The New Pathologic Diagnosis

Peggy Noonan adds a new diagnosis to our medical lexicon today: "Goldmansach's Head:"

"I think there is an illness called Goldmansachs Head. I think it's in the DSM. When you have Goldmansachs Head, the party's never over. You take private planes to ask for bailout money, you entertain customers at high-end spas while your writers prep your testimony, you take and give huge bonuses as the company tanks. When you take the kids camping, you bring a private chef. Goldmansachs Head is Bernie Madoff complaining he's feeling cooped up in the penthouse. It is the delusion that the old days continue and the old ways prevail and you, Prince of the Abundance, can just keep rolling along. Here is how you know if someone has GSH: He has everything but a watch. He doesn't know what time it is.

I remember the father in the movie script of "Dr. Zhivago," inviting what's left of his family, huddled in rooms in what had been their mansion, picking up the stump of a stogie and inviting them to watch the lighting of "the last cigar in Moscow."

When you have GSH, you never think it's the last cigar.

But you don't have to be on Wall Street to have GSH. Congress has it too. That's what the stimulus bill was about—not knowing what time it is, not knowing the old pork-barrel, group-greasing ways are over, done, embarrassing. When you create a bill like that, it doesn't mean you're a pro, it doesn't mean you're a tough, no-nonsense pol. It means you're a slob.

That's how the Democratic establishment in the House looks, not like people who are responding to a crisis, or even like people who are ignoring a crisis, but people who are using a crisis.

Precisely.

"We must act! Now! It's urgent! Don't forget $200 million for contraceptives! $600 million for our new fleet of government cars! Make sure those millionaires can afford their COBRA payments! Let's shove our obsolete health care IT solutions on doctors with a cool $20-billion. I mean, our innovative solutions will be free! And oh, and while you're at it, be sure to throw in $2 billion for child-care subsidies (where are the subsidies for Moms who elect to stay at home?) and another $7 billion for modernizing federal buildings and facilities! Gosh, this all so... well..... stimulating!"

Yep. Slobs. Feeding at the trough.

-Wes

Specialist Health Care of the Future?

AsktheMedicalSpecialist.com: Two questions answered for $19.99... within 48 hours... guarenteed or your money back. With some liability disclaimers, I'm sure.

-Wes

PS: I'm still trying to figure out how their cardiologist will handle my symptoms of an acute MI. Maybe he'll just say, "Best of luck?"

Thanks for Taking Care of My Family

Whoever invented this Bacon Explosion, cardiologists everywhere thank you.

-Wes

PS: At least it's Adkin's friendly.

Who Needs a Stethoscope?

... when you can have a pocket-sized echocardiogram.

And better yet, this stethoscope comes with CPT procedure codes.

-Wes

Reference:
Specs on Seimen's Acuson P10 pocket-sized echo machine (pdf).

Price-Breaks for Uninsured Coming to Hospitals

An interesting bill, the Illinois Fair Patient Billing Act, recently became law and the impact of the price concessions that uninsured patients can request were printed in the Chicago Tribune this morning, irrespective of income level. Note: The online version of the story does not contain the graphic printed in the paper, so here's what was printed:

Price Concession Amount for Uninsured

Discount Percent	Hospital System
15%	Alexian Brothers Hospitals (Alexian Brothers Medical Center, Elk grove Village; St. Alexius Medical Ctr, Hoffman Estates; Alexian Borthers Behavioral Health, Hoffman Estates
20%	Advocate Heath Care (Bethany Hospital, Christ Medical Center, Condell Medical Center, Good Samaratan Hospital, Good Shepherd Hospital, Illinois Masonic Hospital, Lutheran General Hospital, South Suburban Hospital, Trinity Hospital)
25%	Northwestern Memorial Hospital; University of Chicago Medical Center; Resurrection Health Care (Ressurection Hospital, Our Lady of Ressurection Medical Center, St. Joseph Hospital, Sts Mary and Elizabeth Medical Center, Holy Family Medical Center, St. Francis Hospital, West Suburban Medical Center, Westlake Hospital)
30%	Elmhurst Memorial Hospital
35%	Northshore University HealthSystem (Evanston Hospital, Glenbrook Hospital, Highand Park Hospital, Skokie Hospital)
40%	Loyola University Medical Center; University of Illinois at Chicago Medical Center; Provena Health (Provena Covenant Medical Center, Provena Mercy Medical Center, Provena St. Joseph Hospital (Elgin), Provena St. Joseph Medical Center (Joliet), Provena St. Mary's Medical Center (Kankakee), Provena United Samaritans Medical Center (Danville))
50%	Rush University Medical Center
55%	Edward Hospital, Naperville

How this will effect basic pricing structures remains to be seen, since hospitals are under no constraint to keep prices at their current levels.

According to the Illinois Fair Patient Billing Act, hospitals can charge 35% above cost for services provided to the uninsured. The natural question we should ask, then, is why the insured should have to pay "full price" if a profit margin is already built into the price offered to the uninsured.

The reason, of course, is simple: someone has to pay for the insurer's offices and staff salaries, don't they?

-Wes

How to Scare a Reporter

Just show him an angioplasty with a little Bezold-Jarisch reflex and a brief bout of ventricular fibrillation then watch him bail into the control room.

Heh.

-Wes

PS: Note the size of the clot they aspirated from the artery. (Yes, Mr. President, it doesn't take much to bring a young smoker to his knees.)

The Drawbacks to a 48-hour Work Week

In England, it seems bureaucratic work limits might have drawbacks:

The survey showed significant under-reporting of hours worked by trainees as NHS Trusts struggle to meet the new restrictions.

It found only 25% of surgeons think their human resource departments accurately reflect their actual working hours.

And 85% come in to do surgery on their days off.

More than two-thirds reported a deterioration in the quality of training and operative skills as a result of the new working patterns.

When we adopt this policy, just make sure I get the day shift, okay?

-Wes

EKG Du Jour #11 - One Not to Miss

She was in her 80's and new to our system, a grandmother from a land far away. She spoke no English at all but was able to communicate through her daughter who accompanied her. She was brought to the Emergency Room by ambulance, after her daughter had noticed her complaining of shortness of breath and dizziness since last evening. The ambulance crew noted her pulse was very low and the EKG disclosed the following:

Click image to enlarge

I was called to evaluate her. She was lying in bed, at approximately forty-five degrees, was tachypneic but conversant with her daughter. She had a history of heart failure, and had been admitted to the hospital on four different occassions in the past 6 months. Her physical exam demonstrated a normal BP of 130/56, pulse of 38 beats/minute, respirations of 24/minute and cannon A waves in her neck and an interesting exam finding that was also noted on chest xray:

Click image to enlarge

Her EKG's from the four prior admissions for heart failure exacerbation looked similar, and demonstrated a characteristic that was missed by multiple attendings, echo technicians, residents and medical students from each of her last four admissions:

Click image to enlarge

So, what was not appreciated?

-Wes

Selling a Bill of Goods

A provocative piece about Dr. Anthony Marlon, former chief executive of Sierra Health Services appeared in the Las Vegas Sun today:

Marlon is the founder and former chief executive of Health Plan of Nevada, the Las Vegas Valley’s introduction in 1982 to a health maintenance organization. Since early last year, Marlon has worked as a consultant for UnitedHealthcare after selling Sierra Health to UnitedHealth Group for $2.4 billion. His contract is up in February.

. . .

In 2007 Marlon was the highest paid nongaming executive in Las Vegas, with total compensation of $14.5 million, according to In Business Las Vegas’ 2008 Book of Business Lists.

Today the company has 500,000 members.

And that health insurance companies put patients before profits “is an age-old adage as inane as the person mouthing it. You don’t stay in business, and build an organization as we have here, by screwing the public. (emphasis mine) That’s not the way it works. You’ve got to provide a quality product that somebody comes back and wants to buy again.”

Health Plan of Nevada offered the first insurance policies that covered preventive care when its doors opened in 1982.

$14.5 million in compensation made off the backs of the its 500,000 members? Hmmm, that translates to $29 per policy holder, just to pay his ridiculous salary each year.

Seems like a screw job to me.

So, as a scientist and fellow physician, I ask Dr. Marlon to please, please, please explain the merits of his salary to his members who paid his salary year after year from their ever-increasing premiums. Why, exactly, does an insurance executive warrant a salary that is over 41 times a general cardiologist's salary?

After all, it's all about transparency, right?

What, cat got your tongue?

-Wes

Change of Shift Is Up

Change of Shift, nursing's weekly best of the blog-o-sphere, is up. Be sure to read to the end of the post - our host, Kim over at Emergiblog - is looking for feedback.

-Wes

Toprol XL's Run Out

My office is being flooded by patients who take Toprol XL (metoprolol succinate - generic form - marketed as Toprol Succinate ER - "extended release") because of a supply shortfall. Reportedly there's another generic kid in town, but for some reason they can't keep enough of the drug on the shelves. Anyone else have more info on this?

Seems doctors are the last to know about such things...

-Wes

The Presidential Inagural Grand Rounds Edition

On this Presidential inaugural day as we celebrate the first president of African-American descent, Dr. Val hosts Medical Grand Rounds over at MedPageToday with a plethora of suggestions for Mr. Obama on ways to fix American health care.

So enjoy today, Mr. President. They'll be plenty of work waiting for you tomorrow.

-Wes

Robots Getting Rusty

There can be no denying that the highlight of the Boston Atrial Fibrillation Symposium was the lively debate between Andrea Natale, MD and Carlo Pappone, MD. It was a spirited affair between the soft and the stiff - catheters that is - of the Sterotaxis robotic system vs. Hansen Medical's system. Pappone argued that Hansen was not safe due to its stiffness. Natale countered that it is safer than conventional techniques. Pappone said "I don't believe you." Natale related Pappone's data to a little boy who though he saw a Ferrai because he saw a white horse on a red car as his father had mentioned. At least until he showed him the picture of what he had seen:



To which Pappone countered that after hearing Natale tell this story so often that he decided to have a real Ferrari made to order, custom, and had Natale's name imprinted on it.

Both seemed happy with their good-hearted performance.

But the winner of the debate between the two came from an audience member who, after sitting throught the many earlier sessions devoted to tackling afib ablation, asked the pointed question: "Can either of the robotic systems accommodate a cryo balloon or multi-electrode catheter to evaluate for CFE's (continuous fractionated electrograms)?"

The room was briefly silent. The audience knew the importance of this question, particularly since no one is fooling them selves any longer just how demanding (physically and emotionally) these procedures can be for the operator. The audience was looking for a means to make these procedures not safer, but more effective on the first attempt, and they had heard promising news on other technical fronts.

Natale and Pappone had to admit that neither robotic system could not accommodate these other catheters.

And suddenly, the both robotic systems started to look a little rusty.

-Wes

Once Again, the Airlines Have the Answer

I made it back from Boston the other night after attending the Boston Atrial Fibrillation Symposium - a huge affair that has grown way beyond my expectations. There were very-well prepared talks with doctors from (literally) all over the world in attendance. (Imagine a football field with eight giant big-screen TV's at one end).

But traveling to and from was tough.

At lunch the last day, I sat with some nice nurse practitioners from Canada and asked them about how things work at their hospital in the electrophysiology department - after all they worked for a big regional hospital outside a major metropolitan city like mine. I asked how many electrophysiologists they had there: three - two of whom do afib procedures and one who does more device rather than ablation work. I asked how many defibrillators performed a year and asked who paid for them, and she said the government. "But we got authorization to do five more devices next year," she said.

"Only five?" I asked in disbelief.

"Yep, and we were lucky. Other centers got fewer. They're expensive, you know. We have to be very careful about who we select to get one of those. It's not like America - people here are used to waiting."

"But what about SCD-HeFT and MADIT-II and the other trials?"

She smiled and looked down at her plate. "We have no choice, people up here don't have to pay for their care, so we have to choose who we think the best candidates are and do the best we can."

Suddenly, I thought about American Airlines. That's because my cell phone rang. An automated lady's voice answered: "Hello, this is American Airlines. We are calling to notify you that your flight, number.... 1-1-7-8 from.... Boston to....Chicago O'Hare.... has been cancelled." The phone went silent. I held, hoping beyond hope that the voice would continue with more information, like if I was rescheduled on another flight and when that flight might be, or why, just my flight to Boston my flight was cancelled. None came: only a faint background hiss. Silence. So I hung up.

I called back to arrange an alternative flight. I waited.

I smiled as it dawned on me, just as before, that while many have championed that the health care industry should emulate the airline industry, the airline industry has also learned a thing or two from the health care industry in its time of cost overruns:

... like covert rationing.

And then I wondered: would America ever be capable of overt rationing, as in Canada?

-Wes

Hurry, Help Fund Healthcare!

Get your new million-dollar Obama bills here.

-Wes

h/t Instapundit.

Alternative Medicine's Last Gasp

I just got back from dinner, turned on my laptop, checked my e-mail and was treated to this simplistic, idealistic take on alternative medicine as the cure-all for our health care crisis (and for coronary heart disease in particular) by none other than our now infamous promoters of preventing all that ails us: Deepak Chopra, Dean Ornish, Rustum Roy and Andrew Weil. I don't know how I missed this.

In a near breathless twist of of statistics, dripping with such cynicism it would make one's head spin, we hear:

The choices are especially clear in cardiology. In 2006, for example, according to data provided by the American Heart Association, 1.3 million coronary angioplasty procedures were performed at an average cost of $48,399 each, or more than $60 billion; and 448,000 coronary bypass operations were performed at a cost of $99,743 each, or more than $44 billion. In other words, Americans spent more than $100 billion in 2006 for these two procedures alone.

Despite these costs, a randomized controlled trial published in April 2007 in The New England Journal of Medicine found that angioplasties and stents do not prolong life or even prevent heart attacks in stable patients (i.e., 95% of those who receive them). Coronary bypass surgery prolongs life in less than 3% of patients who receive it. So, Medicare and other insurers and individuals pay billions for surgical procedures like angioplasty and bypass surgery that are usually dangerous, invasive, expensive and largely ineffective.

While there are clearly patients who have received unnecessary angioplasty (and likely bypass) procedures, the authors conveniently fail to mention the benefits these procedures provide for patients suffering from angina pectoris and exertional dyspnea from ischemic coronary disease. Angioplasties and bypass are often not performed to "prevent heart attacks" or "prolong life" but rather to relieve symptoms.

The authors also discuss the INTERHEART trial, a case-control trial which evaluated risk factors in 15,152 incident cases of acute MI and 14,820 controls matched by age (± 5 years) and sex but with no history of heart disease from self-reported survey data, chart reviews, and a single physical exam and blood collection before discharge. Unfortunately, only 12,461 of the MI cases and 9459 controls were analyzed (that's right, over one third of controls were lost to follow-up).

Now, (who knew?) the heart attack patients were more likely to have larger abdominal girth, smoke, have a higher apoB/apoA1 ratio, have diabetes, and be stressed. Okay, I'll agree they found a statistical correlation.

But then they make some audacious claims: like if everyone just ate vegetables, stopped smoking, fixed their lipids, rid themselves of their diabetes and lost weight, 90% of heart disease could be prevented!!!!!

What the...?

Heelllllooooo! Anybody home? What does a case control study say anything about cause and effect?

Simply put: absolutely nothing.

The INTERHEART trial's design to determine outcome effect of the correlations was limited in every type of major research bias going: selection bias (including referral bias and non-respondent bias), measurement bias (self-reported questionnaires, memory bias), and intervention bias (contamination bias, timing bias, compliance bias, and very likely proficiency bias from multiple countries performing the evaluation). The audacity to suggest that changing lifesyles would affect the outcome of coronary disease to such an extent (90%) based on this single trial is clearly overreaching and outright dishonest.

A case in point: when the all-knowing Ornish's own diet was compared head-to-head on a prospective, randomized basis to the several others, it was not superior for weight loss or cholesterol lowering. So if their diet had limitations, what does this say about it's effects on preventing heart disease?

But the voodoo doesn't stop there:

Integrative medicine approaches such as plant-based diets, yoga, meditation and psychosocial support may stop or even reverse the progression of coronary heart disease, diabetes, hypertension, prostate cancer, obesity, hypercholesterolemia and other chronic conditions.

Prostate cancer? Are they serious?

But alas, they are. So serious in fact that they never seem to find it in their hearts to discuss all the interactions that can occur between their herbal concoctions and supplements and conventional medications. (You mean there can be problems with herbs? Say it ain't so!)

But then, there might be an ulterior motive to promoting this approach, like this or this.

But the real reason for this opinion piece was placed in the Wall Street Journal?

These approaches emphasize both personal responsibility and the opportunity to make affordable, quality health care available to those who most need it. Mr. Obama should make them an integral part of his health plan as soon as possible.

These guys know the government is looking to cut costs, and (fortunately and correctly) their workshop will be first to suffer the fall of the axe.

-Wes

Education Time

Dr. Wes will be attending the Boston Atrial Fibrillation Symposium for the next few days (weather permitting), so blogging might suffer a bit. Since my early AM flight has already been cancelled and rescheduled for later in the day (thanks to the gorgeous *cough* weather at O'Hare Airport), I hope I can make enough of the conference to make the costs worthwhile.

It feels like that ol' Visa tag line:

Registration fee: $675
Airline Ticket: $310
Hotel: $400
Transport to/from the airports: $100
Chance to learn something new: priceless?

We'll see.

-Wes

When Investigators Bite the Hand That Feeds Them

... it can get ugly:

A scientific dispute has become a slander suit, in a legal case involving NMT Medical and its device for closing congenital holes in the heart.

The lawsuit, pending in London, was filed in 2007 by NMT Medical after a clinical trial failed to show that its device could eliminate migraine headaches in people with the congenital heart opening, known as a patent foramen ovale, or P.F.O.

NMT Medical contends that one of the British researchers in the study slandered and libeled it when he was quoted in an online publication as saying the trial may have failed because the product did not work well. The researcher, Dr. Peter Wilmshurst, was also quoted as saying the company had withheld trial data because it feared that it might undercut sales of the device for other uses, like stroke treatment.

“I’m not as concerned about the companies as I am about the fact that the patients who are in the studies will suffer,” Dr. Wilmshurst was quoted by the publication, theheart.org, which covers cardiology.

The controversy surrounding this trial has been ongoing since 2007 when Dr. Wilmshurst stated:

In an interview with heartwire (registration required), Wilmshurst, a cardiologist, alleges that NMT has attempted to marginalize his role in the trial--including claiming that he was never a co-PI for MIST I--and to bar his hospital from participating in MIST III. He also asserts that NMT has repeatedly blocked his attempts to view the complete MIST I data set, lied about whether echocardiograms from the MIST patients have been independently reviewed, and massaged the data to portray its PFO device in the best possible light.

But we must continue to ask where are the regulators in this case? Why has this contentious argument between corporation and investigator been permitted to come to one of litigation?

What a mess.

While this trial has exposed the underbelly of the scientific process when egos, patient interests and business interests collide head-on, the new legal actions also make a mockery of England's regulatory process to resolve these differences before they reach this level of contentiousness.

-Wes

Surgeons Joining the Ranks of Traveling Salesmen

Over a year ago, I commented upon the phenomenon of the physician as traveling salesmen for hospital systems. I noted how physicians spend increasing time between facilities as hospital systems expand, but at the cost of becoming commodities in larger health care systems as they find they must rely on others to deliver care when they are elsewhere.

The hospitalist movement is not much different these days for general internists, as they relinguish their patient's care to others while they are in acute care hospitals. The difference in this model, though, is that doctors can still maintain their identity in their workplace.

Today in the Wall Street Journal, we find that general surgeons, the "primary care" of surgery, are now finding that declining or flat insurance payments, paired with ever-increasing overhead (like office staff and malpractice) have had to resort to folding their practices and traveling to hospitals in need of their expertise in order to survive:

Now the economic and cultural forces reshaping U.S. medicine are prompting an exodus from this once venerable field, creating a growing market for temporary surgeons-for-hire.

As a general surgeon in her hometown of Franklin, Tenn., Jennifer Peppers could no longer keep her practice going after eight years in business. Faced with rising overhead costs and declines in reimbursements, she and her partners stopped drawing salaries last winter. To pay her home mortgage, Dr. Peppers had to borrow from a credit line.

So the surgeons shuttered their practice, and Dr. Peppers, 42 years old, hit the road. Her typical month might now include a weekend in Springfield, Ore., removing ruptured spleens or repairing obstructed bowels, followed by two weeks at a rural Kentucky or New Hampshire hospital. Though she misses her husband, she earns double her old salary and has paid off a big chunk of her medical-school debt. "I'd much prefer to be in my hospital in my little town," says Dr. Peppers, who is now licensed in five states. "But I don't see how that's possible."

While some think this trend might be sustainable, life will eventually catch up with this model, since I believe work-place identity and gratification play as big a role of physician retention as salary, if not more.

-Wes

Our New Economic Stimulus Plan

Colorado is a perfect example.

Right now, the snows have come early and often in Vail, Colorado but the skiers, it seems, aren't coming:

Vail Resorts said that from the start of the season through Jan. 6, total skier visits to its five properties were off 5.8% compared with the same period a year ago, while lift-ticket revenue fell 7.5%. Bookings as of Dec. 31 are down 14.8% on a room-night basis.

Aspen, on the other hand, has an economic buffer plan. They've gotten smart and decided to turn to health care instead. It seems when times are hard and money is free-flowing from the government for health care, turn to hospital construction:

Hospital officials want to redevelop the existing 75,700-square-foot facility into a two-story building that adds another 214,395 square feet.

The expansion includes a parking garage, a rooftop heli-pad and numerous improvements to medical departments.

...

The planned expansion would be on the hospital’s largest piece of land, a 19.1-acre parcel that has a total area of 832,085 square feet. The size of the new hospital would be 290,095 square feet.

Funny how no one seems to care what this will cost. But it's all about the economy and jobs, right? Who cares how much more each and every patient will have to pay to cover the enlarged facility's overhead.

Gosh, rumor has it the contractors will even throw in a chair lift to the slopes for the visiting families, too.

-Wes

When the Lights Go Out

... so too, might the medical devices:

Roughly 2 million people use home oxygen machines, mostly "concentrators" that make oxygen on the spot as long as electricity flows. Just a few years ago, oxygen-gas tanks that don't require home electricity were the norm.

At least another 10,000 people breathe with home ventilators, and thousands more have implanted heart pumps called VADs, or ventricular assist devices.

...

Millions more use other at-home equipment: dialysis machines, nebulizers, IV and nutrition pumps, CPAP breathing masks. But power failures bring the most immediate risk for users of ventilators, heart pumps and oxygen.

Ventilators and heart pumps have internal batteries that last 45 minutes to a few hours, time to put on longer-lasting batteries or get to help. Some portable oxygen concentrators can run on batteries for three or four hours or be plugged into a car adapter, but patients typically depend on oxygen suppliers to deliver old-fashioned tanks of the gas for emergency use.

And the situation can be made worse by HIPAA health care privacy rules:

Federal patient-privacy rules limit sharing, cautioned Bill Desmarais, a co-owner of Home Care Specialists Inc. in Haverhill, Mass., which had about 800 oxygen-dependent customers using backup tanks when last month's Northeast ice storm cut power.

Patients with such devices would be well-advised to communicate with their local emergency medical services and the power companies to review actions to be taken in the event of power outages.

-Wes

Best Medical Weblog of 2008

Make sure to go over to Medgadget and vote for this year's Best Medical Weblog. There are some fantastic finalists selected from a large number of nominees.

In addition to the best overall Medical Weblog, other categories to vote upon include:

Best New Medical Weblog (established in 2008)

Best Literary Medical Weblog

Best Clinical Sciences Weblog

Best Policies/Ethics Weblog

Best Technology/Informatics Weblog

Best Patient's Weblog

You can vote for each category above, so be sure to support your favorites.

Congrats to all the finalists who have made this such an acceptional year for medical blogging!

-Wes

Blago's Impeached

Surprise, surprise.

Now that the fall guy's taken it, will pay-to-play politics cease to exist?

No.

But at least we now can feel good we did something about it.

-Wes

The Spin

"Mr. Daschle also said that health-care premiums have doubled since 2000, but even with insurance, many people can't get adequate care."-WSJ 8 Jan 2009 5:23PM

"... even with insurance, they can't get adequate care."

What does that mean?

It means Mr. Dashle doesn't think that doctors can think independently about how to deliver care. I means that Congress will decide what adequate means by insisting that doctors fill out more forms to determine "appropriateness" or document their "performance" before they will be paid. He means that he thinks he knows how to control costs through bureaucracy, even though that raises costs to employ all the bean counters out there. He means that he understands that patients can't afford their health care, that businessess can not afford to pay for health care, that insurance companies can no longer afford the high costs that they are incurring, and that the only way to maintain our system is for the government to continue printing money. It means that as long as they continue to print money, that real, meaningful and sustained change to our health care crisis will be put off for another day.

Please Mr. Daschle, cut the hyperbole. It distracts from meaningful discussions about health care reform.

-Wes

Our Inappropriate Appropriateness Criteria

Ladies and gentleman, if there is any question that clinical judgement has been relegated to the back bowels of medical care, a new breed of healthcare-payment-denial-criteria-for-insurers has been born: so called "appropriateness" criteria for cardiac revascularization.

Actually, it started for cardiac imaging, and somehow, some way, our cardiovascular leadership who cozy up to our well-intensioned-but-clueless legislators on the Hill thought it would be a good idea to (QUICK!) develop even more complicated "appropriateness" criteria for cardiac revascularization!

I mean, what kind of word is "appropriateness?" Shouldn't it just be "appropriate" criteria?

But alas, just as we have seen the invasion of the word "wellness" into our health care lexicon by insurers, so too comes "appropriateness."

As if I can have more "appropriateness" than my other colleagues. Nah-nah-na-nah-nah.

In an absurd and utterly shameful attempt at categorizing every permutation and combination of coronary disease that comes our way and categorize it into three levels of judgments regarding care (Appopriate, Uncertain, and Inappropriate), the authors have succeeded in dispensing with what really matters in treating patients: clinical judgement.

That's right, your "score" will mean more than your judgement. Just get over it.

As if such a scoring system will keep the less-than-honest amongst our ranks from making sure their patient qualifies as "appropriate."

Please, spare me.

But what's really ironic (and telling) is that cardiologists don't need these criteria clinically. We can define if a patient needs revascualization MUCH better than any "score" or table ever could. That's because we can actually see and examine the patient. We can appreciate the myriad of confounding co-morbidities that shape clinically relevant treatment recommendations, like cyanosis, severity of heart failure, pulmonary disease or peripheral access issues.

But that's not good enough for insurers - especially Great Big Governmental Ones that are convinced (and I mean convinced) that Doctors Are The Evil Ones when it comes to cost overruns. Doctors are out to scalp the system, relentlessly. We never have the patients' best interest at heart. It's always about our wallets, right?

Give me a break.

Week after week we sit in cath conferences with our surgical collegues and discuss in great detail not necessarily if an individual needs revascularization, but which form would be more appropriate: bypass or stenting. Do these so called "appropriateness" criteria for revascularization help us with that decision? Not at all!

Really, how "appropriate" is that?

But maybe, just maybe, my keeping these criteria "appropriately" vague and limited to "only" 4000 potential permutions, the authors tacitly achnowledge the limitations of their efforts. Unfortunately, by creating these inappropriate "appropriateness" criteria, they have helped the insurers grant more reasons for denial of payment than they have helped their collegues manage patients. They have virutally guarenteed that in the end, as the ongoing battle between those that deliver care and those that pay for it continue to lock horns, the patient will bear the brunt of the battle and remain the most confused about their obligated portion of their health care bill.

And to me, that's what's really inappropriate.

-Wes

Chilled to the Bone

A remarkable case of hypothermia to a core temperature of 60 degrees that survived.

-Wes

The Car Wash Heart Mystery Solved

It made for intrigue and drama and cost the tax payers of Michigan a pretty penny to investigate, but alas, the mystery is now solved.

-Wes

Missing My Cardiologist

There was an eerie pall to the office after the New Year Day break – I noticed my cardiologist was missing.

Not that I need a cardiologist. But if I did, this man would be the one I'd see.

He’s the same man who took care of my father when he was gravely ill and needed pre-operative clearance before urologic surgery. The same man who took the time to go the extra mile, review the studies personally, listened and treated. Professionally. Quietly. Firmly. Thoroughly. All without another unnecessary echo, or stress test, or Holter. He knew he’d get through just fine, (and he did) but followed up with him afterward anyway, just to be sure. Early in the morning. Before most of us ever thought about arriving to the hospital.

A man we’d all like to call our doctor.

That’s the way this man is: the penultimate clinician who loves his work. He is a man who has seen the sickest of the sick, the eldest of the old, the poorest of the poor and the always adds another "patient-who-really-needs-to-be-seen" to his already-overcrowded clinic: as if he has all the time in the world. He sees things that others never saw, knew things that most of us had forgotten, and helped those that many could not help. His exams are actually performed, not copied. His notes are succinct and to the point, wonderfully devoid of the meaningless verbiage or electronic medical record spam created by the New Generation’s dot-phrases. His professionalism is constant, his kindness infectious. He loves his patients and they, in turn, love him. Many have been with them as long as they can remember.

At his core, he is a family man, but he also enjoys his quiet walks on the beach in more contemplative moments. He never shied from a good joke or a very occasional Glen Levitt. His blood runs orange and blue: a wild fan of his alma mater, the University of Illinois. He still misses the now-banned Chief Illiniwek, so much so that he is, and will forever be, our “Chief.”

More recently I found him huddled in his office, his head upon the desk between patients. Nauseated and in pain he saw his patients anyway, even though he was probably the sicker patient in the room. This, after all, is what he loves, his therapy, his mission. He never revealed the discomfort and illness beneath to avoid the difficult psychological counter-transference that could occur if the patient became more concerned about him. He never wanted this. It was always about the patient, you know. I have no idea how he’s done it for so long, with so much grace and compassion. But now at last, the doctor must become the patient, and I wish him the best as he undergoes his necessary treatments.

It’s strange to see the office now. Oh sure, the patients keep coming and the folks keep hustling and bustling about. Time, after all, does not sit still. But it’s still not quite the same. Perhaps this once, time should take a pause, however briefly, to acknowledge this wonderful man’s work on behalf of his fellow man and the many lessons of compassion and grace he has taught us all.

Best of luck, Al, and hurry back. We miss you.

-Wes

My 4:30AM Wake-Up Call

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"Could you help? I've had to shock him three times now."

-Wes

Health Care Utopia's First Great Challenge

Welcome to Health Care Utopia, young doctor-to-be!

Now that you've completed medical school and post-graduate training, we've decided that you'll be the perfect candidate to join in our government-directed social experiment. You see, we've decided that all doctors straight out of medical training (irrespective of subspecialty) should make the same Perfect Starting Salary of $200,000. No need to fuss over medical specialty, no. We've taken those discussions out of the picture, because irrespective of the speciality you decided to pursue, everyone in Health Care Utopia makes the same starting salary!

Now, to keep it simple, you only have two choices about where to practice after you've completed your training: (1) Socialist Hospital in lovely city of Mount Pleasant or (2) Capitalist Hospital in the thriving city of Prosperity. To keep your decisions simple, every state in the Utopian Union has only these two cities. Also, we mean no offense, but you're just too green-around-the-gills to be subjected to the challenges of private practice and have no money to buy our required electronic medical record that holds the key to all health care payments in Health Care Utopia).

Now, the only difference between the two hospitals in which you will be an employee is their compensation model. These, we have learned, can be very sensitive subjects for our doctor-employees. Since we're not quite sure which model to impose nationally, young doctor, we're going to insist you become part of our Great National Experiment.

So here's the deal: Socialist Hospital pays all their doctors the same amount by pooling all their revenues and dividing them up at the end of the year evenly. This way, everyone is happy. Well, at least at first. If all the doctors work harder each year, we'll pool those earnings for them, divide it up evenly, and everyone makes more money! Isn't that great? No more fuss and muss with productivity bonus earnings here. If everyone keeps working hard, you'll all make a bit more money year after year. If someone is a slacker, well, you all might not get paid more even though YOU worked harder, but hey, this is Socialist Hospital! It's how they work. They'll be able to follow each and every one of your work schedules because they follow our perfect Work Unit measures and eventually fire the slacker-doctor, really they will. Now you might not make as much money as those guys at Capitalist Hospital, but you might have a life outside the hospital here. And you know what's great? I've heard some doctors in this model can even work really hard four days a week and sometimes just take the fifth day off (although some of their colleagues seem a bit perturbed by this, since they have to be at work when you're not).

Capitalist hospital, on the other hand, works on a slightly different model. At Capitalist, the harder you work, the more you'll make, irrespective of what your colleagues do. If you want to make a lot of money, just work harder! The sky's the limit! It's really simple at Capitalist: more Work Units means more money. So if you work really hard, take call as often as you want (even ever other night, if you want), and keep your clinic visits to just 5 minutes instead of seven, you can see more patients and see a TON of income! Be careful not to give too much work to your colleagues, though, or you might not make as much money since they'll earn those Work Unit points instead of you. The challenge at Capitalist will be if you want a life outside the hospital. In that case, your Work Units are likely drop quite a bit, a so too, your salary. I mean, that's the way it goes. But that's how things work at Capitalist Hospital: every man for himself.

So tell me, young doctor-recruit, which will it be?

-Wes