Friday, January 23, 2015

Care Pathways and Their Kin

Transitions of Care in Heart Failure, Circulation Heart Failure, January 2015

Living in Washington DC Brochure

(Getting 50% of Liquor - Courtesy

(Choosing a Medical Specialty - Courtesy Surgical Sciences blog)


Wednesday, January 21, 2015

Katz: In Defense of the Annual Physical

David L, Katz, MD, Director of the Yale University Prevention Research Center and President, American College of Lifestyle Medicine, makes aa case in defense of the annual physical examination, once a cornerstone of American medicine.
I would argue, then, that glib dismissal is misguided. Rather, the safest and most promising option in the absence of answers to all relevant questions, is to optimize the annual exam, not discard it. There is no need for a battery of perfunctory procedures or ridiculously low-yield lab tests. But these could be replaced with a review of lifestyle practices and use of relevant preventive services; with time for pertinent, customized lifestyle counseling; and with attention to whatever happens to be on a patient’s mind, building that very thing to which modern, evidence-based medicine may pay all too little attention: a relationship. A fundamental human connection.
Read the whole thing.


Tuesday, January 20, 2015

"Science" Takes ACLS Backwards

Food and Drug Administration (FDA) regulations have become the new pathway to riches for the pharmaceutical industry.

First, there was generic colchicine, used for years and years to treat gout for  pennies a pill.  The only problem was, there wasn't an FDA trial proving colchicine's efficacy in the treatment of gout.  Takeda Pharmaceutical, seeing the opening, performed a trial and rebranded the formerly generic colchicine to Colcrys®, "the only authorized generic indicated to prevent and treat gout attacks."  And how much does Colcrys® cost?  Just $203 for thirty tablets at Costco.

But that's not all.

Today I learned that generic vasopressin (which can be stored at room temperature in stable form on crash carts), must be switched to the FDA-approved brand called Vasostrict® that requires dilution and refrigeration.  It seems the generic form of vasopressin will no longer be available to be kept on crash carts since it's not "FDA-approved" for the indication of "increasing blood pressure in adults with vasodilatory shock (post-cardiotomy or sepsis) who remain hypotensive despite fluids and catecholamines." Vasostrict®, on the other hand, is "now the first and only vasopressin injection, USP, product with an NDA approved by the FDA." The catch is, it must diluted before use and discarded after 18 hrs (or after 24 hrs if refrigerated). This little regulatory quirk is a big deal for America's hospitals looking to save costs.

But hey, why should we worry about costs in health care?  After all, you can never be too safe.


Monday, January 19, 2015

The Cancer of Our Profession

  229. Unity and friendship in the medical society is important.

The first, and in some respects the most important, function is that mentioned by the wise founders of your parent society - to lay a foundation for that unity and friendship which is essential to the dignity and usefulness of the profession. Unity and friendship! How we all long for them, but how difficult to attain! Strife seems to be the very life of the practitioner, whose warfare is incessant against disease and against ignorance and prejudice, and, sad to have to admit, he too often lets his angry passions rise against his professional brother. The quarrels of doctors make a pretty chapter in the history of medicine.

Sir William Osler
On the Educational Value of the Medical Society, In Aequanimitas, 335-6.
Never has the divide between the practicing work-a-day physician and the non-practicing ivory tower elite physician been greater. It is the cancer of our profession: quick to spread, difficult to contain.

But this should not surprise us. It is a recurrent theme in history, just as Osler was quick to remind us. But the ideal that Osler advocated for has disintegrated under political, financial and partisan agendas that covertly operate without transparency.

If nothing else, social media is helping expose this divide and its corrosive effects on our profession.


Friday, January 16, 2015

Grass Roots: It's Time To Take Action on MOC

As many long-term readers of this blog are aware, because of concerns over its coercive nature, I have been investigating the American Board of Medical Specialties (ABMS) Maintenance of Certification (MOC) program implemented in large part by the American Board of Internal Medicine (ABIM) since studying for my third round of re-certification.  As part of that investigation, I have uncovered what appears to be a carefully crafted propaganda campaign using poor scientific methods, non-practicing authors from think-tanks, the veterinary profession, and the ABMS/ABIM hierarchy to serve as "evidence" of the program's legitimacy, as well as much more troubling financial dealings of the ABIM and the ABIM Foundation.

I brought these concerns to the leadership at the Heart Rhythm Society via an email left on their website on 2 January 2015 that included a link to my investigation of the ABIM's tax records.  The Heart Rhythm Society's office as closed at that time (they returned 5 January 2015), but I never received a response to that email initially.  So I called the Heart Rhythm Society on the 14th of January and asked to speak with Mr. James Youngblood, their President and CEO, about my concerns regarding the ABIM. I seems he was unavailable at the time but I was assured they had found the email and that I would receive a response  "in 24-48 hours." Yesterday I received the email and this is what he said:

"Sorry for the delay in responding to your email request. We appreciate the information you shared and your opinion in this matter.  Regarding your follow-up voice message inquiring about what the HRS offers in support of ABIM-MOC, HRS provides the opportunity for members to earn up to 42 MOC medical knowledge points on a complementary basis. (Opportunity for MOC points expires 10/15/15)

We have extensive additional information provided at

We have provided ongoing feedback to the ABIM around our concerns with their approach to the MOC program. We will continue that dialogue.

With regard to an financial concerns with ABIM, we will continue to monitor the situation closely and inform our members should any action be required.

Thanks, J

James H. Youngblood
Chief Executive Officer
Heart Rhythm Society
1325 G St. NW, Suite 400
Washington, DC 20005
(Phone numbers redacted)
It seems the very public outcry by practicing physicians over the entire ABMS/ABIM-MOC program is being met with little action despite the evidence of its corrosive effects on our profession of medicine. Therefore, I have decided to begin a grass roots effort to ask my own professional medical society, the Heart Rhythm Society, to immediately cease their promotion and marketing of the ABMS/ABIM MOC program and instead to turn their considerable resources to removing the corrupt ABMS MOC program from the Affordable Care Act. To that end, I am now circulating a petition for Heart Rhythm Society members (and other interested practicing physicians) to sign to send a clear message to our society's leadership that we need more than words, we need action, to stop the use of this unproven and unethical MOC program that has been foisted without evidence of its effectiveness for improving patient care upon practicing US physicians. Anything less is unacceptable, given what we now know about the program.

I would ask that Heart Rhythm Society members who agree with this petition to sign it and designate their membership status with the Heart Rhythm Society in the "Notes" section and then send it on to your colleagues. 

It is time we send a strong message to our professional organizations that we demand more than words in response to our deep concerns with the ABMS/ABIM MOC program.

Thank you -


Tuesday, January 13, 2015

Some Thoughts on the National Board of Physicians and Surgeons

I admire Paul Tierstein, MD's honest attempt to create a greatly simplified alternative to the  ABMS's Maintenance of Certification® (MOC) program called the National Board of Physicians and Surgeons (NBPAS).  I hope he's successful, but I sense there will be large headwinds for the effort ahead.

Here's why.

The Affordable Care Act (ACA) modified Sections 1848(k) and 1848(m) of the Social Security Act which defines how CMS pays physicians for their services.  Section (k) is the section that defines how a "Quality Reporting System" is to be set up (with subsection (4) requiring the "Use of Registry-based Reporting") and Section (m) defining physician incentive payments physicians might receive if quality reporting occurs properly. (Sadly, those CMS incentive payments do not cover the cost of participating in MOC for most of us.)

Section (k) was modified by the ACA to include the ABMS MOC program as a "physician registry."  The registry was "defined" as requiring all four parts of the MOC program created by the ABMS, including the much-maligned "practice improvement modules" that have been described by the physician community as overly time-consuming, irrelevant and may even violate federal research statutes regarding the study of physicians, their practices, and patients.

Unfortunately the new NBPAS does not address these requirements of the our new health care law, leaving the creation of the NBPAS to look like a Rand Paul moment all over again with physicians signing up for something that, legislatively, means nothing.

Welcome to the concept of "regulatory capture."

Screenshot of Heart Rhythm Society webpage
Physicians should realize that special interests and their lobbyists (including the US hospital, pharmaceutical, survey companies, and insurance lobbying groups) were highly influential in the creation of our new health care law.  They are also very good at politics.  It is unlikely that these entities want to see MOC go away, irrespective of how corrupt the system has become.  There's just too much money involved.  Even our own specialty societies use the MOC program's educational requirements to coerce physicians to take their educational courses to "earn MOC points" to help pad their bottom lines as physician attendance (and corporate sponsorship) at scientific sessions has dwindled over the past years.

But what's more important to our patients in the long run? Time for their needs or time for test-taking and survey collection?  Is it more important to satisfy government requirements or address the real needs of our patients?  Certainly continuing education of physicians is needed, but irrelevant work for an unaccountable  third-party organization so they can measure us rather than help us is not.

A second Heart Rhythm Society webpage devoted to MOC
Physicians need to take the stick, but we can't do this alone since we care for patients.  So we need to ask this question: will our specialty societies commit to supporting practicing physicians or the  new bureaucratic divide? (They can't do both.)  Will they truly step up to the plate and commit their considerable staff, dollars, pager-less hours, lobbying and legislative efforts to help remove the corrupt MOC program from the Affordable Care Act or allow practicing physicians - their members - to wallow in the corrupt status quo as they are coerced to participate in MOC?

I remain pessimistic that creating another "board" will fix the current deep-seated problems with the ABMS MOC construct with ABMS as the mothership directing a flotilla of 24 member boards.  In my view the only way to truly "change" MOC is to have a coordinated effort from all specialty societies to insist our legislators remove the portion of our new health care law that requires we participate in a "physician registry" that robs not only practicing physicians, but patient care itself.

HRS and ACC, are you on board?


Saturday, January 10, 2015

Behind the Scenes of the Choosing Wisely® Marketing Campaign

How it's marketed:

How it's paid for:
Email received yesterday by some US doctors (click to enlarge)

Any questions?


P.S.: For details, click here.