Wednesday, September 25, 2013

When Doctors' Names are Bought and Sold

Recently, an envelope arrived for me containing an advertisement from Mercedes-Benz:

Mercedes Benz Offer (Click to enlarge)
The advertisement was co-branding with the American Medical Association, leading me to suspect the obvious: my name was sold.

Why does this bother me so?  After all, the AMA advocates for physicians, don't they?  Surely they need the money to do all their important policy papers and lobbying activities on Capital Hill, right?

But read the advertisement.  It says: "Mercedes-Benz and the AMA have entered into an agreement to provide members in good standing an incentive of up to $4000 on the purchase or lease of select new 2013 or 2014 Mercedes-Benz Models."

So, is there a kickback for the AMA as well?  That is, for every referral that the AMA gets credit for, they make even more money?  How much?  And what about the Physician Payment Sunshine Act now in play?  Will doctors that claim the credit be on the hook for public disclosure?  Why am I, an AMA non-member, receiving this notice?  Are they counting me in their statistics of supporters when AMA policies are developed?


I understand the simplistic logic behind the AMA's move to sell my name. But policy makers should be aware of this practice and how the AMA may be using doctors' names in their database to reinforce their positions.  The AMA also sells my name to drug companies who track my every prescription, and the results of this practice since the new novel oral anticoagulants have been released has been even more dramatic.

You see I am an early adopter and an influential thought-leader to drug companies who scour the internet for physician feedback.  Well, it's time to give some to make a point.

The next time a drug rep for Xarelto (rivaroxaban) follows me to the parking garage arguing why their drug is better than Eliquis (apixaban), consider the consequences.  But why did this unfortunate episode happen?  It happened because my personal information could be tapped by pharmaceutical companies courtesy of the AMA's Physician Masterfile, so my prescription practices are carefully followed.  When I use a competitor's drug instead of someone else's, the drug lunches suddenly appear and the persuasions begin.  You can almost hear the pharma managers in the back room: "Get over there, show the guy how rivaroxaban's better!  We had sicker patients!  We're a better company!  He's easily swayed! Buy 'em a better meal but be sure to have him sign in for his lunch!  Go!  Go!" 

What a mess.  All because my name is for sale to anyone who wants to cough up a pretty penny to the AMA. 


Monday, September 23, 2013

Reviewing the 2013 EP Board Review Course

This past week I sat for my third board review course in anticipation of my upcoming third EP board recertification. It was a well attended event of about 150-160 electrophysiologists, some from as far away as Alaska. That, I suppose, is one of the attractions of having this course in a city like Chicago: it's a major central airport hub and has plenty to see and do for those hearty and financially solvent enough to spend the evenings out at a nice restaurant or club. For me, a native of the Chicago area, I was lucky enough to stay in my own home and just had to brave the traffic and $35-a-day parking fees. Others from out of town bore a much larger expense in terms of lost days from work, hotel and transportation fees. The meeting was held at the Marriott Renaissance Hotel on 1 Wacker Drive in Chicago, just a few blocks from Michigan Avenue's shopping district downtown - not the cheapest hotel in Chicago, nor the most expensive. Perhaps it was held there for the comfort of the rooms, the size of the lecture hall, or a need to provide a central Chicago location, but given the amount of time we spent in the lecture room and the social life of most serious electrophysiologists I know, I wondered why it wasn't held somewhere less expensive. After all, cost remains a huge concern (if not overriding one) for doctors attending these courses.

The course began Thursday afternoon at 1pm and went until 8:30 pm Thursday, 7:45am-5:30 pm Friday and Saturday, and concluded Sunday with a rushed morning review of pacing principles from 07:45 am to 12:30pm. (Completing the course on time was critical for those who had to catch planes home on Sunday)

I paid the extra money for attending a maintenance of certification test session before the main session began to earn a few points. This clearly was not worth the extra money in my view, as it was just an extra Workshop that included a bunch of typical board-style questions with the answers in the back of the book. My recommendation would be to save your money and take the online versions that come with one's recertification fee. It just seemed to be another cash cow for the ABIM and HRS.

The course materials were printed, and the majority of doctors polled (75%) preferred their materials this way, despite the Heart Rhythm Society (HRS) clearly leaning to providing the material electronically on a thumb drive. They also offered (with a $1300 discount if you attended the session) the full lectures (with audio and slides) to members who wanted to cough up even more money so they could review the materials at another time. (I passed).

The main course was taught by established names in EP and the Heart Rhythm Society: Ken Ellenbogen, N.A. Mark Estes, David Haines, Fred Morady, William Stevenson, among others. These are guys that taught me, they've been doing it a while, and they're good at what they do. As such, the lectures were paired down to the essential principles and generally well-organized with good audiovisuals and sound, but were peppered the same pimp items that you'll still have to memorize despite our new era of Google. I suppose having these things pass your cortex once so the recognition of these syndromes might be realized in one's practice, but in this era of Google whether memorization is really necessary is another matter.

But did I learn anything? Okay, I have to admit I did. New things I learned included a few pearls about Early Repolarization Syndrome (and is probably fair game for boards), the genetics of plenty of obscure diseases, and about how many ways a doctor can get pimped on a cleverly written examination. Given these realizations, I hope my chances for passing my board certification were improved as a result of attending this course. We'll see.

It was kind of sad (yet psychologically affirming) to see Sonny Jackman, an icon of accessory pathway ablation and EP, in the audience with me. It was particularly entertaining when he had to hop up and explain a tracing to the audience on behalf of the lecturer (truly a highlight). But I also wondered why Dr. Jackman was there. Sadly, I knew the answer: he's no different than the rest of us now and understands that it won't be long before the bureaucratic machine called medicine will require passing an irrelavent test to practice medicine.

It was this last issue that was most relevant and prescient. Mark Estes (someone who has sat on the test-writing committee in the past) tried to explain how the ABIM decides how many recertifying doctors ultimately pass their examination. "This is a sensitive and unpopular issue for EPs in practice," he said quietly. You could see people agreeing. But as he explained how the ABIM determines how many recertifying EPs pass the recertification exam he admitted, "I really have no idea how they decide." He continued, "But when we look at the trend line for the percent passing from prior years, you can see that last year's percentage was down a bit." He then showed the trend line.

Think about that. No one has an idea what consitutes the criteria for a "passing" grade for recertification, yet here we are spending too much money on a process that has little to no proven patient care benefit in terms of quality care. This non-transparent scoring criteria adds to the problems with recertification in my view, since it would not be difficult to think that granting of a passing grade for re-certification could be used against certain subspecialites for any number of obscure reasons (eg., the desire to downsize the specialty, political differences, etc.) One only has to consider how the IRS was used against non-profit political organizations to get my paranoid drift in the era of medical cost conservation here. Perhaps this is a bit overdramatic, but it makes you wonder, doesn't it?

So I'm back in the salt mine of everyday practice now. Hopefully the course helped and will prove itself valuable for me in the future. Honestly, every effort was made to make the sessions tolerable and informative, I just wish I understood why the re-certifiers needed to be there. But I'm trying to cope with the reality of the times and I just hope the ABIM won't decide not to pass me for what I've said here.


Saturday, September 21, 2013

Shadow Puppet: An App That Lets iPhone Pictures Tell a Story

They say a picture is worth that thousand words, but nowhere is this more true than with a new, free, iPhone app called Shadow Puppet that lets you turn selected photographs on your iPhone into a narrated video storyline.

I saw this app reviewed over at Techcrunch and immediately saw its potential as a teaching aid.  The app allows you to pick a series of iPhone photos from your camera roll, order them, and then record a narrative about your pictures.  What is unique is that you can zoom or move between photos as you tell your story, annotating them by touching areas on the photo that you are discussing as it records the video.  (Very cool).

Here's my very first video I made with the app describing the new Zio XT patch monitor that records 14-days of a patient's heart rhythm that we've been using in our clinic.  Simply made, these video clips are easily shared via email, Facebook or Twitter.  For this particular video, I still had to edit portions of the patient's report on Photoshop, then sent the images to my iPhone but, still, that was easily done.

Want to teach a fellow how to implant a pacemaker?  Take some photos and show them!  Have an EKG that has a finding that you're not sure about?  Snap a picture (without patient identifying information, of course) , annotate it with your question and send it to your EP!  Simple, elegant, and who knows, maybe even life-saving.


Friday, September 20, 2013

For Medicine: Go Slow

Three years ago, in the midst of all that was happening with health care reform, I thought about if I'd ever recommend medicine to my daughter.  I thought and thought about that issue and looked deep inside myself for reasons one might still choose this profession, then penned "The Top Ten Reasons to Be a Doctor."  It is, by far, the most popular post on this blog, having been read by more people than any other I've written.

But little did I think my youngest might heed this advice.  Unknown to me, she left for college as an environmental studies/economics major, to abruptly decide one week later after some soul-searching of her own to consider a pre-med curriculum.  I couldn't help but feel a rush of pride, but also a huge amount of concern, for no one can tell anyone else what this path is like until it's been traveled.  One thing I know: it she wants it, she's very capable of doing it.

And as part of her growing enthusiasm for this field and (I suspect) recent rewarding experiences she had as a lifeguard at our public beach this past summer, she's even thinking about training to become an EMT while studying at college.

My first thought, of course, was "Heck ya!  Dive in! You'll love that!  What a great skill to have!"  But after a night of rest and reconsideration, I have another piece of advice for her.

Go slow.

You see there's a little secret every doctor lives with throughout their career and never talk about: their closet.  We've all got one and we use it sparingly, and you don't want to fill it up too soon because it has to last your entire medical career.

You see, your closet is where you store life's experiences that are so horrible, so painful, so shocking, that you can never tell anyone (except, perhaps, another doctor) about them.  It is the place where you put the images you see that you'd really rather never talk about.  Ever.  Really: the gross stuff: the gross images, the gross sounds, and the gross smells.  Things so bad I can't even write them here.  That stuff.   And I know EMTs, like doctors, have a closet of their own.

You'll be surprised how dark that closet is and how fast it can fill.

But you also need to know that the closet exists, it is real, and how to clean that closet when considering the path toward becoming a doctor.  This is probably one of the most important skills outside of medicine that a doctor can muster.  So, I'll ask that my daughter to reconsider the EMT class for now and do something entirely, crazily, stupidly different and fun. (Whether she'll do this or not remains to be seen.)  For this is how we have to learn to clean a bit of our closet, or at the very least, make it a little bigger.  Use this precious time before all of the isolation of studying and commitment that medicine requires to expand yourself.  Learn to play badminton, to paint, to play a guitar, to debate, to sing, to ballroom dance, to fly or just to love and appreciate what's out there.  What ever.  The point is this: learn to do other things besides medicine that will engage your brain, hold you firm, and make you happy.  Because medicine's a long haul: a lifelong haul that never keeps adding to that secret closet.

As a student of medicine, your job, throughout all that lies ahead, is it to make sure you always have the renewable resources to get outside medicine so life stays rich and medicine remains, net sum, rewarding. Because as as rewarding as medicine can be at first, it can wear you down unless you always know how to properly size (and maybe even start to empty) a bit of that secret closet that doctors all share.


"Emptying the Closet"
Oil on Canvass, 36" x 24"

Thursday, September 19, 2013

Review: The Strategy That Will Fix Healthcare

Two days ago, I was directed to a piece entitled "The Strategy That Will Fix Healthcare" from the October issue of Harvard Business Review by a reader of this blog who knew I had an interest how we can get our heads around the enormity of lowering costs in health care. The piece was written by Michael E. Porter and Thomas H. Lee. Mr. Porter is a Bishop Lawrence University Professor at Harvard University based at Harvard Business School. Dr. Thomas H. Lee is the chief medical officer at Press Ganey and the former network president of Partners HealthCare and has been a professor at Harvard Medical School and Harvard School of Public Health, as well as an associate editor of the New England Journal of Medicine in his former life. Needless to say, they are perfect fodder for the Harvard Business Review.

In their article, the authors speak of their "fundamentally new strategy" that, "at its core is maximizing value for patients: that is, achieving the best outcomes at the lowest cost."

Boy, who wouldn't want that?

In their piece, they then propose six steps to "fix" healthcare:
  • 1: Organize into Integrated Practice Units (IPUs)
  • 2: Measure Outcomes and Costs for Every Patient
  • 3: Move to Bundled Payments for Care Cycles
  • 4: Integrate Care Delivery Systems
  • 5: Expand Geographic Reach
  • 6: Build an Enabling Information Technology Platform
But where, exactly, are the author's going? Is their prescription really a "fundamentally new strategy?"

As nicely written as the article is, I don't think so.

To me, their "Integrated Practice Units" sound strikingly similar to the "Pit Crew model" previously promoted by others. Measuring Outcomes and Costs, while it sounds nice, is enormously difficult as "outcomes" that benefit business might not be "outcomes" that benefit patients and costs (both direct and indirect) are rarely, if ever, disclosed publicly.  "Integrated Care Delivery Systems" with their high through-puts sounds an awful lot like someone else's Cheesecake Factory analogy. And bundled payments are hardly "new," having already been implemented in some health care markets.   When put this way, the authors'  "new strategies" sound like a  rehash of plenty of Harvard "old school."

Here's A Real Idea to Ponder

If these authors were really about value to patients, they need to think like patients.  Here's an example:

Some time ago, I inquired from one of the major medical device companies if they would sell a defibrillator directly to a patient.  That's right: direct-to-consumer with no middle man.  They could name their price for he had the cash to buy it. That's because he is self-insured business owner. Being a business man, he wanted to purchase the device himself and then shop the implant between centers to get a deal in a way not too dissimilar from the way one man recently shopped his hernia repair.

But what I was told was surprising.

I was told they could not sell the defibrillator directly to a patient because "we cannot ship directly to patients due to regulatory requirements around product tracing abilities."

What the...?

Seriously? Our regulatory environment prevents such a deal? Where's patient "value" there? Why do medical device companies sell  "only to doctors and hospitals" and not to patients themselves? Where is the patient "value" opportunity there?

But to Porter and Lee, this form of "value" is ignored.  They're business guys.  In their pro-business environment, "value" is defined as lower overhead, lower expenses, and more volume.  And thanks to prices that are artificially held high by the government's (Medicare) payment rates, they can continue to mark-up prices to cover other expenses which may not be of value to the patient, like lobby facades. After all, they have large indirect costs to support. Insurers, too, must assure their cut for profits as they negotiate what they'll pay for device implants.  And still more layers of bureaucracy exists with complicated coding, billing and collection that also has limited "value" to patients, especially in the case of a patient who is willing to pay cash.

We should ask ourselves if these intermediaries are the reason we are where we are in the meltdown of health care costs.

I think this more transparent model (or a variation of it) will become more common in the years ahead as patients are forced to foot more of their medical care bill.  Certainly, it won't be for everyone.  But as we continue down this health care reform path, patients will turn a keen eye to health care out-of-pocket costs.   To assure value for themselves, patients will demand THEY pay for the device, THEY chose their provider  or treatment facility, THEY decide who receives funds for care delivery, and THEY have access to their medical and device data.

THAT is the novel health care cost model that's coming that will be disruptive, not an overly simplified six-step business school "fix."  Businesses involved in all aspects of health care that provide patient-care materials, be they drugs or devices, would be wise to be an early adopter of the patient-empowerment movement. 

After all, most patients (I believe) will eventually demand real medical value for themselves, not business.


Sunday, September 15, 2013

When We Conflate Health Care With Medical Care

From Marilyn M. Singleton, M.D., J.D.:

Politics is the art of looking for trouble, finding it everywhere, diagnosing it incorrectly, and applying all the wrong remedies.” -Groucho Marx

The politics of selling the Affordable Care Act (ACA) focuses on promising health and wellness. Somehow, having “coverage” is supposed to get you to a primary care doctor, who will keep you healthy. And if he doesn’t, he will be held accountable by not being paid.

The fact is that “healthcare reform” is not going to cure America’s health problems.

Physicians, think tanks, and politicians are pointing out a myriad of problems with ACA. But most of them miss the main point, which starts with calling it “healthcare reform.” The term, and the conversation about it, conflates health care and medical care. But they are not the same thing. Individuals are in charge of their own health care. Physicians provide medical care to those who become sick.

(Read the rest, especially the comments)
As I and others see the problems with "wellness initiatives" promoted by politicians and the insurance industry as cornerstones of our efforts to cut costs in our medical system, we should consider if institutional financial incentives will thwart any effort to achieve cost savings as physician productivity quotas are increasingly turned to as the driving force de rigueur for hospital profitability. Unfortunately, physicians are losing their ability to be stretched much further, especially as they struggle to keep up with the mushrooming number of inefficient certification and data-entry requirements, flooded e-mail in-boxes, and coding requirements necessary to continue practicing medicine in our new "reform" era. Then add the increasingly frequent hassles doctors are experiencing with their patients' insurance claim denials that go on for months. Medical care suffers as a result. Even our frontline force for quality medical care, nurses, are being stretched thin as many of their ranks are either let go or recruited as cleaning crews on top of their other patient care responsibilities.

Meanwhile, the insurance companies are recording record profits as Americans pay more and more into our system.

But, hey, thanks to the Electronic Medical Record and health care "reform" it sure is easy to order another colonoscopy in the name of "wellness" and "health care," right?


Thursday, September 05, 2013

When Media Doctors Play Doctor

After George W. Bush's recent controvertial stent placement, news organizations were hot to jump on the media buzz created by a former President's health issues. Perhaps the funniest moment of all came from Fox News' proported medical "A-team" member, Marc Siegel, MD.

Dr. Siegel is an internist by trade, and when internists are handed a cardiac stent to open on TV, the ensuing moments were something to behold:

The special moments begin a 2 minutes into the video where Dr. Siegel attempts to open the stent packaging (even resorting to using his teeth 22 seconds later). After failing, he hands the package back to the anchorwoman who hands the challenging packaging to her TV crew to open.

Once the package contents are returned to Dr. Siegel, he remains baffled and displays the stents flush port to the TV audience as the stent.

Sorry, but it rarely gets better than this on TV...


Tuesday, September 03, 2013

Left to My Own Devices: A New EP Blog is Born

Good scientific writing is hard to find, but sometimes good writers find scientific writing. 

Such is the case with Edward J. Schloss, MD, a cardiac electrophysiologist from Cincinnati, Ohio who entered the social media space via Twitter (@EJSMD) several years ago and began writing a series of articulate and remarkably prescient guest posts for about St. Jude's Durata defibrillator lead's structural similarities to the Riata ST lead (see here, here and here) , among others.  As he hesitated to enter the blog-o-sphere personally, he also posted on fellow EP colleague John Mandrola's blog as well.

Now, with a bit of trepidation, Dr. Schloss begins his foray into the blog-o-phere with a great review of  the utility of cardiac resynchronization in patient with narrow-QRS-complex cardiomyopathy on his new blog, Left to My Own Devices.

Go now.  Welcome Dr. Schloss.  Then bookmark his blog's webpage and add it to your feed reader. 

You'll be glad you did.