Monday, December 31, 2012
Here were my five most-read posts from 2012:
#1: DOJ Hands Heart Rhythm Society and Hospitals Its Decision on Defibrillators
#2: The Growing Culture of Hostile Dependency Toward Caregivers
#3: How A Sudden Cardiac Arrest Survivor Handles the World Cup
#4: The DSM-Tw: Handbook of Twitter Personality Types
#5: EKG Du Jour #29: Tangoing with Two
As you can see, news, fun, and EKGs continue to dominate.
Thanks to all of you who drop by this site. May each of you have a healthy and Happy New Year in 2013!
Friday, December 28, 2012
With this explosion of regulatory bodies has evolved a network of licensure bodies so complex that doctors have a hard time keeping up with the numerous affilitations, acronyms and name changes for these bodies. Worst of all, fewer have time to perform their requirements without impacting patient care.
Monday, December 24, 2012
So comes the clear and cold and weather wintry,
To cast in stark relief the trees against the sky,
Reviving long forgotten lacy beauty,
Submerged before the leaves of Autumn fall to die.
So need we really find it all so odd,
That when some dark and wintry burden comes around,
Some comepensating gracious gift of God,
Some darker beauty, silent joy, strange hope is found.
An ancient instinct knew to call for song,
Amid the chilling deep December cold,
To tell again that in the deepest wrong,
Eternal love still lives as surely as of old.
For ancient Babe came not to candlelight,
Was welcomed not by soft and sentimental glow,
His love he lived into the darkest night,
Held fast against life's eerie ebb and flow.
So seek to make your season what you want,
Pile high the joys and sing the songs you should,
Remember tho', should feast be as you planned
Or not, your God is there and life is ever good.
-- Gilbert W. Bowen, D. Min.
Saturday, December 22, 2012
Who make Christmas happen
Even when their hearts are heavy
Moments of rest too few…
You are Christmas.
To all the suffering
Who rise to the occasion
With a smile or a simple gift
Or permission for others
To celebrate without them…
You are Christmas.
To all the doctors and nurses and hospice workers
Whose own trees go undecorated and gifts go unsent
Because it seems every year
The hospitals are full at holiday time...
You are Christmas.
To all the parents
Who recapture the innocence of the season
For the sake of their children
With a song, a story, a silly ritual…
You are Christmas.
After all, it was never about the strong, the powerful, the rich,
It was always about the humble, the faithful, the courageous,
The quiet, hopeful ones.
The scared young family standing in wonder at the manger,
Trusting, holding faith, believing in good,
Believing in love.
From both of us – Merry Christmas,
Di and Wes Fisher
Friday, December 21, 2012
Wednesday, December 19, 2012
"Paul Rossi DO, a Cigna Medical Director, reviewed Use of an intracardiac electrophysiological 3-dimensional mapping system in the diagnosis, treatment, or management of ventricular arrhythmias or any other condition because there is insufficient scientific evidence to support use and determined the service(s) is not a covered benefit as indicated below:These denials are part of life for doctors - it's all part of the game. But the era of social media is upon us, and with it, revenge.
Service referenced: Electrophysiological 3-Dimensional Mapping and Catheter, electrophysiology, diagnostic/ablation, 3D or vector mapping
The use of an intracardiac electrophysiological 3- dimensional mapping system is considered medically necessary when used to guide supraventricular arrhthmias. Based upon current available information, coverage cannot be approved to support the use of intracardiac electrophysiological 3-dimensional mapping in the diagnosis, treatment, or management of ventricular arrhythmias or any other condition because there is insufficient evidence to support its use. At the present time, it is considered non-standard testing and falls under the category of experimental/investigational/unproven."
We should first ask ourselves if Paul Rossi, DO, whose google search reveals he was an emergency room doctor working in "preventative medicine," should have ability to determine what constitutes standards of care in the field of cardiac electrophysiology when he, himself, is not credentialed in this subspecialty.
But that's not all.
Even Cigna's own recently published "guidelines" for approval state:
The CARTO® EP Navigation System (Biosense Webster, Inc., Diamond Bar, CA) received 510(k) premarket approval in December 1999 by the U.S. Food and Drug Administration (FDA) as a Class II device for catheter-based cardiac mapping (FDA, 1999). The FDA indications for use state the intended use of the CARTO EP Navigation System is catheter-based cardiac mapping. The CARTO EP Navigation System and accessories have had numerous enhancements with the latest device, the CARTO 3 Version 1.05 EP Navigation System and accessories, receiving 510(k) premarket approval in 2009 (FDA, 2009; FDA, 2006; FDA, 2000).Hardly experimental.
Furthermore, those same recommendations detail at least 8 different studies where 3-dimensional mapping was used for VT ablation and include this statement from the Joint Heart Rhythm Society/American College of Cardiology guidelines for ablation (2006):
"Electroanatomic magnetic mapping capabilities are being applied to aid in the diagnosis and nonpharmacological treatment of arrhythmias. The authors state, 'although not yet established as requisite or "core" equipment for the EP laboratory, these and other emerging technologies have had, and will continue to have, a major impact on the practice of cardiac arrhythmia management.'"I'm sorry, but I do not see the words "experimental" in Cigna's own documentation nor does their document suggest that appropriate standard of care for 3D mapping be reserved exclusively for "supraventricular" arrhythmias.
Welcome to the world of social media, Cigna. I can only hope that every employee out there with an option to choose insurers strongly consider picking another insurance carrier since they will be much better (and more safely) served when they need their ventricular tachycardia successfully ablated. Rest assured, my response to Dr. Rossi's coverage denial decision is forthcoming.
Thanks so much for wasting my time.
Sunday, December 16, 2012
Aside from being a bit warmer than usual, it was a typical Friday afternoon. A patient with syncope, a paucity of heart beats, the need for pacemaker. The lab techs rolled their eyes as the room was prepped. An early as exit was not going to happen after all.
I believe that every human soul is teaching something to someone nearly every minute here in mortality.
- M. Russell Ballard
But the later hour promised efficiency for the only way out was through. We each did our thing and like so many times before, sighed in relief that things went smoothly. Home at a reasonable hour was to happen after all.
Until the ER called while I was closing.
"Another patient, 97, heart rate 21, needs a pacer, too," they said.
“What does the family want? He is 97 after all…” I asked as I placed the final layer of sutures.
“The patient wants it. Takes care of his wife…,” they said.
“I’ll finish here and you guys get the room ready. I’ll see the ER patient. Has the family of this patient been called?”
Once again, the staff excelled. Patient transported from the table, family contacted, then the room cleaned and readied for the next potential patient.. For me, the note would wait. A brief discussion, orders entered, then ER visit, wondering all the while if the next pacemaker needed to be done.
It was easy to find the ER bay as every nurse and technician pointed the way to a small-framed man who was alert and conversant, but clearly not feeling himself. His symptoms started earlier in the morning and just didn’t get better- his medications hadn't changed.
“Do we have a potassium?” I asked.
“’lytes are fine,” someone said, “K’s 4.5.”
History, physical, review of the data – all pointed to one thing: a pacemaker. We talked risks, alternatives, pros and cons. He looked at his wife, quietly seated in the corner. “Of course you need it!” she bellowed.
And that was that.
And so it was. A temp wire, then permanent pacer with tripling of his heart rate. He became more talkative, his blood pressure easier to obtain.
But as the tension lifted, the chatter grew.
“Did you hear?”
“About the kids…”
Detail after horrible detail came to those of us shielded from the day’s events. The shock. The evil. The senselessness of it all.
I looked down at the tissue beneath my hands: thinned, frail, bleeding still as the closure was being completed. As time passed, the lab grew strangely silent, the irony clearly palpable...
... one old heart mended, while the others...
God, there are no words...
God bless them. God bless their families.
God bless us all.
Wednesday, December 12, 2012
So grab some coffee and strap in. Here are my 2013 predictions of life as a cardiologist in 2013. (Please feel free to add your own predictions in the comments section.)
Valvular Heart Disease
- TAVR for critical aortic stenosis will be applied to progressively younger and healthier patients.
- As smaller delivery systems for percutaneous heart valves gain widespread acceptance, government payers will look for new and inventive techniques to restrict patient access to these devices. No heart valve will remain untouched as creative uses of the approved devices are attempted in non-surgical patients.
- Innovations valve design will improve the safety and effectiveness of this therapy.
Ischemic Heart Disease
- The push for more drugs and less stenting will continue in stable ischemic coronary disease.
- Acceptable (payable) door-to-balloon times will shrink from 90 to 60 minutes as payers give the most reimbursement for centers with the faster times.
- Radial artery catheterization and interventions will grow in acceptance and CABG will continue to have a more prominent roll for severe 3v disease (continuing the "reduced stenting" theme) compared to multi-vessel stenting.
- Lipid therapy recommendations will remain unchanged.
- Pressure on AF ablation to prove its superiority over medical therapy will continue, especially given ablations re-do requirements, up-front cost of therapy and uncertain utility compared to medical therapy. Still, until enrollment of the multi-center NIH-sponsored CABANA trial completes, catheter ablation of atrial fibrillation will remain a mainstay of therapy for symptomatic patients with paroxysmal atrial fibrillation.
- Novel oral anticoagulants (NOA) will see an expanding role the management of AF patients over aspirin and warfarin. Apixaban will be FDA approved and quickly command the largest market share of the available agents based on clinical data. Antidotes for reversing these agents will continue development and once developed and proven effective, NOAs will completely change the standard of care for management of stroke-prevention in non-valvular atrial fibrillation.
- Subcutaneous ICDs will show a slow growth in acceptance as doctors insist on a smaller device with fewer early battery depletions before adopting the first-generation devices more widely. Also, look for other companies to enter the subcutaneous ICD market with devices of their own.
- Standard pacemaker and ICD implant rates will remain flat.
- Readmission rates will be reduced by increasing admission rates to extended-care facilities when heart failure relapses (at least it's not a hospital!)
- LVADs will see a slow increase in utilization, but expenses will limit wide-spread adoption at lower-volume centers.
- Ultrafiltration will die its slow, inevitable technological death.
- Biventricular pacing might see a slight uptick as hospitals seek every possible opportunity to prevent readmissions while maximizing revenues with the first heart failure admission.
- In 2013, physician computer screen time will officially far exceed all direct patient care time.
- The Electronic Medical Record will look more like Microsoft Office as basic features of letter writing, e-mailing, scheduling assume higher priorities for communication and coordination in patient care.
- Reliance on Big Data to shape proper medical care will consistently be shown to be a poor surrogate for carefully constructed prospective randomized trial due to the inability to code physician logic from progress notes. Furthermore, associated widespread diagnosis and procedural coding flaws will continue to plague the field. The implementation of ICD-10 will only make this problem worse. More data does not mean better data. Despite these facts, the heavy marketing of Big Data to doctors and hospital administrators will continue.
- Speaking of guidelines: New guidelines recommending the appropriate guidelines to use will emerge (Should a doctor use guidelines from the AMA, American Heart Association, European Society of Cardiology, American College of Cardiology, American College of Chest Physicians or the Society for Cardiovascular Angiography and Intervention? Oh, and which year?)
- Physicians will tire of completing data entry field for such random and byzantine criteria like appropriateness criteria, safety checkboxes, and quality measures. But because these criterias' completion will be increasingly insisted upon by Central Planners, administrative employees in medicine will continue their brisk hire rates in 2013. Doctors will then be forced to complete these fields at home.
- The smart phone (and its apps) will officially supersede the stethoscope in importance to practicing doctors of all types (even cardiologists). Guidelines for appropriate app use will be developed. The FDA will require their tentacles to extend to this space and stifle innovation here.
- Patients will be responsible for a higher and higher portion of their health care costs which will lead to a rising voice for price transparency. This push will be in direct opposition to large medical center/insurance industry efforts to shield their privately-negotiated pricing arrangements.
- Look for online health care pricing to grow in popularity.
- Appointment availability will dwindle as more patients enter the system.
- Patient expectations for continued relatively immediate, exceptional care will persist despite the reality of more bureaucratic requirement for physicians. This will continue to grow the sense of hostile dependency toward physicians and their staff.
- Finally, the push to pay only for outcome-based care will create incentives for facilities to tacitly triage the sickest patients away from some hospitals to their competitors.
- Doctors will get increasingly tired of attending administrative meetings - especially those that generate more meetings.
- Doctors will assume more administrative responsibilities as business policy foot soldiers as they join forces with hospital systems.
- The tendency for administratively-minded doctors to clash with clinically-minded doctors will be an inevitable consequence of this new administrating physician prototype.
- Despite the outward appearance of more involvement with decisions, administrative physician decision-making autonomy will dwindle as payers exercise their growing sway over drug and device choices and pay only based on clinical outcomes.
Health Care Terrain
- Rich hospitals will get richer as poor hospitals get poorer.
- Indigent patients who will soon qualify for care will have to travel further for that care.
- Emergency rooms will continue to experience larger volumes of patients as the full effects of health care reform have yet to be implemented.
- The building spree that has consumed many of the larger health care facilities will taper as financial pressures mount.
- Employers will seek ways to cut health care costs by negotiating their own prices directly with hospital systems without insurance company intermediaries.
Education / Research
- Clinical cardiologists (who are increasingly employed) will find less time and money for educational pursuits compared to the time and money required for licensure requirements. Since most employed cardiologists will have expense allotments that cover both endeavors, higher licensure and credentialing fees will limit professional meetings doctors can attend. The long-term effects of this reduction of continuing education as it pertains to patient care is uncertain. Doctors are likely to turn to online courses rather than meeting attendance to fulfill CME education requirements. As such, abstract submissions to meetings is likely to fall.
- Clinical research opportunities will continue to concentrate at the largest centers with the largest clinical volumes.
- Academic cardiologists will have growing pressures to become more clinical as the prospect of expanding patient access looms in 2014.
- Academic cardiologists will also find research funds in shorter supply as medical device companies and pharmaceutical companies wean expense items like research protocols. Government grants, too, will be more competetive than ever.
Summary for 2013
- Patients will continue to get sick.
- Patients will continue to die.
- Each of the above will continue to occur despite millions of dollars spent on prevention initiatives and early-detection programs.
- Despite all of the changes, the hassles, and the headaches coming next year, doctors will continue to care for their patients.
- Doctors will continue to have sleepless nights worrying about their patients.
- Doctors will still enjoy the reward of seeing their patients improve.
- And when the dust settles in the years ahead, doctors will remain the only ones ultimately (and yes, still legally) responsible for their patients' health and well-being.
- Some things, you see, never change.
Sunday, December 09, 2012
Suddenly, the colorful trinkets and tchotchkes that were the first items pulled from the health care law's brightly colored bag are now being followed by a hefty bill that most people aren't too happy with paying: their personal tax bill.
The political backlash was so swift, so sure, that even the White House noticed.
So how did the White House respond?
... Treasury Secretary Timothy Geithner has the power to adjust how much is withheld from paychecks for tax purposes — for all taxpayers or just for some. By doing so, Geithner could ensure paychecks reflect the White House position that wealthier taxpayers with annual income higher than $250,000 see their taxes rise. Geithner at the same time could leave withholding tables where they are for the middle class, ensuring those workers don’t see a higher cut from their paychecks.But America's doctors should remind the White House why this is not a good idea. After all, Congress uses this kick-the-can-down-the-road approach with us each time they grant a reprieve to the scheduled physician pay cuts mandated by law as part of the Medicare sustainable growth rate adjustments contained within the Balanced Budget Act of 1997.
Look where this approach has gotten physicians: each year, since 1997, CMS threatens to cut Medicare payments to physicians some 2.5%. Instead of making the cuts each year as directed by law, Congress caved to political pressure and has delayed the cuts year after year. But the cuts don't go away: they're just added the the following year's paycut amount. Now the amount has grown to nearly 30% or so with no easy solution in sight.
Imagine what could happen to America's patients if the same approach delay tactic for collecting taxes to pay for our new health care entitlement law is taken. Can America's health care cost crisis really afford this political approach that ignores reality?
I'm just a doctor, but methinks this idea of leaving withholdings from people's paychecks unchanged is not a good idea just so the White House can dodge a political bullet.
Since the White House and democratically-controlled Congress helped push our new law through, they should deal with its ramifications responsibly. To do otherwise is fiscally irresponsible and risks making our horrible health care cost crisis even larger.
Friday, December 07, 2012
Thank you for hosting my response to a recent blog post by Carolyn Thomas at www.myheartsisters.org. Ms. Thomas is a well respected medical blogger with an emphasis on cardiac care and women’s cardiac issues in particular. She has certainly helped many patients and been a great advocate for women’s cardiac issues. We recently had a 3-Tweet interaction that lead to her writing a blog about me. Though Ms. Thomas made excellent points about patient privacy issues and the use of Twitter in general, I feel that her words justify a clarifying response.
The following is a guest post by William Dillon, MD, a relatively new cardiologist to Twitter. He describes his experience with a recent patient-doctor interaction on Twitter that sounds an important message. -Wes
Let me introduce myself. I am an interventional cardiologist and new to using Twitter. Two areas of focus for me in the last 18 months have been radial artery catheterization and heart attack care. Social media was recommended as a vehicle to get the word out on heart attack care. My state, Kentucky, ranks a dismal 49th out of 50 states for MI mortality. I aim to improve this.
The problem started after a particularly challenging and successful radial artery catheterization procedure. I tweeted that “Radial cath is like playing golf. You must do it often to be good. Some will never be good at it no matter how hard they try.”
Without going into the nuanced details of radial vs. femoral artery catheterization (already a controversial topic for interventionalists), Ms. Thomas responded with a thoughtful question of her own: “But how do heart patients being practiced on know if their interventionalist falls into the 'never will be good' category?”
This was one of the first times anyone had ever interacted with me on Twitter, so I tried to help. I am used to helping total strangers; that’s what we do everyday in treating acute heart attack patients.
But in retrospect, maybe I should have remembered mom’s advice: “Don’t talk to strangers!” Ms. Thomas wanted to know how patients know if their physician falls into the “never-will-be-good” category. Because I did not know Ms. Thomas, nor that she had had prior personal experience with a radial artery catheterization, I was left at a conversational disadvantage because of the loss of context that is inherent to 140-character interactions on Twitter. Unfortunately, the answer to Ms. Thomas’ question leads to a thorny area—the truth. As Gloria Steinem famously said "the truth will set you free but first it will piss you off."
The truth here is simple: it’s not easy to know if your physician is good. This is a complex issue, and surely not suitable for Twitter. Engaging on this medium on this topic was a mistake. I learned from it. But let’s be honest about a few things: most honest proceduralists would agree that a cath lab nurse or tech has valuable inside knowledge. These folks have first hand experience and interact with a variety of physicians on a daily basis. They know. The problem of course is that the general public does not have access to the inside scene. However, it surprises me that most patients research toaster ovens more than they do which physician to see.
But even if they did research their doctors it would be hard to sort out the best. Here’s why: Though all physicians complete certain minimum standards and maintain competency through continued medical education, that’s a low threshold. The credentialing process at hospitals weed out incompetent docs, but it is far from perfect or nuanced. It's like grading tests on a pass-fail scale.
Outcomes measures—if they existed—would also be flawed. If our procedure outcomes were scrutinized, you could be sure that high-risk patients would not have many willing doctors.
All cath labs have a Director that should be reviewing complications. Peer review also has merits, but that's tough to accomplish in the real world as well.
Back to the tweets.
Ms. Thomas said: “It never occurred to me in ER in mid-MI to ask, by the way is this guy any good?” I continued to try to explain. Again a mistake on Twitter. I recommended asking EMS to take you to the best center during an MI. This is actually a crucial comment and a vital step to surviving a heart attack. Call EMS! The best treatment is a percutaneous coronary intervention (PCI) done at the nearest center with around-the-clock coverage. EMS providers know which hospitals perform PCI for AMI and will direct patients to those centers.
After this last tweet I got uncomfortable with her line of questioning and elected to stop responding. Unfortunately, the damage was done.
What have I learned from this? I realize that one needs to be careful with comments placed on social media. While Ms. Thomas has likely helped many patients through her blog, my comments were greatly misconstrued. It was certainly not my intention to cause such a furor. I am stunned how a 3-tweet interaction can lead to such a defaming and inflammatory blog response from someone I have never met with, spoken to or interacted with beyond a total of 400 characters. A reputation is a lifelong and daily building process. To have it torn apart in a very public way is extremely damaging and upsetting.
I hope that something positive could come of this. Already I have learned and am sorry for any controversy I have caused. But I would like to sound a warning to patient advocates and physicians alike. If what we all want in healthcare is more truth and transparency, tearing down those who dare to speak, to join the conversation, surely will not help.
William Dillon, MD
Wednesday, December 05, 2012
|The back of my demo |
AliveCor ECG iPhone 4s Case
Setup Screen (beta)
|Inside of My Demo |
AliveCor iPhone Case
Note: no wires.
|My unretouched ECG recorded with my hands|
today (yep 1st degree AV block!)
Lead I of the standard EKG was recorded with the left and right hand holding the device with the left and right hand fingertips touching the electrodes on the back of the case. It was important to hold the device with the iPhone's round button to the right to assure the device did not record an inverted lead I.
|Options for sending tracings (beta)|
Without exception, every physician I showed this device recognized this device as a compliment to the doctor's stethoscope. It was a uniform hit as they gazed in amazement at the device's ability to record their real-time ECG. I found this device was capable of instantly differentiating the irregular rhythm of atrial fibrillation from the irregular rhythm caused by premature atrial or premature ventricular beats or even atrial flutter with variable AV conduction. Some care was required to get noise-free tracings or to obtain the appropriate EKG vector on the chest with which to identify lower-amplitude atrial arrhythmias. But most limb leads can be replicated by the device (hold the R electrode with the hand and apply the left electrode to the knee to see lead II, for instance), or angle the leads in different directions on the patient's chest to obtain a new QRS vector. (Obviously, the angle the electrodes were placed on the chest to acquire a particular limb lead requires some rudimentary knowledge of ECG basics.)
Perhaps the most interesting aspect of this device is what happened when it is placed in the hands of patients and friends unfamiliar with ECG tracings. Their first reaction as they sit transfixed at their own ECG tracing dancing across the screen is "Cool! .... But what does it MEAN?" Then comes "Am I okay?" And then of course when tracings are compared between friends: "Why is my heart rate so much faster/slower than his/hers?" Or you might hear: "Man, I'm out of shape!" And if the device occasionally had difficulty calculating the heart rate from a noisy tracing, three little dashes would appear instead, leading the person to ask, "Does this mean I'm dead?" Any one of these reactions could came from generally healthy people who have never had a major medical problem.
What was more interesting to me was the nuanced reaction I noticed from patients who had had a complex medical history before but were seeing this device outside a medical facility for the first time. When they encountered this device in a social setting, it was common that these patients refused to have their tracing performed "for fun" for fear they might be sent packing to the nearest medical establishment. IT became immediately clear that discretion should be exercised if the device is to be passed about at cocktail parties. (Yes, doctor, not everyone wants to see your cool gizmo.) Hence, it appears that deploying this device on the general public has some challenges ahead, but I suspect it will come: gradually at first, then more generally. It is clear that this really does take an understanding of ECGs to use effectively, so doctors (or techs) familiar with ECGs will have to be involved. Liability and responsibility for reading remains a thorny issue one the device is released to the public. I suspect these are relatively easy issues to resolve for AliveCor going forward.
Still, for doctors and medically-savvy patients, this device is a game-changer. The number of ECG tracings obtained in clinics will probably diminish one day as this device enjoys a wider distribution amongst physicians since it doesn't require a special technician or equipment to obtain much of the information doctors need to manage their arrhythmia patients. But caution with this single lead ECG device should be maintained, too. Because multiple ECG leads are not collected simultaneously, the device could miss the subtle findings of a heart attack in locations remote from the there the single tracing is collected by the device. Still, for routine rhythm analysis, this device has huge potential for time-savings, practical rhythm interpretation, and maybe even the potential to provide for considerable technical health care cost savings.
PS: I have no commercial interest in AliveCor (darn it).
The AliveCor iPhone ECG Case website
(Santa, are you listening?)
That's right. Thirty-three percent.
Couched as "only five additional dollars each month" by the government, it passed because doctors don't make the Federal Register part of their weekly reading list and because our professional lobbying organizations were either asleep at the wheel or distracted by the whole health care reform mess.
You see if you want to get more money for government programs, you should tax the "rich" doctors - the very same doctors that are enjoying (and have experienced the delays in payment caused by) the joys of the annual congressional cat-and-mouse game of a threatened 30% pay cut wrapped up in the fiscal cliff negotiations. (Don't worry docs, *wink wink* it really won't happen).
The "tax" I'm speaking of? Why it's the new $731 DEA registration fee.
Until 2011, the three-year fee was $551. Now it's $731.
You do the math.
And why were the fees against doctors increased?
Because the DEA needed more money. According to the FDA Law blog, the DEA cited a number of factors justifying the fee increase including:
•Expanding the use of Tactical Diversion Squads comprised of DEA diversion investigators and special agents, state and local law enforcement and regulatory officers conducting criminal investigations;That's right, in addition to paying ever-higher taxes, licensure fees, credentialing and continuing education fees, doctors are footing a larger and larger tab of the nation's drug war while simultaneously trying to fight it on the front lines.
•Increased scheduled registrant investigations and inspections;
•Increased drug scheduling actions;
•Responding to the expanding number of synthetic substances such as synthetic cannabinoids and synthetic cathinones; and
•Establishing and maintaining information technology systems for registrants.
And people wonder why doctors are burnt out and fed up.
PS: For more
Monday, December 03, 2012
It's a horrible, exhausting feeling.
Yet one we all must come to grips with: knowing when to stop.
There you are, six hours into a case, legs rubbery, mind racing, and barely conscious of the world outside the narrow view of the operative field. A life, literally in your hands, asleep now, but hoping (with you) for the best of outcomes on this last try.
"Maybe if I just..." you think, and a new idea is tried to no avail.
"Now, let's look at that again," you ask your techs. "Which electrogram's earlier? That one is CLEARLY earlier...right?" as you try to convince yourself that another choice is better. "What about here?" You go back and recheck once more, just to be sure...
So you do.
And it's still a dangerous spot to burn.
"Maybe it's on the left side?" So you cross to the left side and repeat the process. Everything maps back to the spot your dreaded before.
"Maybe if I give just a little energy here...." You hold your breath.
"But if I burn here, I risk giving the patient a pacemaker. We never talked about a pacemaker," you think.
Yet the tachycardia persists, as if laughing at you and your inability to locate its origin.
* Bruuuuhaaaahhaaaahhaaaa... *
"Bastard!" you think. "I can get this!"
So you map above, below, left and right, forward and back...
* Bruuuuhaaaahhaaaahhaaaa... *
Like stubborn mule, you fail to give in. Again.
... you quit. A white flag raised. It beat you. Yes, you lost.
The supporting team with you, ever helpful, feels the patient's loss with you. They are relieved, though, for a pacemaker will not be in the offing. Like you, they know there will be another day, another arrhythmia: another victory to quell the sting of this defeat.
And while the Defeated hangs his head low to talk to the family, you then realize the the family is just as exhausted and concerned as you. They thank you for trying. They understand.
That's when you know you did the right thing.
Sunday, December 02, 2012
To dream the impossible dreamThe transformation has arrived: welcome Physician Leaders one and all! We are health care's future!
To fight the unbeatable foe
To bear with unbearable sorrow
To run where the brave dare not go
To right the unrightable wrong
To love pure and chaste from afar
To try when your arms are too weary
To reach the unreachable star
This is my quest, to follow that star
No matter how hopeless, no matter how far...
"The Impossible Dream" from the play "Man of La Mancha"
Our overriding mantra: "Patients first."
We are about quality. We are about safety. We are about patient satisfaction. We are about leadership, mentorship, inspiration. We are about the feel-good. These principles are how successful companies succeed. We are a team.
There is no use in resisting the transformation. It is here.
It is us.
So smile. Pitch in. Make it our own. Invest in the future. Teach. Research. Educate. Take call. Produce.
And enjoy the meetings, the flip charts, the consultants, the checklists.
All of them.
So much to do, so little time. There are difficult times ahead, but we can make it work when others can't because we're the new generation of Leaders. We know medicine. We get input. We involve the staff. We'll make the tough choices. We keep it upbeat. Always upbeat.
March on, dear Leader!
This is our future, our patients' future.
Now, get back to work, will you? And don't forget the meeting at 7 am.
See you then!
Oh, and say "hi" to your kids for me.
Thursday, November 29, 2012
Medtronic says federal rules prohibit giving Ms. Hubbard's data to anyone but her doctor and hospital. "Our customers are physicians and hospitals," said Elizabeth Hoff, general manager of Medtronic's data business. Medtronic would need regulatory approval to give patients the data, she said. It hasn't sought approval because "we don't have this massive demand."
. . .
Some legal experts say the 1996 U.S. law governing patient access to their health files—HIPAA, or the Health Insurance Portability and Accountability Act—hasn't kept up with technology. The law gives patients the right to access information held by doctors and hospitals. However, the raw data gathered by an implant isn't held by a doctor or a hospital: Typically it goes directly to the device maker, which provides a summary report to the doctor. Because of this, the raw data falls outside the scope of HIPAA's patient-access requirements. In addition, Medtronic said, business agreements with doctors and hospitals restrict it to relaying information only to them.
"Is the device itself a depository for medical records?" said Paul C. Zei, a cardiologist at Stanford University Medical Center with a patient, Hugo Campos, who wants the same access to his cardiac-device data as the doctor gets. "Or is it part of the patient, and an extension of vital signs that we download into a medical chart?"Gee. Someone saw this coming years ago.
But as patients pay for more and more of their health care, companies better remember who's really their customer. Furthermore. patients should have access rights to all of their medical information, irrespective of where it resides.
Tuesday, November 27, 2012
Now, there is a dramatic shift of scientific content in our journals to politics and policy.
No where is this more evident than the much-heralded and widely read New England Journal of Medicine. (The Journal of the American Medical Association (JAMA) is not too far behind either.)
As an example, I was struck by this week's New England Journal of Medicine article titles:
"Use of ADHD Medication and Criminality" (an observational study)I decided to look just 10 short years ago and compare what article titles existed in the New England Journal of Medicine from the week of November 21, 2002. Here are the article titles from that issue:
"Mammography Screening for Breast Cancer" (complete with poll)
"The Future of Obamacare" (Perspective)
"Lessons from Sandy" (Perspective)
"Drug Policy for an Aging Population" (Perspective)
"Intravenous Immune Globulin — How Does It Work?" (Review article)
"Transient Ischemic Attacks" (Perspective)Perhaps the shift from science to politics in our major medical journals is an brief aberration, but I don't think so. I have noticed this phenomenon and expressed my concerns in 2006. The trend has only continued to grow: even our presidential candidates for the last election had postition papers published in the New England Journal of Medicine just before the election.
"A Controlled Trial of a Human Papillomavirus Type 16 Vaccine"
"Glycoprotein-D–Adjuvant Vaccine to Prevent Genital Herpes"
"Extended Transthoracic Resection Compared with Limited Transhiatal Resection for Adenocarcinoma of the Esophagus"
"Normal Vision despite Narrowing of the Optic Canal in Fibrous Dysplasia"
"Specialty of Ambulatory Care Physicians and Mortality among Elderly Patients after Myocardial Infarction"
But the reality of politics and policy determining how medicine is practiced remains front-stage in medicine as cost and new structural concerns dominate health care. Medical questions, research and inquiry are increasingly second fiddle to health care political white papers. Adding to this lack of reporting of scientific discovery in major medical journals are the multiple rapid-fire, diverse portals for publication that exist for doctors and researchers these days thanks to the explosion of specialty publications and the Internet's impact on information delivery to doctors. As a result, there is a fierce media race underway to keep doctors eyes focused on these antiquated journals' content as doctors increasingly migrate away from print to electronic content.
If a major scientific journal like the New England Journal of Medicine decides to focus on policy instead of medicine, I suppose that's okay. That is their prerogative. But perhaps now that politics and policy have grown to such an extent in a major medical journal like the New England Journal of Medicine, the editorial board of this journal (and the others of similar political bents) should consider changing their name from the New England Journal of Medicine to the New England Journal of Perspectives.
At least then our young doctors of tomorrow will fully comprehend what they're getting.
But what I found most interesting in the article was the patient who was recommended for the device: a dialysis patient, was a patient who was specifically excluded from the FDA trials to approve the device (specifically, patients with GFR < 29 were excluded).
If you are a company that wants to get a device approved by the FDA, you want the best chances of having the fewest complications possible with new gadgets in medicine. Because sick dialysis patients have a way of having more complications with device implants, and the device companies know this, they are not included in trials to get a device approved.
Those of us who deal with ICDs in dialysis patients recognize the problems when ICD leads and dialysis catheters co-exist in the same vascular tree: the odds of infecting the ICD lead system is extraordinarily high. In fact, the overall mortality advantage of ICDs in dialysis patients is much less than patients not on dialysis. For this clinical circumstance, subcutaneous ICDs would seem to clearly be the better choice.
But dialysis patients are beset by another problem: challenges with potassium level regulation. Periods of hyperkalemia are quite common in dialysis patients and hyperkalemia commonly causes severe bradycardia. In these patients, pacing could maintain a patient's heart rate until their dialysis could be adjusted to lower their potassium and thereby improve their cardiac function. Subcutaneous ICDs do not have pacing capabilities, however.
So the reality of the effectiveness of the subcutaneous ICD to prolong life is uncertain in dialysis patients. This theory has never been tested - we just tend to think it makes intuitive sense to apply a new technology when other medical device choices are not perfect either.
The subcutaneous ICD FDA approval process is a good example of how clinical dogma spreads amongst doctors and patients without any proof of a device's effectiveness in some subselected patient populations. A new technology is approved by the FDA and receives a governmental stamp of approval. Doctors, then, serve as well-meaning spokespersons. The media gushes over the latest and greatest technology. And sales explode...
... all while some patients in whom the device is deployed doesn't realize the safety and efficancy of that device was never tested in their particular clinical circumstance.
We should remember that exclusion criteria in FDA clinical trials are important. They tell us who might and who might not benefit from a new technology. Too often we forget this.
And so does the FDA.
Saturday, November 24, 2012
We are moving from Mom-and-Pop medicine to Big Box corporate machine medicine.
We are moving from innovation to rote checklists.
We are moving from tangible slow paper to imperceptible high-speed electrons.
We are moving from manuscripts to sound bites.
We are moving from teaching points to talking points.
We are moving from original research to corporate research.
We are moving from the bedside to the desktop.
We are moving from patience to impatience.
We are moving from length of illness to length of stay.
We touch less, view more from a distance.
We are becoming risk-averse, safety-conscious, feel-good salesmen of the impossible as we follow more and lead less.
Like food, we need a slow movement in medicine:
Tuesday, November 20, 2012
We met at the small wooden kitchen table that used the wall-hung telephone as its centerpiece and pierced the air with the loudest ring I’d ever heard. (I later learned her husband had been an infantryman in the Korean war who had heard his share of mortars.)
She had fixed dinner for the family – all of whom were arriving to meet her daughter’s new boyfriend: a small salad, ham, yellow mustard, mashed potatoes, and creamed onions.
The latter, I was to discover, was her personal favorite. Any gathering of family importance had them; the small iridescent pearls of tiny onions resting on cream-based sauce carefully created from a flour roux and can of the pearly whites. If it weren’t for her enthusiasm, I probably could have passed on them, but as it was, I had no choice but to place them on my plate. That’s the way she was.
A few Thanksgivings ago I sat with her, her eyes more sunken, her temples more defined. Her legs were thinner than I had remembered them just months before, and her voice was softer. Her graciousness, however, remained. She arrived bundled in her nicest jacket, her gait assisted by a quad cane and her husband’s gentle lift only a day after being discharged from the hospital. She smiled at the cacophony that greeted her. Folding chairs were pushed aside. She was led to a prime location to supervise the kitchen, a more stable chair arranged. The matriarch had arrived.
She saw that her son’s house was as hers had been this time of year: abuzz with activity and controlled chaos. Within the hustle and the bustle of meal preparation and family photos, came a phone call. Her daughter answered. Amongst the chatter a recipe was mentioned. It seems her granddaughter, unable to attend the local meal, had called to share a tradition involving small onions in her home. I saw the tiniest of smiles rise from her lips. For a brief moment the tumor didn’t matter, her pain forgotten as the recipe was recited.
Before long the meal materialized. Turkey, oyster stuffing, potatoes, green bean casserole, and there, hidden in the corner hidden in a warming dish, her creamed onions. More food than could ever be consumed. As we all waited our turn, her husband made her plate with tiny flecks of turkey, a strand or two of green bean, a half teaspoon of sweet and mashed potatoes, and a single creamed onion.
Her husband said the grace. “Bless us, o’ Lord, and these thy gifts which we are about to receive…” I stared at our plates and then at hers. The tiny onion, there alone. Her eyes closed and soft hands folded. I wondered what she was thinking. What does one think at their last Thanksgiving? I hated myself for wondering.
Really, it didn’t matter. It was about the here and now that mattered. “Life is what happens when you’re making other plans,” my wife still reminds me. And sure enough, despite a week and a half of food intolerance and dehydration, she ate it all.
Even the creamed onion.
And for that, we were all incredibly grateful.
P.S. Here's wishing each of you the Happiest of Thanksgivings.
Monday, November 19, 2012
Heh. Looks like a heart rate of about 120 is about right.
No wonder Illinois is a Certificate-of-Need state - it prevents any real attempt at disrupting the status quo. Still, as direct costs to patients rise, I predict this model will become more common.
h/t: Glenn Reynolds
Sunday, November 18, 2012
They sat together, staring down at their feet not sure what to say.
One was a silent war hero from the French Resistance, the other his doctor.
It was a chance encounter. He, supporting his wife as she checked in to the orthopedic clinic, the other, there himself for the first time as patient. For each, as life, it was unexpected.
They sat smiling, reflecting on the irony of it all.
Their story together, while brief at first, was rich. On a trip back to his homeland of France, he had brought down a 747 single-handedly as his defibrillator fired repeatedly. The event both humbled and embarrassed his doctor whose hubris had assured him of the effectiveness of a prior ablation, only to awaken to the epiphany that arrhythmias, like life, are difficult to predict. An AV junction ablation would be required to quell another unexpected arrhythmic onslaught. Both realized they were doing the best they could at the time. Neither were in control. But both had prevailed together. And through their long history together, more stories were told - secret, personal stories - as they developed a deep sense of admiration and appreciation for the other. But the stories were always told on the doctors' turf.
There they were again: younger doctor joining the war hero once more as equals.
Fighting the fight on the same field now. Quietly sitting. Staring. Smiling.
Friday, November 16, 2012
Better yet, imagine doctors using cellphones to help care for patients.
It's a beautiful thing, really: efficient, timely, graphical. Doctors, like most people, love the convenience and utility of their smartphones.
But doctors aren't like normal people. We are carefully regulated. We must abide by health care privacy rules and so, too, must the hospitals where we work. So communications about work, be it text messaging, e-mail, SMS messaging - all must be HIPAA compliant.
But an interesting collision of doctor's privacy rights and patient's privacy rights can occur in our new world of mobile health care computing, thanks to a kill switch present inside Apple's iPhone and cloud computing, especially if doctors were to use an EMR app on their cell phone.
Doctors are well advised to understand how their personal smartphone and its information could be affected by corporate and patient security concerns.
Caveat emptor. Not only might your work place data disappear, but also your personal data, too.
- Jim Harbaugh, the NFL's reigning Coach of the Year and the face of the 49ers' resurgent franchise, had what the team termed a "minor procedure" performed at Stanford Hospital on Thursday - my bet: cardioversion.
- 5-hour energy drinks under federal investigation for possible proarrhythmia - reporters decide to test the theory on one of their own: "In an unscientific test at Florida Hospital Tampa’s Pepin Heart Institute, we had photographer Taylor Vinson drink one 5-hour Energy drink..."
- Jeff Green of the Boston Celtics - is back from repair of his aortic aneurism.
- Who knew? It seems there are concerns that Pittsburg Steelers quarterback Ben Roethlisberger’s rib dislocation could puncture his aorta.
Tuesday, November 13, 2012
It has been interesting for me to reflect on what I've written here. Over 3100 posts - some good, some not-so-good - reside here. Some day they will be succumb to spam bots and the electronic ether, never to be seen again. No matter.
This blog has evolved from a marketing mission for my t-shirt website to a place for creative reflection about the decline of my father's health and his eventual death, to an even more recent reflection of my perception of health care's effects on doctors and nurses. It has been silly at times, but remarkably heartfelt at others. It has covered wide range of topics - some based on news stories, others based on one guy's life experiences. I have nurtured it, worshiped it, and disliked it at different times in its relatively short career. But I realize now what it's been for me most: my inexpensive therapist.
Here I can get lost in nuance and subtlety. Here I can describe my joys and frustrations with health care and our profession. Here I can laugh at the ridiculous, the mundane, the silly. Here I can mourn a colleague, an experience, or family member's death. This blog has connected me with people I would never have met while being one of the more isolated and personal activities I pursue.
New content for this blog, at least like I want it to be, is getting harder for me to come by. Perhaps this is why I find I'm writing less and less. Perhaps it's because what I want to say, I've said before. Perhaps it's because I don't always want to sound like the sky is falling in health care, but there remains so much to be concerned about in our new era of health care going forward. Feel-good story lines that ignore reality in favor of an agenda are dangerous. Increasingly, doctors are having a hard time behaving as Walmart greeters, ever pleasant and ever smiling as we are the manipulated tools of the trade. I'm not a big fan of fiction.
My writing, like all of us as we mature, is changing. I find now that I like to discuss the psychology and physiology of what's happening to doctors in our new, changing health care world. I find I like to discuss the the story-behind-the-story or the Bigger Picture more that my take on a news story or study result. (Believe me, it's easy to criticise studies yet far harder to perform them). And yes, I still enjoy teaching about an EKG finding or two. Still, much of what gets written here has felt like I'm fencing at windmills as forces far more influential in health care move forward. As such, my idealistic goal of influence has adapted to a goal of realism. Time is real. So are the kids. So are work demands. As a result, blogging suffers.
Life's priorities change. My wife, kids, family, friends, dog and workplace will forever supersede this space. Life is incredibly short. Yet I find I still cherish my precious time behind the keyboard when I can take a moment to reflect on issues that concern me or excite me about health care and this thing called being a doctor. Yes, it is harder now. But this therapeutic blog continues to teach me one thing I never imagined as a math, science, and engineering nerd who later became physician:
I still really enjoy the creative process of writing.
Saturday, November 10, 2012
Mouse over and click to choose a shirt
This year, we will be donating 100% of all proceeds we have received from the sales of shirts from 2012 to the various charities that each shirt design supports. A partial list of charities we support can be found here.
So consider buying a shirt or help spread the word by "liking" us on Facebook or re-tweeting this post.
Thank you and happy holidays!
Diane and Wes Fisher
Thursday, November 08, 2012
But there is a little-appreciated issue that I see brewing: doctors (and maybe even patients) are quietly being buried by electronic information overload. As a result, I believe doctors are being placed at an increased liability risk.
Let me explain.
In the past era of medicine, nothing happened without a doctor's order. Nothing. If you wanted a medication, lab test, invasive procedure, opportunity to participate in rehab classes - anything - you needed a doctor's order. For the years of paper records and independent doctors offices, this work flow assured that doctors (1) knew what was happening with their patients, (2) saw their patients, (3) prescribed the proper therapy, and (4) assumed the risk for the intervention or treatment prescribed. Information proceeded in a logical linear fashion and the doctor was always at the head of the information line.
But we are no longer in the old days in medicine. We are in the era of near-instantaneous information flow, multi-directional electronic communication, and geographically disparate order entry by "caregivers," (think nurses, nurse practitioners, advanced practice nurses, clinic operators, registrars, etc.) who help us take messages, continue care, and order things. In this electronic process, messages are no longer passed from just one individual to another, but rather are passed to two, three, four, or more individuals simultaneously from any one of several different clinical locations - some of which might be many miles apart. There is an incredible amplifying effect of all of these messages, orders, and notifications -- so much so that even the most tech-savvy doctors are struggling to keep up. In fact, it is not uncommon for a doctor these days to work for two hours on a procedure and return to the computer to find twenty or thirty new notifications, e-mails, or orders have been deposited there. Head back in for the next case and then another thirty items appear. Pretty soon, it's an avalanche of items. Worse: doctors must click on each one of these notifications individually to "verify" he or she has looked at each and every single one.
Doctors understand that the reason we have to click on all these orders is because (a) no one gets paid in our system unless a doctor orders whatever-it-is and (b) someone has to be the fall guy if there's a problem with a nurse, medical assistant, or lab technician that "orders" something on behalf of the physician. There is even a trend to auto-order things (like a pneumovax vaccine, for instance) that assure the hospital maintains excellent public reporting metrics whether the doctor ordered them or not with the order later appearing in our inbox to be clicked.
But worst of all are the silent notifications sent from fellow physician colleagues buried amongst the other notifications. They tell of an important story, one that needs fairly urgent attention, but because people no longer pick up the phone, are not immediately noticed or highlighted. It's like a landmine sitting in a doctor's inbox waiting to be stumbled upon.
* Click* *Click* *Click* * Click* *Click* *Boom*
With all these people and devices ordering and sending, the limited number of doctors out there are being bombarded from multiple directions. It is getting harder to keep up these days. Orders and notices come to us on names we don't recognize or have been long forgotten. (Computers don't forget that you saw the patient eight years ago). And once an order is placed and acted upon without our knowledge these days, we click on the order to clear our notices and thereby assume all the legal risk for the care.
The legal buck still ultimately stops with us.
Doctors need to speak up about this problem. We are not in the old days any longer. We are in the fast-paced, electronic medical record era where things happen (literally) at the speed of light. We need the electronic medical record companies, payors, hospitals and legal community to come together to help us find a solution to this current infomation overload crisis that maintains patient safety and improves efficiencies while limiting legal risks to the doctors who are doing their very best just to keep up.
Tuesday, November 06, 2012
Monday, November 05, 2012
Recovery Mode is what every doctor experiences after a rough night on call, a stressful case, a phrenetic day or week of constant clinical ups and downs.
No matter what the cause, it inevitably takes a while to recover.
And as I get older, I reflect on how Recovery Mode has impacted me and my family more. Perhaps it is the years of entering and exiting Recovery Mode. Or maybe, it's because with age, it's harder to rebound, I'm not sure. But usually, there is relief that you've made it through another test of your endurance, both physically and emotionally when you leave Recovery Mode and reenter a more normal work pattern.
Recovery Mode should not be confused with doctor burnout. Rather, Recovery Mode it is a natural and expected consequence of our job that involves sleep deprivation, tough decisions, and the high levels of attention to more and more details required of doctors that are often proscribed by others. Inevitably, it takes time to recover to baseline after an unsual amount of these "normal" events.
But the effects of Recovery Mode are real. I know it. The kids know it. So does my wife.
And writing here means there's hope.
Thursday, November 01, 2012
Instead, it is quickly morphing to Skynet.
Like a black hole, everything goes in to Skynet now. Nothing escapes its gravitational pull.
Schedules, supply chains, staffing grids, calendars, medicines, pharmacies, insurance plans, pay for performance initiatives, quality measures, door-to-balloon times, billing codes, procedure codes, everything.
Ever-expanding. Spreading. Consuming.
All left unchecked.
The office computer was used to be Skynet's reach, but it quickly expanded to the home computer and the cell phone, provided you're willing to have the cell phone's memory swiped clean if you leave Skynet's grasp. Personal schedules, too, have fallen victim to Skynet as everyone's whereabouts are tracked for all to see in the name of staffing and operating efficiency.
And this week, "personalized medicine" moved a step closer as the complete DNA material of more than 1,000 people from 14 population groups in Europe, Africa, East Asia and the Americas were sequenced so they may serve as a standard reference against which doctors could one day compare a patient's genome profile, even during a routine checkup.
Yes, more fodder for Skynet.
Kind of makes you wonder when we'll be terminated, doesn't it?
Wednesday, October 31, 2012
Thursday, October 25, 2012
"No," I said, taking a moment from the surgery I was performing. Here's what I saw:
|Click image to enlarge|
"Hmmm. Boy that's strange. Did you ... ?"
What did I ask? How would you sort this EKG out?