It's Not Balanced Billing by Doctors, It's Just New Fees

Looks like after hours phone calls will cost patients at some centers here in Chicago:

Some Northwestern Medical Faculty Foundation patients are about to be hit with new administrative fees as the group attempts to ease its physicians' workload.

Patients of the foundation's general internal medicine division were told recently that starting Friday, they will be charged $25 for placing non-emergency phone calls to their doctors outside of office hours. The division is open from 8 a.m. to 5 p.m. weekdays.

The foundation said in a letter to patients that it's implementing several new fees because the time physicians spend addressing patient needs outside of office visits has compromised the hospital's ability to provide "efficient service."

While other fees will also be levied, some come with a convenient catch:

New fees are also being levied for filling out patient-requested paperwork outside of an office visit ($25 to $50), for patients who miss an appointment without a day's notice ($50) and for providing online medical consultations ($25).

Northwestern Medical Faculty Foundation won't charge a fee for after-hours calls or online consultations if they lead to an office visit within seven days or if they are used to clarify a physicians' instructions following a visit within the past week.

It will be interesting to see what patients think about these new fees and the higher insurance co-pays they'll be seeing soon. As far as I know, our institution is still holding out on such fees.

-Wes

Drug Disposal

It's amazing how many drugs go unused:

Saturday’s Department of Drug Enforcement sponsored drug take back in Naperville brought in about 250 pounds of prescription drugs, filling six large boxes to capacity.

“It exceeded our wildest expectations,” Naperville Police Cmdr. Greg Waitkus said of the first time Naperville participated in the national event, which safely disposes of unused medication.

He said many people don’t know medication cannot be thrown away by standard methods, and that pitching pills in the trash can sometimes get them into the wrong hands.

Unused medications can also end up in the environment, so not throwing them in the trash makes sense.

Still, it seems a shame that in these days of high drug costs that we can't find a way to safely recycle unused medications.

-Wes

A Sad Day in the Medical Device Industry

Forbes magazine noted the departure of Boston Scientific co-founder John Abele from its list of the 400 “Richest People in America.” Abele missed the billionaire mark after shares in the Natick medical device maker plunged.

(siffles)

-Wes

News You Can Use: Sex and Your Defibrillator

Have a defibrillator and feel like getting frisky? For the first time that I can recall, there's a very helpful article published in Circulation addresses the concerns of implantable cardiac defibrillator(ICD) patients and sexual activity. There's all kinds of helpful tidbits, like this one:

A study of 1774 patients who had experienced an acute myocardial infarction showed that sexual activity was a likely contributor in fewer than 1% of cases. In fact, regular physical exertion, such as that associated with sexual activity, was associated with a decreased risk of cardiac events in patients!

Now that's helpful!

Recall that defibrillators are designed to detect rapid, potentially life-threatening arrhythmias. Most of the time, sexual activity does not lead to heart rates at a level that ICD's would consider elevated during intercourse. (This, of course is patient-specific). While your doctor can tell you the rate cut-off at which your ICD might possibly fire, watching your heart rate rise with a monitor during those moments might be a bit of a, shall we say, turn-off..

My rule of thumb: if you have a defibrillator (ICD) and can walk up two flights of stairs without getting a shock, you'll probably be okay having sex. (Be sure to check with your doctor, these are just my ballpark recommendations. Also, this rule of thumb may not apply to those involved in extramarital affairs. As we've heard, heart rates accelerate much more when a naughty, clandestine element is involved). But please be careful: if one flight of stairs makes you too exhausted or short of breath, you'd better check with your doctor first.

Now, what about the partner? What happens if the defibrillator fires and you're at the peak of passion?

First, you might give out a "yelp." That's because the shock often causes the diaphragm and vocal cords to contract. It happens very suddenly, and your partner might not mind this part, but the kids down the hall... well, that's another thing.

Second, ICD shocks won't hurt you partner. On the contrary, it might be... well, let's put it this way... interesting!

Third, if repetetive shocks occur as a result of your activities, well, sorry my friend, you've had enough and probably should head to the ER. Realize this is an infrequent event, but any time there are back-to-back shocks it means one of several things: (1) you're having a lot of rhythm problems, (2) your device might need to be reprogrammed to avoid shocks at this level of exertion, or (3) (least likely) you might have a faulty lead that needs repair.

Common sense should dictate each person's individual approach, but for the most part, ICD's needn't hold you back!

-Wes

Reference: Lauren D. Vazquez, PhD; Samuel F. Sears, PhD; Julie B. Shea, MS, RNCS, FHRS; Paul M. Vazquez, DO. "Sexual Health for Patients With an Implantable Cardioverter Defibrillator." Circulation. 2010;122: e465-e467.

Great Quality - Now What?

It's the fear of every quality assurance organization - when everyone achieves perfect quality targets:

For evidence-based treatments, hospitals achieved around 95 percent composite performance on 12.5 million opportunities to perform care related to the measures, the Joint Commission said. In 2002, the hospitals got 82 percent composite performance on 957,000 opportunities.

For instance, in 2009, almost 98 percent of hospitals provided proper heart attack care, such as giving aspirin at arrival or beta-blockers at discharge, compared with only 89 percent seven years earlier. For surgical care, such as giving antibiotics an hour before surgery, overall performance improved to 96 percent, up from 77 percent in 2004. For pneumonia care, results jumped more than 20 percentage points - in 2002, this measure was only at 72 percent. By 2009, it reached 93 percent.

While I understand the theory (and no doubt patients with heart disease in particular have benefited), if everyone consistently achieves near-perfect benchmarks because that's how they're paid and resources are expended to make sure that's the case, how do these quality managers justify their continued existence?

The answer is simple: make more quality measures. This is, in fact, what has happened every year since this program's adoption in 2005.

The concern, of course, is that at some point more money will be spent on hoop-jumping in the name of quality scores and patient satisfaction surveys than on the actual care delivered, especially to areas not measured.

Then what will we have achieved?

-Wes

Specialty E-consults

Partner's Healthcare in Boston has made it happen and even breaks down how much a second opinion might cost you:

The total cost of your consultation will depend on which services are chosen and the number of studies that are evaluated by our specialists. You may speak with a Consultation Coordinator to estimate your costs before your case is submitted and actual costs can be defined after your material is received.

The components of the total cost could include:

Specialist Opinion: $495 each
Radiology Review: $200 each
Pathology Review: $250 each

Welcome to the new world of on-line specialty consultation and these guys are demonstrating how being first-to-the-e-market can benefit large health care systems.

-Wes

Reference: Partners Online Speciality Consultation Home Page

This Week's Cardiology Creativity Award

... has to go to Mark Glazer, M.D., who, along with colleagues from the Vanderbilt Heart and Vascular Institute, produced a music video to promote the American Heart Association's Heart Walk, scheduled for Saturday, Oct. 2:



Somehow, I expected a parody with more twang, it being Nashville and all...

But not bad. Not bad at all.

-Wes

Our Health Care Happy Meal

"...health reform would allow for them to receive preventive care services without having to pay anything... Health reform starts at birth -- health plans will no longer be able to refuse to cover children younger than 19 simply because they were born with a medical condition... adults and seniors will no longer have cost-sharing provisions for preventive services... Together this all adds up to more patient protections than we have ever had, and this is just the beginning."

-Kavita Patel, "Will health reform be repealed?", CNN.com

Parents the world over know the magic of McDonald's Happy Meals. There's something about the promise of a Happy Meal - the way it's packaged, the free toy - young families and especially kids find them irresistible. But anyone who's purchased one of these knows the reality: that toys within the Happy Meal are typically played with for no more than three minutes and the plastic tchotchkes are discarded faster than the accompanying 2% milk.

And yet, despite the fact that the toy is worthless, kids clamor for the Happy Meal again and again. It's human psychology - we simply can't help ourselves. Hope springs eternal that next time the next Happy Meal will contain a better, more stimulating toy. It's the possibility of the unseen, the thrill of victory, something for nothing, and all with the word "free" attached that causes us to gravitate to these types of things time and again with no learning curve.

A distinctly American Way.

This, of course, is nothing new to marketers. But this promise has become the linch-pin of Obamacare spin from its inception. If it's free, do we care what it really costs? If it's free, do we care what the quality is? If it's free, do we care what the data about the utility of the test is? If it's free, do we care how the results are delivered?

Of course we do.

When the results come back and we're clutching the phone hoping to hear a familiar voice when none is there - that will be our new reality - but we're not pitching reality. Or costs.

There's a common sense saying: "If it sounds too good to be true, it probably is too good to be true." Even if we find that the $19.99 infomercial slicer/dicer doesn't work at home as it did on television, American's love the psychological reassurance that this time the government will make health care available to all without restriction, expense, or consequence, be they boys or girls, legal or illegal, young or old, right-handed or left-handed, with preexisting condition or not, - no one will be left behind in our new omnipotent era of Patient Protection and Affordability.

We should all know better, but the sad fact is, we're all suckers.

Not that some of the promises made wouldn't be useful, helpful, or even critical to many families. But to position health care reform (and the Patient Protection and Affordable Care Act in particular) as a win-win with no hard choices, no limits to health care for our seniors, no future commoditization of medicine, unlimited access to procedures and doctors, and all with no enormous financial cost, is to stick one's head in the sand.

Package it, spin it, wrap it in plastic - then put it next to a cheeseburger.

No matter what you call it, it's still Hopium.

-Wes

Reference: Images courtesy of 'A Bite to Eat,' Craftster.org

Taylor's Remarkable Gift

Take 4 minutes from your busy schedule to watch this gripping story (video) about how one thirteen year-old's gift of life that changed two families' lives for ever.

If you want to see the healing power of heart transplantion, this is it.

-Wes

h/t: Ramona Bates, MD via Twitter.

Another Robotic Catheter Joining the Afib Ablation Fray

... and according to this press release, this one deflects in a very cool way (video here):

Existing commercial catheters are manually controlled and can only move in two directions. These catheters require doctors to painstakingly manipulate the catheter to control exactly where each individual lesion should be applied.

But the robotic catheter developed by Buckner's team significantly reduce operating times, utilizing "smart materials" to provide significantly better maneuverability. The smart materials act as internal muscles, contracting when an electric current is applied. This allows the catheter to bend left, right, up, down or any combination of those directions. Furthermore, doctors can use a specialized joystick to locate key points on the atrium. A computer program can then trace a curve along those points – essentially connecting the dots – creating a solid line of scar tissue that will block the electric signals causing fibrillation.

A few words of caution about this press release. First, to my knowledge this catheter has not been commercially developed nor tested in humans.

Second, I find catheter manipulation is not "painstaking" but fun (just me, I guess). Further, moving catheters to a location in the heart is the relatively easy part during catheter ablation - holding it at a location and applying an appropriate amount of pressure to the heart so that energy can be applied safely without perforating the heart are even more important engineering prerequisites for any of these robotic catheters to be adopted clinically.

Still, the prototype's flexibility and mobility are impressive and sure would make for some exciting entertainment possibilities at home in the lab, too!

-Wes

Reference: Press release from North Carolina State University

"Health Disparities" and The Future of Your Health Care Privacy

"The right of the people to be secure in their persons, houses, papers, and effects, against unreasonable searches and seizures, shall not be violated, and no Warrants shall issue, but upon probable cause, supported by Oath or affirmation, and particularly describing the place to be searched, and the persons or things to be seized."

4th Amendment, U.S. Constitution

Arie Friedman, MD examines Section 4302 of the Patient Protection and Affordable Care Act of 2010 (PPACA) and breaks down the use, distribution, and upcoming protections of your personal health care data by the government including this passage:

(1) IN GENERAL- The Secretary shall ensure that, by not later than 2 years after the date of enactment of this title, any federally conducted or supported health care or public health program, activity or survey (including Current Population Surveys and American Community Surveys conducted by the Bureau of Labor Statistics and the Bureau of the Census) collects and reports, to the extent practicable--

(A) data on race, ethnicity, sex, primary language, and disability status for applicants, recipients, or participants;

...

(D) (emphasis mine) any other demographic data as deemed appropriate by the Secretary regarding health disparities.

Be sure to read Dr. Friedman's article that touches on the protections assured by the new law. I tend to think I have a pretty balanced readership on both sides of the political spectrum so I'd be interested to hear what others think.

Are we giving up our health care privacy in return for medical coverage in the new PPACA law or do we feel the protections mentioned by the law are sufficient?

-Wes

Northwestern University Medical School Gets $45 Million Dollar Bailout

Wow. So where's all that bailout money coming from?

The university and the hospital each is providing $10 million, the note said. The $25-million contribution from the faculty foundation consists of expense reimbursements, including advance transfers of projected operating surpluses, and self-insurance premium credits released to the foundation from insurance reserves.

Besides covering an unspecified deficit at the school, the cash infusion will provide academic program support, the note said.

Hmmm. "Unspecified deficit." Are we seeing a medical education cost bubble beginning to burst?

-Wes

Combating Alarm Fatigue

It happens in every hospital telemetry ward: alarm fatigue. Thanks to the need to draw attention to nurses who manage four or more patients at a time using bed alarms, infusion pump alarms, call buttons and telemetry monitors, nurses and nurse's aides are increasingly barraged by noises. With time, these noises fall into the daily hum drum of hospital care and are often missed. Most of these sounds are bell-like noises - often of varying intensity.

But there might be a better way.

I would suggest systems be developed with unique "ring-tones" not too dissimilar from various ring-tones we find on cell phones that would be more apt to draw people's attention - the European ambulance sound for a bed alarm, or fog horn blast for sustained ventricular tachycardia might be heeded to a greater degree than gentle "pings" from our current generation of monitors. For course, a few bars of "Stairway to Heaven" might be a bit inappropriate, but certainly to generate a smile as the nurse rushed to the patient's aide.

Then again, dedicated monitor nurses or techs would work, too.

-Wes

Board Certification - Pay to Play?

Board certification used to be a voluntary means for physicians to demonstrate their clinical competencies and separate themselves amongst their peers. Now, it looks like it will just be one more way for insurers and regulators to withhold physician payments in the name of "accountability:"

Physician licenses are issued by state medical agencies. That's not the same with specialty boards, which used to test doctors once and granted certification for life.

In recent years, these groups have changed their policies and now require physicians to be tested every six to 10 years. But many older physicians are grandfathered in and don't have to update their qualifications.

Those doctors say they stay current by reading medical journals and taking continuing-education courses that are required for their state licenses.

Plus, board recertification can require travel to Chicago or Atlanta and cost $3,000 to $4,000 for the test.

"I think the initial reaction from a lot of people is, 'This is a bunch of crap; I did all my work in medical school. Why do I have to do it now?'" said Dr. William Cotton, a Columbus pediatrician.

But constant changes in medicine can quickly make what a doctor learned in school outdated, he said.

Cotton, who graduated from medical school in 1981, was grandfathered in in his specialty but decided this year to recertify to stay current.

Who cares about up-to-date certifications beyond savvy patients? Health insurers and hospitals. Starting next year, doctors who are recertified might be paid more by Medicare under federal health-care reform.

"There needs to be accountability in showing that they are, in fact, a specialist and are up to date on changes in their medical profession," said Kelly McGivern, president of the Ohio Association of Health Plans.

Sadly, board certification is a straw dog for exceptional clinical competency. It has been devalued by the lack of enforcement of the meaning of "board certification." Even the American Board of Internal Medicine who receives large sums of money from physicians and creates the instructional material and tests admits to the sad fact there are still guys out there you can pay $500 to to get a "certificate" to hang on your "board" so you can call yourself "board certified."

By permitting the board certification process to become devalued and merely a means to justify full payment from insurers and hospitals, the American Board of Internal Medicine has officially acknowledged that they are now serving new masters. Because of this, we now understand why the board certification has become a complicated floor of minimalist competencies rather than the pinnacle of one's professional achievement.

And it's one incredibly expensive floor that will now cost you even more dearly if you don't renew.

-Wes

Anomalous Coronary Artery - A Cause of Cardiac Arrest

... and also a correctable cause for this high school football player.

Sometimes it's hard to think it's a lucky thing, but for this young man, it's a correctible cause of cardiac arrest and a very lucky thing that this worked out the way it did.

-Wes

Medicine: From Altruism to Cynicism… and Almost Back

“I’ve always wanted to help people.”

“How can the brachial plexus be exactly the same for every person?"

“Why do they put microbiology, pharmachology, and pathology in the same semester?”

“Physical diagnosis is so frickin’ cool! Look what you can see if you know what you’re looking for!”

“She didn’t want to see me; she wants to talk to the attending.”

“Why? He was so young, 2 kids, nice wife. Worse, he was my age!”

“People are idiots. He blew his whole hand off and for what?"

“What do you mean I didn’t get paid? I spent two hours with that guy!”

"I can't believe she set fire to their trailer with the baby there..."

“Since when did that ICD-9 code have to be paired with that CPT code?”

“Why is it the nurse always wakes me at 1 AM so the patient can have a sleeping pill?”

“Screw it. Tylenol, Ambien, milk of magnesia are now standard meds in my admission orders.”

“What do you mean there are no blood pressure cuffs on the wards?”

“They charged the patient how much for that surgery?”

“Stethoscopes are worthless. Get an echo.”

“With chest pain, all roads lead to cath.”

"E-mail, too?"

“Volume. Need more volume. Have you talked with PR?”

“I can't stand this EMR."

“Why aren’t we being asked to do more research for those guys?”

“It’ll be every third weekend for a while now that we’ve added another hospital to the mix.”

“Mom’s got a mass – looks like the pancreas.”

“I hear they’re doing some amazing research. And they've got a helluva surgeon.”

“I can’t believe what they can do these days. They technology is amazing.”

“Why she losing so much weight?”

“I hate that she has to run around all over the place for another appointment.”

"Here, let me help you with that door."

“I can’t believe she made it through! The team was… frankly… amazing.”

“We spent Christmas together, I'm glad we had that time together. I miss her.”

"I have no idea how I'd be able to do medicine without that EMR."

“The key is to not only look at the lines of the page that represent the heart’s activity, it’s to use deductive reasoning to make a diagnosis.”

"I've never felt so good. Thanks, doc."

“Dude, medicine is so cool.”

-Wes

Re-Learning Heart Failure Semantics

Thursday, Boston Scientific received word from the FDA, that three of their implantable cardiac defibrillators capable of cardiac resynchronization therapy (CRT-D), or biventricular pacing, have been approved for use in patients with "left bundle branch block who have either mild heart failure or heart failure with no apparent symptoms."

This is an interesting discovery - people can have heart failure without symptoms!

This, of course, flies in the face of most of the definitions of heart failure. Take, for instance, this definition from Mayo Clinic:

"Heart failure, also known as congestive heart failure (CHF), means your heart can't pump enough blood to meet your body's needs."

How is someone supposed to know that the blood flow needs from the heart are not met if the patient has no signs or symptoms? Saying it another way, does this mean that everyone with left bundle branch block and no symptoms might actually have heart failure?

*Sigh*

The lines of classifying the severity of heart failure have never been clear, despite what our medical coders and researchers would like us to believe.

In reality, in the upstream push to prevent heart failure, MADIT-CRT (the study the FDA cited to reach its approval of Boston Scientific's CRT and CRT-D devices) has demonstrated that intervening BEFORE symptoms occur in patients with weak heart muscles and left bundle branch block can improve mortality and reduce hospitalizations for heart failure. This a good thing.

But what we also have learned is that patient symptoms are immaterial for device implantation any longer in patients with weak heart muscles (EF <= 30%) and left bundle branch block (with QRS width of 130 msec or more) on their EKG. As such, classic symptoms of "heart failure" like shortness of breath, swollen legs, and the like, are also immaterial to qualify for a cardiac resynchronization device.

This makes me wonder if we should still be calling CRT devices "heart failure" devices or rather, "heart preserving" devices.

For now, they'll have to stay "heart failure" devices, despite all of the negative connotations. For whoa to the doctor that forgets to give the diagnosis of at least "Congestive heart failure, NYHA Class I" (or, "congestive heart failure without symptoms") when they ask, pretty please, for permission to implant one of these devices from our insurers in our new era of cardiovascular guidelines mandates.

Such are the billing and coding games we must continue to play.

-Wes

Reference: The NEJM publication of MADIT-CRT.

Are Large Health Care Systems Gouging Patients?

With patients having to pay more of what's charged for their health care, comparisons between medical systems like this one in Pennsylvania, makes us wonder if bigger necessarily means better:

The Pennsylvania Health Care Cost Containment Council study looked at four regional hospitals that offer cardiac surgery: Geisinger Wyoming Valley, Plains Twp.; Community Medical Center and Mercy Hospital, Scranton; and Pocono Medical Center, East Stroudsburg.

Among the four, Geisinger Wyoming Valley carries the biggest price tag. In 2008, the average hospital charge for a coronary artery bypass graft surgery was $108,029 and the average hospital charge for valve surgery was $132,740, according to information in the report.

Having both surgeries simultaneously at Geisinger resulted in an average hospital charge of about $162,051.

Coming in as the most affordable in 2008 was Community Medical Center, according to the council's report. The average hospital charge that year for bypass surgery was about $63,767, and the average hospital charge for a valve surgery was $90,411.

Pocono Medical Center was the most affordable when it comes to having simultaneous bypass and valve surgeries - the average hospital charge was $92,352.

Hospital charges are a poor way to compare costs since they are often inflated. Worse, retrospective data that is several years old is of little use to patients seeking care today. But as patients are left to pay more and more out-of-pocket for their care, these types of data might tarnish patients' love-fest for large "branded" health care systems that historically have used their brand and market share to raise prices.

At least that's the hope to our more ardent reformers.

But there is the political reality that hospitals are large employers. Also, they are slow to publish this information lest they show their hand to insurers with whom they negotiate group prices or risk discouraging their patients from using their shiny new facilities up front. This is why patients have a tough time determining what a procedure will cost before they have it.

If we were to continue to permit personal costs to loom larger in our new health care reform era, as larger health systems' catchment areas overlapped it would be likely that the institution that moved first and most aggressively to make cost data available prospectively while maintaining quality might be the one with a significant advantage over their non-disclosing competitors.

But the costs and consequences of such an approach is unacceptable to our professional politicians. Things must be kept "easy" and "painless" for their constituents. As such, patients will soon have even less skin in the game for their care as we move forward with the "Affordable" Care Act in 2014, allowing this ridiculous, unrelenting upward cost spiral will continue. Bundled government payments for services won't be enough since they'll likely be negotiated to keep prices artifically inflated.

Don't think so?

Just look at the construction going on right now at area hospitals around the country. I would say our big, branded hospital systems are loving their prospects in the years ahead.

-Wes

Change of Shift Is Up

Change of Shift, the weekly presentation of nursing's best-of-the-blogosphere, is up over at Emergiblog.

-Wes

On Humanizing Medicine

An excellent opinion piece by Sally Satel, MD, a psychiatrist, appeared in the Wall Street Journal this AM about white coat ceremonies as ways to reinforce the humanistic qualities of medicine. The best part, however, was this perspective:

But the question of whether empathy can be taught—and, in particular, whether a white-coat ceremony is a good means for promoting that virtue—is a matter of some debate.

Judah Goldberg, a young doctor at Chilton Memorial Hospital in New Jersey raises an intriguing paradox. He asks how the white coat can bring doctors closer to the subjective experience of patients when, as an icon of the profession, it is meant to isolate and distinguish them from the lay community.

"To the extent that empathy can be taught through a ritual," Dr. Goldberg told me, "a hospital gown, the common garb of human frailty, would be more fitting than a distancing white coat."

I must say, the thought of everyone seeing each others' posterior sides as they paraded across the stage at such a ceremony did make me smile.

I think that humility as a doctor comes with life experiences: it is difficult to have empathy for a young mother bringing her child into the ER at 2am until you've had a sick child. It is difficult to empathize with a grieving widow until you've lost a parent or loved one. It is difficult to comprehend the anxiety of surgery, until you've been under the knife. It is difficult to comprehend cancer, until you have been so diagnosed.

Once these experiences happen to a doctor, that doctor is forever changed on how they approach patients. These are life's great lessons for doctors. And depite these noble efforts to impart empathy to doctors using this symbolic gesture, no white coat will ever impart humility better than real life.

-Wes

Some States Finding It Tough to Retain Physicians

Take, for instance, Virginia:

A recent study found Virginia retains only 35 percent of its medical school graduates and ranks 31st among other states in retaining doctors.

In 2008, Virginia spent more than $50 million from the general fund to support medical education and had nearly 600 new physicians graduate from Virginia's four medical schools.

Despite this, Virginia still struggles to retain medical graduates, with less than 25 percent of Virginia's physicians graduating from medical schools in the Commonwealth.

Some feel incentives might work:

Dr. Greenawald says other states including North Carolina have incentives to keep medical students in state. He hopes Virginia considers following suit. Dr. Greenawald also said the over burden of paperwork and insurance company oversight have taken doctors away from what they love doing which is providing care to patients. He said that's prompted many doctors to retire early.

I'm not so sure.

Until more medical students feel primary care is worth the effort, the mass exodus to specialties (and the out-of-state training that is often required) will continue.

-Wes

If I Were to Change Medical Education, I Would...

... add typing and coding to the curriculum.

Hey, and here's another idea (though I'm not sure I agree with this one).

-Wes

P.S.: Add your proposed changes (serious or not) in the comments section in preparation for the AMA's new historic conference of medical leaders to explore the future of medical education to be held in Washington DC 20-22 September.

Look, I call 'em as they're sent to me in press release, nothing else.

Heart Attacks: How Early Should We Intervene?

Imagine.

There you are sitting outside on a warm, sunny day having a leisurely picnic with your family. You hear an ambulance in the distance getting closer. You’re not on call.

Suddenly, the paramedics hop from the vehicle’s cabin and pronounce:

“Excuse me sir, your heart's not getting enough oxygen and you might develop a heart attack. Please, come with us.”

Sound far fetched? Well, maybe not.

A new device is being tested that might detect “silent” ischemia and notify the patient (or even call 911) that they are showing signs of heart ischemia on the wire installed in their chest:

The AngelMed system uses a device, similar in size to a pacemaker, which is implanted in the left pectoral region of the chest and has a lead with an electrode to the right ventricle. If there are ischemic changes of significance, an algorithm in the AngelMed Guardian system will identify these electrocardiographic ST changes and alert the patient. It is the same as a positive treadmill test or abnormal EKG, but can be identified much earlier in many patients. To notify the patient, the device will give either a “911” signal, which directs the patient to immediately go to the ER or call the paramedics, or a “Call your doctor” signal, which is a different signal pattern that originates with the implanted device and is sent via telemetry to a hand-held telemetry device carried by the patient. In addition, the signal provides an audible as well as vibratory ring under the skin, so if the patient has difficulty hearing, they can still sense the vibration and know when to call a physician.

Gee - just think how this device could reduce our door-to-balloon time!

On a more serious note, I have often wondered about patients’ acceptance of such “screening” cardiac devices. Will patients want to have such an invasive device that might interrupt their life at any time before they feel bad? What might be the psychologic implications of such a device?

Given what we know about our ability to predict heart attacks, the potential for underdetection (false negative) or overdetection (false positives) due to the many causes of ST segment shifts, and the need to now prove superiority (rather than just non-inferiority) of devices clinically, I wonder if this innovation ever stands a chance to catch on.

Still, Inspector Gadget would be proud.

-Wes

ICD Implantation: How Good Are We?

Some interesting data were published in the journal HeartRhythm recently:

Based on the registry, which has collected data on 486,025 ICD implants from 2006 to 2009, the demographics of ICD recipients are mainly male (73.8 percent), approximately 68 years of age, Caucasian (82.8 percent), high rates of hypertension (75.3 percent) and relatively low rates of diabetes (36.7 percent).

Some key findings from the 2009 registry include:

• Total complications for new implants (including death in the laboratory) have decreased over time from 3.77 percent in 2006 to 2.87 percent in 2009.


• Medicare beneficiaries accounted for 67.7 percent of patients.


• The device was placed for primary prevention in 78 percent of patients, two-thirds with coronary artery disease, the average left ventricular ejection fraction was 29 percent, and 82 percent were NYHA Class II-III.


• Among 5,246 physicians who implanted ICDs between 2006 and 2009, only 438 physicians provided information about their training. Among those 438 physicians, 56 percent completed an electrophysiology fellowship, accounting for 83 percent of ICD implants.


• Of patients receiving cardiac resynchronization therapy with defibrillation, 68 percent were shown to meet published national guidelines.


• Of patients receiving an ICD for primary prevention of sudden death, 78 percent met published national guidelines.

-Wes

Grand Rounds Is Up

This week's best of the medical blog-o-sphere is up over at "Bedside Manner:"

The theme of this week’s Grand Rounds is hot topics in healthcare communication.

Enjoy!

-Wes

Midodrine's Updates

On 16 August 2010, the FDA published a "Proposal to Withdraw Low Blood Pressure Drug" about the generic blood pressure-raising medication, midodrine:

The U.S. Food and Drug Administration today proposed to withdraw approval of the drug midodrine hydrochloride, used to treat the low blood pressure condition orthostatic hypotension, because required post-approval studies that verify the clinical benefit of the drug have not been done.

Patients who currently take this medication should not stop taking it and should consult their health care professional about other treatment options.

Phone lines were flooded. Doctors scratched their heads because the "options" for alternate therapies to replace this drug amounted to exactly... none.

Two days later on 18 August 2010, Shire pharmaceuticals announced they will stop manufacturing midodrine 30 September 2010, adding fuel to the patient backlash of the FDA's prior announcement:

Shire plc (LSE: SHP, NASDAQ: SHPGY) acquired ProAmatine (ed's note: trade name for midodrine) as a part of the acquisition of Roberts Pharma in 1999 and Shire conducted and completed the post marketing trials that the FDA required. The FDA, however, viewed these trials as inconclusive and required that additional trials be conducted for ProAmatine to maintain its marketing authorization. As a result, Shire elected to withdraw the product effective September 30, 2010 and notified the FDA in November 2009 and healthcare professionals earlier this year of this decision. Shire's withdrawal of the NDA was not related to any concerns regarding the safety of ProAmatine.

Doctors scrambled. Patients complained. Finally, news about the FDA recanting came via a New York Times article on 3 September 2010:

The agency’s flip-flop demonstrates the difficult choices regulators face in policing the nation’s drug market. Cracking down on drug makers sometimes means stranding desperate patients. And now that Congress has given the Food and Drug Administration greater powers to insist on better information about life-saving medicines, such disputes may become more common.

Sadly, not until a 10 September 2010 press release from the FDA could the information published in the New York Times be confirmed and a plan of action taken to assure patients and their physicians aren't blind-sided by the FDA's actions on this matter:

Since the agency notified the manufacturers of the proposed withdrawal of midodrine, we have heard from professional organizations, doctors, and patients about their concern about losing access to midodrine. We have also heard from organizations that have expressed interest in conducting the clinical studies necessary to establish effectiveness, as well as doctors and patients who support the conduct of such studies. FDA intends to work with Shire, the generic manufacturers, and other organizations to discuss the data that are necessary to establish the efficacy of midodrine. FDA will post this information in a public docket.

So what have we learned with this regulatory fiasco?

First, once the FDA approves a drug with strings attached, they have an obligation to assure to the public that those strings mean something long before a drug goes generic. Why impose regulatory requirements if they're not going to enforce those requirements in a timely fashion? We are left to wonder how many patients might have been harmed by their inaction had there been a problem.

Secondly, news agencies now appear to be our best source of new information about updates on drugs and their availability. This should be of considerable concern to physicians who need to verify the legitimacy of information published in the mainstream media. Admittedly, the New York Times got the story right, but such is not always the case with media reports about drugs and innovations in medicine. At the very least, the FDA should provide midodrine updates at the same time this information is provided to the media. Verifiable information is increasingly needed in our new era of web-enabled patients and doctors.

Third, this was one small example of the power of government to intervene on our patients' care rapidly and without warning to the populace at large. Fortunately, the public outcry over their action was not ignored, but patients should be aware that litigation against the government should harm arise as a result of such an action would be very difficult and expensive to prosecute.

Hopefully, the FDA has learned a few lessons with this fiasco.

One thing's for sure: you can bet our patients did.

-Wes

And I Thought I Had a Cool Job

I work with the heart's electrical system every day and impressed at how remarkably sensitive (and vulnerable) the heart is to even the smallest amounts of electrical current. As I've mentioned previously, it only takes 1 milliamp of current applied for a sufficiently long period of time (seconds) for the myocardial cells to reach threshold and fire haphazardly, creating ventricular fibrillation.

So to see this guy climbing on to high-voltage power lines from a helicopter and not fibrillate his own heart is a wonder to behold, indeed:



-Wes

First the Residents, Then the Attendings

Residents have such long work hours! I fully support residents only having to work 56 hours a week:

Last week several groups, including Public Citizen and the American Medical Student Association, along with leading medical researchers, petitioned the Occupational Safety and Health Administration to step in and limit the number of hours that physicians-in-training can work. They contend that shorter hours will protect patients as well as the doctors' own health and safety.

Resident physicians should have work limits to reduce mistakes caused by fatigue, just as the federal government restricts the time spent working for employees in aviation, railroad, maritime and highway transportation jobs, according to the advocates.

The groups want OSHA to require that hospitals record and retain the work schedules of residents and fellows and that the agency conduct surprise inspections, establish confidential whistle-blower procedures and levy fines for violations.

Responsibility for regulating and enforcing work hours for resident physicians now falls to the Chicago-based Accreditation Council for Graduate Medical Education.

I say, go for it!

Then make sure attendings get the same treatment.

After all, we know medical issues only happen during the day. As you can plainly see, as we extrapolate these same workplace restrictions to attending physicians, nurses will risk being in violation of OSHA regulations if they call us after hours!

Perfect!

No, more late night interruptions of my sleep cycles. No more weekend call! Patient's won't suffer a bit! Even they'll get more sleep! See how good this will be for everyone? Especially when we add tens of millions of more people to the health care ranks in 2014 - everyone's going to LOVE the hours!

Really. I'm likin' this!

-Wes

Tweeting Your Own Heart Attack

It's funny, until it's not:

Opportunity + Instinct = Profit. A good journalist can sense the moment that a story is developing and seize the moment. That’s why when White House correspondent Tony Christopher started having a heart attack, he immediately logged into Twitter and started covering it:

Approximately at 6pm on Sunday afternoon Christopher wrote, “I gotta be me. Livetweeting my heart attack. Beat that!” Presumably a few minutes later the paramedics arrived to tell Christopher he will be stable after his crisis.

An hour later Christopher joked about needing to own a cardiac cat, referencing a viral video in which a cat is trying to revive his dead feline friend. He also updated his followers about the pain he was feeling, “even after the morphine.”

So is this the message the White House wants sent to America?

Seems to me his time might have been better spent on (1) taking an aspirin, (2) calling 911, and (3) calling a friend, (4) and assembling a list of his current medications and past medical history for the doctors in case he loses consciousness.

But that's just me...

-Wes

Tomorrow's News

Tomorrow marks the day that $125 million in ad spending will commence to convince folks they really DO like the new health care reform law recently passed.

With that kind of government and special-interest spending, it looks like direct-to-consumer Viagra ads on the Nightly News will seem be a bit, er, limp.

To kick things off, a pro-Dem group will air a $2 million dollar ad campaign touting the law's benefits:

"The ad campaign launching Wednesday will focus on the theme “Not Anymore,” showcasing how health reform combats existing insurance practices. The ads will highlight the industry reforms coming online Sept. 23, such as provisions that bar insurers from denying coverage to children younger than 19 who have pre-existing conditions.

“The idea is you don’t have to worry about the stability of your coverage anymore,” said Health Information Campaign communications director Erikka Knuti. “These are all things that you don’t have to be concerned about now with the new law.”

And yet this ad campaign will fail to mention what the health care law has already done to insurance premiums:

Health insurers say they plan to raise premiums for some Americans as a direct result of the health overhaul in coming weeks, complicating Democrats' efforts to trumpet their signature achievement before the midterm elections.

Aetna Inc., some BlueCross BlueShield plans and other smaller carriers have asked for premium increases of between 1% and 9% to pay for extra benefits required under the law, according to filings with state regulators.

These and other insurers say Congress's landmark refashioning of U.S. health coverage, which passed in March after a brutal fight, is causing them to pass on more costs to consumers than Democrats predicted.

Look, as one much more astute health care policy analyst has noted, you can't have your cake with insurance for millions more beneficiaries and and eat it too with lower costs, no matter what the politicians and advertisers would like us to believe. Oh sure, we can work to cut waste, and that always helps to cut costs, but how long has Medicare been existence without an ability to prevent such fraud in a meaningful way?

There is no place is easier to hide money than in a bureaucracy - just ask Don Berwick, our now head of CMS, who managed to receive over a whopping $1.4 million (Source, IHI's most recent Form 990) toward his retirement in just six short years from sources with interests in health care that he recently refused to disclose to the Senate Finance committee chairman.

See how technicalities can play to your favor in governmental bureaucracies?

No matter how we cut this, the lack of financial transparency, governmental and special interest inner-dealings, and political side-games spell disaster for this new law's ability to control health care costs and we haven't even gotten out of the gate.

And all the advertisements in the world will not change these sad facts.

-Wes

References:

Senator Grassley's letter to Dr. Berwick
Dr. Berwick's response to Senator Grassley

What's a Cardiologist's Favorite Food?

Why, deep fried butter!

-Wes

Lessons

It was the start of a new month.

A new academic year with a new batch of fellows.

And a young man’s life was about to be changed forever.

“My father arrives here Tuesday and I might not be here that day,” he told me. I must have looked puzzled. “He’s coming from overseas.”

“That should be nice,” I said, trying to sound interested as I typed my earlier case’s orders, eyes fixed on the computer.

“We just found out that he has cancer.”

I stopped, looked up from my keyboard.

“What?”

“Lung cancer, squamous cell - already Stage IV. It’s so weird. One minute he has a little cough, goes to his doctor, gets a chest x-ray and has a huge mediastinal mass.” He stopped and tried to gather his composure.

“I’m so sorry. How old is he?”

“Sixty. Been healthy all his life. Doesn’t smoke.” He looked away.

“Take the month off if you need to,” I told him. “This can wait. Spend as much time with him as you need to – you’ll never regret it.”

“No, that’s okay…”

“I mean it. I had a similar circumstance with my father – had the luxury and support of my friends and colleagues and spent a much time as I could with him during his final days. We had a change to talk about lots of things and nothing, all at the same time. Sometimes I just sat and watched him sleep. I noticed little things, that I never appreciated before – like his hands – it was great just to be there. I realized those hands taught me a lot.

No doubt a successful doctor like you got where you are by his influence… Dads are important to sons.” I stopped, seeing him try to discretely wipe his tears.

Shifting, I asked: “Does he have insurance?”

“No. My wife and I will be self pay. She works. We’ll get by. What else are we put on this earth for anyway, if not for family…”

I listened. He went on with the details of his father’s visit that seemed so critical, at least to him: his father’s appointment schedule, possible treatment plans. But I could help but admire this young man’s resolve and commitment to his father.

“What else are we put on this earth for anyway… if not for family.”

I wished his father could have heard him say that.

-Wes

Take A Trip Down a Normal Right Coronary Artery

... courtesy of some cool video reconstruction:

UsefulProgress, a Paris-based startup, uses NVIDIA GPUs and CUDA technology to create stunningly detailed 3D stereo visuals like these from image sources such as X-ray, CRT and MRI.

-Wes

Is America Losing It's Innovative Edge in Cardiology?

Some interesting observations from Larry Husten, editor of Cardiobrief.org, who attended the European Society of Cardiology (ESC) meeting this week:

While many observers of the AHA and the ACC (including myself) have been critical of the close relationship of these organizations to industry, it is clear that the ESC has a much cozier relationship with industry than its US counterparts. Here’s one way this could impact attendance: a substantial percentage of ESC attendees have their travel and registrations costs paid by industry. To the best of my knowledge this type of wholesale support no longer occurs at US meetings, though I believe that foreign doctors often have their trips to ACC and AHA organized and paid for by industry. The ESC estimates that about half of all “delegates” receive financial support for attendance, but doesn’t know what percentage of that comes from industry as opposed to support from universities or other nonprofits. But it seems likely that this support may well play an important role in the rise of the ESC.

But there are other challenges that face US investigators. The fact that the path to regulatory approval is much longer in the US than Europe is lost on no one in industry. As a result, new innovative technological and medical trials are increasingly not only migrating outside of the US for their tests runs, but increasingly are being conducted primarily outside the US. This leaves many large American academic centers scrambling for tidbits from industry to fund their existing research infrastructure. (Some companies have capitalized on this hunger for cash by offering post-market studies with rosy financial incentives in an attempt to gain product market share, only to find some quickly become subjects of whistleblower lawsuits.) This same hunger for cash has increasingly converted once happy researchers with "protected time" to unhappy clinicians with productivity quotas as the financial noose is tightened in many research centers.

America still has fine institutions and creative thinkers, but the fiscal challenges of our health system, current health care recession, and regulatory climate make the promise of speedy innovation in America more limited than anytime in our history.

-Wes

HRS Survey: Our Most Current EP Workforce Assessment

From the most recent Heart Rhythm Society Electrophysiology Workforce Survey (pdf), co-authored by yours truly:

The median work week for physician respondents was 60 hours, with 41% of physicians working 50–60 hours per week and 29% working 61–75 hours per week. There was no significant difference in work hours based on a physician’s credentials, demographics or geographic location. Age was only a differentiator for people older than 65 who have trimmed their hours to 40–50 hours per week. For every respondent age-range queried, the volume of work over the next five years was expected to increase. Of respondents over 60 years of age, 23% expect to retire in the next five years.

Lots of interesting stats, but the data in this survey were collected well before our new health care reform had passed.

-Wes

Link to the HeartRhythm article.

Warning: Nipples Conduct Electricity

... and plugging them into the wall is not advised:

Last March, Kyle Dubois, 18, put an alligator clamp on one of his nipples, with a classmate placing the clamp on his other nipple, while a third classmate plugged the cord into the wall.

For three seconds, Dubois endured the electrical shock, dropping him to the floor and stopping his heart, the New Hampshire Union Leader reported.

Wow! This certainly sounds more exciting than what we do in EP labs with 9-volt batteries!

-Wes

Update: The video.

The Scarlet Letter

... if you need a pacemaker or defibrillator as of 1 September 2010 in Illinois:



(Like UnitedHealthcare patients were so easily identifiable...)

-Wes

PS: Who will have the first pacemaker or defibrillator denial? Share your stories in the comments!