Change You Can Count On: Insurers Buying Hospitals

It started with the Stark Law that physicians couldn't buy hospitals to block self-referral, but we have no problem with insurers owning hospitals.

If state and federal regulators sign off on the plan, Highmark officials say the deal will allow them to move away from traditional fee models that reward providers for providing unnecessary procedures and services.

Instead they would pay salaries to doctors, offering them incentives to achieve quality and efficiency goals. The integrated model would also rely on primary-care doctors to coordinate patients' care and focus on preventive efforts.

Highmark officials said the deal is the best way to keep West Penn in business. "It brings our expertise as an insurance company into the provider system," said Kenneth R. Melani, Highmark's chief executive.

Add to this that the Accountable Care Act and its Accountable Care Organization construct virtually requires all doctors to become employees of hospitals, we see there is little chance that independent private practices can survive much longer. So doctors lose more professional independence and autonomy and have even more chance that clinical decisions will be compromized by bureaucratic dictates. Yet ask patients who they want steering the boat when they get sick: their doctor.

It continues to be clear who the winners and losers are as health care reform unfolds. But when doctors lose autonomy, patients lose autonomy.

It's that simple.

To argue that the only way to control the health care dollar is to bloat the bureaucratic levels of our system is a fool's game. However, bureaucrats promote bureaucrats - it's always been this way. Until doctors and the public speak up, there's simply nothing to stop this train.

-Wes

For Interns: Ten Rules to Go By

He sat in a crisp white coat, staring at a computer screen, note cards in his lap. Occasionally, I noted him jot a note to himself as he compiled his list. A nurse sat next to him, pounding feverishly on the keyboard as she recorded her nurse’s note. He tentatively moved his mouse, then clicked, still staring.

I recall my first day in clinical medicine: no computer, an ER rotation, a white board filled with names and abbreviated medical problems next to them with little magnetic color-coded labels nearby. Room 1: Head trauma. Room 2: Abscess. Room 3: UTI, Room 4: Rash.

I got room 2. It was the biggest, bad-est infected sebaceous cyst on a guy’s back a newly minted doctor had ever seen. Can you say “softball?” “See one, do one,” they told me. And off I went.

Much in medicine has changed since then, but much remains the same. Medicine is miraculous, terrifying, then rewarding all at once. Fortunately, there’s a method within the madness that can serve to preserve and protect those who first start out. Every doctor has had the fortune to learn from those who passed before them as begin their journey to refine their title of “doctor” (literally, “teacher.”)

I thought it would be interesting to put a few of the “Rules of the Road for Medicine” down on paper (with the help of friends on Twitter) for interns and residents as they embark on their own incredible journey ahead. The list is not exhaustive, but hopefully can serve as a resource for our new doctors as they head off to meet their clinical challenges ahead.

Rule #1: Treat every patient like your mother
Obey this rule and you’ll do the right thing more often than not. If it means staying late, do it. If it means going the extra mile, do it. If people disagree as to a specific approach to care, ask yourself “What would my mother want?” Then go that direction. Be kind. Be respectful. Wear clean clothes, brush your teeth, comb your hair, and look your best. (Note: @DrElizabethLee was quick to remind me that kids are not always kind and respectful, so their age might require a slightly more top-down, “parental” approach.)

Rule #2: There are an infinite number of ways to get screwed
That’s right – not a thousand, not a million, not ten billion – but an infinite number of ways… Check and recheck. If you’re not sure, check it again. Somewhere out there, born 20 years or so ago, there is a person whose sole mission in life is to thwart your efforts to protect your patient. It usually is not intentional, mind you, but it happens. Like the nurse who feeds the patient breakfast when they’re NPO after midnight, or the orderly who accidentally trips and pulls out the IV or better yet, the pacemaker wires. Oh yeah, it happens. So double-tape where single-tape might do. Communicate. Involve the team. If you’ve got a better idea, say so. If someone else has a better idea, defer to them. Park your ego at the door and work to avoid the errors. Everyone will benefit if you do.

- Corollary: “If there’s a test for it, just get the test.” (h/t: @gruntdoc)

Rule #3: Do the rectal.
Surgeons always emphasize this point, but it extends far beyond the obvious. Consider it shorthand for “do the physical.” Trust no one except yourself and what you see, hear, and feel. More often than not, you’ll be rewarded with the satisfaction of finding something no one else has, simply because you made the effort to lift the covers and do the exam.

- Corollary: Believe none of what your hear, half of what you see, all of what you do. (h/t: Benjamin Franklin via @MGKatz036)

Rule #4: Medicine is like life – no “always” and no “nevers”
So research, research, research. Don’t be cocky. Humility is paramount since there’s nothing like the vagaries of medicine and individual circumstances and personalities to take the wind out of your sail. No single person (or website) has all the answers. Attend the lectures while you still can: you’ll never be spoon-fed like that again. Remember: the learning never ends. (h/t @sonodoc99 and @shartiga)

Rule #5: Your family is your anchor
Spend time with them. Make them a priority. Surprise your spouse or significant other with flowers, or better yet, carry-out. If safe to do so, leave work to attend the kids’ assemblies at school or their sports games and return later if you still have work to do. Do this and they might even help with your laundry once in a while. (h/t @DoctorNatasha)

Rule #6: It’s okay to say “I don’t know”
… just be sure to add “… but I’ll look it up.” More often than not, someone else might have an idea, so bring in the cavalry. Use the phone and call the expert – even if he or she is in another state or country. Still, if the answer remains elusive, it really is okay to say you really don’t know what to do. Sometime there is nothing you can do. And once in a while when all other options have been exhausted, don’t forget to ask the patient or family for their help to see if they have another idea that you haven’t tried. (h/t: @kevinmd)

Rule #7: If you screw up, say you’re sorry.
Lots has been written on this, and certainly there’s an appropriate time and place for doing so, but take the time to offer your apologies if a mistake occurs. Work to make sure the mistake doesn’t happen again and realize there is an important bond that forms when a doctor sticks with his or her patient through thick and thin. (h/t: @kevinmd)

Rule #8 – Play nice
Nurses, respiratory technicians, physical therapists, nurse practitioners, dietary personnel, pharmacists, and the EMT's/paramedics are your friends – keep them that way. Be respectful, appreciate their skills, and use their expertise. Most important, before you try to lie down on call, ask the covering nurse(s) if there’s anything they need before you retire. It might just save you a page. (h/t: @rlbates)

Rule #9 – Crazy people get sick, too
So be sure to attend to rules #1, #2, and #3. (h/t: @InpatientMed

Rule #10 – Do the dirty work
All you have to do is help with nurse with a digital disimpaction, enema, or cleanup of a dirty bed and you’ll be an instant hero. Word travels fast. After all, believe it or not, you are not above the others. You are part of a team: just one member with a bit more responsibility at times. By helping, you’ll be helped. By caring, you’ll be cared for. And sometimes, your new patients or colleagues might even bring you cookies.

-Wes

10:20PM CST Addendum: The corollary to Rule #3 was added and edits to Rule #8 made to include EMT's and paramedics. Thanks to all those who have contributed to this post! (Keep 'em coming!)

Appointment Phishing

Imagine you're a doctor and receive this phone call:

“Hi, my name is Alexis Jackson, and I’m calling to schedule the next available appointment with Dr. Michael Krane. I am a new patient with a P.P.O. from Aetna. I just moved to the area and don’t yet have a primary doctor, but I need to be seen as soon as possible.”

Doctor’s office: “What type of problem are you experiencing?”

Patient: “I’ve had a cough for the last two weeks, and now I’m running a fever. I’ve been coughing up thick greenish mucus that has some blood in it, and I’m a little short of breath.”

Upon hearing his, you cancel two other follow-up patient appointments to make room for this longer new-patient appointment. Sadly, you later find that "Alexis Jackson" isn't a real patient but rather a decoy - a so-called "mystery shopper" paid by our government - just so that wait times for your appointment could be determined.

Most patients I know would understand a doctors' need to make room for a new patient with an urgent problem. But I am also quite certain that most of my patients would not tolerate finding out that a government-paid stand-in lied to me and intruded on their care just so the government could gather information on my appointment availability.

When information gathering trumps patient care - particularly fictitious care - we've got a problem. Is this a new quality standard we can expect from our new government health care initiative?

Just like scam-artists that phish for unsuspecting people's financial information online, governmental appointment phishing should not be tolerated in any way, shape, or form. It is fraud - plain and simple.

Otherwise, many people's health care will be adversely affected as a result.

-Wes

Reference: Pear, R. "U.S. Plans Stealth Survey on Access to Doctors." New York Times. June 26, 2011.

28 Jun 2011 10:30PM CST Addendum: Wow. Maybe this blog matters after all: New Tork Times: "Administration Halts Survey of Making Doctor Visits"

It's Friday, Are We Grilling?

I could have sworn they were preparing to grill us some bratwurst this morning:

Dang. Just a new cleaning cart...

-Wes

When Speech Trumps Privacy

I just read the recent report on the Supreme Court striking down the Vermont law that bans the practice of data mining. “Data mining” occurs when third party corporations purchase prescribing information from pharmacies and match it to individual doctors through a 44 million dollar deal with the AMA to utilize its physician master file. The third party corporations then sell this linked data to pharmaceutical companies to assist their detailers in their marketing efforts.

In days gone by, pharmaceutical companies had a hard time acquiring this information because doctors wrote their prescriptions by hand. Today, as we all know, doctors must e-prescribe, that is, electronically transmit their prescriptions via the internet to pharmacies. Each of thise prescriptions are carefully tracked by our significant "stake-holders" of health care: hospitals, pharmaceutical companies, governmental regulatory bodies and the like.

What interests me from this ruling is that the act of collecting this information -- the prescribing physician's name and address; the name, dosage, and quantity of the medication; the date and place where the prescription was filled; and the patient's age and gender -- was considered "speech" with the justices ruling that "the creation and dissemination of information are speech for First Amendment purposes."

Think about that: writing a prescription and disseminating that information is now "speech."

What I wonder, of course, will all our prescribing practices that are entered on an Electronic Medical Record, be they for a medical device, test, order, or request, similarly be classified as "speech" protected under the First Amendment? Might this ruling significantly impact a patient's right to privacy about their health condition as innumerable third parties can now access prescribing (aka, ordering) information in the blink of an eye electronically?

Oh wait, they already are.

-Wes

Grand Rounds is Up

It's been eighteen hours and counting since a storm squall passed through Chicago last evening knocking out about 250,000 folks' electricity, including mine. Fortunately, Shrink Rap has offered a well-timed Summer Soltice edition of Grand Rounds on "hot" topics for your enjoyment while I see if I can get a battery backup system for my sump pump...

-Wes

What the Department of Health and Human Services Doesn't Know About Cigarette Ad Graphics

... despite what the graphic says, they can't be subject to copyright by the Department of Health and Human Services.

-Wes

Cell Phones: The Latest Target for Infection Control?

Alright doctors, time to give up the cell phones. (Never mind that there has not been a study linking cell phones and hospital acquired infections).

From the American Journal of Infection Control:

A cross-sectional study was conducted to determine bacterial colonization on the mobile phones (MPs) used by patients, patients' companions, visitors, and health care workers (HCWs). Significantly higher rates of pathogens (39.6% vs 20.6%, respectively; P = .02) were found in MPs of patients' (n = 48) versus the HCWs' (n = 12). There were also more multidrug pathogens in the patents' MPs including methicillin-resistant Staphylococcus aureus, extended-spectrum β-lactamase-producing Escherichia coli, and Klebsiella spp, high-level aminoglycoside-resistant Enterococcus spp, and carabepenem-resistant Acinetobacter baumanii. Our findings suggest that mobile phones of patients, patients' companions, and visitors represent higher risk for nosocomial pathogen colonization than those of HCWs. Specific infection control measures may be required for this threat.

What specific measures might they consider?

They better be careful what they wish for or they might also have to take away all those dirty EMR computer keyboards, too.

-Wes

Heart Failure Therapy Inappropriately Bashed

People who stretch the limits of science need to be called out.

Especially when their intent appears to be to change therapy recommendations based on conclusions from a retrospective meta-analyses. Meta-analyses are nothing more than selectively-pooled studies aggregated by statistical pseudoscientific hand-waving and data manipulation fraught with so many examples of bias that we have to wonder if the intent of the lead author's comments about such a study to the media were not focused on whether their hypothesis was an appropriate topic for future study, but rather if some just had another axe to grind.

Repeatedly this week we have seen the lead author of the meta-analysis that attempts to determine if QRS width can predict future responders to cardiac resynchronization therapy (CRT) promulgate opinion in the name of science. In fact, the study's lead author, Ilke Sipahi, MD leaps to such amazing conclusions about the study's findings that the mind just boggles. From the Wall Street Journal, to Consumer Reports and now, that bastion of scientific reporting, the New York Times, his comments resulted in a main stream media feeding frenzy on the technology. His conclusion?

"In this in-depth analysis, we found that pacemaker patients with less severe electrical disturbance in their hearts did not receive any benefit whatsoever from these expensive and potentially risky implants. Given the abundance of data showing lack of efficacy in this patient population, current treatment guidelines should be changed."

Wow. I'm speachless. Cause and effect to change medical practice from a meta-analysis! Since when?

Since never.

And how did the mainstream media interpret the study?

Here's a sample comical passage from a Consumer Reports article entitled "Many Heart Failure Patients Don't Benefit from Pacemakers:"

Current American Heart Association guidelines say that patients with a QRS (the measurement of the activity of the heart's left and right ventricles) of greater than 120 milliseconds should be treated with CRT (Cardiac Resynchrtonization Therapy). But the study found that patients with a QRS between 120 ms and 150 ms—38 percent of the participants—received little to no benefit from CRT. In contrast, the 60 percent of people who had a QRS of 150 or higher did benefit.

Said another way, 38% (about 40%) of patients with QRS widths between 120-150 had no benefit to CRT pacing, and 40% of patients with QRS widths greater than 150 also had no benefit to CRT pacing. (Yet a remarkably large 60% of these very sick patients with or without wide QRS complexes - most NYHA Functional Class III - benefitted from the therapy.)

Yep. That's the real data: pre-procedure QRS width does not predict who will respond to biventricular pacing therapy clinically. Some will. Some will not. Truth is, we can't predict a priori which patients will respond to this form of pacing therapy for heart failure. To suggest (suddenly and miraculously) that QRS width can predict response from these poor data aggregations when numerous other studies have failed to show such an effect is an irresponsible leap.

Now, please guys, can we stop bashing the best form of heart failure therapy for patients with wide QRS complexes above and beyond our maximal medical therapy and move on to more important issues like bathing salt bans extolled by our AMA leadership today?

Now there's science!

-Wes

P.S.: (For a much calmer evaluation of the trial and the media's response, see Dr. John Mandrola's blog.)

Reference: Sipahi I, Carrigan TP, Rowland DY, Stambler B, Fang JC.
Impact of QRS Duration on Clinical Event Reduction With Cardiac Resynchronization Therapy - Meta-analysis of Randomized Controlled Trials
Archives of Internal Medicine Published online June 13, 2011.

Disclaimer: Dr. Fisher is on the speaker's bureau for the medical device companies Medtronic and Boston Scientific and earned $2000 from each company in the past year for that teaching. Also, he often cares for real patients with heart failure and, yes, earns a portion of his living implanting CRT devices as a board-certified cardiac electrophysiologist.

How the Housing Market Is Affecting Doctors

Six years ago:

Low-interest loans, virginal credit records, an MD degree.

Need a home, doctor? No problem! How about one of these super-duper snazzy townhomes in a nice neighborhood. Just sign here!

Now:

A marriage, a young family. Perhaps time to buy a new place?

Oops. They can't. The townhome next to them is priced for a short sale at 60% of their purchase price and hasn't had an offer in a year.

Can you say, "under water?"

"Walk away from the mortgage!" many say. "It's not worth it!"

Until they realize they won't have any credit for about, oh, nine years.

Or maybe they could try one of these options.

It's not just about higher medical education expenses and lower salaries for our younger doctors. Like many others in today's economy, it's about the housing crisis, too.

-Wes

Small Miracles

There are very few things that qualify as electrophysiology emergencies, but recurrent ventricular tachycardia with subsequent implantable cardiac defibrillator shocks is one of them. Especially when it continues despite your best efforts to quell the arrhythmias with our most potent antiarrhythmic medications. The options are few at that point: attempt a ventricular tachycardia ablation, refer the patient for possible transplant, or turn the device off and move the patient to hospice care.

For patient's in their mid-70's, the options wean to two of those - do or die - literally.

So after long discussion with the patient and his family, the young electrophysiologist booked the case, knowing full-well it's difficulty but hoping to locate the focus of the predominant ventricular tachycardia in hopes of buying a bit more quality time for the patient free from the painful mechanical hourly disruptions.

Things progressed well at first: The patient was anesthetized and device deactivated. Access was reasonably easy. Monitoring lines were placed without difficulty. A complicated array of sophisticated mapping equipment was installed into the various chambers of the patient's heart. Before long and a few ventricular extrastimuli later, several forms of ventricular tachycardias were easily induced. Regretfully, these were not the clinical arrhythmia. But with perserverence and a few more extrastimuli, there it was: sustained monomorphic ventricular tachycardia just like the patient's clinical arrhythmia - a moderately fast, tough-to-pace-terminate beast.

"Burst at 360." (our lingo for pacing at a 360 millisecond cycle length, or 167 beats per minute)

Nothing. The arrhythmia continued.

"Burst at 320."

Still nothing.

"Burst at 300."

"Doctor, his blood pressure."

"Okay, let's shock him."

The defibrillator charged and delivered the life-saving jolt across the patient's chest. And there it was. A paced rhythm. A moment of relief. Then,

"We've got no pressure!"

"Give him a second." Pacing was fine, just no mechanical movement.

"Still nothing!"

"Start CPR! How about some EPI! Anything? Check the airway! Call for an echo, stat! I'm deflating the mapping array.... Continue CPR. Anything?"

"Got a little pressure with CPR..."

And on and on it went. Seven minutes that felt like a lifetime. Finally, a pressure without CPR. An exhausted staff. An anxious anesthesiologist. An uncertain electrophysiologist.

Thoughts flooding: "Will he be okay? Did I do the right thing? What went wrong? I never had that happen before. Such a nice guy..."

The hours after passed quickly as the patient was transferred to the ICU, pressors infusing, the patient still asleep under the merciful mix of general anethetics as the ventillator moved his chest up and down. The walk to the waiting room. The discussion about what happened, the uncertainty of how the patient would fare. Then returning to compose the note that could never captivate the sense of helplessness of the moment while still not knowing what had happened. No effusion, heart looking as it had, the chest x-ray unchanged.

Finally, after rounding on several of other patients that had been left neglected during the kerfuffle he returned home, exhausted both physically and emotionally, questioning his ability, his career choice, his resolve. Did he do the right thing? Would he ever do that again?

He parked his car, then walked inside and collapsed on his sofa, just wanting to escape for a brief moment to peace, quiet and solitude for a moment all his own.

Then he felt it, a tiny hand upon his cheek.

He turned, and there was is 18-month old son, with outstretched hands peering up into his flooded eyes, grinning with a fragment of mascerated Goldfish cracker in his lips and holding a fist-full more in an attempt to feed him.

And in a flash, as if sent by God himself, all was right with the world.

-Wes

Tag, You're It

It's in your inbox: the results of a nasal swab for MRSA that you never ordered.

Tag, you're it.

Scores of monthly INR results for patients from the past 10 years of care. They're now cared for by "your" nurse practitioners. Has someone addressed all these?

Tag, you're it.

The ER with "your patient." The one you saw once in consultation back in 2004.

Tag, you're it.

A pneumovax given that you nevered ordered. A patient who's angry with a bill.

Tag, you're it.

An EKG result you've already read. And signed. But that's not enough. It's scanned in to the computer now so please click on it to "sign it," will you?

Tag, you're it.

Confirmation of an e-mail message that you sent to your patient. Click again, please, so the computer knows that you know that you sent it.

Tag, you're it.

You didn't call her with her results within 24-hours?

Tag, you're it.

It's astonishing: the speed, the volume, the ability to recall information today from days, weeks, even years before. Like a overspun conveyor belt with information packages coming at you from everywhere spinning faster, faster, faster still.

Someone has to be responsible for all the mandated care, the results, and the labs tests ordered behind physician's backs in our new era of electronic medicine.

So doctors: tag, you're it.

But here's a little secret from the IT department: just highlight them all, then right click. It's so much faster.

See?

Then a knock at your door.

A summons.

Tag, doctor, you're it.

-Wes

The Double-LVAD

There's a nice picture of a paired left ventricular assist devices (I guess to serve as left and right ventricular assist devices) over at Wired magazine:

Kind of cool.

Of course it would be nicer if it wasn't a post-op chest xray with four chest tubes...

-Wes

Addendum: h/t to @rlbates on Twitter to pointing me to this nice piece from NPR about this case.

What If Obamacare Were Found Unconstitutional?

Health care is a sensitive issue politically.

And as things would have it, it now is a sensitive issue legally.

So my thoughts now are not meant to be partisan, but rather a "ground-floor" perspective on what would happen if the Patient Protection and Affordable Care Act were found entirely unconsitutional.

What would happen?

Would a bunch of post-college aged kids ages 21-27, promised insurance beginning this year, suddenly no longer be eligible for care? Probably not. Most insurance policy constructs last a year, so changing coverage would take a while. Still, there will remain a need for some type of insurance coverage for this group outside of classic employer-based insurance since jobs are few and far between for this group. Irrespective of whether the PPACA is enacted or not, employer-based insurance is becoming a thing of the past.  (Update 26 Jun 2012: the nice insurance industry has found this provision to be both popular and highlly profitable since young folks rarely get sick, hence they will continue this provision, even if the PPACA is struck down)

Would doctors who sold their practices lock, stock, and barrel to large health care organizations be able to disband from these large health care organization superstructures (and their associated non-compete clauses) to restablish independent practices? No way. For doctors who performed imaging procedures in their offices at a discount to what hospitals charge, CMS claimed "self-referral" incentives for these procedures, and stopped paying for them in the outpatient setting (but interestingly, not for hospitals). Consequently, by banning payments to doctors for these services, independent physician practices no longer were viabile, except those in affluent neighborhoods where concierge medicine could establish a foothold. The employed physician model and more hospital consolidation seems inevitable going forward irrespective of the outcome of legal challenges to the PPACA.

What about people with pre-existing conditions? It would seem that care would be delivered as it is now for this group. Charitable care, ER care, Medicaid programs would likely have to expand putting even more pressure on our state budgets. But then, isn't this why many states are concerned about the PPACA in the years ahead anyway?

Will the electronic medical record and electronic prescribing, the cornerstone of purported cost savings and efficiencies under the PPACA suddenly disapppear? Of course not. The EMR has been wedging its way into medicine since at least 2004 (that's the last year we had paper inpatient charts at our institution). Newly minted doctors today have never manually written inpatient orders, have never had to walk to radiology to "pull the films" to see a chest x-ray, or go to the microbiology lab to review culture results. They are wired. They expect instant test results. They expect to be able to read outpatient notes. They expect to be able to find another responsible doctor in the care history of a patient. In fact, novelty patients now are those who have never had an entry in their electronic medical record: "Gee, no one's seen this guy before!" Bottom line: an unconstitutional PPACA won't derail the electronic medical record.

It has been estimated by the CBO that repealing the PPACA would cost $210 billion dollars if this occurred between 2012 and 2021. What that money would be used for is anyone's guess (legal and political PR fees?). We have to wonder. But common folk like most of us are not privvy to the intricacies of government self-serving budget-making.

So what if the PPACA is found unconstitutional?

It. Won't. Matter.

Irrespective of the outcome of the pending legal battles for or against the PPACA, we continue to have a huge cost of care crisis in America. Our problem (hate to say it) was never a need for "insurance reform." It remains a problem of costs. And the PPACA does little to help us understand where cost savings would be realized. Why is this?

The legislation was authored by powerful interest groups who were "brought to the table" to feast on the last vestiges of fee-for-service health care. To date, they continued to gorge themselves. I'm not seeing a concern about costs. I'm seeing a consolidation of monster health systems accross our land. Much as the insurance industry found profits by eating their own before, so now are hospitals. Bigger, more doctors, more huge facilities gobbling up their competitors until the last Great Health System can claim the "Too-Big-To-Fail" prize. And why not? Our jobs and economy depend on it. We continue to want the best of care without compromise (though there are responsible rumblings out there about end-of-life care.) Bigger systems running more smaller systems. Not only will it be bigger, more efficient, but safer, too! Our wonderful Utopian vision of the future. Costs be damned. We've got to build for the future and the influx of newly-eligible health care customers!

There is no interest in shrinking the middle man.

Instead, our entire system is cloaked in financial secrecy as we continue to build our Health Care Hindenburg under the auspices of the PPACA, or not.

-Wes

Deception

This came in the mail today:

Click image to enlarge

Any idea what it's for?

-Wes

PS: The "little bit of everything" is on the reverse side, for those who must know.

When the Stuff Hits the Fan

Easy case.

Seen it a hundred times.

Old guy (or gal).

Comes into ER.

Found "down."

"Hey doc, looks like his hearts goin' slow. I think he (or she) needs a pacer."

"On any meds that might do this?"

"Nah."

"How's his (her) potassium?"

"4.3, normal."

And like lots of times, you head in. Glad you can help. Call-team's on their way, thanks to you. Called the device rep to make sure they can be there just in case, too. Cool as a cucumber. Nothin' to it. Been here, done this.

You arrive to a guy (or gal) that looks pretty good. Maybe has one or two medical problems. Heart rate's better thanks to the atropine and the fluids they gave him (her) on arrival. The intraosseus line in the tibia is impressive, too. ("At least he (she) wasn't awake when that happened," you think.)

So you review, examine, plan your approach. EKG on presentation? Ouch, heart rate agonal. Wide complex rhythm of right bundle branch rhythm. Look at the monitor: "lots more right bundle branch rhythm there, thank goodness, P waves, too." you secretely notice.

Seems he (or she) is willing (how many times does he (or she) want to pass out at home?), understands what lies ahead, that the crew's on their way. "We'll be taking you over in just a few minutes. Any other questions?" There are none.

Perfect.

And after a while the crew arrives, assembles the poor guy (or gal) on the table and ships him (or her) over to the cath lab area. Chest is prepped, equipment assembled, antibiotics given, monitors connected...

... damn we're good. Smooth operators.

So the local anesthetic is injected and the incisions made. Dissection to the pre-pectoralis fascia just above the breast muscle accomplished, even the wires passed easily into the vein using ultrasound guidance. Even having a nice chat with the guy (or gal).

Poetry in motion.

Sheaths placed in the vein over the guidewire, pacing leads placed through the sheath. Until, from the control room...

"We lost our EKG."

You glance up. Nothing on the monitor. Brain shifts from 33 rpm to 78 rpm, then higher....

"Okay, boys and girls, let's find the problem. Device rep? Turn on pacing from your PSA." You fluoro. No heart motion. Curved stylette goes into the longer lead.

"I've got the airway," the nurse shouts. "Should we start CPR?"

"Not yet, moving the lead to the ventricle..."

"Crap, he's (or she's) moving. Seizing. Sh%^#t! Hold him on the table! Need... him... under... flouro.... just... one... more... second..."

"There! Turn on pacing!"

You look up. Pacing has begun. EKG shows capture. Your sphincter relaxes. A bit. Until beneath the surgical drape, thrashing ...

"It's okay sir (or madam)! You just passed out. Don't try to get up off the table. You're in surgery, remember?"

Calm ensues.

Suddenly flat line on the monitor again....

"What the?..."

You step of the flouro pedal again. Lead looks good. Moving.

"He's still with us," the nurse shouts. "Still got a pulse ox reading. Must had knocked off the EKG lead..."

"Come on, guys! How many changes of underwear do I need to bring for these cases? Sheesh! ... Sir (or Ma'am), you doing okay?"

"Uh, yeah, doc. What... happened?..."

"You passed out again on us. Just like you did at home. It's all good now, we got that lead in place."

And so, as dusk settles over the horizon on another thrilling ride in the EP lab, you stop to reflect on just how lucky you and the patient were that day. By the grace of God you had access to the vein already, the lead in the right atrium, and the presence of mind and experience to position the lead to the ventricle in the nick of time.

You know others before you weren't so lucky. You know that others, despite their best efforts, had the patient die. You know how terrifying those seconds were. You wonder if they got sued.

No fault of their own. Just fate.

So you vow from that day forward that you'll always place a temporary pacing wire from the leg before you start an emergency case like this on the weekend.

It's all about having control.

And reducing your underwear cleaning bills...

-Wes

The Making of a Doctor

... or mad scientist:

7th Grade Frog Dissection (Click to enlarge - if you dare)

Some say my tongue's still out when I do pacemakers... just hard to see behind the mask...

Heh.

-Wes

So Much For Paying Me for Keeping You Healthy

Okay, America. Stay healthy. Eat only two thousand calories per day, exercise five times a week, don't smoke, keep your body mass index at an appropriate level and for goodness sakes, don't let me find your hemoglobin A1C over 6.5, ya hear? I demand it.

Okay, Mr. Hospital-Employer, I did my part, now pay me, okay?

What? You won't? What do you mean when you say I haven't DONE anything?

I have just broadcast to the world (via the internet, no less) exactly what I should be doing to keep people healthy. Isn't this payment-for-keeping-people-healthy thing supposed to be our new payment model going forward? We're all in this together, right? You know, one big happy Accountable Care Organization. Accountable for the quality of care we provide and for our ability to keep people out of our doors. What's better than preventing illness for lowering our costs to the health care system?

What's that you say?

What do you mean I have to work nights and weekends now? I've been your stalwart foot-soldier! I've done everything our administrative directors and the government has asked me to do: click questionnaires, completed my charts, looked at patients in the eye when I care for them, even went above and beyond to blast sincere public service announcements on your behalf!

What's that? They're getting sick anyway?

No way. They can't! They've done everything right! They've followed my every message! People don't just get cancer! We can STOP that, darn it. Maybe we can issue a few more sincere press releases and policy ideas...

Yes, sir. Sorry, sir. I'll try to do better. No problem going to another hospital that you bought. Really. No that's fine. What's a few more RVU's, right? Yes, sir, I understand.

* pause * (Reaching for his cell phone)

"Honey, I'm going to be a bit late tonight. Looks like I have to see a few more consults..."

-Wes

On FDA's Simvistatin 80 mg Tablet "Label Change"

For those of you who may have missed it, the FDA came out with a "label change" recommendation for simvastatin 80 mg tablets yesterday. In short, doctors, stop using this dose.

Now what I find interesting is not the recommendation, but the background for it.

This recommendation comes for a drug (ahem, the ONLY) generically-available statin (read, "cheap") for our patients who don't have the cadillac drug benefits many folks still have. It also heralds not from a late-breaking clinical trial, but a clinical trial from.... (drum roll, please) ... two-thousand and EIGHT. (What the *$%^#$*?) Yep, that's when the SEARCH Trial on 12,000 patients comparing the LDL-lowering effects of simvistatin with high- (80mg) versus low-dose (20mg) doses of simvastatin was published.

Realize that the SEARCH Trial showed a trend toward reduced heart attacks and death from higher dose simvastatin but did not reach statistical significance, yet had a higher incidence of rhabdomyolysis in patients on the high-dose simvastatin therapy.

So where has the FDA been the past three years? Why now? Why not a similar advisory on the 80-mg dose of Liptor? Or high-dose Crestor? Might it be because higher-dose statins might actually save more lives and reduce stroke? Or should we be more concerned about rare side effects like rhabdomyolysis which, last time I checked, while can be life threatening, is often reversible when recognized.

Further, this is on one of our most widely prescribed statins out there. The recommendations proposed have impacts that span far and wide for our patients. The FDA recommendations go beyond the results of the SEARCH trial to include additional recommendations regarding dosage adjustments for other well-recognized simvastatin-drug interactions. Worse, their recommendations conflict with their earlier drug-adjustment recommendations and are far more restrictive. (Data, please?)

For instance, earlier, the FDA wanted us not to use more than 20 mg simvastatin for our patients on Amiodarone. These new recommendations tacitly cut the recommended maximum dose in half to 10 mg. Why? Just because? Or are they now more concerned about rare side effects than they are about the number of heart attacks and strokes our patients might have on the lower dose of medication?

Additionally, where are the recommendations and compensation for making changes to our patient's medication regimens? Our electronic medical records do not have the ability to query medication dosages, time taken, interactions readily available. Oh sure, someone can probably build one at great expense, but does that mean we need to contact all of these patients and make the changes? Are we negligent for not doing so now?

Merck has published a website called "simvastatininfocenter.com" where patients can get more information so the company can to cover their derrières.

Doctors have no such means for a mea culpa.

Won't be long before we see the website MuscleAchingOnSimvastatinSoSueYourDoctor.com.

Thanks, FDA.

-Wes

The Rise of Specialty Hospitalists

It started as just a figment of the hospitalist movement years ago when I saw an ad in Florida advertising for a cardiology hospitalist. Now it seems the trend is continuing to other specialties like neurosurgical, orthopedic, OB-GYN, and ENT hospitalists.

In the new construct of health care reform ahead, will specialists evolve to mere proceduralists?

If so, should we insist our hospitalist colleagues obtain additional specialty training and board certification in their chosen "specialty" fields? Or is a mere "label change" of the hospitalist title enough to assure quality care for our patients?

This trend toward lower-cost, less-trained individuals subsuming titles of "specialists" so hospitals can meet their bottom lines leaves me lukewarm regarding patient care quality. Yet ironically, I suspect that 90% of things we do day to day in my field will be managed fine by this construct.

It's just the other 10% of cases that aren't routine that I remain concerned about. It's like that old Harry Callahan line spoken by Clint Eastwood in the movie Dirty Harry:

I know what you're thinking. "Did he fire six shots or only five?" Well, to tell you the truth, in all this excitement I kind of lost track myself. But being as this is a .44 Magnum, the most powerful handgun in the world, and would blow your head clean off, you've got to ask yourself one question: Do I feel lucky? ... Well, do ya, punk?

-Wes

The Government's Research Double-Standard

If you want to sell a new drug or therapy in America, you must perform a prospective, randomized clinical trial to prove its safety and efficacy. Further, if that trial does not reach one or more pre-specified clinical endpoints, you can't advertise or publish the trends found.

But if you want to limit costs in medicine, it seems the government is intent on looking the other way:

At stake in the Harkonen case is a much broader debate over the standard for drawing clinical conclusions from scientific data. FDA typically requires two forward-looking or prospective trials, in which patients are randomly picked to get either an experimental drug or a placebo. That might be an appropriate standard for FDA approval, but it's an excessive burden for private firms that merely want to share their truthful research conclusions with doctors. The restrictions may also violate the First Amendment; Dr. Harkonen is appealing on those grounds to the Ninth Circuit.

At the same time government is limiting what private companies can legally communicate about their drugs, it has set a much lower standard for federal health agencies. President Obama has created new institutions with the sole mandate of running trials based on softer statistical standards. Retrospective studies will be the core occupation of a new "comparative effectiveness" research agency that has $4.1 billion to conduct government studies on medical products. The results will be used to inform federal treatment guidelines, as well as Medicare's payment policies.

At least $100 million of that $4.1 billion is being spent on promoting research results. The Agency for Healthcare Research and Quality recently paid $26 million to the PR firm Ogilvy to "market and promote the adoption" of the findings.

And it doesn't stop there.

Our clinical treatment "guidelines," now number some 2,766 for physical and psychiatric treatments according to the government's "Guideline Clearing House" (even, ironically, one for "Wandering"). These prescripts for care use a cornucopia of non-scientific methods, including opinions and case studies to formulate their recommendations, stating:

"Research findings and other evidence, such as guidelines and standards from professional organizations, case reports, and expert opinion were critiqued, analyzed, and used as supporting evidence."

So when scientific rigor is given only lip-service by our government regulators, what will happen to the quality of care provided to our patients?

Maybe government recommendations should come with a food-label like disclaimer:

-Wes

Regulations Gone Wild

We certainly have seen regulations upon regulations appear for health care over the past several years, and this letter to the editor of the Wall Street Journal (1 June 2011) from the Commissioner of the Consumer Product Safety Commission, Nancy A. Nord, should cause us all to pause:

As a commissioner at the U.S. Consumer Product Safety Commission (CPSC), I can attest that no such (regulatory reform) activity is happening at this agency. We certainly have not combed through our regulations to eliminate those that are "out-of-date, unnecessary, [or] excessively burdensome," as he suggests is being done across the government. Instead, we are regulating at an unprecedented pace and have pretty much abandoned any efforts to weigh societal benefits from regulations with the costs imposed on the public.

In health care, we have seen an unprecedented rise in regulations for in-hospital MRSA screening while little data have been forthcoming about its patient benefits. Doctors are under increased administrative burdens to complete Pay for Performance questionnaires without any evidence of their benefit to patients. Burdensome and costly re-credentialing programs have never been shown to improve health care quality. In fact, we're seeing so many regulations on how we provide care foist upon us without any clear indication that patient outcomes have benefited that we have to wonder if, like the CPSC, common-sense regulation will even get a head nod as well.

How doctors will work to free themselves of these administrative burdens while maintaining the clinical care volumes in the years ahead now that they are increasingly beholden to a larger health care management organizations remains to be seen, but I suspect once patients encounter problems with access to their own care, there might be a chance for effective reappraisal of which regulations really are in their best interest.

Until then, with more centralized control of health care, look for more and more regulations heaped on providers to control costs, safety and improve efficiencies "just because."

-Wes

Twitter at Scientific Sessions

Bryan Vartabedian, MD over at 33 Charts has an interesting post on his blog today: Should Twitter be Restricted at Scientific Meetings? I encourage all to read it.

Increasingly, scientific sessions (many of which have heavy corporate sponsorship) have evolved from scientific endeavors to those of marketing and media endeavors. While there are benefits to pharamceutical and medical device representatives gaining "access" to "key opinion leaders" to explore ways to further innovate in medicine, there is also a chance that these interactions will influence and bias.

Doctors know this. So do device and pharmaceutical reps. As do the media.

But at most of the recent Scientific Sessions that I have attended, there is usually a sign at the door of the meeting telling us photographs are prohibited. And yet, without exception, I have seen people snapping pictures of slides and posters and friends, among other things.

Who are we kidding? The ubiquious nature of cell phones capable of snapping a picture and sending it around the world in seconds exists on nearly every attendee at these meetings. Yet somehow I haven't seen anyone wrestled to the ground to surrender their cell phone to authorities to date.

And most of these scientific meeting sponsors have welcomed social media as part of their marketing efforts, publishing updates on sessions underway, not to mention encouraging companies to market their wares at the meeting as well. Should doctors, then be restricted? We're not talking censorship of the scientists are we?

So should we restrict the use of Twitter at scientific sessions?

My thoughts on this: if you've invited the media to cover the event, then by default, you've invited Twitter.

-Wes

The Case of the Missing Pager

It happens to every doctor at some time in their busy career: the missing pager. Usually, discovering the locale of the digital disrupter is quite simple: you simply page yourself provided, of course, that the contraption is not on "vibrate" mode.

And so it was with me some time ago.

The scene was a familiar one: rushing off to work, heading out the door while contemplating the upcoming caseload of the day with my mind wandering off to great medical thoughts when, suddenly, I reached to my hip to find that I had forgotten my pager.

Dang.

So back to the house I go and scramble for the telephone. My wife, hearing the door opening calls back from upstairs: "Something wrong, dear?"

"No, just forgot my *@#$&#*& pager. No biggie."

So I called the paging number and waited. (Why it takes so long for electrons to travel to space and back is beyond me.) Some time later I heard in the distance:

* Bleeep, bleeep, bleeep *

"Whew," I thought, "at least it's not on vibrate mode."

I turned and proceeded to the bedroom, ready to corner my prey. I looked and looked and still, no pager.

So I paged it again. Fingers tapping and frustration growing, I wait. Finally:

* Bleeep bleeep bleeep *

"Shoot, it's in the other room," I think. "No wonder." So I proceed to the office accross from my bedroom, sure I'd find the little bugger on the desk beneath some papers. So I move everything in sight. Under here? Nope. How about here? Nope. Oh, COME ON! Where can that stupid thing be. I retrace my steps, check my pockets, my waist band, pull out my car keys just to make sure it's not hiding with them: nothing. So I page again.

* Bleeep bleeep bleeep *

There you go! It's not in the bedroom or the office, it's in the hall! Probably fell off my pants. Or maybe it's in the laundry hamper... Clothes removed, checked, piles quickly scanned: still nothing.

By now I feel my temperature rising. How can I be this thick-headed? Five more pages, fifteen more "bleeeps," and back and forth from room to room, all with the same result.

And then it dawns on me....

Could it be?....

There, right smack dab in the middle of the back of my waistband it hung, well out of way of my usual reach as it dutifully bleeped and projected its sound to the room that was always behind me.

Ugh.

Stupid is as stupid does, I suppose. (I guess it could have been worse.)

-Wes