The Lost Art of Auscultation

From the nice piece just published in the New York Times:

“He told us that one of the things that had surprised him most about being a patient was that every single person he interacted with — be they nurse, resident, senior physician, respiratory tech, physical therapist — it was as though they had a neon sign on their forehead that said either ‘I care’ or ‘I don’t care.’ ”

But what illuminates those neon signs? What are the clues that were so starkly apparent to me, even in second-year medical students?

Perhaps the answer lies in the medical lexicon. Auscultation — listening to heart sounds with a stethoscope — is a required skill.

Read the whole thing.

-Wes

The Big Squeeze

About a week ago, an editorial from a plastic surgeon Lloyd Kreiger, MD, appeared in the Wall Street Journal entitled "ObamaCare Is Already Damaging Health Care." While I'm not sure I'm ready to concede that Obamacare has already damaged health care in America, I will agree the law is certainly is changing health care, aligning health care corporate interests with political interests, with doctors feeling the squeeze between the two.

Last year in the MGMA's most recent survey of practicing physicians, an important milestone was reached: over 50% of doctors are now employed by large health care corporations. This has been driven by two factors: (1) significant cuts to ancillary service fees that doctors used to collect in their offices and (2) a significant climate of economic uncertainty for doctors going forward as the new health care law is enacted. As Dr. Kreiger pointed out:

Doctors and hospitals, meanwhile, have decided that they cannot survive unless they achieve massive size—and fast. Six years ago, doctors owned more than two-thirds of U.S. medical practices, according to the Medical Group Management Association. By next year, nearly two-thirds will be salaried employees of larger institutions.

Consolidation is not necessarily bad, as larger medical practices and hospital systems can create some efficiencies. But in the context of ObamaCare's spiderweb of rules and regulations, consolidation is more akin to collectivization. It means that government bureaucrats will be able to impose controls with much greater ease.

Which, of course, is precisely the way our current government thinkers have intended it.

But whether it is Obamacare or another "PerfectFuture care," I suspect the same "collectivization" would occur in ANY government-funded health care entitlement system going forward. The reality is, our current system is not economically sustainable. In government-funded health care, the move toward capitated payments to doctors and hospital systems now seems inevitable, thanks in large part the the development and distribution of large billing and tracking health care information systems.

The changes we're seeing right now in health care in our area are all in preparation for the inevitable cuts coming to our health care entitlement programs: the day the government says they're going to pay twenty percent less than they are paying now, come hell or high water. To accomplish this, lump sum payments will be made for episodes of pre-specified care in the form of payment "bundles," supplied to large (and as yet poorly-defined) "Accountable Care Organizations." How these funds will be later divided among those that provided the work will depend primarily upon who receives the funds from the government.

We can expect that senior administrators will be spared as funding cuts are forthcoming. This does not mean all administrators will be safe, however; mid-managers will also feel the squeeze as overhead is trimmed.

Non-essential equipment purchases and hires will stop or be significantly slowed. All personnel will be asked to do more with less, or else.

Since people are expensive and politically unpopular to fire, every effort will be made to "improve efficiencies" using computers. Data-mining of tests, laboratory studies, procedures and radiology/pharmaceuticals will be culled, processed and pureed for their expense with an eye toward perceived "value."

Patients can expect more lower-paid "mid-level" care provider interaction. I suspect "primary care" doctors (however that term evolves) will opt for shift-work to offset the inevitable trims to salaries that are likely to occur in the setting of over-burdened patient volumes. Other hospital-based doctor-employees (i.e., "proceduralists") will be paid on some form of "productivity" basis rather than straight salary, despite how non-conflictual a salary structure might seem at first glance (straight salaries breed complacency, too). To continue to trim costs, "non-productive" doctors' ranks can be thinned if they slow their "production."

Research endeavors, especially at academic centers intent on a "sheltered workshop" environment for their physician-researchers, will be a casualty of this shift to "productivity" as well. Philanthropic fund-raising or grant applications will become more important than ever before to support existing ongoing research efforts. Researchers inefficient at self-promotion and fund-raiding will face a "time-to-provide-clinical-care" imperative. Some research projects will survive, but many ongoing research efforts will cease. Rapid innovation in health care will be an inevitable casualty to these cuts.

And what can our new doctor-employees expect going forward?

It's hard to say where the dust will settle.

I suspect that doctors realize that if they can't beat 'em, they'd better join 'em. Those resistant to a collaborative style will not be happy and defect to other non-clinical arenas in health care or business. Those that "play well with others" will work with their employers to find ways to be more efficient and work to save costs. Their efforts will only go so far at first, unless they are privy to the actual prices of equipment and personnel under their purview. Also, since malpractice risk continues to weigh heavily on doctors' ordering practices, who better to address the best way to limit the consequences of defensive medicine practice patterns than doctors?

If large health care institutions decide, instead, to play "Father Knows Best" and unilaterally make cuts to services or change doctors' work-flows without their understanding or approval, they will likely do so at their own peril. To their credit, however, there are clear signs that health care organizations realize the benefit to co-opting strategically-aligned (and paid) staff doctors to serve on their care and oversight advisory boards. Are there ethical concerns to patients when business concerns of a health care system contradict health care concerns in such a set-up?

Of course.

But I really don't see an alternative to such a construct right now given our current political, social and economic milieu (other than for doctors to move completely back to cash-only practices - a scenario unlikely to happen nationally in my life-time). Better for doctors to be part of health care delivery solution going forward. Hopefully, the many smaller voices of front-line doctors and other health care providers will serve as an army of Davids that constantly whittle away at the inefficient and overly costly Goliaths of our health care delivery complex while limiting the collateral damage to our patients.

-Wes

Doctor-Bashing Headlines

While I know it grabs the eye, it really didn't matter what the article was about:

Click image to enlarge

... the headline says it all: doctors are the problem, not the system, right?

-Wes

Klout: How "Influential" Are You, Doctor?

I stumbled across Klout.com recently, thanks to an tweet by the well-respected web strategist and industry analyst at the Altimeter Group, Jeremiah Owyang. Needless to say, it's not a place doctors venture much.

But I found the site, and it's potential to characterize physician's on-line influence, interesting.

It works by giving people on Twitter and Facebook a "score", influenced by the lists that people are on, the number of original "tweets," number of times things are re-tweeted by others, and so on and then uses the metrics to classify the type and influence of the individual using social media. I suppose an analogy might be that its like looking at a bunch of personality tests to understand the type of person you're following.

So I looked into the scores and characteristics of a few physician bloggers. The results were interesting.

Yours truly gave a meager "Klout score" of 48 at the time of this writing and was classified as a "Specialist."

Kevin Pho, MD is a "Thought Leader" with a score of 69.

Grunt Doc, an ER doctor and long-time blogger is a "Thought Leader", too, but has a score of 38.

Doctor Anonymous is an "Explorer" with a Klout score of 50.

Ramona Bates, MD - a plastic surgeon - is a "Specialist" too with a score of 54.

Happy Hospitalist has a Klout Score of 24, but is considered a Thought Leader, too.

(You can check your "score" and inflence type with a twitter account and then enter it here.)

By the way, I have no commercial relationship with this website, but I found the concept intriguing for doctors as we enter the new internet age of social media. Certainly this is not the only site that purports to measure the influence of someone on social media (see Peerindex, for instance), but it was interesting to see it's accuracy in determining these few individual's influence on the internet based on their content tweeted.

While Mr. Owyang does a nice job explaining the limitations of these metric websites (especially as it relates to lack of a "Sentiment Index"), but I must say that from my cursory look at the few fellow physicians I queried, it classified some of these more prolific bloggers and twitter users that I know pretty well.

Looking forward, it would not be unrealistic to think that some day a new variant of the Klout website might just serve as another form of doctor rating website. If so, the benefit of developing an valued online social media "physician brand" now might pay professional dividends later.

-Wes

Grand Rounds, Dr. Rich-Style, Is Up

... over at the award-winning Covert Rationing Blog and it's definitely worth a read:

Especially since the events of last week, it would be absurd for DrRich to think that everybody is out to get him. Still, it seems plain that, of late, not all individuals enjoy his efforts here at the Covert Rationing Blog.

Two years ago, for instance, DrRich was “invited” to testify as a witness before a federal grand jury in a matter involving one of his consulting clients. While under oath, DrRich was caused to understand that the Feds (at least certain members of the DOJ) are well aware of this blog, and of the general tenor of its content. The impression left by this experience makes DrRich doubt whether many of his fans come from that particular precinct.

Further, the CRB has been the victim of two targeted denial-of-service attacks just in the last several months. Perhaps this is a common experience for healthcare bloggers, but then again, perhaps not. Finally, there’s the fact that last May (some readers may recall) a nasty hacking exploit completely trashed the CRB at the server level, resulting in the loss of the first three years of DrRich’s endeavors here (which, some have said, is the greatest tragedy to befall posterity since the burning of the Library at Alexandria).

And so, Dear Reader, while DrRich is certainly happy to be hosting Grand Rounds for the fourth time, and is particularly delighted with the quality of postings which he has the honor of featuring this week, it occurs to him that hosting an event with such high (and well-deserved) visibility might draw certain “extra attention” here. So perhaps you had better read this quickly.

-Wes

Electrophysiologists' New Annuity: Percutaneous Aortic Valve Replacements

From Circulation:

One third of patients undergoing a CoreValve transcatheter aortic valve implantation procedure require a permanent pacemaker (PPM) within 30 days. Periprocedural atrioventricular block, balloon predilatation, use of the larger CoreValve prosthesis, increased interventricular septum diameter and prolonged QRS duration were associated with the need for PPM.

With the compact AV node immediately adjacent to the non-coronary cusp of the aortic valve, it's remarkable AV block is not more frequent.

From the discussion section of the paper came these recommendations regarding the monitoring requirements after transcatheter aortic valve implantation (TAVI):

Recommendations based on our findings would suggest that patients who do not develop a broad QRS complex postprocedure can be safely discharged, from the electrophysiological viewpoint, without need for prolonged monitoring, especially if there has been no disturbance of conduction during implantation and the smaller 26-mm valve has been used. However, patients who develop bundle-branch block should probably be monitored for a minimum of 5 days (emphasis mine) for the development of higher-grade AV block.

Interestingly, the conclusions of the same article recommend that 7 days of monitoring may be more appropriate:

The increased rates of PPM implantation in patients with postprocedural bundle-branch block and overall median time to implantation of 4 days (interquartile, range 2 to 7 days) in those who required pacing lead us to recommend that these patients be observed for higher-grade conduction disturbances for up to a week postprocedurally, with greatest care taken in those with periprocedural AV block, those receiving the larger 29-mm device, and patients with greater IVSd."

Even with a week's monitoring, pacemakers were seen even later in a small group of patients (from the Results section of the paper):

Eighty-one of 243 patients (33.3%) underwent PPM implantation within 30 days. Nine patients received their implants on the same day as the index procedure. A further 7 patients (2.9%) underwent PPM implantation during longer-term follow-up at 31, 42, 42, 53, 132, 152, and 187 days.

-Wes

Reference:
Khawaja MZ, Rajani R, Cook A, et al. "Permanent Pacemaker Insertion After CoreValve Transcatheter Aortic Valve Implantation: Incidence and Contributing Factors (the UK CoreValve Collaborative)" Circulation 2011 DOI: 10.1161/CIRCULATIONAHA.109.927152

What's the Difference Between MRI-Safe and Conventional Pacemaker Leads?

... a little thicker, certainly, but otherwise (at least on the surface), not too much:

The recently-approved MRI-safe active-fixation lead from Medtronic (left lead in each frame) is compared to their conventional active-fixation lead. The arrow denotes the radio-opaque marker that can been seen on x-ray to identify the type of lead in the patient's body. A fluoro image of the two leads is shown below, again with Medtronic's MRI-safe lead on the left:

While the engineering hurdles were no-doubt considerable to make an MRI-safe pacemaker lead, given the growing body of evidence that newer pacemakers (when carefully monitored) can be scanned in MRI machines, I suspect the biggest difference in these leads is not their design per se, but rather the regulatory paperwork (and research) that had to be completed to document their safety.

Of course, the fact that CMS would not pay for MRI scans performed on patients with pacemakers before the advent of these newer devices probably also limited the number of scans performed.

-Wes

MRI-Safe Pacemakers - Version 1.0

Mary Knudson, a health journalist and author of the Heart Sense blog, does a great job covering the story behind the story on the newly approved MRI-safe pacemakers in a guest blog post at the Scientific American. She discusses the challenges ahead in regard to the widespread clinical adoption of MRI-safe pacemakers, the issues with Medicare coverage of MRI's of patients with these devices, the logistics involved in their use, and includes commentary from a number of physicians, including a tidbit from yours truly.

-Wes

For Guidelines: Hyperlinks, Please

This week, in response to the approval of Boehringer-Ingelheim's dabigatran (Pradaxa®) by the FDA, guideline writers were relatively quick to issue a 'focused update' (pdf) to the recently-released 2011 guidelines for the management of atrial fibrillation to include the new medication.

With this "focused update" came a new era for doctors.

Now, instead of guidelines for care of a malady being published in a single publication, we are finding guidelines can morph across multiple articles. As such, the size and breadth of guidelines that are increasingly used for mandates for clinical care can stretch over a virtually limitless publication domain.

In this era of electronic, near instantaneous publication with the now-apparently limitless potential to expand to unlimited size, doctors should insist that electronic hyperlinks be established between published guidelines, their addenda, and their associated references.

-Wes

When A Cardiologist Has a Heart Attack

... the revelations for both the cardiologist and his patients are profound:

The doctor-turned-patient admits he’s faced some challenges in following the advice that he has given cardiac patients all these years.

“I try to go to the gym several times a week. It’s very difficult to fit that into my schedule,” he said. “I had adjusted my diet years ago, avoiding salt and eating less red meat. Now I’m eating oatmeal for breakfast five days a week.”

Lewin joined the cardiac rehabilitation program at the Ortenzio Heart Center at Holy Spirit, where he often ran into his own patients, who were surprised to see their doctor walking the treadmill.

“Some of them thought I was just coming to exercise,” Lewin said with a laugh. “People would tell me, ‘Gee, I have an appointment to come see you next week.’”

Lewin said his personal experience with cardiac rehab helps him relate better to his patients. “I can identify more now with what they’re going through and the concerns they face,” he said — and the challenge it can be to follow doctor’s orders.

-Wes

From Mice to Men?

-Wes

h/t: Medgadget

Maestro Muti Gets Pacemaker

Feeling poorly in October, 2010, the Chicago Symphony Orchestra's Maestro Riccardo Muti traveled to the World Health Organization's #2 country for health care delivery, Italy, to be evaluated for "abdominal discomfort" and was diagnosed with "extreme exhaustion" while costs of care are held to a minimum:

After a series of medical tests at San Raffaele Hospital, it was determined that Maestro Muti is suffering from extreme exhaustion as a result of prolonged physical stress. In this case, as often happens, the exhaustion manifested itself in abdominal pain and other physical symptoms. His physicians believe that he was able to work through his symptoms in his first two weeks, given all of the heightened excitement, but, that as time wore on, it became increasingly more difficult to do so.

Maestro Muti’s medical doctors have prescribed one month of complete rest, which he has begun at his home in Italy. The Maestro reports that he is feeling “not perfect, but relieved” to know it was not something more serious as first indicated by his symptoms.

Later, he returns to the United States just before the great #SNOMG, collapses at rehersal in Chicago, has facial fractures and receives America's finest: a permanent pacemaker, courtesy of the good ol' 37th WHO-ranked U. S. of A.

While hindsight is always 20:20, you can bet his workup and treatments were thorough, timely, and quite expensive here in the United States.

Suddenly, though, #37 doesn't sound so bad, does it?

-Wes

Our New Medical Vernacular

"It's that time of year."

"For what?"

"For our annual performance reviews. You know, where we rank our employees as "does not meet expectations, meets expectations, or exceeds expectations." They laughed. It was a plesant, social affair, and while he didn't work in a hospital, he did work for a health care corporation. I couldn't help but listen to the conversation, since it sounded so familiar.

"... and if they don't meet expectations, we have to develop a 'PIP'."

"PIP?"

"A Performance Improvement Plan. And that will lead us to a good discussion about an ACR."

"ACR?"

"Annual compensation review. This of course, drives the merit increase conversation."

"Merit increase conversation?"

"The merit increase must average 2.5%, ranging between 1 and 4% depending on whether you're below expectations, meet expectations, or exceed expectations. Hah! It doesn't really matter, now does it, since state taxes have gone up so much around here. So there you have it. I love my job," he chuckled as he sipped his beer.

It's strange how much our medical vernacular has changed and is starting to sound like the corporate vernacular:

"Meaningful use."

"Guidelines."

"P4P"

"Measures."

"MGMA Benchmark."

Won't be long until I have a PIP.

-Wes

Pradaxa's Not-So-Long Shelf Life

Dr. John Mandrola, a fellow blogging electrophysiologist, keeps us up to date regarding the shelf life issues of dabigatran (Pradaxa®):

Once dispensed, most medicines expire after a year. Dabigatran, however, is far from the usual pill. It’s packaged in pellet form within a capsule. These pellets are highly susceptible to water and humidity. So when dispensed in a typical vial–not a single-sealed blister pack–the drug expires in only 30 days.

I learned today from our pharmacy personnel that you can specify blister packs on a prescription which will assure a longer shelf-life of the medication (just be sure your patients can open them).

-Wes

How Hospitals View Cardiology Groups

It is no surprise that hospitals are acquiring cardiology and primary care groups groups in droves lately. It seems there is a signficant financial incentive to do so for now, but doctors (and especially cardiologists) should read the tea leaves ahead:

While hospitals are limited to paying fair market value for practices, they can gain an edge over competing hospitals by offering longer employment contract terms or better electronic medical record systems and management services. If hospitals move forward with a transaction, Ms. Kaplan suggests they limit employment contracts to no more than two years if possible and rebase compensation annually based on productivity.

"In healthcare you shouldn't assume anything is permanent," says Ms. Kaplan. She cautions that the revenue increases that are currently available to hospitals through expanding outpatient cardiology services may not last forever, which is why she urges hospitals to limit employment contracts and other agreements to only a few years. Doing so will afford an "out" for the hospital if the service line goes from a money-maker to a money pit.

-Wes

Cardiologists as "Heart Whisperers"

... a creative moniker if there ever was one, but it should probably be reserved for primary care specialists, instead.

-Wes

Publishing for News Events

It's always interesting the see the incredible media buzz a so-called "scientific study" can receive if its release is timed to some upcoming predictable news event. This weekend's story is, of course, Superbowl XLV.

Just in the nick of time came this study entitled "Role of Age, Sex, and Race on Cardiac and Total Mortality Associated With Super Bowl Wins and Losses" published online in an online publication called "Clinical Cardiology" on 31 January 2011.

Coincidence?

Unlikely.

The study reportedly went back and looked at LA county coroner death certificates:

from 1980 to 1988, covering only the period of January 15 through the end of February for each year. Data included total number of deaths as well as number of deaths due to diseases of the circulatory system, ischemic heart disease, acute myocardial infarction, heart failure, and congestive heart failure. Data on the entire population have been previously published.9 In the present study, we separately analyzed data on men, women, those aged < 65 years, those aged ≥ 65 years, those of white/Hispanic ethnicity, and those of nonwhite/non-Hispanic ethnicity, for each of the 2 Super Bowls. We compared death rates for days related to the 1980 Super Bowl (January 20, 1980 plus the following 14 days), which Los Angeles lost, with control days (all other days in January and February from January 15, 1980 to February 1983). To remove the impact of the known peak in total and cardiac death rates around the winter holidays, all analyses excluded data from January 1 to January 14. Death rates were reported as deaths per day per 100 000 population (using total deaths and average population). Parallel analyses were performed for Los Angeles's winning Super Bowl on January 22, 1984. During these time periods, Los Angeles County death certificates classified Hispanic patients as white; hence, white and Hispanic death-rate data are combined.

The authors ran some statistics on this narrow 14-day window from the various years and concluded:

The 1980 Super Bowl loss triggered more deaths in older patients compared with younger patients. It did trigger deaths in both men and women. In addition, there was a nonsignificant trend for a Super Bowl win to reduce death slightly better in older than in younger patients, and in women.

Needless to say, the media have had a field day with this article published just before the Superbowl. A quick search of Google at the time of this posting has identified 12,641 articles that have been written regarding this publication (excluding my current post). Without exception (at least as far as I could discern), all articles have assumed the article's conclusion is scientifically valid.

For medical students and residents, it might be helpful to dissect this study and its methodology so that they can enjoy the festivities without fear of dropping dead if their team loses.

First of all, this study is limited by a number of significant research bias's:

Selection bias (short window of dates, limited years studied)

Contamination bias (How do we explain the deaths of those who never saw the outcome of the game?)

Co-intervention bias (Recall that air polution standards in 1980 in Los Angeles were much worse in 1980 than later years and may have served as a co-intervention bias not explained by the researchers). The lack of a limitations section in this report to offer alternate explanations to the author's findings suggest an expectation bias and is a helpful sign of a poorly analyzed data set.

Finally, the use of diagnosis codes culled from death certificates hardly explains the mechanism of someone's death, but rather classifies (poorly) their most likely major underlying disease state. The retrospective nature of this trial can only point the way for future research, rather than imply causation.

So there you have it. Even if your team loses, you're not likely to have a heart attack.

Unless, of course, you have a hefty bet on the game.

-Wes

Stayin' Warm

... after a blizzard:

... of course, it helps to be a kid.

-Wes

Another Busy Year of Cardiovascular Innovations

The FDA just posted a nice summary of recently approved cardiovascular innovations, just in time for Heart Month, of course.

-Wes

February: Heart Month or Marketing Month?

Heart disease and February. What relationship could be more cozy?

From the scary risks of shoveling snow (yep, you could DIE, so be sure to lift a little at a time!), Mercedes-sponsored red dress parades and government-sponsored National Wear Red Day®, to tips for identifying heart attacks in women (men, you need a different month I guess), February has all the important stories to improve your "awareness."

Such a polite term, "awareness."

But I wonder, now that the internet is upon us and people are seeing their insurance rates and co-pays skyrocket if maybe we're shooting ourselves in the foot with all this heart month marketing hype. People are sick and tired of testing "just to be sure." It's starting to directly cost them a fortune, and people are pissed at having to pay a fortune for health care, let alone heart care.

I know, I know, I should be at the forefront of working with patients to stomp out heart disease. And goodness, people DO need to be attuned to diet, exercise, and weight loss. But the reality is, if we're giving you the ten latest tips on how to detect a heart attack, we're probably a bit too late.

That's the problem with all these press releases: while there's a need to raise "awareness" of heart health, there's also a very real need for people to take us, heart disease professionals, seriously to help cut costs in health care here. The last thing our health care system needs is more frivolous testing. Yet this is exactly what all this marketing does for our health care system: and it helps those with the largest PR budgets most of all.

Of course, there are researchers who depend on a portion of the funds raised to continue their work. After all, research is ridiculously expensive. There really is a need to raise funds for these scientists if we're going to continue our tradition of creative innovations in cardiovascular health care.

Maybe that should be the story line.

Maybe it would be nice to highlight these researchers' work and what that work hopes to bring to people rather than splashing a big feel-good red dress parade all over the media. Maybe we could focus on real life stories and less on the hyperbole. Maybe we could focus on the challenges, rather than the accolades and perfection.

Maybe then we'd have people take us seriously.

-Wes

Chicago Blizzard Protocol

After hours of digging out cars, this was found posted on a car window after Tuesday's #SNOMG:

Heh. Second City, my as$...

-Wes