Tuesday, May 29, 2012

Time Therapy

Sgt Bernie Goulet, Spring, 1951

He sat before me, remembering.

"I was 19 back then.  Too long ago.  You know, there were some things you never forget.  One of them was my company commander, Capt Harold Willecke.  Great guy.   Somehow he took me under his wing - my mentor.  Showed me the ropes, how to fight.  We were pretty effective, had plenty of successful engagements against the enemy."

As the surrounding conversation became muted by his hearing aides, his eyes, twinkling and animated, were fixed on me as he continued. 

"There was one time with Willecke I'll never forget.  We were pinned down, the Chinese advancing all around us.  Staying put was certain slaughter.  Willecke knew we had to move, but most of us were too scared.  Willecke wouldn't have any of it!  He got up and started running, gun blazing.  I followed right behind.  His actions got the whole group of us going.  But he never saw the hidden bunker to his right.  I saw a three or four shots from a burp gun rip across his chest.  The thing about a burp gun is it's not as powerful as a machine gun.  If it had been a machine gun, the rounds probably would have gone through him and hit me.  He fell forward face-first right in front of me.  I heard just a slight groan, then a few kicks of his legs, then nothing."

He paused as it became difficult to speak.  His lower eyelids welled up with tears as the memory was replayed as though it was yesterday. 

"Then we had to get up and keep going.  Poor guy.  I ran right by him and saw him motionless.  Nothing I could do.  Damn it." 

He paused again to regain his composure.  After a moment, ignoring all of the other conversations underway around the Memorial Day picnic table, be continued.

"Hey, you know what my son did?"

I shook my head, "no."

Bernie Goulet, Memorial Day 2012
"He took me to his grave.  Not too far from here - near O'Hare airport.  And you know what? "  He slowed his delivery, as though to build suspense while emphasizing his newly-realized epiphany.  "The damn thing... it... was... so... OLD!  I couldn't believe it.  There it was: the headstone was neatly kept, mind you, and it wasn't a typical military style headstone - his name was there with a nice brass engraving.  But the grave itself looked so old.   I guess I shouldn't have expected anything different, sixty years later and all.   But that wasn't how I pictured it would be.  It was hard to believe that that was him.  It was something.  But there was something helpful about seeing that.  A bit less survivor's guilt.  Really.  It helped. "

Then suddenly, the present day returned as his daughter's voice broke through:

"Hey Bernie, try some of this cheese I brought or maybe a little of this wine?"


PS:  Bernie's photo collection, courtesy of the Lincoln Library. 

Tuesday, May 22, 2012

The Outcome Fudge Factor

How hospitals will be paying cardiologists in the years ahead:
“Two or three years ago, 100 percent of cardiologist compensation was base pay,” he said. “Increasingly, that has shifted.”

Administrative time and performance incentives are factored in when considering the total take-home pay of a cardiologist. While most of a cardiologist’s income still derives from a base salary, Mr. Palazzo predicts that will change.

“As accountable care moves along, it could go to as much as 50-50 three to five years from now, where 50 percent is paid based on outcomes,” he said.
I find this concept of paying doctors "based on outcomes" interesting but also troubling.

If you do an echo really well and take a million measurements when others just do the bare minimum - what's the outcome?  If you spend four hours with a patient when others spend 15 minutes a patient, what's the outcome?  If a patient has chest pain, gets stented, goes home the next day, but an expensive drug eluting stent is used where a bare metal stent would do, what's the outcome?   If the patient dies despite doing everything correctly duing a three-week hospital stay, what's the outcome?  If you order a test because the family insists, what's the outcome?

What "outcomes" are hospitals taking about?  Outcomes for the patient, doctor, or hospitals themselves?  Are physician outcomes going to be based on "quality metrics" (like open encounters, performance measures completed and percentage of generic drugs prescribed),  quantity of patients seen per week who didn't die,  "Best Doctor" status, or corporate politics?

I wonder if a "good outcome" will really mean nothing more taking in more money than you spent on providing patient care. 

Does anyone really have a clue what "outcome" fudge factor means? 

I suspect not.

More likely what will evolve in my view, is that doctors' productivity bonuses will disappear in favor of straight salary with their income docked if simple, easy-to-measure "quality measure" endpoints are not met. 

Unfortunately, just because endpoints are easy to measure, does not mean they make a difference for our patients.


Sunday, May 20, 2012

The End of House, MD

Tomorrow Fox television’s, “House” will air its last show and the timing could not be more appropriate.

Dr. Gregory House, MD was a fictitious diagnostic physician, played by British comedy fixture Hugh Laurie, who took our original view of the physician, Marcus Welby, MD, to a more-twentieth century high-tech level. His diagnostic skill trumped his personal flaws allowing him to keep his job despite an opiate drug addiction in a large, presumably academic medical center. No diagnostic test would remain outside the realm of diagnostic possibility as residents scanned, biopsied and drug-tested their way to the ultimate pathologic truth.

Yes, the image of Gregory House MD must end, because like Marcus Welby, MD, he no longer exists.

That’s because instead of “House,” our medicine is now morphing into the “Office.”

As disparate physician groups, each with their unique personalities, join expanding hospital consortiums, an almost comical realignment of priorities is taking place as physicians must be molded into a large employee corporate construct. As this occurs, we see the “Office” plan hours upon hours of meetings to organize its burgeoning physician workforce unaccustomed to “Office” protocols, employee handbooks, quality initiatives, and ever-expanding performance measures.

Some of the “Office” employees adapt easily, others not so much.

For patients, gone are the white boards, the brainstorming sessions, and long nights of anguishing as your personal physician attempts to debug your mysterious seizure-like activity and symptom set. In its place are teams of administrators, doctors, nurses and techs working shifts. Check-boxes are checked to fulfill the proper mandated computer-generated workflows. Tests are minimized. Work hours and productivity ratios are carefully tallied. Bedside contact is minimized to improve efficiency and safety. Yes, nuance, subtlety, and psychology blanch under the fluorescent lights of the “Office.”

But rest assured you will be treated according to an approved clinical pathway that follows multiple and ever-changing guidelines for care. The path might be the wrong one, but all the mice in the maze will be busy as the path is dutifully followed. Cubicles will be buzzing and computers keyboards clicking as the goal now is to get you out and keep you out, never mind the diagnosis, just so the Office gets paid.  And when the doctor becomes team-leader with a caseload of hundreds of patients, “House” becomes a relic of the not-so-distant past.

This is not what doctors wanted. This is not what patients wanted. And I doubt our medical students of today expected they'd be hourly shift-workers, too.

But while Steve Carel might have been funny as the frustratingly bureaucratic boss in a Dilbert-like “Office,” as we move to our new model of comically-named Accountable Care Organizations, I worry that the joke might be on us.


Friday, May 18, 2012

How Bad Is Azithromycin's Cardiovascular Risk?

The paper from the New England Journal of Medicine that reports azithromycin might cause cardiovascular death is not new to electrophysiologists tasked with deciding antibiotic choices in patients with Long QT syndrome or in those who take other antiarrhythmic drugs.   Heck, even the useful Arizona CERT QTDrugs.org website could have told us that.

What was far scarier to me, though, was how the authors of this week's paper reached their estimates of the magnitude of azithromycin's cardiovascular risk.

Welcome to the underworld of Big Data Medicine.

Careful review of the Methods section of this paper reveals that "persons enrolled in the Tennessee Medicaid program" were the subjects, and that the data collected were "Computerized Medicaid data, which were linked to death certificates and to a state-wide hospital discharge database" and "Medicaid pharmacy files."   Anyone with azithromycin prescribed from 1992-2006 who had "not had a diagnosis of drug abuse or resided in a nursing home in the preceding year and had not been hospitalized in the prior 30 days."  Also, they had to be "Medicaid enrollees for at least 365 days and have regular use of medical care."

Hey, no selection bias introduced with those criteria, right?  But the authors didn't stop there.
This study used a "matched" control period in which no antibiotics were prescribed and were "frequency-matched according to a propensity score that was calculated from 153 covariates."  (Editor's note: No doubt there are no more covariates in medicine than the 153 they studied.)

Then, as if to finally admit a smidge of bias to their study design, "to attempt to control for confounding by indication, we also included as additional control groups who took three other antibiotics."  As if THAT will fix the data fields erroneously entered or neglected in the interlinked retrospective databases. 

But why focus on the details?  The authors had something to prove!

So they processed and pureed the data and checked "for misspecification of the propensity-score regression models" by evaluating "whether the covariate distributions were balanced across study groups."  In other words, they made sure the data worked the way the authors thought it should. 

Hey, why not?

Finally at the end, they "estimated" (their word, not mine) the difference between the cumulative incidence of cardiovascular death during a 5-day course of azithromycin and the incidence of a similar period of amoxacillin use. 

Never mind that they admitted in their discussion that "as many of 25% of patients would be misclassified as having died from cardiovascular causes" and that "they cannot establish a specific causal mechanism."

To think that despite all of the confounding factors that the authors had the balls to state that "as compared with amoxacillin that there were 47 additional deaths per 1 million courses of azithromycin therapy; for patients with the highest decile of baseline risk of cardiovascular disease, there were 245 additional cardiovascular deaths per 1 million courses" is ridiculous.  Seriously, after all the manipulation of data, they are capable of defining a magnitude to three significant digits out of a million of anything?


But we should not dwell on these details, should we?  After all, this work was published in the journal with the largest impact factor out there: the infamous New England Journal of Medicine.  No doubt we can look for more high quality retrospective database reviews in the years ahead as Big Data Medicine takes hold.


Paper-based Charts: How Soon We Forget

Suddenly, I don't miss paper charts anymore.   While doctors might be our most expensive typing pool, maybe there's a reason after all:

A recent paper-based progress note.  (Click image to enlarge)

Thursday, May 17, 2012

Mind Over Matter

The wonderful world of biomedical engineering is demonstrated beautifully in this video from the journal Nature.  It shows a tetraplegic woman controlling a robotic arm with nothing but the thoughts from the motor cortex of her brain:

Take 4.5 minutes to view this incredible work.  It will make your day.


Wednesday, May 16, 2012

Durata: Questioning the 99%

One of Many St. Jude Ad Trucks Seen at HRS 2012 Scientific Sessions
The boxing match about the safety of St. Jude Medical's newer Durata defibrillator lead reliability continues to spark interest in the EP community.  In one corner is the supporter of the reliability claims made by St. Jude, respected EP and lead explanter Charles Love, MD from Ohio State University Medical Center.  In the opposite corner this morning on Cardiobrief, comes respected ICD-watchdog Robert Hauser, MD:
Cardiobrief:  "Unfortunately, Dr. Greenberg was unable to attend today, but St. Jude’s Dr. Carlson stood bravely in the breach (no pun intended) to describe the performance of St. Jude’s 3500+ Durata leads in its OPTIMUM registry. Follow up was 2.4 years, and my only comment is that 2.4 years in my view is an early experience, not a mid-term experience. The event free survival was >99%. Excluding dislodgments and perforations, which may be operator dependent, there were only 5 lead mechanical problems, namely conductor fractures, in over 8400 implant years. Now this is truly spectacular. There were no inside-out insulation abrasions and no all-cause abrasions. But I have to say, that the Durata leads that I have been looking at in the FDA’s MAUDE database must not have been included in this study."
I'm starting to see the makings of a Tyson/Holyfield match.


Monday, May 14, 2012

"The Tin Man is Happy"

... because he's living without a heart:
Carter was diagnosed with a disease called amyloidosis two months ago, a condition that damages the heart through protein build-up.

“It just sort of fractured as we cut across it,” said Mayo Clinic Cardiovascular Surgeon Dr. Lyle Joyce. “It was just crunchy.”

As a result, neither ventricle could pump blood. Joyce performed the operation, first taking out Carter’s real heart. For a man without a heart, Carter shows a lot of heart.

Sunday, May 13, 2012

Amazing Grace

“Would you like some crackers? Maybe some cheese?  You must be hungry.”

“No thank you.  But could I have a glass of water?”

I sat outside perplexed, reading assembly instructions for a small gas grill that contained no words, only pictures.  She sat inside, a prisoner of sorts, worrying about me.  I, of course, was fine, but she had sent a foot soldier to make sure I was fine. 

Much has changed, but much remains the same.

Soft supple skin has given way to tissue paper. Arms and shoulders once cushioned by the right amount of subcutaneous fat and muscle have given way to boney prominences punctuated with atrophic recesses.  Her ankles, once speckled with tiny varicosities that she blamed on us, were wrapped to provide physical pressure where oncotic pressure has failed.  Her beautiful blue eyes stood fast and captivating, only their lids proved unreliable.

Much has changed, but much remains the same.

With my recent trip there, we spoke of the parties, the anniversaries, the projects, the plans.  While short, she would chuckle at the craziness of it all.  She could still marvel at my pictures: the kids, my wife, my wife's family and especially my father.  Her tender gaze and audible sigh spoke volumes as she pined for another time and him. 

Much has changed, but much remains the same.

I wish that I could be there today to make you breakfast.  I wish that I could see your smile.  I wish you could see the kids - they’ve gotten so big   I wish you could see our flowers.  Maybe we could watch a movie together? Or share a bit of guitar?  It was  hard seeing your appetite dwindle, Mom, your challenges with solid food. 

Could I get you some crackers or maybe some cheese? You must be hungry. 

Are you sure?


PS: Happy Mother’s Day, Mom.

Saturday, May 12, 2012

More on the DOJ ICD Investigation

Edward J Schloss, MD reviews comments made at HRS regarding the recent DOJ investigation of ICD implantation indications on Cardiobrief :
Suneet Mittal MD of Columbia University gave a detailed account of his group’s experience with a Department of Justice investigation of ICD implantation outside of NCD guidelines.


In his HRS discussion, Mittal was careful to distinguish between a CMS audit and a DOJ investigation.  CMS is responsible for enforcing National Coverage Determinations (NCD).  He indicated that the NCD for ICD implants is unique:  “this is the first time in the history of US medicine that a National Coverage Decision is being nationally enforced.”  To CMS, the NCD is “analogous to the 10 Commandments” with little room for nuance or interpretation.
In contrast, the Department of Justice serves as a bridge between CMS and clinicians, and has the ability to exercise what Mittal termed “incredible prosecutorial discretion.” Their charge is enforcement of the False Claims Act and Mittal found them to exercise more flexibility than CMS.  
Mittal said that penalties for unacceptable deviations are still being determined.  Penalties under the false claim act can recover up to triple the monetary damages of the event.  He added the DOJ would consider prior patterns of infraction and ongoing hospital corporate integrity agreements in assessing penalties.
Good stuff.  Read the whole thing.


A Heart Rhythm Society 2012 Scientific Session Wrap-Up

This year’s Heart Rhythm Society Meeting in Boston, MA was a relatively well-attended affair with plenty of excitement, controversy, and collegial interactions for all.  It’s always great to head to these sessions each year and catch up on the latest advancements in our field and to see good friends and colleagues from over the globe.  I was particularly struck by the number of senior electrophysiologists I spotted who helped shape the Heart Rhythm Society in its earliest days as NASPE and continue to do so today: Ralph Lazarra, MD, Ben Scherlag, MD, Warren (Sonny) Jackman, MD, Melvin Scheinman, MD, Doug Zipes, MD, to name a few.

HRS 2012 Poster Session

But I also noted another trend: the number of attendees from overseas compared to those from the US.  It was pretty cool to walk through the poster sessions and listening to the people from Germany, the Netherlands, China, Japan, England represented.  Sure there were plenty of US doctors, too, but it seemed the proportion of US doctors was less compared to earlier years - as if it’s become too expensive for our own doctors to attend but prevalent industry sponsorship for foreign doctors remains.  (Just a hypothesis)

On Wednesday I attended and live-tweeted  the Atrial Fibrillation Symposium.  (Here's an interactive map of ALL of the the tweets with the hashtag #hrs2012 – click on my “node”  to see my list of tweets and scroll down).  The event was VERY well-attended (sold out, I think) and had pearls from many of yesterday’s and tomorrow’s leaders in our field packed in a very short period of time.  Clearly the work of Sanjiv Narayan, MD from San Diego VA, originally presented at last year’s Scientific Sessions via the preliminary CONFIRM trial, was a standout.  His physiologically-based ablation approach (identifying and targeting the mechanism of the arrhythmia using FIRM (Focal Impulse and Rotor Modulation) mapping), rather than a strictly anatomically approach, was intriguing.   I discussed the mapping system with other physicians who had used the system from U of Indiana and Ohio State and they shared similar excitement.  The technique is not without its skeptics, however, but the initial reports from others with some limited experience suggested “it’s real” and “doesn’t work on everybody but seeing persistent afib stop with ablation is pretty common.” The mapping system is being marketed by Topera Medical

Staying at the Seaport Hotel in Boston, while lovely, proved very interesting.  At 2 am early Thursday morning, I was woken from a sound sleep by a fire alarm saying "This is NOT a drill."  After gathering my cellphone and donning enough clothing to be presentable, I proceeded down the stairs 16th floor (!) with other bedraggled hotel patrons.  I couldn't help but think how ironic it was that I came to Boston to escape my pager only to be awakened like this!  Seeing folks in their robes, t-shirts, nightgowns all huddled beneath a neighboring building's overhang was somewhat comical and the light show created by the stairway alarm strobes was captured (Quicktime movie, 500K - turn your head sideways) by yours truly and proved quite entertaining. (No, those are not defibrillator firings!) Fortunately, the hotel soon received an "all clear" from the fire department.

The following morning (Thursday), the Riata lead recall updates were presented.  Needless to say, I didn't quite make that packed session early enough.   Edward J. Schloss, MD (@EJSMD) live-tweeted this event for us.   (Click on his “node” on the above Twitter graphic to display).  Ultimately, many people wanted to know how likely St. Jude Medical’s later-generation defibrillator lead, the Durata, might fare since it shares some of the design characteristics with the Riata family of leads.  Enter Charles (Chuck) Love, MD whose presentation went far at allaying many of those fears, at least for now.

My late Thursday morning was spent discussing and planning a possible social media session at the 2013 Heart Rhythm Society Meeting in Denver, CO with Kevin Campbell, MD (his reflections on HRS can be found here) and John Mandrola, MD – two guys I had known from social media circles but had never met face-to-face.  There was lots to consider and some buy-in still needed from the Heart Rhythm Society, but so far the interest appears strong.  As we move forward in this endeavor, input from others is welcome as we try to construct a session and perhaps a how-to hands-on breakout session on how to use social media for information feeds, marketing and professional collaboration.

Cars at Scientific Sessions?
John Mandrola, MD
The exhibit floor did seem too overdone: most people there appeared appropriate – no food vendors selling “heart healthy diets” were detected, seems those have been relegated to the ACC meeting.  But of course, John Mandrola and I still had to check out the Ford Motor car that was supposed to have an EKG-sensing optional passenger seat installed. (We wanted to be the "Walt Mossbergs" of EP and do a cutting-edge review.)   Sadly, we learned the one working prototype remained in Europe.  Nonetheless, we had an opportunity to ask about the concept with one of Ford's German engineers.  He was kind enough to provide us with a bit more technical information (1.2 Meg pdf file) beyond what I have blogged about (somewhat tongue-in-cheek) regarding the concept last year.  Still, even without the nerdly car seat in place, John Mandrola, MD appeared ready to buy the car anyway.

Dr, Wes in action
Thursday night concluded with my social media talk for doctors.  It was very well attended by nurses, ancillary care providers, physicians and as a surprise dignitary, Dr. Mel Scheinman – my former fellowship director at UCSF.  Despite AT&T’s data service dying just before the event (seriously, no internet) things went off without a hitch, thanks to some faithful Zoll LifeVest employees and Dr. Schloss’s iPad that used a Verizon data plan!  (Thanks, Jay!)

Friday was filled with more sessions: left atrial appendage occluding devices, a few talks of the newer anticoagulants and anti-arrhythmic choices for people with atrial fibrillation, and a lively debate on the pros and cons of cryoballoon ablation catheters from the folks from Germany nicely rounded out the meeting.  Then, before I knew it, it was time to head back to the airport.

So there you have it: a brief synopsis of what I felt was a very interesting and interactive scientific session this year.  Thanks to everyone who made it such a great affair!


Friday, May 11, 2012

A New Day: Interim Thoughts on the 2012 Heart Rhythm Society Scientific Sessions

I woke this morning to sunshine pouring through my hotel window as the heavy clouds of the last several days in Boston have disappeared.  A whole new day has arrived.

It has been interesting to take a 50,000-foot view of our scientific proceedings in Boston so far, especially since I carry with me many memories of former scientific sessions, including those of the American College of Cardiology sessions earlier this year.

What is clear is that my field of cardiac electrophysiology, like a dividing amoeba, has nearly completely divorced itself from its former professional and scientific kin, the ACC.  While many similarities of the two meetings' format are similar, many differences are apparent, too.

As Bruce Wilkoff, MD, President of the Heart Rhythm Society, read the teleprompter at the opening plenary session Wednesday, we heard that the Center for Medicare and Medicaid Services (CMS) has officially sanctioned the field of cardiac electrophysiology as its own separate billable specialty.   I wondered (ever-so-briefly) why this mattered.  But a quick reality check reminded me that up until now, thanks to a convoluted and ever-changing set of governmental billing rules, CMS would not pay electrophysiologists for their expertise in patient care because (not uncommonly) the patient had already been seen by a cardiologist from the same practice group on the same day.  Never mind that the two specialties really are different.  That's the way it had stood electronically according to CMS until this year.

But this divorce from our general cardiology colleagues comes with mixed feelings to this older clinical cardiac electrophysiologist.

You see we miss important connections to our general cardiology colleagues when we separate ourselves from them for billing purposes.  The irony in all of this (and part of my concern) is that cardiac electrophysiologists still must maintain general cardiology board certification as a prerequisite to remaining board-certified in cardiac electrohysiology according to our certification overlords, the American Board of Internal Medicine.  Obviously, the separation of specialties makes staying current in both fields even MORE expensive and time-consuming now.  For the leadership of our professional societies who are nearing the end of their productive clinical careers, there is little concern about this issue.  But for our younger specialists facing recertification in two separate specialties every ten years, the ability to stay current in both fields so we may remain certified is now officially a costly and burdensome full time job that encroaches significantly on our time with patients.

Beyond this regulatory concern, we also now see that very few electrophysiology posters hang at the ACC meeting any longer.  Likewise, there was not a single coronary stenting poster anywhere at these HRS Scientific Sessions.  No doubt many will applaud this.  But at the ACC meeting, general cardiologists' concern about maintaining skill at complex EKG reading and pacemaker management is forgotten.  So too is my basic understanding of new, powerful antiplatelet agents commonly used after coronary revascularization procedures.  We lose something when we divorce ourselves intellectually from our general cardiology colleagues.  But perhaps this is part of the plan, since dividing the two fields makes us more manageable for hospital administrators, too.

But it's a new day in medicine, isn't it?  Despite all that's happening, the sun still shines bright some days.  There is tremendous value in attending meetings like this for those of us relegated to the dark confines of the EP lab or office much of our existence.  Seeing the original innovators in this field who have grown to become close friends, like Ben Scherlag, MD and Mel Scheinman, MD, totally clears the air for me.  Connecting with EP social media pals Jay Schloss, MD (aka Edwin Janszen Schloss, MD on Cardioexchange) and theHeart.org's John Mandrola, MD (whom I have never met in person until yesterday and who secured a press pass to scoop me, damn it) was fantastic and forever seals our friendship. 

And while many of the posters I have seen are strikingly similar to posters that were there years ago, there are still remarkable insights to our field that are occurring.  The work on mapping rotors in atrial fibrillation may have promise.  The improvements in 3D mapping systems, while expensive, seems to be making our job safer.  And although there are still too many company reps for too few doctors here, getting back to the basics of sharing science and professional connections, rather than tracking our every movement with RFID tags (yes, they are no longer on our name badges!), still gives me hope that as a professional society, we're getting somewhere.

And yes, I'm looking forward to my last day here.


Wednesday, May 09, 2012

Reality SoMe: Live Tweeting Brain Surgery

Reality TV has officially come to the operating room and the health care marketers are going wild:

Doctors will live tweet the brain surgery from Houston's Memorial Hermann hospital beginning at 8:30 a.m. EST Wednesday morning, reports Mashable.

Dr. Dong Kim, the neurosurgeon leading the procedure on the 21-year-old female patient, tells ABC news that the point of the brain surgery Twitter broadcast is to educate patients on what happens during surgery.

“The main reason I wanted to do this was for the educational possibilities. I spend a lot of my time with patients on what to expect and what the steps are,” Kim said. “A lot of anxious patients want to know exactly what happens. With this they will be able to see what happens.”

According to ABC News, Dr. Kim's co-worker will live tweet from the operating room using a laptop, while a video camera will shoot clips of the surgery and a photographer will take shots on a digital camera.


Natalie Camarata, Memorial Hermann's digital marketing manager, told Mashable the plan to live tweet the operation was hatched following the open-heart surgery, which was viewed an estimated 125 million times through Twitter, Storify and media coverage.

It's hard to argue with a stunt that garners such a marketing reach. People love blood and guts. And no doubt Memorial Hermann's lawyers have looked into the legal implications of encroaching on HIPAA's Privacy Rule and it's 18 Personal Health Identifiers. But we have to wonder if the government is sanctioning this media circus at the expense of one 21-year old woman's privacy in Houston, Texas, while simultaneously bitch-slapping doctors who posted their surgical schedule on a publically-available internet calendar.

No doubt this patient gave permission to have this surgery live-tweeted, photographed, videoed and posted online for the world to see, but we have to wonder how this influenced the planned surgical approach when the doctor spoke with her about the procedure. We should wonder how the distractions of the photographers and videographers and social media marketers will have on the surgeon. We should ask ourselves what will happen if things go a little sour. And what about this whole notion of distracted doctoring?  Could brain tumor patients who view this hand-picked surgery be misled about brain surgery's risks in general as a result?

Nah. Never mind. There's bigger, more lucrative efforts that take precedence to patient safety and privacy, right? This is the new world of Reality SoMe! Marketing baby, marketing!

And it's all in the interest of the public's "education," remember?


Tuesday, May 08, 2012

The First Annual Heart Rhythm Society Worst Accepted Abstract Award

As many of us head off the the Heart Rhythm Society's 33rd Scientific Sessions in Boston, MA this week, we leave to see some of the best science of the year in our field.  Abstracts, posters, discussions, Live Case demonstrations, - the whole works - will be there.  Media will cover reports of late breaking clinical trials, the benefits of our new oral anticoagulants, the amazing clinical workings of the subcutaneous ICD, and late-breaking clinical trials filled with fantastic innovations and controversy. 

Sadly, no one will cover the worst abstract that made the cut for the meeting. 

But now, thanks to the entrepreneurial spirit of the blog-o-sphere, the worst abstract of this year's Scientific Sessions can be crowned!!  The criteria for such an award HAS to include the abstract that contributes the smallest amount to our field while demonstrating the worst grammar, the most bureaucratic lingo and, of course, verbosity. 

Ladies and gentleman, I give you the unofficial 2012 Heart Rhythm Society's Worst Accepted Abstract of the Year:

The sentence that clinched it? 

The conclusions:
"Conclusions: The harmonization of endpoint definitions, terminology, and clinical trial design paradigms provides consistency across clinical trial studies that can facility (sic) clinician acceptance of results and the evaluation of safety and effectiveness of devices and medicines for atrial fibrillation."

Congratulations, Abstract # AB35-01!


Saturday, May 05, 2012

The Real Life Repercussions of Medicare Audits

This 21-minute video documentary produced by the North Caroline Medical Society and Physician's Advocacy Institute chronicles the challenges of a Medicare audit for a 35-man physician practice in rural North Carolina.  The pernicious nature of these audits and their real-life implications to doctors and their patients is revealed:

And we wonder why there's a primary care physician shortage in rural America -


h/t: Art Fougner, MD via Twitter

Wednesday, May 02, 2012

A Quick Reminder

For those readers out there attending the Heart Rhythm Society Scientific Sessions May 8-12, 2012 who would like to share some good times, good food, and good information on social media in medicine, be sure to register for my talk Thursday, PM at Ruth's Chris Steakhouse at 6:30 pm in the heart of downtown Boston (click for details on the event and how to register here).  They're trying to establish an approximate head count to acquire the appropriate room size. 

Let's shock 'em with our support of health care social media, shall we? 

So please go now and register if you haven't already.  A couple hundred registrants should do...

See you there!


A Telltale Sign of Improving Heart Failure

... from the foot exam (used with permission):


Tuesday, May 01, 2012

The Dark Side of EKG Screening in Athletes

They sat nervously with their son in the doctor's office, wondering why they were there.  John was, after all, the picture of health and had just received a scholarship to Stanford University to play soccer.  His mother and father had been to every soccer match through his formative years, enduring the travel schedule with its weekends away from home, long hours, horrible weather.  John was staring at his iPhone, his mother clutching a Kleenex.  John's father stared out the window.  It was raining.

The door opened.

"Hello, I'm Dr. Kiljoy.  They asked me to see your son about a finding on his EKG."

"Hello," they said back.

"As you know, we've been looking into EKG's in athletes because we have suspected for some time that an EKG will help us better detect students who might be at risk for sudden cardiac death while participating in sports.  You know, even if we can prevent one death in these young people, it would be worth it.  None of us want a young person to die.  That New York Times article yesterday... dang... with that crying family and all right there at the top... poor boy collapsed, people had no clue what happened at first, people thought he overheated, then waited... only later did they find that AED.  Then it didn't work 'cause the battery was dead.  So sad!  We really are trying to prevent that from ever happening.  Seriously.  Sad as hell.  And to think we could have caught this if that teenager had just had an EKG..."

"Yes, of course!" said John's mother.  "I'm SO glad you did this!  We'll be so reassured to know that John's going to be okay. "

A pause filled the room...

"He IS going to be okay, isn't he?" she asked.

"Well, Mrs Smith, we're not sure, we have to run some other tests.  You see he had a slight elevation to his ST segments in these leads here, see?  Then look at his heart rate, it's so slow!  And that voltage here, it's more than we usually see...  It's probably okay, but I'm going to order an echo to look at his chamber sizes."


"And a then I'm going to have one of our EP people see him to make sure he doesn't have a congenital ion channel disorder..."

"A what?"

"A channelopathy - a genetic defect of some ion channels in his heart - the most common form is called Brudaga Syndrome..."

"How do you spell that?" She waited with pen and paper to jot it down...

"B-R-U-G-A-D-A.  Look, he's probably okay, be we want to be absolutely sure, especially with that ST segment elevation in those leads...  We'll also check a stress test to make sure his heart rate comes up appropriately with exercise and that there aren't any funny EKG changes with exercise that might suggest an anomalous coronary artery - I've seen three people die like a dog with that one!"

"How often does that happen?" she asked.

"Well, it's pretty uncommon, but if it's there, sometimes we have to do open heart surgery to reimplant it so that it won't get pinched between the pulmonary artery and aorta when he exercises."

"But he's never had a problem!  And no one has ever died suddenly in our family - ever!"

"Mrs. Smith.  Remember why we're doing this: John's safety.  This is all about John's safety."

"And if you find something in all these tests, then what?"

"Well, he wouldn't be able to play soccer."

John's eyes suddenly lift from his cell phone.  "What did you say?" he asked.

"You won't be able to play soccer," Dr. Kiljoy repeated.

"Mom, what the f#$*!?  If I don't play soccer, I don't go to Stanford.  If I don't go to Stanford, I'll never play soccer again!  Are you serious?"

The father, sensing his son's concern, returns to the room from his window transcendental meditation.

"Son, let's just get the tests.  Your mother's concerned."

"Mom's concerned?  What the hell do you mean 'Mom's concerned?'  What about me?  I never wanted to get this frickin' EKG anyway!  Look, I'm FINE.  I never so much as farted wrong.  We have no family history of heart disease.  I've never felt my heart race, I've never passed out, I'm faster than everyone else on my team and we just won the State Championship!  How's THAT for a stress test?  I've worked my ass off for YEARS to get this scholarship.  And now, just because of this EKG with bullshit findings that don't pertain to kids my age they're going to do a million tests just to be sure?  Seriously?  Honestly Dad, you gotta be kidding me...  How much is all this gonna cost, huh?  And maybe I'll lose my scholarship, too?  How much is THAT worth?"

"John, honey, it's for your safety," his mother whispers, tears streaming down her cheeks.  "We love you so.  We just don't want anything bad to happen to you...."

"Your Mom's right, John.  We just want to be sure... really....", Dr. Kiljoy continued.

John looked up at Dr. Kiljoy, and said slowly, painfully, with tears in his eyes:

"Doctor, f*&% you."


P.S.: For more, please see Dr. John M's take on the New York Times's abysmal reporting on this issue.