How Nurses Deal With a Heart Attack

... on one of their own:

Although the EKG told a different tale, Glowacki felt well enough to call her husband and explain to him she was having a heart attack.

"My fellow employees were just looking at me going, 'You don't look like you're having a heart attack,' " Glowacki said. "I said, 'I don't feel like it,' and they said, 'Get off the cell phone.' "

Good idea.

-Wes

The Importance of Our Health Care Myers-Briggs

With all the talk about special interest groups in health care reform, there is another force afoot that is much more influential: psychologic interest groups. Here I take a rough stab of characterizing those I've noticed in our ongoing health care debate:

The Libertarians (L)- "Let the Market Sort It Out"

Characteristics of this psychologic construct include:

• Free market sunny optimism
• Faith in human nature, against all odds
• Competition will assure price controls
• Complete denial of the human frailty and greed
• Cynical about humanitarianism

Fairy Tale Believers (F)- "I'm not comfortable with anyone going without anything"

• Insist on fear-based appeasement: if you don't give them what they want, the peasants will come knocking at your door.
• Secret elitist belief that I'll get what I want anyway
• Infantile inflexibility to alternatives from their beliefs
• I'll-hold-my-breath-until-you-cry-uncle form of debate
• Discomfort with their own aggression or shadow side
• Politically active

Distrustful (D) - "No stick is big enough"

Characteristics of this psychologic construct include:

• Aggrieved, victim mentality
• Some history of real inequities or being disenfranchised which colors all perceptions
• Safety first - no quality control will ever be enough
• Doctors are greedy and will work best a pernicious, punitive environment
• Group oversight is superior to individual oversight
• There can never be enough bean-counters
• Politically active - often protest marchers

Alfred E. Neumann (A) - "What Me Worry?"

This group never has health care issues until they do. Characteristics include:

• Immature, emotionally unmodulated
• Extreme anxiety/neediness in the hospital but complete denial when they hit the exit door.
• Discussions of doctor availability are of no relevance until they are pressing the nurse call button
• Politically inactive, rarely vote

So, which are you?

To date, many doctors have lived in our own fairy land when it comes to health care policy. We have preferred to insist that human beings will think in a fair-minded, scientific, data-based manner. Who would have known that we should have had a psychology or marketing degree? Perhaps this is why the debate has become so divisive.

Unless we address these powerful, subliminal psychologies head-on, our influence on the larger social policies influencing health care delivery in the future will remain limited.

-Wes

The Invisible Two Percents

No one seems to mind two percent.

“Mrs Jones, you have a 98% chance of doing well with your surgery.” Most of us would leap at those odds when two percent is couched that way.

But like banking computers that round the penny in the bank’s favor, two percent can add up remarkably fast. Even worse, it's hard to track lots of 2 percents if they happen over and over again.

Now take a moment and think of all the places where the government has decided to withhold two percent from physicians lately:

“EPs (eligible professionals) who do not demonstrate that they are meaningful users of certified EHR technology will receive an adjustment to their fee schedule for their professional services of 99 percent for 2015 (or, in the case of an eligible professional who was subject to the application of the payment adjustment under section 1848(a)(5) of the Act, 98 percent for 2014), 98 percent for 2016, and 97 percent for 2017 and each subsequent year.”

“CMS Electronic Health Record Incentive Program Final Rule,” Federal Register, 28 July 2010

“Beginning with the 2010 eRx Incentive Program, a group practice may also potentially qualify to earn an eRx incentive payment equal to 2% of the group practice's total estimated Medicare Part B Physician Fee Schedule (PFS) allowed charges for covered professional services furnished during the 2010 eRx reporting year based on the group practice meeting the criteria for successful electronic prescriber specified by CMS.”CMS eRx Incentive Program

“Eligible professionals who satisfactorily report quality-measures data for services furnished during a PQRI reporting period are eligible to earn an incentive payment equal to a percentage of the eligible professional's estimated total allowed charges for covered Medicare Part B Physician Fee Schedule (PFS) services provided during the reporting period.

Below are the authorized incentive payment amounts for each program year:
• 2007 PQRI – 1.5% subject to a cap;
• 2008 PQRI – 1.5%;
• 2009 PQRI – 2.0%; and
• 2010 PQRI – 2.0%.
(Note that these “incentives” are actually withheld by CMS until they are “earned” back)

Physician Quality Reporting Initiative

With each of these incentives comes ghastly and nearly uninterpretable governmental paperwork requirements to retrieve all those 2 percents. Take, for instance, this detailed example of the form that must be completed to recoup 2 percent (90 cents!) of a single $45 office charge based on PQRI measures.

Oh. My. Goodness.

And tracking that "incentive" payment to assure payment? Best of luck.

The governmental two percents. Going… going… gone.

Over and over again.

That, my friends, is what doctors must now accept if they're going to survive in our new era of health care "reform:"

.. the invisible, burdensome, and untraceable two percents... all soon to be "bundled" away.

-Wes

Be Careful Out There This Weekend

... especially while driving. You never know when you might encounter a reluctant dragon:

This little guy was found roaming our halls.

-Wes

Today's Tie

Happy Halloween!

-Wes

P.S.: Remember to get those posts in for next week's Grand Rounds by midnight on 31 Oct 2010!

REPROGRAMU Results Released

PRESS RELEASE – FOR IMMEDIATE DISTRIBUTION

Chicago, IL – 29 Oct 2010 (AP): Results of the three-year REPROGRAMU trial (Realtime Evaluation of Physician Reactions to Organized Group Affiliations and Meaningful Use) were released by Dr. Benditt Throckmorton, MD, noted board-certified psychiatrist and principle investigator of the trial. The trial studied 3142 physicians’ attitudes regarding the implementation of “corporate group think” and a newly developed prerequisite called “meaningful use.”

“I was surprised to see how many doctors no longer feel meaningful,” said Dr. Throckmorton. “Depression, anxiety, and psychotic measures were at an all-time high as doctors searched for the cause of their ennui,” he said. When asked why this might be, he noted that while this was only preliminary research, the requirement to feel “meaningful” by e-prescribing, addressing quality measure checkboxes that pop up unrelated to the patient’s complaints, handing them a piece of paper they throw away, and reporting their patient’s race to the government might result and the “pile-on” of potential patient dissatisfaction scores that might result from NOT attending to their patient’s needs. “When the government comes first, it’s hard for doctors to feel meaningful for the care they provide,” he said.

Thankfully, it seems there might be help on the way. “We’ve found that forming Meaningless support groups really helps,” Throckmorton said. He also noted that recent preliminary studies have also found that “low-T” might be contributing to the condition. "It seems the symptoms of Meaningless Use Syndrome (lack of libido, lack of energy and enjoyment of life, and reduced, um, ‘height’) are similar in both conditions,” he said. “Our ongoing ‘T for TWO’ trial performed with Solvay Pharmaceuticals should help answer this question. If we find they correlate, then perhaps just a small injection will help male AND female physicians feel more meaningful soon.”

* * *

-Wes

Twice Shocked

It was a beautiful time of day - early evening as the sun was setting. She has just turned sixty and traveled south to visit her 39-year old daughter in a warmer climate. Both had decided to go swimming at the local pool early one evening. The water was perfect: not too warm and not too cool. The clear blue water was made more inviting by the pool lights that illuminated the swimming lanes. Most of the people were packing up to head home at the end of the day, offering her an opportunity to go some extra lengths to improve her endurance.

It had been eleven years since she had received her first defibrillator for a rapid, life-threatening heart rhythm that had unveiled her weakened heart muscles to doctors. By now, she had grown accustomed to its presence - only bothered by the occasional follow-up visit to check its functionality.

Her strokes were long and regular as she swam and for a while, she picked up the pace a bit to test herself. Not long thereafter, she grew tired and decided to rest at the deep end of the pool before finishing the last half-lap back to the shallow end.

She swam up to the wall and pulled herself up a bit and rested her arms across the cement and rested her head on her arms. With that, she noted she suddenly could not move, her arms locked in place as a tingling sensation coursed through her body. Try as she may, she was unable to move. The seconds seemed like an eternity. She thought, "This is it. I'm doing to die."

Suddenly, a huge jolt coarsed across her body that threw her from the pool's wall into the deep water and caused her to cry out involuntarily. Her muscles, fatigued by their prior capture, were of little use as she struggled to breathe. Her poolside daughter, turned to see her mother disappear below the surface of the water. She jumped in and swam to her, pulling her to the shallow end of the pool and eventually to a neighboring chair. Slowly, after both had regained their strength, they pondered the circumstances but quickly dialed 9-1-1 and pleaded for an ambulance to come as soon as possible.

Later, in the emergency room, her defibrillator was queried and the following noted:

PROGRAMMED SETTINGS
(Click image to enlarge)

RR INTERVAL PLOT OF EVENT
(Click image to enlarge)

RECORDED DEVICE ELECTROGRAM FROM THE EVENT
(Click image to enlarge)

At this point, it became clear what had transpired: she had been electrocuted at the end of the pool. It seems she came in contact with the pool light's cover as she rested her arms the the pool's edge. Her implantable cardiac defibrillator, detecting the electrical current in its circuitry, did what it was programmed to do when non-physiologic signals are detected on its lead: shock her to restore her rhythm back to normal. And yet as seen by the electrograms from her device, her rhythm was normal at the time and the device had detected the noise from the alternating current coursing through her muscles, causing the device to fire. By that very action, she was thrown far enough away from the current source to escape the deadly grasp of the myoclonic tetany caused by the electric current.

I'm not sure I have ever seen an electrocution stopped by a defibrillator before.

A call was made to the pool operators later the same day as the incident occurred. The pool was closed and the pool's electrical systems inspected. It was later that she learned that the pool's lights had been changed the day before and a grounding wire to the light had became disconnected, resulting in the leak of current to the light's metal housing. The pool has now been re-opened, rendered safe by the county's electrician just in case anyone else without a defibrillator would like to take some laps.

-Wes

(Story retold with the patient's permission and edited for effect)

Pumpkin Envy

There's more where that came from here as well as a tutorial from artist-sculptor Ray Villafane.

Incredible.

-Wes

Heart Rate Variability and the Financial Markets

... it seems in both, lack of variability can lead to death:

Given the above information, one may conclude that we are currently on the verge of the stock market equivalent of "sudden cardiac death", but that's not entirely accurate. Although the dominance of HFT in the market has helped destroy healthy variability, it is not the root cause of systemic instability. That designation is more appropriately reserved for the decades-long credit (complexity) bubble which has ensued all around the world, but especially in the United States.

The reality is that the "critical point" for U.S. financial markets was already reached in 2008, and as most Americans are aware, the markets almost died back then. Cue the federal government and federal reserve, which provided trillions in "liquidity" to artificially create the variability that had been lost. The politicians and central bankers would like to think of themselves as the defibrilator that has sparked the financial "heart" back into a healthy rhythm.

However, that analogy is simply not accurate, as evidenced by the current equity market's painfully boring microstructure. They are more like the artificial respirator that is keeping the brain-dead markets "technically" alive. Their tireless efforts are simply masking the terminal reality that lies underneath, and now we're all just waiting for someone or something to finally pull the plug.

My 401K can attest to the accuracy of this analogy.

-Wes

More EP Woo: The Hill Gets Duped

Politics and medicine shouldn't mix.

To prove the point, The Hill recently ran a story reviewing a study that suggested that cell phones may cause heart irregularities.

Little did they know that the "study" is nothing more than a re-hash of the author's concocted "electrohypersensitivity syndrome" that I de-bunked earlier in November, 2009. Seems these guys can't get enough of their fear-mongering tactics.

Note that the current 23 October 2010 press release claiming "new research" that was "just published" in the obscure print-only Italian journal European Journal of Oncology uses the exact same data graphs they used in their earlier 'work' in November, 2009.

Geez.

-Wes

Addendum: "Electrohypersensivity syndrome" link fixed.

Election 2010: Dr. Wes to Host Grand Rounds

In just eight short days America will head to the polls to vote for their favorite midterm candidates. In the next six short days, you can have an opportunity to tell your candidates what you think of health care today.

That's because yours truly will be hosting the Election 2010: The Politically (In)Correct Edition of Grand Rounds. Think "Indecision 2010."

But before you Tea Party and Coffee Party candidates "tea" off on each other to bring the world the best of the medical blog-o-sphere, please realize there are carefully crafted ground rules for engagement.

So if you want to be included, send me your most politically incorrect OR (if you must) politically correct blog post title, it's URL, and the STATE (OR COUNTRY) YOU REPRESENT. Send your "candidate entries" to wes-at-medtees-dot-com and include "Grand Rounds" somewhere on the subject line (otherwise, your entry might be classified as political porno spam).

Be creative. Make a statement. Don't be shy. Write like your political career depends on it!

The most PG-13 or R-rated politically-incorrect entries (think: a whole new way to take back medicine, weird cases, radiology of sex (good Sitemeter candy) - those types of things) OR best of class of politically-correct entries (patient care experiences, teachable moments) will receive top billing. "Do-gooder" entries like healthy eating or living tips need not apply (this is politics, remember - IT'S ALL ABOUT ENTERTAINMENT VALUE!).

Entries must be submitted by 23:59 pm on 31 October 2010 (yup, Halloween evening) to be considered.

See you at the polls!

-Wes

Accountable Care Organizations: It's So Sad, It's Funny

Thanks to Scott Hensley over at Shots, NPR's Health blog, for highlighting this sad, but funny, video on where we're going with health care:



Scary what happens when theory meets reality.

-Wes

The Empty Room

It stands as a monument to a bygone era; clean, quiet, spacious. Mail cubbies adorn the wall with hundreds of names beneath each one - most with dust, but a few contain a few pieces of multi-colored papers within. A bulletin board sits on a wall with skewed notices of a car for sale, a house to rent, or an upcoming meeting - hoping, somehow, that someone will take notice. In the back, an oversized coffee pot sits with day-old coffee and a few styrofoam cups where once there was a fruit basket, granola bars, yogurt cups and collection of pastries. A few lockers have padlocks, but whether they are opened any longer is uncertain.

A desolate expanse. If a breeze blew, you could almost envision tumbleweed passing.

It's just not he same anymore in the hospital's Doctor Lounge.

-Wes

Al Gore Speaks to Cardiologists

... and explains the relationship of the heart to the earths "hydrology" while in India:

As he addressed the gathering predominantly of doctors, especially cardiologists and cardio-vascular specialists, the 2007 Nobel laureate sought to see similarities in the role of the heart in the human body with the hydrological cycle of the earth. Just as the heart's regular beating helped in the distribution of blood to the various parts of the body, water moves through processes of evaporation, condensation and precipitation to return through rivers and streams to work its way back to the ocean, he said.

Might he be implying that the heart's metabolic activity is responsible for global warming?

-Wes

Finally: Dabigatran - A New Oral Anticoagulant is Approved by the FDA

A new era of non-valvular atrial fibrillation management has arrived.

Today, the FDA approved the first new anticoagulant in fifty years, dabigatran (marketed by Boehringer Ingelheim Pharmaceuticals Inc. under the trade name Pradaxa®) for stroke prevention in patients with non-valvular atrial fibrillation. The move was widely anticipated after the drug's unanimous 9-0 FDA advisory panel recommendation for approval a month ago. The drug will be available in 75 an 150 milligram dosages and is taken twice daily.

Patients at high risk of thromboembolism from non-valvular atrial fibrillation are candidates for the drug including patients with previous stroke or transient ischemic attack, a left ventricular ejection fraction of less than 40%, New York Heart Association class II or higher heart-failure symptoms within 6 months before screening for the medication, and an age of at least 75 years or an age of 65 to 74 years plus diabetes mellitus, hypertension, or coronary artery disease.

Patients who should NOT receive the drug include patients with the presence of a severe heart-valve disorder, stroke within 14 days or severe stroke within the last 6 months, a condition that increases the risk of hemorrhage, a creatinine clearance of less than 30 ml per minute, active liver disease, or pregnancy. Patients taking quinidine should also not take the medication because of a significant drug interaction.

The drug does not typically require measurement of blood thinning levels (prothrombin times expressed as and international normalized ratio (INR) of clotting time to a standard clotting control).

The approval was based on the prospective, randomized RE-LY trial recently published in the New England Journal of Medicine that compared the safety and efficancy of two doses of dabigatran (110 mg and 150 mg twice daily) to conventional warfarin (Coumadin®) therapy in 18,113 patients:

Rates of the primary outcome (stroke and systemic embolization) were 1.69% per year in the warfarin group, as compared with 1.53% per year in the group that received 110 mg of dabigatran (relative risk with dabigatran, 0.91; 95% confidence interval [CI], 0.74 to 1.11; P < 0.001 for noninferiority) and 1.11% per year in the group that received 150 mg of dabigatran (relative risk, 0.66; 95% CI, 0.53 to 0.82; P < 0.001 for superiority). The rate of major bleeding was 3.36% per year in the warfarin group, as compared with 2.71% per year in the group receiving 110 mg of dabigatran (P=0.003) and 3.11% per year in the group receiving 150 mg of dabigatran (P=0.31). The rate of hemorrhagic stroke was 0.38% per year in the warfarin group, as compared with 0.12% per year with 110 mg of dabigatran (P < 0.001) and 0.10% per year with 150 mg of dabigatran (P < 0.001). The mortality rate was 4.13% per year in the warfarin group, as compared with 3.75% per year with 110 mg of dabigatran (P=0.13) and 3.64% per year with 150 mg of dabigatran (P=0.051).

It should be noted that the FDA did not approve the lower 110 mg dose of the medication.

The drug's most common side effect was dyspepsia (GI upset) but liver enzyme elevations were not any different than that seen with warfarin.

The questions now are two: (1) when will it be available and (2) how much will it cost?

Typically it takes about 3 to 6 months to finalize product packaging, labeling and distribution after a drug is approved (others may have info they can share here). As far as price - my bet is that it's going to cost about ten times that of warfarin - I'd estimate $6 to $9 per day (another author suggested the anticipated cost of dabigatran in the United States, as calculated on the basis of its cost in Canada, would be approximately $7,000 to $9,000 per patient-year (four to five times the cost of warfarin, despite the increased physician and laboratory costs required to monitor the international normalized ratio [INR])). One researcher from the RE-LY trial countered:

It should also be kept in mind that total direct and
indirect costs for management of anticoagulation with warfarin far exceed the cost of the drug. In a recent study, the direct costs during the first year of nticoagulation with warfarin in primary care were calculated at Swedish krona 16,244, corresponding to U.S. $2,230. This does not include expenses to patients for travel to the laboratory, lost time from work, or an accompanying caregiver.

Given its cost, I suspect it will be hard for insurers to swallow this drug at first and coverage may not be immediately available, but hopefully the superior convenience and stroke prevention will justify the drug's initial price. Fortunately, other thrombin inhibitors will soon arrive to offer price competition to dabigatran's exclusive first-to-market reign.

-Wes

Addendum: MedPageToday: Dabigatran: The Case of the Missing 110-mg Dose

Healthcare's Facebook

This morning, the Wall Street Journal's front page story exposed a significant privacy breech of online personal information via the world's most popular social networking sight, Facebook:

Many of the most popular applications, or "apps," on the social-networking site Facebook Inc. have been transmitting identifying information—in effect, providing access to people's names and, in some cases, their friends' names—to dozens of advertising and Internet tracking companies, a Wall Street Journal investigation has found.

The issue affects tens of millions of Facebook app users, including people who set their profiles to Facebook's strictest privacy settings. The practice breaks Facebook's rules, and renews questions about its ability to keep identifiable information about its users' activities secure.

How could they? Imagine the nerve of marketers using Facebook ID's to develop profiles on people using little socializing games! Facebook has a privacy policy! I was assured that if I set my privacy settings to 'maximum,' this would never happen!

To which I say: "Duh!"

When it comes to money, people get awfully creative.

So while Facebook grapples with its latest public relations nightmare, we should realize our electronic medical record app vendors are doing exactly the same thing. Worse, it's perfectly legal, even though each of use has been assured our privacy settings are set to 'maximum' through the reassurances of the Health Insurance Portability and Accountability Act of 1996 (HIPAA) and the The Patient Safety and Quality Improvement Act of 2005 (PSQIA).

That's because Clause 4302 of our new Patient Protection and Affordable Care Act of 2010 (PPACA) dealing with "Health Disparities" mandates:

The Secretary (of Health and Human Services) 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) any other demographic data as deemed appropriate by the Secretary regarding health disparities.

Just like Facebook's apps that look for certain characteristics of social media games, patients with health "disparities" will be mandated by law to have their data transmitted to "the Office of Minority Health, the National Center on Minority Health and Health Disparities, the Agency for Healthcare Research and Quality, the Centers for Disease Control and Prevention, the Centers for Medicare & Medicaid Services, the Indian Health Service and epidemiology centers funded under the Indian Health Care Improvement Act, the Office of Rural health, other agencies within the Department of Health and Human Services, and other entities as determined appropriate by the Secretary."

Welcome to healthcare's Facebook.

In comparison, the open-ended phrasing of many portions of our new PPACA law makes Facebook's privacy issues look like chump change.

-Wes

On Call: The Accountable Care Organization's Case of Mistaken Identity

03:45 am - * bleeeep bleeeep bleeeep *

Pulling his head from the pillow, he fumbled for the pager. Reaching across the nightstand, the contraption is knocked to the floor, sending the device's holster skittering across the cool, dark floor. After a few expletives were uttered beneath his breath, he locates the black sleep-deprivation device and presses its button:

"888-555-1234 CARDIAC ELECTROPHYSIOLOGY ON CALL"

His heart sinks. "At least it's not the ER" he thinks.

He carries the cordless phone to the adjacent room in a futile attempt to avoid waking his wife and calls the number. A robotic voice on the other end answers:

"You have reached Cardiac Electrophysiology. Our office is closed. If this is an emergency hang up and dial 911 or you may leave a message at the tone to be handled the next business day. If you'd like to speak to the doctor on call..."

He hits zero to shut the robot up. Horrific music with some type of horn that sounds like it has been flattened squeaks in the background. He waits.

And waits...

Finally:

Good morning. Cardiac Electrophysiology. How may I help you?

"This is Dr. Fisher returning your page."

"Yes, doctor, let me look up the page."

The horrific music returns, then:

"The call is from Justaya Smith. She has a fever to 101. He said her doctor is Dr. Jones."

Confused, the semi-comatose duty physician wonders silently when his colleague, Dr. Jonathan Jones, cared a damn about someone's fever. Coming to, he asks:

"What's the patient's date of birth?"

"6/2/2009."

"You must have the wrong doctor."

"He said her doctor was Doctor Jones. Would you like their number or should I connect you?"

Realizing the futility of the situation, he states:

"Both, please."

"Thank you. Just a moment..."

Soon a man answers.

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

"Yes, thank you doctor. My daughter sees Doctor Jones and she's had a fever for the past five days. We've tried alternating Tylenol and ibuprofen, but her fever keeps coming back. This evening, she started to vomit..."

"Excuse me. Sir?"

"Yes?"

"I am the cardiologist on call, covering for Doctor Jonathan Jones."

"But my daughter's Doctor is Dr. Sally Jones. I don't need a cardiologist..."

"I'm very sorry sir. I think you'll need to call your doctor's office and have them contact the person covering for your daughter's doctor."

"But that's what I did!"

"I would suggest you call then again, but this time be sure to give them the first AND last name of your daughter's doctor ...

... Oh, and if you know your the date of birth of your daughter's doctor, you might want to give THAT to the answering service, too."

-Wes

Look! Up There! It's a Bird... It's a Plane...

... it's a mosquito heart!

Click image to enlarge

And to think how many times I've crushed this architecture with glee...

-Wes

"Um"

I never like to hear "Um..." from nurses or industry representatives during surgical procedures.

Most people think that the worst thing you could hear while undergoing a surgical procedure is "Oops..." or "Sh*t", but I would have to politely disagree.

You see, people working in EP labs and operating rooms never want to sound hysterical if they've recognized a problem during a surgical procedure. To do so might startle the operating physician and make them tense or angry. Instruments have flown for less.

So nurses and industry representatives are carefully trained to first say "Um..."

"Um, is his lead impedance always so high?"

"Um, is his blood pressure always 60 systolic?"

"Um, you wouldn't have connected the atrial lead in the ventricular port and the ventricular lead in the atrial port, would you?"

But savvy surgeons recognize "Um" and act quickly, politely stating the obvious:

"High impedance? Boy, those old leads don't hold up like the newer ones. Looks like we'll be placing a new one..."

"Sixty? What do you expect when they've been NPO all night? Could we start some dopamine, please?"

"Leads reversed? Just making sure you were awake..."

So beware of "Um" and for surgeons, be prepared to act accordingly.

-Wes

Quantity Versus Quality

Lately, I’ve been wrestling with an issue that I’m sure many bloggers face: should I try to increase the quantity of blog posts or accept a reduce number of posts in the interest of maintaining the quality (or, more specifically, the originality) of posts. Said another way: is it better to get a post up one or more times a day to drive traffic or is it better to get one really good post up less frequently?

Gosh, come to think of it, this same conundrum will soon pertain to health care delivery, too. Blogging and patient care are not too dissimilar.

When starting a blog, lots of posts placed very often helps drive blog traffic provided, of course, that the content is not just spam. Adding unique ideas or adding appropriate commentary to stories that appear on the web adds value for a reader and grows readership.

Likewise, when starting out as a new doctor you need lots of cases with good outcomes to develop a following. People have to get to know you. Volume of cases that go well builds trust amongst your peers. Early on you’ve got to get out there and develop a track record – how else will people know your talents?

And like the blog-o-sphere, as time goes on as trust is gained, friends refer friends. Things ramp up and you hit a stride and become more efficient - a well-oiled machine. It’s great.

But with this added volume come new issues. The pressures to produce more and more grows whether written or surgical. The potential to grow revenues with more volume in both fields exists.

That’s the reality in business-related ventures.

But in each of these endeavors, time remains the one constant. Eventually more of anything reaches its capacity, and whether blogger or physician, we all must make a choice: do I continue building quantity at the expense of the quality of my work? Clearly for me, the choice is no. Limits must be set lest my quality on either front suffer.

Lately, I am finding new patients are having a harder and harder time getting appointments with me. My established patients remain. Like a blog, I must make a choice - see more patients in less time, refer my established patients to others, or cut my volumes. Or maybe I should use physician "extenders" to help with me the load? Might they be like using ghostwriters?

In the years to come doctors will continue to be tasked with seeing more patients in less time with a constant pressure to reduce costs to the system (and hence, their salaries). You simply can’t add millions of more people to our health care system in our new era of “health insurance reform” and not expect that the demand for clinical care will diminish and the associated costs decline. As price pressures mount, the pressure to cut "overhead" expenses will grow and adding more expensive doctors to the system to offload the pressure-head will not be as simple as it sounds. So for now, our greatest challenge will be to see more patients in less time with less salary without affecting health care quality.

And the truth be told: like blogging, something has to give.

-Wes

Life and Death With an LVAD

Left ventricular assist devices (LVADs) are dramatically altering the field of heart failure care. There are pros and cons with the use of these devices, and this Reuter's article does a good job exploring them in simple terms.

Cardiologists need to become more familiar with these devices' limitations, too:

We have to address what is the meaning of death on one of these pumps," said Dr. Valluvan Jeevanandam, chief of cardiac and thoracic surgery at the University of Chicago Medical Center and an investigator for Thoratec's clinical trials.

Roughly 70 percent of patients on the HeartMate II were alive after a year, and nearly 60 percent were alive after two years, according to the latest data.

"It's not hard to imagine a person who has had severe stroke that has impacted both sides of the brain, the kidneys are shutting down, he is on a respirator, but yet the LVAD just keeps churning along," said Martin Smith, a clinical ethicist at the Cleveland Clinic.

Under U.S. law, patients are allowed to ask that implanted devices be turned off. But Dr. Diane Meier, a professor in the department of geriatrics and palliative medicine at the Mount Sinai School of Medicine, said cardiologists are particularly bad at preparing patients for death, especially this kind of death.

Like pacemakers and ventillators, these devices intervene on the natural course of the dying process and when the quality of life declines sufficiently after their use, it is ethical for patients and family members to request such support be withdrawn.

The challenge, of course, is what to do when these members of the care team aren't there...

-Wes

Un-Insurance Reform

Who doesn't need insurance reform? Why the insurers like Aetna, Cigna and BCS Insurance!

By threatening to raise health care premiums by 200 percent or threatening to drop coverage altogether, the companies got the Department of Health and Human Services to cave. Now the companies have our government’s blessing to continue offering “insurance” to their employees that is capped at a few thousand dollars per year instead of the $750,000 required in the health care law.

Perhaps Gruntdoc said it best:

"I am not an Obamacare fan, and would like it repealed, with smaller, more focused Bipartisan fixes, but if the government is going to pass something then roll over this easily to special interests… it’s already worse than useless."

-Wes

Duke vs UNC-Chapel Hill

The classic rivalry continues...

... especially for heart surgeons.

-Wes

My Epitaph

If fortune should have it that I receive a pacemaker, I think I want this epitaph on my grave:

"Gone to the dogs."

-Wes

Oncologists - We're Coming to Get You

... as cardioncologists.

Be afraid. Be very afraid.

This is what happens when they take our imaging payments away...

... we metastasize to other specialties and create our own international societies.

-Wes

Biotronik Responds to Europace Exploding ICD Case Report Article Withdrawl

Yesterday evening, I met with Rex Richmond (Vice President of Marketing) and Dan Schlewitz (Executive Vice President U.S.A. Sales) from Biotronik, Inc. to hear their side of the controversy surrounding the withdrawal of a case report previously published in Europace pertaining to an "exploding" Biotronik implantable cardiac defibrillator (ICD). They claimed they have been transparent regarding the reporting of this incident to the FDA, filing their incident report with the FDA within seven days of the event (within thirty days is required). Mr. Richmond granted me permission to release their internal company memo (pdf) circulated to their employees regarding the case report.

I must supply several comments.

First, regarding why the case report was withdrawn, they state in their memo:

The author reported that after submitting the case report to Europace in June, further analysis was conducted but not included in the original report. As such, there are inaccuracies that need to be corrected. Specifically, the author stated that the term "explosion" was not accurate given that the device was distorted, but had not exploded as previously described. The author also observed that while this is the first such incident with a BIOTRONIK device, it is not in fact the first experience of a battery overheating in the industry.

Note that the updated MDA was submitted to the FDA 6 June 2010. The published article was submitted to Europace 29 June 2010 and accepted after revision 16 August 2010. Wouldn't these "inaccuracies" have been corrected with the revisions submitted back to Europace following their review well before the 27 Sep 2010 publishing date?

Second is the issue of FDA reporting mentioned in the memo:

Where do reports like this end up? Aren’t they public?

Yes, they do become public. The FDA posts MDR’s to their online Manufacturer and User Facility Device Experience (MAUDE) database at the following address:

http://www.accessdata.fda.gov/scripts/cdrh/cfdocs/cfMAUDE/TextSearch.cfm

(ed: Emphasis mine) Although the FDA has our MDR, it has yet to be posted to the database.

I do not know why the FDA would not have published the MDA's received in May with revisions in June on their website by 31 August 2010 (August data appear to have the latest updates available online) if the original MDA was submitted in May as Biotronik suggests. Does it really take this long to review MDA's before they are published? It is one thing to verify an MDA from the public before publishing on the FDA MAUDE database, but a manufacturer's MDA regarding their own device should be published without delay.

-Wes

Reference: pdf of my personal copy of withdrawn Europace case report obtained online 5 Oct 2010 before its withdrawl with timeline of the article's submission/revision dates.

CORRECTION - 12:55pm CST 12 Oct 2010: Here's a link to the FDA report regarding this incident filed on the FDA's MAUDE database. I apologize for the inaccuracy.

Addendum 09:45 AM CST 12 Oct 2010 - Reactions from around the web:

Cardiobrief: "The Plot Thickens in the Case of the Exploding ICD"

Happy Hospitalist: "Exploding ICD Gets Biotronik Response"

Defensive Blogging

I woke early this morning with a pit in my stomach - a very familiar pit.

There's an old saying, "Fool me once, shame on you. Fool me twice, shame on me."

I'm not as dumb as I appear.

That's why, until I hear from the editor of Europace, A. John Camm, MD (whom I e-mailed last evening) about why a case report published in their journal and reported by me was retracted, I have decided to bring down my blog post. The case was about a recent Biotronik 340 VR-T implantable cardiac defibrillator (ICD) battery failure that ruptured the device, injuring a patient. In that post, I published a portion of the figure from the case report with a link citing the reference. The pictures were dramatic.

But like an X-rated movie, for some, they might be too dramatic.

That's why today I've decided to practice something I rarely do - defensive blogging - and brought down the post. The ramifications of those photos to the multi-billion dollar medical device industry were simply too compromising - for them and me.

Perhaps more importantly, we should ask ourselves how far we've gotten with the whole issue of device failure reporting to the public. Ever since the 2005 published report in the New York Times about Guidant's failure to disclose flaws in its line of Prism defibrillators, the industry has worked hard to improve its image on how adverse device events are reported. Large websites and complicated trade-marked systems have been put in place to better quantify when a device "advisory" should be issued to the public in conjunction with the FDA.

And now this - a horrible, unusual and exceedingly rare single case of an ICD battery failure from a device that was supposed to just sit there and prevent sudden cardiac death splashed all over the Internet.

Hard to put those pictures in perspective to the over 250,000 patients have had these devices implanted with numerous lives saved as a result.

You never hear about the saves.

But the real reason this case was so important is that we now see that one set of photos is probably worth thousands of safety databases and there's not too much any group of engineers or doctors can do to change that reality.

-Wes

My Professional Goals

"Keep 'em alive 'til eight-oh-five."

As a resident in medicine, that was our mantra. (We turned over our patients to the next on-call residents at morning report each day at seven AM). "Keeeping 'em alive" meant you were a capable resident. To not acheive this goal was a sign of weakness amongst our peers - a tongue-in-cheek way of ascerting your clinical acumen between peers - and it was the prevailing zeitgeist for training at the time.

And in some ways, it's not a bad goal to aspire to as a doctor.

Each year, we're all asked to decide on next year's professional goals that we'd like to achieve in the upcoming year. "They must be measurable," they say.

At first, I must say I flinched at this idea. My normally cynical and paranoid self immediately intuited where this was going - "won't be long before they tie my pay to whether I meet my pre-determined goals by next year."

But it might be valuable to consider one's goals in medicine. It helps us focus on what's important and what we'd like to achieve. Lots of tiny goals achieved by larger system goals possible.

But what goals might need to be considered when seeing patients and caring for the sick?

Is it to do more and see more people in less time, thereby helping more people?

Maybe.

Is it to grow your procedural volume?

Maybe.

Is it to arrive in clinic on time?

Maybe.

Or is it to enroll more research patients than ever before?

Maybe.

Or is it to stop and listen, hold more hands, and slow down a bit more?

Maybe.

Or to get home before 7PM each night?

Maybe.

Or make every meeting on time?

Maybe.

Or learn a new procedure?

Maybe.

What is clear is that many of these goals serve different masters. Each goal is critical to the master served.

But what stuck me with this exercise is that the family master and the patient master never ask for these goals to be articulated. Workplace goals are. As such, workplace goals will always get bigger over the years and have the potential to to supercede family- and patient-related goals.

My personal goal is to never let that happen.

-Wes

A Rare Case of a Spontaneously Exploding Defibrillator

Dr. Wes removed this post on 7 October 2010.

Why?

He was practicing a little Defensive Blogging.

The World's First Artificial Heart

Alexis Madrigal of The Atlantic displays some great pictures of the first totally artificial heart implanted 41 years ago.

To understand how far we've come, the newest devices being tested now are adapted left ventricular assist devices used as "destination" therapy that are about the size of a C-sized battery and are implanted entirely within the chest. The device is powered via a "plug-like" connection implanted behind the patient's ear. One such experimental device was recently implanted in a 15 year old boy with Duchenne muscular dystrophy in Rome.

-Wes

References:
Cooley DA, Liotta D, Hallman GL, Bloodwell RD, Leachman RD, Milam JD. Orthotopic cardiac prosthesis for two-staged cardiac replacement. The American Journal of Cardiology November 1969; 24(5), pp 723-730.

Farrar DJ, Bourque K, Dague CP, Cotter CJ, Poirier VL. Design Features, Developmental Status, and Experimental Results With the Heartmate III Centrifugal Left Ventricular Assist System With a Magnetically Levitated Rotor. ASAIO Journal
May/June 2007; 53 (3), pp 310-315.

Uh-"O"

... Saw a little tidbit, courtesy Sitemeter: it seems this blog was mentioned in "O" magazine as a "Four Doctor Blogs to Read Now", along with surgeon Jeffrey Parks, MD of Buckeye Surgeon, Lucy E. Hornstein, MD from Musings of a Dinosaur, and Kimberly D. Manning, MD of GradyDoctor.com.

Man, and I haven't even put up a post today...

Ouch!

(Welcome to all three of my new readers! Hope my sidebar samplings will do for now.)

-Wes

Health Care's Seismic Tremors

Today marked the official announcement that the 12-man cardiology group, North Shore Cardiology, will officially join NorthShore University HealthSystem on 1 January 2011.

In other words, they'll be employees of our large hospital system like me.

For long-term readers of this blog, most will recognize this as an expected result of our most recent health care climate change. These days with reduced payments for services and tests, paired with the threat of bundled payments for episodes of care around the corner, such a consolidation is a logical consequence for cardiology practices in large urban environments. Private cardiology groups have felt a particularly heavy blow to revenues after the government slashed payments for some diagnostic tests nearly 40% since the first of the year (hospital systems were not affected to this extent).

For patients, they shouldn't note much difference, but referrals to hospital facilities will now be along hospital affiliation lines, rather than patient geographical preference. Subspecialist referrals also might be a bit different, since subspecialist utilization will be along the lines of hospital affiliation as well. It will not be to the employee-cardiologist advantage to refer cases outside your own system since that would be like biting the hand that was feeding you.

There used to be some advantages to cardiologists to remain independent. For instance, they could advocate for greater roles on leadership in the hospital administrative levels or insist on better staffing for their patients by threatening to refer their patients to a competing health care system. But this method also used patient referrals as pawns in these political games.

No longer will that occur.

But doctors will increasingly find greater conflicts between the needs of their patients and the needs of their business-minded hospital employers. Their loss of independence will require they been seen as "productive" lest their salaries or jobs be cut. They are now dispensable workers rather than critical caregivers and entrepreneurs.

There is also the challenge of joining cardiology groups and maintaining a fair compensation arrangement. Hospital systems need skilled specialists and deals are always cut to consummate these unions. No doubt there was a long process of bargaining on both sides of the deal. For those already in large systems, they understand that they also are at risk as hospital systems look to thin their payroll overhead. Fortunately, the expected bolus of patients to the system in 2014 paired with the stiff competitive environment locally is likely to help deter physician layoffs in the near future.

But there are competitive advantages - a strength in numbers if you will - to having a solid group of cardiologists at your health center, especially ones based close to the hospitals themselves. It forms a formidable competitive environment for others who want to stake a claim to the geography inhabited by these doctors for they are the locals - well known by the community - and supplanting them will come with significant costs in terms of marketing and facilities to those who might desire to enter the area.

The seismic shifts in health care delivery are well underway - from ongoing practice consolidations like ours with larger and larger competing urban health systems, to McDonald's threatening to drop their "mini-med" insurance plans and Principle Financial Group exiting health insurance altogether.

It's going to be an interesting time, but one thing's for certain...

... resistance (at least for the forseeable future) is futile.

-Wes