Tuesday, July 31, 2007

Summer EP Fun

Here's how electrophysiologists entertain themselves (used with permission, thanks to a great patient):

A 21 year old who has otherwise been in excellent health, noted the onset of some substernal chest discomfort when taking a deep breath that is new from the day before. He was working as a camp counselor in Wisconsin and presented to the camp nurse who noted his pulse was low. He vehemently denied shortness of breath, cough, fever, chills, rash, prior heart disease of any kind, murmur, or family history of heart disease. His exam, other than a slow, slightly irregular pulse and occassional bounding neck vein, was entirely normal.

He was sent to the local ER. Here's his presenting EKG:

Click to enlarge

He was admitted and two hours later, his EKG repeated:

Click to enlarge

So, what are the EKG findings and what's the diagnosis?

(Hint: The diagnosis was made by a small hospital that was NOT one of the 50 Best!).


The Singing Bee

“I don’t know what’s happening. I just wasn’t sure.”

She looked at me, tears welled up, but never spilled over.

“I was scared. Thanks for coming.”

“It’s fine. I’m glad you called.”

I looked at him. Change was underway. His eyes were slow to steer my way. Lifting his head to see was a chore. Trying to change the subject, I asked her, “How long has it been since your marriage?”

“It was sixty years as of June 20th.”

She paused, smiled, and looked at him. “It doesn’t feel like sixty years , does it?”

Seemingly intuitively, he replied, “No, it doesn’t.”

He drifted back to somewhere between sleep and consciousness, his head leaning to the left. By now, he spent more time sleeping than awake, but somehow knew when to wake and adjust his seat, raw from constant sitting. His foley dangled to the floor, his legs were now too weak to support him. She sat staring at him, unsure what to say, but I could tell a million memories flooded her mind. She looked for anything to say. “Did you have enough to eat?”

“Sure did, Mom.”

“You know, last night I thought I was going to die,” he said softly.

“How so?” I asked.

“I was in bed and breathing kind of shallow, like I was short of breath.” He stopped to breathe. “But it was nice, I was comfortable, peaceful. I wasn’t scared. I wish I’d gone then.”

“God’s going to decide, Dad. You’ll know when its time.”

“The sooner the better,” he said and drifted back to his level of consciousness just above sleep. Shortly he aroused again, “Would you turn on the TV?”

“It’s the one thing I’m good at these days,” she said. She reached over and pushed the power button on the remote. “Nights are tough,” she said. “He sleeps with the TV on.” The TV came alive with “The Singing Bee.”

His head raised slighty, his gaze turned upward, then he saw what was on.

“I hate that show,” he uttered and drifted off to pseudosleep once again.


Monday, July 30, 2007

Cigarette Wrapper Can Create a Heart

Here's instructions on making a plastic heart from a cigarette package wrapper. Funny, the instructions state:
"When melting the plastic, try not to breathe the evaporation, it can be a bit toxic."
Never mind the toxicity of the cigarettes, I guess.

But hey, at least the plastic heart might replace the heart you destroy, eh?


Spam No More

Whew! Finally, my blog has been released by the Google reviewers. For those of you unaware, it seems Google has deployed little roaming "spam bots" that seek out blogs that are thought to be spam. These spam bots decided by blog was spam and locked me from being able to place further posts on my blog until it was reviewed by the Gods of the Blogosphere. (Seriously, is it really that bad???).

I was unaware these "bots" existed and was completely halted in my tracks. I was afraid Google sent these to my blog because of my prior post heckling Google's Health Care Advisory committee. I wonder: will they send out little "bots" anytime doctors get a bit ornery with the new electronic healthcare system that Google envisions? * Sigh *

I was impressed how I felt the anxiety of acute blog withdrawl - palpitations, lightheadedness, emotional lability - it was ugly.

But now, renewed in my ability to post some sixty hours later, my symptoms are resolving and I can get back to some more therapeutic posting...


Saturday, July 28, 2007


I stare at this white page, wondering what to say. I wonder, “Are you awake too, Dad?” Words don’t come easy. You thanked me for playing tonight, but the words came hard then, too. For both of us. I hope you’re not panicked – please tell me you’re not – just a little short of breath, right? I wish you weren't so aware of all of this...

If I could save time in a bottle
The first thing that I’d like to do,
Is to save every day
Till eternity passes away
Just to spend them with you.

The chaplain came by today. I wish I’d been there. He read you a prayer about a bird with a broken wing. You liked it, I was told. You stored it in the pocket of your walker, remember?

Blackbird singing in the dead of night
Take these broken winds and learn to fly.
All your life,
You were only waiting for this moment to arise.

You seem tired, sleepy. It must be strange. We’re waiting. You know we’re waiting. It’s taken longer than you thought, hasn’t it? I’m sorry. Everyone keeps asking me how long it will take. A week, two? It might be faster, longer, I don’t know. Sorry about the parade of people that want to see you one last time to say goodbye. It must be hard. Do you remember the dogs running about? It seems even your dog is less important to you now. We’ll take good care of her. Tonight, it was beautiful outside. I wish you’d wanted to go out, even for a little bit – you always loved it outside. People don’t care how you look. Really. I’m so sorry. I feel, I don’t know, it’s all so … so strange. I know, this is what you wanted, but …

In the clearing stands a boxer,
And a fighter by his trade
And he carries the reminders
Of ev'ry glove that laid him down
And cut him till he cried out
In his anger and his shame,
"I am leaving, I am leaving."
But the fighter still remains…

You look peaceful now, sleeping there. I hope you liked the music, Dad. I love you. Remember, if you get short of breath tonight, take the morphine, okay?


Friday, July 27, 2007

CT Surgeons as Virtual Heroes

Has the CT Surgery market become so compromised that they need to turn to virtual surgery games for training?


Quote of the Week

"Seriously, I thought I just fell asleep..."
His telemetry:

Click to enlarge


An Unforeen Consequence of Smoking Bans

With the decline in cigarette consumption in Illinois with our new state-wide smoking ban, it seems our senators will have to increase the increase in cigarette taxes to make up for budget shortfalls.

Might this happen with the new Congressional initiative to fund the State Children's Health Insurance Program (SCHIP) program?


How to Find the Best Doctor

Tell him you can whip his butt any day of the week.


Thursday, July 26, 2007

128-element CT Makes Its Debut

Some pics debut here. Total body scans in 15 seconds - but how much radiation does the patient receive?

According to the Seimen's website, when imaging just the heart:
50 %* lower dose at typical heart rates compared with today’s most dose-efficient, single source CT scanners.
5.5 msv at 80 bpm.**

Depends on system configuration. *Results may vary. Data on file.** Typical regular heart rate of 80 bpm, 12 cm scan range, male patient, small ECG-Pulsing window.
Whole body scans will be much, much more radiation...


Paint By Numbers

I remember my fascination with colors in art class.

I was painting with primary-color watercolors and would watch the myriad of colors created as the colors were allowed to blend: subtle shades of every color in the rainbow. Then, as if magic, a stroke of a clean brush containing water passed over the colors would cause them the streak and fade to the point where the color was no more – a graduated fade to white again. Where did one color end and the other begin? It was impossible to tell precisely.

True artists knew the power of subtle shades of color – they highlighted, shaded, rendered visible that which was previously invisible, and conveyed subtle, but important, messages to the viewer. It is the ability to work with these media in subtle and creative ways that brought life to the work and defined the great masters of art: Rembrandt, Cezanne, Renoir, for instance. These subtleties evoked emotion.

In the fifties, Paint by Numbers took hold, promising to make “Every Man a Rembrandt.” Anyone could place the pre-mixed paint colors and render a recognizable colored picture just like the next person. It was art for the masses.

But the pictures appeared flat when finished. Fine shades and subtle hues with their gradations were lost and made for poor renditions of the intended image. Appropriately, none of these paintings ever made it to the Louvre or other great art museums. And the poor soul that devoted countless hours to filling in the little numbered areas on the white paper with the pre-defined colors knew that the finished product never looked as good as they hoped.

Medicine, regrettably, is becoming paint by numbers.

We even now are beginning to try to determine when someone is just about dead - by numbers.

Follow the potassium – by numbers.
Follow the white count – by numbers.
Diagnose a heart attack - by numbers.
Determine the quality of the care delivered – by numbers.
Develop a medical record – with numbers.
Determine the quantity of patients to see – by numbers.
Determine time to see each patient – by numbers.
Survey the patients’ satisfaction – with numbers.
Determine the quality of the doctor – by numbers.
Determine productivity – with numbers.
Protect your ass from litigation - with more numbers.

And pre-defined critical pathways, now an integral part of medical care and quality assurance initiatives, are supplanting independent thought.

But can numbers quantify handling of tears after a diagnosis of cancer is delivered?

Will numbers find the rare diagnosis?

Can numbers quantify the skill of the surgeon who spends hours in an operation creatively reconstructing a new route for GI contents to travel after a tumor is resected?

Can numbers quantify a smile? A touch? Or an emotion?

* * *

“How’s she doing?”

“Her respiratory rate is 28.”

“No, how’s she doing?”

“She’s pissed that the specialist didn’t get by to see her today and she wants to sign out Against Medical Advice.”

* * *

Now I ask you, which paints a better picture?


Wednesday, July 25, 2007

Did the AMA Kill Medicine?

Wow. Regina E. Herzlinger states the case against the AMA.


Anybody Know A Good Lawyer?

We're gonna need it. It seems UnitedHealthcare is up to no good again:
In the Washington metropolitan area, UnitedHealthcare has been gathering and evaluating data on physicians and in January rolled out a Web site that ranks physicians with zero, one or two stars. Officials at the District of Columbia Medical Society said they were told that the goal of the Premium Designation program was to encourage physicians to refer patients to two-star doctors and for patients to seek out two-star physicians.

"We were shocked that they would be profiling physicians for the past 18 months and not tell anyone," said Peter Lavine, chairman of the board of the medical society, which met with UnitedHealthcare officials last fall.

Officials with UnitedHealthcare, the nation's second-largest health insurer and a unit of UnitedHealth Group of Minnetonka, Minn., said the goal is merely to provide information to consumers and to help doctors improve their performance.

"Our focus is really on transparency," said Lewis Sandy, UnitedHealth Group senior vice president for clinical advancement.

UnitedHealthcare announced it would delay launching its program in New York, New Jersey and Connecticut after doctors complained and after New York Attorney General Andrew Cuomo threatened legal action.

One doctor fighting ratings systems is Seattle internist Michael Schiesser, who said his rating plummeted from excellent to the 12th percentile within a few months. He said initially Regence BlueShield, an insurer in the Northwest, ranked him in its top 90th percentile of doctors and awarded him a $5,000 check.

Later, when Regence cut him from its network and patients had to pay out-of-pocket to see him or go elsewhere, he pressed to see his report. He said he discovered that he had been penalized because of errors in data-gathering.
What other recourse do we have?

With their flawed data, it's garbage in, garbage out. Unfortunately, the potential for unfair market practices threatens the very hallowed ground the insurance industry now enjoys. With this system of proported "transparency," physicians are being proven guilty without the benefit of a fair trial.


Who Knew?

...that doctors might be important at implementing new health care policy initiatives?
On the day Ms. Lewis signed up, she said she called more than two dozen primary-care doctors approved by her insurer looking for a checkup. All of them turned her away.

Her experience stands to be common among the 550,000 people whom Massachusetts hopes to rescue from the ranks of the uninsured. They will be seeking care in a state with a "critical shortage" of primary-care physicians, according to a study by the Massachusetts Medical Society released yesterday, which found that 49% of internists aren't accepting new patients. Boston's top three teaching hospitals say that 95% of their 270 doctors in general practice have halted enrollment.
I've got just one word to say:



PS: There's a nursing shortage, too.

Tuesday, July 24, 2007

Medical Residency's Decline

Although I never considered myself as an "old-timer" in medicine, I guess the fact that I was trained before the new Residency Review Committee's work-hour limits makes me just that: an old fart in medicine.

The Wall Street Journal's Health blog has a review of an article published in the Archives of Internal Medicine regarding the perspective us "old-timers" have on residency training. The comments that ensued on that blog demonstrate the fervor that residents feel regarding the cheap labor and long hours they provide for hospitals, and certainly, no one wants care provided by an individual who can barely stay awake.

But some old-timers, trained by The Man, also feel that residency experiences have declined because they don't suffer like we did. What are you, wimps? You're missing all the good cases!

But has residency training suffered just because of the RRC's restrictions on work hours? I don't think so. It is just too easy to blame work hour restrictions on the decline of residents' training. I certainly agree that care has become fragmented, in part because of these restrictions. But I would argue that there are other more powerful forces in play.

I see many, many more patients shunted to in-hospital hospitalist services that are productivity-driven. These eager inpatient attendants to health care are a formidable challenge to managing inpatient teaching services: patients are seen quickly, decisions expedited, and lengths of stay minimized, making a powerful inducement for hospital systems to employ these services. Teaching services are rarely as efficient since teaching takes time and, regrettably, time is money. After all, exceeding lengths of stay and the razor-thin cost margins that hospitals must work within to make ends meet are quickly upended. Where is the financial incentive for the teacher to teach? Training hospitals get a reimbursement bonus for training from our government, why not our teachers?

And lets not forget the Electronic Medical Record. Careful decisions regarding the appropriateness of tests have been supplanted by order "panels" that remove decision making from the doctor. Just push a button and the "critical pathway" orders are automatically generated. No thought needed. Zillions of often unnecessary and waistful tests created in the blink of an eye. What, you DARE to remove a checkbox? Off with your hand!

Academic centers across the US are all confronting these challenges as cost escalate, reimbursements decline, and centers are squeezed to find good teachers willing to work for non-reimbursed time. The impersonal technology, from EMR's to robots, has supplanted the bedside touch. It is no wonder that residency education has suffered in kind.


Monday, July 23, 2007

A Real No-Brainer

An amazing case of minimally-symptomatic hydrocephalus from Lancet.


Medtronic Settles

Medtronic joins Boston Scientific by agreeing to settle some 2000 lawsuits over its battery recall in 2005 for their Marquis and Insync Marquis ICD product lines (Models 7274, 7230, 7277, 7289, and 7279). This defect involved a short in the battery on Devices manufactured before December 2003 that caused premature battery depletion and occassional overheating of the device.


Sunday, July 22, 2007

Bend Over Rover

Today’s New York Times article entitled “Vet Hospitals Compete for Best In Show” represents a healthcare business opportunity the size of which takes the breath away.

Logistically, we have arrived at a moment where the pet health care industry stands poised to be organized just like our human one. If the animal health care industry follows the same roadmap, we can expect that the real beneficiaries of the over-the-top care described in the article to be the remora-like support services that are sure to grow around the hapless pet and pet caregiver.

Think of how many sectors of the healthcare business world will pile on to Rover or Whiskers. Before, Whiskers was the family feline who might get an occasional feline distemper shot. Now Whiskers is a potential gold mine for a whole new multi-faceted revenue stream! And who ever dreamed of this same potential for the family ferret? Think of the millions and millions new health care consumers this market has – it’s an animal hospital executive’s wet dream!

And the animal hospital industry has already started the spin:
‘The bond that people have with their pets is increasing exponentially, the closeness they feel, viewing them as family members,” said Dr. Thomas Carpenter, president of the American Animal Hospital Association.
Soon quality care initiatives, innumerable pet “best-practice” guidelines, establishment of the new Animal Electronic Medical Record, new billing and diagnosis codes organized by each species, establishment of the Department of Health and Animal Services (HAS) which oversees such agencies as the Department of Mammalian Services (DMS) which, happily, can be further subdivided into the Department of Canine, Feline and Rodent Services. (DCFrS) can be created.

Of course it would be unconscionable to leave our fine furry and feathered friends without legal protection. If a family experiences emotional angst when Fido is felled by the overly-eager veterinarian, the grieving family should have legal recourse. And with the need to develop ever-helpful animal care regulations, who will represent the animal lawyers’ interests, the Animal Bar Association (ABA)?

But the costs are already too high to directly pay for all of these services. Enter the animal health insurance industry, ever eager to defray the costs to the struggling animal health care consumer. to preserve profits, the animal health care insurers will be forced to reduce the reimbursements to their veterinarians who will be forced to see more and more pets in less and less time. And of course, since the insurance industry is willing to shoulder this prodigious burden, one can only expect that they would be willing to underwrite these humanitarian (animalitarian?) efforts by being allowed to exploit the obvious data-mining opportunities; Nestle (Purina), Procter and Gamble (think Iams), Del Monte Foods (Milkbones) and others will benefit from new ways to target their carefully-researched heart-healthy diets to the family pet.

But don’t leave out Big Pharma and the Medical Device Industry. They would not want to risk appearing unconcerned if they did not move to quickly to develop new drugs and devices to respond to the ever-changing needs of our animal friends. Canaries, after all still lack water-based treadmills. Lunches and speaker revenues for the veterinarians willing to promote their products will flourish. The US Food and Drug Administration, ever in need of new funding sources for more oversight staff to monitor this burgeoning health care market, will be funded, of course, by the very same pharmaceutical and device industry interests.

But don’t worry, for those uncomfortable with these corporate and governmental health care solutions, there is already a community of animal healers, “channelers” and alternative health care experts standing ready to assist.

When so much money stands to be made by so many people, trivial concerns involving morality, priorities, allocation of resources are obscured by third-party profit motives. If we find the animal health care scenario portrayed today in the New York Times to be morally objectionable, perhaps we should ask ourselves why the grotesque profit pyramid for human care is also not morally repugnant.


Photo credit.

Friday, July 20, 2007

Cigar Smokers Are Fumed

Tax Mike Ditka's cigars to support health care for more needy children? Sounds nice like a plan.

But what happens when the government wants to provide more health care to uninsured or underinsured adults, too? Who or what will be taxed then?

Meanwhile, the third-party medical juggernaut continues with UnitedHealth's net profits soaring.


Having Fun With MRI's

What do cardiology fellows and medical students to for fun? Heck, just throw the medical student in the MRI to look at his heart!


Addendum: If you look closely, you can see a small central jet of tricuspid insufficiency during systole. (The tricuspid valve is the valve between the upper atrial chamber and the lower ventricular chamber on the left side of the movie. The dark flow of tricuspid insifficiency backward from the ventricle to the atrium is clearly seen. A small amount of this leakage is typically seen in normal hearts and is used to estimate the person's right heart pressures on echocardiography using the continuity equation.)

Thursday, July 19, 2007

Genomic Associations and Your Heart

Congratulations! You're the proud owner of chromosome 9p21.3!

What does this mean? It seems it means that you have better-than-even odds you'll get coronary artery disease!

Gee, thanks.

This week's New England Journal of Medicine discusses the use of the inverse solution of sorts that was used to determine which loci on the human genome are likely to be determinants for coronary artery disease. Now I'm no genome nerd, but I guess this is important. But how will John Q. Public apply this information? Will you want to know? It's probably too early to know what this means to the average doctor or patient today.

But there are some interesting potential implications of this new work. The prevelance of coronary artery disease is SO prevelant - millions and millions of dollars are spent on lipid lowering therapies and dietary prevention measures - will your DNA dictate to whom we should guide therapy? What mutations of this gene lead to peripheral versus coronary arterial disease?

Such questions are just the tip of the iceberg. As noted in the accompanying editorial:
The onus now lies on researchers to explain how variation in the function of these genes leads to clinical disease. The results of such genomewide studies tell us that a particular gene is important in the pathogenesis of a given condition, but they do not tell us the mechanism that is responsible. Once we achieve this understanding, which will not be easy, we should have the keys that will lead us to eventual improvements in patient care.
It used to be that we were concerned about issues from the cell to bedside. Now it looks like we'll soon have to understand the implications of one's DNA as it applies to the bedside.


Image credit.

Your Best Doctors


Imagine if I hung this notice in my office? I mean, it is so endearing, isn't it? Certainly people would be clamoring to see me, and I'd be free from legal recourse, right? What a deal!

And yet people seek advice from the health insurance industry who post such claims on their websites every day. By the thousands.

Sites that promote "best doctors" and offer medical advice and referrals have these claims. And each is really out there to help you with no hidden agenda.

Really. But just be sure to read the fine print:
As part of our services, Best Doctors may provide you with the names of doctors from our Best Doctors® database. This database consists of practitioners who have been recommended by their peers. Inclusion of a physician in our database does not constitute an endorsement of or warranty relating to the services of that physician for your case. Nor does it constitute an endorsement of or warranty relating to any particular treatment that a selected doctor may recommend. The names we provide to you are based solely on the information you give us. If you choose to use the services of one of the doctors from our database, this decision is entirely your responsibility. The medical services provided by that doctor are entirely his or her responsibility.

Oh, sorry. It seems there's no guarentees...


On Cell Phones and Remote Diagnostics

Imagine the day where your Bluetooth headset, coupled with a cell phone on your waist, might transmit a text message to an emergency room that you're having a heart attack or cardiac arrest. The text message would contain your GPS coordinates and notify an ER and ambulance dispatcher automatically.

Far fetched? Well maybe not.

But the implications of such technology are not trivial. Would resources exist to respond to all the messages received? What would the battery drain be on such a cell phone device for such monitoring? How does one confirm that the device is not sending a false signal? What are the steps after a message is received - call the patient or do we just send the ambulance to reduce the "door-to-balloon" time? Who will man the telephone 24/7? How will they be paid? Are funds best allocated for damage control like this, or prevention of the heart attack in the first place?

While there might be a role for such services in patients identified at high risk for cardiac problems, deployment of such technology to the population at large might overwhelm our already understaffed ER's.

What is interesting in this story, however, is the potential for delivering therapy (not just making a diagnosis) in patients with previously-implanted cardiac pacemakers and defibrillators using wireless technology. Medtronic, St. Jude, Boston Scientific and others already have wireless platforms available for their defibrillators that feed information from their devices to a central server for doctors to review on-line to assess device function and the treatments delivered. What if the doctor could review an event real-time and program a device remotely to respond in kind?

This ability may not be far off and offers a dazzling array of potential for remote therapies as well as diagnostics: imagine remote-controlled drug therapy or the ability to reprogram the device to prolong battery longevity without the patient having to make a trip to the doctor's office. Likewise, if a previously undiagnosed arrhythmia arises that can be managed easily by repramming the device remotely, maybe we could save a few more trips to the emergency rooms.

But similar issues remain as with the cell phone mentioned earlier - reliability of internet connections and wireless transmissions, the problems with battery drain on the device for such computer-monitoring overhead, reimbursement for such "therapy-delivery" expertise by the "treating" physician? Is it safe to do in the first place? These are just a few.

The potential for significant medical cost savings and patient convenience might just drive this bus. And if these engineering and logistical issues for such technological therapies can be resolved, it will be a whole new era in medical device therapy.


Photo credit.

Wednesday, July 18, 2007


On hospice:

"Do you think it's infected?"

"Grab a culture and gram stain."

Should we give antibiotics?

Yes, will start Vancomycin empirically.


"How long will this take?"

"We never know, but rest assured we'll do everything possible."
"I don't know, but rest assured he'll be comfortable."


Tuesday, July 17, 2007

An MP3 Player That Whips Your Heart

Exercise enthusiasts will enjoy this clever idea: due this fall, an MP3 from Yamaha called the "BodiBeat" that selects the song to match your workout needs:
Strap the player to an armband, and it monitors your heartrate. If it senses your rate is dropping, it'll queue up a faster paced song; should your heartrate exceed your target range, it'll pick a slower song to bring you back into the zone.

You'll have to run your songs through Yamaha's BPM (beats per minute) detection software before loading them onto the device, but other than that, the process sounds fairly easy to master. The BodiBeat also tracks your average pace, calories burned, and maximum heart rate; I assume this data gets loaded back onto your computer, so you can track your progress over time.
I'm afraid my MP3 would constantly be playing Flight of a Bumblebee...


Monday, July 16, 2007

A Greased Landing

“Wes, I love to fly, LOVE it! Damn, if I could pick how I’d like to go, I’d be at 10,000 feet and have the engine stall. Crash and burn, baby. That’s how I’d love to go!”


“Wes, I wonder if you could come out and look at Dad.”

“What’s up?”

“Well, he’s having a hard time breathing.”

“Did you take his temperature?”

“Well, I tried to find a thermometer, but with everything going on lately, I just can’t seem to find one. I hate to bother you…”

“No problem, Mom. I’ll be right over.”

I grabbed a stethoscope and thermometer, dropped off my daughter at a friend’s house, and headed out to their place. It was a beautiful day, light breeze, sunny, light-blue wildflowers lined the road. How come I never noticed them before? The hour-long drive passed quickly. Lots to think about.

I soon arrived and knocked.

“Hi, Wes. Thanks so much for coming. I just got done bathing him, brushing his hair and putting some lotion on him…”

There he was in his mechanical-lift chair – his favorite lately – one that helps lift him part way to a standing position. He smiled and was happy to see me, but I could tell he had another agenda.

“Hi, Wes. It was so nice of you to come,” he said.

On the surface, he didn’t look that much worse that I remembered, perhaps because my mother had spent much of the morning making sure he looked presentable. He sat there with his shirt off, much as I had remembered him from earlier years sitting poolside during so many other summer months. And as I looked closer, he was breathing more rapidly. Accessory muscles could be seen in play over his hearty ribcage. Like a dutiful doctor-son, I listened to his lungs and didn’t hear many breath sounds over his right lung field. His neck veins were prominent, even when sitting upright. His pulse was slightly irregular, but not rapid. I placed the small electronic thermometer beneath his tongue. 97.4.

“I’ve been thinking,” he said. “It’s time. I just feel miserable all the time. The last year has been hell. I go through all of this, and I just never feel better. I’m getting weaker and weaker. I try to walk six feet, and I’m just exhausted. My fingers have nowhere left to check my blood sugars, all I ever do is sit in this chair and watch TV. Hell, I can’t even do that – I just fall asleep. Everything is a chore, and it’s costing us a fortune. And for what? I just worry about your mother. She’s been so good to me.”

“I even tried to play some family videos of our earlier years, and he doesn’t even want to those,” she chimed in.

I looked at him and realized that the decision was final. This isn’t how he’s wanted to live. "... Crash and burn, baby. That’s how I’d love to go!"

“I’m okay with that, Dad. There’s no one whose worked harder for their health. It’s hard to believe all you’ve been through.”

I looked up and could see a tear forming at the edge of his eye. I followed suit. I’ve got to keep it together here. I looked across the room to my mother, fully engulfed in the emotion of the moment, but shaking her head in agreement. We all knew.

“I mean, what’s going to happen now? I don’t want it to be ugly.”

“Well, Dad, I mean, nothing’s going to happen right away. I mean it’s like you’re at 35,000 feet – sometimes it takes a while. I mean, we can get hospice in here, and hell, they could make it easier for you. You know, like a greased landing! Not a crash and burn – greased.”

“I’d like that.”

“So I’ll call your internist tomorrow and take the day off. We’ll meet with hospice and get things arranged. I’ll be here for you and Mom.”

“I’m the luckiest man alive – I mean I’ve had a eighty-three wonderful years, three beautiful kids and a wonderful wife….And damn I’ve had some fun….”

We sat in silence. My mother was brave and looked at her husband with an exhausted, and perhaps relieved gaze. But she sat somewhat catatonic as he rose with great difficulty to the table to take his medications, staring into space, shocked at the implications.

“Let’s start the descent,” he said.


Sunday, July 15, 2007

How Much Do I Cost?

A patient asked me once: "How much do you cost?"

I had no clue.

Through our convoluted health care system, I have no idea what the cost of my services I provide to my patients will cost them. You see, I'm employed by my hospital system. I earn a salary from the hospital system. The amount billed to a patient is dependent on rates they set, not me. And those rates are typically inflated well above what the hospital will receive from an insurer for my services. And of that, an individual patient has to pay their co-pay, which varies from insurer to insurer, and a deductible, which varies from insurer to insurer. And how much of their insurance premiums are going to the care I provide my patients? Really, it's impossible for me to determine what I cost a patient.

And for those without insurance? OMG. I have no idea how this is handled. Seriously.

But it turns out we'd better start learning.

It seems the New York Attorney general's office has asked the insurer UnitedHealthcare to halt its planned introduction of a method for ranking doctors by quality of care and cost of service, warning of legal action if it did not comply:
Linda A. Lacewell, a senior lawyer in the office of Attorney General Andrew M. Cuomo, wrote in the letter that the ranking would apparently be used to steer consumers toward selected doctors. “To compound the situation,” she wrote, “we understand that employers may act on these ‘ratings’ to offer financial inducements such as lower co-payments or deductibles to promote ‘cost-effective’ doctors to their employees.”

Ms. Lacewell said patients might be steered toward doctors based on flawed data and UnitedHealthcare’s “profit motive.” She wrote, “Consumers may be encouraged to choose doctors because they are cheap rather than because they are good.”
But there might be a bright side to this bogus website the UnitedHealthcare wants to publish: maybe with this program I'd find out how much I cost UnitedHealthcare.

But I still won't find out what I cost my patients, will I?


Fat Tax?

Sandy Szwarc, RN over the Junkfood Science does a great job debunking a study that suggests taxing fatty foods might be good for you.


Friday, July 13, 2007

Boston Scientific Settles Defibrillator Suits

And they got off relatively cheap:
(WSJ) Boston Scientific Corp. said it agreed to settle all pending federal lawsuits against the company alleging harm from faulty defibrillators and pacemakers for $195 million, well below the sum the company had estimated as its likely liability.

The company acquired liability for the suits through its 2006 acquisition of Guidant Corp., which was forced to recall more than 100,000 cardiac-assist devices in 2005. One of its defibrillator models occasionally failed to deliver lifesaving shocks to the heart when needed.

Several attorneys representing plaintiffs declined to comment, saying they were subject to a judge's order not to speak.

Guidant already has settled some cases brought on behalf of patients who died. The vast majority of pending cases -- about 1,850, covering more than 5,000 individuals -- were brought by patients who had their devices removed because of the Guidant recalls, complaining that the company waited too long before informing them and doctors of the flaw.

The case has been consolidated in U.S. District Court in Minneapolis.

Boston Scientific had estimated the suits would cost it $732 million but hadn't set aside any reserves. Also pending are about 100 state lawsuits that aren't part of the settlement. In addition, a number of state attorneys general have said that they were probing the matter, which could be a source of added liabilities.
This settlement might now breathe some much-needed air into this struggling company, but some good CPR is still needed for the stent market. (Oh, what a line...) But seriously, maybe now they can put most of this mess behind them.


A Dirty Little Secret

After seeing a patient today, I looked and looked for a computer terminal on which to write my consult. Most of them were used, but I finally found this one and had to do a double-take when I saw this mouse on the desktop next to a little coffee stain.

Sorry about the quality - Shot from my Treo 680 cameraphone.
I quickly looked down at my tie and decided my tie was cleaner.

Although I did not send this instrument for culture, it would have been interesting to see what little critters resided on this computer peripheral...

And yes, I went right ahead and used the terminal, but washed my hands afterward.


Addendum: Seems there's an answer to everything... (Hat Tip: the WSJ).


"I'm sorry doc. I'm not feeling well. I don't think I can have my procedure today."

"Really? I'm sorry to hear that. Would you like to rechedule now?"

"Er, no, not right now. Ya know, it just doesn't feel right. I'll call back Monday."

Damn paraskevidekatriaphobia.


Monday, July 09, 2007


First the auto-industry, now healthcare: the invasion of the robots. Talk about transformers...


More from the New York Times.

Negotiating Deals

I wonder if Boston Scientific wants hospital administrators who negotiate contracts with them to know about this. Why on earth do they need a helipad when they're facing mountains of litigation for their Guidant acquisition?


Sunday, July 08, 2007

How to Destroy Public Health

1. Build a big, new hospital.
2. Fire physicians and staff.
3. Make the remaining docs do more with less.
4. Take a survey to see why people are unhappy.
The survey was conducted last month; 178 of about 350 physicians at the hospital responded.

It documents doctors' widespread dissatisfaction with working conditions at Stroger and their concern that the hospital's mission of caring for the underserved has been severely compromised.

Almost one out of three physicians who responded said they had already found another job (6.9 percent) or were getting ready to do so (26.4 percent). An additional 31 percent said they were thinking about leaving, compared with 35.6 percent who said they planned to stay at the hospital.
5. Make anemic PR claims that miss the point:
County administrators have a different perspective. Rashid cited a number of accomplishments, including a doubling in the number of patient exam rooms at the busy Fantus Clinic across from Stroger, a decline in wait times for phone calls to Fantus, and the addition of several new pharmacies.

Officials will be launching a new effort to "inform doctors of all the changes we are implementing," Rashid said.
6. Watch the rest of the doctors leave.

Who loses?

The patients.


Saturday, July 07, 2007

A Bit -o- Medical Humor

Rounding today, I saw this posted on our ICU wall and it made me smile:

A chicken and an egg are lying in bed. The chicken is smoking a cigarette with a satisfied smile on its face and the egg is frowning and looking a bit pissed off. The egg mutters, to no-one in particular, "Well, I guess we answered THAT question!"


Atrial Fibrillation Ablation Scrutinized

Today's New York Times has a fair piece on catheter ablation of atrial fibrillation's controversies:
With politicians and employers debating ways to tame the explosive growth in health care costs, such treatment stands out as another potentially budget-straining medical commitment.

“This is one of those areas where the practice of medicine has moved faster than the approval process,” said Daniel G. Schultz, head of the Center for Devices and Radiological Health at the Food and Drug Administration. “This is very high on our list of areas that need concerted attention.”

Dr. Schultz said the F.D.A. would soon schedule a public meeting with medical and industry experts to discuss what is known — and still needs to be known — about the welter of drugs and devices now being used without approval to treat atrial fibrillation.
Just what we don't need. Imagine stifling the iterative process that is occurring worldwide to get a better handle on this procedure, just because the FDA can't regulate what tools are used.

The field of electrophysiology has a history of far-exceeding regulatory capabilities in the bureaucracy of government. Look at radiofrequency catheter ablation. If we hadn't moved from DC shock to radiofrequency energy sources, many, many more people would have been harmed during catheter ablation procedures. Doctors did this because it was safer for patients and less anxiety-provoking for them during the procedure - not because of governmental regulations.

To think that doctors are not keenly aware of the risks involved with this procedure is ludicrous - we spend far too many (unreimbursed) hours in the lab to think otherwise. Believe me, none of us are proud of the 25-30% recurrence rate seen with this procedure, none of us enjoys the long procedure lengths nor the procedural risks involved, but collectively many believe that we should be able to eventually improve on the technique and therefore, the time and expense of the procedure. Like anything new, there is a learning curve. Catheter ablations for simple accessory pathways used to take four to six hours - now they take one to two. Those who do atrial fibrillation procedures are doing them because, not uncommonly, it works when nothing else has worked before for our patients. And there are real benefits to the patient if it works. Finally, doctors have recognized the need for mortality trials to evaluate outcomes (e.g., the RAAFT Trial and the NIH-sponsored CABANA trial).

So please, FDA, let us do what we do best. After all, it's still a work in progress.


PS: More from the NY Times regarding their recommended centers:
Because the procedure is a difficult one, success rates often track the experience of the doctors doing it. But with new technology and techniques constantly being introduced and doctors occasionally moving, patients should look further than the hospital’s track record in deciding where to turn. In addition, there are cardiac centers in France, Italy and India that have performed the procedure more often and charge significantly less.
I wonder if the author of this piece considered the limitations of overseas care, like limited legal and medical recourse should complications arise.

Bloggus Interruptis

“Dude, how come you didn’t post to your blog today?”

“I’m suffering from bloggus interruptis.”

“How come?”

“Sometimes you get busy. Or sometimes you need, you know, a break. I mean, it’s good not to prematurely … oh, never mind.”

“Dude, I’m down with that.”


Thursday, July 05, 2007

Male Physicians Leaving Primary Care

According to the Center for Studying Health System Change, it seems men are leaving primary care for specialites like cardiology and dermatology, while women are heading towards primary care. Also, one in four primary care physicians are international medical graduates.
An exodus of male physicians from primary care is driving a marked shift in the U.S. physician workforce toward medical-specialty practice, according to a national study by the Center for Studying Health System Change (HSC). Two factors have helped mask the severity of the shift—a growing proportion of female physicians, who disproportionately choose primary care, and continued reliance on international medical graduates (IMGs), who now account for nearly a quarter of all U.S. primary care physicians. Since 1996-97, a 40 percent increase in the female primary care physician supply has helped to offset a 16 percent decline in the male primary care physician supply relative to the U.S. population. At the same time, primary care physicians’ incomes have lost ground to both inflation and medical and surgical specialists’ incomes. And women in primary care face a 22 percent income gap relative to men, even after accounting for differing characteristics. If real incomes for primary care physicians continue to decline, there is a risk that the migration of male physicians will intensify and that female physicians may begin avoiding primary care—trends that could aggravate a predicted shortage of primary care physicians.
Thanks to CMS, we can count on further shortages.


Working Hands

His hands told his story.

Theirs was a story of manual labor, for several distal phalanges were missing. Work was his life. Scars adorned the dorsum of several fingers and the skin was hyperpigmented from the sun. A few bruises were present from blunt trauma since they remained active still.

But the thinness of the skin was also telling, as each tendon sheath was now clearly visible beneath its crepe-like veil; each distorted joint more clearly visible. The thenar and hypothenar eminences, too, were wasted. Clutching a fork or spoon had become a challenge.

I noticed a small pearly nodule of the dorsum of his hand, just proximal to his index finger whose distal phalyx angled abruptly from arthritis. The nodule was smoothly circumscribed, with a small arteriole visible near the crest of its prominence. A basal cell tumor, I wondered? Near his wrist, was the irregular pulse that still pounded as it struggled to supply these hands with blood.

“I’m worried about that port they want to put in my arm,” he said. “My left hand isn’t worth a damn, but they can’t put the damn thing in there, since my vessels are so small. It seems they must use my right arm. But that’s my strong hand. I need it to use my walker. They think I won’t be able to use my walker for three weeks, and if I stop moving, well, hell, I might as well be dead."

“Maybe you could have physical therapy during that period of time,” I said, reaching for some consolation. The need to mention the nodule on his hand seemed unimportant.

“I think I've used up my Medicare allocation."

I wasn't sure. I should know this.

His hands shook as they reached for the eleven pills on his table. His right thumb and index finger opposed with difficuly to grasp each pill separately. His stuttering hand placed each pill slowly in his mouth, one after another. He reached with his two hands to grasp the cup of milk. They wavered as they brought the cup to his lips as he tried to wash the particles into his stomach.

"It's just so hard, you know. Driving an hour to dialysis, feeling like hell the rest of the day, just so I can feel good four days out of seven. And I just keep getting weaker. I worry about this, you know. And if they take my arm for that shunt, I won't be able maintain my strength, that'll be it. But then, what choice to I have?"

"You don't have to have the shunt, you know."

"I know, but I want to give this dialysis thing a try. Maybe I'll feel a little stronger, I don't know. If I don't, then to hell with it." He paused, then he asked reflectively, "If I didn't have the shunt, what will happen? I was told it might be ugly, especially for my wife."

"It doesn't have to be."

"I mean, how could I be sure I die with dignity? I don't want to be lying there in my urine and feces in front of her." (He pointing with his crooked finger to his wife).

"Hospice can really help," I told him. "They deal with these kinds of issues all the time. You have to decide if you want to be in your home or a hospice facility."

He said nothing. I felt impotent.

His hands reached for his walker. They grabbed the handles like they had hundreds of times before, then he rocked forward and back three times before lurching forward to stand on his wobbly legs. He stood for a moment to gain his bearings. His left hand could only lean on the walker; the heal of that hand steadied his balance while his right hand grasped the walker a bit more firmly.

"I'll give it a try a bit longer," he said.


Wednesday, July 04, 2007

Happy 4th of July

Want to win a few grand this 4th of July? Consider competetive eating where "gurgitators" go wild.


Tuesday, July 03, 2007

Electronic Messages Are Part of the EMR

Quick quiz:

What exactly defines portions of the “medical record” in the electronic era?

(a) The patient's family history
(b) The physical examination
(c) The Medication Administration Record (MAR)
(d) Patient chest xrays
(e) Patient billing information
(f) Discharge summaries
(g) Operative reports
(h) Physician “In Basket” Electronic Messages within Electronic Medical Record (EMR) software (specifically defined as NOT "e-mail")
(i) Physician office e-mail messages outside of the medical record software.

Sadly, I learned today that for physicians who use an EMR, “all of the above” is the right answer. No longer can physician colleagues communicate electronically about a patient without fear that their electronic communications are “discoverable” in the eyes of the law. It seems physicians who have adopted the EMR have tactitly agreed that electronic messages are part of every patient's medical record.

I never learned that in medical school.

Back then, we just had the chart in our hands. We used to be able to go down to a medical record room we'd put in a request for a nice lady to "pull the chart." She'd return with a definable entity in her hands. Certainly, e-mail threads were not part of that record.

But in the electronic era, that no longer applies.

Certainly, the potential liabilities in e-mailing patients has been well-recognized. But messaging colleagues about your concerns or doubts about a specific treatment plan for a given patient? It seems that it's all potentially fair game for legally-minded interested third parties.

So if you're thinking about acquiring an EMR, beware. Being forewarned, you're now forearmed.


Grand Rounds With an Eye on Transparency

Over My Med Body takes the honors this week.

In this mix was Colorado Health Insurance Insider's approach to taping conversations (mp3 recording - speakers required) with office staff when shopping for surgical procedure prices... I wonder what my office staff would say to these questions? Would their answers have been different if they knew they were recorded?

Empowerment of the health care consumer takes on new meaning, eh?


Monday, July 02, 2007

More Physician Medicare Cuts Appear Inevitable

Remarkably, CMS wants to cut physician's reimbursements by as much as 10% in 2008.
According to the Congressional Budget Office, without congressional action Medicare physician payment rates will be reduced 10 percent in 2008. The 2007 Medicare Trustees report predicts total cuts of about 40 percent by 2016.
I continue to be amazed that most professions in America can usually expect at least a cost-of-living increase in salary to adjust for inflation, but physicians can virtually guarentee continued annual cuts in their salaries. Am I missing something? Consider these pearls about corporate CEO's:
It’s hard not to be cynical when the CEOs of America’s biggest companies received a collective 38 percent pay raise last year, boosting their salaries to $7.5 billion, according to a May issue of Forbes. That’s an average salary of $15.2 million apiece. Could any CEO be worth that much?

Certainly not, says Bill George, the former CEO of Medtronic for 10 years and a professor of management at Harvard Business School.
Cynicism rules indeed...


Updated to reflect corporate salary increases.


She was crushed.

“What do you mean?” she asked as she fought back tears. “You mean, despite all of the fancy tests and close follow-up that it’s back?”

And so began her evening after surgery. It had started like so many of her surgeries before: the check-in, the issuance of a special HIPAA privacy number to tell her friends whom she wanted to permit to call an check on her, the paperwork, the donning of her surgical gown, the holding area, the meeting with her anesthesiologist and surgeon in the holding area, the trip on the gurney to the operating room.

But no one had prepared her for the news post-operatively. It was to be a routine revision of her breast reconstruction. Instead, the news changed everything. It seems the tumor had recurred locally – an occult recurrence – a finding that no one could have predicted or anticipated. And now she laid in the recovery room full of drugs, full of despair, full of questions, and full of pain.

She was wheeled back to her room – her head spinning. The nurses were attentive, checking on her every hour or two, helping with her physical and emotional needs. The pain was significant and made worse by the realization of the surgical findings. He mind was flooded. Only the drugs could dim the reality and pain of the moment, she drifted in and out of consciousness. Finally she slept.

But sleep would not visit her for long. She woke at 2 AM at first with moderate discomfort, but soon the pain grew. She pushed the nurses call light on the side of her bed and waited.


She pulled the IV infusion pump closer to her bed and used the light from the illuminated panel to assure she was pushing the right button. There it was, the small figure of a nurse with one of those characteristic nursing caps on the button. She pushed it again and waited.


After twenty minutes, she rolled to the opposite side of her bed – the side her surgery had been conducted upon, and found the other nurse call button and pressed it along with the other button.

Still nothing.

She scanned her room. By now the pain and throbbing were unbearable. She fought back tears. She couldn’t understand why no one would come.

And then she saw it. Glimmering faintly on her bedside table. Her cell phone. She was able to reach up and pull the bedside table closer. She grabbed the phone. She dialed the only number she could think of:

4 – 1 – 1.

The robot answered: “Welcome to 4-1-1 Connect! Which city and state, please?”

“St. Elsewhere, IL,” she said.

“What listing, please?”

“St. Elsewhere Hospital”

“One moment please…. The number is….” And finally it said… “Connecting.”

The phone rang and rang. Finally, a pleasant receptionist answered. “St. Elsewhere Hospital, how may I direct your call?”

“I need my nurse!”

“Excuse me?”

“I need my nurse! I’m a patient in your hospital and can’t get my nurse in here!”

There was a pause. “Oh. What room are you in?”

“How the hell do I know? They brought me up here after my surgery. I don’t know what room I’m in!” She thought for a moment. “But I know my HIPAA number! It’s 4-2-7-5!”

“You don’t know your room number?”

“Dammit! No, I don’t know my room number! I just need my f*&()^ng nurse!”

“Okay ma’am. Please calm down. I’ll get them for you right away.”

She felt like a jerk. But her pain was intense. She collapsed back in bed, exhausted.

In a short time, her nurse came running in… “Oh I’m so sorry. Why didn’t you call?”

“I tried to. I pressed my frickin’ call buttons about eight times!”

“Oh, those don’t work. You were supposed to push this one above your head.”

She looked at the white board at the foot of her bed. On it contained her nurses’ name, the date. She thought for a minute. How was she supposed to know, on a mechanical bed where all of the buttons move the bed in a seemingly infinite number of directions, that two of those buttons did not work?

“Sally?” she said. “I need more pain medicine.”