Friday, September 29, 2006

Post-market Surveillance of Heart Devices

Most people are aware of the marvels of technology that help prolong life in people with heart disease. This is particularly keen in my field, where heart rhythm disturbances can cause sudden unexpected death, but implantable cardiac defibrillators are an effective weapon against this risk. Nonetheless, these complicated mechanical devices have a certain failure rate and can be subject to "advisories" from the manufacturer warning about certain problems that develop after the introduction of a new make or model to the public.

Unfortunately, occassionally these problems can lead to peoples' death, as we have seen. Doctors in their judgement have rushed to replace these devices, only to find later (hind site is always 20-20), that the risk of infection replacing the device can exceed the risk of failure of the device. It's a complicated and worrisome problem for all involved.

The Heart Rhythm Society has come forth with its recommendations to attempt to correct the existing shortcomings regarding the long-term management of device failures. They include:


  • Should inform patients not only about the benefits and risks of devices, but also about the overall expected performance of devices, including potential malfunction rates.

  • Should return all malfunctioning devices after explant to the manufacturer for analysis whether the replacement is routine or because of a malfunction. This will lead to more timely identification of potential malfunctions and a better understanding of the true 'denominator' for a particular device.

  • Should consider the risks of explantation and re-implantation of a new device when considering with their patients how to respond to an advisory notice that a device malfunction has been identified.

  • Manufacturers:

  • Should use expanding wireless and remote monitoring technologies to identify abnormal devices earlier and automatically.

  • Should establish independent, standing committees of outside experts to analyze device performance reports and to recommend appropriate action.

  • Should communicate with physicians and patients directly using standard physician and patient communication forms to notify patients regarding potential malfunctions.

  • FDA:

  • Should use simple language to communicate important information about device malfunctions and eliminate the term "recall" in public communications.

  • Should enhance the existing databases to more readily identify devices that may pose a danger to patients.

  • Should establish a post-marketing surveillance advisory panel of independent expert advisors to assist FDA with this function.

  • Congress:

  • Should recognize the FDA needs the appropriate resources, funding and focus to perform post-market surveillance, analysis and reporting.

Doctors will now have to think about adding a line to their documentation of "informed consent" that discusses performance failure rates of devices, but care should be taken to keep this "failure rate" broad, since these rates are not published for all devices and all manufacturers yet.

No doubt the manufacturers and FDA will do their part, too. But Congress giving more money to the FDA? There's the sticking point. From my perspective, Congess will try to get the manufacturers to foot most of the additional cost for oversight.

Hopefully these recommendations will serve as a wake-up call to Congress.


Thursday, September 28, 2006

Teaching the Teacher

I will be traveling out of town for a bit as an invited speaker in Minneapolis, MN on he application of pacing techniques for the treatment of congestive heart failure, specifically biventricular pacing. At these engagements, I used to think that I was the one doing the educating – one likes to think they’ve got something brilliant to say. But as the years have passed, I now find that such engagements tend to do more for the speaker than for the student. The time spent organizing a talk, updating outdated slides, and preparing for an onslaught of thoughtful questions – or at least trying to anticipate those questions – improves my understanding of the challenges we face every day and the gaps in knowledge yet to be understood.
“Sixty years ago I knew everything; now I know nothing; education is a progressive discovery of our own ignorance.”

-Will Durant

Hmmm. It seems teaching and blogging are strikingly similar in this regard.
"Thought flows in terms of stories - stories about events, stories about people, and stories about intentions and achievements. The best teachers are the best story tellers. We learn in the form of stories."

-Frank Smith


Wednesday, September 27, 2006

Little Secrets

He was a huge man, the football-player type, proud, athletic, slightly overweight. Everyone knew him as “Coach.” He stood by the sidelines of all his boys’ games, cheering them on. He had taught legions of young men the game, strategy, and work-ethic of football. But when he could no longer walk the thirty feet to the sideline from his car, he asked his cardiologist and neighbor his options.

After much reluctance, he presented to my office. Suddenly the large-framed man was meek and reserved. “Do I really need this thing?” he asked.

“Here are your options, Coach,” I said. I went on to describe that he had run his course on medications, his heart was getting too weak without some help, and that more conservative measures hadn’t worked. Basically, it was a biventricular defibrillator or heart transplant. He chose the defibrillator.

So when the time came to have his procedure, he was terrified, but stoic. You could see it in his eyes. I asked if he had any last-minute questions. He said “No.” So I turned to prepare my pre-op assessment note and prepare for surgery. But he did have one last request.

“Can I leave my underwear on?” he asked the nurse. “Sure, Coach, it'll be our little secret,” she said in a wonderful gesture to maintain some element of dignity for him.

Off to the operating room he went. Things proceeded smoothly at first. But the first clue to impending problems occurred as we laid him on the table. “Can I sit up?”

We placed a wedge beneath his back to assist his breathing. He was sick as sick could be. Everyone knew it. Everyone knew he had few options left. At 44, he just seemed too young. So we proceeded.

Venous access was easy, and one lead of the three leads was placed without difficulty, but then trouble arose.

“I, I can’t, I can’t breathe! I have to sit up! PLEASE Doc, let me sit up!” And the wrestling match began. “I’ve done this a thousand times, just let me sit up and I’ll be better, PLEASE!” We held him down. With an open wound and no other option for long term therapy, we couldn’t let him rise.

“Call anesthesia, stat. 100% oxygen by facemask, 2 mg morphine, start dobutmaine at 10,” etc., etc., I barked.

Within a minute or two (was it that short?) anesthesia arrived, and the patient was now in dire straights, oxygen level plummeting, heart racing, my sphincter tightening. But with all the skill he could muster, the anesthesiologist placed the endotracheal tube right where it needed to be, and sedated the patient. His blood pressure and oxygenation remained tenuous.

“Call one of the interventional guys and place an arterial line and balloon pump.” Clothes were cut off, the groin area prepped. And once again, the gods answered. The balloon pump added tremendous additional cardiac flow to his weak heart. A foley catheter and new IV’s were placed and he stabilized just long enough to place the biventricular defibrillator, close the wound, and get him out up to the intensive care unit.

Overnight he did better, as his kidneys removed liters and liters of excess fluid from his lungs. The next morning, the breathing tube was removed. We were all eager to see him. But was most impressive to me, was the nurses and techs who wanted to see him, too. After all, they had braved the tense moments, the anxiety, the fear. “Can we follow you up there?” they asked.

“Sure. You guys can cover my back in case he gets mad at me for what we did,” I joked. So up to the ICU we went, our little electrophysiologic entourage.

And there was Coach. Looking exhausted but breathing better than ever. “I don’t rattle anymore,” he said. Everyone was grateful.

Then, time stood still for a moment. The nurse that had been there just before his procedure leaned over to him and whispered shyly and apologetically:

“I know you wanted your underwear on, but I had to cut them off.”

He smiled and said,

“Sweetheart, you're the best. Thank you.”


Tuesday, September 26, 2006

Testosterone Storm

I can feel my gonads squeezin’.

Maggie Fox, Health and Science reporter for that bastion of news reporting, Reuters, had this little expose’ on the brain-damaging effects of too much testosterone. It seems she decided to do an itty bitty story on how too much testosterone can make you blind, er, brain-dead (well, kind of). She referenced a study by a team of researchers from Yale University and lead by (wouldn’t you know) a female senior researcher, Barbara Ehrlich.
“Tests on brain cells in lab dishes showed that while a little of the male hormone is good, too much of it causes cells to self-destruct in a process similar to that seen in brain illnesses such as Alzheimer's.”
But it seems rats weren’t enough. It seems the ladies had to go and cross the line:
"Next time a muscle-bound guy in a sports car cuts you off on the highway, don't get mad -- just take a deep breath and realize that it might not be his fault," Ehrlich said in a statement.
What a patronizing, sexist statement. Now it’s my turn (and I’ll try to be a bit more polite).

Have you ever been on the road at the hours between 3PM and 4 PM and seen a woman on a cell phone, sipping a latte, driving an SUV like a bat out of hell as she rushes to pick up her kids from school? It makes us 'muscle-bound guys' look like fairies! Never, ever, pretend such a woman gives a damn about anyone else on the road. Just stay out of her way. It seems womens’ amygdala are in epileptiform tetany at this time of day. Please, Dr. Ehrlich, don’t be too quick to judge male driving habits.

And what about the effects of too little testosterone? What might happen to us guys? Well, we might have to stop and ask DIRECTIONS!

Do us all a favor, Ms. Fox and Dr. Ehrlich, stick with your rats.


Tobacco Suits "Light" Up

So much for the "light" cigarette claim. From this morning's Wall Street Journal:
A federal judge's decision to grant class-action status to tens of millions of smokers of "light cigarettes" exposes major tobacco companies to a new $200 billion claim for damages and will delay an expected plan by Philip Morris USA parent Altria Group Inc. to spin off its Kraft Foods Inc. unit.

U.S. District Judge Jack B. Weinstein in Brooklyn, N.Y., made the pretrial ruling yesterday in a 2004 lawsuit alleging that Philip Morris USA, Reynolds American Inc.'s R.J. Reynolds Tobacco Co., and Loews Corp.'s Lorillard Tobacco unit, among others, falsely marketed "light" and "low-tar" cigarettes as a lower-risk alternative to conventional higher-tar smokes.

Lawyers for the plaintiffs argued that tobacco companies reaped between $120 billion and $200 billion in additional revenue because of what they describe as a pattern of deceiving the public about the dangers of smoking light cigarettes. Because the suit is being brought under federal racketeering law, the amount of damages in the case could be tripled.
I guess that $145 billion they got reprieve from in the Engle case in Florida might not be such a reprieve after all.


Medical Insurance Identity Theft

I recently traveled to that garden spot of the midwest, Minneapolis, Minnesota, and stopped by a bookstore at the airport. My flight was delayed, so I found a worthless novel and used a credit card I rarely ever use to make my purchase. It passed the time, and I didn't think much about it.

The next morning, I headed to work and received a call by 09:00AM from my wife.

"Honey, I got a call from some VISA guy. Said he needs to talk to you. You better call him at 800-xxx-xxxx."

So I made the call and learned that my card was "swiped" and digitally reproduced in Mexico City, Mexico and used for a purchase there - for a whopping $4.97. But shortly thereafer was another charge: this time $80.62. Gratefully, the charges were not approved, but the craftiness of this scam was staggering, nevermind subjected me to the inconvenience of having to visit my bank during bankers' hours - never easy for a doctor.

Now it seems a similar scam might occur with your health insurance.

And thanks to Health Insurance Portability and Accountability Act (HIPAA) of 1996 that protects certain health information, it can be VERY dificult to track down the perpetrators of such a scam.
The bitter twist on medical identity theft is that once a person tells a keeper of records that someone else's data might be intermingled, the file becomes even harder to obtain. Why? Because it includes another person's medical history, which many hospitals argue can't be turned over without consent.
The LA Times article recommends the following precautions:
To guard against identity theft, patients should:

• Ask to see their medical files from each provider on a regular basis;

• Scan medical and insurance bills for services, medicine and equipment they didn't receive;

• Demand an annual list from their health insurance company of benefits that have been provided.
And I'd like to add one more idea:

Protect your health insurance card like you would a credit card lest some health care charges show up in Mexico City (or another town) for which you're responsible.


Monday, September 25, 2006

Grand Rounds - Vol 3, Number 1

This week's medical Grand Rounds is up (a bit early thanks to the efforts of Enoch Choi, MD) at Tech Medicine:
As this is an anniversary, I wanted to host a party here at Tech Medicine, and invite you to partake in the delicious treats you find at different celebrations we all love. In a few instances I’ve made the treats more by linking to a couple writers that talk up the same topic to give a fuller richness to the conversations‘ multiple points of view.



Got whacked on call this weekend. Need a little breathing room. More serious post soon - maybe....

If you have got a minute, Jason Rubenstein, MD has a funny video of a red-neck rocket launcher. And to think he's smoking as he's setting up the fuses....


Friday, September 22, 2006

Heart Devices and MRI's

Finally, it might just me okay to order an MRI for a patient with a pacemaker or an implantable cardiac defibrillator.

In two recent reports from this week's medical journal Circulation, researchers from Johns Hopkins University, Univeristy of Pennsylvania, and Germany have outlined a protocol that permits safe MRI scans (references below). The devices are first reprogrammed to a "pace only" mode (so they cannot be inhibited by outside noise interference), shock therapy is suspended for the brief time of imaging, and the MRI signal intensity is reduced to about one-half its usual intensity (from 4 Watts/kg to 2 Watts/kg). Only pacers from 1996 and later and defibrillators from 2000 and later were tested sucessfully ini 1.5 Tesla MRI scanners in both studies. Once the scan was completed, the device was reprogrammed back to its original setting.

There were some important exclusions as mentioned in this editorial from the FDA:
Meaningful exclusion criteria included pacemaker dependency and the need for a thoracic MR scan for the Sommer et al study and the presence of an epicardial, nonfixated, or abandoned lead for the Nazarian et al study.
There were some important findings. 7 of 115 patients switched to a "noise reversion mode" or factory reset setting, and 21 of 47 patients had the magnetic reed switch fail to close during the MRI (a means to prevent detection of arrhythmias or revert to pace-only mode in pacemakers). Hence, pacemaker-dependent patients might lose pacing output in such circumstances. A slight change in pacing threshold was also noted in several patients.

Although not yet endorsed by the Heart Rhythm Society, FDA, or manufacturers, this work demonstrates that such MRI imaging can be performed safely in appropriately-selected patients under careful observation.


References: Clinical Utility and Safety of a Protocol for Noncardiac and Cardiac Magnetic Resonance Imaging of Patients With Permanent Pacemakers and Implantable-Cardioverter Defibrillators at 1.5 Tesla.
Nazarian, Saman MD; Roguin, Ariel MD, PhD; Zviman, Menekhem M. PhD; Lardo, Albert C. PhD; Dickfeld, Timm L. MD, PhD; Calkins, Hugh MD; Weiss, Robert G. MD; Berger, Ronald D. MD, PhD; Bluemke, David A. MD, PhD; Halperin, Henry R. MD, MA

Strategy for Safe Performance of Extrathoracic Magnetic Resonance Imaging at 1.5 Tesla in the Presence of Cardiac Pacemakers in Non-Pacemaker-Dependent Patients: A Prospective Study With 115 Examinations.
Sommer, Torsten MD; Naehle, Claas P. MD; Yang, Alexander MD; Zeijlemaker, Volkert PhD; Hackenbroch, Matthias MD; Schmiedel, Alexandra MD; Meyer, Carsten MD; Strach, Katharina MD; Skowasch, Dirk MD; Vahlhaus, Christian MD; Litt, Harold MD, PhD; Schild, Hans MD

Food and Drug Administration Perspective: Magnetic Resonance Imaging of Pacemaker and Implantable Cardioverter-Defibrillator Patients.
Faris, Owen P. PhD; Shein, Mitchell MS[Editorial]

Thursday, September 21, 2006

Pharmaceutical Industry Had It Coming

It's too bad, but the pharmaceutical industry deserves this: the "Wal-Mart-ization" of generic drugs. Will hospitals also turn to Wal-mart to stock their pharmaceutical shelves? Time will tell.

Fat Cat pharmaceutical companies are about to go on a much-needed diet.

Too bad, those lunches were good.


Wednesday, September 20, 2006

Weird Accident - Cool Outcome

Interventional cardiology can be pretty cool sometimes. This young man was incredibly unlucky, then later incredibly lucky as a skilled interventional cardiologist came to his aide.


World Heart Day

In case you missed it, "World Heart Day" is coming on 24 September 2006. Sponsored by the World Heart Organization, a nongovernmental organization based in Geneva, Switzerland, that "is committed to helping the global population achieve a longer and better life through prevention and control of heart disease and stroke, with a particular focus on low- and middle-income countries. It is comprised of 189 member societies of cardiology and heart foundations from over 100 countries covering the regions of Asia-Pacific, Europe, the Americas and Africa."

Their campaign, "How Young Is Your Heart," will include health checks, walks, runs, jump rope, fitness sessions, public talks, stage shows, scientific forums, exhibitions, concerts and sports tournaments. Last year in Singapore for example, a World Heart Day heart fair attracted over 60,000 participants who took part in health screenings, aerobics classes, health quizzes, exhibits, school performances, nutritional counselling and food sampling.

In reviewing the upcoming activites planned, I was interested to see that India has many activities planned, but the other largest population center, China, with its large smoking population, was as yet unlisted, even though there have been reports suggesting that the smoking incidence there is decreasing.

Coronary artery disease and stroke are clearly global disease processes, and the organizers should be congratulated in their efforts to raise heart disease awareness.


Singapore's Quackbuster

Singapore's Quackbuster, Angry Dr, takes on the QRay bracelet scam and does a good review of the pearls and pitfalls of alternative medicine studies.


Tuesday, September 19, 2006

Music's On My Mind

Boy, after Moof's musical meme, and last Sunday's Chicago Tribune article on music in the hospital operating room, it got me asking, what music should NOT be on an iPod or played in the operating room. The Tribune article offered a few suggestions:
- "Knockin' on Heaven's Door" (Bob Dylan)

- "Fixing a Hole" (Beatles)

- "Bad Liver and a Broken Heart" (Tom Waits)

- "Don't Let Us Get Sick" (Warren Zevon)

- "What's the Ugliest Part of Your Body?" (Frank Zappa & the Mothers of Invention)

- "She Blinded Me With Science" (Thomas Dolby)

- "I've Got You Under My Skin" (Frank Sinatra)
Well, I have a few more suggestions, some of which are SO obvious:

- "Stairway to Heaven" (Led Zeppelin)

- "Tears in Heaven" (Eric Clapton)

As a service to our fellow surgeons, perhaps we should assemble a more complete list... Any other suggestions?


Grand Rounds

Medical blogger Grand Rounds is up in the Alaskan Tundra at Tunda Medicine Dreams.

Some great posts, but the pics (especially the REALLY big salmon) are awesome.

Hey, is the grill on?


"... Just A Very Thin Bag of Water"

This makes what we do over here seem pretty mundane. No matter what our beliefs are about the war in Iraq, we mustn't forget these brave men and women. These medics, many of whom have never completed high school and certainly not college, are the real heros. Just ask any doc who's been over there. That's why these guys are our chosen charity from the "amputee section" of our t-shirt web site. Think about supporting them through a donation before the end of the year.


Monday, September 18, 2006

My Tagged Obligation

Okay, I screwed up. Thanks to me, Moof had a temporary gender transposition due to the ommision of an "s" from "he" in this post, so I was tagged. I will be forever repentant. So now I must describe my favorite 7 songs of the moment. Here they are:

(1) 'Wild Card", from the album First Name Terms by the group Equation - I was so impressed by this 5-man group's first album (1999) called Hazy Daze, that I had to listen to their newer album. They're new to me and thoroughly enjoyed.

(2) "Secret o Life," James Taylor

(3) Dvorak, Piano Quintet in A, Op 81 - 3. Scherzo (Furiant): Molto Vivace; Menachem Pressler with Emerson String Quartet

(4) "When You Say Nothing At All" - Allison Krauss and Union Station

(5) "The Sinister Minister" - Bela Fleck and the Flecktones

(6) "No Such Thing" - John Mayer

(7) "If I Aint Got You" - Alicia Keys

It's a bit eclectic, but I really AM listening to these on my iTunes as I type...

By the way, check out the new John Mayer album, Continuum, released 12 Sep 2006. It's great.

Now, I'm gonna depart from the part about tagging 7 others to do the same (I hope I'm not breaking some unspoken etiquette, but I's just getting my feet wet here in the blog-o-sphere). Please, Moof, don't be offended...


Self-Taught CPR - About Time

I'm glad the American Heart Association has decided to permit more and more people to learn cardiopulmonary resuscitation (CPR) in their own homes. The statistics of improving survival with CPR are staggering. CPR can keep people mentally intact after cardiac arrest by circulating blood to the brain. No CPR or ineffective CPR does little to preserve the mental state of the individual after cardiac arrest. I can't tell you how many people I've seen resuscitated by total strangers in my career. And every one of them has an incredible story to tell: one of amazing bravery, fortitude, and just plain luck.

Like the guy who was playing platform tennis with his friends, and collapsed suddenly. CPR was started immediately. Why? Because he was playing an orthopedic surgeon. It took ambulances 10 minutes to find the court. No automatic external defibrillator (AED) was nearby. The ambulance crew arrived, placed an AED on his chest and it recognized ventricular fibrillation and fired. A normal rhythm was restored. The patient made it to the ER, then to the intensive care unit. He awoke the next morning, awake, alert, and wondering who won the match! Incredible. He was found to have a tight narrowing of a coronary blood vessel, had the vessel angioplastied, stented, and returned home 4 days later. That was one year ago - I saw him playing platform tennis again this year.

Or the jogger who collapsed while running. An ambulance was driving the opposite direction on a divided highway and saw him fall. They did a U-turn, did CPR, then shocked him back to life. Another save.

Or the guy grilling burgers on his apartment balcony. The neighbor upstairs noticed him one floor down as he collapsed against the table on the balcony. He rushed to his apartment, noted the door was locked, kicked it in, and started CPR while asking other neighbors to call 911. They did. Eight minutes later the ambulance crew arrived, defibrillated the patient, he was brought to the Emergency Room, and survived to grill another day.

And even the gentleman celebrating his 45th wedding anniversary dancing on a ballroom floor, only to collapse amongst a team of hospital nurses. They performed CPR until the ambulance arrived. He's celebrating his 48th anniversary this year.

And there are many, many more stories. All with happy endings. You see the brain can only survive for about 4 minutes without oxygen. Blood is the transporter of oxygen to the brain. Rarely can ambulances arrive within the short 4-minute period of time, so CPR is essential. Just saving the heart is not the point. You need to save the brain, too.

Now the real question is: will people spend the $30 for the manikin? I'm not sure. But for the cost of 6 frappachino's at Starbucks these days, it's worth it. It's only drawback? The DVD video should also be supplied free as a streaming video on the Internet - it's where things are going, you know.


Calling It Quits

For the physician, we are bound by the Hippocratic Oath:
I will neither give a deadly drug to anybody who asked for it, nor will I make a suggestion to this effect. Similarly I will not give to a woman an abortive remedy. In purity and holiness I will guard my life and my art.
But with the ever-increasing economic burden of health care, realization of the irreparable and irreversible nature of some illnesses, and desire for many people to look for "control" of their last days, it is no wonder this Swiss organization is gaining such popularity. And although investigated for a least one inappropriate death, their doors remain open.

While the world looks at "shock" with this Swiss organization's approach, we must not be too quick to judge. Most doctors I know understand when it's time to call it quits; we just have another name for this process.

In America, we call this "hospice."


PS: The irony? The Swiss organization is run by a lawyer, Ludwig Minelli.

Sunday, September 17, 2006

Botulism in Carrot Juice

Today the FDA also reported three cases of botulism poisoning caused by unrefrigerated carrot juice in Georgia.

One of the most disturbing cases I have had he fortune to care for was an individual with the first reported case of botulism that came from their own gut after ingesting contaminated honey from their kitchen cabinet. What was unique about the case was that the person ingested the bacteria, and instead of the bacterium being killed in their stomach acid, this individual had had previous gastric bypass surgery and the bateria were able to grow inside the blind Roux-en-Y pouch of the gastric bypass, secreting the poisonous toxin before it was diagnosed by it's classic "descending paralysis". The case was reported in the New England Journal of Medicine (Reference: "Botulism in an adult associated with food-borne intestinal infection with Clostridium botulinum," Chia J. K., Clark J. B., Ryan C. A., Pollack M. N Engl J Med 1986; 315:239-241, Jul 24, 1986.). It was sad, because the person was in the hospital for months on end, paralyzed in every muscle except he could twitch his left index finger to communicate "yes" and "no" answers. Cases like this stay with you.

So when I saw this notice, I pray the individuals haven't had to suffer the fate of my former patient. Please, heed today's warning. Botulism poisoning can be disastrous.


This Spinach Thing is the Real Deal

Today's FDA report states that now 102 people have been effected by the E.coli bacterial contamination, with 16 cases of hemolytic uremic syndrome and one death. Diarrhea is the most common problem with this outbreak.

Hemolytic uremic syndrome, for those unfamiliar, is caused from the toxin secreted by these nasty bacteria that can damage the lining of blood vessels and causes tiny microscopic clots to plug up the kidneys (I'm being pretty simple here) and the kidneys don't work well when this happens. Also, the platelet count (one of the components of blood) falls. It usually has a pretty good prognosis once the illness is treated.

All of this leads to one conclusion:

Popeye's depressed.


Saturday, September 16, 2006

Weekend Fun

Okay, I cruised over to Moof's blog and saw a puzzle he she posted. It was too tough to figure out, so I punted. But it got me thinking of my college days, and a fun trick I saw.

Now, in honor of the weekend, and in consideration of folks that might need to make some money through a little wager at the local bar or Rotary Club, I thought I'd give you another trick to keep up your sleeve. It involves another puzzle... so be patient...

Take one dime and place it on a table. Place a cup approximately 3-4 inches high behind the dime. Stare at them carefully. Now, your job is to place the dime into the cup without moving or touching EITHER the dime or cup! (A picture of the set-up is shown below):

Think hard. Science is at play here. CONCENTRATE! Show it to your friends. Walk away and come back before seeing the answer. It'll seem that much cooler if you do.

Really, take a minute to think about it...

And if you must, I have included an unedited live video of me performing the solution for you. (For the record, I did this on the first try.)


Friday, September 15, 2006

Excessive ER Wait Can Be Homicide

Although we don't know the circumstances regarding the ER environment that night, we have to be aware that having patient's "take a seat" after they are registered in the Emergency Department with chest pain can have disastrous outcomes and lead to a homicide conviction, particularly when that care is well outside the standard of care.


No Segue for Segway

According to the Wall Street Journal this morning:
Segway Inc. is recalling all 23,500 of the self-balancing scooters it has shipped because of a software glitch that can make its wheels unexpectedly reverse direction, throwing off the rider -- and in at least one incident, break some teeth.
Hardly a smooth segue...


Thursday, September 14, 2006

Guidant Elects to Settle

In the first series of litiation of Guidant Corporation (a division of Boston Scientific) has elected to settle their suits. I'm not surprised, Boston Scientific is not into bad press right now and is working hard to clean up their image.

So one down, 476 to go...


B.O. and Your Daughter

Now for something bordering on the ridiculous:

Each night I walk my Cocker Spaniel for her "evening consitutional" prior to retiring. I have always been fascinated how she hones in to the scent on a particular bush where obviously other male dogs have marked their territory. Clearly there are some incredible odors there that I am grateful I cannot enjoy as she does.

It is with this frame of reference that I was amazed at this latest "research" coming from Penn State (Actual reference: Am J Hum Biol. 2006 Jul-Aug;18(4):481-91):

It seems these researchers feel my B.O. is going to keep my daughter from maturing.

Two (fatherless?) researchers from the Penn State took some surveys:
Researchers, including Elizabeth Susman, the Jean Phillips Shibley professor of biobehavioral health at Penn State, collected menarcheal data from 1,938 college students to explore the link between girls' social environment and their sexual maturity. The data included information on factors such as the girls' family size, social environment, and how long the father had been absent.
It seems they found girls without Dad at home had their menses 3 months earlier than those whose Dads were at home. Fair enough. But how did they collect the data of the Dad’s pheromones to make their smelly conclusion? Did they do anaerobic bacterial samples? Their leap to pheromones is incredible:
"Biological fathers send out inhibitory chemical signals to their daughters," said Robert Matchock, assistant professor of psychology at Penn State's Altoona Campus (and lead author). "In the absence of these signals, girls tend to sexually mature earlier."

Matchock speculates that urban environments provide greater opportunities to get away from parents' inhibitory pheromones, and encounter attracting pheromones from unrelated members of the opposite sex.
Maybe geographical, ethical, or social issues play a significant role, folks. Look, I’m sure I don’t smell like a rose after working out (yeah, those shoes can get pretty ripe), but to conclude that I am delaying my daughter’s development because of my B.O., stinks to high heaven.

Unless my daughter has the same sense of smell as my spaniel...

I just wonder whose dollar is funding this garbage…


Wednesday, September 13, 2006

On Salt

Today's New York Times discusses the "War on Salt" and references a "study" that estimates 150,000 lives would be saved by 2010 if we could get people to stop eating so much salt:
In 2004, researchers at the National Heart, Lung and Blood Institute published a study in The American Journal of Public Health concluding that 150,000 lives could be saved annually if sodium levels in packaged and restaurant foods were cut in half.
For the record, there is no such study. The "study" was actually an editorial by Dr. Stephen Havas, the lead author and his comments are conjecture. The exact words from his editorial:
Recognizing the importance of action on this issue, the American Public Health Association adopted a policy resolution at its November 2002 annual meeting calling for a 50% reduction in sodium in processed and restaurant foods over the next 10 years. New JNC VII guidelines have endorsed this resolution. We estimate that, when fully implemented, this reduction will result in at least a 5 mm Hg decrease in systolic blood pressure levels, a 20% reduction in the prevalence of hypertension, and 150 000 fewer deaths.
While I agree that lowering sodium content in food is important to control blood pressure, I take issue with government intervention on calling salt "dangerous." In all my years as a physician, I have never seen "Cause of Death: Salt" listed on a death certificate. If we go there, then "sugar" is equally "dangerous" due to the lives lost from obesity. We need more patient education here, not more government intervention.


Why I Blog

I suppose anyone who has embarked on this strange undertaking called a “Web Log” or “blog” has asked themselves this question: why blog? I have been at this for almost a year now, and I now find myself asking the question: what am I trying to do here?

I have to thank Dr. Helen, first of all, for exposing me to the blog-o-sphere. I was introduced to her after my website was barraged by hits from her blog after she posted a picture of herself with one of our t-shirts. Somehow the slogan, "Death, Been There, Done That" got people's attention. So I e-mailed her and she was gracious enough to share her story about her undiagnosed heart disease with me and gave me permission to post the story on our site as an noteworthy example of an underappreciated problem in women: heart disease. I am forever grateful to her for this. But unbeknownst to me at the time, Helen is the wife if the infamous Glenn Reynolds of Instapundit fame, one of the earlier blogs on the internet with exceptionally high traffic. I was fascinated by Glenn's "Army of Davids" concept, and was hooked. But how to start?

Each of us tries to find a voice. Some make short, brief entries. Others make long, detailed discussions with extensive cross-references. Some blog entries extend over several days. Some post daily, some only sporatically. Others post photos, some only text. Networking and a social exchange is important to some, so comments are permitted, while others discourage commentary. The topics are as varied as the individuals and personalities on this planet. So why did I join the fray?

To me, the internet is an incredible forum to discuss the varied, complicated, and even (especially?) the ridiculous aspects of health care. Information moves so quickly now that keeping abreast of changes has become difficult. The number of medical journals have expanded so dramatically in my short career that it is challenging to keep up with the voluminous information flow. Thanks to the wonders of “RSS (Really Simple Syndication),” I have found that blogging has permitted me to stay abreast of thoughts and trends in medicine far better that I ever could with reading a small sampling of my field’s literature. (I mean, there are so many journals and so little time!) As I delve ever-deeper in the electronic cosmos, I have stumbled upon some remarkable insights and perspectives from my fellow blogging colleagues, many of whom are much more eloquent at prose than me. Dr. Charles comes to mind as does Dr. Grumet. And Kevin, where DO you get all those feeds? But I could go an and on, not just about doctors, but nurses, administrators, and patients, too. Each of us adds our own unique insights to the collective Medical Zeitgeist. I think we doctors, nurses, patients, politicians, and Big Business interests are better for it.

I am a nerd at heart. I love things electronic and technical. As a biomedical engineer in college, I suppose I have grown to miss my engineering “inner self.” But my fields of cardiology and cardiac electrophysiology have allowed me to experience a unique intersection between engineering and medicine that continues to grow. I feel I can lend some unique commentary to this aspect of medicine. But I also acknowledge I have missed other aspects of my inner self in my relentless pursuit for a medical degree: writing, music, art, and a million other things. So with this blog I hope to expand on a few of these interests as well.

Within the medical device industry, innovation has also occurred at an incredibly rapid rate. Communicating this doctor’s opinion to the large corporations had heretofore been impossible. But now, post a criticism or complement on your blog, and (thanks to Google Alert) the company reads your comments with their morning coffee or while perusing the Google finance page. The little guy matters on the web.

And this blog speaks to the little guy, too. I find more and more patients, caregivers, and others turn to the internet for medical information. This information is often discretely carried to their appointments with me. This is a good thing, I believe. While the internet might not always be the best or most reliable source of health care information, it empowers the patient to take responsiblity regarding their concerns, or at least identify questions to ask their doctor. I find that patients who have consulted “Dr. Google” before I see them usually ask really smart questions. One thing is certain: everyone feels better if they’ve done their pre-health-care-visit homework, and blogs are a unique venue for exposure to a variety of expertise and experiences. On occasion, patients do get it wrong, however. So I always ask that individuals who find information here to discuss it with their own doctor before acting on any advice or commentary I dispense. Your situation might be special.

Finally, this blog forms a written diary about me, my life, my concerns and thoughts for my family, friends, patients, health care and device industry, and colleagues. The views are solely my own and do not reflect the opinions of my employer (I love my job, really). While it might reference an experience with a patient or colleague, rest assured the names, circumstances, and identities will forever be held confidential. My intent is not to denigrate, but inform. Constructive commentary and criticisms add unique perspectives, so I have chosen to include them. It is through these collaborative discussions we learn and grow. My patients give me an incredible gift of confidence when they open their hearts and minds to me, and for that I am forever grateful and respectful. Hopefully, this blog will serve as a place to give back to them a portion of what they have given me.


Tuesday, September 12, 2006

Tuesday's Grand Rounds

Medical Grand Rounds is up at Diabetes Mine with an "educational" theme.


Northwestern Still Near Top in Business

Congrats to the Kellogg Business School for making it near the top of the Business School rankings again. After taking a few courses there, I can vouch for the quality of their "business in health care" portfolio.


Monday, September 11, 2006

Q-Ray Quieted

Con men are made every day, but getting 'em back is rarely accomplished. That's why today's ruling against Q-ray, Inc of Mount Prospect, IL was so sweet. All those people with debilitating arthritis that coughed up $69.95-$249.95 for one of these "bio-metal, ionic" hoaxes might get their money back.

Heh, heh, now for the laser guys...


Patient Beware: Insurers' New Ploy

If you decide to use an out-of-network physician for services, it seems some insurers are now considering your ENTIRE bill (including hospital expenses) out-of-network (even though the physician services were performed at the same previously in-network hospital), and sticking patients with the higher deductible and payment percentage. This practice was disclosed today in the New York Times and identifies Oxford Health Plans, a division of one of the largest health insurance providers, UnitedHealth. Reportedly, other insurers have similar new arrangements.

Hospital and physician groups should lobby against this practice, since non-network, (and often specialist) physicians will be adversely effected, and these specialists will bring fewer cases to the effected hospital.


Where Were You?

Where were you when the world stopped turning on that September day?
Were you in the yard with your wife and children?
Or working on some stage in LA?
Did you stand there in shock at the sight of
That black smoke rising against that blue sky?
Did you shout out in anger
In fear for your neighbor?
Or did you just sit down and cry?

Did you weep for the children
Who lost their dear loved ones
And pray for the ones who don't know?
Did you rejoice for the people who walked from the rubble
And sob for the ones left below?

Did you burst out with pride
For the red white and blue
And the heroes who died just doing what they do?
Did you look up to heaven for some kind of answer
And look at yourself and what really matters

I'm just a singer of simple songs
I'm not a real political man
I watch CNN but I'm not sure I can tell you
The difference in Iraq and Iran
But I know Jesus and I talk to God
And I remember this from when I was young
Faith, Hope and Love are some good things He gave us
And the greatest is Love

--Alan Jackson

I'll never forget. I had just completed a pacemaker battery change, just 6 months after starting my current job... "a plane hit a building in New York," the lab techs told me. At first disbelief, then shock as a second plane hit, then gripping empathy for those in the buildings, then sadness as it all came to an end and eternity started too soon for so many.

View outside St. Paul Chapel's front door looking toward where the twin towers once stood.

A few of the photos of those who died that day

But what was most remarkable after this devastating loss was the incredible outpouring of generosity, kindness and love between total strangers of all races, color and creed. A call to action by those who cared. And not just here, but a world-wide outpouring of solidarity, resolve, and acts of kindness that went above and beyond the expected. The Red Chasuble of Father Mesa, a Roman Catholic priest who volunteered in St. Paul's Chapel across from the site of the World Trade Center and upon which rests patches of the volunteers who responded to the call to help:

And there was a sudden, pressing need to tell those we loved how much we loved them, to remind ourselves how fortunate we are in this wonderful country.

The last standing beams from the World Trade Center

God bless those who died.

And God bless America.

Take a minute and remember.


Saturday, September 09, 2006

Notre Dame vs. Michigan

I had the luck of knowing a guy (he's a Domer) who has four precious tickets to the Notre Dame/Michigan game next week, and was kind enough to offer one "golden ticket" to yours truly. I mentioned this to a colleague of mine, and asked him what I should wear, since I was not affiliated with either of the teams involved, but wanted to "show my support." My colleague suggested at first that I dress like a leprechaun. "Nope, I just can't do it," I said, "and that might be taken as an insult."

So he thought a bit longer and suggested I wear a "Beer Belly" and strap on a "Stadium Buddy."

Although I don't have the nerve, I bet I see tons of these at the game. The funniest part of this are the excuses people give to get these past security:
  • This is a medical device that I think we’d both prefer not discussing or viewing in public.

  • My wife is pregnant and, as part of our maternity class, I have to develop empathy by wearing this thing around in order to look fat and give myself backaches.

  • Department of Homeland Security. We’re testing a new stealth form of body armor to protect our undercover agents overseas in the Global War on Terror. Don’t make me shut this place down.

  • It’s full of urine, so step back or you’re gonna be sorry.

  • It’s part of my religion to wear this…non-Muslim, of course.

  • Want a beer?


Making Deals

As further evidence of the importance of government helping Big Business, and, in turn, effecting health care policy here in the U.S. (Pioneer Press):
On a road trip to promote President Bush's $5.9 billion initiative to bolster America's business competitiveness with the rest of the world, U.S. Commerce Secretary Carlos Gutierrez, above left, stopped Thursday morning to speak with Medtronic Chief Executive Art Collins, right, and several hundred Medtronic employees at the medical-device company's headquarters in Fridley (MN). Gutierrez cited Medtronic as an example of a competitive U.S. company that is "in the right business at the right time" and has its "best years ahead" of it. The Bush administration's competitiveness initiative would double funding for basic research over the next decade, update and expand research-and-development tax incentives, and make improvements to education, training and recruiting efforts.
But what is Medtronic giving Mr. Bush and how will that effect defibrillator and pacemaker costs?


Health Care's Impact on a New Car

“Chrysler expects to spend $2.3 billion in health care annually in the U.S. this year, or the equivalent of $1,400 per car built. Mr. (David) Cole estimated Chrysler’s health care costs could fall to around $800 per car if it gets terms similar to those GM achieved (in their negotiations with the United Auto Workers).”

- Wall Street Journal 9 Sep 2006

Yet another example of the little guy getting squeezed by health care as corporations seek ways to cut costs to remain profitable.


Friday, September 08, 2006

A Plan Hatched

Mr. S. was a cantankerous old man, bitten by the frustrations of growing old, sitting in his 2-flat, angry over every detail of his health care. After all, what else did he have to think about? When he did his best to comply and obtain a bi-weekly blood test, he wanted the results now! “What the hell’s wrong with this medical establishment?” he’d ask. “Don’t you guys communicate?”

He had always been a “do-er,” rising early to tackle the day’s challenges, highly disciplined, and organized. A star football player in his younger days, the reveled in his pre-game psychological exercises performed before every outing, he planned every play before the game began. His workouts were famous – always going farther, harder than his teammates.

But now his health problems included the usual suspects: diabetes, coronary artery disease, hypertension, and worst of all, arthritis. His health was clearly on the decline, as was his attitude for living. Life was getting too hard. Even walking to the bathroom was difficult. He isolated himself others, except his responsible wife, who had served as co-dependent to his declining attitude for too many years to argue now. She, too, was depressed, angry, frustrated, yet at the same time felt too sorry for her husband’s plight to put up resistance now.

His mother had also had diabetes. She had required gradual amputations of her feet, then lower limbs, from the scourge of that disease. He had seen her die after becoming bedridden. “If I stop walking, I’ll die,” he’d say. So each day, painful step after painful step, with the determination of General Patton off to war, he ambulate from his bed to bath, bed to lounge chair, bed to his home office. His shortness of breath be damned, it was good for him, he’d say.

So the issue of providing a scooter was out of the question. Even though this might get him out and about, able to interact with others, see a bit more of the world than the few corners of the world he had grown to know. “No, if I stop walking, I’ll die.”

What does a doctor do, in this circumstance? Certainly, maintain the status quo might be one option.

But there was another approach, a plan hatched and tacitly suggested. Get his wife a scooter. Have her use it and have him puff along side. Leave it parked next to his bed. Take it for small errands to get the mail. She could get out and breathe fresh air. So it went.

And slowly, bit by bit, he saw the advantage to her and the distinct disadvantage to him. Then he “borrowed” it. Soon he’d ride it about, say “hi” to others, smile again, engage his mind on other pursuits, read a book and discuss it with friends. Live again. The clouds parted, ever so briefly, but perceptibly. And at the end of the day, he’d hobble a short distance on a new voyage, from his scooter to his bed, thrilled at the prospect of riding again.


Medicare Boss: Cut and Run?

I now have figured out why McClelland is leaving his post at Medicare: seems the cuts might happen after all, so it's time to run. Why take the fall?


Is 100 the New Old?

I think I side with the Europeans on this one.
"U.S. guys are more in the life extension, they're talking about life extension, living 150 years. For the Europeans, it's more live a good life, vital and healthy."
Given the number of sponsors of the American Academy of Anti-aging Medicine and their meeting locations, there sure seems to be alot of interest in being 150 years old. But closer inspection demonstrates who might be attending these meetings.


Thursday, September 07, 2006

Teen Smoking and the Movies

I recently traveled to Springfield, IL for my wife's 30th high school reunion. It was a festive affair and very small - her tiny parochial high school had only 72 classmates. While she seemed to enjoy it immensely, it was remarkably dull for the spouses who where brave enough to attend. We huddled together to make idle chat and few of us had much in common, but, thankfully, that made it a tad bit interesting. Suffice it to say that it was a small-town, potluck affair, so I grabbed by plate, loaded it with a sampling of the best that Southern Illinois could offer, an took a seat outside on the beautiful summer day with other like-minded shunned spouses.

Upon retreating outside, I spied another wedding party who was sharing the facility the same day. There they were, music blaring, the bride and groom nowhere to be seen, all the groomsmen in their tuxes with untied bow ties donning the hippest shades over their eyes, bridesmaids in gorgeous paint-on dresses with spaghetti straps (was I ever that young?). One notorious fellow was clearly three-sheets-to-the-wind, and another gent proceeding to light up the other kids' cigarettes. I did a double take as they took long drags on their cancer sticks, oblivious to the long-term effects of their actions, all with a devil-may-care attitude. Ah, youth!

Cigarettes are back, unfortunately. Here was proof in living color. And in my unscientific humble opinion, it seems to be back in spades. There are a myriad of causes and it has occurred despite all of the legislation against the cigarette industry. So why is it happening?

While there may be many causes, peer-influence remains strong, as do the influences of the movie industry, it seems.
"The attorneys general blame films that show smoking for influencing hundreds of thousands of U.S. adolescents to begin lighting up every year.

They cited a 2005 study released by Dartmouth Medical School that found 38 of every 100 youths who tried smoking did so because of their exposure to smoking in movies.

The attorneys general said 73 percent of all youth-rated movies show tobacco use."
Recently, there is a move to include anti-smoking videos before DVD movies. Not surprisingly, the Motion Picture Association of America (MPAA) is "considering" the move, but has yet to act.

The three short movies are "Body Bags", "Shards o Glass", and "1200." (Sorry, I couldn't find the link to this one). These are worth a look, if you haven't seen them. They're not new, but effective. Heck, show 'em to your kids.

The inclusion of these short features seems like a reasonable intervention to me. Kids aren't stupid, but sometimes peer-pressure drives them to make some pretty foolish choices. Certainly the cigarette industry seems to be really interested in increasing the addictive power of cigarettes. Additionally, the cigarette industry continues to use the movies as an effective location to perform global "product placement."

I say let kids make their own choice - they'll do the right thing if they get a balanced perspective. It'll be interesting to see if the MPAA succumbs to this increased pressure to save our youth.

For our kids' sake, I hope so.


Addendum: Other votes for the anti-smoking ads that work include this one from New York, or this one from the Netherlands, or this one from the UK.

Wednesday, September 06, 2006

The Furor Grows: Stent with or Without Drug?

MedPageToday does a good job of balanced reporting on this issue. My feeling is that there are clear times when drug elluting stents are of value: when patients can take aspirin and clopidogrel (Plavix). If the patient is looking at surgery soon (knee replacement/hip replacement, etc.), then bare metal stents might be best.

We'll have to wait for more trials....

But it DOES appear clear that it is prudent to continue anti-platelet therapy after stenting for AT LEAST a year. I think our guys are continuing it indefinitely, if its tolerated.


Dog of Boy With Cancer Returned

I'm glad "Chemo" was returned to this boy with cancer. But I wish I could find a picture of the dog: a Chihuahua-Doberman pinscher mix!


Tuesday, September 05, 2006

$250,000 for a Couple of Weeks

Boy, no sooner did I finish my last blog posting and this appeared on the wire (Reuters):
Seriously ill heart failure patients expected to live only a month and ineligible for transplant can get an implant of a permanent artificial heart, U.S. health officials ruled on Tuesday.

The grapefruit-sized, titanium-and-plastic device -- Abiomed Inc.'s AbioCor artificial heart -- may give patients only a few extra months and costs about $250,000.
*Sigh* It seems death is not allowed in health care any longer, but bankruptcy is (don't expect Medicare to pay for this one).

Will there be any money left over for the rest of us in 10-20 years?


9/6/06: Addendum - Dr. A offers other insights.

Pay for Performance Won't Perform

With ever-increasing health care expenditures by businesses and employees in America, there has been an urgent need to reign in the costs of providing health care in America. It finally has dawned on many people that Medicare will be insolvent by 2018, a mere 12 years from now. In a desperate attempt by the American Medical Association (AMA) and the Center for Medicare and Medicaid Services (CMS) to get control, an initiative to pay physicians a bonus if they improve “quality” was born called “pay for performance.” The lead editorial in the Chicago Tribune this morning entitled "Paying to get it right" expoused the virtues of this initiative. On the surface, it sounds logical, an imperative for health care today. After all, who doesn’t want quality health care and doctors who “perform?”

Historically, part of the problem has been that doctors (and hospitals, I might add) have figured out that in the current Medicare payment system, quantity translates to increased revenues, not necessarily quality. See more people and do more procedures and you get paid more. (Many doctors' personal lives have failed pursing this model, I might add). Unfortunately, on the way to prosperity, corners have been cut, follow-up has been less than perfect, and errors have occurred. Ancillary staff feel the pressure, too. Turnover of nurses is at an all-time high and competition between health centers so keen that incredible incentives are offered to keep existing staff. And when they lose these staff, hospital administrators, desperate to maintain adequate inpatient staffing, cut corners and hire aides or technicians as “nursing extenders.” Care suffers.

In this respect, I completely agree with the need to improve the quality of care delivered. No physician today can argue that things aren’t like they used to be. But is pay for performance the way to improve the system? Or is pay for performance merely another bureaucratic hoop through which doctors and administrators must jump to be paid that further detracts from the real issues? Will this initiative rob more of our precious face-time with patients in the name of “quality?”

Fortunately, doctors are uniquely gifted at filling out check-boxes or fill-in-the-blank forms. We learned this in high school, college, and medical school our first two years. From the SAT’s, ACT’s, MCAT exams, and even our board certification exams, we’ve learned to fill in the little circles with our No. 2 pencils. So what the heck is another check box on the way to getting paid? Bring on pay for performance! No doubt it will cure all that is ailing in health care! According to the Tribune, the AMA is developing “more than 100 standard measures of quality to judge performance. Some of these measures will be reported to the federal government” with private employers and large insurance companies enthusiastically “joining the push.” We’ll just have to fill in a few more check boxes during our visit to get paid. I have no worries. The electronic medical record will make sure we complete our forms. And I’ll be thrilled that we're REALLY improving quality of health care! (Sense any sarcasm here?)

Unfortunately, as I stare at the screen and swear at the keyboard to complete these electronic computer forms, I’ll not be looking at the patient. But what do most patients care about when they see their doctor? Most will tell you it is a doctor who is willing to spend the time with them to listen to their complaints and concerns, review their history and examine them carefully, and act accordingly. Not sit at a computer screen and complete check boxes as "performance markers."

And will these “quality markers” do anything about the ridiculous sums of money that are bilked from the health care system by corporate leaders of the large insurance industry? I mean, really, is Mr. McGuire of UnitedHealth worth $2.7 billion in options? This sum is five orders of magnitude larger than any physician salary with whom I work. And this wasn’t even his salary. From the Providence Journal:
William McGuire, of UnitedHealth Group, the nation's leading insurer, was the third-highest-paid CEO on the Forbes list. His pay of $124.8 million could cover the average health-insurance premiums of nearly 34,000 people.
But McGuire is not the only one. Take a look at the insurance industry's CEO salaries. Now what is wrong with this picture? You, dear reader, are paying their salaries with your insurance premiums. So with this compensation, why would the insurance industry promote this "pay for performance" initiative? Well it’s all about the money. If doctors forget to check one of those little performance check boxes, then they won’t get paid. And this saves lots of money for the fat cats in the insurance industry, their profits soar, and their CEO’s get richer. And the insurance industry is not the only one – consider this about the pharmaceutical giant, Merck:
CEOs can win big even when the company loses. Merck, for example, had to pull its Vioxx pain medication off the market, because it increases stroke and heart-attack risk, and Merck stock was down 28 percent last year -- but CEO Ray Gilmartin got a supposedly performance-based bonus. His total 2004 compensation was $37.8 million, and he received a new grant of 250,000 stock options.
Now I am not suggesting that all corporate endeavors be stifled by limiting executive compensation, especially when drug companies bring such incredible drugs to market. But compensation within reason relative to the cost it exacts on our health care system should be considered.

But let's not exclude another cause of the rising cost of health care: lack of liability reform. This certainly has required insurers to raise their premiums to cover extraordinary losses from malpractice claims. How can any cogent discussion about health care costs not include this important consideration? Yet the Tribune left this issue off the table in their editorials.

Finally, could we be part of the problem, too? As the Tribune article states:
Americans expect – demand – medical miracles, high-tech tests, wonder drugs that cure. Many times they get them.
Let us not forget that these treatments are incredible and have added many years of quality living to our patients. But will we continue to demand these high tech options and unlimited amounts of wonder drugs, even for our 90 + year old father and mother? Will anyone in positions of leadership or government ever consider limiting the age at which we provide these expensive forms of care? Probably not, since politically (and some will argue, ethically) this would be suicide.

But one thing is clear. Any system that must, by law, provide health care to everyone over 65 in America with a fixed budget and is subject to an ever-growing and aging population and to continued inflationary costs, well this system cannot and will not support itself indefinitely.

Serious changes are in the wind. I just hope that doctors don't bear the brunt of the changes as they have in the past. Certainly we do not act alone. All of the pieces of this Big Medical Conundrum have participated in the improvements and innovation in health care that we've experienced over the recent years. But fixing this problem should not be limited to imposing "pay for performance" on the physicians and health care institutions. Instead, all of us, the patients, hospitals, doctors, insurers, and lawyers will have to contribute to the solution to the health care crisis. Anything short of this is just poor performance.


Medical Blogging Grand Rounds - Volume 2 Number 50

Grand Rounds is up over at Clinical Cases:
This week's Grand Rounds is loosely structured in a "medical journal format" using the table of contents of one of my favorites -- the British Medical Journal.
It is cleverly conceived and contains interesting data on this week's medical bloggers.


Could Symptom Recognition Help Avoid Sudden Death?

In today's online version of Circulation, researchers from Berlin, Germany reviewed the circumstances surrounding a large number of cardiac arrests and found some important data:
Typical angina (chest discomfort or heaviness) was present for a median of 120 minutes in 25% of the 274 patients with witnessed arrest and in 33% with a symptom duration of less than 1 hour.
There's no better way to precipitate a malignant heart rhythm disturbance that to deprive the heart oxygen, and angina is the classic symptom of this oxygen shortage. Symptoms can include chest "heaviness," or "pressure", a choking sensation, jaw discomfort, arm or back discomfort, including a sensation of a band-like grip around the chest - especially with exertion. Shortness of breath with exertion and even burping with exertion can be seen.

So why didn't these people summon help? Perhaps ignorance played a role.

More likely, though, it was denial.


PS: If this happens to you or a loved one, please call for help.... immediately.

Monday, September 04, 2006

Who's Performing Your Walletectomy?

Today’s Chicago Tribune editorial, titled " A Cure for the Walletectomy", is part of a series of pieces about health care reform and "transparency". A title reflecting the current health-care spending panic, shared by those who have been stunned after receiving their recent hospital or outpatient health care bill. Certainly, carefully considering the proposals discussed in the editorial and how they affect each and every one of us is a good thing.
Americans clip coupons, bargain hard for cars and other big ticket items, search the Web for the best airline fares. Most, however, have never even considered shopping around for medical care. They get a referral from their doctor and they follow it. They don't really wonder if they could get a better deal because, in most cases, the insurance company is paying.

That's changing now. It must. The Bush administration and the insurance industry are pushing low-cost, high-deductible insurance tied to accounts that let consumers save tax-free for their health bills. The concept is simple: If more of their own money is at stake, patients will shop for health care, the same way they shop for cars. They'll find value. The better they shop, the more efficient the market will become, eventually driving prices down.

The problem is, in order for that concept to have even the slightest chance of working, people need to know what they're getting for their money
But how many people understand what is required for making proper medical recommendations? How, exactly, will patients "find value?" Is the cheapest health care always the best? Is the doctor who tackles complicated cases or has the most experience or training the "worst," because he’s most expensive? Will the average non-medical patient understand or comprehend what tests or procedures are needed to confirm or reject a diagnosis in the first place? Most people I know don’t have a clue about what I do. "The heart has electricity?" they say.

The thesis of today’s editorial is simple – in laymen’s terms it’s about health care cost transparency. I’ve discussed this is in my previous post. What interests me now: who’s working to stuff this transparency thing down everyone’s throat? It is not difficult to foresee: anyone who stands to benefit from its implementation. In other words: Big Business.

You see, doctors are really excluded from any meaningful discussion about health care policy. We are the worker bees. Oh sure, there are physicians spouting the benefits of transparency in controlling healthcare dollars. But if one takes a closer look, most promotions of this policy are non-physician CEO’s of these new commoditization corporations. Others stand to profit handsomely from book royalties or speaking fees as they flit from one policy conference to another. Think tanks hover over their every word. After all, health care is big business, consuming 15% of our entire gross national product. Thousands of corporations (with many more dollars than physicians) stand to win, or lose, on the basis of such public policy and turn to these activists to create a "solution." From the Wall Street Journal:
Aetna, UnitedHealth Group Inc. and other insurers already offer in some markets quality and cost-effectiveness information on some physicians, plus rough cost estimates of certain services. And health-information companies such as WebMD, HealthGrades and Subimo supply information such as physician information and hospital data on complication rates, estimated costs and available technologies.
Do we really think Marcus Welby, MD is making such policy? And where is the American Medical Association in this debate? Unfortunately, their ranks have been so diminished by their displays of self-interest and corporate co-mingling that many physicians have fled their ranks. Front line patient-care doctors look toward their physician leadership with a jaded eye.
Doctors are not scared about having better-informed patients as the editorial suggests, rather we’re scared of whose making the policy.

It’s a shame. Where are the policy makers who advocate for the patient? With all the pomp and circumstance of this Great Reform in health care, who will guide the patient through the bureaucratic nightmare that is sure to follow? Who will help the patient decide which health care treatment or test is most "cost-effective," has "value" or which center has the most doctors with the best "performance" record. It will be the same person they’ve turned to in the first place.

It will be the front line patient-care doctor.

Or worse: a representative from Big Business – like a Walgreens pharmacist. The bureaucratic "money saving" transparency ruse will be complete.

And the patient-care doctor will be paid even less for those advisory services in the interest of "cutting costs."

You can bet on it.


Medicare Crisis - What to Do?

I have to congratulate the Chicago Tribune for posting this editorial on Saturday. I'm not sure where I was, but I missed it initially. The editorial does a reasonable job at exposing the real impending crisis facing our largest health care 'provider' for millions of seniors. But the commentary regarding suggestions for correcting the crisis, unfortunately, falls flat.
There are ideas for repairing this system. First of all, reimburse doctors based on the effectiveness of their service, not just the volume of service. At present, the system pays a set fee whenever a particular service is performed. This creates an incentive for doctors to order more procedures per patient without much accountability as to whether the procedure is necessary or effective. Rewards for procedures that work best, not those that cost the most, would help to remedy what ails the current system.
Perhaps it was space limitations. Perhaps it was a myopic perspective that health care can be commoditized. I'm not sure. But certainly the incentive for more procedures is not just driven by ever-lower reimbursement for physicians. The threat of litigation to the physician who does not call a consultant or order every conceivable test as a "rule out" cannot be overemphasized.

I have often thought about the issue of "transparency" in health care. I have even remarked about it in prior postings. But how on earth do we expect to classify the infinite permutations of disease manifestations that confront physicians each day and gauge "effectiveness?" It is this variability that keeps our job of caring for patients interesting and challenging. It is also this variability that defines us a experts in our chosen field. And I dare say that I have never seen two patients who present the same way - even when the they are eventually discovered to have the same disease process as a prior patient. Recall that each disease never exists in an isolated state. It presents amongst the medical milieau that came before it - with all the individuality of a person's prior disease processes and confounding psychologies already in play.

Just watch the TV series House sometime to appreciate this variability and difficulty. Are the doctors trying to discover the root cause of an illness "effective" when they order 30 tests to make a diagnosis? If they end up being correct, some would say they were effective, but if they are wrong and miss the boat, are they "ineffective" or performing a logical exclusionary test? Who will decide?

The Tribune also commented on the increased use of MRI's:
Charges for physician-related services and hospital outpatient services have continued to skyrocket. Use of magnetic resonance imaging (MRI), for example, and other high-cost high-tech imaging techniques has more than doubled in the last five years, Medicare officials say.
With MRI, the imaging is unparalleled - the opportunity to exclude malicious processes better than other imaging modalities - but it costs more. Is ordering this test rather than a cross-table lateral xray of the cervical spine more "effective" after head trauma? Perhaps. But is it "effective" at saving money? This is less clear. If a subtle diagnosis were missed because only a conventional xray was obtained, what will be the long-term costs to the patient and the physician in terms of disability and potential litigation? Unfortunately, Americans do not accept fallibility in medicine. We are expected to always get it right, no matter what. Is this not the tacit message of the series House?

These issues get even more complicated when one considers the elderly. Recently a well-publicized example might help illustrate the point. In August, 2005, Pulitzer Prize-winning oral historian Studs Terkel underwent open heart surgery at the age of 93 here in Chicago. Gratefully, he survived the surgery. As did his wit and brilliance. But were the doctors "effectively" spending health care dollars? Chicago's writers, historians, and literaries would argue they were. Life insurance actuarial curves might suggest otherwise.

So here we are. Left wondering. Many bright minds and think tanks are wrestling with these issues, many with political aspirations at heart in the short term. And these issues are by no means simple. But they must be wrestled. And soon. But transparency might not be the best way out, because if people could see the real costs... all of 'em... and then be left to pay the bill directly, without any third party insurance "provider" at all... just the patient and the doctor and no middle men fighting it out "mano-a-mano"... they would be left to realize they couldn't afford it. Healthcare and all of its wonderful technology is just too damn expensive for the average man, woman or child in America.

And guess what... that's why this is such a mess.

But in prior years this was not uncommon. The doctor often took care of patients that could not afford his services. But doctors and their patients would reach an agreement ahead of time - perhaps barter a skill instead for the care rendered. Non-monetary renumeration. And things worked out.


Perhaps the part about getting rid of the middle men, maybe this is where we should look...


Saturday, September 02, 2006

Lack of Cost Transparency Costs Hospital

In a sign of what's to come, the University of Washington lost a lawsuit over lack of cost transparency:
John Phillips, the lawyer who filed suit on behalf of a patient who felt gouged by the UW's billing system, believes that the settlement is the first of its kind, but he hopes it will help set a precedent for better consumer information in medical care.
I suppose when "facility fees" are 20 times the physician fee, what do you expect?
Heidi Rothmeyer, the patient who initiated the lawsuit, had a skin lesion removed at a UW clinic in June 2005. The doctor's portion of her bill amounted to about $400, but she was also charged $8,000 for a "facility fee," Phillips said.
Having said this, it is not easy to derive "real costs" to any hospital system. There are utility, rent/mortgage, support-employee salaries (cleaning crew, facilities manager, security, food-service personnel, administrators, billers, receptionists and the like) that are paid from these "facility fees." Certainly those costs should be covered. But what is not clear are the pre-arranged reimbursement rates negotiated between hospitals and insurers. The consumer patient is powerless to know what their insurer is willing to pay out of that $8000 facility fee. That number is held close to the hospital administrator's chest, since to disclose this amount might set the bar during negotiations with other insurers eager to reduce their costs to the hospital system. A cogent discussion of this was recently reported in the Chicago Tribune:
The obstacles to making medical prices available are significant. The health-care industry has a strong tradition of secrecy and is enormously fragmented, with data scattered among hundreds of thousands of doctors, thousands of hospitals and scores of insurance companies.

Although providers support transparency in principle, they worry that pricing data could be misinterpreted. The cost of care can depend on many factors, from how sick a patient is to the quality of care delivered to whether a medical center supports teaching and research.
But as reported by the Seattle Post-Intellegencer, other lawsuits are coming:
At least one other hospital in this area is already facing a similar billing lawsuit.

Phillips has filed a class-action lawsuit against Virginia Mason Medical Center over its billing practices, noting that the cost of having the same procedure done varies at the medical center's various clinics. That suit is scheduled to be heard before King County Superior Court Judge Gregory Canova later this month.
So when prices are "disclosed" (as they most assuredly will be now), I suspect the costs listed will be like those of used car lot or sidewalk flee market: markedly inflated and still negotiable. The problem is, when the facility fee is 20 times the physician's fee, there's wiggle room for the hospital to negotiate. For the physician struggling with ever declining reimbursement rates and ever increasing costs to provide care (especially in the area of malpractice insurance), the wiggle room left long ago.

And I wonder if John Phillips is willing to disclose his renumeration for all of these suits.

- Wes

Friday, September 01, 2006

R.I.P. Dronedarone

Dronedarone (marketed as 'Multaq' by Sanofi-Adventis), amiodarone's weaker cousin, was initially hailed as a potentially safer drug substitute for long-term management of atrial fibrillation. Unfortunately, the drug died a quiet death at the hands of the FDA yesterday. The writing was on the walls, since earlier studies demonstrated only marginal efficacy compared to placebo. According the to Wall Street Journal today:
In a setback for Sanofi-Aventis, the Food and Drug Administration rejected the French drug maker's application to sell Multaq, a cardiovascular drug the company had hoped would become a blockbuster.

In a brief statement, Sanofi said the agency issued a "nonapprovable letter" for the drug's use against atrial fibrillation, a type of irregular heartbeat. Such a letter means the FDA found Sanofi's application didn't adequately demonstrate its safety or efficacy. Sanofi didn't say why Multaq was rejected but added it planned to resubmit the drug for approval in 2008, once it concludes a new clinical trial. A Sanofi spokesman declined to comment further on the FDA letter. An FDA spokeswoman also declined to comment.
Too bad. But the search for an Amiodarone substitute (to avoid its significant side effects) continues...


The Great Adventure

I am awake at 2AM, but I am asleep.
I have nurtured you, at least I thought.
Cared for you, but remained deaf and dumb.
Watched your struggles, tears, yet inside, I cry.
You are bigger now, I am wise, yet a neophyte.
You are stubborn, yes, but listen.
You cannot. You must not. By why?
Words whisper.

I was once like you are now, and I know that its not easy,
To be calm when you’ve found something going on.
But take your time, think a lot,
Why, think of everything you’ve got.
For you will still be here tomorrow, but your dreams may not.

Succeed yourself, not for me. Stumble. Get up.
Care for others, not for me, yet remember me, I pray.
I will never understand, will I?
Just pick up the ball and throw it back, will you?
It’s not hard. Is it? Yes, it was. I am sorry.
Will we be friends? Can we talk? Will you close the door?
I know not.

How can I try to explain, when I do he turns away again.
Its always been the same, same old story.
From the moment I could talk I was ordered to listen.
Now there’s a way and I know that I have to go away.
I know I have to go.

The Great Adventure is at hand.
Go easy. Your way.
But do it, just do it. Do it the best you can.
Life is an adventure. Live it, love it.
My words sound so diminutive.

All the times that I cried, keeping all the things I knew inside,
Its hard, but its harder to ignore it.
If they were right, I’d agree, but its them you know not me.
Now there’s a way and I know that I have to go away.
I know I have to go.

Images: sandbox, paramedics, northern pike, treble, chickens, saxophone, Wales, sacred cows, boulders in Jamaica, UPS, drivers license.
So fast, fleeting. Where did it go?
There’s so much to say, but the clock has expired.
But the game is just beginning.

Play hard, son.

I hope you never fear those mountains
in the distance,
Never settle for the path of least resistance,
Living might mean taking chances
But they are worth taking,
Loving might be a mistake
But it's worth making,
Don't let some hell bent heart leave you bitter
When you come close to selling out
Give the heavens above more
Than just a passing glance,
And when you get the choice to sit it out or dance
I hope you dance . I hope you dance.

We love you. God speed.


With thanks to Cat Stevens and Leanne Womack