Friday, September 19, 2014

Case Study: What They Don't Teach You in EP Fellowship

These days, pacemakers and defibrillators are often interrogated via a home-monitoring system that uploads information contained in the implanted cardiac devices automatically to a central server so it can be accessed by physicians remotely.  This feature was added to most defibrillators after the rash of recalls struck the industry in 2005-6.  Not only can the information be uploaded electively by the patient, it can also be automatically uploaded if a nightly self-check detects a parameter out of range.  In this case, the patient was being monitored by Medtronic's Carelink remote monitoring system.

"Dr. Fisher, I think we have a problem with Mr. Smith's RV lead (not his real name)," my device nurse said as she handed me the Carelink transmission that triggered an superior vena cava (SVC) high voltage coil impedance warning:

Click to enlarge

"What did the last interrogation look like?" I asked.

"Here's the old one was sent just three days before and looked fine," she said. "It's so weird.  We've not had a problem with this patient's device since it was implanted in 2012."

Click to enlarge

Real-time intracardiac electrograms seen on the earlier transmission - Click to enlarge

"Strange.  I'm not sure what to make of this.  Give him a call - we might have to change that RV lead," I said.

"Okay," she said, then returned to the device clinic and I went back to seeing patients.

Some time later, my nurse returned.

"Um, Dr. Fisher, could I speak with you a moment?" she asked.  "I got some more information.  I think you better look at this" and she handed me his most recently transmitted real-time intracardiac electrogram recording that was sent with the latest transmission.

What did it show and why were the RV lead parameters abnormal?


Wednesday, September 17, 2014

Rebuttal: A Bit More on MOC Failure Rates

Recently, David H. Johnson, MD, Chair of the American Board of Internal Medicine (ABIM) Board of Directors and Internal Medicine Chairman at UT Southwestern Medical Center in Dallas, and Rebecca Lipner, PhD, Senior Vice President of Evaluation, Research, and Development at the ABIM published a "guest blog post" over at MedPageToday regarding Maintenance of Certification (MOC) pass rates, entitled "Debunking the MOC Pass Rate Myths." I do not know if they were directing their comments directly to me, but since I was the one who brought the issue of rising MOC failure rates to the public's attention some time ago using the ABIM's own published data of first-time MOC takers, I thought I should respond.

I appreciate Drs. Johnson and Lipner providing more insight into how the MOC examinations are constructed and scored.  The ABIM's arbitrarily-defined "65%" marker based on "expert consensus" and undisclosed "psychometrics" is an interesting one, and at least now we understand how this benchmark was arbitrarily created. They also acknowledge that "significant changes in the practice of the discipline may require that the passing standard be reset."  Unfortunately, they do not disclose what those changes might be, which way their 'standard' might be adjusted, or what internal or external force might mandate such an "reset."

Drs. Johnson and Lipner also confirmed the rising failure rates of board examinations over the past five years.  Oddly, they then seem to imply that this "decline in pass rates" is due to a misunderstanding by "some social media observers" of their testing and scoring process:
"Recently, based on a slow decline in pass rates over the past 5 years for the American Board of Internal Medicine Maintenance of Certification exam, some social media observers have made erroneous assertions about how the exams are constructed and scored.

Without a full understanding of the exam process, they have nevertheless claimed that the exam is being made more difficult, that the standard for passing the exam changes every time an exam is given, or that the exam is 'graded on a curve.' These assertions are all incorrect."
Rather than attack what was said or what wasn't by those unruly social media types, I will merely say this: my assessment of the rising failure just focused on simple math.  Because there are higher numbers of doctors taking this examination year after year due to the American Board of Medical Specialties' recently-imposed MOC requirement, the stable "65%" pass rate means there is necessarily an INCREASE in the number of total physicians who are FAILING the examination.  It goes without saying that a requirement for repeated testing or adding more people to the testing pool handsomely profits the ABIM and similar subspecialty organizations that provide proprietary subspecialty MOC-preparation courses taught by ABIM test question contributors (this relationship is also conflicted, by the way). But the downside of more testing is multi-pronged: it also redirects physicians away from direct patient care to formal classrooms, expensive hotel meeting rooms in cities often outside the physician's hometown, and ultimately to expensive corporate test taking centers.  The ABIM never considers these high costs nor the negative effects absence from one's practice has on patients or a physician's limited family time.

Drs. Johnson and Lipner also remind us that "pass rates are higher among first-time test takers." While there are likely many reasons for this, we must conclude that significant AGE BIAS against older, more experienced physicians exists.  Since this proprietary MOC process was cleverly made a "quality measure" imbedded in our new health care law, the logic of this biased process contradicts common sense.  Are patients not our best teachers? Are we to assume that physician experience after years of direct patient care is of less value than ABIM-selected facts and principles culled from an exponentially-growing body of medical literature regurgitated on a computer screen in an expensive testing center?  Furthermore, how the test is constructed or scored is of little relevance to more procedural based specialties of internal medicine like mine because these skills are never assessed.

Drs. Johnson and Lipner also mention (without supporting data)  that physicians who take their examination three times (at their expense) ultimately achieve a 95% pass rate. As if this is the point. Instead, we should ask what patients and physicians lose each time they must repeat this onerous, time-consuming and unproven process.  Can the personal, financial and professional losses of repeated testing ever be regained? How, exactly, does repeated testing of a flawed process help our patients?  What marginal utility to our health care system does this whole test-taking exercise really provide?  Does this MOC process actually separate the good physician from the bad physician or the good test-taker from the bad one?  Since ABIM never knows a doctor's scope of practice before their assessment, they make some heady assumptions about what they should test.  In reality, the ABIM only tests what THEY think should be tested, rather than what matters to the particular physician's patient population.  Worse still, since the ABIM remains completely unaccountable to doctors or patients in regard to their MOC process, their assessment may have absolutely no relevance to a particular physician's practice.  Shouldn't we be discussing these issues before arguing how the test is constructed and scored?

No physician I know argues with the need for continuing, life-long education in medicine, especially when its performed in a relevant, transparent, informative, collegial and feedback-oriented process without a ulterior financial motive.  If fact, most of us do this every week as part of our state licensure requirements and have plenty of continuing medical education credits to prove it.  Allowing the ABIM to monopolize this process as we have through artificial MOC point acquisition exercises that are often irrelevant to a physician's scope of practice not only circumvents more healthy and sustainable learning environment, but also might cause more harm than good if that physician loses their practice privileges as a result. 

In summary, I believe the ABIM's lucrative MOC process is no more valid than what doctors have already been doing for years before the American Board of Medical Specialties decided to make their MOC program an annual exercise.  The MOC process remains unproven in its ability to improve patient care and (as we've now confirmed) discriminates against more senior physicians. Those of us who have endured this process multiple times have witnessed the growth of "board certification" from a self-imposed professional milestone to a money-making scheme filled with clinically-irrelevant busywork that often detracts, rather than augments, patient care (especially those non-validated "practice improvement modules").

It is time that doctors of all ages insist that these self-appointed non-profits organizations cease their attempt to become expensive continuing education providers and stick to what they do best: assessing a doctor's ability to reach a level of exceptionalism of their practice during their career, rather than pretending that they can assure some arbitrary level of ongoing practice adequacy for the business community.  Until the ABIM comes to grips with their increasingly bipolar agenda, their ability to remain credible and relevant to practicing physicians, the public, and the mysterious "stake holders" they claim to serve will continue to be challenged, both on social media and in the court of law, as "significant consequences from losing certification" occur with increasing frequency to experienced and fully-capable physicians.


Thursday, September 11, 2014

The Big Flail

After you've written on a blog for a long time, you begin to ask yourself why.  Oh sure, there are the great opportunities for a single person to make a point, to act as a tiny tugboat trying to push a corporate mothership in a slightly different direction, but you begin to realize that there are very few times that actually happens. You try to provide a voice to issues that are often unheard, then realize that voice is only occasionally appreciated but more often duly noted, then ignored.  This is the nature of internet and quite frankly, medicine now - it is a world of competing interests.  On one side you have the patients, doing a messy job of getting sick, and corporate health care systems - either government, private, for-profit or non-profit - doing their very best to make sure their illness is neat and tidy, easy to control, perfectly understood, and quantifiable.  To this end, each has their own agendas that must be served, be it another regulation, value-added improvement, or a profit motive to secure the bottom line. 

This idea came to me yesterday in clinic.  Increasingly, every microsecond of my day, my week, my weekend has now been efficiently parsed into tiny computerized scheduling chunks.  It doesn't matter where I work, because like The Cloud, location doesn't matter - schedulers and administrative handlers can reach me, be it by beeper, computer, Outlook email, EPIC email, desk phone or my personal iPhone. There are so many places to check for messages that when I don't respond, the person trying to reach me just moves up the chain of communication options.  Eventually there's no down time, no time to think, there are few places to go where there is quiet any longer. It's become life by a thousand interruptions - a Big Flail.

Increasingly, there's a push to do away with beepers and move telecommunications in medicine to my personal iPhone.  But I an resisting this because I need to set a boundary between work and my personal life - if for nothing else but self preservation.  We are told this is being done in the name of "security" and "non-secure beeper messages" but I think it's because people don't want to wait.  They need their answer now. I really wonder what the evidenced based data on beeper message hacking is in health care and if more patients were helped or hurt by beeper data breeches.  There's a better idea, they say: consolidate.  It's more "efficient."  I know, I'm such a Luddite. But to whom do I respond when that head administrator calls on my iPhone as I'm  examining a patient?  How to I separate a Twitter message from an ER message? Does the act of looking at my phone when I'm with a patient engender trust or an appearance of distraction?

It's hard to argue with "security" when someone creates a new medical policy.  We all want to be secure.  We all want to know that our most private and personal  medical information is protected from prying eyes.  But quite frankly (and this is very politically incorrect to say) real information security in medicine is a joke.  After all, people's lives are perfectly encoded on a computer now and eight different billers, coders, insurance company trolls or hospital marketers can delve into that database of information and find specifics about a patient or group of patients with simply the click of a button.  Phishing schemes make a mockery of our passwords.  Seriously, who are we fooling? Let's be honest: paper charts housed in a known location behind a locked door were MUCH more secure. 

Hurry up.  Click here, click there, "Excuse me," "Can I have a moment of your time?", "There's a the 7 am meeting tomorrow," "What was that Ms. Jones?", "Yes, I'll try to make it," "Did you try it unipolar?", "Yes, I'll check my inbasket,""You left your addendum open,""They're calling for the cardioversion,""Should we add him in?", "I have to take my board review course, can you take call?,"The ER's calling,""Can you check her pacer, too, when you see her?", "Did you sign the EKG?"

Doctors need some quiet, down time, some time to think, to pay attention. We need to create our own boundaries between our personal and professional lives that are respected.  We need to think we can get away, to regroup, have some quiet time for ourselves or with a patient, even for a moment.  And if that means that some of us want to separate work from home by the use of a beeper instead of an iPhone, so be it. 

Otherwise, our personal lives will become a Big Flail, too.


Monday, September 08, 2014

Another MacGyver Moment in Pacemaker Implantation

Installing a permanent pacemaker or defibrillator has become commonplace event in cardiology these days.  These devices implanted in a patient are comprised of two main parts: the lead(s) and the pulse generator.  After installing the leads in the heart and connecting them to the pulse generator, the lead and pulse generator assembly are then placed beneath the skin in a small subcutaneous (or in rarer cases, submuscular) "pocket" that is created surgically.  Considerable care is taken to cauterize bleeding vessels when the pocket is created.  To facilitate visualization of these occasional bleeding vessels deep within the created pocket, I prefer to use a surgical headlamp to direct the light deep within the pocket cavity rather than relying on a conventional overhead surgical light.  I have found that headlamps have helped me limit my incidence of post-operative pocket hematoma development.

So as things have had it, I seem to have a knack for attracting every eighty- or ninety-plus year old who needs an emergency pacemaker on the weekend when I'm on call, and this past weekend was no exception.

So the team was assembled and the pacemaker implantation equipment readied.  They knew I liked a headlamp, so they dug deep into the recesses of their inventory to pull out their only headlamp that appeared to be from a bygone surgical era.  Being pressed for time, I couldn't argue and had to make due, but knew that this headlamp might not be very reliable, especially as I saw how the headlamp's fiberoptic cord was secured to the light source that generated about as much light as a few well-lit candles by a cumbersome spring-loaded Rube Goldberg contraption.  As I placed the headlamp on my head, and tightened the plastic strap that housed the headlamp to my head, I needed a backup plan in case the light failed.

Would I have to use the overhead light and make do, or might there be another way? 

I needed another MacGyver Moment.

That's when my on-call staff team came up with a brilliant, simplified idea:

iPhone to the rescue!


(PS:  This device is experimental and has not been approved by the FDA.  Use this device at your own risk.    If you experience headaches, nausea, difficulty with concentration, or an erection lasting for longer than four hours, discontinue use of this device and contact your doctor immediately.  I have no commercial interest in this device.  Also, since the headlamp still worked this weekend, no workaround was needed for the patient, but something tells me we might be getting a new headlamp soon.)

Friday, September 05, 2014

Cybernetic Medicine

Cybernetics, the scientific study of control and communication in the animal and the machine, used to be the stuff of science fiction.  Today, thanks to a Faustian bargain between corporations, regulators, and politicians, it is defining medicine.

Every day, the exponential explosion of data entry and regulatory requirements doctors endure boggles the mind, all in the name of "health care." 

Feedback is critical to field of cybernetics.  And when Medicare's straps have you by the balls, you comply.

No longer is it good enough to learn a diagnosis or procedure code, doctors must attend online courses to learn how to use a new "calculator" to determine a more proper code.  After all, there will soon be over 70,000 of them.  Each more specific than the other, each more ridiculous.   There are five data-entry fields to click on that calculator, each another tiny, yet time-consuming decision to be made, just to determine a code.  No doubt teams of clever twenty-something computer programmers are overjoyed with their coding calculator and the way it pops up automatically on our screen when needed, then disappears.  So pretty.  So cool.  See how easy they've made it to complete that regulatory requirement?

And this does not begin to address the increasingly algorithmically-driven electronic medical record and procedures envisioned in the years ahead. As if all things can and must be perfectly defined and quantified in medicine.  No mistakes.  No judgment needed.  No need to type. Just close your eyes, click a few buttons, and follow the pathway.  Stop thinking. Just do it. Enter the data. Resistance is futile.

After all, it's about the money...

... and perfect physician cyborgs.

Feel that strap tightening?


Friday, August 22, 2014

Where To Teach?

As I begin another year teaching EKG's to our new residents, I find I am increasingly asking myself "Where to teach?"

I do not mean to imply a geographic sense to the word "where" (although this is difficult, too, as residents move from hospital to hospital in large health care systems like ours as they change rotations), but rather as more of a "level." What level do I teach our residents the art of EKG reading? Do I keep it rudimentary or do I teach it at the level of a good cardiology fellow? Are we striving for excellence or striving for adequacy in EKG interpretation? Said another way: do I teach at a Dubin's level of EKG interpretation or a Marriott's?

This is not an easy decision for those engaged in teaching medical students and residents.

Every year I am evaluated by the residents for my instruction, and every year I get good marks. But an e-mail received from our program director made me concerned, because a criticism they had heard from the residents was that my instruction was too advanced. (This was a first for me despite using similar core lecture materials year to year).

Which led me to wonder, is my curriculum too advanced for our newer residents or are medical students not receiving instruction on EKGs in medical schools before residency? Or has is the art of EKG interpretation evolving to simply reading the computer-generated interpretation at the top of the tracing? Should residents just be taught basic ACLS-level tracings or the more subtle findings of hypothermia and hypercalcemia?

I wonder why there's such a difference now, why there is a draw to spoon-feed our residents rather than to teach them basic principles upon which to grow their understanding. Perhaps residents are flooded. Perhaps they are scared. Or (more likely) perhaps we need to do a better job leading by example. Perhaps, as one fellow of mine said, our attendings in medical schools are so hurried to get back to clinic that they never do chalk-talks or EKG reading with residents any more. Maybe the pressures to make medicine more efficient is robbing from education.

Whatever it is, there is a change.

I'm sure I'm not the only teacher who's encountered the same difficulty knowing where to teach now. But I continue to believe that our youngest doctors can rise to any challenge they are given as long as they have enough time, so don't expect it to be any easier from now on, but maybe just a bit slower.

My time, after all, is unlimited. (* cough *)


Friday, August 15, 2014

To the ABIM: What Real Life-long Learning Should Look Like

He left a little early to stop by the cath lab to see his patient before her procedure.  Cordial "Hello's" and "Good mornings" and "Any last questions?" were mentioned before she signed her consent.  The team was working feverishly to prepare her for her procedure.  "Have you met the anesthesiologist yet?" was next, and almost on cue, the anesthesiologist arrived and took over for a bit.

He hurried upstairs to the conference room.  There, was an all-too-fattening array of welcoming donuts and bagels, a coffee and hot water dispenser, and a few remaining empty cups. This was the stuff of breakfast on more hurried days.  Still, a small cup of coffee was welcomed and poured quickly. Another nurse had arrived with him and he asked, "Can I pour you one?"  She accepted and they quickly made their way into the conference room after signing the attendance sheet.  They didn't want to miss the start of the conference for that was sometimes the best part of the conference.

In a stroke of genius, the organizers of the Cath Conference quickly review the news of the week, both locally, nationally, and medical.  They even show wild things colleagues did the week before outside of conference, like flyboarding or a shot of a colleague holding a huge striped bass they caught the weekend before with their 8 year-old daughter.  Complaints about the design of the restrospective trial reviewing digoxin's use for atrial fibrillation, sodium's uncertain consumption recommendations this week were met with rolled eyes, and the possibility of transcaval retrograde transaortic valve replacement in patients with no other access was discussed, with a quick aside of direct translumbar aortic punctures and even direct left atrial punctures being performed by surgeons in earlier times.    In short, they shared the other side of themselves together, the reality of science, their humanness.

Then they shared cases.

The cases are not always pretty.  Some were tough cases, wonderful cases, cases no one had seen before.  They discuss the complicated social situations that bring even more complicated dynamics to the case.  They discuss the errors and the complications.  Importantly, they all understand this is a legally protected conference - a morbidity and mortality conference, if you will -  a place where there are frank discussions about the right way to treat things and the wrong way, but a place that is supportive to those who have struggled, and incredibly helpful to those who still struggle with many challenges.  Administration hears about the problems doctors had with the lab equipment or staff or whatever - professionally.

And it's the most popular conference in our hospital.  People of all ages and technical backgrounds are welcomed.  Old and young, cath lab staff, nurses, quality personnel, research staff, administrators, guest speakers, cardiologists and surgeons.  Everyone, that is, except industry or pharmaceutical folks.  This is, after all, the work of health care, not marketing.

At the end, they greeted, however briefly.  A quick question is asked.  A consult requested.  A research form signed.  Then off they went on their ways for another week to do their jobs.

This is lifelong learning as it should be: cordial, professional, collaborative, fulfilling, timely, up to date, and self-generated.  And it happens because it has to, not because it's directed by a centralized bureaucratic money-making organization who claims they know what's best for doctors and what's best for society.

When doctors, nurses, technologists and health care teams learn this way it's sustainable for a lifetime for one simple reason:

... because it's enjoyed.