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.

-Wes

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.

-Wes

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.

-Wes

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

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.

-Wes

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?

-Wes

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...

-Wes

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 Cardiobrief.org 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.

-Wes

On Sabbatical

I will be sparsely interacting with the internet as I take my last child off to college this week.  It's a strange time - one where the home becomes more quiet as a moment ends for the parent yet heralds and exciting beginning for their child.  Others have recently articulated this strange time well, so I leave you with the words of a much better writer, Michael Gerson of the Washington Post:

"Eventually, the cosmologists assure us, our sun and all suns will consume their fuel, violently explode and then become cold and dark. Matter itself will evaporate into the void and the universe will become desolate for the rest of time. ... (Read the rest)

-Wes

The Cloudy Aspects of the Physician Payment Sunshine Act

Another seemingly harmless bureaucratic initiative aimed at physicians sunk its taproot deep in the daily workings of medicine this month. The Physician Payment Sunshine Act promises transparency in all industry dealings with physicians by shedding "light" on the issue of payments to physicians from pharmaceutical companies and medical device manufacturers. In turn, it will save the system money, since all those freebies bestowed upon physicians when the corporate world came knocking can now be accounted for and physicians will be shamed into proper behavior.

Meanwhile, back at the drug company headquarters, some poor schnook gets to type all the names of the nurses and technicians that enjoyed their meal from the echo lab, cath lab, stress testing lab and were asked to place their name on a sign-in list so it can be entered on a multi-million dollar database designed to feed the government Big Data Bosom in the sky.  Busy doctors dart in, grab a bite, and go.

No need for them to sign-in.

You see, it's a bad marketing strategy to ask a doctor to sign a form as you peddle your product. And since no one is monitoring the accuracy of the sign-in sheets, as they have a few names to justify their effort and expense, well, they've done their part.

Why is this expensive data collection charade taking place? How much does it cost us? Does it change pharmaceutical tactics for marketing to doctors?   Of course not.  Yet there remain central planners who remain convinced (I mean, convinced!) that such monitoring works. It's a classic wish: just like the government's new HospitalCompare website, which promises to collect data on readmission, pneumonia, infection and death rates (with more to come) in the hopes that people will make "smart choices" about their health care. Do people really make their choice of health care facility based on such poorly-collected data placed on a website? I don't think so. Most people never think about their health until they have to arrive in an Emergency Room blindsided by an unexpected health crisis. They are not checking websites about payments to doctors - especially websites set up by the government. They want access to their local health care system and prompt, quality care. Yet were we are once again using Big Data filled with Bad Data as an ill-conceived and expensive social engineering exercise.  And this cost is passed on to health care consumers. In short, it's another perfect storm of wasted resources in the practice of medicine.

"But Dr. Wes, how can you say such a thing? Can't you see this Sunshine Act developed by Congress as part of the Affordable Care Act will disclose all of those greedy physicians who want to suck the health care system dry of all of that money? Aren't there benefits to the public transparency of these payments?"

The irony of this whole law is that Big Pharma and Big Medical Device Company already reports the money they give doctors to the government via the IRS in the form of a 1099-Misc. (Recall that the IRS is now firmly a part of our new health care law).  But instead of looking deep within the bureaucratic governmental morass for solutions to physician payments from industry, a new knee-jerk law was enacted to parade before the press to show how sincere the medical device companies and pharmaceutical companies are about the need for such transparency. Meanwhile, it's business as usual as backroom pricing of drugs and devices continues.

War room strategists have known this policy tactic for years: it's called diversion:  collect data on every $20 dollar physician lunch handout as our new breed of physician-employers (aka "Accountable Care Organizations) negotiate sweet deals with their insurance pals, prices of hospital system charge masters edge ever higher, drug prices and device charges continue to exceed tens of thousands of dollars thanks to Medicare payments, and insurance companies offer "health plans" rather than "insurance" to their policy holders.  And let's not even talk about the favors our Congressmen and Congresswomen are afforded.

But then again, better to put doctors in the limelight rather than speak honestly of the pricing games taking place behind American's backs, right?

-Wes

Why Do I Try So Hard?

It's always the same: It's the fifth hour of the procedure. As your ankles ache and the perspiration drips beneath your lead, you stand there wondering why you try so hard to fix this arrhythmia. You realize this is not cost effective. You're tying up the lab. The staff and anesthesiologist are getting restless. The music drones on. You feel you're not getting anywhere. "Then again, maybe if I just try this...," you think. And you try this and it fails. Meanwhile, the fluoroscopy clock ticks, your fight continues.

Then you remember the story: the syncope, the wife, the kids, the vocation. They're depending on you. Not a tech, not an anesthesiologist, not a nurse, not an administrator. You. So you keep going, just a bit longer.

And then, sometimes, miraculously, you win. It's all worth it. You've completely changed that person's life. You are the hero. You are the superstar.

But just as often, you have to quit. Your feet are too sore, the radiation dose too high, and the hour too late to safely continue. You have to face the family, the disappointed looks, the doubt about whether you were the right person to do this procedure, and the sad look on your patient's face when you break the news.

And you find yourself asking once again:

Why do I try so hard?

Why?

-Wes

When Placing a Pacemaker, You Know You're on the Wrong Side When

... your wires look like this: 

AP fluoroscopic view


... and the venogram looks like this: 

Results of a left subclavian venogram


-Wes

Heart Check Indeed: American Heart Association and Campbell Soup Company Sued

From Bloomberg:

Campbell Soup Company and the American Heart Association (AHA) were sued by a consumer who claimed the AHA fraudulently certifies the company’s products as healthy.

The association labels more than 30 of Campbell’s Healthy Request soups as “heart-healthy” even though a can has at least six times as much sodium as the organization recommends, according to a complaint filed yesterday by Kerry O’Shea in federal court in Camden, New Jersey. Those soups display the AHA’s “Heart-Check Mark” logo, which the organization licenses, according to the complaint.

Campbell, the world’s largest soup maker, and the heart association “falsely represent” that products with the logo have cardiovascular benefits lacking in other soups, according to the complaint.

Oh the irony, eh?

Who's next?  The Heart Truth® campaign, NHLBI, and the Coca Cola Company? 

- Wes

EKG Du Jour 32: The Misfiring Pacemaker

A dual chamber pacemaker was implanted the prior day by a local surgeon in the operating room.  The next morning, an EKG is obtained that showed the following:

Click to enlarge

You checked the CXR and all leads appeared to be in the proper location. 

Does the patient have to go back to the operating room?  Why or why not?

-Wes

Marketing Shared Patient Appointments

As health care reform kicks in to high gear, a new innovation in health care delivery is being touted at Cleveland Clinic: shared patient appointments. On the surface, this idea seems so efficient and social as patients with similar medical problems sit around in a group therapy session that masquerades as health care. After all, with the large influx of new patients to our health care system underway and the limited health care personnel resources available, the push for such a model was inevitable.

But many Americans are also noticing another disturbing trend: higher insurance premiums to offset the cost of those who do not have sufficient resources to pay for their care.  While the reality of our higher health care costs demand that the added costs be paid by someone, I suspect most of those who will be paying higher premiums didn't think they'd have to "share" their physician appointments with others. 

But here we are.

For large health care systems, shared patient appointments offer the promise of high revenue streams with low overhead costs.  As such, there is no downside to promoting such a model:

Since 2005, the percentage of practices offering group visits has doubled, from 6% to 13% in 2010. With major provisions of the Affordable Care Act due to be implemented by next year, such group visits are also becoming attractive cost savers — patients who learn more about ways to prevent more serious disease can avoid expensive treatments. (ed's note: Sales pitch - there are no data that group appointments "prevent" more serious disease or "avoid" expensive treatments)

“It’s a different way of speaking about health that is more about friends around a circle learning together than talking with an authority figure in a white coat,” says Dr. Jeff Cain, president of the American Academy of Family Physicians, in describing shared medical appointments. Think of them as a blend between group therapy and support groups. The net effect is the same – a sense of comfort, support and even motivation that comes from sharing similar experiences. (ed's note: Easy for him to say.  Any proof?)

Looking at this, how could anyone argue?  It seems like such a helpful premise.  But patients subjected to such a system have to agree one very important issue: surrendering their privacy:

But they do require divulging and discussing private medical information in front of strangers (albeit ones who have signed waivers not to talk about other patients’ medical histories outside of the visit).

We should ask ourselves: how will assurances of patient privacy in such a setting be enforced?  If another patient discusses a participant's health care needs and concerns outside of such a meeting, will that person be reprimanded?  If so, how?  And what extent must HIPAA privacy laws be waved as a result of this model?  

 

These are only a few of the concerns for patients.  We should also ask what the outcomes are for such a model?  What value to patient's get for their health care dollar if another member of the group is more vocal and insists on speaking while others have to remain mute?  Will they be guaranteed an opportunity to have their question(s) addressed?  And how will patient's be selected for participation in these groups?  Will diagnosis codes be used?  If so, what happens (psychologically) to a group of early diabetics who are placed in a group with a diabetic with more extensive disease?  Might there be negative repercussions when a young diabetic sits with a diabetic amputee or renal patient?  

 

Efficient health care delivery models are needed going forward, but attempts at social re-engineering that can alienate some patients in favor of others and stands to profit a system rather than the individual demands careful evaluation before marketing such a model as gospel to our health care system.

-Wes

A Case of Fraud

He was a slender-framed man, mid- to late-sixties, with a kind of ridden-hard-put-away-wet complexion.  It was clear the years had not always been good to him, but being the kind soul that he was, he had plenty of friends.  It was a beautiful summer day to spend with friends for a barbecue, but he arrived feeling puzzled why he collapsed at home earlier in the day.

He stopped at the keg and poured himself a beer in a red solo cup, and as he approached his friends with a smile, he did it again, this time which such gusto that his beer went flying and the thud he made when he hit the ground made everyone gasp.  He laid motionless for a moment face down on the ground while his friends rushed to his aid.  An ambulance was summoned as others rolled him over onto his back.  He began to move - slowly at first - then more purposefully.  As sirens approached, he asked his friends, "What just happened?'

A bit later, he arrived in the Emergency Room, awake, alert, pleasant, and seemed - on the surface at least - fine.  His vital signs were normal - perfect, in fact.  About the only things immediately noticeable was his thin frame, his coffee-stained teeth, and a clump of grass in his hair that the nurse kindly removed.  He was placed in the gurney, an IV was started, blood was drawn, and EKG was performed as a few "hellos" and "what happeneds" were exchanged, then off to the CT scanner he went to rule out an intracranial process.  It was normal and his EKG showed a first-degree AV block and incomplete left bundle branch block without evidence of acute injury or prior heart attack.

He returned from the CT scanner and was examined a bit more closely.  A loud, blowing, holosystolic murmur was heard by the medical student.  In fact, it was loud enough to create a "thrill" - a palpable vibration on the thin man's chest.  The medical student seemed pleased with himself, then ordered his first echo which revealed a relatively weak heart with a few chamber walls that didn't move so well, and a very leaky heart valve.  He was admitted, placed on telemetry, and seen by a cardiology consultant.  Closer inspection of the echo revealed a dilated left ventricle with a posterior wall motion defect and a central jet of mitral regurgitation large enough to fill the left atrium with a mosaic of color that extended to the pulmonary veins.  It was clear he'd need surgery, so a diagnostic catheterization was performed.  It showed three-vessel coronary artery disease and confirmed severe mitral regurgitation.  His medications were adjusted and surgery consulted.  A date for surgery was arranged at the neighboring hospital the following week and all seemed well.

But he had different plans.

As he settled down for dinner, he felt suddenly flushed, lightheaded, and broke out in a sweat.  With that, the telemetry alarm sounded and soon the room was full of people, crash carts, and hysteria.  His dinner table was shoved aside and he was laid flat as his chest was made bare.  He didn't know what all the excitement was about, but heard the words "He's fibrillating!" and then felt the cool metal discs covered with cold goo applied to his chest.  "What are you do...?" and with that, he felt his chest and arms jerk violently just before he passed out.  "Shit, he's still fibrillating!" someone shouted.  So they charged again and shocked him, this time to sinus rhythm.  The anesthesiologists who had arrived on the scene of the arrest took no chances: he was intubated and expeditiously transferred to the ICU.

Upon arrival to the ICU, the patient was clearly recovering well and quickly extubated the next day.  Beta blockers were administered additional anti-anginal and anticoagulants given.    Once stabilized, he was transferred to the surgical hospital and underwent urgent bypass surgery with mitral valve replacement.  At the time, the surgeon could see considerable endocardial scar.

His recovery was uncomplicated, but four days after his surgery, he still required external pacing.  Cardiac electrophysiology was consulted to consider an ICD placement, given his history of sinus node dysfunction, cardiac arrest, diminished LV function, and the visible presence of endocardial scar during surgery.

The electrophysiologist reviewed the case and noted that the patient's original in-house arrhythmia at the time of his "arrest" was actually an organized, rapid ventricular tachycardia that was then shocked into ventricular fibrillation by an asynchronous defibrillation attempt.  An echocardiogram performed post-operatively showed a very low EF of 23%, but a good repair of his valve and he appeared to be progressing quite nicely in his cardiac rehabilitation.  Still, it was felt he was at high risk for another arrhythmic event, so a wearable defibrillator as ordered as they waited out his conduction system a bit longer to see if it would recover function.   It never did.

So 10 days later after the sinus node failed to recover, the electrophysiologist had a choice: implant a pacemaker, or implant a defibrillator?   It shouldn't be a difficult decision in this case, should it?

But the electrophysiologist knew he'd be committing fraud if he implanted a defibrillator and billed Medicare for the device and procedure.  That's because Medicare's 2005 National Coverage Decision requires doctors to wait 90 days and then "reassessing" the patient's heart function later before implanting a defibrillator once the heart is revascularized surgically.

But he wondered about the extra risk of infection created by two surgeries (one for a pacemaker and one later to upgrade the device to an implantable defibrillator) instead of one.   He wondered if anyone ever considered the frequent venous occlusions that preclude later upgrade of pacemakers to defibrillators via the same side as the original pacemaker implant.   Even if he implanted a defibrillator lead at the same time he implanted the original pacemaker, wouldn't he be committing fraud if a more expensive defibrillator lead were billed to Medicare instead of a pacemaker lead?   And what about the added cost, inconvenience, and poor compliance rates of patients issued wearable defibrillators as they wait out the 90-day waiting period for an ICD?  Finally, what are the ethics of asking his patient to sign a form that obligates the patient to pay for his defibrillator if Medicare fails to do so when the actual costs involved to implant a defibrillator are closely held institutional secrets?

So he wrote his note.  He documented his rationale thoroughly.

Then proceeded to commit fraud.

-Wes

Refs: 

Fogel RI, et al. The Ultimate Dilemma: The Disconnect Between the Guidelines, the Appropriate Use Criteria, and Reimbursement Coverage Decisions JACC, 2013;() doi:10.1016/j.jacc.2013.07.016.

Dr. Wes: When the Feds Come Knocking

Images of Change: The Patient Appointment

Time Discarded

Submitted as part of Image of Change: A Health Care Evolution Photo Contest. Feel free to submit yours (Instructions at the link).  -Wes

Images of Change: Clicking is Caring



 “The secret of the care of the patient is in caring for the patient.” - F. Peabody


Submitted as part of Image of Change: A Health Care Evolution Photo Contest. Feel free to submit yours (Instructions at the link).  -Wes

Images of Change: Going Private

The Loss of Roommates, courtesy D. Graf

"I spent several days, in 2012, as a patient at two different hospitals in my pre-ablation period. I had roommates at both locations and each of them was named George. The rooms I was in are no longer shared bed facilities, they are now private. This is a profound change in health care. I learned much from both Georges and was able to listen in as their doctors and nurses filled them in about their conditions. I overheard specific information about their prescription drugs, their recommended diets and their health summary. (George I and II were able to see and hear my health are team, too). I also saw their relatives and friends come and go and felt able to ascertain which ones were there to encourage their loved one and which ones were going through the visitation motions. I heard some visitors talk about wanting to be granted Power of Attorney privileges and others asking about location of car and house keys. I also saw true friendship and empathy from some of the visitors. During the quiet times, mainly in the late nights after visitation, we would talk, compare notes about our healthcare providers, review the quality of hospital food, ask about each others work and hobby interests and generally bond. I haven't kept in contact with either George since we were hospital roommates, but it felt good to be together in a shared experience. The end of shared hospital rooms is, from a patient perspective, a major change in health care policy."

Submitted as part of Image of Change: A Health Care Evolution Photo Contest. Feel free to submit yours (Instructions at the link).  -Wes

Images of Change: Charting

Image courtesy Kathy Neider, MD, Staff Physician, Baptist Health

"I'm sitting where my credenza used to be, stacked high with charts. I figured if I was going to be in my office till late at night finishing electronic charting, it might as well be in a comfortable place."

Submitted as part of Image of Change: A Health Care Evolution Photo Contest. Feel free to submit yours (Instructions at the link).  -Wes

An Open Letter to Patient's With Pre-excited Afib and Ischemic VT

Dear Mr. or Ms. Patient With Pre-excited Afib or Ischemic VT:

I just wanted to let you know, if you come to our ER, you are screwed.  Currently, our best drug to deal with your arrhythmias of pre-excited atrial fibrillation (afib) or ischemic ventricular tachycardia is not available anywhere: procainamide.  It seems the one drug company who makes this drug (Hospira) has a few manufacturing delays (oops), so the drug is on backorder. 

So come ready to have your heart shocked. 

Hopefully we'll have some analgesic or anesthetic drugs available in our pharmacy that aren't on backorder so you won't feel your cardioversion.

Wishing you the best, as always...

-Wes

Images of Change: A Health Care Evolution Photo Contest

Much of my interest in writing about health care has been the changes I've noticed and experienced over the years of practicing medicine: some good, some not-so-good.  Pictures of these changes to health care, I've found, are limited.  Sooo, I thought it would be fun to create a contest of sorts: perhaps it will be well-recieved, perhaps not, I have no idea.  But the idea is this: try to capture an aspect of change in health care that you've noticed in a single photograph.

Almost all of us carry a smart phone.  As such, we have a perfect opportunity to capture images that might embody some change we have seen in health care.  Send it to me at wes - at - medtees dot com, tell me why you think this represents "change," and I'll add them to this blog from time to time if there's enough interest.   Be careful not to include any patient images, please (HIPAA frowns on that), and keep the content professional.  Send as many as you want, but please don't send super-high res images or my mailbox will become overloaded quickly. (I am celebrating that my blog finally has more than two readers a day!)  After I collect as many as I can over the next several months, I'll post all of those I've received in a photoshopped collage, then let people pick the image they feel best depicts health care's most significant "change."  So tell friends at the New York Times, the Wall Street Journal, retweet the post, put this exceptional contest on Facebook, Pinterest, and LinkedIn - the more the merrier.  Then have fun.

What will you receive for your efforts?  Once selected, the grand prize winner will receive worldwide recognition as the "The Biggest Change Agent, 2013!"  (Sorry, monetary prizes are easily gamed and might miss the spirit of the contest - yes, Virginia, this is strictly for fun and entertainment.)  (If someone want's to help contribute some real coin to the effort, e-mail me and maybe we can make a real prize contest out of this...)

So be thinking about this (in all of your spare time), snap a pic, and send it on.  I'd love to see what others are seeing around the country (or around the world) as health care changes faster than ever. 

To get you started: here's a picture I took today.  I think it speaks volumes:



Mailboxes in the Physician Lounge
(Click to enlarge)

 -Wes

When Your 26-year Old Needs Insurance

My son was born in 1987.  Like many kids his age, he is currently "underemployed" as he struggles to get an internet start-up idea off the ground.  Thanks to our new health care law, he was able to stay on my insurance until he reached the magic age of 26.  But the honeymoon has ended and recently I began the process of deciding if I should continue him on my Cobra plan at the high price of $485.14 per month or seek a high-deductible major medical plan instead.

Being former military, I have homeowners and car insurance through USAA. So I was interested when they  sent me a marketing e-mail suggesting I might want to look at health insurance options available for my son.  The plans were offered by "Assurant Health Care," so I thought I'd explore what this one company offered. 

First, Assurant Health offered three options for coverage: (1) Fixed-benefit Insurance starting at $67 per month, (2) Temporary Insurance starting at $86.74 per month, and (3) Major Medical Insurance starting at $90.74 per month.  So far so good. 

Fixed-benefit insurance, I learned, is different from major medical insurance since it pays set cash amounts (fixed benefits) when a person receives medical services. Depending on what providers charge, my son might (scratch that, probably will) have to pay a portion of his health care bill and cap at a $1 million, $2 million, or $3 million lifetime benefit, depending on much he'd like to pay each month. 

Temporary insurance is marketed as "30 to 180 days of short term insurance coverage. Protection is provided when you're between jobs, waiting for employer benefits, or in temporary, seasonal or contract work."  Hmm, this seemed like a possibility provided he can get a job in that period of time.  Oh wait, this hasn't gone so well so far, so this might not be the best option for him.

Major Medical insurance: was being marketed as insurance similar to what I have now, except with a varying sized deductibles and no life-time care limit.

On the surface, each of these options looked possible until I read the fine print on all of them: pre-existing conditions would not be covered by any of the above plans.  But my son has a few pre-existing conditions.  Wait, doesn't our new health care law cover people with pre-existing conditions? 

As I recall, the Pre-existing Condition Insurance Plan (PCIP) is overseen by the Center for Consumer Information and Insurance Oversight (CCIIO) created through our new health care plan and under the auspices of the Department of Health and Human Services.  To be eligible for the PCIP, “individuals must have a pre-existing condition and have been without creditable coverage for at least 6 months prior to application,” explained the Governement Account Office that limits “the program to individuals who likely have been unable to access insurance because of their pre-existing condition.” 

Now he just lost his insurance, right?  So he has to wait 6 months?  Can you say "Catch-22?"

To make matters much worse, the PCIP ran out of money in February, 2013 so the Department of Health and Human Services  stopped enrolling patients with pre-existing conditions who might need coverage.  What does this mean for the rest of our new health care law's ability to pay for U.S. citizens as insurers offload all their patients with pre-existing conditions on them? Will Congress assure there be enough money available to care for patients with pre-existing conditions when the new health care law goes into effect?  And why hasn't this been fixed by now?  This should sound a prescient warning concerning correcting problems with the law to us all.

His only other option currently is to enroll in Illinois CountyCare, a Medicaid program constructed on the back of the Affordable Care Act.  It provides limited services and not all doctors are part of CountyCare, I learned.  In fact, according to their website:

"Only doctors that are part of the CountyCare network may accept CountyCare patients. When an individual enrolls in CountyCare, they will be asked to select a patient centered medical home site from a list of participating providers. Choices will include Cook County Health & Hospital System sites as well as some other community providers, such as community health centers."

But at least he'd have some health care, right? 

It is hard to say.  He might have insurance, but access to providers might be very difficult, especially when we consider Cook County, the second most populous county in America, has 40.5% of the entire population of Illinois within its border. 

Given these options, it appears my son will likely continue his Cobra plan for now, since the devil you know is better than the devil you don't know.

Now I consider myself fairly medically savvy.  I read fine print.  I am fortunate to have financial resources.  And I like the ability to choose between options for my son's insurance needs.  But it looks like the depth and breadth of health care options for young adults without pre-existing conditions is going to be staggering but with many coverage loopholes.  For those young adults with pre-existing conditions, their options for care will remain quite limited, especially if they're unemployed or underemployed.

I feel for the young, under-employed who are less medically-saavy and have no fallback options for care.   Will they obtain the wrong insurance or be underinsured as they fumble through a variety of websites that offer hundreds of coverage options?  Will they have to find a new doctor beginning in 2014?

It seems so.

Welcome to the insurance nightmare of the Obamacare Underworld.

-Wes

administration’s Health and Human Services Department (HHS) has stopped enrolling any new people in the program, according to an audit by the General Accountability Office (GAO). - See more at: http://cnsnews.com/news/article/gao-hhs-already-rationing-enrollment-obamacare-s-pre-existing-condition-plan#sthash.EZVgmKIe.dpuf

administration’s Health and Human Services Department (HHS) has stopped enrolling any new people in the program, according to an audit by the General Accountability Office (GAO). - See more at: http://cnsnews.com/news/article/gao-hhs-already-rationing-enrollment-obamacare-s-pre-existing-condition-plan#sthash.EZVgmKIe.dpuf

Paying It Foward

Finally, a warm, sunny day in the city of Chicago after an unusually cool, rainy Spring.  The fireworks the night before were watched through a low layer of clouds on a dreadfully still summer night, but the threatening rains never came.  Today, though, had been sunnier, brigher, and a wonderful day to enjoy the beach.  The July 4th crowd was large but manageable, and most were returning home to get ready for the evening's activities.

Philip noticed the other gentleman not much older than himself as he was returning his Catamaran to it's rightful spot on the beach.  The other man had just returned his kayak to its slip and was loading his car with beach supplies.  As he finished loading the car, he slammed the back hatch door of the car, turned to walk away, but suddenly collapsed to the ground in a heap.

He didn't move.

Seeing the strange sight, Philip ran to his aid.  The fallen man was lying there with eyes staring skyward, not blinking.  His lips and ears were turning bluish as the tall man shouted at him.  He didn't respond.  Philip checked for a pulse: nothing.  Others were circling, curious as he positioned the man face up on the nearby asphalt.  The onlookers looked confused, amazed at what they were witnessing.  He began pressing on the lower part of the man's chest.  Again, again, and again.

He looked up and shouted as calmly as he could, "Call 911." The bystanders, still dazed, reached for their cell phones as fast as they could and dialed.  By now the attendants at the sailing shack had noticed what had happened and had radioed for help, too.  The AED and oxygen were at the swim beach, about a quarter of a mile away.  A young 16-year old lifeguard, his first day on the job, ran to the scene and reached in to his fanny pack to remove the facemask and worked with the tall, fit man doing CPR.

"Hang in there, Bill!  (not his real name)," the onlookers shouted.   "Don't leave us!" he remembered them saying as they stood by in tears hugging each other.  He kept doing CPR.  "They're coming with the AED!" someone shouted.

He could hear the sirens approaching ...

* * *

Twenty five years earlier, he was home with his mother in the kitchen when the girl arrived in their kitchen, bloodied, and wearing a large blue garbage bag as shorts.    "Help me," she pleaded, "I was raped, but I managed to shoot him," she claimed.  The bloodied shorts and two guns she held in her hands seemed to substantiate her claim. She was trembling, aggitated and seemed terrified. "The police are going to find me and think that I'm a murderer!"

"It's okay," the mother said, trying to calm her.  "Sit down.  What's your name?" 

"Laurie," she said.  "Laurie Dann." 

"It's okay, Laurie. You're going to be okay," she said as she tried to console her.  "I can get you some shorts.  The police will understand that you were just trying to protect yourself."  The girl still looked too upset, untrusting.  The son stood watching carefully as the mother left only briefly and returned with a pair of girl's shorts.  "Here, put these on." 
The girl put down the two handguns and went behind the counter briefly to to put on the shorts.   Phil, not turning his back to the girl, quietly managed to pick up and pocket one of the guns.   "Maybe you should call your family?" he asked.  She shook her head in agreement and he handed her the phone.

She took the phone and dialed, still holding the remaining gun.  "Mom, oh my God, I've... I've done something horrible!   He tried to ...  The police are going to get me, Mom!  Oh, God!..."  She broke into tears unable to maintain her composure.  She  handed Phil the phone.

"Ma'am, my name is Philip Andrew and your daughter is here with us.  She is fine, but looks very upset.  She tells us she's been raped and might have shot the man who raped her.  I think you should come over..."  The mother said she'd try to get there as soon as she could, but she didn't have a car.  Phil felt uneasy with the situation, but the girl looked confused.  They tried to console her.

A short time later, the father arrived home.  He saw the girl with his wife and son sitting there, trying to coax Laurie into giving up her gun.  She wouldn't budge.  She rocked too and fro describing the scene, her terror, her anxiety. The family kept trying to console her, explain the rationale for giving up the gun.   Deflecting, they asked, "Maybe you should call your mother again."  They handed her the phone.  She called. 

This time, the mother managed to leave the house as Laurie spoke with her own mother.  Her words were disjointed in some respects, calculating in others.  After pleading with her mother to come, Laurie handed the husband the phone so he could speak with Laurie's mother.  He told her about the gun Laurie still had and asked the mother if she might plead with her daughter to give up the gun.  He handed the phone back to Laurie and told her he would not remain in the house to protect her from the police unless she put down the gun.  She still refused, so the man left the house.  As Phil tried to leave, she ordered him to stay. She pointed the gun at him.  He stood motionless, terrifed.

The standoff continued until just before noon and she became increasingly aggitated.  As Laurie saw the police approach, she shot Phil in the chest and gave chase, furious at the situation, but he managed to escape out the back door before collapsing.   She ran upstairs.

As he laid there, he could hear the sirens approaching...

* * *

They slapped the AED pads on his chest and stopped compressions.  "Analyzing..." the screen said.  The device detected ventricular fibrillation and shortly after the device said "Stand clear!" the man jerked.  They resumed CPR for a short time, but in 30 seconds the man started moving.  The sirens were almost upon them now.

As the ambulance crew arrived, they couldn't believe their eyes.  The man who moments ago had had chest compressions administered and an AED shock delivered, was getting to his feet.  They helped him to the ambulance.

"This impressed my crew, my guys, so much …" Wilmette Deputy Fire Chief Mike McGreal said a the recent Wilmette park board meeting honoring the beach staff.



But to Philip Andrew, now a crisis negotiator for the FBI who was on the beach with his wife that day, he'll never forget the sound of the sirens...

... and the emergency responders that saved his life twenty five years before.

"There's something really beautiful about being able to pay it forward," he said.

-Wes

References:

"Wilmette lifeguards honored after July 4 rescue"

Laurie Dann Wikipedia page

The Silent Majority

There is so much entropy in health care right now.  So much finagling, so much shifting, so much arguing, so much uncertainty, so much shock.  Shock at prices, shock at waiting times, shock that doctors don't know how to increase referrals, shock that doctors aren't doing more to help.  What gives?

In triage, you don't spend time with the expectant.

Doctors are keeping their heads down.  They are still seeing patients.  They are still going to work and taking the calls. 

But they are tired.  They are frustrated by the system that puts the system of care before the people doing the caring and those needing care.  They are tired of the empty promises.  Like the promises that staring at a keyboard will fix things, do things better, save money.  It's complicated, this health care thing, right?  We are told we need more automation.  We need more quality managers.  We need more safety officers to see more people with less to keep it safe.  We need more administrators to implement the rules: more people willing to take less to make it work.  Complicated, I tell you.

But the promises, we're learning, have been part empty, for they have enriched the system for the system's sake while leaving the people the system is supposed to help, increasingly broke.  We're $500 billion over budget so far and counting. 

Promises are for politicians and business people.   Real health care workers don't make promises, they do the best they can with what God gave us.  As patch after destructive patch of interweaving laws and back-slapping favors are handed out in Washington, corporate board rooms, and union meeting halls, a silent health care majority watches from their peripheral vision, trying not to notice, trying not to be disgusted, for the work for them never ends.  The silent majority is waking to the fact that the business part of health care was, is, and somehow forever shall be, broken.  There is simply too much money involved, too much economic return that can still be made, too many opportunities to deceive others for personal gain, too many people, too many workers, too much of our economy, to accept that things will ever really change.  Too very, very big...

... to fail.

Like Detroit.

I sit before a computer screen that says "Order entry:"   I no longer need a pen thanks to handsome government subsidies and a push to centralize and nationalize.  Let others do the deciding.

I type in an order.

Five choices instantly appear based an a sophisticated word-search algorithm.  I find what my patient and I, as their caregiver, need.  I click on the item.

But a price never shown.  So there is never a discussion about cost.   That's the intent.  There is never a word about the difference of retail price and what it really costs or what you'll really have to pay.  Like a shopping spree without the prices.  Because, according to others, doctors should not think of these things when health care is involved, nor should Congress - it's about your health, remember? 

So thousands and thousands of your dollars are put at risk, dear patient, with a single click of a button. Courtesy of government subsidies.  And you will never know.   Nor will I, as I load the gun of your economic destruction.

So efficient.  So clean.  So tidy.

How was I supposed to know I ordered a collection agency for you, too?

But the silent majority is stirring.  They are upset they must pay their mandate, upset the corporate guys don't.  The are seeing the bills, the denials, and the undecipherable bills.  They are seeing the cost.

The Silent Majority is stirring.

Because they have a check box, too.

In November, 2014.

-Wes

Spousal Travel Fees and the Cost of Medical Board Certification

Recently, I have been enduring my "Maintenance Of Certification" (MOC) training so I can continue to call myself  "Board Certified" in Cardiovascular Diseases and Cardiac Electrophysiology.  Later this year, I will sit for my re-certification examinations.  But I was also recently reminded just how expensive this process has become for doctors. 

Yesterday, I received a $775 bill for my "additional examination fee" from the American Board of Internal Medicine (ABIM) in the mail.  I was surprised and had to ask myself, "Why?"  Especially since this rate is more expensive than staying at a five-star hotel room in Chicago for a day.

In total, the out-of-pocket expenses for Maintenance of Certification in both of my subspecialties above have been as follows:

Enrollment Fee: Maintenance of Certification:  $1840 (this includes only one exam fee)
Additional Examination Fee:     $775.00

ACC Self-Assessment Program (ACCSAP 8): $620
Heart Rhythm Society Board Review Course and ABIM Recertification Module $1440

So far, that's: $4675 just to "maintain" my certification this time around.  (Per annum: about $500 per year).  (Note that this cost does not count the lost revenue I sustain from leaving my workplace to attend the Board Review Course, to study , or take the tests.)

And to think I get to do this every ten years!

But when we learn of the salaries of the leadership of the ABIM, it becomes clear why these fees are so high.   According to the publically-available IRS Form 990 from 2012 (the last available), ABIM Executive Christine K Cassel received salary and benefits of $786,751 in 2011, plus payments for spousal travel. (At that salary, why are testing physicians picking up travel expenses for Dr. Cassel's husband?)

Equally outrageous has been the ABIM's recent requirement for re-certifying physicians to complete a "Practice Improvement Module" as part of their re-certification requirements.  For those unfamiliar, doctors have to find something to improve in their practice, measure how its going, make a change, then measure the effect of that strategy in hopes it will improve patient care.  On the surface this requirement seems so, well, nifty!  How could anyone argue with the intent of such a requirement?  But imagine the time it takes to conceive and execute such a project.  How much patient care suffers as a result?  So doctors who are already stretched for time look for ways around this requirement and luckily, they find it is easily gamed.   So they talk to their hospital's quality coordinator, get some useful data, enter it into the MOC website, then answer questions that ask "what-did-you-learn-as-a-result-of-completing-this-module?" and, presto!  Their module is done!

Really, is this useful?  Maybe we should include handwashing exercises, too.  Or is this more about the ABIM maintaining their leadership's benefits and political favor?  As I performed this painful part of my re-certification requirement, I couldn't help but hear echo's of Don Berwick's Institute for Healthcare Improvement's educational curriculum that helped pave the way for the life-long healthcare guartantee he received for himself and his family for life.  Could the leadership of the ABIM have similar aspirations for a similar golden parachute?

I can't help but wonder.

As I wrote my additional exam fee check, I also reflected on what the "value" of this re-certification process is for physicians like myself that have been previously certified.

Will doctors get more income for having this certification? No, especially in the current payer climate that seeks to continue to limit physician payments.

Will doctors get more prestige for having this certification?   Not really, especially when nurse practitioners  at Walgreens can call themselves "board certified," too.  (It is interesting to note that their certification only costs $395 - 8.4% of the cost for medical re-certification.  Maybe doctors  should take their test instead?) What responsibility does the ABIM have to protect the value of the term "board certification" for physicians who invest in this process?  Given the ongoing board "certificate" fraud perpetuated by others directly under the nose of the ABIM, we are left to wonder if they have any authority to protect physicians' investment in this process.


Is the time required to re-certify worth it for doctors and patients?  Will doctors be smarter for having this certification?  I think the ABIM does try to make the knowledge assessment modules relevant to new knowledge in the medical field.  (Actually, I found these almost fun to take).  But I already stay up to date with current innovations and studies in my field thanks to my teaching responsibilities, ongoing state licensure requirements for continuing medical education credits, and my rather healthy social media presence.  Do these costly re-certification tests improve my knowledge significantly enough to affect my patient's outcomes?  I honestly don't think I've ever felt so.


Surely the public wants to know their doctors are quality doctors.  But what is more important, years of direct medical care experience or just having their doctor pass an expensive test every 10 years?  With the expected avalanche of patients entering our health care system, does the public want to pay for irrelevant bureaucracy that just feeds the system rather than improving physician availability?.  I suspect that the public would rather have their doctors engaged in their care rather than being distracted by unproven testing exercises. 

But it seems bureaucrats must endlessly continue the money flow that assures their spousal travel fees, so maintenance of certification will likely soon be tied to the granting of hospital credentials or state licensure. We should ask ourselves if we really want this.  In 2011, the ABIM received $44 million in fees from doctors sitting for  board certification and maintenance of certification.  That's a hefty chunk of change.  So much so that at least one doctor has recently sued the ABIM over concerns of monopolizing the process.

Doctors need to speak up, especially when others stand to enrich themselves on the labors of their colleagues.  If doctors can't get use a pen from a pharmaceutical rep, they sure as heck shouldn't being using their own colleagues' hard-earned funds for their spouse's travel.


Please think of these things when you cash my latest $775 check, ABIM, will you?

-Wes

Case Study: Um, A Post-op Chest X-ray

Radiologist: "Um, doctor, there's something funny on your patient's post-operative chest x-ray:"



Post -operative Chest X-ray
(Click to enlarge)

(Remember, you never want to hear the word "Um.")

What did the radiologist see?

-Wes

The Clash of Cultures

"It looks like you've done very well, Mr. Smith..."

"Thank you, doctor."

He left the patient's room and ambled back to the nurses station, legs tired and ankles somewhat swollen.  It had been a long case and now he just had to type his note, send an email message, and review his schedule for the following day.  He sat down at the computer and logged in.  That's when he looked up briefly and saw them.

They looked so young.  Their newly-pressed white coats accentuated the faint glow of the computer screens on their perfect skin.  They looked like thoroughbreds, while he the old horse put to pasture, if they had noticed.  But they were each staring intently at the electronic screen arranged along the desk countertops, one with his back to the other two.  Occasionally the one would turn to ask the other two a question, then return with a blank stare to the screen before him.  The new residents had arrived.

"So different," he thought.  There they are, seated before a computer looking more like telephone operators rather than doctors.  "What were they thinking?" he wondered silently, then pondered how things had changed.

For now he realized that they didn't have to know where the blood or microbiology laboratories were.  They didn't have to search for an x-ray.  Instead, they had to find which button to click.  This day, this moment, was probably their dream come true.  For it was the day they had waited and worked so hard for, the day they became a working doctor.  Underneath the electronic facade, they were probably excited, eager, wanting to do a good job: excitement and anxiety, all rolled up into one.

But somehow, it was different.  The new doctors rarely looked at each other as they stared vacantly into their computer screens.  It was as though they were transfixed by medical porn.  It looked as though they were being bred into an interchangeable electronic medical documentation team, not a cohesive, personal one equipped with interpersonal skills.  After all, they really didn't have to see or listen to each other any more. They could send each other an e-mail, text messages, or chose to stay isolated, listening to the rapid-fire clicking taking place next to them.  Emotionally and physically, they could be miles apart or seated together, it really didn't matter any more.    It was so efficient, so neat, that their organized orientation to electronic dehumanization required very little movement, very little patient contact.

But young doctors, he realized, were meeting their patients like they've always met new friends on Facebook: electronically first.  Was this better?  He wasn't sure.  Would the initial impressions garnered from the chart skew their ability to look independently and objectively at their patient?  Will they be capable of accurate empathy?  Will a patient's undocumented concerns be missed?  Will new doctors forget to use the subtle signs and symptoms brought forth by the physical exam to head off disaster or just wait for the test results to return before reacting instead?  Will they see enough, smell enough, do enough, sweat enough, to learn enough?

He wondered.

But they were young.  They could learn.  They would learn.  They'd adapt.

And they could type faster.

Perhaps.  Maybe.  We'll see.  "I can only hope," he thought, realizing he wasn't getting any younger.

He turned his gaze back to his own screen and clicked the icons slowly, the way he had done hundred of times before, filling his note with voluminous immaterial drivel the government required, then added a single line: "Doing well.  Home today."  So meaningful, he silently quipped, meaningful indeed.

He rose to say goodbye to the unit clerk, who smiled as she peeled her eyes from her iPhone, "Goodnight, doctor."

"Take care of the new guys, okay?" as he pointed to the people behind her with the new white coats.

"You bet," she said, not turning to see them.  Her eyes reset to to her iPhone screen instead.

-Wes

Case Study: The "Simple" ICD Revision

The following is an actual cardiac electrophysiology case study offered with the patient's permission. It's technical and contains an image that might turn some folks' stomachs, so for those who are a bit squeemish or just ate a meal: consider yourself warned and feel free to pass on this post. For the rest of you who remain interested and don't mind medical images, good luck.

It was supposed to be a simple ICD revision.

A prior abdominal ICD has been implanted in 1995. As was the norm of the day, the large ICD pulse generator was implanted in the left upper quadrant of the abdomen and an connected to an old Guidant Endotak Model 0074 lead that was implanted via the left subclavian vein and then tunneled down to the abdominal pocket. The device served the patient well for many years until its battery depleted in 2003. At that time, a new, smaller ICD with an appropriate header  replaced the old abdominal device and because the defibrillator lead worked well, the smaller ICD pulse generator was left in the abdominal pocket.

Years passed and the patient followed reliably in the Device Clinic for his routine defibrillator checks. While the lead impedance and capture thresholds remained normal, about a year ago intermittent periods of noise with non-physiologic short RR intervals suggestive of possible impending lead fracture began to appear on the patient's device checks. Because the patient was not pacemaker dependent nor near the time when his existing ICD battery would have to be replaced again, it was elected to wait until his battery reached it's elective replacement indicator before revising his system. When that time came, a new defibrillator lead could be implanted and connected to a more conventional VVIR ICD pulse generator implanted in the upper chest area (the patient has chronic atrial fibrillation). The old pulse generator could then be removed from his abdomen and the old lead capped and left in place.

So the day came for surgery. The patient felt fine: no fever, chills or other unusual symptoms pre-operatively. A venogram performed immediately before the procedure disclosed a patent left axillary and subclavian veins, so it was decided to first proceed with the new ICD implant on the same side as the site where his first defibrillator was implanted followed by removal of the old ICD pulse generator from the abdomen.  Pre-operative antibiotics were administered. To make a long story quite a bit shorter, the new single-chamber ICD implanted via the left axillary approach was performed without a hitch. A dressing was applied to the wound and preparations made to explant the abdominal pulse generator.

The lower abdominal area was similarly prepped and draped. Local anesthetic was infiltrated over the prior abdominal scan and an incision made at this location. Using electrocautery dissection, the incision was carried to the pulse generator capsule which appeared to be quite thick, but uninflammed. The fibrous capsule surrounding the pulse generator was then opened. What was found was startling to all.

Inside the pulse generator pocket was the device and lead system surrounded in a thick fluid that looked, for lack of a better way to describe it, like wet, brown mud. There was no odor. The device was extracted from the pocket after the suture holding the header of the device to the pocket wall was cut. A portion of the lead was also cut removed with the device. A picture of the removed device is shown here:

Soooo. What now?

Imagine you are the surgeon with this device in your hands. You have another case after this one. You struggle to find where this situation falls within our clinical "guidelines" for care and find very little. You aren't sure what you're seeing, but only know that this "chocolate-coated" ICD pulse generator is not the norm. (Usually they are nice and clean without debris.)

Ideas?

-Wes

Physician Pay Redistribution: A False Sophie's Choice

Sophie's Choice is a novel by American author William Styron, whose plot ultimately centers around a tragic decision Sophie was forced to make upon entering the Nazi concentration camp: on the night that she arrived at Auschwitz, a sadistic doctor made her choose which of her two children would die immediately by gassing and which would continue to live, albeit in the camp.

While not of the same gravity,  I have seen the discussion by policy wonks about physician payment reform evolving into a smackdown between primary care physicians and specialty physicians for the remaining coins tossed on the health care floor.

James Hamblin MD, The Atlantic magazine's health editor, recently published an article entitled "When the Best Hospitals are the Worst," that assumes prestigious hospitals are the "worst" because they fail to train an adequate number of primary care physicians relative to the federal subsidy they receive for training residents:

But many hospitals aren't using that money to do what the taxpayers most need. 158 of them produce zero graduates that go into primary care. The worst offenders, in terms of the number of primary-care physicians produced, are the hospitals we hold in highest regard. 

To bolster his point, he references another article from the July-Aug 2013 issue of the wonkish Washington Monthly by demographer Phillip Longman entitled "First Teach No Harm."  Both Hamblin and Longman claim the following:

The nation’s residency programs are producing too many of the wrong kinds of doctors in the wrong places, while not producing enough of the kinds of doctors we most need to sustain the U.S. health care system.

Specifically, the programs turn out too many specialists who go on to practice in places where such doctors are already in oversupply, and where, according to numerous studies, they often inflate health care spending by engaging in massive amounts of unnecessary surgery and other forms of over-treatment. 

While both Hamblin and Longman make excellent points about the work conditions of today's primary care physician's, they veer into dangerous territory when they pile on the assumption that the problem with our nation's health care delivery and cost problem is the distribution of dollars between different types of physician training programs.  American's need doctors - all kinds of them - thanks to the ever-growing and aging population.  What they don't need is the mushrooming and very costly administrative overhead that plagues physicians today.

Here's a radical thought: all physicians should be paid a respectable and competitive salary commensurate with their years of educational investment and competitive training and receive the quality training they need to do their work.

But rather than acknowledging this fact, Hamblin and Longman want us to make a false Sophie's choice: picking which types of physician training programs should receive federal funds based on the types of physicians they train, rather than working to improve the lot of all physician training programs to assure excellent doctors in the years ahead for our health care system.

Perhaps rather than wondering how to redistribute $13 billion dollars of educational funding for medical residencies that flows to all residency programs, Hamblin and Longman should ask how we should cut the mushrooming and incredibly costly administrative overhead of our system that already  stood at $320 billion (and counting) way back in 2003?  How much is that overhead expanded thanks to the introduction of over 110 government agencies created by our new health care law?  Which bean counter should be fighting with the other bean counters for their share of administrative dollars?  Which new data miner, quality coordinator, hospital administrator, database operator, or government agencies that share similar functions (like the PCORI and AHRQ agencies) yet provide no care should be fighting to save themselves?

Maybe rather than peeling the dollars from any doctor's training pocket as he charges down the hallway to see the next patient in his 14-hour day, we should determine how to peel the even larger amount of dollars held in the pockets of the five administrators trailing him.

This is our real health care system cost Sophie's choice.

And doctors of all specialties would be wise to remind Congress and their respective medical associations of this fact.

-Wes

A Chest X-Ray You Don't See Everyday

... unless, of course, you're a cardiac electrophysiologist:

An anterior-posterior (AP) and lateral (LAT) chest radiograph
(Click image to enlarge)

-Wes

PS: Answer here.