrest playing the game he loved.

Sometimes, doctors don't listen, that is true. Overburdened by higher patient volumes, more documentation requirements, and reduced compensation models in health care today, doctors are pressed like never before to do more with less time. Listening to patients sometimes takes a back seat to these demands. But patients, too, increasingly expect that they know what's best for them - after all they read it on the internet - and don't hear what their doctor says, or they ignore their advice completely.

Believe it or not, sometimes patients need to realize they have a role in their health care, too.

Even when the advice isn't what they want to hear.


Health Care Information Giants Like the Auto Industry?

Rick Peters, MD over at The Health Care Blog thinks so, describing them as "a few large players who build big, expensive systems on outdated technology platforms."



h/t: Dr. Bobbs via Health Care BS.

Saturday, December 27, 2008

The Fat Tax

Beware, it's coming to economically strapped city councils near you: the fat tax.


h/t: Instapundit


Driving in the Midwest, one cannot help but be impressed at the vast expanses of seemingly endless terrain on the prairie where heaven and earth meet without a tree or a structure separating them. You can drive for miles and look with wonder at the emptiness of it all - a strange beauty all its own. Only occasionally, the scene is interrupted by silos - tall, monolithic structures that stretch perpendicular to the horizon as they punch through the sight line to touch the clouds. Beautiful in their own right, they help interrupt the monotony of the drive but are only seen rarely, making their presence all the more appreciated.

The silos house grain that has been carefully gathered by the farmers and stored to later sell at market or to feed the livestock, especially in leaner times. Not only do they house the grain, they also permit it time to dry properly for later sale on the commodities market. Silos serve as an invaluable resource to farmers and cost them a hefty investment to install.

Eventually, though, the grain must leave the silo on its way to the commodities markets or to the cattle to ready them for the next batch of grain. The strategically-placed silos efficiently fill the train cars or trucks parked before them. In good times, the farmer can make a hefty profit from his grain and reinvest it into more fields and building another silo, usually near the last. If the farmer works hard and remains profitable, a cluster of silos eventually appears. Through such acquisitions the farmer's profits grow. Eventually, however, the farmer's land expands to touch a neighboring farm with its own shining silos.

To continue to grow, competition for land becomes paramount to survival for grain is the commodity that generates the capital required for growth. Either one farmer must buy the land of his competitor or a large fence must be erected between properties as each farmer weighs his options.

But what if a cow on one side of the fence closest to the competing farm wanted some of the grain from the silo of a neighboring farm? Could he get it?

Not easily. The silos have come too valuable to each farmer as they raise their separate herd of cows. Sprinkling grain across the fence would place one farmer at a distinct disadvantage over the other. But the reason the competing cows are told they cannot get the grain? Because the grain's privacy might be compromised and if it touched the ground it might not be safe to eat.

And so, the competing cows are left to create their own new grain to be grown on their own side of the fence.

And so it is with our current iteration of developing electronic medical records: huge information silos of vital information hoarded by the farmers and never simply shared with neighboring cows.


Photo by Cindy47452.

Wednesday, December 24, 2008

Merry Christmas!

I made saw a few patients, read some Holters, and then came home his afternoon to two kids working feverishly in the front yard. Excited, they exclaimed, "Look, it's Santa and his reindeer!"

Careful inspection disclosed a moderately obese male, looking younger than his stated age without a palpable pulse, axillary temperature of 32 degrees and no discernable blood pressure nor respirations. Nonetheless, it was clear the instruments most have been malfunctioning, because the patient and his companion looked very real indeed, one with a carrot nose and the other with a cherry-tomato nose. Clearly, the spirit of Christmas is very luch alive!

Click image to enlarge

Merry Christmas to all the patients, friends, colleagues and loyal readers of this blog. May you have the healthiest and happiest of holidays.


Tuesday, December 23, 2008


It was a day like any other, time spent in front of the television, relaxing. He sat on the sofa after she had put the kids to sleep. She returned to the large recliner and put her feet up on the ataman as she browsed their movie selections. With the dishes done, they settled back, chose a film, and each breathed a large sigh.

They’d been soul-mates since high school: married for 15 years. They had grown comfortable with each others’ idiosyncrasies and limitations, but they always worked things out for the better. Now, in a moment of peace, they were content as one more day was coming to a close. And yet, as is the case with life’s great unknowns, they had no idea it was the calm before the storm.

As a commercial aired she heard something. She had never heard that sound before. Was it gurgling? She looked over at him. He stared blankly. “John, knock it off. That’s so inappropriate,” she said. The sound grew louder. He did not respond. “John, come on, that’s not funny.” Then he collapsed to the floor.

Instinctively, she rolled him on his back, panicked. “John? John? Dammit, John, wake the hell up!” He was turning blue. She ran to the phone and dialed 911.

“911, how may I help you?”

“My husband just fell to the floor – he’s not breathing! He’s blue! I think he’s had a cardiac arrest! Please, send an ambulance to 123 Main Street NOW! PLEASE!”

“I’ll send an ambulance right away. Do you need help with how to do CPR?” She dropped the phone and dashed back to him.

She started pressing. “Dammit, John, come on!” She kept pressing. Then she realized: the front door was locked. She jumped up and unlocked it, then returned to him, pressing. She wondered, “Should I wake the kids? Oh my God, please, not now! Keep pressing.” Moments later she heard the sirens. “Thank God! Come on, John! Hang in there!” she thought. She kept pressing. She could see the lights now as their iridescent flashes brightened, then darkened, the room. She could hear the squawk of the radio as they came in. They saw her sweating, pale with adrenaline. “Thank God!” she said.

One of the men opened their bag. Someone tore open his shirt. Stickers. Tubing. Patches with wires. The machine said something. They stopped. Why? She saw her husband’s body jerk slightly. They waited. A faint green line moved. Slowly at first. Then accelerated. They checked his leg. It was faint, but present.

“I think there’s a pulse!” Another man stood at his head with a silver instrument. Another man moved her away. “He’s putting a tube in to help him breath,” he explained. Things were a blur now. Tape, fluids, radios for assistance. Calls to others, more people arriving. “Seventy-eight over forty,” she heard them say. A cart entered the living room. They lifted him together. He wasn’t moving.

All too soon, he was gone.

She stood, shocked. People asking questions, she answered, but didn’t know what she said. “Will be be okay?” she thought. “Did I do enough? Where’s he going? My God, the kids! What will I do?” She called her best friend for help, for someone to help with the kids. “I think they’re taking him to General,” she told her.

“I'll be right over.”

* * *

He had woken the third day after 24 hours of medically-induced hypothermic coma. At first, he moved his leg, then his head and arms, then moved quickly to try to pull the tube from his throat as he opened his eyes. The next day the tube was out, he spoke to her, smiled, and asked what had happened. He soon knew how lucky he was. He squeezed her hand.

She held back tears and smiled.

Two weeks later, he received his defibrillator and returned home to the kids. It was snowing soft flakes. The house glowed with Christmas lights placed there by the neighbors. A nativity had been placed above the fire place. They stopped and took it all in as they hugged and gave thanks nervously. Uncertainty remained but they knew they were still together for a reason.

Angel after incredible angel.

All smiling.


Monday, December 22, 2008


Look for this clever detective work on next season's "CSI-Finland:"
Sakari Palomaeki, the police inspector in charge of the case, said it was the first time Finnish police had used an insect to solve a crime.

"It is not usual to use mosquitoes. In training we were not told to keep an eye on mosquitoes at crime scenes," he said.

"Care Integration"

Is this just another name for buying physician practices - even those across state lines?

I really don't think so.


Look how this is marketed:
...could allow Prairie to expand its cardiology services to Wisconsin, as well as parts of central and southern Illinois where Prairie doctors don’t currently visit or maintain offices...

...better able to thrive financially amid major changes in how the federal government and private insurers pay for health care...

“We are enhancing the future of health care for our patients and their families by working collaboratively with physicians to make the delivery of medicine more efficient and more structured around them, with their best interests being the highest priority.” become more efficient... more closely to improve care.

...Multiyear efforts to reduce waste as part of the care-integration plan will include “operational efficiencies in hospitals and clinics” and “better use of best practices in medicine,” according to HSHS. The plan doesn’t call for any job cuts, said Dave Urbanek, a heath system spokesman.
So what, really, is "care integration" that promises such efficiencies?

It's nothing more than the electronic medical record.

Or more specifically, an electronic medical record tied to accounts receivable software and credit checking.

Thanks to exhorbitant costs of implementing EMRs in physician practices, the Medicare requirements for billing and prescribing electronically, and the prohibitive documentation requirements mandated by CMS in the name of "quality," independent physician practices of all types will have no choice but capitulate to larger entities that have a fully integrated electronic medical record paired with collection software.


Sunday, December 21, 2008

What History Can Teach Us

As we look toward more government policy directing our course in health care, perhaps it would be wise to take 25 minutes to reflect upon the roots of our current financial crisis and ask ourselves if we could be setting ourselves up for a similar crisis later with health care as Americans subsume an increasing amount of their health care costs.

As Blogojevich has taught us, it might be wise to take pause:
The scandal washing around Rod Blagojevich, the Illinois Governor, has sent ripples of unease through an American political establishment that has long traded favours or appointments for campaign donations.

Some suspect that the only difference between the traditional deal-making that lubricates Washington and the effort to sell Barack Obama's vacant Senate seat was that the Governor got caught.

h/t: Instapundit

Why Shouldn't Patients Pay 14% More for Their Healthcare?

Especially when it's all in the name of quality?
In early 2007 Partners kicked the Beverly doctors out of its network. It said that because the local hospital was referring some patients needing advanced care to non-Partners hospitals, it could no longer ensure quality. The administrators said they weren't being disloyal and only turned to other hospitals for help on tough cases when Partners' teaching hospitals wouldn't.

Some members of the Beverly medical staff saw a different motivation for Partners' action. They believe Beverly Hospital was getting in the way of Partners' expansion.
Read it. All of it. This battle is coming to a metropolitan area near you.

Never mind that Massachusetts can't pay its healthcare bill.


Saturday, December 20, 2008

Lambs Being Led to Slaughter

I have decided that men should never shop.


Especially during the few remaining days before Christmas.

That’s because we go to a mall, and the very first questions we ask ourselves is:
What the heck am I doing here?

No plan. No strategy. No tactics upon which to rely.

In short: lambs being lead led to slaughter.

Instead, we wander.


In search of the perfect gift that we haven’t thought about.

We walk by foreign lands with names like “Ann Taylor” or “J. Crew.”


Oh, we’ve heard of Tiffany’s, but guys know better than to get sucked in there, lest we lose our shirts: Tiffany’s is only approachable the day before Christmas if you’re really desperate.

We try to look like we have a clue, browsing and all. A helpful sales person comes up and asks, "May I help you?" and we politely state: "No thanks, just looking."

That's because guys never ask for directions: it's a sign of weakness.

So we continue, roaming. Lost. Looking at all the people who seem to have a much better plan than we do, carrying those big bags and all.

But there, like an oasis amongst the desert of untouchables, is the Apple Store. Simple. White. Comprehensible to men. Teaming with people, all looking at little expensive electronic gizmo’s like Romans amongst aphrodisiacs. Transfixed. Mesmerized. Stupefied. Like moths to a flame, they come. Drawn. And next to them stand a bunch of black-shirted skinny twenty-somethings with black-rimmed glasses wearing electronic money-suckers on their belts demonstrating the gadgets. The lowly gents mouths hand open. Small amounts of drool appear. Dripping.

Then the phone rings and terror strikes:


“Honey, are you just about done shopping? We’ve got a party in 30 minutes.”

“Uh, just about, honey. Be there soon.”

And to their terror, they realize they have to come back…

… to shop again.


Friday, December 19, 2008

Does Anyone Know Who This Heart Belongs To?

A heart: found on a car wash floor.

But who or what's heart?

Ah, the mystery... (I'm bettin' a deer's heart... I hope...)


1400 CST: Update here.

Listening Sessions

Sounds like not much is "changing" on the Hill, eh?

But boy, they sure are "listening."


Christmas Came Early

... to Chicago area kids this AM: it was a snow day!

Now there's at least one more young adolescent nestled snug in her bed with one happy smile on her face as Christmas break began one day early.

I not sure I could have planned a better early Christmas present.


Thursday, December 18, 2008

The Open ECG Project

Sometimes some of the most beneficial ideas in medicine come from a single individual with a vision.

Dr. Igorn Kovic from Croatia has recently started the Open ECG Project to fulfill the following need:
The importance of having such a(n open source) diagnostic tool readily available is further emphasized by the fact that we are facing a global heart disease epidemic and that these diseases are the No. 1 cause of death in most countries of the world. Unfortunately, ECGs can be quite expensive and not all medical facilities or doctors can afford them. This is especially true for those living and working in countries of the Third World, but not just them.

If this project fulfills its purpose such people could build their own affordable, safe and clinically useful ECGs or have someone else do it for them. Since the solution would be open and free, interested companies could start producing and selling it for a more competitive price than those of commercially available products on the market today.
This is a great idea. Further, the concept of using a wiki to engineer low-cost medical solutions for the Third World has interesting appeal.

Here's a shout-out to Igor to wish him the best in his efforts!


Wednesday, December 17, 2008

Five of a Kind

ondansetron (Zofran)
Click image to enlarge

One drug.

One packaging sleeve on an anesthesia cart.

Five different generic manufacturers.

Five different labels.

Any wonder why there are medication administration errors?


h/t: A loyal reader.

New State License Plate Slogan

Just told to me by a patient and circulating on the 'net:
"Illiniois - where the governor(s) make your license plates."



I wish we had more women cardiologists, I do. But does the fact that the field of cardiology (especially interventional cardiology) requires exposure to xrays mean the field of cardiology is discriminatory against women? I don't think so. Trust me, my little gonads gets radiated just as much as the next gender's gonads when I stand before an xray tube.

But now we find that the field of cardiology is being accused of "discrimination" on the basis of training duration, exposure to xrays, or work hours that are inflexible because of patient "emergencies" in the press.

I find it interesting that differences in vocational choice and marital status are considered discriminatory by our professional leadership:
"Discrimination based on gender and parenting is still prevalent. Female cardiologists remain less likely to be married or to have children."
And yet, from the same article, we find our "discriminatory" field has accomplished the following:
"The number of female cardiologists and fellows has nearly doubled in the past decade since our last survey. Coincident with this, we have seen an increased emphasis upon and fulfillment from mentors, increased flexibility in work hours, and a universally high level of satisfaction with career and family."
So we must now ask, what else we can do? Should we rid our profession of emergencies to better meet the needs of female cardiologists? Or perhaps we should shorten work hours to make life more "family friendly?"

Look, people's decisions regarding career choice must consider many factors. To suggest that the field of cardiology is "discriminatory" based on gender and marital status ignores the biologic differences in being a man or woman and casts a sexist pall on the inroads made to improve women's presence in our field.


Monday, December 15, 2008

Not Paying to Play

Look what happens when hospitals offer doctors office space at below-market rates through the use of "grants:" they get investigated by the US government:
"The Condell settlement resolved deals that included improper loans made to physicians, leases with doctor practices that were below fair market value and hospital payments to doctors who performed "patient services without required written agreements," the U.S. attorney's office said in a statement.

"Northwestern Memorial HealthCare and its subsidiaries Northwestern Memorial Hospital and Northwestern Memorial Foundation have each received a subpoena from the U.S. Department of Health and Human Services' Office of Inspector General. The subpoenas request information regarding the structuring of various arrangements between Northwestern Memorial and the Northwestern Medical Faculty Foundation. A subpoena is a formal request for information and is not an accusation of wrong doing."

Panicking the Panicked

It's as easy as 1, 2, 3:
Step 1: Research people with panic disorder.
Step 2: Publish your results.
Step 3: Leak it to the press.
And what's the best line of the press article? This one:
"Dr. Walters cautions panic attack sufferers should not worry about these findings, as the increased risk of CHD and heart attack is small. The vast majority of panic attack sufferers will not go on to develop the conditions."
It's funny if it weren't so sad.


Sunday, December 14, 2008


Be prepared to laugh. Hard.


Oh, and here's the unedited, more developed version.

Doubling Down

Barack Obama is placing a heavy bet on health care as the nation’s economic savior.

I wish him well as he goes “all in.”

But his "prescription for change" contains potions that are not a safe bet for our economy. And yet we are told, we have to change, immediately:
“It’s not something that we can sort of put off because we’re in an emergency,” he said. “This is part of the emergency.”
I nearly had to slap myself when I realized he was saying what I said they'd say:
“Now we are in crisis. There is no choice in crisis. You must do as we say.”
And so, as part of the Great Promise, we are led to the three cornerstones of the current already-constructed-but-not-yet-implented plan: Information Technology, Prevention, and Paying Incentives for better care. These things, above all others we are told, will save us from ourselves and ultimate economic collapse.

And I’ve got some ocean-front property in Arizona I’d like to sell you.

But before you put down a contract, let’s look briefly at these cornerstones:

Information Technology to Build “Efficiency”

To frame my comments, realize that I work in a hospital system with one of the most “efficiently” deployed installations of the hospital information system EPIC in the country. We have inpatient and outpatient versions of the software fully implemented. It is a wonder to behold as I efficiently type my operative note, copy the referring physician, and send a copy of my note to our billing personnel before the patient even leaves the operating room. Within seconds, literally, the ICD9 codes are analyzed, the diagnoses cross-referenced to assure they jive with the procedure codes, the whole package sent to the billing “scrubbers” to be sure the electronic Medicare claim submission form has all the t’s crossed and the i’s dotted, and * BOOM* off to Medicare the bill is sent, even before the patient leaves the laboratory. Man, talk about efficiency!

If there’s something out of whack when Medicare gets it, it’s sent back electronically, with a pointer to the boo-boo, and because of the “efficient” claims denial service that “works” the accounts receivable to get back to me as I see another patient so I can change the diagnosis code to a “more appropriate one” that will insure payment according to their “efficient” reimbursement assurance algorithm: *ZAP* we send it back. It’s the most efficient game of electronic ping pong you’ll ever see! So efficient, infact, that instead of our accounts receivable of 110 days before the system, we’ve now cut them to about 38!

And as anyone in business knows, cutting the time in accounts receivables to less than half is REALLY how you measure efficiency of any business system!

Oh sure, there are plenty of other “efficiencies” built into IT like ours. It’s hard to quantify them all. Nurses love the "efficiencies" of charting now. And who can argue with the efficiencies of lab reporting with this system? It’s truly remarkable to order a test and get the results routed to your inbasket the same day or maybe even within the same hour. Seriously, it’s impressive. I’d hate to do without this now that we have it. This is "good" efficiency because it helps doctors to their jobs. Zipping those reports instantaneously to me and providing them to the referring physicians probably shortens hospital stays and saves money, but is that enough to offset the cost of the additional testing that's being performed these days? I wonder.

That's because electronic medical records greatly facilitate ordering tests, too. Tests that haven’t been done in a year or screening tests that are made to assure “quality.” (“Gee, I wonder how his ejection fraction is doing? Maybe I should get another echo.”) Alerts can be programmed to assure you order tests or consults. Just a simple *click* and another test is on its way. Increasingly when patients are admitted, nearly every one has a “critical pathway” designed for “efficiency” of care based on “best practices.” Panels of tests and consults medications are ordered automatically with just one click rather than ordering them individually. What could be more efficient? Heck, it’s so easy, I just want to order MORE, don’t you? Get them in, get them out. Over their length of stay? Where’s our Coordination of Care representative? Can't we move him to a skilled nursing facility? Let’s GO people! Efficiency, efficiency, efficiency!

Seriously, where is the cost savings to our health system with this model of “efficiency?” Is it to our health system as a whole or for the business administrators who get their money faster from the Medicare National Bank while it’s still solvent? Will skilled nursing facilities be our Great Savior in this time of economic need as we try to demonstrate cost savings to the system, or will they just facilitate patient bounce-backs? Will we dare to examine this?

Prevention to Save Costs

This cornerstone scares me because short of the public health initiatives of seat belts and smoking bans, we’ve done poorly at saving money with “prevention” initiatives when it comes to costs. One only needs to look at Illinois who still permits motorcyclists to ride without a helmet to have some understanding for my skepticism here. Or nationally, we can look at the Jupiter trial that promises to save millions of lives if we just put patients on a little Crestor. I’m feeling cost savings there! And prevention effectively means more testing of the healthy, more ominous spin from reporters assuring your death if you don't get checked, and plenty of advertising to boot, which leads to more revenues and costs. But it's all in the name of “efficient use of our health care dollar," remember? We're so proud of our "guidelines," too. Even when these "guidelines" are manipulated to assure people receive expensive tests or devices "in the name of quality." It's hard to see the cost savings here, folks.

Paying Incentives for Better Care

Now this is an interesting concept that is so flawed it boggles the mind. If we just do as the Big Boys say, walk lock-step in unison with the ever-growning (now, 153) Great Directives, we will be paid the full amount due. Seriously, do the policy wonks think hospitals and doctors were born yesterday? Presently, legions and legions of people now work on the Hill just to get a jump on the Lastest Edict coming from On High so they can implement the change to their work flows and assure payment from the Medicare National Bank. (You know, I’ve got a dog I can train to do just about anything I want, too.) But where are the cost savings with this model? To date, pay-for-performance initiatives have been a dismal and utter failure at controlling costs. By their own admission:
"Since we began accepting the quality data in July 2007 for the 2007 PQRI, we have identified and begun to remedy issues and questions raised about the 2007 PQRI results and feedback. CMS analysis of the results of the completed first cycle of reporting has identified a number of unanticipated issues we believe may have impacted the success of physicians and other professionals in meeting program requirements for reporting quality data. These issues, which are outlined in more detail in this report, include claims-based reporting mechanisms issues, National Provider Identifier (NPI) numbers not being included on the claims forms, incorrect quality reporting data or claims submission errors and the content of the feedback reports."
In our system, it cost more to implement this "initiative" than earned from Medicare. But why stop? We should do MORE! Change those doctors' behavior! Tell the IT boys with their “efficient” systems to put a “hard block” in their orders so they HAVE to be sure to order another test or write a prescription or show that we’ve counseled them on smoking (we did, didn’t we?) to assure we get paid. Look how “efficient” we are! See the money we're saving?

And so it goes.

IT, Prevention, and Pay-for-Performance: all bad bets for cost savings. But as Mr. Obama goes “all in” by building health care bigger, we must realize the risks inherent to this approach for our economy. Can we really provide “affordable, accessible health care for every single American,” without even a modicum of conversation about the true costs involved?

These bedrocks for change, while interesting, will be a losing hand for our economy without serious constraints on spending. Instead, get the employers out of the game (what are they for anyway? They only cloud the real costs involved). Provide incentives for training and maintaining primary care doctors. Work tort reform nationally. Discuss and implement end-of-life care limitations. Transparency. Cut the middle men. Do the Insurance Pool thing. Spend a little up front on IT so we can SIMPLIFY billing and collections.

But please, oh PLEASE, stop touting prevention and pay for performance as our health care saviors.

To do otherwise is risking fiscal disaster.


Saturday, December 13, 2008

A Step Toward Transparency

Massachusetts is setting a new bar with their website "My HealthCare Options". As reported in the Boston Globe:
"Brigham and Women's Hospital, Massachusetts General Hospital, Children's Hospital, Boston, and a few others are, on average, paid about 15 percent to 60 percent more than their rivals by insurers such as Blue Cross and Blue Shield of Massachusetts and Harvard Pilgrim Health Care. The gap is even more striking for individual procedures, which can be two or three times more expensive in one hospital than in another."
It will be interesting to see if the stark price differential between centers affects where people seek their care. How important will "brand name" become when people are saddled with higher and higher proportion of their direct health care costs?

But what is clear is a precedent for reporting this data is established. As we consider this step, will patients actually use the information? Will it really affect their decision-making or where they seek their care? Will their trust in their doctor take a back seat to price? Will patients, finally seeing what a procedure costs, delay their care or do without entirely?

On first glance, the website seems understandable and easy to use. But to find the actual cost ranges for procedures, the patient has to "drill down" deeply in the site to see the actual cost estimates side by side. Further, the choices of procedures available to view were very limited. I could not find any information of procedures for cardiac electrophysiology, for instance, while angioplasty and open heart surgery were listed. But even with this information, patients will still be unable to decipher their direct out-of-pocket costs, since there are a multitude of insurers and "plans" out there with even more deductibles. This might serve as a deterrent to using this site, since patients still find the billing and payment cycle of today's health care far too confusing as they try to understand what they have to pay.

But this is a step in the right direction, I think. Insurers can use this data to negotiate with hospitals. Hospitals can use this site to compete against the other hospitals in town and display ads that say "The Cheepest Angioplasty in Town!" (As an aside, I wonder if people really want the "cheepest" since it might infer an inferior product. Ah, the joys of being a medical marketer...)

Unfortunately, for patients outside Massachusetts, there's still a long way to go. But I suspect other states will soon be forced to follow Massachusett's lead as the Big Boys in Washington wrestle with our ever-escalating health care costs.


h/t: BNET Healthcare.

Addendum: 11:50 AM CST: Oh, and what about that little problem of doctor professional fees and out-of-network providers? Just because the patient knows the cost of the hospital procedure, these published costs say nothing about the "professional" costs billed separately by the doctor. (See how confusing this is to the patient?) Needless to say, we've still got a long way to go before this mess is simplified.

Friday, December 12, 2008

Pay-to-Play: Could It Happen With National Health Care Reform?

Say it ain't so.

But as the depth and extent of the pay-to-play backbone of Chicago politics unfolds, we should ask ourselves if the same scenario could happen nationally as the government Big Boys consume increasing influence over health care, the backbone of our economy.

One only need to look at the indictment of Governor Blagojevich to see the depths that people go to acquire Mercy hospital's Certificate of Need approved by the State Planning Board (a la the Tony Resko scandal), or of the threatened withholding of funds to Children's Hospital by the governor when he didn't get his backdoor campaign contribution from CEO Patrick Magoon.

Again in the Tribune today, we find a story about a fundraiser for Jessie Jackson, Jr. with more than two dozen attendees aimed at supporting Mr. Jackson's bid for the soon-to-be-up-for-sale Senate seat in Illinois, one of whom was a Joliet pharmacist Harish Bhatt.

It seems Bhatt's two Basinger Pharmacy outlets might have needed a few "regulatory favors" after helping the state's top pharmacy regulator win his job.

And why would Raghu Nayak, a political community leader in Chicago's Indian community "who has raised several hundred of thousands of dollars for Blagojevich, including more than $200,000 from Najak, his wife, and various corporations" need to support Blagojevich? Could it have something to do with the series of surgery centers Nayak owns on Chicago's North Side or the drug testing laboratory with millions of dollars in Illinois public aid contracts in which he retained an ownership stake?

Could similar behind-the-scenes dealings happen as our new health care policy initiatives are constructed and the Big Boys on the Hill make their plays with their campaign contributors in mind? Could there be, like the Tribune's columnist John Kass suggests, a man or two behind the curtain as our new health care plan is being hatched?

Say it ain't so.


Thursday, December 11, 2008

The Spirit of Christmas

'Tis the season for giving:
"Doc, could write that refill a little early so I don't get hit by my co-pay after the first of the year?"


"Can I get that done before I head to Florida next week?"


"Thanks for everything Doc, I just can't miss my flight Tuesday."
Ho ho ho.


What Price Safety?

In February, 1996, the FDA issued this directive:
"In keeping with its commitment to speed up patient access to new medical devices, FDA is exempting 122 categories of low-risk devices from premarket review, adding to the 450 categories already exempted from such review. Since the exempted devices will no longer have to wait for premarket review, they can reach patients sooner and FDA can shift resources to more critical needs."
With the increasing complexity of implantable medical devices and a growing desire to innovate ways to manage patient's chronic medical conditions remotely, there is a need to downsize connections of leads and sensors to the computer electronics of these sophistocated devices. Until now, a standard two-electrode connection system called an "IS-1" standard has been used to connect leads and sensors to the housing of implantable cardiac devices.

For at least the past three years, the large medical device manufacturers have been developing a new 4-electrode connection system called "IS-4" that promises to supplant the IS-1 connection system. Because the medical device industry has argued that the changes to the IS-1 standard used to implement the IS-4 standard were minor, they applied for pre-market approval through the FDA's 510K exemption that does not require human clinical testing prior to market release of devices, but rather relies on historical information from existing technology supplemented by animal and specialized bench testing. While this approach has worked well for some new defibrillator leads, others have not fared so well.

Earlier, the Medtronic Sprint Fidelis defibrillator lead family, a thinner cousin of prior defibrillator leads, was released under the same 510K exemption ruling of the FDA, but subsequently recalled in October, 2007 after post-market surveillance demonstrated an increased failure rate of this lead family compared to its predecessors. Some 235,000 patients were affected.

Now, just before the release of new defibrillator leads containing the new IS-4 standard connections, Drs. Robert G. Hauser and Adrian K. Almquist of the Minneapolis Heart Institute are sounding their concerns over upcoming release, arguing that human testing should be performed before the lead is released to the public at large. They argue, in part, four concerns:
  • "In our opinion, the decision by the FDA and industry to forgo premarket clinical testing of the connector is not in the best interest of patients. For starters, the four-pole connector is a complex electromechanical design that requires major changes to the ICD lead and pulse generator; it should therefore be considered an investigational technology."

  • "Second, no published study has shown that the results of bench testing or testing in animals accurately predict the clinical reliability of ICD systems. If they did, recalls would be uncommon."

  • "Third, there is no medically necessary reason for rapidly deploying the four-pole connector. Current connector systems have been in use for more than a decade and are performing reliably."

  • "Fourth, FDA approval would allow the four-pole connection system to be used in patients without the level of informed consent that is usually required for investigational devices. After the recent Supreme Court decision in Riegel v. Medtronic, FDA approval would also leave patients without the ability to sue the manufacturer for compensation for injuries caused by a four-pole connector."
Hauser's and Almquist's concerns are being voiced at a particularly sensitive time as batteries of the devices connected to the recalled Sprint Fidelis leads are expiring. Doctors are sensitive to the particular challenges that lead revisions impart in the management of their patients since lead revisions or replacements during battery changes greatly complicates an otherise simple battery change procedure.

But the FDA, in their accompanying editorial, countered:
"When preclinical studies and existing clinical data support approval and expected long-term failure rates are low, postapproval studies may provide an appropriate means for verifying long-term device performance. Ensuring device safety does not necessarily require that every device be clinically evaluated before marketing. Approval of some implantable leads with IS-4 connectors may be appropriate without new clinical data. The FDA decides what information is needed to support an approval on the basis of its review of an individual application. This is a scientifically sound approach to protecting public health.
So which side is right in this debate?

Well, in some respects, they both are. No one can argue that patient safety should take priority in this debate, but at what cost? When we review the failure rates of even a known faulty lead like the Sprint Fidelis, its failure is only slightly higher than prior leads. For instance, the failure rate of a "good" Medtronic Model 6947 Sprint Quatro lead has a 1.9%% failure rate at 3 years, versus the 5% 3-year failure rate of the "bad" Medtronic Sprint Fidelis lead. Detecting a signficant difference of 3 percentage-point failure rate would take two fairly large patient comparison groups randomized and followed for many years to detect such a small difference in failure rate with sufficient statitical power. This would add signficant cost to devices, certainly, and would delay market release of newer innovations. The chilling effect on device development would cause every company to think long and hard before bringing any new technology to market.

But the public has grown wary of lack of regulation in many sectors of our economy, especially that portion that has been ridden roughshod by the financial sector. They are aware that the FDA needs the device manufacturers for their review fees, and hence have become skeptical of the FDA's ability to remain unbiased in their review process. They are no longer naïve about the physical and psychological toll such failures have upon patients, thanks, in part, to the unrelenting press coverage that these recalls generate ("Bad news sells best, 'cause good news is no news.") Regretably, we rarely hear about the lives saved by these devices every day.

The technology boom in medicine is under tremendous pressure to contract as health care costs continue to skyrocket and Congress looks for new ways to cut costs. The days of unfettered capitalism and quick profits in medicine are quickly coming to an end. Hitching the bandwagon to "patient safety" will be a powerful driving force for policy advocates to stifle innovation in the health care sector as we cling to the security of the known during this economic contraction.

What are the implications of the loss of post-market surveillance as a means of determining patient safety? What are the implications for costs of devices going forward? How much are we willing to spend to assure relative safety perfection? How safe is safe enough? Have not the existing standards for device approval resulted in some very beneficial and reliable systems? Must we assume there is too little value or economy to post-market surveillance to permit it's exclusive use for introducing new technology?

There's no question that Drs. Hauser and Almquist make important points. The bigger question might ultimately be: how much do we want to spend?



Hauser RG, Almquist AK. "Learning from our mistakes? Testing new ICD technology." N Engl J Med 2008;359:2517-2519.

Shein MJ, Schultz DJ. "Testing New ICD Technology," New Engl J Med 2008; 359: 2610.

Tuesday, December 09, 2008

Grand Rounds is Up

Over at Sharpbrains, President elect Obama asks the medical blog-o-sphere some pointed questions about healthcare. It's a great summary of this weeks best of the medical blog-o-sphere.

On my cursory review, the always insightful and fun-to-read Dr. Rich earns special mention for his Thanksgiving thanks for the uninsured.

And there's lots more where that came from...


It Was Coming

I now know why they didn't use the song "Another One Bites The Dust" from Queen for the CPR song and instead used the sweeter, "Stayin' Alive" from the Bee Gees.

It's because they wanted to reserve it as the theme song for Illinois governors.


Smoke-Free White House?

It seems the White House is a smoke free zone. So what will happen when Barack Obama, who we find has yet to quit smoking, takes up residence there?
"Uh, excuse me Mr. President, we have to ask you to put out that cigarette."

"Tom, I'm tired of all of your nagging! You big ol' senators think you know it all. If I weren't so perplexed about the health care system and needed someone to take the fall when the next attempt at reform fails, you'd be fired! You hear me? Fired, I tell you! So be glad I offered you that post over there at the Department of Health and Human Services. Hey, how's the sale of your book going now that I appointed you? Good? Glad to hear it! Now you go about your way now and leave me alone. I've got bigger fish to fry with this damn economy. Criminy!"

"But Mr. President, sir, the White House has balconies..."

"Tom, dammit! Stop! Wouldn't you suck on one of these babies if you had to figure out a way to shore up our economy? I don't see you working like I am. I hired all of those famous economists and they keep telling me this and that - who knows what's right? And if I get cancer, well then, heck, at least I'd be leading by example and supporting the continued reliance on health care to support our economy, right? I mean look at all the new jobs we've created there - even now as the rest of the economy tanks. You could scan me and test me time and time again, then give me one of those super duper chemo drugs that costs, what, $5000 per month, and save my sorry little butt so I can get back to work. So I don't have to stop smoking, Tom. The nation needs me in this time of crisis to show them the way!"

"But health care's struggling, too, Mr. President. I mean ER's are seeing more and more of the uninsured, they're overcrowded. Pressures being put on hospitals to see these folks who can't pay..."

"What do you mean, hospitals are hurting? I know that some are doing quite well. Some are building like crazy. Some are growing. Don't tell me hospitals are hurting!"

"Really, Mr. President, some are. Lots of them have thought about closing - not because they can't continue seeing patients and raising prices. It seems it's really because they couldn't get credit to update their facilities and make 'em look as nice as their competitors. So all they could see were the locals. They couldn't attract people from outside their locale that could actually pay their bills and got stuck with the hoi polloi - and lots of those common folk have lost their insurance when they lost their job, Mr. President."

(Loud sucking sound heard, followed by a plume of smoke rising from the Predident's lips) "Oh, hell, Tom, you're such a fuddy duddy. We all know who's paying their bills! Medicare! What the hell you taking about? Those guys just keep seeing the over-65 crowd and they're set! You know as well as I do that we're providing them a bigger continuing bailout package than GM! Maybe WAY more! They just hire those hospitalists to keep ordering tests and workin' like beavers and with all those fancy electronic medical records auto-ordering tests and immunizations and drugs, hell, they're in the money. We pay 'em well enough, Tom. They'll make it. Let's focus on the big stuff. Don't weigh me down in such trivialities - we have the finest health care system in the world."

"But Mr. President, aren't we suppose to find all that waste, fraud and abuse in the hospitals? With those damn electronic records, that's getting hard! Won't that take even more money from the hospitals?"

"Tom, seriously. You know how this works. If the programs are making it tough to find some loopholes, just change the rules! That's what we do, remember? All we have to do is find a few million here and there so the press feels we're doing our job to save our health system from ourselves and it'll buy time. Don't get bogged down in such trivialities. We need our hospitals right now! Just make those doctors fall in line a bit more! Withhold a few more billion of their pay and then offer them a chance to earn back a few more percent in payments by prescribing electronically! We all know only 15% of those suckers don't have EMR's, so that should be a win-win for us, right? And the pharmacies and drug companies will love us, too, as those scrips go flying out the door! And speaking about the drug companies, can't we jack up the FDA's drug review fees some more? They're under your umbrella. There's a revenue stream if I've EVER seen one! And what's up with Grassley? Doesn't he know what's important right now? Geez! Isn't there another committee we can give him?"

"(* cough *) Mr. President. The smoking..."

"There you go again, Tom. Look, just give the people what they want. Make it look free, or affordable, and for God sake, universal. Right now we've got the world by the balls. Make a new line item deduction on peoples' paychecks. Make the businesses pay, too, and we'll get through this. Don't start to ask about why things cost so much. Just get it done. Don't worry about all the middle men. Hell, if we start trimming there, we'll have a real mess on our hands! You know what the unemployment numbers would look like then? Just keep it complex. Keep it fuzzy, and keep those billing, collections, and regulatory people employed, dammit! You know how to do it: make sure every last sucker scrubs their hands with expensive gels rather than plain ol' soap and water. Feed the economy, Tom, feed it! (*sssslllluuuurrrrrpppp*)"

"Okay, Mr. President, but what about your daughters. What will they think about your smoking..."

"Tom, leave them out of this. Look, I'm already giving them a puppy..."

Monday, December 08, 2008

Thievery, or Worse

Alright, they’ve gone too far.

I don’t ask for much, really I don’t. I come to work, I do procedures, I chart, I take call, I attend meetings and conferences, I send messages to hoards of people using e-mail, I teach. I do all that stuff doctors are supposed to do.

But I like my coffee.

And every day, I enter the cath lab break room and have a cup. Carefully brewed, always using 1 ½ packets of the coffee grounds supplied (need the extra ‘kick,’ you know), wait patiently for the brewer to deliver, then head on my way.

One small Styrofoam cup o’ Joe that I nurse ‘til its gone.

And I rushed off. I was in a hurry.

I needed to see a patient to see if they needed a pacemaker.

I walked up to the ward. Set down my coffee far from the computers, far from the monitors, and far from the patients’ rooms. Far from a place any mortal human being should be able to find. Then I reviewed the telemetry, used the jell goo on my hands and said “hi” to the patient. She needed the pacer after all. And then I returned to my cup.

But it was gone.

Gone, I tell you! I mean, who would do such a dastardly deed? Who’s messing with my psyche? My fix? Geez, I was just on call. Is this too much to ask? For goodness sake! This is a patient safety issue!

I looked around and saw her typing.

“Um, excuse me.”


“Uh, have you seen a cup of coffee that I left over here.”


“You didn’t throw it out did you?”

“Of course I did!”


“You didn’t hear?”

“No. What?”

JACHO’s here.”


Two Codes

On call. Two codes. One over eighty, the other forty.

Which one survived?

The eighty-something year old.

And yet somehow, in the scheme of things and looking at the chaos and its aftermath, I wonder which patient was the more fortunate.


Sunday, December 07, 2008

The Holiday Party

It was a subdued event this year.

Our surroundings were lavishly decorated. Beautiful. But it was different.

Not one person talked about it directly. No one dared. Spouses, loved ones, even some kids. Mingling. We smiled courteously. We talked about the kids, what they were doing, how they were fumbling and stumbling through adolescence and their formative years. We liked that topic because it mattered. We talked about how nice she looked or how handsome he was, probably because in the big scheme of things, it really didn’t matter.

We talked, we smiled, had a drink, had a mushroom, and later, tried to dance.

That’s because we knew we were lucky. Lucky to be standing there exchanging pleasantries.

And lucky to have a job.


Keeping It Real

Here's some good ideas for the holidays.


Saturday, December 06, 2008

When Technology Fails Technology

When Boston Scientific's SimSuite goes sour, it never ceases to amaze me how the media can still spin the event favorably for the company:
The virtual patient, "Simantha," had unexpected technical problems that short-circuited the presentation by SimSuite Medical Simulation Corp. employees.

Had Simantha been virtually alive and kicking, staff and physicians would have been able to try their hand at saving her life by performing a virtual cardiac procedure using new technology. Chances were good that she would have died during training in order teach the staff how to handle a crashing patient. None of that was able to happen thanks to intricate technology and its flaws.

SimSuite, the 35-foot bus travels year round and stops at hospitals and medical centers in the hopes of training the staff on the latest treatments for lesions in coronary arteries that are difficult to treat due to their location or size.

"This is a great way for staff to get hands-on training without a real patient on the table," said Chris Mitchelli, field clinical educator. "We can simulate an emergency."

Dr. Karthik Sheka, interventional cardiologist at PMC, was on hand to test out the new technology but never got the chance.

"All of the devices coming out now are much more advanced than before. It is something that you don't want to try out on a patient so this is a great idea to get the practice," he said. "There are always risks and complications with procedures such as this so you are able to play around with your options on a simulated patient.

Medicine changes fast so physicians need to keep their skills up-to-date. When Simantha is working properly, she is there to help."
Gosh, I feel the love for Simantha, don't you?


Friday, December 05, 2008

Overhead vs. Access

A glimpse of the problem from Dr. Thomas E. Chappell of (relatively rural) Cumberland, Maryland:
Maryland ranks 48th in physician reimbursement by health care insurers. We have a monopoly of two heath care carriers that dominate the market and cover 85 percent of those insured. Our legislature would not tolerate this domination in any other industry. In many cases reimbursements have dropped by 50 percent over the past 10 years.

Has anyone seen a drop in premiums? Instead we are seeing a growth of over 10 percent per year. Where is this money going? Certainly not to our health care. Administrative overhead and inefficiency are consuming health care dollars at a voracious pace. Insurance company CEOs are given bonuses and buyouts that often exceed $100 million. It is the same broken system that is bankrupting Wall Street.

What can we do? On a national level, the progress will be slow and painful to gear up training of new physicians. On a local level we can urge our local and statewide elected representatives to take serious measures to address the physician migration out of our state and to find ways to promote our local students in training with enticements to return home to practice.

We need to strive hard to maintain quality medical care in this community as we embark on a new era in the new Western Maryland Hospital System hospital. We have built it but will they come?
As a physician formerly licensed in Maryland, I think he knows my answer.


Are the Feds Propping Up Hospitals, Too?

It seems so. But already-struggling states are at a loss to use the money because they can't come up with their portion of the required buy-in.


Text Messaging Your Smoking Status

With insurance rates tied to a history of smoking, this will never happen here.


Thursday, December 04, 2008

In Defense of Specialists

Bloom Stimulator
Click picture to enlarge

Not too many family practice docs and hospitalists can drive this baby now, can they?

For those unfamiliar, this is my favorite instrument in the EP lab: the Bloom Stimulator. With the flick of a few switches, we can start or stop most heart rhythms as fast as you can say "S1, S2, S3 or S4."



Wednesday, December 03, 2008

Web 4.0: Surgery by Text Message

Pretty amazing story that heralds the new generation of medical communication for surpasing Web 2.0: texting surgical instructions.


Continuing Continuous Continuity

Insurance for insurance: just what the economy and perverted health care system ordered:
Called UnitedHealth Continuity, the product is not actual medical insurance, but is aimed at people who may have insurance now but are worried they may lose it — and may not be able to obtain replacement insurance on their own. They may expect to retire early, for example, before they qualify for Medicare. Or they are worried about the possibility of losing their job and their health coverage.

People who are already sick will generally not be eligible for the new product. Those who do pass a medical review, will pay 20 percent each month of the current premium on an individual policy to reserve the right to be insured under the plan at some point in the future.

“What this product is designed to do, for a very modest premium, is to essentially protect your insurability for the future,” said Richard A. Collins, the president of UnitedHealth’s individual insurance unit, who says he is the first policy holder. His monthly fee is $50.
Who says these guys aren't thinking ahead?

Now, just so they don't think doctors aren't one up on the insurers, I'd like to introduce "Dr Wes's Continuous Continuity Continuation Insurance," guaranteed to be sure you can get other Continuity insurance from any and all other insurance vendors sure to hop on the insurance-on-insurance bandwagon. It is available for nominal premium of $1 a month, payable directly to my bank account and conveniently payable through PayPal. (Why should I be left out of the fun and games?)

These financial guys are something, aren't they? Its another product similar to the derivatives market for the housing industry, no?



ER Overcrowding

Kevin Pho, MD of KevinMD fame, has a nice summative article on the topic of ER overcrowding and the challenges ahead in USA Today.

Tuesday, December 02, 2008

Grand Rounds Are Up

... over at Medico Medical Student - Richard Strauss style.

For My Brother

A brief diversion:

Adolescence carries its own unique challenges, especially those of the dermatologic variety. God knows the conversations with my brother on this topic never seemed to end back then, so this link is for you, Big Bro.

(Please, don't read the link if you've just eaten or are under 18, but the experiences described, well, 'nuf said.)


h/t: A Day In the Life of An Ambulance Driver

New Afib Video

I never like high def. Sheesh, I look old.

But after seeing lots of patients with atrial fibrillation, my colleagues and I decided to collaborate on producing a video to introduce patients to atrial fibrillation. It was placed online today and runs about 8 minutes.

The intent is for patients to have an opportunity to view this video just before I see them so they have an opportunity to ask questions about their condition during their visit, rather than me spending the entire clinic visit reviewing the basics.

What do you think?


One Percent

"Medicare has, in fact, had success in mitigating the climb of health costs. From 1970 to 2006, Medicare spending per beneficiary rose 8.7% annually, compared with 9.7% for private insurance."
Sen. Max Baucus (D., Mont.)
Finance Committee
Reference: "Letters to the editor," Wall Street Journal 2 Dec 2008

And what was the annual inflation rate for those years? About 3.5% annually.

It is difficult to see how the meager 1% savings touted by our currently christened leadership will save our continuing medical construct from economic collapse without some significant changes to both payment systems in terms of cost containment.

Look for draconian audit forces to be deployed soon.


Monday, December 01, 2008

Can You Say H-I-P-P-A?

I just got this nice letter from Pfizer sent to my professional e-mail:
Dear Health Care Provider:

As you might know, Pfizer launched a new direct-to-consumer advertising campaign, "A LIPITOR Heart to Heart," featuring a real LIPITOR patient and encouraging patients to have a discussion with their health care provider about the importance of treating their high cholesterol. When a sample of consumers were presented with the "Heart to Heart" ad, they connected with the real life experience, found it engaging and credible, and felt motivated to speak with their physicians about their CV risk. We are considering expanding this campaign to feature several other real LIPITOR patients and would like your help in identifying potential candidates. All you have to do is click here and download "What was your wake-up call?", which is a brief instructional letter you can provide to the potential candidate(s) to help them learn how they can share their story with Pfizer.

The first ad in the LIPITOR Heart to Heart campaign featured a real LIPITOR patient, John E., who was diagnosed with high cholesterol in his forties and was not treating his condition with medication. Unfortunately, he had a heart attack last year at age 57, but that event served as a "wake-up call" to take better care of his health. Since that time, John has been treating his cholesterol with LIPITOR, along with diet and exercise.

We are asking for your help in identifying patients like John E. who you think have a story to share that would motivate other at-risk patients to talk to their own doctor about their CV risk. This patient's story could be potentially shared via TV, print, internet, or patient education. To be considered, patients should meet the following criteria:

LIPITOR patient for at least 6 months
At cholesterol goal with LIPITOR monotherapy
Age 50-65

If your patient is selected for further consideration, we will follow up with you to obtain copies of their medical records. Your patient will be asked to sign a HIPAA consent form authorizing this release.

If you would like in-office materials to help your patient have a heart to heart with you about their CV risk, please do not hesitate to contact your Pfizer representative.


Pfizer Inc

Dear Pfizer,

No doubt you've sent the above letter to lots of other well-meaning doctors. But what you must realize is that I cannot offer you my patient's name since it would completely violate their trust in me regarding divulging aspects of their healthcare to non-interested parties. It is especially troubling that you do not ask the world at large, but rather approach doctors who then risk this ethical compromise. I hope this practice will cease immediately.


Westby G. Fisher, MD
aka, Dr. Wes

A Portal to NoWhere

Boy, not only will insurers take your money to "spread the wealth" of risk for healthcare, they're now into web portal design and maintenance! I mean, I want insurers to tell me about sweet potato soup recipes, don't you? It's such an efficient use of our health care dollar, right?

And don't get me started about their helpful symptom checker, designed specifically to delay a call to a health care professional that would take a fraction of the time to deal with a patient's concerns. Oh no, we can all be reassured that diagnoses made here are MUCH more accurate as the poor patient is dragged through this an algorithm-driven, inflexible system. We've seen how good others were at this approach. I mean, why talk to a person?

I find this development concerning. First, to suggest that "wellness" is going to reduce health care costs is contradicted here. Is this not just another attempt to market for services? How much does this marketing camppaign cost the patient already burdened with ever-higher insurance premiums? Where, exactly, are the cost savings in sweet potato soup recipes? Are people really saving money as they are directed to yet another website in the interest of becoming "AlphaWell?"

And where else might this disgusting display of waste take us?

I'd say, to the cleaners.


h/t: WSJ (subscription).