In Comparing Hospitals, What If They're All the Same?

Quality measures. Patient satisfaction surveys. With our new health care reform law, these "performance measures" are the new black in health care.

Hospitals are currently spending, conservatively, tens of millions of dollars to bolster these "performance measures" in hopes of securing a refund of a mere 1% of payments that CMS will soon withhold from them in the name of "assuring" quality improvement.

But what if, nationwide, there wasn't a big difference in these measures between hospitals? What happens then? Might payments then be made on political grounds?

Performance measures have been collected for some time now in anticipation of this new payment initiative by the government, so data exist to evaluate. In fact, Kaiser Health News was nice enough to aggregate the findings from our government's Hospital Compare website for my review.

So I calculated the mean, median and standard deviation of the results of all of this data collected across 50 states and 2 territories and found very little difference in measures collected between states:

MEASURE	Nurses Always Communicated Well	Docs Always Communicated Well	Always Got Help When Needed	Pain Always Well-controlled	Staff Always Explained Medications
Median	76%	80%	65%	70%	61%
Mean	76.06%	80.31%	64.42%	69.29%	60.71%
Std Dev	2.99%	2.84%	4.85%	2.19%	2.89%

MEASURE	Room & Bathroom Always Clean	Always Quiet at Night	Given Info for Recovery	Hospital Rated 9 or 10	Definitely Recommend Hospital
Median	72%	58%	82%	67%	69%
Mean	71.44%	57.67%	82.00%	66.85%	69.25%
Std Dev	3.86%	6.14%	2.95%	4.38%	3.78%

Perhaps most remarkable is the fact that none of these data are skewed (means are virtually identical to the medians) and that there is very little variability (2-6%) between the data sets.

The fact that these data are so similar across states is a testament to the nationwide health care quality that US citizens can currently expect in America.

But these data also lead to a disturbing question: if the data are so similar across every state or territory, will similar findings hold true between hospitals? How is the average Joe or Sally (or Joe or Sally government worker) going to see a meaningful difference in performance measures between states OR hospitals when they show performance differences of as little as ±3%?

The realistic answer?

They can't.

-Wes

ACC Responds (Again) to Why They Track Their Membership

I appreciate the American College of Cardiology responding to my concerns regarding the finding of RFID tags in our name badges at the recent ACC.11 & i2 Summit Scientific Conferences and expanding upon their earlier explanation. I encourage all readers of this blog to read it.

Now for a bit of a respectful rebuttal.

I admit: I missed the need to "opt-out" of this tracking when I registered for their meeting. But I really didn't realize that registering for a scientific meeting also required signing (checking?) a contract to not permit tracking when I registered at the time. Who knew?

Now more than ever, I believe the use of our personal data should be on the basis of an “opt-in” policy rather than an “opt-out” policy. Requiring someone the check a box to NOT have something is a pernicious way to illicit approval for an activity. I get that we could “opt-out,” but why should I HAVE to? My privacy (and that of all of the ACC’s membership) should be kept confidential first and foremost, marketing efforts should come second.

The ACC states that they use the RFID data for “two main functions,” (1) meeting planning and (2) to collect “rent” for the use of RFID data by exhibitors:

Exhibitors were able to rent RFID readers from the vendor. They are able to use the data in much the same way as the ACC – to evaluate how effectively their work stations are structured and to improve their offerings to attendees….ACC’s intention was not to create a revenue source by offering attendee data to exhibitors (in fact, only five out of more than 300 exhibiting companies decided to invest in RFID in their booths), but rather to provide exhibitors another resource by which to understand the traffic flow in their booths and to better align their displays with attendees’ needs.

They suggest that the ACC’s “intent” was not to create a revenue source by offering attendee data to exhibitors because only 5 vendors opted to pay for the rental. If so, why not offer the data for free? While the data given was reportedly “the same information that was available on meeting attendees badges in print (name/city/state/institution). No contact information is provided” we really see that other data were also derived from this meeting, and hence distributable:

The attendee then goes to a session on appropriate use of PCI, followed by a session on imaging because he or she is interested in new advances in the intersection of imaging and intervention. Let’s also say that several other people in these sessions followed a similar track. In this scenario, the ACC would receive a report of aggregated data, showing a significant level of physician interest in both imaging and interventional sessions.

If the ACC collected and controlled the data themselves, then the ACC could assure the data’s privacy, but they did not. The ACC contracted with an outside vendor, Alliance Tech, to collect the tracking data and, as such, they have the ultimate control over it. By supplying our demographic information to Alliance Tech, the ACC makes the tracking data useful to vendors and others. What assurance do members have that Alliance Tech has the same good intentions with the data as the ACC? Realize that this same tactic was used by the American Medical Association to provide our prescribing information to Heath Information Organizations with the same "opt-out" requirement.

This is not to say the ACC does not need the revenue. Putting on these meetings is expensive. But we must not lose sight of the real purpose of these meetings, education. Many doctors I know shook their head when the opening plenary session started with a light show and red carpet walk. Is funding of these “shows” why they need to see our personal data? Like it or not, we have to wonder.

Also, RFID data are easily hacked. One only needs to watch the short video of Adam Savage from the popular TV show Mythbusters at the 2010 Hackers Conference to see why the Discovery Channel opted not to air their show on RFID technology to understand how important this data is to businesses.

No doubt the ACC need to find ways to raise funds as pressure mounts on all of us to cut costs in health care. These scientific meetings are a major source of revenue for their organization and they do perform an important advocacy role for cardiologists in Washington. But there is a need to remember why they exist in the first place: to advocate for their physician members while respecting their practice of medicine, not sell us (and our personal data) short to other industry interests.

-Wes

Toward More Transparent Physician RFID Tagging at Scientific Sessions

Heh. Gotta love physician activism.

-Wes

Monitoring Patients in the "Cloud" Is for the Birds

... because when a "cloud-based" system like Amazon's goes down, patients lives are at risk and your company is at the mercy of ...

... gee, I'm not sure.

-Wes

Update: The thread linked could be a hoax (see last comment) but Amazon's "cloud" outage was not.

Social Media as Research Tool

With overregulation of the clinical research arena, the whole area is ripe for disruption, especially for research performed on rare disorders. Today, it appears that a new mode of assessing efficacy of novel therapies using social media might just be the perfect disruptor:

The new study, published online in the journal Nature Biotechnology, represents an early example of how social networking could play a role in clinical trials, an area of medical science with strict procedures that many would consider especially difficult to apply in the online world.

"The approach has tremendous potential,'' said Lee Hartwell, a Nobel Prize-winning scientist now at Arizona State University, and formerly president of the Fred Hutchinson Cancer Research Center. Standard clinical trials play a central role in the research enterprise of both of those institutions.

Dr. Hartwell, who wasn't involved in the study, said social-network trials aren't likely to replace conventional randomized, double-blinded, placebo-controlled trials, the gold-standard for generating medical evidence. But such trials have become so complicated and time-consuming that new models are needed, he said.

It's about to be a whole new world...

-Wes

Reference:
Wicks P, Vaughan TE, Massagli MP, Heywood J.
Accelerated clinical discovery using self-reported patient data collected online and a patient-matching algorithm Nature Biotechnology 24 April 2011 | doi:10.1038/nbt.1837

The Implications of Physician Tag and Release

Not everything that counts can be measured.
Not everything that can be measured counts.
-Albert Einstein

Recently, a disturbing trend of monitoring physician quality and accountability has taken another ominous turn: tracking physician's movements at scientific conferences (so called "tag and release") using RFID tags imbedded in attendees name badges at national scientific sessions. Having had personal experience with the recent American College of Cardiology meeting, this technology will also be imbedded in the name badges for attendees at the upcoming Heart Rhythm Society meeting to be held in San Francisco in May.

On first blush, it shouldn't be such a big deal, right? It was all just a great way for companies to obtain, for a fee, the names and institutions of people who visited their display booths and for the conference organizers to track the movements of attendees. (Heck, maybe they can partner with an industry sponsor to pick up our traffic tolls on the way to the conference hall or arrange other exciting activities for us! [Said tongue-in-cheek, of course])

Instead of "opting in" for tracking at scientific meetings, doctors must "opt out" from the use of tracking technology when registering for scientific meetings. At the upcoming Heart Rhythm Society meeting for instance, doctors had to "opt out" from the use of RFID technology tracking by checking a box that says:

Badge scanning technology will be utilized at this event in order to better understand attendee/delegate interests and preferences. The information collected will be used to improve future events to better address your preferences. No personal information is stored in the RFID badge, only an ID number. We encourage all participants to take part in this process to ensure the most accurate data is obtained. You may check this box to opt-out of the RFID data collection.

There's full disclosure, doctor.

But to me, the default tracking of doctors is disturbing on several levels.

First, tracking was approved by our professional society organizers upon their own members. It is no secret that these societies make a significant portion of their operating revenues from industry sponsors at these meetings. By instituting tracking, the value of their membership's privacy has taken a back seat to the income generated from tracking revenues. By NOT checking a box, we have implicitly "agreed" to this tracking. (Realize we MUST wear our badge to attend these conferences where we gain our REQUIRED continuing education credits.) Because we have "agreed" in this manner, the tracking data are now legally "discoverable." At the risk of sounding like a conspiracy theorist, it is not too hard to imagine one's credentials being called into question in court because a doctor did not demonstrate enough time in CME activities at the scientific sessions to quality for credit or because these data implicate a doctor in a purchasing agreement between a vendor and hospital system simply because a doctor visited a display booth.

Doctors have seen this sort of activity before when "only" our license and demographic information was sold by the American Medical Association (AMA). The AMA currently "licenses" physician state medical license numbers and demographic information to health care information organizations (HIOs), HIOs then collect and compile this information with prescribing data that contains the doctors' license numbers (no names, mind you) and then sell the lists to pharmaceutical companies. The AMA tells its members it does "not collect, license, sell or have access to physician prescribing data" and this is true. But the AMA facilitates an intermediary's ability to pair doctors' license information to a their prescribing habits via a third party. One can only speculate how out prescribing and practice profiles are being developed by other similar health information companies with the use of our RFID tracking data.

Behind all of this is a bigger issue: doctors are frustrated by the increasing intrusion into our day-to-day practice of medicine to measure things. Take, as one example, our "quality performance measures" that have done little to facilitate patients office visits, but rather add burdonsome documentation requirements in the interest of government payments. A number of hospital administrators have confided in me that it costs more to collect this data than they make in government payments. In fact, whether these programs are ultimately are found to be cost-effective or improve the quality of care has been brought into question in our literature. Yet we continue to collect these measures and expand them. We are now dispatching legions of people to collect and compile data to "prove" that Electronic Medical Records are used in a "meaningful" way. But an honest appraisal of this policy discloses the reality: these measures permit health care systems to collect another $40,000 per doctor from the government because they are using computers, not because it improves patients' care in any "meaningful" way. As proof of the overburdensome nature of all this data collection for the physician, doctors (or their health care systems) are increasingly employing "scribes" to relieve them of the data-entry burdens in the name of "efficiency." How much, exactly, do these scribes cost our health care system? Few dare to ask the question since no one wants to deny themselves of that juicy $40,000 pot of gold being paid per doctor.

Adding insult to injury, all doctors will soon be required to disclose if we receive anything over $100 from industry representatives. Like the public, most of us recognize the pernicious nature of industry influence upon our profession. Yet we now find we are being used. Should our professional organizations be any less forthright with their industry dealings and the use of our demographic data at national scientific sessions? How much is at stake?

Finally, we see more and more onerous licensure requirements and fees paid to the same tag-and-release operatives at considerable cost to ourselves. We now spend thousands of dollars to remain "credentialed." We wonder how much the RFID "return on investment" to industry sponsors adds to our annual membership fees. Could it reduces them? Who knows? Maybe, like other IT models, we should insist our membership fees be waived if we agree to being RFID tagged and released because most of us realize someone's making money on this deal.

In summary, doctors increasingly find the imperative to guard the privacy of our patients without regard to our own personal and professional privacy with the very same patients disturbing. Everything about doctors is being measured these days and it's taking its toll on patient care. We are frustrated with the governmental bureaucratic standards that threaten our time with patients. But time with patients does not pay bills. Meeting data-collection milestones do. Our government and employers have lost sight of the main issue here: improving and expanding our contact with (and the ability to do good for) our patients.

But as long as there is money to be made with our personal information, it is clear that there will be those that will try to capitalize upon it, whether we realize it or not. Only by demanding constant accountability and transparency from the collectors of this information be they government bureaucrats or our professional society appointees, can we hope to maintain any modicum of professionalism in our tenuous doctor-patient relationships of the future.

-Wes

ACC Explains the Use of RFID Tags on Attendee's Name Badges

In response to my earlier post on the use of RFID tags at the ACC's Scientific Sessions, I left a message on the ACC's blog to inquire about this practice. My comment was not initially published, but today I noticed that traffic came from their blog and that my comment and a response to my inquiry was published on the 12th of April. Here's what they said:

Hi Dr. Fisher,

Thanks for your question and your feedback on the meeting. RFID is used by many large meetings -- the technology allows us to track which sessions an attendee attends, and also to track flow -- this will help us a lot to plan the education program next year, as we will be able to use data to determine co-location of pathways etc. to make for an ever better attendee experience on show site. Info that the ACC collected at ACC.11/i2 will help us better plan meeting rooms and expo entrances, adjust our conference programming & expo hall floor plan, and quantify to exhibitor prospects the value of investing in our event, among other things. We are not using the RFID to award CME.

Thank you again for your feedback. Please know we will certainly take your concerns into consideration as we plan for 2012.

All the best,

Sue Sears Hamilton
Associate Vice President, Annual Scientific Session
American College of Cardiology

First, this was very nice of them to respond. I am concerned, however, that this company that tracks these RFID tags can identify the individual and their associated institution in real-time at these meetings (see their promotional video). As Calvin Powers from IBM notes on his blog:

Is it OK for the ACC to give the names, demographic information, contact info, etc of every individual that visited the booth?

At this point in the continuum we have moved into the realm of identified tracking and I suspect most people would feel like their privacy had been invaded if their individual movements were tracked and this level of detail was sold to the exhibitors. When the tracking becomes identifiable down to the individual, privacy practices regarding transparency, opt in/out policies, etf become very important.

We do not know if this practice occurred, but we do know that the capability was there.

My bet: there will be one heck on an "opt in" clause for this technology going forward for future meetings.

At least I hope so.

-Wes

It's Your Chance to Help Out

If you've got a minute, shoot on over to Shrink Rap's blog to take part in their Attitudes Towards Psychiatry survey. They're looking to get as many peoples' opinions as possible.

Thanks-

-Wes

How Clinical Guidelines Are Mirroring the Tax Code

The above graph from the Cato Institute demonstrates the growing complexity of the U.S. tax code over the years. After doing my taxes recently and trying to track the ins and outs of the law for my wife's private practice, I can attest to the graph's accuracy.

But then I was reading an interesting editorial in Circulation: Arrhythmia and Electrophysiology by N.A. Mark Estes III, MD and Jonathan Weinstock, MD that reviewed an article by Roos, et al in the same journal that found only 27 of 698 guideline recommendations from the European Society of Cardiology (median 1.2% per guideline [IQR 0.95% to 3.7%]) were correctly referenced as Class I or III Level of Evidence A recommendations, calling into question the accuracy of guideline recommendations. In their editorial, Estes and Weinstock defended the guideline process but also mentioned the following shocking statistic:

There have been 2413 guidelines published by 267 organizations over the last 2 decades.

To bolster their point, they referenced the government's own website designed to tract these guidelines.

So I checked the number of guidelines so far just for cardiovascular diseases: 457 and counting.

Given this, one thing is becoming abundantly clear:

... doctors will soon be behaving less like doctors and more like tax accountants.

-Wes

References:
Estes NA M, Weinstock J. Guidelines for Cardiac Arrhythmias
Practice Makes Progress Circulation: Arrhythmia and Electrophysiology. 2011; 4: 119-122.

Roos M, Brodbeck J, Sarkozy A, Chierchia GB, De Asmundis C, Brugada P. Critical Analysis of the Scientific Evidence Behind International Guidelines Related to Cardiac Arrhythmias Circulation: Arrhythmia and Electrophysiology. 2011; 4: 202-210.

An EKG You Have to See

... over at the Happy Hospitalist's blog.

Just added this one to my armamentarium.

-Wes

Doctors' Not-So-Social Social Media

As doctors increasingly become employees of large health systems, restrictions are being placed on what they can say in social media. Take, for instance, this public social media policy of Kaiser Permanente regarding proprietary information:

Employees may not disclose any confidential or proprietary information of or about Kaiser Permanente, its affiliates, vendors, or suppliers, including but not limited to business and financial information, represent that they are communicating the views of Kaiser Permanente, or do anything that might reasonably create the impression that they are communicating on behalf of or as a representative of Kaiser Permanente.

So doctors, be mindful and don't talk about any of those contract dealings that might conflict with your patients' best interests, okay?

Unless, of course, you like unemployment.

-Wes

Should Authors Write Editorials About Their Own Paper?

In January, 2011, an article authored by Sana M Al-Khatib, MD and others appeared in the Journal of the American Medical Association (JAMA) entitled "Non-Evidence-Based ICD Implantations in the United States." The resultant headlines were widespread, appearing in theheart.org, the Wall Street Journal, ABC News and many, many more news outlets and blogs. So widespread was the story that even the Heart Rhythm Society had to make a statement about this study.

Now, to be fair, the study brought to light the fact that many ICD's were not implanted according to "guidelines." Most of us in the business acknowledge that fact. But there are many many shortcomings to the original article, the least of which were that new guidelines were published in 2008 in response to new data about ICD's, but because CMS still uses outdated 2005 "guidelines," the authors stuck to their original story line.

* sigh *

No matter: the specter that perhaps only 77.5% of America's doctors were implanting ICD's appropriately was just too juicy for mainstream media to ignore.

Fast forward to March, 2011.

A follow-up article by the same group was published more quietly in Circulation: Cardiovascular Quality and Outcomes entitled "Extent of and Reasons for Nonuse of Implantable Cardioverter Defibrillator Devices in Clinical Practice Among Eligible Patients With Left Ventricular Systolic Dysfunction" with Sana M Al-Khatib as second author. In that paper, they looked at just one institution's data for only seven months to find:

Of the 542 potentially eligible patients identified, 224 (41%) did not have an ICD. In the initial adjusted analysis, female sex (odds ratio 1.90; 95% CI, 1.28 to 2.81) and increasing age (odds ratio 1.07; 95% CI, 1.04 to 1.11) were associated with a higher likelihood of not having an ICD. After detailed chart review, of the 224 patients without an ICD, 117 (52%) were ineligible for the device and 38 (17%) patients refused the device, resulting in only 69 (13%) patients eligible for an ICD who failed to receive one.

Realize that this was a retrospective chart review study: not a single patient or doctor was contacted. Further, a tiny sliver of data was evaluated: 7 months of data from one center (we must assume it was the authors' institution since the study was approved by their institutional review board). But even with such a small sampling of data, the authors acknowledge a myriad of reasons patients did NOT get ICD's and only "13 percent" of patients didn't get ICDs who should have.

Interesting... if you can believe the results from such a poor data sample.

But this was not the best part of this story, not by a long shot.

In the same journal, Al-Khatib writes an editorial about their group's work and extols the virtues of their study by stating:

"The authors (ed's note: me included) should be commended for taking on this onerous task. Detailed review of hundreds of charts requires substantial resources. Their research is important because administrative and other national registries have limited clinical information and may not capture vital information, such as contraindications to a particular therapy, patient refusals of recommended interventions, and long-term follow-up."

And if that is not enough, continues, "this study was conducted at one of the premier institutions in this country."

And finally... "this study by Allen LaPointe (ed note: and me, Al-Khatib) is a good addition to the literature because it highlights the importance of verifying findings derived from registries through chart reviews."

Oh, goodness gracious. Can't we at least be the tiniest bit critical of our own work and demonstrate a modicum of humility?

And how much "quality" can we attribute to the editorial efforts of Circulation: Cardiovascular Quality and Outcomes when authors write their own editorials?

Then again, maybe the media spotlight has gone to all of their heads.

-Wes

REFERENCES:

Al-Khatib SM, Hellkamp A, Curtis J, et al., Non-Evidence-Based ICD Implantations in the United States. JAMA 2011 305(1): 43-49.

Allen LaPointe NM, Al-Khatib SM, Piccini JM, et al. 'Extent of and Reasons for Nonuse of Implantable Cardioverter Defibrillator Devices in Clinical Practice Among Eligible Patients With Left Ventricular Systolic Dysfunction' Circulation: Cardiovascular Quality and Outcomes
2011, 4: 146-151.

Al-Khatib SM. 'Toward More Optimal Use of Primary Prevention Implantable Cardioverter-Defibrillators How Do We Get There?' Circulation: Cardiovascular Quality and Outcomes 2011, 4: 140-142.

Numbers

Numbers. Lots and lots of numbers.

Increasingly, we are seeing the way numbers are used to direct patient care:

• Need a defibrillator? Check their ejection fraction.
• Have diabetes? What's their glucose level?
• Need a cholesterol-lowering medication? What's their LDL?
• Are you a good doctor? What's your patient satisfaction score?
• Are you using the computer in a meaningful way? Please, count the numbers.

Even some insurers have recently begun promoting "health in numbers" on big, splashy, television advertisements and on their self-promotional websites.

As if everything in medicine is linear, predictable, mathematical.

I recently saw a patient urgently because his ejection fraction number had declined and the patient who had a pacemaker implanted about 2 years ago felt fatigued. Sure enough, his number had declined from 0.56 on an echocardiogram to 0.40 on a nuclear scan. The referring doctor was concerned and thought he might benefit from upgrading his pacemaker to a more sophisticated biventricular pacemaker. Certainly, this might be a very appropriate referral. But the patient had a little caveat mentioned on the nuclear scan next to the 0.40 number and it said this: "This value might be an underestimation." Why? Because the patient was not in sinus rhythm at the time the study was performed. In fact, he's never been in sinus rhythm for years.

But the comment was not a number. Therefore, it never registered on a computer that tracks these numbers, nor entered the referring doctor's mind. Comments are like that - poorly quantifiable but remarkably important - numbers are not. Numbers are linear, predictable, unflinching, and some might say, wholey accurate.

Except when they're not.

All of us have seen numbers following blood tests that are "lab-omas" - lab values that make no sense when viewed with other numbers next to them and when related to clinical circumstances. Those labs are repeated and, more often than not, return very different than before. Or consider the automatic blood pressure cuffs and telemetry monitor that often give faulty "numbers."

So what gives? Shouldn't numbers be infallible and uniformly reliable?

Of course not.

Numbers are one piece of the grand puzzle called medicine. Numbers certainly can help us, spotting trends and quantifying, but they almost never conclude. For instance, a very high white count might be so for very different reasons: like pneumonia, leukemia, or steroids. Each of these medical problems demands a very different clinical approach irrespective of what might be the same elevated number.

But the message is everywhere. At home. In the hospitals. On Capitol Hill. Numbers are king. We're all about numbers. Especially in advertisements to doctors and patients via TV ads, drug reps, and hospital administrators. Numbers for cholesterol, one's prostate, ejection fraction, HbA1C, quality scores, numbers of procedures, duration of erections, and now, insurance 78,000 employees managing 70 million people. Numbers, you see, will help us save billions of other numbers, we are told.

Too bad no one talks about the numbers spent on the collection of all of these numbers that are used to justify the other numbers in health care.

That, you see, would be a VERY big number.

-Wes

Just Fine

It was 11:00 pm when the pager vibrated, then beeped: it was the ER, Hospital #3.

"This is Dr. Fisher returning your page?"

"Thank you Dr. Fisher, just a moment for Dr. Frigamafratz."

A brief pause, then:

"Wes, I think we'll need your services. Old guy, found down at the nursing home, brought in unconscious, pulse 25 - hooked him up to an external pacer, he's back with us now."

"I'm on my way."

When I arrived, there was the usual cacophony of activity in the Emergency Room. Someone screaming in one corner. Intercom sounding. Ambulance en route to our location. Breathing treatments underway in Bay 5. Room 10 headed to the CT scanner. Has room 12 got a bed? By comparison my patient was easy: his disposition in the eyes of the ER staff had been made: he was on the Express Track to the EP lab.

There he was, chest twitching. Big forceful jerking. He was a big guy, uttering something with purpose but impossible to understand. Next to him, his wife, just arriving and removing her coat. "Is he going to be okay?"

My head scrambled for an answer. "He's okay for now," I think I replied.

I went about the business of trying to understand the situation, history, physical exam - at least as much as can be done with one constantly being externally paced and unable to articulate his situation - labs (have they even drawn them?), EKG, chest xray. What do we know about this gentleman? Answers were tough to come by, but slowly I learned about the speech difficulties for the past six months, the difficulty ambulating, the diabetes, the medication that hadn't been changed, "he was fine yesterday."

Stepping back from 50,000 feet, it was clear that he was not "fine." "Fine" is a relative term. "Fine" from an hour ago, a day ago, a year ago might be very different. "Fine" when your 90 means something very different that when you're "fine" at 50. "Fine" for him meant his speech was intact, though incomprehensible, "fine" was his prior stroke but alive, "fine" was bedridden yet impossibly non-communicative, "fine" was dependent on others to help him bathe, feed himself, and clothe himself. All perfectly "fine." At least until he lost consciousness earlier today. Suddenly, he wasn't "fine."

I turned to the stunned wife, thrown into the whirlwind of the Emergency Room amid bright lights, IV lines, medications, blood draws, monitors and strange devices that cause the chest to twitch to maintain a heart beat with her pleading husband's eyes as the backdrop. I explained to both of them that didn't have to continue, that we could keep him comfortable, that if the pads were stopped the jerking would stop and he would likely just pass out, painlessly, otherwise he'd need to undergo urgent implantation of a pacemaker - a minor surgery, mind you, but surgery nonetheless and his long-term prognosis would be impossible to predict.

Out of all of that, I think she heard one word: pacemaker.

This was her husband. How was I going to possibly understand their history together, their memories, their love? How could I spend the time to explain what this might mean in such a circumstance? She didn't know me and I didn't know her. How could I explain my rationale for withholding therapy to these strangers? He was awake, could hear, but could not speak in an understandable fashion. He shrugged his shoulders when asked what he wanted. Did he not understand, or did he not really want it? How could I tell? In contrast, his wife was awake, could speak and be understood, but metaphorically she could not hear. I tried, but the visuals before her were just too dramatic.

"If he has a pacemaker will he twitch like that?"

"No," I said.

"He should get the pacemaker," she said with resolve.

I slept well after his pacemaker was implanted and he was tucked in on the ward later that night. His procedure had corrected his principle problem, his chest no longer twitching. But I felt I had taken the easy road: doing something in medicine is always easier than doing nothing. When you do something, there is defined closure. There is a structure. Sure, there are risks, but we know what to do to prevent them. In contrast, to not do things is complicated, messy, risky, uncertain, constantly worrisome and even more time-consuming.

I lost track of that gentleman after he left the hospital to return to his nursing home. I often wonder what his ultimate fate became, how his days were played. I still wonder if I had really helped him that night – his existence in such a state prolonged. How might I have done things differently?

Yet strangely, even now, I find myself taking comfort in the fact that he's probably doing just "fine."

-Wes

Twitter Trepidation

"Dr. Wes, I've done Twitter before, can you show me what I need to do?"

It was easy, I helped her sign up, showed her how to send her first tweet to me and sent her one in turn. She giggled. I even showed her how she could send a more private "direct message" and how to search for things using hashtags. I then demonstrated how she could take URL's of a favorite webpage and place it into the dialog box and, presto, the URL would be shortened and the link shared with the masses.

I even became her first follower. "Now everyone will want to follow you," I joked.

She was thrilled to have learned so much so quickly. Yet anxious. "So that's all I have to do?"

"Pretty much. You'll get the hang of it in no time!"

No one explains the psychological cost of Twitter to first-time Twitter users.

She went home and logged on with her own computer, just to be sure she could remember how. There it was, her first tweet and my smiling avatar off to the right in her follower column. She logged off.

She came back a few days later just to look, not sure what to do. No change. She was relucatant to send another tweet. What should she say? Will I sound stupid? Why would anyone want to know what I think? She looked at her lone follower and wondered, is having lots of followers the good news or the bad news?

Until.... one day some time later.... she logged on and there it was:

... her second follower.

"What? Who's that?"

She had no clue. She knew she was going fishing in this great pool of social media, but no one told her there would be minnows nibbling at her toes once she waded in. The unexpectedness of it. The terror.

Having another Twitter follower means, implicitly, you're obligated to lead doesn't it?

Caveat emptor, Twitter newbies.

-Wes

What They Know

Here's a picture of the back of my badge at the recent American College of Cardiology Conference held 2-5 April 2011 in New Orleans, LA:

And here's the scanners used to track those RFID tags above one of the conference rooms:

I wonder what they know about me and if I'll still get credit for the sessions that I walked out early on?

-Wes

Addendum 8 Apr 2011: here's an excellent take on these issues from Calvin Powers from IBM's blog.

Lessons

It was one of those lectures you never forget.

Years ago, in my first year of medical school, we took our first of many amazing classes: human anatomy. There you were, day 1, all bright-eyed and bushy-tailed, walking to the basement of the hospital with your assigned fellow-students after a rousing introductory lecture into the anatomy lab.

There, in a huge well-lit room, stood a sea of steel tables covered in thick plastic bags with their most unusual contents: human cadavers.

Your first job?

To remove the bag as a team.

No one can forget that day, or that semester for that matter, as a medical student. The smell of formaldehyde that pierces your nostrils and permeates every pore of your hands while seemingly flavoring your lunchtime meals. The smell was your identifier as you stood in the lunch line: you were a first-year.

It would be easy to write about those days in the lab, but this is a story outside the lab that stuck with me through all of these years in the every-Friday lecture called “Clinical Correlations.” In that lecture we would apply the anatomy we had learned from our careful dissections earlier in the week to other clinical scenarios. The class was conducted by a brilliant radiologist. He shared his vast library of carefully-categorized radiographs with us in class and pointed to a spot on the radiographs while asking: “What’s this?” Or as we learned more disease processes that affected anatomy: “What disease might cause this?”

Very cool.

One Friday late in the year after we had completed the laborious task of dissecting the entire abdominal contents, he brought in a series of “unknown” radiographs. He would have us compete to see who could answer correctly first: winner got a trinket; losers (incorrect answers) got public humiliation and laughs from their peers. It was always a very lively class.

Little did we know what he had in store for us.

Up went the first radiograph, a pause, then: “The kid swallowed a penny!” someone would shout. “No, a quarter,” he would answer, “… but close enough.”

Then another. People stared for a while, couldn’t recognize what it was but we all knew it was something mechanical, there, in the projection of the ascending colon. Um, could it be? Yes, another foreign body that had migrated there with the switch turned on. We call cringed, amazed that he had seen such a thing. (We were young).

Then finally, as if we had not had enough, a final flat plate of the abdomen. I think I saw it first, and started laughing. He looked at me with eyes that could have pierced the thick hide of a water buffalo. He didn’t crack a smile at all. Suddenly, another female classmate blurted out, “Oh my goodness, is that a lightbulb?”

He replied to our amusement, “Yes it is: a 60-watt bulb, wide end first, in a 40-watt rectum.” By now the entire class was howling while simultaneously turning to each other and cringing. But he looked serious.

“I’d like to say something to you as future physicians,” he said above the din of laughter. Things quieted a bit as he spoke. “You will see things in your careers that are far stranger than this,” he continued, “and you must forever remember that you are dealing with a real person in real need.” Silence. “This was a situation that required the utmost discretion to manage: can you imagine what would happen to that patient if the bulb broke?” We considered the horrible consequences. “How would you handle this?”

Suddenly, the entire class felt impotent, struggling to imagine themselves in such a scenario. We quickly realized the joke was on us. We were clueless as our minds whirled to find a solution. No one could.

In the end he described the general anesthesia, the delivery forceps, and the team approach required to manage such a challenging situation and closed with these words:

“Guys, no matter how weird, how repulsive, how funny, or how crazy a situation might seem, when you see that person you MUST speak with them as though it’s the fifth case like that you’ve seen that day and respect the person’s dignity no matter what. Don’t ever forget that.”

I never have.

-Wes

Pradaxa, Your Days are Numbered

It was supposed to be the greatest thing since sliced bread: the first new oral anticoagulant in 50 years that did not require INR testing in the majority of patients. It's time to effective anticoagulation was measured in hours instead of days. There were even some data that suggested a possible propensity to lower intracranial bleeding rates compared its older counterpart, warfarin.

But the world changed for dabigatran (marketed by Boehringer-Ingelheim Pharmaceuticals as Pradaxa®) yesterday. That was the day the new proposed rule for structuring Accountable Care Organizations (ACOs) was proposed by CMS and published online with its addendum of 65 quality measures.

Sadly, dabigatran (and probably most of the other direct thrombin inhibitors being developed) will no longer represent "quality care" for patients with heart failure and atrial fibrillation. Quality measure #51 requires the use of warfarin, not dabigatran, for atrial fibrillation in patients with heart failure.

I am not a dabigatran drug representative, nor economist, but it is clear that innovative medications that have the potential to improve our patients' quality of living by unshackling them from the constant blood testing and phone tag with doctors required by warfarin have been officially deemed expensive and bad medicine.

Sadly, this new ACO rule is already outdated and permits the perpetuation of the status quo. The rule steps backward to tie our patients to warfarin instead of newer anticoagulant agents in the name of an "important quality measure." Once in place, this rule will tie our heart failure patients to our overburdened health care system by requiring all of those with atrial fibrillation to get their at-least-monthly prothrombin times (blood thinning levels) and then contacting their ACO for instructions for warfarin dosage adjustments.

Even more concerning, it will take legislative action (and probably expensive additional "Comparative Effectiveness Research" trials) to change these rules once they become law, and then only after a non-elected body decides it should do so. Never mind that such a study has been done.

This, my friends, is life with an ACO in the years ahead. It is for your own good and the good of our country. I'm sorry I will no longer be able to use my clinical judgment on your behalf soon to select the anticoagulant that's best for you. (Pradaxa, it's been fun.) But rest reassured: my quality scorecard, tied to my salary, will look impeccable. After all, I'll soon be practicing nothing but "quality" and "cost effective" medicine in our new Accoutable Care Organizational structure.

-Wes

Guts

He must have been about eight at the time. I had made the mistake of watching doctor shows on TV with him and he had probably heard my wife and I describe the challenges of my doctor lifestyle at times over dinner. For the most part, he seemed oblivious and liked the things that most young boys at that age do: sports, jungle gyms, mud, and bicycles, but he had never seen his Dad at work.

So the day came when my wife was doing errands and stopped by the hospital with the kids to drop off my pager which I had inadvertently left at home. As timing would have it, I had just scrubbed in a case, so she was kind enough to bring the pager to the electrophysiology lab control room where the technicians could retrieve it for me. My son, realizing how close he was to my workplace asked within earshot of the technician, “Mom, could I see?” She looked at the technician, and he nodded agreement. Cautiously, they entered the control room just to wave “hi” briefly through the glass.

To a young boy, the lab must have looked like the cockpit of the Starship Enterprise: monitors, switches, microphones, overhead monitors, keyboards, and a large, thick picture window through which he could peer. He stood motionless, transfixed at the sight.

There before him stood a several individuals with masks over their faces and funny bouffant hair pieces with ugly black spectacles on. There was someone else at the other end of the room in a funny multicolored skirt with a mask on, bending over to talk to the big tube above a large blue sheet. Two others stood closer, off to the side of the draped table. One looked a bit like Dad, after all he waved at him briefly with eyes peering over that goofy mask. The other person was a stranger, though – he never saw him before. Both were standing in weird blue gowns over a large sheet with two holes cut in it that was draped over some kind of table. They were working on something and looking at those black and white TV screens. The guy that resembled portions of his Dad handed the stranger a small white object that looked like a small cloth that returned from the circle with a very different reddish color. The thing was contorted as those guys threw them into a small blue bowl on the back table. A few more of these strange blood-stained objects returned from the circle, only to be placed into the same bowl again.

Finally, my son, puzzled but realizing what was happening, leaned quietly over to my wife, eyes fixed on the table, and whispered,

“Hey, Mom, those things in that bowl …

… are those guts?”

-Wes

Off to the Land of Make Believe

Tomorrow I head off to Land of Make-Believe: The 2011 American College of Cardiology Scientific Sessions in New Orleans, Louisiana.

I say this not out of spite for the organizers who have toiled to streamline the registration process and prepare the display hall, nor because I have anything against the presenters who have spent hours perfecting their talks and preparing their slides, nor because I won't learn anything there, nor because I don't have faith in the incredible will and wonder of the people of New Orleans. Seriously, it's a huge, fun, informative conference in a warm, welcoming, and conference-friendly city.

Rather, I say this because I fear these meetings will have less and less influence on how health care delivery will occur going forward as limits to how and how much care is delivered - at least as far as technology and innovation are to be used in the years ahead.

The sands are shifting beneath our feet. Every doctor I speak to knows it - some with more foreboding an outlook than others - but no one dares to show it lest they not appear to be a "team player." Instead, most of us act on the outside as though we are stalwart stewards of the status quo marching ahead to our future Land of Make Believe.

As such, we’re elated at the prospect that percutaneous aortic valve replacement will be available to all of our patients over eighty years of age with multiple severe co-morbidities soon (at least those are the only patients studied so far) and that all us who are fantastic interventionalists will soon be able to perform the procedure for all of our patients to meet the overwhelming demand. After all, the data at this meeting will show how safe the procedure is for them, right? Surely CMS would never drag it's feet toward approval of this expensive technology, would they?

Make Believe.

We watch the Stent Wars between companies and clinical investigators like a good Ultimate Fighter match: each company sparing for the right to claim a hair-thin victory over their competitor. And those bio-absorbing stents? Rock on! Surely the winner hear will take the sales prize, right? Especially since doctors have such influence over purchase orders these days. Everyone will be watching when a p value gets low enough and the legions of Press Corps spring to action as willing sycophants to the marketing hype so critical to promotion and adoption by the cardiovascular community at these meetings. As if it will soon really matter.

Make Believe.

We urge our medical students, residents, and fellows to attend these meetings and offer cash rewards to our best and brightest Young Investigators as if to suggest that most of them can still become entrepreneurs in the medical device arena in the years ahead. After all, regulatory approval hurdles for new technology aren't prohibitive, right? And those fees to the FDA, they're not too high, are they? Profits surely will be showered upon our young employee-inventors, too, right?

Make Believe.

And then there will be the transparency about how much all this stuff displayed costs, like the hybrid cath-lab/operating rooms (being developed now to install all those percutaneous valves in our elderly patients). Better to ignore this in favor of the bright, the shiny, and the new. Never mind that doctors and hospitals will soon be paid in lump sum payments from Medicare. Never mind that those payment amounts will be about 20% of where they are now. The sky's the limit for these purchase orders, right? Hospitals will get their return on investment quickly and doctors will still get their fare share of those bundled payments. Finally, look for these issues to be discussed front and center every single day at these Scientific Sessions.

Make Believe.

But I still can’t stay away. It will be a welcome respite from the cold to enjoy some nice warm weather. There’ll be nice people from all over the country and all over the world there. I enjoy speaking at these events, too: you realize the depth and breadth of commitment of today's doctors despite the forces that are changing. There’s a unique camaraderie that's developing, I feel, despite all of these changes. No matter what happens ahead, so far we are still afforded the luxury of meeting face-to-face to share our stories of patient care – both good and bad. And once in a while those stories can sometimes be shared nice glass of self-bought wine.

Better yet: it’ll be my excuse to leave those insidious Electronic Medical Record communications, office and patient e-mails, and results-reviewing behind for a few days.

Oops, I forgot.

Make Believe.

-Wes

P.S.: Anyone who wants to share some stories and a good glass of wine between e-mails at the ACC 2011 Meeting can reach me via Twitter at @doctorwes. If you're still not on Twitter, here's how and why you should consider signing up.

On Yesterday's Blog Post

... and the deconstruction of the 23-blog April Fool's Day conspiracy.

It was lot's of fun and had two over-arching lessons from my standpoint:

(1) Be critical of what you read: not all news that fit to print is fit to read, and
(2) it really is possible for lawyers and doctors to work together.

-Wes

Orson Welles: Meet the New York Times

The news grows more frequent and increasingly ominous as a cylindrical meteorite lands in Grover's Mill, New Jersey. A crowd gathers at the site and events are related by reporter Carl Phillips. The meteorite unscrews, revealing itself as a rocket machine, and onlookers catch a glimpse of a tentacled, pulsating, barely mobile Martian before it incinerates the crowd with Heat-Rays. Phillips' shouts about incoming flames are cut off in mid-sentence. (Later surveys indicate that many listeners heard only this portion of the show before contacting neighbors or family to enquire about the broadcast. Many contacted others in turn, leading to rumors and confusion.)

The War of the Worlds Radio Drama by Orson Welles Plot Summary
This 1938 coupe was a classic example of how mainstream media can manipulate their audience. As we all know, these examples continue today and should serve as a powerful reminder to medical students, residents, doctors, nurses and ancillary health professionals how all sorts of instantaneously-available information, be it health care information or otherwise, can be shaped, manipulated, processed and pureed.

Want an example?

How about this: once again, the mainstream media's darling, The New York Times, gets punked.

-Wes