Sunday, April 28, 2013

Story Lines

Doctors are trying to rationalize our current story line:  the loss of autonomy and pay cuts are a necessary evil for the greater good.   We're taking one for the excess-health care cost team.  We're willing to take this personal sacrifice for our fellow man and woman.   It is the noble thing to do.   It will be good for America's healthcare system if we do our part, work harder to improve inefficiencies.   There are even doctors in leadership positions who reflect in their three-year "honest assessment" of our current health care law that higher taxes and near-30% rise in insurance premiums are a necessary evil for extending insurance to 30 million more Americans.  "I am glad to do my part," they comment.  How could anyone argue with such beneficence?

Doctors who sacrifice and give tirelessly to their patients are our storybook ideal; what every American loves to envision.  But we should also acknowledge that there is another story line: that many physicians are deeply concerned with the realities of what's taking place in health care lately.

Doctors are witnessing health care costs greatly outstripping inflation, especially since our new health care law was put in place.
  • People aren't using their coverage because they fear the cost of their much higher deductibles.

  • Insurance companies have created their own convenient loophole to avoid the consequences of their own new law.

  • With the initial deployment of the law only eight short months away, the promised insurance "exchanges" have yet to be fully deployed nor explained to the public.

  • The small business health care program has been delayed.

  • People with pre-existing conditions stopped being covered in February, 2013  because the government agency responsible for this portion of the law ran out of funds.
  • More concerning for those who are budget-minded, as of today, not a single member of the the law's Independent Payment Advisory Board, the 15-member panel that is supposed to recommend cuts to the Medicare program beginning 1 January 2014 to maintain its solvency, has been selected, much less approved.
Meanwhile, our nation's leadership is enjoying the black-tie White House Correspondent's Dinner in appreciation of those who serve as our Great Distributor of Washington story lines, aptly named "Nerd Prom."

Perhaps I shouldn't be so harsh.  After all, it was just in the spirit of poking fun.  I should also accept that since American Medicine is our largest employer and nation's largest business, American Medicine will forever be tainted by politics.  But as we have seen time and time again, it is common in politics to sell Story A when, in fact, the real motivation for something is Story B. When political initiatives are deployed that are uncomfortable there has to be something that people will emphatically rally behind.  How else could we send our children off to war, for instance?

And so it has been with health care.

Story A was that this whole health care story line was about the uninsured.

Yet people were never waving flags and demonstrating in the streets for wellness initiatives with free mammograms, physicals and flu shots.  People were not looking for more and more middle layers of bureaucracy, red tape, and management.   People are not demanding that first-year medical residents see patients for only 12% of their day because of training rules. People were not looking for their doctor to become a nursing supervisor, medical coder or typist.    People were not picketing the Supreme Court for double-digit insurance company stock market returns so they could enjoy higher premiums and deductibles.    People were not hoping for $100-million golden parachutes for pharmaceutical executives. People were not lobbying for bigger hospitals competing with other hospitals for wealthy patients, each filled with outdated computers, waterfallsbig screen TVs and kiosks in "anticipation" of what was to come.   And people were REALLY not expecting the government to burn through their cash so fast that they'd be asking for more money so soon.  

Yet here we all are, realizing our new, disturbing story line.

Doctors, patients, ...

... and Nerd Prom.


Thursday, April 25, 2013

A Few Words About this Week's Block-HF Trial

Today, press releases about Medtronic's BLOCK-HF trial filled by e-mail inbox, just 24 hours after the results appeared in the New England Journal of Medicine.  For those unfamiliar, the trial studied the efficacy of biventricular pacing to reduce a composite endpoint of death, heart failure admission and a particular echo parameter called the left ventricular volume index.  The study, reported one of the lead studies in the New England Journal of Medicine, was hailed as "game-changer" in our field because it potentially expanded the indication for biventricular pacing in properly selected patients.

But we should always question composite end-points, especially when they are the primary endpoint of a study.  In this case, the primary endpoint was defined as "By intention to treat, a composite of all-cause mortality, HF-related urgent care (any unplanned hospital visit requiring intravenous heart-failure therapy), or greater than 15% increase in left ventricular end-systolic volume index by echocardiography, over a mean 36-month follow-up."

Note the word "or" between each of these measures.

What I found interesting in this trial was that most of the composite endpoint benefit was driven primarily by the echocardiographic measure of left ventricular volume index.  (A portion of Table 2 from the New England Journal of Medicine is duplicated below):
biV PacingRV PacingbiV ICDRV ICD
Primary Endpoint1081275263
  Event Related to LV Volume Index56793136
  Urgent Care Visit for Heart Failure40381623

It is not surprising that biventricular pacing improves the LV volume index (biventricular pacing improves the coordination of contraction of the medial and lateral LV walls by its very physiology).  But the as far as heart failure and death as subsets of the therapy, there really wasn't much of a difference. 

To me, this is not that surprising.  In the MIRACLE trial (the sentinel Medtronic trial of biV pacing in heart failure that I participated in years ago), patients were required to have left ventricular ejection fractions (LVEF) less than 35% and a QRS complex greater than 130 msec.  Subsequent analysis of that trial showed that LVEF improved on average about 5-6% with biventricular pacing (a small but significant improvement).  Patients with severely reduced LV functions at the outset of the MIRACLE trial, then, had the most to gain clinically from the 5-6% LV function improvement compared to patients whose LV functions were less compromised.  Therefore, it is not surprising to me that biV pacing had less effect on the clinical indices of heart failure visits or death in the BLOCK-HF's cohort of patients whose LV functions were more robust.

It will be interesting to see if CMS sides with Medtronic's conclusions and agrees to pay for the extra lead placement in complete heart block patients with only mildy reduced LVEF less than 50%.

Since I implant these devices, I certainly hope so.


Technorati's Social Media Update 2013

In preparation for my upcoming talk at the Heart Rhythm Society's 2013 Scientific Sessions in May, I came across this information from TechnoratiMedia's 2013 Digital Influence Report.  While these data are primarily directed to general online consumer influence, doctors interested in social media might find this information interesting (my comments are italicized):
  • When it comes to community size, 54% of consumers agree that the smaller the community size, the greater the influence. (Healthcare is a niche market, subspecialties even more so)

  • Online services most trusted: (1) News Sites (51%), (2) Facebook (32%), Retail Sites (31%), YouTube (29%). Blogs (29%), Google + (26%), Twitter (16%), LinkedIn (5%) (Heh, glad to see blogs ranked neck-and-neck with kitty videos)

  • Online services shared the most: (1) Facebook (57%), (2) YouTube (40%), Blogs (26%), News Sites (26%), Google + (25%), Twitter (18%), LinkedIn (5%)  (Blogs are shared more than Twitter? Surprised by this - perhaps this is because of the relatively static nature of blog posts.)

  • Concerning creating influence: 86% of "Influencers" blog - one third of which have been blogging for more than five years.  (Rock on!)

  • Most bloggers operate 2-5 blogs (52%) while 43% operate just one.  (OMG, I can barely handle one).

Wednesday, April 24, 2013

Retaking Medicine

If you are reading this, do not forward this to colleagues.  Do not forward on to your state medical association.  Do not demand relevant discussion of this at your next professional meeting.  We are good boys and girls, dear doctor, not activists -- leave that to the lawyers and lobbyists.
I think I'm seeing something, something I haven't seen or felt before in medicine: doctors awakening from our own torpor.

The fuel for the fire has been there for some time: cumbersome (and even dangerous) electronic medical records, excessive bureaucratic mandates, subtle social re-engineering of patient care by guideline and charting directives, meaningless "meaningful use" criteria, an overabundance of administrators and regulators, loss of autonomy, meeting after meeting that lead to nowhere, constant insurance payment denials for procedures that are standards of care, declining patient access to care, cuts to income, and perhaps worst of all, our own peer Inquisitors turning against their own.   Until now, doctors have (for the most part) kept their chins up, they held their tongues. They hoped for beneficial change.

But there's a movement afoot.  Slow. Purposeful. Effective.

Doctors are re-taking medicine. 

Ophthalmologists walked out of a session on the
Affordable Care Act Sunday during a national conference
held in San Francisco (via @kksheld)
The confluence of negative forces described above have coalesced to bring this on.  It's not one thing but many.  And  the signs are everywhere.  Ophthalmologists are walking out on speakers discussing how to "implement and comply" with the Affordable Care Act.  Other groups of doctors are suing the physician medical board re-certification establishment on the basis of the Sherman Anti-trust Act.  Doctors are donating money to advocate for themselves.  Doctors are realizing, thanks in part to the speed and transparency of social media, that they have a voice in the healthcare debate.  They're mobilizing.  And it's not just specialists, but generalists, too.

It remains to be seen what comes of all of this, but make no mistake, the sleeping giant is stirring and it's scaring the hell out of the establishment.

The question is, who will you be, doctor?  Is your profession worth preserving?  Will you be the one who looks down at your feet, the dissembler as the troops march past?  Will you just hope your bills get paid or will you take a stand?  Will you mobilize others or will you be invisible?  Will fear dominate or will leadership?  Will you be the last one to look up?  

This is our hour, our test of character.  

It's happening.


The American Board of Medical Specialties Gets Sued Over MOC

From Sermo this AM:
The Association of of American Physicians and Surgeons (AAPS) filed suit  in federal court against the Amercan Board of Medical Specialties (ABMS) for restraining trade and causing reduction in access by patients to their physicians. 
According to the complaint:
"Defendent ABMS has agreed with 24 separate corporations, and acted in concert with the Joint Commission, to compel physicians to spend enormous amounts of time and money to comply with Defendent's proprietary ABMS Maintenance of Certification (MOC).©  There is no justification for requiring the purchase of Defendant's product as a condition of practicing medicine or being on hospital medical staffs, yet ABMS has agreed with others to cause exclusion of physicians who do not purchase or comply with Defendent's program.  Defendent's program is a money-making , self-enrichment scheme that reduces the supply of hospital-based physicians and decreases the time physicians have available for patients, in violation of Section 1 of the Sherman Act."
Read the whole complaint because there's more.  Physicians interested in supporting this effort should consider contributing to the American Health Legal Foundation.


Tuesday, April 23, 2013

The American College of Cardiology Gets a New CEO

Since when does a pharmaceutical executive become CEO of the American College of Cardiology (ACC)?

Since now.

Call me crazy, but does this strike anyone else as strange?  Are physicians now officially incapable of leading the ACC or any other major professional doctor organization?  Have we not learned anything about the appearance of co-mingling pharmaceutical or medical device company executives with doctors? 

Oh, wait...

Maybe this is happening thanks to our grand health care reform efforts underway.  Maybe cardiology future battles will not be fought at the bedside, but rather in the boardroom or the halls of Congress.  When government calls the shots, lobbying is king, not 60-minute door-to-balloon times.

Need more Regulations?  Check.  Need some Appropriateness Criteria?  Check.  Guidelines?  Check.  Steering committees?  Check.  Ways to keep industry at scientific sessions?  Check.  Need an industry thoughtleader to write white papers on physician payment reform?  Check.

What was I thinking?  After all, pharmaceutical executives have "unique skills" and are accustomed to back-room deal-making, facing regulatory hurdles, basking in paperwork, and getting great benefits for themselves!  They know how to schmooze and mollycoddle the political class much better than doctors do, so why not turn to them for advise?  I get the plan - it's brilliant!  Who needs clinical cardiologists for leadership positions in their professional societies?

Seriously, what could possibly go wrong?


Monday, April 22, 2013

To Burn or Freeze During Catheter Ablation of Atrial Fibrillation, That Is the Question

With the deaths that have recently surfaced caused by esophageal perforation following cryoablation procedures for the treatment of atrial fibrillation, Dr. John Mandrola (a fellow colleague and EP-blogger) delves deeper into the incidence, issues, and current recommendations that might improve the safety of the procedure over at today.  It's an excellent review of the current state of the art as he's been able to review it.  Go now and read his piece.

Of course, as Dr. Mandrola points out, although the incidence of this deadly complication is rare, there is still much we don't know about this procedure's long-term safety, especially as newly-engineered cryoballoons  enter the EP community's ablation toolkits.  Careful long-term assessment of this technology's safety and efficacy, as well as its safety compared to more conventional radiofrequency ablation techniques for pulmonary vein isolation, remain unknown.


Saturday, April 20, 2013

From the ER in Boston

From the Wall Street Journal this morning, Emily Loving Aaronson, MD, an Emergency-medicine resident at Harvard who is on staff at the Brigham and Womens and Massachusetts General Hospitals, reflects on the scene in the Emergency Room on the day of the Boston Marathon bombing attack:
"... The first wave arrived with similar injuries: severed limbs, open fractures and puncture wounds from shrapnel. We worked to control patients' bleeding, to "reduce," or set, their badly broken bones in an effort to save their limbs, and to administer medication to help their pain and prevent infection.

Then the next wave arrived. These people had less obvious injuries but had suffered an insidious threat: Their singed facial hair and sooty mouths alluded to the degree of damage that could be in their lungs—raising concern that subsequent swelling could impede their ability to breathe.

The ER got louder and stretchers continued to arrive. Each new arrival seemed to be accompanied by a new wave of doctors, nurses and support staff from all over the hospital who had come to help. The team that emerged in the minutes and hours that followed was truly amazing. Nurses worked with singular focus on the patients in front of them, support staff hustled to ensure that supplies were available and equipment at the ready, and administrators organized and systematized the care. And as doctors, we kept seeing patients.

As the night wore on, word of incredible acts of kindness emerged. When the Sandy Hook shootings occurred in Newtown, Conn., in December, we had sent a pizza delivery to the staff at a nearby hospital in Connecticut; now 50 boxes of pizza were delivered to our ER, courtesy of those same folks. Our social workers labored tirelessly at bedsides to try to reunite families, struggling to determine who the patients were and to find out if they had family members who had been injured and taken to other hospitals. Chaplains roamed the ER and spent hours in the waiting room, comforting distressed families. ..."
Read the whole thing (subscription required).


Friday, April 19, 2013

Our Fascination with TEDMED

I've been following the Twitter stream regarding TEDMED 2013 with interest this year, mainly because I recognized and "know" (virtually, mind you) one of the participants this year, @Zdoggmd.  Seems he knocked his talk on empathy out of the park and received a large, booming standing ovation after his talk.  Too bad I wasn't there to witness it.  I could only see a snippet so far and it looked great, but ...

... I had to work.

I love innovation in medicine.  I'm a technology junkie, I like to think of myself as an early adopter, and even though I am a "seasoned veteran" in medicine, I still think I keep reasonably up to date.  So it comes as no surprise that I find myself, admittedly, jeolous that I can't be there to hear the inspirational talks and leave feeling better about myself and the state of medicine.   After all, there is still so much to like about our profession, despite what we hear and what I sometimes write on this blog.

But I also love and respect the science of medicine, and this is the part that bothers me about TEDMED.

TEDMED isn't science.  TEDMED is show: really, really beautiful, articulate, polished, high-definition-brought-from-a thousand-angles-of-view, show.  We are wowed.  We wish we could speak like that.  We cherish the graphics that are shown.  We are taken places where we haven't gone before.  We see the 62,253,416 impressions, 21,023 tweets via 4,420 tweeps and weep.  We see cool things and hear cool stories while doing other things on our computer.  "God, it's beautiful man!"

And we are shown, convincingly, "The Way," through marketing. 

Do not ask.  Do not dare question.  Listen.  Accept. 

Then, while you're there, hob nob with the intellectual hoi polloi.  They are the "influencers."  You are, for that moment and for many thousands of dollars, in the inner circle: an intellectual elite.

It's addicting.  It's so easy:  an aphrodisiac for the tired medical soul.  Seriously, what's not to like?

But real scientific inquiry and discovery takes cynics, doubting Thomases, and critics, not just ideas and stage shows.  Medicine isn't practiced in corporate suites or in front of a computer (despite what others think), it's practiced at the bedside.  It is practiced face-to-face.  So while bringing great ideas together to brainstorm for "breakthroughs" is fine and dandy (even, as they say, "magical"), it is a very corporate way to think. 

But real, lasting ideas that work in medicine require more than just show and entry fees; they require inquiry, critique, testing, critical appraisal, buy-in, and most of all, action. 

Buy-in is tough if ideas are top down.  Buy-in is tough if only certain ideas are amplified by unknown "idea curators" while others are tossed aside too quickly.  Buy-in is impossible if ideas aren't responsibly vetted for they might be incorrect or dangerous.  Buy-in won't happen if leaders don't lead and are different from their followers.  And followers won't implement ideas if they think they are contrived.

So we should watch TEDMED for what it is - entertainment - and for what it's not.  THEN we can keep an appropriate perspective to what we need as we get back to the real work at medicine.

After all, our patients in this troubled medical system still need us firmly based in science and reality.


Wednesday, April 17, 2013

With Patient Deaths, the Afib Cryoablation Bloom is Off the Rose

Cryoballoon ablation of atrial fibrillation, once considered a safe means of performing pulmonary vein isolation for the treatment of atrial fibrillation because it was widely believed to be a safer form of ablation, has claimed its first deaths.  Two cases of esophageal perforation, one posted on the FDA Maude database 3/27/213 and another 9/18/2011, has received remarkably little public dissemination as far as I can tell in the EP community.

It has long been recognized that esophageal ulceration can occur with cryoablation balloon catheters, but esophageal perforation has previously not been widely reported.  The challenge for the technology, of course, is the ability to control the depth of lesion during long applications of freezing applications is difficult, especially when the technology is compared with the rapid onset and offset of existing radiofrequency energy applications.

I suspect we'll be hearing more about this soon in the scientific literature (at least I hope), but for now, electrophysiologists should be aware that cryoablation for pulmonary vein isolation in patients with atrial fibrillation, just like radiofrequency ablation, can cause esophageal perforation and should be used with appropriate caution.


Addendum: The direct link to the FDA Maude database reporting the patient death from cryoablation.

Another case report in the literature:;jsessionid=ABE88B7ED0954662425E6946A0633063.d04t02?deniedAccessCustomisedMessage=&userIsAuthenticated=false

Tuesday, April 16, 2013

How to Change The Battery in Your iPhone's Alivecor Heart Monitor Case

After recording about 120 electrocardiogram (ECG) tracings from your Alivecor iPhone case, the device will suddenly stop recording EKGs when the battery in the case cover runs low.  Fortunately, replacing the battery is a very simple process.

First, assemble all of the items needed: (1) a new 3-volt model 2016 battery (I got mine from Walgreens), (2) a tiny Phillips screw driver (used to repair eye-glasses and often found in hardware stores), and (3) your Alivecor iPhone case as seen below (Excuse the DEMO sticker - I was a beta-tester for the iPhone 4S case):
Click to enlarge
Next, unscrew the plate on the inner side of the iPhone case as shown:

This will reveal the old battery below the case cover.  Set the cover aside using care not to lose the tiny screw that attached the cover to the case:

In the upper left corner of the battery holder is a small recess where the battery can be carefully pryed from the holder as shown:

Carefully remove the battery to reveal the contacts below it:

Take the new replacement battery and remove the adhesive backing on the battery before installing it back in the holder:

Be sure to place the replacement battery in the holder with the writing side up, using care to first place it beneath the metallic retaining clips in the lower right side of the battery holder:

Once seated back in the case, screw back on the cover:

Then just place the cover on your iPhone and you'll be good for another 100-130 ECG tracings or so!


Social Media Ethics and the Control of Physician Speech

The position paper from the American College of Physicians and the Federation of State Medical Boards, is a humbling reminder of the challenges that today's physicians face when entering the online space. 

Their recommendations for online medical professionalism, written by ethics committees for the two organizations, "provides recommendations about the influence of social media on the patient–physician relationship, the role of these media in public perception of physician behaviors, and strategies for physician–physician communication that preserve confidentiality while best using these technologies" -- no small amount of territory to summarize.

But given the tenure of their document, I should probably hang up this blog right now.  After all, why risk being vulnerable in the online world?  While well-meaning on one hand, we should appreciate that physicians have officially been put on notice on how to behave online.

To be fair, I agree with most of what they say.   All the things about patient confidentiality are appropriate.  All the things about respect for persons, better still.

But to me, the part of the document that wanders off into the "influence of social media on the patient-physician relationship" and the influence of social media on the "public perception of physician behaviors," is more difficult to gauge in its benefit or detriment to the public discourse.  After all, perception is in the eye of the beholder.  When central health care planners muddle the ethics of patient safety by facilitating the deployment and mandating use of untested electronic medical records, should doctors sit quietly and act "professional" as the age-old ethics of research and study are cast aside in the name of the "public good?"   Taking it a step further: should doctors, in the interest of political correctness, cower in our newly constructed cubicles and tow the corporate party line, even though it harms our patients, lest we run afoul of corporate social media gag clauses?

Yes, dear doctor, according to the guidelines, you should. 

Don't harm the "profession."  Be polite.  Be respectful.  Don't stir the waters, or if you do, stir them very gently.  Stick with medical issues and don't wander into the political or the social mire.  Instruct.  Speak of the many wonders of medicine.  Don't raise red flags for they may affect "public perception" of not just doctors, but the institutions that employ them.  Tread very, very lightly, and if you can't play nice, don't play at all.  To do otherwise, dear doctor, might affect our growth strategy.

This is the challenge that doctors must face online these days.  It's not just about being ethical, for the lines of "ethics" is being blurred by others' perceptions of what we should be now, but rather it is being true to ourselves and our patients.  Doctors increasingly work for large, soon-to-be "accountable care organizations" (ACOs) where ethical standards for an organization's success can conflict with the ethical requirements for the autonomous patient.   With whom should we side, the patient or the organization?

The academic elite with little or no real experience with the nuance and complexities of this online world have little realization of the complexities of behavior online and even less appreciation how their position papers of online professionalism can come back to haunt those who delve into this space to tell our story.  "Doctor, we want to talk to you in the front office about your blog.  Do you remember that ethics document from the American College of Physicians and the Federation of State Medical Boards?"

Yes, perhaps I'm an alarmist, but we should appreciate the gravity of these seemingly well-intentioned documents to online physicians who strive to be patient advocates in an era of ACO employment of physicians. 

This is our new professional calling.

Respectfully and ethically, of course.


Wednesday, April 10, 2013

Maintaining Board Certification Every Two Years

Remember the good ol' days when taking a single board certification examination from the American Board of Internal Medicine (ABIM) was good enough to call yourself "board certified" in a medical specialty?

Those were the days.

In 1990, things changed.  Board certifications became time limited.  To remain "board certified," the ABIM stipulated that doctors had to undergo a Maintenance of Certification (MOC) examination every 10 years to remain board certified, even though no data existed then (or now) that such testing achieves the ABIM's stated goals of promoting "lifelong learning and enhancement of the clinical judgment and skills essential for high quality patient care."

Now things are changing again.

I just received a notice in the mail (pdf here) that states the following: beginning 1 January 2014, the ABIM will require that at least one Maintenance of Certification "activity" be performed every TWO years and for EVERY TWO YEARS thereafter.  In addition, doctors will have to earn 100 ABIM "points and complete a patient survey and a patient safety module by December 2018 (in FIVE years and EVERY FIVE YEARS  thereafter). That's right: more testing of doctors and no data to support the testing's ability to maintain a quality physician workforce.

For those interested, more information can be found at .  According to this website, annual cost to physicians will be "about $200 per year" and "If you are maintaining more than one certification, the cost will be the fee of the most expensive certification plus half for each of the others."

Instead of assuring quality, then, it seems doctors are really being asked to improve the ABIM's cash flow.  Also, as a result of this initiative doctors will be spending consistently more time away from patients.  

It's crazy.

Clearly no one is listening to doctors on the front line.  Doctors are already overburdened with too many unproven bureaucratic requirements.  Adding these costly, unproven "certification" requirements to things like meaningful use, pay-for-performance, results checking, email answering, patient satisfaction surveys and the like just adds insult to injury.  How much time do the members of the ABIM think we have?

How much quality to we impart to our patients when we asked to stare at more and more computer screens rather than care for our patients?




Being Schooled

An interesting phenomenon is occurring in media circles these days.  No doubt others have seen it, too. 

Lately, doctors are being schooled by the media.

From how to learn empathy, to improving communication with patients, the breadth and depth of what we should do for our patients is endless.  Why, some even have our own colleague "experts" tell us how we should really do things.

These efforts, while probably well-intentioned, are patronizing.  Do doctors tell journalists how to write or what to print?

Why are doctors seeing these main stream media efforts?  Is it because most doctors are really incapable of the ability to listen and communicate with our patients?  Is it because we must keep a stiff upper lip for what's coming in 2014?   Or is this not-so-subliminal agenda of social engineering underway for some other reason?

It goes without saying that all of us should communicate better.  (Think how many wars or family fights we could have avoided if we had, for instance.)  And every doctor should turn their head away from computer screens and toward their patients, hold the patient's hands, look into their eyes, listen to their concerns, put ourselves in their place, do a thorough physical exam, have constant empathy and insight, read back medications, write out written instructions in 5th grade English, escort our patients back to the waiting room, or utilize highly skilled and educated assistants with all of these tasks, too.  But the reality is this: time and ancillary resources are limited these days for doctors.  Helpers cost money.   Productivity must occur before new helpers are hired.  More people than ever are entering health care thanks to intense marketing campaigns and new mandates for care.  And there are so many doctors with only so many minutes in the day.

So doctors have to triage.  Sickest first.  We move as fast as we can to remain productive, because that's what's REALLY valued in healthcare these days.  So is patient loyalty because that's what keeps them coming back.  But in the process of growing loyalty, we increasingly have to document everything or other payers think it doesn't happen.  So we type.  And click.  And type.   And click.   And print.  To get paid.  Talk about a communication and empathy buzz-kill!

Yet for those looking in, we must communicate better!  "Listen to our "experts!" they proclaim.

Medicine was once considered a place where patients could confide in their doctors about their most intimate concerns and doctors had time to listen. Notes were one- or two-line jots in a chart.   We'd spend the extra time because we were valued for our skills and for our knowledge and there was more to it than just pay.  We had skin in the game. We got paid in chickens.  We knew our patients.  Back then, seven-minute appointments didn't exist.  Now, doctors are cultivated as shift workers.  Patients have Google.  Everyone has information at their fingertips.  Our new story line has become there are no limits to what patients can have in health care.  Perfect data.  Perfect health care access.  Error-free health care with perfect delivery.  Perfect communicating doctors.  Always.  We're building our medical Utopia.

But this effort to school doctors on our path to Nirvana has a serious downside for health care workers on the front lines. 

As I've said before, there's a growing culture of hostile dependency that continues to grow toward doctors  these days.  The theme is like an adolescent who realizes his parents have feet of clay.  He comes out of his childhood bubble and realizes his parents have failures and limitations because they are human beings.  This results in the adolescent feeling unsafe, unprotected and vulnerable.  Since this is not a pleasant feeling, narcissistic rage is triggered toward the people he needs and depends on the most.  None of this occurs at a conscious level.  Most of us understand this behavior simply as "adolescent rebellion," not understanding the powerful issues at play.  So when we spotlight one side of what doctors should do for patients, be it improve communication or empathy (or whatever) without acknowledging the realities health care workers face like looming staffing shortages and pay cuts, we risk fanning the flames of narcissistic rage against the very caregivers whom we depend on the most - the very caregivers who are striving to communicate, do more with less, check boxes while still looking in the patient's eyes, meet productivity ratios, all while working in a highly litigious environment. 

So be careful.  Maybe we should school doctors less and value them more. 

Who knows?  Such a move might make things better for everyone in the long run.


Monday, April 08, 2013

Psychology's New Adjustment Disorder

You can see it in their eyes as they dart left and right, up and down.  Their hands make rapid, self-flagellating movements over their chest, hips, buttocks.  Their pulse quickens.  Cold beads of sweat rise across their upper lip and forehead.  Their breathing is shallow at first, then builds, gradually, to a large sigh.  Inaudible words are whispered and the individual appears agitated, often pacing in circles as they speak.

They stop.  They frantically look about, rechecking pockets, coats, desktops, and even peer under the keyboard.  Their thoughts circle, pupils constrict, palms moisten, and mouth goes dry.  

Then, as fast it came, nothing.  They try to stay calm but the damage is done. A blank stare descends as they look toward somewhere in space, as if every hope, every friend, every loved one, is lost.

"Doctor, are you okay?"

"Oh,  I'm sorry.  Acute Rectangle Deficiency...."

 "... I think I left my cellphone at home."


Friday, April 05, 2013

The Physician Payment Reform I'd Like to See

In case you missed it, the "National Commission on Physician Payment Reform" issued their glossy, industry-produced white paper on 4 March 2013 containing twelve recommendations to provide a five-year "blueprint" for transitioning physician payment methods to a "blended payment system that will yield better results for both public and private payers, as well as patients."

Rules Are Only for the Little People

I was alerted to the presence of this report after an "Online First" article entitled "Phasing Out Fee-for-Service Payment" by Steven A. Schroeder, M.D., and William Frist, M.D. for the so-called National Commission on Physician Payment Reform was published March 27, 2013 in the New England Journal of Medicine.  (So much for Journal's Ingelfinger Rule that prevents the publication of works previously published elsewhere.  It is interesting that Dr. Schroeder, the lead author of this New England Journal of Medicine article, failed to disclose that he currently serves as an editor for the New England Journal of Medicine.  No doubt he "exempted" his own piece from the Ingelfinger Rule because this 5-year, 12-step program [pun intended] was felt to be "public-health information that needs to be brought to the public's or profession's attention without delay.")

But the concerns about this article and its authors' backgrounds go much further.  We should realize that this 14-member "National Commission on Physician Payment Reform" was supposedly created out of thin air by an obscure general internal medicine group called the Society of General Internal Medicine (SGIM) comprised of approximately 3000 academic internists. We are led to believe the SGIM doctors chose their 14-member National Commission with physician payment reform solely as their guiding light.  And why not?  What physician wouldn't want to enjoy not being paid for the work they do?

Whose Interests Are Served By Physician Payment Reform?

So let's look at a few of the members of their "National Commission."

First and foremost is the "honorary" commissioner and former US Senator, William H. Frist, MD.  Doctors should ignore Dr. Frist's deep, deep ties to Hospital Corporation of America (HCA), the largest operator of health care facilities in the world.  After all, he only held a few blind trusts that his 2005 financial disclosure form valued between $15 million and $45 million.  And we should ignore the fact that he sold his interests in those trusts just one month before HCA stock price precipitously fell in 2005 and was subject to a SEC investigation.  To be fair, no wrongdoing was ever found.  But that hasn't stopped our "own" Dr. Frist from serving as partner and Chairman of the Board for Cressey and Company, LP, a private investment firm based in Chicago and Nashville "focused on the health care industry."

I'm seeing this effort for physician payment reform as being all about patients, aren't you?

But there's more.

Another member of the 14-member commission is none other than Dr. Troyen A. Brennan.  Dr. Brennan is Executive Vice President and Chief Medical Officer of CVS Caremark, the nation’s largest pharmacy health care company.  In this role, he oversees the company’s MinuteClinic, Accordant Health Care, clinical and medical affairs, and health care strategy.  CVS was so happy about his appointment to this National Commission that it even sent out a press release!  While I have no idea about Dr. Brennan's salary with CVS, I'd bet my medical degree that his salary is higher than that of most US physicians.  One only has to look at the relative salary and benefits that CVS Caremark's Chief Executive Officer earns and you see why I am confident about Dr. Brennan's relative salary.  I mean, who wouldn't want that private jet?  No doubt America's doctors will feel nothing but goodwill and fuzzy feelings about helping to fund the nice retirement package CVS routinely gives to its chairmen as a result of Dr. Brennan's efforts on the Commission.

Another member of the Commission is none other than Dr. Lisa Latts.  Dr. Latts also serves as the Vice President of Public Health Policy for WellPoint, Inc, the largest managed health care, for-profit company in the Blue Cross and Blue Shield Association.  They insure nearly 11% of the US population.  But one could argue, cheap doctors should mean cheaper insurance, right?   I don't think so.  After all, it's not easy to keep paying for retirement packages for your retiring CEO's that cost $20.6 million.  But no worries.  Wellpoint's new CEO's compensation will include just an annual base salary of only $1.25 million with eligibility clauses for an incentive bonus of up to 300% of that amount, not to mention that he is also getting equity-incentive grants for 2013 with an $8 million target value, restricted shares with a grant date fair value of $1.5 million as "an inducement to joining" the company and a "make whole" payment currently estimated at almost $3.6 million for compensation he'll forfeit in switching jobs.   Poor guy. 

So physician payment problems really ARE a major cause of those high health care prices today, doctors, don't you see? 

So let's hear it for the Society of General Internal Medicine and the New England Journal of Medicine for providing their white paper to America on how to implement physician payment reform!  I'm so glad to see that all of the members of the National Commision of Physician Payment Reform were willing to do their part to sacrifice part of their hard-earned salary on behalf of our national health care cost crisis, too, aren't you?

Oh, wait...

A Solution?

Look, here's my idea: stop redirecting the truth about what's really eating up the cost of health care.  It's time we address the excessive costs of all of these excessive middle management healthcare leeches.  If you want physician payment reform, stop creating ridiculous fronts called "National Commissions" of doctors that act has our modern-day Physician Inquisitors.

Instead, pay us what we're each worth (trust me, it's not that hard to find out and it sure as heck doesn't take a year of meetings held at expensive hotels that results in just one white paper with 14 co-authors that carry innumerable conflicts of interest into the discussion.)  Pay us by the hour at our fair rate. And pay us for everything we do for our patients: every minute we type at the computer, answer a health-related e-mail, sit on a phone, sit at their bedside, remove an brain tumor, teach a medical student, look up labs, grow our practice, explain a procedure, or care for your mother after hours, too.  Then pay us double for every minute we take call after hours. 

Dissolve the RUC.  Flush the SGR formula that is never followed anyway and wastes too much time and money each year.  Rid us of stupid proprietary CPT procedure codes that must be linked (properly, mind you) to a ridiculous list of ICD-10 procedure codes so we can be paid.

Keep it simple, stupid. It's not that hard to do.

It's only hard to make changes to our current physician payment system when everyone that wants "physician payment reform" also wants to make sure they get their part of our already dwindling pay.


Wednesday, April 03, 2013

Judgment versus Big Data

Knowledge in Numbers?
Decisions in medicine are supposed to rest on concrete obervations and hard evidence. 

Often, hard evidence does not exist or when it does, it isn't used.  Why is this? 

Concrete observations, too, are increasingly missed as we stare at computer screens longer and patients less.  Yet we persist. Why?

This is our reality now; our evolving medical world.

But if we stop and think about it, medicine, by definition, is a world of technological faults, systemic frailties, and human inadequacies.  We are convinced we know how a patient dies, for instance, thanks to the wonders of unprecedented imaging capabilities but stand slack jawed when an all-too-underperformed autopsy discloses a surprise cause of death that was completely missed by all.

And our answer to these inadequacies?  Stop doing autopsies.  Even though autopsies have consistently shown that one in four deaths occurs from an unexpected outcome or complication of care.

Why did we stop doing them?  Let me count the reasons: we are human, you see.

History repeats. 

Increasingly we are foregoing clinical judgment and intuition in favor of "Big Data" to make decisions.  We construct 70-page Appropriate Use Criteria for ICD documents that cover (really) just a few special clinical circumstances for patients, as if the authors ever really know a patient's clinical circumstance.  Ask yourself how good we are at predicting the day a person will take their last breath?  Like the weather, life is impossible to predict even when you have a billion data points or more.

Big Data and its certainty are our hottest trend in medicine and academics right now.  We know why this is: we love technology.  It is rational.  It is understandable.  It is linear.  We want, desperately, to understand and compartmentalize our human condition, to minimize its variability, so we can ration our resources logically.  But rather than acknowledging the limitation of such an approach, we forge ahead and create logic from dissociated databases with incomplete or empty data fields based on highly-selected patient populations to make our points.  Outliers are considered nothing more than acceptable loss rations.  We manipulate and massage the incomplete or erroneous data using statistics to make our points seem more valid.  Then, like the azithromycin folly, we extrapolate that data and transmit our firmly held beliefs through government agencies to the masses.  We feel good about our myopic analyses and are happy our academic salary was secured for another day.  In return, the importance of medical judgment, experience, and intuition to medicine are cast aside by our fervent belief that trials, databases, and data manipulation are always free from bias and the influence of greed.

More inadequacies.

But in the face of medical uncertainty, what other than judgment and intuition does a physician have - or a patient have, for that matter?  The real patient that sits before us demands an answer where, more likely than not, no real answer exists. Real concrete clinical challenges are rarely represented in a clinical trial or computer database. So we listen. We observe. We review data. Perhaps we get a second opinion. Patient judgment, life experiences, and intuitions are factored, too. Then we decide, together. Medical judgment and intuition are like that: not all luck, not all logic.

But now with Big Data, the new requirement for wellness and fitness is going to be for patients to keep proper symptoms that stay within the lines.  Symptoms and findings must fit new rubrics.  If they don't, your "caregiver" won't know how to treat you, the computer won't know how to treat you, and the rubric won't know how to treat you.  Who are you to say your symptoms are unique? Who are you to deserve a special look?  In the great cattle call of commoditized medicine created by Big Data, who do you think you are?   A liability risk?  Please, stay normative; align your symptoms with Big Data.  And be happy about it, dear patient, because the ends justifies the means.

Ironically, the folly of man has always been that we think we can have all the answers.  Perhaps we should stop for a moment and really think about what we're creating, courtesy of Big Data.