Time in a Bottle

If I could save time in a bottle
The first thing that I'd like to do
Is to save every day 'til eternity passes away
Just to spend them with you.

From: "Time in a Bottle", by Jim Croce

Was it a day with you at Wrigley?
Or an extra day at the beach?
A chance to see a few more recitals?
A tack, a turn, or broad reach?

What will we miss, I wonder?
What should we have done?
Sorry, Superman was busy.
Sorry there was so little fun.

You see I used to save time in a bottle,
Time I’d supposedly earned.
But you can’t see time, now can you?
So, the rules were easily turned.

What comes now, I wonder.
When the grains of sand are lost?
What did we lose together?
What has it really cost?

There’s one sure thing going forward,
One particular thing I know.
Time stands still for no one.
So the bottle has to go.

-Wes

EKG Du Jour #21 - The Post-op Heart

Sometimes a case comes along that reminds you why this job is so much fun. Maybe it's the fact that not a lot of thinking is involved, or maybe it's just that you realize that, as a heart rhythm specialist, you think differently than others do. Whatever it is, I still find that human physiology remains remarkably interesting.

Take the following case:

A nice guy gets bypassed and is recovering in the Intensive Care Unit. Everything has gone as planned and his post-operative course has been completely uneventful. He is extubated post-op day one and is sore, but breathing fairly well, has a good blood pressure and urine output, and (most importantly) the ICU nurses are happy.

Until the following morning. Suddenly, he starts "throwing PVC's" and then, BLAMMO, this happens:

Click image to enlarge

The ICU nurse recognizes the rhythm and shocks the patient back to normal rhythm, the ICU intern starts Amiodarone and calls the cardiologist. The cardiologist recommends to pace the patient faster and call the EP to see what can be done to prevent this from happening.

You recognize the simple problem that took place and fix the problem.

What did you see and do?

-Wes

Non-Screen Time

Lately, like several times before, I have found it challenging to keep up with the demands of time this blog requires. In the hyper-speed world of electronic communication and the world's insatiable quest for new entertainment content, I find I need more non-screen time this time of year, especially now that the kids are home from school.

And yet, even though my hours in front of the screen have declined, time in front of patients has not. Call and work demands, staff and co-worker vacations, the end-of-the-year push for procedures as annual deductibles are paid in full, and the winter birds whose travel plans demand they get seen before heading South, continue to pull me from the kids. I guess it's the nature of what we do: the 90-year's pacemaker yesterday preempted my attendance at the annual Christmas pageant at church. I guess you could say we had our own pageant as we wheeled our nice lady into our lab. We prepped, we timed-out, we performed, we smiled, we bowed and went on our ways.

But we did it with our work families rather than our own.

By now, my kids have grown to understand this. They tell their friends why their Dad's not there, and the story still plays well amongst their peers: "Dang, your Dad does pacemakers?!?"

But I know quietly they had other thoughts: maybe hot chocolate or a Sunday breakfast after church? Or maybe a little more sleep would be nice. What do you mean clean up my room?

Thankfully, they did find time later to debrief me about the two lost black sheep amongst the sea of two- and three-year old white ones that were ushered down the aisle.

-Wes

St. Jude Withdraws Riata Defibrillator Leads

St. Jude Medical announced they are withdrawing a portion of their thinner 7Fr Riata defibrillator lead line despite earlier glowing company reports because of a higher degree of insulation failures in the earlier design of the leads made with silicone insulation material:

The Riata and Riata ST family of silicone defibrillation leads have exhibited an insulation abrasion rate of 0.47% over 9 years of use. Silicone rubber, while representing the industry’s most commonly used defibrillation lead insulation material over the past 20 years, has been observed to be vulnerable to abrasion. Abrasion of silicone defibrillation leads is acknowledged within the clinical community as a well known clinical risk and is well documented in the literature as the number one cause of lead failure across the industry with reported failure rates ranging from 3 to 10 %. Lead insulation damage and its possible effects are also described as a potential adverse event in all silicone defibrillation lead user’s manuals, including Riata User’s manuals.

Later St. Jude lead designs with their newer "Optim" polymer insulation appear to not be affected by this action. St. Jude had hoped their Riata line of defibrillator leads could replace the niche left by Medtronic's earlier withdrawl of their downsized Sprint Fidelis defibrillator leads after Medtronic's line of 7Fr defibrillator leads experienced higher-than-expected fracture rates.

Just as with the Medtronic Sprint Fidelis defibrillator lead withdrawl, St. Jude does not recommend the affected leads be extracted. I would suspect that doctors will weigh the risks vs. benefits of placing a new defibrillator lead at the time of device battery changes.

In November 2007, the Riata line of defibrillator leads were plagued by concerns of a higher-than-average rate cardiac perforation, but these were quickly disputed by the company.

-Wes

My Top Ten Blog Posts of 2010

It's always fun to look back and review the blog posts from the preceding year and pick a few that stood out for me. Clearly, not all are literary brillance, but they stood out nonetheless. From 2010:

Humor

(10) Swiss Call Girls Offer Full Cardiovascular Services

(9) 'Twas the Week Before School Starts

(8) Accountable Care Organizations: So Sad, It's Funny

Patient Care

(7) Preconceptions

(6) When the Doctor's Always In

(5) Twice Shocked

(4) Al Fine

Health Care Reform

(3) Our Health Care Happy Meal

(2) Our Health Care Reform Illusion

General

(1) Top Ten Reasons to Be A Doctor

Enjoy! (again)

-Wes

Grand Rounds Are Up!

Over at Dr. John M(androla)'s place:

Welcome to another edition of Grand Rounds, a collection of writings from medical bloggers, the world-wide.

Here are this week's posts, collated into four chapters, with just a little commentary and a few selected images.

Enjoy!

-Wes

Who Do They Think They Are?

Who do they think they are, those pesky judges who rule that those piddling, nagging, annoying rights of the individual matter? Who do they think they are getting in the way of grand sweeping visions?

But who they are is Americans. This is what makes America unique: the profound belief that the individual and their rights matter above the interests of the government. As messy and maddening as that may seem, it is, and has been, our strength as a nation.

I wonder if such a suit would have happened in any other country in the world.

Russia? France? England? Germany? Cuba?

Never.

Only in America the beautiful.

-Wes

Get $5 Off Medical T-Shirts Today

.... over at Cafepress's marketplace. (In fact, ALL shirts are $5 off today only) Just use code LRTXY99 at checkout. Offer good 'til midnight tonight.

-Wes

So You Want to Be a Clinical Investigator

Young doctors raised in the sheltered environment of hospital systems are finding the foray into a private practice setting increasingly anxiety-provoking thanks to the economic uncertainty of such a practice due to the recent health care reform legislation. Consequently, many are turning to clinical research as an alternative career path. But what does it take to become a productive clinical researcher?

Here are some points to consider:

1. First, think like a medical device company. By and large, companies are usually the ones funding the research. They want to save costs since many companies have limitations to their research budgets. Every step in clinical research, from the design of the trial to the support documentation and prototype patient consent form(s) should be carefully assembled to reduce delays in approval from an hospital's investigastional review board (IRB). Months of delays with IRB's can occur without this documentation and remember, time is money. An acceptable number of patients with the studied ailment must also be seen at your institution. For instance, if the trial requires congenital heart disease patients and your clinic only sees ten of these patients a quarter, you will probably find the trial will be completed before your center has an opportunity to enroll even a single patient. In return, you get nothing more than the enjoyment of completing tons of paperwork.
2. Make sure your center can afford the trial. All research centers require budgets. Most require an itemization of direct costs and then an overhead fee for "indirect costs" (think lights, heating, facilities charges, etc). These costs cut both ways: centers that have "indirect costs" that are excessive will never be approached by companies for research work (unless they are suicidal) and likewise, companies that don't offer some amount for these real-life expenses to conduct the work, shouldn't be performed at your center. Working out the budget needs BEFORE the research is submitted to the IRB will save countless hours of work in the end.
3. Learn to write. Most doctors are great at math and science, but far fewer are skilled at writing. The most productive researchers I have met are not only good doctors, but great writers as well. They can construct an organized research paper complete with a thorough literature review on their first pass. Learn this skill and you will be a highly sought-after researcher.
4. Be a cheerleader. Patients have to believe in the work and so do your referring doctors. If you can't articulate the importance of the trial to these folks, you'll never be successful. Also, since trials take time, keeping your trial at the forefront of your collegue's minds will be one of the toughest challenges that any young researcher will encounter. Other doctors will not have the passion or commitment for your work, so frequent reminders about your trial (along with follow-up on patients that are enrolled) will go a long way to improve trial enrollment. Again, time is money.
5. Be prepared to work after hours. The days of sheltered research time have long since passed. In today's clinical environment, you'll still need to see your usual cauldron of clinic and procedural patients, lest your clincal productivity (and maybe your salary) suffer. While some clinical trials can increase your clinic volume as patients are referred for evaluation in trials, this is usually not the norm.
6. Be timely at returning e-mails and phone calls.
Believe it or not, corporate time is just as important as yours.
7. Be transparent. In today's world, it is not okay to keep your relationships with a device company private. Tell everyone what you're doing and how much you make doing it (they'll find out anyway). If a speaking or consulting junket sounds too good to be true, avoid it. Sticking to this advice will help keep your clinical research career not only viable, but fruitful, for years to come.
8. Get help.
In today's regulatory environment, the number and scope of rules for research are greater than ever. Many centers have people that can help young investigators stay out of trouble. Find out who these people are and use them. Often.

-Wes

"This Is The Way It's Done"

Stephen L Snyder, attorney for Dr. Mark Midei, comments on the US Senate's Finance Committee's staff report (4.4 MB pdf file) of stent usage at St. Joseph Medical Center in Towson, Maryland:


-Wes

Defibrillators Make Top Ten Technology Hazards List

In a desperate attempt to reach an even number is seems, hospital defibrillators were added to ECRI.org's top ten health technology hazards list of devices that threaten to kill or maim patients:

The Top 10 Health Technology Hazards list is updated each year based upon the prevalence and severity of incidents reported to ECRI Institute by healthcare facilities nationwide; information found in the Institute’s medical device problem reporting databases; and the judgment, analysis, and expertise of the organization’s multidisciplinary staff. Many of the items on this year’s list are well-recognized hazards with numerous reported incidents over the years.

If one honestly looks at the number of saves versus the number of deaths from defibrillators, I wonder how many of this highly esteemed group of "multidisciplinary staff" of the ECRI might reconsider.

Clearly, most of them have never been in a code situation.

-Wes

h/t: Wall Street Journal Health Blog

How to Catch a Perp

... thank him for saving someone's life:

"He administered CPR until paramedics arrived and then left. We just want to identify him and thank him. It's nice to know that people are there to help."

Police released a photo of the man in the store.

But Wright said the man "also committed a crime at this convenience store, but we . . are not releasing any of this information at this time."

Gee, I wonder if he'll step forward...

-Wes

Preconceptions

One more to see after cases were completed. It had been a long day, and I was finding it challenging to summon the effort for one more case. I reviewed the chart. Her past medical history in the Electronic Medical Record read much like a Rorschach blot: ninety-one, uterine cancer, hysterectomy, colostomy, breast cancer, mastectomy, a digit had been amputated, hypertension, hyperlipidemia, recent stent. The medication list was complicated, but not incomprehensible - at least most of the drugs were familiar. I noticed that anti-platelet agents, but not anticoagulants, were part of the mix. "Fall risk," I thought. I braced myself for another hour's work, realizing the inevitable. What room was she in again?

The hall was bustling with activity as family members stood outside rooms discussing their loved ones, nurses skittered from room to room answering call lights and bed alarms. Patient transportation personnel were lifting the last patients of the day on to their neatly pressed bed linens, as they promised a rapid response from the dietary staff.

Her door was closed while most others were open. Why do a procedure on someone so limited? I entered and looked for the quick-wipe alcohol foam dispenser and squirted the foam in my hand, turning to see her. Startled, there was not one person there, but around the small intervening wall her husband could be found, too.

This was not a dismal, dreary place I had foreshadowed. Quite the contrary. I had interrupted the fiery proclamation emanating from the tiny frame lying in bed as she challenged her husband's desire for her to stay another night. "We'll discuss this later," she said, "the doctor's here now." She turned to me, smiling, "Yes?"

I introduced myself and explained the purpose of my visit. "Yes, yes," she said, fully comprehending the circumstances, challenges, potential reasons for her six readmissions in the last three months. She was sharp, engaging, a remarkably accurate historian - not at all what her Rorschach had predicted. She rifled through her own history, explained her symptoms concisely, and looked at me willingly: "Now, how soon can we get going?"

My Rorschach had spoken.

She was a simply a delight - a firestorm of personality and drive that even the most ardent supporters of the electronic medical record could never have predicted. It was then that I realized its stony information lacked her vision, her wit, her charm. Suddenly, her procedure made sense.

And so we proceeded.

And so did she, right out the door, just as soon as her 93-year-old husband would let her.

-Wes

Our Health Care Reform Illusion

The greatest minds are assembled to discern the answer in health care reform. Powerful interest groups are aligned to design solutions to protect their turf. Rubrics, formulas, slogans and taglines get designed, spun, pitched and thrown out. The burden of finding alignment, an answer, a plan that suits everyone seems insurmountable.

Unless we don’t.

The idea of a fit for all is an illusion. Justice and equity are seen differently. We imagine some public consensus at our own peril. But honesty has been in short supply. To paraphrase Oprah: what do we know for sure?

Some people want a relationship with a trusted doctor who knows them well. They want to pick the doctor, the neighborhood and the hospital they attend. Others want immediate access and have little trust or interest in a personal relationship with a doctor.

Some people want interchangeable access to medical care in the most convenient venue – they care little if it occurs at Walgreens, Doc in a box, by a nurse practitioner or by a newly minted resident – it is about access that fits their lifestyle – which may be at a late hour, and may be chosen by shortest waiting time at an ER. To others, this type of medical care is anathema.

Some people do not trust the medical field – they want oversight, monitoring, zero errors, and do not want to rely of a doctor’s judgment. They prefer rubrics, computer generated solutions and objective control. Others live in fear of losing the right to confer with their doctor as to his best judgment,, with freedom to choose treatment, medication and plans made between doctor and patient.

Some people expect to pay nothing for their health care – they want health care provided as a right, an entitlement, a government administered program that can never disappear. They do not want to have health savings accounts, worry about saving for care, or plan for medical expenses. Others are prepared to pay for the type of health care they want and when they want it. These people would rather have choice and control over the security of someone else being in charge.

Some people see health care as a chance to exercise equity and redistribution – the chance to level the playing field in health care delivery trumps the issues of rationing, waits, doctor availability or any other front line problem. Others do not support redistribution or using health care as a method of forcing equity in a country that has thus far been thought of as a meritocracy.

We will not find agreement. If there is one thing we can agree on – it is that.

What to do then?

Most obviously, a forced solution shoved onto an unwilling public is wrong. A government that takes a position to advocate for either side of the preferences and needs listed above is on dangerous territory. Can both types of health care exist? What would that look like? Or do we kill one in the race to get to the other?

Much of our current conundrum is a failure of courage. We know what we secretly believe but we are unwilling to say it. If we publicly endorse health care for all as a right, while privately planning on paying for our own special needs at a future date – we hamper any honest resolution. We need to be honest about what kind of a society we live in and how we see health care fitting in. Guilt, shaming, intimidation and fear are poor policy planners. How do we explicitly acknowledge the differing needs and plan for them without denial of either group?

We will not solve the issue of trust. We will not solve the issue of lifestyle, cost, access, convenience, or fear of fairness. We will not make all patients compliant, responsible for their own treatment, or responsible for their own expenses. We will not change human nature so that all follow medical plans religiously, or stop chaotic lifestyles or master self-destructive behavior. So we must acknowledge this directly as we design solutions – multiple solutions.

Our society in unique in honoring individualism, freedom and plurality. Can our solutions for health care tomorrow reflect this?

We are not there yet.

Diane Fisher, PhD
Wes Fisher, MD

Should Doctors Join Social Media?

The pros and cons of social media for physicians are nicely reviewed by a number of prominent medbloggers (including yours truly) by Bonnie Ellerin in her recent white paper (pdf).

-Wes

h/t: @hjlucks on Twitter via Smartblog On Social Media.

More on Biotronik's Exploding ('Venting'?) ICD

According to MedPageToday, it appears an earlier case report that was mysteriously withdrawn from the peer-reviewed journal Europace will soon be republished:

A controversial article about problems with an implanted cardiac device -- published by and then withdrawn from the journal Europace -- has been resubmitted and is under review, according to the journal's editor.

"I expect that a decision on publication will be made very shortly," John Camm, MD, of St. George's University of London, told MedPage Today in an e-mail.

Hopefully, the journal will explain why they failed to notify their readers about the withdrawl as well. To withdraw an article of such signficance to their readership without explanation should not be tolerated by the scientific community.

Several other issues:

1. Perhaps even more concerning this whole ordeal has been the FDA's management of the device report made to them in May. It seems public reporting of Biotronik's filing did not appear on the MAUDE database until after my blog post was published in October.
   
   If this is their policy to withhold reports in patients that are injured for this length of time irrespective of "cause," there are bigger concerns with the government's policies that should be immediately addressed.
2. I should also explain my rationale for my "defensive blogging" earlier, too.
   
   The Fair Use Act of US Copyright law has been a favorite place for malicious lawyers to attack bloggers who republish content in their blogs. Irrespective of whether or not one could defend their actions in the court of law on the consitutional basis of "free speech."
   
   But when challenged, as soon as a lawyer gets involved, thanks to the large costs involved, you've "lost" your case even before going to trial. I did not need that expense at the time, so I caved and withdrew the pictures I had published (note: they have since been republished on the blog Cardiobrief.org, courtesy of Google cache, but have included a pdf of my copy of the entire case report in this blog post).

-Wes

Specialists' New Game: Musical Chairs

The consolidation of physician specialty practices in to larger corporate health care systems in urban areas is creating a new challenge for today's doctors when the music stops: there might not be a chair available.

There are simply many fewer hospital systems in large urban areas than there are specialy practices, so the number of specialist positions a large health care system is willing to absorb might be limited. As doctors and hospital systems coalesce into as-yet-to-be-clearly-defined "Accountable Care Organizations," the cost of too many specialists in an organization is being carefully weighed.

This is playing out in our area as more and more cardiology groups join forces with hospital systems. The concern in some circles is what will happen to laggard practices in similar geographic locales. Will they be able to go it alone and refuse government payments for services? Will they have to align themselves with an alternate hospital system that might not be there first choice? Or might they just simply fade away as the specialists in these practices retire?

It's hard to know where this might sift out, but the construct developing suggests that certain specialty services might be even harder for patients to obtain in the years ahead.

But then again, that's probably been the plan of our new health care reformers all along.

-Wes

Co-Opting the History and Physical Examination

This week, new "performance" guidelines were published for adults with peripheral artery disease (or as one drug company brands it, "PAD.")

Interestingly, in explaining the rationale for these performance measures, these guidelines state:

Despite the overwhelming evidence that patients with PAD are at a markedly increased risk of myocardial infarction, stroke, and death, these patients are often undertreated, in that they do not receive antiplatelet therapy or statins with the same frequency as do patients with coronary artery disease (19).

Thus, these PAD performance measures are directed at strategies to improve diagnosis and treatment of patients with PAD with an overall goal of improving patients' walking distance and speed, improving their quality of life, and decreasing cardiovascular event rates.

And we should add, giving them appropriate pharmachologic and interventional therapy.

Fair enough.

But the guidelines push for the performance of an ankle brachial index, or ABI (a part of a thorough cardiovascular physical examination), in all patients determined on the basis of a questionnaire to be at risk for peripheral vascular disease. And they push hard, with statements simultaneously published the the Journal of the American College of Cardiology, Circulation, and reportedly also later in the Journal of Vascular Nursing, the Journal of Vascular Surgery and the Vascular Medicine Journal. The ABI is nothing more than a calculated ratio of blood pressures of the lower extremety systolic pressure divided by the upper extremity systolic blood pressure. A ratio of 0.9 or less is thought to suggest significant "PAD." To speed measurement of both arms and legs simultaneously, fancy new machines have been developed and costs about $75-110 to have performed by ancillary personnel.

Now don't get me wrong, I do think we can do a better job of detecting and treating peripheral vascular disease, but I have to ask several questions:

First, if "8 million persons in the United States are afflicted with PAD" and "the prevalence of PAD is approximately 12% of the adult population, with men being affected slightly more than women," how much will these screenings cost? Cost and the issues of dealing with false positive findings were part of the reason why screening EKG's were not recommended for all high school athletes in the American Heart Association's earlier guidelines. Should we not have a similar discussion for ABI screening?

Secondly, since when did we allow portions of the history and physical examination to be co-opted into billable procedures by professional organizations interested in promoting "quality care?"

How about a few more minutes in the exam room instead?

This is not just a rhetorical question any longer. Doctors are constantly being pushed by more and more "performance measures" to focus on things that might not have anything to do with the patient's chief complaint. Like bugs to a light, we are re-directed by these performance measures, soon-to-be mandated by Medicare, to direct our thinking away from patients toward the bureaucrats in the name of professional organizations' turf preservation.

Every screening measure amplified by millions of people has the potential to raise costs, not reduce them. And this era of a real need to significantly reduce costs of health care delivery, maybe we should have an honest discussion of the costs of these "performance measures."

-Wes

The Need for Doctors' Right To Investigative Free Speech

Imagine having a medical device that is being tested in multiple centers, but one doctor thinks the device has problems. He says so at a national conference despite glowing reviews by others. Should the company sue the doctor for liable and remove him from their investigative panel?

Today, it seems that might not be such a good idea.

This is, in fact, what NMT Medical did regarding comments made by Peter Wilmshurst, MD regarding NMT's patent foramen ovale (PFO) closure device called Starflex:

NMT sued Dr Wilmshurst for libel after he criticized its research at a US cardiology conference in 2007. The doctor vowed to take the case to trial in order to defend scientists' rights to free academic debate.

The company threatened Dr Wilmshurst with libel a second time for subsequent comments he made about the case on BBC Radio Four's Today programme.

"During the last three years, enormous pressure has been placed on my family and me from time wasted dealing with the case, money laid out for legal costs and interference with my ability to work and other activities," Dr Wilmshurst said.

"I'm concerned my case will have a chilling effect because other scientists and doctors will realize the enormous financial and time costs of speaking out about products and the risk of being sued by manufacturers."

For medical device companies that pay doctors as consultants, they have to be willing to have the knife cut both ways during clinical testing of their devices, regardless of the implications to their investors. Releasing an ineffective or defective product would be far more damaging to the company (and patients) in the long run. When concerns arise regarding the performance of a device, companies would be best served by providing additional data or additional independent reviews to support their claims rather than suing their own investigators.

-Wes

What WikiLeaks Means for Health Care Privacy

"By releasing stolen and classified documents, Wikileaks has put at risk not only the cause of human rights, but also the lives and work of the individuals. We condemn in strongest terms, the unauthorized disclosure of classified documents and sensitive national security information."

Official White House statement yesterday regarding Wikileaks disclosure of diplomatic cables

No matter what people think of Wikileaks disclosure of approximately 250,000 classified diplomatic cables to the Internet yesterday with the help of the New York Times, The Guardian, Der Spiegel, and Le Monde, the implications to electronic health care information security are significant.

Day in and day out, I type huge volumes of information on my patients on a computer and my fellow physicians do the same. As a result, vast health care information warehouses are at the disposal of the government, insurers, and major health care institutions eager to become more efficient, strategic, or competitive. We are promised the information is private, confidential, and even stripped of its identifiers for group analysis. It is even protected to remain so by law.

And now we find that even the government's most sensitive and classified diplomatic data is subject to disclosure, some how, some way.

Worse, once the leak occurs, the government is powerless to correct the breech.

While a single individual's private health care information may not carry the gravitas of wartime communiqués, each of us deals with famous patients who might not want their diagnosis, HIV status, or drinking history spread far and wide. For them, this private information might be just as personally damaging as anything disclosed by WikiLeaks.

Yet in our new era of the Electronic Medical Record and government funding of health care in America, we now find that this potential loss of our health care privacy is the price (and risk) for care we'll have to accept.

-Wes

A Free iPhone 4 Heart Rate Monitor

Hey, it's fun AND free!

Use your iPhone 4's camera to measure your heart rate. The application detects how the color of your finger changes when blood flows into it, much like the way a pulse oximeter works.

-Wes

Addendum 29 Nov 2010 06:50 am CST: Seems there's an app for Android phones too.

A Photo Documentary: Apple Turkeys

From our house to yours, a tradition for the kids' plates on Thanksgiving: apple turkeys!









Happy Thanksgiving!

-Wes

For Travelers This Holiday Season

Courtesy of Saturday Night Live.

-Wes

For Thanksgiving: Fat Wars

It seems the Washington Post, cloaked under an anonymous author, wants to use scare tactics to keep most of us from enjoying Thanksgiving with their ominously-titled article, "And for Dessert, A Heart Attack?" They spew all kinds of garbage about how eating a high fat diet might give you a heart attack with very little data.

If you want to know more, consider this reference from some pretty smart folks at Harvard.

Then eat, drink, and be merry without guilt (courtesy of Dr. Wes).

Happy Thanksgiving!

-Wes

Reference: Renata M and Mozaffarian D. "Saturated Fat and Cardiometabolic Risk Factors, Coronary Heart Disease, Stroke, and Diabetes: a Fresh Look at the Evidence," Lipids 31 Mar 2010.

Plenty to Be Thankful For

It's from an old post, but it's worth repeating:

I am thankful for the teenagers who are complaining about doing chores -- that means they are home and safe.

... for homework. It means we live in a country where education is valued and encouraged for all.

... for the taxes I pay; it means I have income.

... for the mess that I have to clean up after parties, because it means I am surrounded by friends.

... for the clothes that fit a little 'too snug' because it means I have enough to eat.

... for the lawn to mow, windows to wash and gutters to clean; it means I have a home.

... for the parking spot I found at the far end of the parking lot, because it means I am capable of walking and am blessed with transportation.

... for my huge heating bill, because it means I am warm.

... for the person behind me in church that sings off key, because it means I can hear.

... for the pile of laundry and ironing, because it means I have clothes to wear.

... for all the complaining I hear about the government; it means we have freedom of speech.

... for the alarm that goes off early in the morning because it means that I am alive!- Author unknown

And for those who can access Facebook at work (we can't), this week's Grand Rounds full of thanks is being held at Amanda Brown, DVM's Facebook page.

Happy Thanksgiving!

-Wes

TSA Security and Health Care

John Pistole, TSA administrator, acknowledged travelers' concerns about body-scanning machines that can see through clothing. He agreed that, to some, the pat-downs, which involve groin and breast checks, are "demeaning." But he said the policy is "not going to change."

Wall Street Journal, 22 Nov 2010

I read this article this morning and could not help but think: as it has been with TSA policy, so will it be with health care policy.

• The new policy for body scanners and pat-downs did not occur overnight - the new TSA policies were likely in the works for months behind closed doors - just like our health care policies eventually were.



• The public outcry over the new security measures didn't occur until the people were actually affected. Once that occurred, then came the recordings, the stories of exposed breast prostheses and ureterostomy bag disruptions in the main stream media. Even a rebellious movement to avoid the scanners and overwhelm the security personnel Thanksgiving weekend was mobilized. (Scores of news organizations are now trying feverishly to quell the uprising.)
  
  We have not yet seen the impact of 32 million or so new people entering our current health care system. Will stories of states closing their doors to Medicaid patients arise? What patient-related horror stores will we hear then? (My jaded eye suspects that, like the so-called "doctor (pay) fix," government will swoop in to provide states with funding and reassurance at the eleventh hour to avoid the impression that health care reform law would be perceived as causing fewer people to be covered, not more.)



• Whether change will happen to the security procedures as a result is anybody's guess. (My guess: the TSA administrator will fall back to public safety to justify the motive and no one argues that the skies are vulnerable, so (as he predicts) little will change.) If people are unhappy when the new health care law takes full effect, what uprising might occur then when the realities of the limitations to care provided kick in?



• At least the security policy as it pertains to pilots was retracted - probably because of union pressures. Will doctors need a similar negotiating voice in the future once they're all employees?



• The matters of security and health care are likely to remain divisive and the force needed to change the existing policies will grow more difficult. Like airplanes, people will have to accept waiting in line for health care soon - at least for the complicated, expensive and highly specialized things.

Oh, the times, they are a changin'. It's going to be interesting to see what transpires this Thanksgiving season in the airports and to ponder what it might mean in the years ahead for health care.

Once thing is for certain though: like flying, most of us will be paying much more for the pleasure.

-Wes

Get $10 Off MedTees

Five years ago, my wife and I started MedTees.com, a medical t-shirt web site that helps support a number of worthwhile charities and non-profits (the list of groups is found on the right-hand sidebar of the site's home page). The philosophy of the site is simple:

At MedTees.com, we pick up where diagnosis and treatment leave off. That is, what happens AFTER the dust settles and you go home and they CAN'T fix what's wrong or the fix is tough to live with.

Lots of folks have used these Medtees in creative ways. As a result, we have contributed nearly $10,000 to our charities and non-profits since we started. The holiday season is particularly important for that effort.

Beginning at midnight tonight (0001 am 20 Nov 2010) and continuing though midnight 23 November 2010, you can get $10 off any purchase of $50 or more by entering the code FRIENDS10 at checkout. The site is powered by Cafepress.com (we don't collect credit card information, they do) and they ship just about anywhere in the world.

So end this notice to friends and family, and if you have any new ideas for shirts, we're still accepting those, too.

-Wes

Ablating Hypertension

Refractory hypertension might be approached with radiofrequency catheter ablation techniques in the future, provided it's found the cure is not worse than the disease.

This week, the first non-blinded, prospective, randomized industry-sponsored Symplicity HTN-2 Trial of drug-refractory hypertension using endovascular low-power radiofrequency ablation within the renal arteries in 52 patients was reported. It is thought that this form of catheter ablation denervates the perivascular sympathetic innervation of the kidneys decreasing renin production and, therefore, blood pressure. (The guys over at Medgadget have some cool industry-sponsored pictures and videos about this technology). The ablation therapy in this trial appeared to carry promise at better blood pressure lowering compared to conventional medical therapy:

106 (56%) of 190 patients screened for eligibility were randomly allocated to renal denervation (n=52) or control (n=54) groups between June 9, 2009, and Jan 15, 2010. 49 (94%) of 52 patients who underwent renal denervation and 51 (94%) of 54 controls were assessed for the primary endpoint at 6 months. Office-based blood pressure measurements in the renal denervation group reduced by 32/12 mm Hg (SD 23/11, baseline of 178/96 mm Hg, p < 0.0001), whereas they did not differ from baseline in the control group (change of 1/0 mm Hg [21/10], baseline of 178/97 mm Hg, p=0·77 systolic and p=0·83 diastolic). Between-group differences in blood pressure at 6 months were 33/11 mm Hg (p < 0.0001). At 6 months, 41 (84%) of 49 patients who underwent renal denervation had a reduction in systolic blood pressure of 10 mm Hg or more, compared with 18 (35%) of 51 controls (p < 0.0001). We noted no serious procedure-related or device-related complications and occurrence of adverse events did not differ between groups; one patient who had renal denervation had possible progression of an underlying atherosclerotic lesion, but required no treatment.

This is an interesting study, but the long-term effects of this therapy to the renal arteries remains to be seen. The effects of low energy (6-8 watts of energy)applied over 2 min for each lesion will likely have variable effects at the tissue level.

Electrophysiologists have had a long history of experience with radiofrequency energy to ablate things. We have learned over the years that catheter tip temperature bears little resemblance to the tissue temperatures achieved. We know that low, long power applications make for larger lesions, provided tip catheter contact is stable. The low power applications used in this technology may have significant effects on surrounding tissues.

But we've also learned about the challenges with this technology inside vascular structures. We have learned (the hard way) about the development on intimal hyperplasia and later stenosis of vessels with radiofrequency ablation (in our case - pulmonary vein stenosis). If bilateral renal artery stenosis were to occur, how might the patient's blood pressure behave? Similarly, we have learned that stents placed in arteries cause inflamation and restenosis as well. Are we to think, naively, that inflamation inside renal arteries that have burn lesions applied inside them are more resistant to inflamation and later stenosis?

Hard to know.

Some protective effect against burns probably exists within the lumen of arteries thanks to the cooling effect of the brisk blood flow there. This convective cooling effect of the blood flow might be why these patients fared as well as they did while sufficient effects of heating occured in the outer adventitial layers of the renal arteries.

But there's also the question: what if it works too well? There are very effective treatments for patients with orthostatic hypotension (blood pressure that falls excessively with standing). It is interesting that one such patient was described in the USA Today article that covered this trial, but no mention of this complication occured in the peer-reviewed journal article published in Lancet which said:

Minor periprocedural events requiring treatment and possibly related to the procedure consisted of one femoral artery pseudoaneurysm that was treated with manual compression, one post-procedural drop in blood pressure resulting in a reduction in antihypertensive drugs, one urinary tract infection, one extended hospital admission for assessment of paraesthesias, and one case of back pain that was treated with analgesics and resolved after 1 month. Seven (13%) of 52 patients who underwent renal denervation had transient intraprocedural bradycardia requiring atropine; none had any sequelae.

No doubt a much larger trial will be forthcoming to evaluate these concerns. Still, this innovation might offer an interesting option for drug-refractory hypertension in the future but the jury's still out on it's long-term safety profile.

-Wes

Grand Rounds is Up

Kim over at Emergiblog hosts this week's edition of the best of the medical blog-o-sphere:

We’ll travel through the medical blogosphere of 21st century...

Enjoy!

-Wes

How It's Spun

I read this morning's New York Times article entitled "Mistakes Chronicled on Medicare Patients" and wondered what would this article be like if it was spun toward the positive, rather than the negative?

So I decided to write a different story based on the positive aspects of the government's data, rather than the former article's negative spin, just so we might consider our quality overlords' agenda:

US Hospitals Remarkable Achievements

Six out of every seven hospitalized patients over the age of sixty five receive remarkable care, according to a new study from the Office of Inspector General for the Department of Health and Human Services. The study said that despite the aging of the general population, their multiple medical problems, the increased oversight and regulatory burdens on today’s physicians, the overwhelming majority of patients who enter today’s hospitals receive exceptional care and can be expected to recover fully.

While there remains areas that we can improve clinically, we should not underestimate the remarkable achievements in outcomes of our patients with cancer, heart failure, pneumonia, and acute myocardial infarctions. “These common conditions occur is patients who are the sickest of the sick,” said Dr. Mortimer T Schnerd, study coordinator. “To achieve such progress in the fight against these diseases is remarkable despite the limitations of the imposed governmental quality measures. Patients today are living longer than ever before and typically present with co-morbidities during their hospital stay. All too often it seems the government quality oversight bodies are not happy with our successes. The seem to feel it's better to continue to expend innumerable resources to assure the unrealistic goal of immortality,” said Dr. Schnerd. “But then again, how else will they rationalize reduced payments for our excellent care to more and more people?”

Funny how we never hear how much money we expend on new hires and the total cost to hospitals for implementing quality measures as a counterpoint to the cost of errors that occur in today's hospitals (ie, the "value" to our health system that these measures represent). Recall that Mr. Berwick, our current head of the Center for Medicare and Medicaid Services, managed to skim $1,404,776 in retirement benefits in just seven short years above and beyond his annual salary from his Institute for Healthcare Improvement in 2008 - a quality managment organization. I dare say that's a sizeable amount for most mortal humans.

No, dear doctor, please don't mention this. That's too unseemly and isn't said in the name of quality care!

But to not mention the cost of implementing and maintaining quality measures dodges an important issue. Where should we draw the line in paying for quality measurement rather than spending that money on the frontline caregivers themselves?

-Wes

What Insurance Will Cost You in the New Era of Health Reform

Now that health care reform has passed, ever wonder how much you'll have to pay for health insurance if you carry no employer-based insurance in 2014?

I have spent some time entering sample scenarios to a helpful Health Reform Subsidy Calculator from the Henry J Kaiser Faimily Foundation. The calculator helps you understand the government subsidy you might acquire for insurance based on your income now vs. 2014, age, employment status, difference between a single person insured vs. a family of four, all adjusted with a regional 'cost factor' based on where you live.

Some interesting cut-offs were noted and I have highlighted a few examples using their calculator:

If a 30 year old man without employer-based insurance enters a government insurance "pool" and makes $15,302, then he will have his insurance paid my Medicaid and pay a "modest" out-of-pocket amount for coverage, depending on his state. If he makes one dollar more ($15,303), his premium will become $3,404 annually, for which the government will provide a tax credit of $2,981 and will require an unsubsidized payment from the patient of $459. This does not include an additional $2,083 of out-of-pocket expenses for health care used, resulting in a possible total cost to the individual of $2,542. (16.6% of his income).

If the same person is 49 years old instead and and makes the same $15,303, the premium rises to $6,717, but the government picks up a larger share so the unsubsidized payment for insurance remains $459 and the out-of-pocket expenses remain $2,083.

Now, if the 49 year old has to cover a family of four and makes $31,155 without employer-based insurance, he and his family will be covered by Medicaid. But if this individual makes one dollar more ($31,156), his premium for insurance will be $16,360 with the government crediting the individual for $15,425 for a total unsubsidized annual premium of $935. Out-of-pocket expenses for health care services for this individual and his family rises to $4,167 for a total cost of $5,102 annually ($16.4 percent of their total annual income).

Finally, if we take a person making $200,000 annually at age 49 who is has no employer-based insurance, their premium jumps to $16,300 annually with no government subsidy available and an additional $12500 in out of pocket expenses to be paid ($28,800 annually or 14% of their income).

What is clear is that health care is about to get MUCH more expensive for the majority of Americans, even those from the government's definition of "middle class."

Take some time and enter your information to see where you'll be under the new law when it takes effect. The results are eye-opening.

-Wes

Salamanca Soccer Player Miguel Garcia's Sudden Cardiac Arrest

How fast does sudden cardiac arrest cause unconsciousness?

Just seconds.

Here's video of Salamanca soccer player Miguel Garcia's episode. At the start of the video, Mr. Garcia can be seen in the background of the image kneeling behind the players in the foreground. Watch carefully as he stands after tying his shoes.



Although it is difficult to see, it appears an automatic external defibrillator arrives in about 2 minutes, though given the fact his shirt is still on as he's taken from the field, we note the device is on his gurney as he's hurried to a nearby ambulance. Reportedly, he survived this sudden cardiac arrest event.

This was NOT a heart attack, but rather an loss of cardiac function caused by a rapid, often disorganized heart rhythm disorder. Compare the relatively long time to resuscitation using an external automatic defibrillator verses the very rapid response afforded to Belgian soccer player Anthony Van Loo whose internal defibrillator was already installed before he played as primary prevention of sudden death from right ventricular dysplasia.

-Wes

h/t: Electrophysiology Fellow blog

Down. Set. Hut. Clear!

Sudden cardiac death survivor stories are never boring. From the NY Post:

A veteran Brooklyn high school athletic director suffered a near-deadly heart attack while announcing a football game yesterday but was brought back to life by the team doctor as stunned spectators listened to the dramatic rescue over the PA system. "Clear!" Dr. Ed Golembe shouted as he applied the pads of a defibrillator on Marshall Tames, the athletic director at Erasmus Hall HS, around 1 p.m. at Midwood High's field. The rescue was inadvertently broadcast over the PA system at the 2,000-seat stadium where Erasmus was in a playoff game with the Bronx's Dewitt Clinton HS.

"As I was calling a play, I turned around and heard all this happen," said Erasmus coach Danny Landberg. "I got flustered."

It seems a defibrillator might have been responsible for the coach losing the game, but it sure helped one man live to see another one.

Hearing the commotion, I wonder if the crowd started singing' "Ah, Ah, Ah, Ah, Stayin' Alive, Stayin' Alive..."

-Wes

Back Up and Runnin'

Seems the server's back up, photos and all.

Thanks for your patience.

-Wes

Technical Difficulties

It seems the server where all my really juicy image content is stored has seen better days. Consequently, images are failing to appear on this blog. Hopefully the problem will be rectified sometime before Christmas Season 2011.

I regret the inconvenience.

-Wes

Addendum

13 Nov 2010 09:50 - More info: Register.com, from whom I purchase server space, was hit by a malicious distributed denial of service attack (ddos). Eeeewwww. Might take a while to recover....

Lab Improvements

I'm loving our new big-screen x-ray monitor recently installed in our newly-renovated EP lab:



The easy video-switching capabilities of this monitor offers vast improvements over earlier models and greatly streamlines productivity:

Click image to enlarge

-Wes

FDA Proposes New Cigarette Labels

The FDA will soon require new cigarette package labeling to deter smoking. So in politically-correct governmental fashion, they are asking which labels you'd like to see. (You can pick your favorites here.) My personal favorite (so far) is the one shown to the left, but its impact factor pales in comparison to this example found in England. (That, my friends, is cancer!)


Ironically, it appears the FDA isn't too sure how forceful it should be in these warnings about the dangers of smoking. They offer a cornucopia of milquetoast labeling options - many of which contain cartoons. Might such unrealistic portrayals defy they hard-hitting message they want to project? Worse, at least one cartoon (seen here) even seems to promote cigarettes AND drug use together!

In an even more astonishing example, some images almost make me what to take up smoking so I can blow big bubbles. Since I could never do this well before, maybe I should take up smoking! Seriously, is an empowerment message what the government wants to portray?

Make these labels big, ugly, and real.

Anything else is a waste of taxpayer's money.

-Wes

Schooling Doctors

If you haven't been introduced to 33 Charts, a blog by pediatric gastroenterologist Bryan Vartabedian, MD, ("Dr. V") take a minute to do so. I was struck by his honest post entitled "Is It the End of Private Practice?" in which he laments:

I was driven out of private practice in 2004 by rising malpractice premiums and plummeting reimbursement. In Texas at the time the trial attorneys ran the place and medmal insurance carriers simply couldn’t keep up with the greed.

Medical practices are just too expensive to run and the services that physicians provide are dangerously undervalued. You do the math. Sure it’s a complicated issue. But the end result is institutionally employed doctors with institutional pay and the risk of institutional service.

Of course we need to contain costs. And I know, it’s about the patient and nothing else. And all doctors are filthy rich. Of course they are.

Self-annointed experts blather about doctors, medical economics, and solutions. Government bean counters and consultants think they’ve got it figured out. They have no idea what we do, where we’ve been, or the staggering self-sacrifice necessary to manage a panel of chronically ill patients.

I spent the best years of my life working 15-hour days as a scut monkey training to get where I am. But the next generation will be more judicious. As society sees what doctors do as a commodity, society will see commodity doctors.

The plight of the physician in America is now considered dead last. But don’t cry for me. Cry for your self.

Almost immediately, as if to quell Dr. V's concerns, came this comment:

Hard to challenge your conclusion as well as the likely direction of the key trends. But ‘interesting energy’ Bryan…perhaps a calling to leadership?

There is way too much fatalism, and ‘poor me’ victimization in dis-organized medicine today; which I also sense in your piece.

Where is the ‘what’s my (our) part’ reflection? Where’s the ‘ownership’ of the dysfunction?

Bryan was "schooled."

Please, good doctor, don't mention these things, it is unpleasant. Don't you want to be a leader, good doctor? It's not nice to buck the establishment. You must conform now. Don't you want to achieve a senior leadership position in our organization?

For doctors, the subtle undertones of such a challenge are tough to ignore. We aren't stupid. There is a disproportionate salary reward for doctors who chose the leadership route in large health care organizations. Since doctors are exceedingly gifted at working systems to their personal advantage (can you say "medical school gauntlet?"), and with large corporate structures with large corporate management teams with large corporate human services departments eager to earn their employee-doctors' trust, they need "key opinion leaders" that can influence their younger peers. The temptation to abandon patient care in favor of "leadership" is seductive. Worse, when clinical doctors and administrative doctors butt heads in sticky situations regarding patient care, the trump card for administrators looms large now lest you be labeled a "difficult doctor."

"You must allow the EMR to order tests automatically, doctor, it's in the guidelines."

"But my patient will have to pay for those tests!"

"Dear doctor, you do not understand, this is in the best interest of quality care."

"But my patient can't afford all these tests!"

"But, dear doctor, our hospital report cards will suffer if we don't have these tests documented every six months on their chart and if our report card isn't as good as our competitor's report card, you won't make as much money either."

"But..."

"Shall we move on?"

-Wes

De-funder Dog

It's one thing to de-fund portions of the PPACA that are particularly egregious, but the Republicans must address and offer solutions to the the many challenges that face patients today: cost of insurance, lack of competition between insurers, lack of health care cost transparency, insurance portability, and pre-existing condition exclusions.

-Wes

The Townhall

They can from far and wide, this evening after. Cordial pleasantries were eagerly extended, like soldiers in a foxhole, I knew I was with friends. These were faces I'd seen a thousand times before over the years, but in very different circumstances. No young faces, mind you - they never bothered to check their e-mail: too busy, they'd say.

"Wes, damn good to see you! Thank for your help with Ms. Smith. Don't you love it when medicine comes together to save a life like that? I mean, damn, that's why we all do this right?" he said jovially.

"Wes, have you met Dr. Fatchamata Cheesedip?"

The young face approached bearing a platter of some sort: "What can I get you?"

Beautiful venue. People on their best behavior.

Or not.

Herding cattle, in the nicest of ways, came to mind.

For there they were, a sea of faces sitting at the table facing down shadowed by the faint glow of a cellphone sending texts or Twittering or emailing: "Take out dog. Get to ur homework, k?" "Oh, sure, 24.9% pay cut 1 January, WTF?" "After elections! Time to f-in' quit."

The gavel descending to bring the meeting to order.

"Aye," the back table mumbled, anticipating the first order of business as people chuckled. With a collective average MCAT score of 13, they knew the protocol: review the minutes, vote on bylaws, give some awards, appoint the head Puh-bah. Thank the organizers. Take one or two ideas from the floor. Thanks for coming.

Of course the room grew quiet when health care reform was mentioned. "We're uniquely positioned." "New era." "With our innovative EMR..."

Nothing new.

Like eerily awaiting the thinning of the herd.

"Think they'll have those yummy sandwiches next year?"

-Wes

A New Leadless Pacemaker-Pill?

The weak link in any pacemaker system are the leads that attach to the heart. Now a new innovation under development by Medtronic is on the horizon that might combine the pacemaker and lead together on a pill-sized device installed in the heart percutaneously:

The company has been developing the pacemaker for about a year now. It looks a cross between a battery and a beetle, with bug-like antenna sweeping back from one end.

The technology has yet to be tested in animals -- never mind humans. It's about five years away from being ready for market, if it's approved by the Food and Drug Administration.

While this first device will offer only backup VVI pacing, using several such devices controlled wirelessly might offer even more potential for sequential or simultaeous multi-sight pacing some day.

Very cool.

-Wes

How to Vote When You Have a Heart Attack on Election Day

... it can be done, but is harder than you might think:

Someone who knew Kopplin and who lived in the same municipality had to print a form from the Internet, take it to the City of Milwaukee Election Commission and testify that he knew Kopplin. Then he had to bring the form to the hospital where Kopplin filled it out and signed it in front of two witnesses. The absentee ballot had to be returned to the commission by 5 p.m. Tuesday. His neighbor couldn't make it and Kopplin's kids don't live in Milwaukee. Kopplin eventually found a friend who is a Milwaukee resident to do the grunt work.

"What I had to go through to get a ballot and get it signed and get it turned in by 5, leave it to politicians to come up with this," Kopplin said.

Kopplin received a stent in his heart and is hoping to go home from the hospital on Wednesday.

This man is a Great American indeed.

-Wes

How E-Prescribing is Just Like Twitter

I'm surprised I didn't notice this sooner, but e-prescriptions will only accept 140 characters in their instructions, just like Twitter. If you still must have longer instructions, you must print the prescription and hand it to the patient for it to be manually filled at their pharmacy.

Then again, maybe doctors will start to use some "twitter-like" abbreviations in their instruction fields now, like:

"Chk ur BP b4 taking b/c itz K 2 hold if nl. TIA."

Dude. That'd b fab.

-Wes

Grand Rounds Vol 7, No.6: The 2010 Politically (in)Correct Mid-Term Election Edition

Welcome to this week's mid-term edition of the medical blog-o-sphere's Grand Rounds! Before we begin, be SURE to get to the polls to VOTE!

This week submissions were classified by state or country of origin. Politically incorrect posts by state were colored RED whereas politically correct posts by state were colored BLUE. (States with both extremes are represented in PURPLE.)

Now what would any political post be without a POLITICAL MAP of the states represented in this week's Grand Rounds?

(Scroll down or click on a desired state)

TENNESSEE


It is rare to find such a wonderful example of our great democracy in action, where even the little guy can run for governor. But along came this must-see video, by far the most politically-incorrect submission to this week's Grand Rounds. This post should serve as a reminder to all of us why we MUST get out and vote today. (Submitted by the Happy Hospitalist). Go Basil! (Return to map)

GEORGIA

The Peach State has both extremes,

• From the very politically correct: Kimberly Manning, MD takes one heck-of-a-big-breath as she offers a refreshingly realistic view of the tenacity required to manage medicine, kids, home and a bit of social life. Doctor-moms never get enough credit. (Via: the ACP Hospitalist blog)


• To the very politically incorrect: Insurance executive Bob Vineyard isn't too happy with the Department of Health and Human Services granting "Obamacare waivers" to large, influential companies and wants to make sure you know about it. Tell us how you feel! (Return to map)

PENNSYLVANIA

Dr. Rich, ever politically incorrect yet astute over at the Covert Rationing blog, shares with us why he feels this midterm election cycle is a yawner: the fat lady, er, man, has already sung. (Return to map)

KENTUCKY

Dr. John Mandrola of the Dr. John M blog, always a bastion of political correctness, explains who should be on death expert panels if he were in charge and why. (Return to map)

ARKANSAS

Doctors who blog add depth to medical stories found on the internet. A fantastic example is Dr. Ramona Bates's coverage of California Republican U.S. Senate Candidate Carly Fiorina’s recent hospitalization due to an infection related to her post-mastectomy breast reconstruction. We need more like this. I wonder if she's thought about a run for Congress... (Return to map)

ILLINOIS

File these under politically correct:

Ever have something break (like an exploding ICD) and want to find out if others have seen the same thing? Check out Tony Chen's FDAZilla search engine that makes it easy to search the FDA's MAUDE database.

John H. Schumann, FACP uses President Obama's handling of the career USDA employee Shirley Sherrod's contextual kerfuffle as an example for "making nice" after we screw up. And while errors are inevitable and this is probably the best way to handle them once they've occurred, the story also reinforces principles to which all blog readers should ascribe: checking sources before drawing conclusions. (Return to map)

NEW YORK

(Political Action Committee) Chris Langston, Program Director of the John Hartford Foundation, happily reintroduces us to the must-see satirical video that lampoons a clueless “health care executive” who has read in Modern Healthcare how to create an Accountable Care Organization (ACO) and “have lots of meetings” to make his board happy. While Langston acknowledges "...everyone interested in health care reform is hoping that ACOs will provide a miracle cure for our ailing health system, no one is really sure how they will work." But like the true executive that he is, he then explains (with the help of Modern Healthcare, of course), how they will work. It's hard to find a better example of executive political correctness.

Elaine Schattner, M.D. shares her review of a new Broadway play Bloody Bloody Andrew Jackson and shares these tag lines:

Some times you have to take the initiative.
Some times your whole family dies of cholera.
Some times you have to make your own story.
Some times you have to shoot the story teller in the neck.
Some times you have to take back the country….

Hmmm. A metaphor? (Return to map)

NEBRASKA

Regarding sentiment for health care reform, the Happy Hospitalist reminds us that some former supporters are throwing in the towel. In a word: change. (Return to map)

MASSACHUSETTS

(Political Action Committee) Julie Rosen of the Bedside Manner blog explains why health literacy matters and brings our attention to the need for good public education and its benefits of such later health care. (Return to map)

INDIANA

(Political Action Committee) Walter Jessen of Highlight HEALTH reports on how the National Breast Cancer Coalition (NBCC) has thrown down the glove to push for a breast cancer vaccine by 2020. This is a great example how special interests confront our legislators every day. (Note: they listen more if you bring lunch!) (Return to map)

CANADA

In "From Plain Film to 3D: Radiologists as Superstars," Notwithstanding Blog argues that radiologists are the economic superstars of American Medicine. Funny to hear this from Canada. Still, it's acknowledged "... the challenge facing American radiologists in my lifetime may not be justifying their value in patient care so much as justifying their value over and above their American-boarded Indian-based counterparts." Exactly. (Return to map)

UNDISCLOSED

Dr. Fizzy over at A Cartoon Guide to Becoming a Doctor explains, as only a cartoon can, why Health Insurance Sucks. Too bad Dr. Fizzy may soon be mandated by law to buy it. (Return to map)

* * *

Before closing, I'd like to point you to a few more salient election day thoughts by Paul Levy, CEO and President of Beth Israel Deaconess Medical Center:

I hope the very good people who lose in tomorrow's balloting will keep up their fights, whether they are incumbents or challengers. They, especially, deserve our thanks for participating in our election process.

Amen.

Next week's Grand Rounds will be hosted by Mother Jones, RN at Nurse Ratched's Place.

-Wes

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!