Sunday, September 28, 2008

Alphabet Soup

What does “MD” mean to you after someone’s name?

To many, in conjures an image of a trusty elder statesman of medicine, a healer, a researcher, a teacher and therapist of all things related to diseases of the human body.

It comes from the Latin, Medicinæ Doctor, meaning “Teacher of Medicine.” In the US, it is the first professional degree for physicians while in other countries, such as Germany or England, it is a higher doctoral research degree resembling the PhD (Philosophiæ Doctor, meaning "teacher of philosophy").

For reasons that are unclear to me, physicians also occasionally include other letters beyond the “MD” in their name. These add little to the MD descriptor, other than to define a professional society with whom the doctor associates themselves. For instance, I am a Fellow or the American College of Cardiology, and have “FACC” sometimes appear on my stationary. I never write this designator when signing my name, but I know my referring colleagues in medicine want to know I’m one of the gang, so it appears there. It also implies that I pay my dues to the American College of Cardiology which also serves as our political and advocacy branch of our subspecialty.

I find patients rarely understand what these letters mean, for there are many such designations. FACS means a Fellow in the American College of Surgeons, a surgical professional group, and FACP means Fellow of the American College of Physicians, a professional group of internists, for instance. Some people, like cardiologists who have first been internists before becoming a cardiologist, like to add both the FACP and FACC designator after their name. Providing, they’ve paid the fee and been vetted by the respective professional groups, no one seems to mind. A signature line becomes virtual alphabet soup as doctors sign their name “John R. Smith, MD, FACP, FACC.”

Big deal.

Regrettably, these initials are nothing more than a narcissistic exercise of self-aggrandizement, rather than meaningful milestone of additional education or skill. Further, in our zeal to differentiate ourselves from our less-specialized colleagues, they have promoted the fragmentation of our profession as a collective bargaining body in matters of public policy important to physicians collectively. The alphabet soup conveys no indication of additional qualification of the physician, only that they have paid for the privilege to add these to their names, have a valid license, and know a few colleagues in their same subspecialty club.

Importantly, these letters do not imply an individual is “board certified” by any one of the 24 Member Boards that make up the American Board of Medical Specialties. Within each specialty like Internal Medicine are often other subspecialties, like gastroenterology, rheumatology, cardiology or cardiac electrophysiology. In total, there are presently 145 specialties and subspecialties in which a doctor can become “board certified” and 145 ways we fragment our negotiating power on Capital Hill as each group fights for their own interests. It’s also 145 ways we confuse the public (and each other), 145 ways we lose our focus on the bigger picture of healthcare in America, and 145 ways that third parties can play us off one another as they forward their agendas over ours.

In effect, our sub-specialized egos and alphabet soup have neutered us as effective voices in healthcare reform.

Worse still, while “board certification” defines an important level of competence that should not be undervalued or disrespected in terms of the expertise required to achieve such certification, the term itself has been confused with the sponsoring professional society memberships' alphabet soup and has obscured our ability to protect this important credentialing designation.

More on this soon.


Friday, September 26, 2008

In Circulation

Sometimes, things circulated on the internet speak volumes:








Wednesday, September 24, 2008

The Cost of Dying

From the Chicago Tribune:
It costs more to die in Illinois, where an average patient in the last six months of life will see a doctor 33 times and spend four days in intensive care, at a cost of more than $26,000. In Oregon, a state with a history of talking more openly about end-of-life care and legalized doctor-assisted suicide, the same patient sees a doctor 17 times and spends two days in an ICU. That average tab runs $19,500.
In my experience, these are very conservative estimates.


Tuesday, September 23, 2008

For the Real iPhone Geek

A cardiologist's dream to improve referrals: a new iPhone heart rate monitor app that uses the iPhone's microphone to detect the pulse over the carotid (neck), radial (wrist) or even the precordium (chest):

iPhone App - Heart Monitor from John Ballinger on Vimeo.

While this is likely to work fine with regular heart rhythms, irregular rhythms like atrial fibrillation will be under-sensed giving falsely low rates because shorter ventricular filling times will cause decreased ejection of blood and hence, decreased sound in the neck area.

Nevertheless, it's sure to be fun for the whole family - just don't call you doctor when it reads zero and you're still conscious.



Grand Rounds is Up

Dr. Val and KevinMD co-host this week's edition of the best of medical blog-o-sphere.


Monday, September 22, 2008

A Low-Cost Solution to Literature Searches

Rural Doc's solution? Use a network of friends on Twitter.


The Employed and Willfully Uninsured

A piece from the Herald Tribune describes the plight of what happens when the willfully uninsured, caught off-guard by an unexpected catastrophic illness, confront their options for care:
Their last resort for care is Medicaid, but it is unclear if the O'Learys would qualify -- or what sacrifices they might have to make to do so.

Florida is one of 33 states where Medicaid covers transplant surgery, and the program pays the full cost, a Medicaid spokeswoman official said. But first the O'Learys would have to qualify.

O'Leary would apply under the program's provision for medically disabled people, and that can take 90 days. Even if approved, eligibility documents show an income limit of $1,027 per month, far below Danae's salary.

That leaves the O'Learys with a dilemma -- to pay for Ron's care, they would be better off if she quit her job, giving up their sole stable income. They also might need to sell the restaurant to avoid Medicaid's asset limits.
It is a shame that Medicare rules require another a spouse to become unemployed to qualify their partner for Medicaid, rather than providing a realistic path to repay their debt to our social health programs.


Sunday, September 21, 2008

Cardiology Unplugged

I spent some time with my brother-in-law and his family today apple picking with the kids. It was a beautiful day, but a bit warmer than I had anticipated for this time of year. After dropping off way-too-many apples in the car, we walked back to meet the group in the shade of a large barn nearby. On our way back, he shared a secret with me:

"Well, I broke down."

"With what?"

"I got one of those heart scans."

"Really? Let me guess, your score was zero, right?"

"Yeah. But I was so relieved, I celebrated by having a bunch of sausage in biscuits and gravy. And you know what else?"


"That Lipitor's good stuff."


Friday, September 19, 2008

Malpractice, Aussie-Style

One defibrillator, three operations, $1700 waived.

This case is remarkable on many fronts. Glad to see he's finally doing well.


Addendum 16:15 CST - Seems some quality data is about to be forthcoming to improve patient's lot over there:
An audit by the health department's Clinical Excellence Commission last year of 1317 patient files at 16 hospitals, previously unnamed, showed complication rates for pacemaker implantation varied from 8.5 per cent for the best-performing hospital to 17 per cent for the worst.
I'm impressed at the relatively high complication rate at all of the facilities...I wonder what they're counting: deaths, infections, lead dislodgements, etc.? Or are simpler things like minor hematomas added in also. This is why quality data, without explanation (or as they mention, without respect to the number or complexity of procedures performed), are difficult to view in context.

Equine Cardioversion

Dang. This would be cool to do: a cardioversion on a horse.

I just finished a Grand Rounds today for our housestaff and came across this helpful compilation of data on improving the success of cardioversion in humans. To summarize:
  • Use anterior-posterior (AP) rather than anterior-anterior (AA) patch position

  • Higher energies up front often lead to lower shock requirements to achieve success

  • Use biphasic defibrillators over monophasic defibrillators

  • If unsuccessful, consider pre-treating the patient with Ibutilide (1 mg over 10-15 min IVPB)
Interesting to speculate how those suggestions might be applied to a horse...


The Price of Life

Once again, Britain shows its creativity in educating it's populace about the costs of healthcare in their system with their on-line Virtual Hospital. In it, the have patients explaining why they should have a second chance for a liver transplant after a life of alcoholism, or a patient explaining how he thinks their system let them down after he tried (and succeeded) for 10 years to have bariatric surgery.

As we consider universal, government-run healthcare, this site unveils the reality of implementing overt rationing of resources.


Wednesday, September 17, 2008

Graduated Pressure Stockings

Suture for a Living has a great review on how to size graduated pressure stockings used to treat deep venous thrombosis (DVT).


What Do Hospitals Have to Do With Baseball?

Parkview Health announced it would pay $3 million over 10 years for the right to have its name atop the new downtown baseball stadium. Parkview Field will be the first major venue in the Summit City to have a corporate sponsor.
And we think drug company direct-to-consumer advertisements are bad. It is interesting to note that 1/2 the monies pay the city and the other half pay the owner. But for people like me who question this practice, they retort:
For those upset the stadium will have a sponsor at all, Grinstead said that is simply the way sports businesses are run today. Because minor league baseball teams have no control over their players, they need to be creative in making money. He said some teams are even having corporate-sponsored patios and parking lots.
Certainly hospital system advertising is not new, and this is just another format, albeit a big one, for the same. Paul Levy, CEO of Beth Irael Deaconess Medical Center, has commented that advertising is less likely to affect hospital's bottom lines, but placate doctor's narcissism about working at the best medical center:
Another purpose is to respond from pressure from your doctors and show them that you support their programs. Before I took this job, I talked with the head of a major Boston hospital who gave that as the primary reason for ads. "There is no evidence that ads work in creating business," he said, "but we need to keep our doctors happy." I have certainly felt that pressure in my place, and so I understand the desire to send a signal to your doctors -- who, after all, are essentially free agents who can easily change hospital affiliation -- that you support their practices.
He also comments later what the real motivation for academic center for this branding is:
I think the ads are posted mainly as a component of creating a broader brand identity. In this regard, hospital ads are remarkably similar to many other corporate ads. But unlike other industries that use it to drive sales, brand identity in the medical field is probably minimally important in generating and maintaining a sufficient level of clinical business. Perhaps more important, it helps create a mindset that the hospital has standing and stature and permanence in the community. This is important in attracting employees, enhancing physician recruitment and affiliations with other hospitals and physician practices, and generating interest from lay members of the community to serve on the hospital's governing bodies and to offer philanthropic support. These three purposes are actually fundamental to commercial viability in the health care world, especially for academic medical centers.
It seems to me that supporting baseball stadiums (and their owners) as a means of maintaining "commercial viability," especially for tax-exempt non-profits, is a bit of a stretch, particularly in light of the cost issues that patients must endure in medicine these days.


Tuesday, September 16, 2008

ICD Class Action: Patients 40%, Lawyers 60%

As reported in the Star Tribune regarding the faulty implantable cardiac defibrillator (ICD) battery suit settled by Medtronic from the recall of 2005:
Less than half of the Medtronic settlement has been mailed to people who received defibrillators that were recalled in 2005 because of concerns about battery failures. The rest of the disbursements remain stalled, as lawyers deal with Medicare and Medicaid issues and third-party liens.

"We wanted to get some money into the hands of the claimants while we get other issues resolved," said Dan Gustafson, a Minneapolis lawyer and co-lead counsel in the Medtronic lawsuit.

But getting 40 percent of your total damages in September 2008 from a settlement that was announced in December 2007 still rankles some of those people who wore the recalled devices.
One would think this legal wrangling would be negotiated ahead of time, but I've got to say that there's some justice being served here as lawyers get to deal with Medicare and Medicaid issues, too.


Monday, September 15, 2008

Our Healthcare Hindenburg

As the world absorbs the news of the bankruptcy of Lehman Brothers investment bank and the rushed sale of Merrill Lynch on the tails of the Bear Sterns, Freddie Mac and Fannie Mae bailouts, we see the collapse of a system that permitted and promoted housing to those who could not afford it.

The sub prime mortgage mess was born of a change in banking rules that permitted more and more people to "quality" for mortgages, even though their incomes didn't change. Initially, things went well. The mortgage banking community profited handsomely from the increased business and by creating new, lucrative debt deals in the "derivatives" market. It was so good, in fact, that the rules were broadened to even more homeowners. So more people piled on more debt than they could afford, comfortable in the fact that interest rates would stay low, and balloon payments renegotiated for another, similarly low-rate mortgage when the time came. Unfortunately, things did change and so did the rules for lending, and these high risk homeowners were left holding the proverbial financial bag as their homes were foreclosed. The middle manager boys never once questioned the Top Dogs' laxity, the assuredness, the hubris of gambling money on such a high stakes game (people’s homes). And the government let them do it. Suddenly, when people could no longer pay, the Big Boys realized they were up the creek without a paddle and ran for cover in bankruptcy proceedings.

I wonder how any health care system, much like the foregone housing market, can sustain itself with our current similar mindset of universal, limitless healthcare for all. It will be bigger, better, the party never ends, and the money never runs out. Piñata-like, we grab as much as we can as fast as we can. This undisciplined, unregulated, lack of self-control or discretion money rush across multiple sectors of the healthcare business is exactly what happened in the mortgage crisis. Like the current housing debacle, opportunism reigns over social responsibility.

We’re now seeing what happens when the Big Boys and the government worked their Ponzi schemes for keeping the housing bubble inflated. We (the little guys) are seeing what happens to financial markets, the security of our 401Ks and investments, and the economy as a whole after the Big Boys have dropped the ball.

But there is little questioning of the effects of gambling on another high stakes game: people’s health and our nation's economy. Health care is our financial life preserver right now – it is the engine driving the economic survival of towns decimated by manufacturing losses. It is the leading employer for many communities as people fight to re-tool their labor skills into healthcare skills. It is generating a colossal 2.3 trillion dollars of revenue a year: much more than any investment bank – and the philosophy right now? It can’t go under. It will only grow. The future is limitless.

And like homes, we buy it.

So what’s the problem? The problem is there are tremors that the our healthcare bubble is going to burst. A bubble by definition is an artificial inflation based on spending money we don’t have. Healthcare has become so expensive that patients are having trouble paying for it. Employers, too, are having trouble paying for it. Insurers are having trouble paying for it. So guess what, the government is going to have trouble paying for it.

The tremors of an impending healthcare bubble, are like those of our current housing bubble, if we cared to listen: the escalating co-pays, pharmacy, and hospitalization costs. We see the rules change behind the curtain as the Big Boys, ever eager to earn your trust, add millions to our national debt through Medicare drug coverages. We see the employers and insurers in fierce battles for profits as they negotiate plans with hospitals as people are stuck with increasingly larger shares of their bills. And woe to the uninsured, already caught empty-handed in a time of crisis, who suddenly realize their payments exceed those of the more fortunate insured. The once expected mandates for healthcare, too, are beginning to find themselves unfunded and political promises left undelivered. We see the people of Massachusetts in their "New Big Dig" of healthcare, finding that $869 million won't pay their healthcare bill in 2009. And yet we see all this even as the new buildings are going up, even as the spas and Starbucks go into shiny marble lobbies – even now - as we continue to build our healthcare Hindenburg.

Then what happens? Well, Medicare fails. I know, I know. This seems no more possible than the idea that people would ever lose their homes - no way no how.

But when it does happen, then what does the inevitable government bailout look like?

It looks like a national healthcare structure that “comes to our rescue” in ways that no one would have voluntarily chosen. Now we are in crisis. There is no choice in crisis. You must do as we say.

Perhaps this is the set up all along by those who believe unfettered capitalism and health care cannot coexist. Let it fail. Let it stumble down a drunken, sated, undisciplined path until it reaches in its pockets and the money is gone.

But, who might exercise enough discipline to keep us from careening into a bureaucratic system that “saves us from ourselves?"

Would it be the hospital administrators? They have to compete.
Would it be the builders? They are just trying to win a bid – it’s the American Way.
Would it be the politicians? Talking frankly to their constituents about not spending money the state doesn’t have. (Hmmm.)
Would it be the journalists? Telling the public the truth about how health care is running out of money instead of doing a Nightline special on the next top dollar technology?
Would it be the pharmaceutical or device industry who cannot survive without designing the next unproven bell or whistle and cannot step out of the box to develop a new system to ensure their survival (i.e. lower profit to more people)
Would it be the consumer? Who figures the Big Boys will "figure out how to pay for it somehow" and just wants junior/grandma/husband to have the best health care out there?

The answer remains to be seen, but the first step remains admitting there's a problem. And the problem isn't the way it's being stated on Nightline. Like the 12-step program for Gambler's Anonymous, we must first acknowledge we have a problem and are addicted to shiny objects, the opulent, and the whizbang. Only then can we start to recover from our healthcare spending orgy earmarked by excessive testing, excessive building, excessive bureaucracy, and excessive expectations. This is the first and greatest requirement, and the others are like unto it: cost transparency, removing employers as insurance providers, health savings accounts, catastrophic coverage, and insurance policies that can be purchased across state lines are just a few of the steps needed to break our addiction to entitlement programs.

I am convinced that the American people are fully capable of marshaling the resources to address these complex issues. But we must first really acknowledge they exist and that fixing it matters. Only then will we land our healthcare Hindenburg before she crashes and burns us all.


Image reference: Wikimedia Commons

I've Got News

... or maybe I should say, "NUHs:"

As I post this, the flags are going up as our hospital system, formerly known as Evanston Northwestern Healthcare, officially announces their new name and brand:
"NorthShore University HealthSystem"
(Be sure not to separate the words).

The new preferred shortened nickname? "NorthShore." The new logo is shown above and contains Nike-like swooshes (representative of the waves of Lake Michigan, I guess) as part of the healthcare cross. ("Cooler by the lake" maybe?)

They decided to go with a more conventional blue hue rather than our former purple motif - certainly not as shocking to the eye. Our new website url has changed from to

So there you have it. Our name has officially changed. For the adminstration and marketers of healthcare, this is a BIG day. The loss of the Northwestern name will require a reassurance to the business community and community at large. As such, there is real risk (and expense) to changing your brand. Stationary, signage, voice messages, policy manuals, and literature distributed to patients must be changed. But the change, regretfully, has become necessary, as consolidation of health systems nationwide continues and large systems compete.

But the real test will be when the rubber meets the road: first impressions for new patients, ancillary providers, and nursing and physician recruits are everything in these days of internet communications, lightning-fast judgements, and "quality ratings." The hope is the new name, coupled with its continued academic affiliation with the University of Chicago, will invoke a sense of community, stability, and prestige. For established patients and their doctors, the change brings more of an inconvenience having to type six additional letters for the internet address; the people, the buildings, and the healthcare are very much the same.

Now, as I'm off to pick up my new lab coat, stand by as the local media branding blitz begins...


Sunday, September 14, 2008

A Conversation: The Legal Morass Caused by the EMR

"The thing I hate about the Electronic Medical Record (EMR) is my name is always there for instant recall, even if I've surrendered by care to another physician."

"Why's that?" I asked, naively.

"Well, once I was subpoenaed in a malpractice case that occurred in 2006. I last saw the patient in question in 2002. But because the lawyers asked for a copy of the medical record, the entire dump of the patient's record was provided. The lawyers took note of every treating physician in this patient's care, irrespective of treating date, and filed subpoenas for 'discovery depositions.' I had to hire a lawyer, respond, and was later released from the case, but not after significant financial and emotional anguish."

"Sheesh. I had no idea it could get that bad...", I said.

"Yep. I just wish there was a statute of limitations about how far back a lawyer could ask for a medical record to avoid these fishing expeditions..."


Friday, September 12, 2008

Keeping Things in Perspective

The New York Times has an interesting piece in their Business section today on implantable cardiac defibrillators (ICDs), but paints a remarkably pessimistic view of the future market for the devices. While I do not argue with the fact that ICD implants nationally have declined, I think it's relatively important to compare the cost of ICDs relative to other therapies we dispense in medicine relative to their life-saving value to our healthcare system.

Although admittedly assembled by Medtronic (who has a vested interest in promoting ICD therapy and yes, I suppose I do, too), there are data of the costs of ICDs relative to other preventative therapies doctors provide as "prevention." Here's a slide from them that adds perspective:

Click image to enlarge
Additionally, although the SCD-HeFT trial demonstrated that 15 patients were needed to be treated before a life was saved, other trials demonstrated a significantly better odds at saving a life:

Click image to enlarge

MUSTT @ 5 years from Kaplan Meier (KM) curve: 55%-24%, NNT=3 N Engl J Med 1999;341:1882-1890
MADIT @ average follow-up of 2.4 yrs, crude mortality rate: 39%-16%, NNT=4 N Engl J Med. 1996;335:1933-1940
MADIT-II @ 3 years from KM curve: 31%-22%, NNT=11 N Engl J Med. 2002;346:877-883
AVID @ 3 years from the KM curve: 36%-25%, NNT=9 N Engl J Med. 1997;337:1576-1583
SAVE (captopril, an ACE inhibitor) crude rate with average follow-up of 42 months: 25%-20%, NNT=20 N Engl J Med, 1992; 327:669-677.
Merit-HF (metoprolol, a BB in HF patients) @ 1 year from KM curve: 11%-7.2%, NNT 26 LANCET 1999; 353:2001-07.
4S (simvastatin) @ 6 years from KM curve: 12.3%-8.7%, NNT=28 LANCET 1994; 344: 1383-1389.
Amiodarone Meta-analysis of 15 trial @ average follow-up of 2 years: 19.2%-16.5%, NNT=37 Circulation, 1997; 96: 2823-2829.

Finally, in terms of cost of other preventative therapies that our society has deemed useful to save a life, I always appreciated this view:

Click image to enlarge
Just trying to keep it in perspective.


My Experience With Government-Run Healthcare

I have seen government-run healthcare first-hand.

Many others have, too, for many a soldier, sailor, Marine or airman, (and even a Congressman or two) have their lives to thank because of that system. But in this time of a new presidential election and the talk of such a system for the nation, I cannot help but reflect on my experiences at an officer in the United States Navy Medical Corps.

My reasons for joining the military at the time were not out of financial need, but rather my desire to achieve financial independence from my family. I did not want my father (the family breadwinner at the time) to pay for my medical education. It was my personal separation from my family as a young adult, and the pride in being able to stand on my own two feet without their financial support, that drove me to seek a military scholarship to pay my way through medical school. I was finishing engineering school at Duke University and a Naval recruiter came to our campus. Since my brother was on a ROTC scholarship to pay for his college education, I learned about their programs for supporting myself through medical school and the service commitments required. I eventually applied to the Health Professions Scholarship Program after receiving my first acceptance to a US medical school and was accepted.

But first, I had to have a recruitment physical. It occurred at a recruiting station somewhere in North Carolina (for I was a Duke at the time).

Walking in clueless, I was asked to sit in a room with what seemed like a sea of other applicants from all walks of life. We were carefully instructed on how to write or names within the boxes on the physical form, where it asked for “Sex” to enter “W” for woman or “M” for male and not “Yes” or No,” and to not complete any portion of the application on side two, lest they be keel-hulled for not waiting for the intellectually less-inclined. Finally, alter completing the medical history forms, we were off to the physical portion. But the physical was not to be performed privately and personally – no, that would take too much time – rather en masse. Men were separated from women, and gradually removed more and more of their clothing. Spines were checked for scoliosis, feet were checked for pes planus (flat feet), a cursory listen to the lungs for wheezes, and finally and most memorably, men were asked to turn around, drop their underwear, spread our cheeks while the doctor examined them for hemorrhoids. Oh baby. What a way to say “Welcome to the Navy!” All I could think was: “Is this what I’ll be doing?”

After surviving that memorable experience, I received my scholarship: full tuition to medical school, reimbursement for books and required medical equipment, and what seemed like a fortune to me at the time: $500 per month. The memory of that fateful exam day faded quickly.

After medical school, I received my first set of orders to report to the National Naval Medical Center in Bethesda, MD. At the time, it was one of the most impressive hospitals I had seen – the pride of Navy Medicine. I was honored to be there. It was a new, squeaky-clean, beautifully-constructed facility attached to the original towering monolithic original hospital whose site was chosen by President Roosevelt but later had proven too impractical to care for patients due its paucity of elevators. Bethesda stood in stark contrast to the recruiting center I initially thought represented Navy medicine.

My colleagues, fellow lieutenants, were equally impressive, hailing from private medical schools across the country. Most were smart, bright, eager to excel, and a only a very rare few, like any workplace, weren’t exactly the sharpest knives on the shelf. My experience with military medicine was some of the best of my life and the friends and colleagues I grew to know, some of the best of my carrier.

When I started, there were 30 patients per medicine ward team and four teams managing patients. Each medicine team consisted of a resident and four interns. It was a hotbed of Naval referrals being the benefactor of military healthcare after the Vietnam war. We saw everything, since we treated not only active duty members and their families, but retirees and their families, too - many from far-away destinations. I will always remember those late-night Medivac admissions!

Working there on occassion, we also saw things others rarely get to see: big blue curtains going up around the hospital. This was when the biggest patients of all would visit, usually for their annual physicals: the President or Vice President of the United States. Needless to say this was somewhat disruptive to have the President, like the Wizard of Oz, somewhere behind a curtain as he was escorted from appointment to appointment, but those of us in the trenches usually went on our merry way without much thought since there was so much work to be done for others.

There was a clear hierarchy of care on several levels in the military: the first by rank, the second by active duty status. Admirals and Congressman were always escorted and given priority for appointments, then active duty, then active duty member's families, then retirees, then those eligible for disability benefits: boarded out with over 30% disability. There was never a question of how to ration health services... ever... for each person had an ID card, each person had a rank, and each person had their duty status.

When caring for the patients lucky enough to acquire appointments, at first we never thought about the cost of healthcare for our military members. I would order a CT or MRI if my patient needed it, no questions asked. The equipment was always state-of-the-art and our basic military medical training was comparable to any in the US. Training for subspecialties was routinely farmed out to the private sector and residents left for a few years, returning from many prestigious programs to share their knowledge and experience with us upon their return. It was medical utopia.

But after the Vietnam war ended and the glut of excessive military healthcare facilities made its presence known on Capital Hill, cost-cutting was rampant as the military tried to shore in its costs through the Base Realignment and Closure (BRAC) initiative. Our medical ward services shrunk over my 10 years at Bethesda from four to one, and the patient census was bearly adequate to satisfy our residency credentialing requirements. I can remember vividly our catheterization laboratory struggling to keep our expenses to $1.4 million dollars annually as we tried to perform required angiography and medical device implants (yep, pacemakers and defibrillators, too) to our members. Slowly, insidiously, patient volumes plummeted as not only because of base closing, but because active duty members were increasingly shunted to the private sector to offload the financial burden to another government pot of money: Tricare – the military's health care insurance system. This system has degenerated into a poor substitute for our military members, as others have recently commented. Regretably, the maintenance of the grounds also suffered as cuts continued - Walter Reed was especially hard hit.

It was a challenging time. I saw many a colleague leave the service for greener pastures in the lucrative private sector. I, too, was eventually lured away because the military, even with their "perks" and tax breaks, just could not remain financially competitive. I left after 13 and a half years, but remained with the Reserves, in part because I enjoyed the camaraderie, but more, because I did not want to throw away the potential for an eventual retirement pension. Family responsibilities have a way of making you think that way.

So I am left to wonder, as the thought of a single government run healthcare is considered by many, should we not learn from our prior experiences? Medicare is about to go broke, the military healthcare system, while constantly shifting as Congress approves or disapproves its budgets, has seen a dwindling of its ability to care for those most deserving due to costs. Rationing has helped the military cope with their limits, but for the military, rationing is simple since rank and duty status are so obvious. What would happen if a similar healthcare system was thrust upon the greater civilian population? Where will people be shunted in our new system when we realize it is too expensive or we have too few doctors to provide the care? In short, how will our "rank" be determined? Can we really expect that universal healthcare will not exact a toll on each and every one of us?

Of course it will. And perhaps it should. But without discussing ways to limit costs, earmarks, grotesque unlimited spending for facilities, lack of transparency of real costs to our system, and ways to shore up the numbers of doctors sure to abandon the profession as the inevitable cuts inherent to such a system are enacted, we're bound to see the same problems as the systems that have come before.


More Consumption

First Roanake, now Cincinnati. As a former electrophysioogist in that town, I know that purchase cost 'The' Christ Hospital a pretty penny.

Gee, I wonder who'll be footing the bill?

Yes folks, the trend continues unabated.


Boys vs. Girls in Junior High

I'm proud of my wife for her efforts to better understand the gender disparity in performance that has developed in boys compared to girls in our local Illinois public schools. She worked with Peg Tyre, author of "The Trouble With Boys: A Surprising Report Card" and a team of other concerned parents to actually measure what many has suspected: boys are not faring as well here as girls in school:

After a four-month review of items such as grades, test scores, and teacher attitudes, they produced a more than 100-page report showing that while there was no difference in intelligence between Wilmette's boys and girls, the boys trailed girls by almost every academic measure. Specifically:
  • In grades 5 through 8, girls had higher grades across all four core subjects: reading, writing, science, and math.

  • Boys were more likely to get grades of C or lower, and girls were 30 to 35 percent more likely to receive an A.

  • For the previous four years at every level of junior high school math, girls outperformed boys.
They were recently featured in this month's Chicago Magazine (though her name was misspelled).

It is interesting to ponder if this might affect our medical school applicant pool in the future.


Thursday, September 11, 2008

Another Epiphany

You know what's depressing?

Going to your child's school Curriculum Night and realizing you're now older than all of the teachers AND the school principal.


They Were Real People

... those who died on this day seven short years ago:

Click image to enlarge

... and those who helped begin the healing:

Click image to enlarge

God bless America. Take a minute to remember.


Image reference: yours truly.

Wednesday, September 10, 2008

More on Doctors vs. Lawyers

Well, I've previously commented on the preponderance of donations to the presidential campaigns by lawyers versus doctors, but today, I'd thought I'd turn to a different issue: the striking differences each profession uses for billing those they serve.

Recently, I have had the misfortune of requiring the services of some of my more esteemed members of the legal profession. My faithful readers will be happy to know that it has nothing to do with malpractice, but it does have to do with this blog. Rest assured I will be more forthcoming in future weeks about the situation, but for now, especially after learning when not to blog about legal proceedings thanks to the misfortune of fellow-blogger, Flea, I will table any discussion regarding my circumstances.

But that does not mean I can’t speak about what I have learned from my lawyers, especially about how their billing practices differ from doctors’ billing practices. To say I am envious how they conduct business is an understatement. For when it comes to accounts receivable, lawyers rock. (I can’t believe I’m saying this, but it’s true).

So here are the differences I have realized so far:
  • Lawyers work in their offices, then travel to court rooms, billing for their travel expenses there. Doctors work in their offices and travel to hospitals. They drive their own car to the hospital and pay for gas that is not reimbursed.

  • Courtrooms do not bill patients or lawyers. Hospitals always bill patients.

  • Lawyers bill by the hour. Doctors bill by the procedure.

  • Anyone can see a lawyer, but they'll have to pay for it. Anyone can see a doctor at anytime (can you say ER?) without concern of having to pay for it.

  • Senior law partners make $595 per hour and junior law partners make $395 per hour. This pays for their expertise, office expenses, including personnel, etc. Doctors are paid irrespective to experience and are paid much less than lawyers, but few really know what their hourly wage is because it differs from patient to patient and procedure to procedure, based on the patient’s insurance plan.

  • Lawyers do not accept partial payment from their clients. With the exception of most plastic surgeons and some dermatologists who are cash-only, most doctors must accept partial payment from their patients based on pre-negotiated agreements with insurers as payment in full.

  • Lawyers divide their hour in 0.1 increments (6 minutes) and bill for work accordingly (the smallest time I was billed for was 0.2 hr – 12 minutes). We must work for over 20 minutes to move to a level “2” evaluation from a simpler, level “1” evaluation.

  • Lawyers bill for conversations, research, phone calls, meetings at the same rate as they do for being in court. Doctors’ do not bill for time spent discussing cases, research, phone calls, or meetings – their income comes from “bundling” of a single Medicare payment from their time before and during surgery.

  • Lawyers continue to bill for additional services rendered after being in court. Doctors cannot bill for any evaluation of a patient after surgery for 90 days, lest they be prosecuted by Medicare for “double-dipping.”

  • Lawyers describe the service rendered and bill for it based solely on the time required to complete the task. Doctors can describe and describe their service until their blue in the face, but unless they add a family history, 12 elements of a review of systems, do 15 back flips and thirty push-ups, they cannot bill a level “5” consult.

  • If lawyers do not get paid, they sue you directly. (God help you.) If a doctor does not get paid, doctors either write off the loss or pay for a collection service to hound you or sue you and, if lucky, receive 60% of the amount due.

In summary, lawyers set their own value, guard it carefully, and increase their hourly wage based on reputation, supply, and demand. Doctors, on the other hand, have succumbed to socialist pressures that have prevented a more realistic, capitalist approach to their economics. As such, they have allowed their value to be set for them by others and have watched their market value (and any ability to negotiate their value going forward) to dwindle, irrespective of specialty.

No wonder there’s a doctor shortage looming.


Tuesday, September 09, 2008


He saw me first.

“Dr Fisher!”

I turned, looked. There he was: tall, regal, smiling. My mind scrambled: I recognized him, but couldn't’t recall his name. Years ago. Did he have a pacemaker, defibrillator, ablation? What was it? Oh, come on now, Wes! Can’t you remember anyone’s name? But I could delay no longer as I walked toward him…

“Hello, how are you?”


“How come you’re here?”

“Oh, I was seeing Dr. Frigamafratz.” (I didn’t know him either…)

“How come?”

“They found a mass on my kidney - cancer.”

Stunned, I wasn’t sure what to say. But he stood with a half-genuine smile, clearly concerned. Now I felt even worse: I couldn't remember his name AND he had newly-diagnosed cancer. I scrambled for something to say:

“Are you going to need surgery?”

“No. We’re beyond that. I’m looking at other options.”

“Oh, I’m sorry. Are you doing okay?”

“Yeah, just waiting for my wife to bring around the car.”

“Best of luck to you.”

“Thanks, Doc.”

He was so level-headed, quick, polite, gracious under fire. Our brief conversation was closing and I wondered if I would behave the same in such a situation. I turned slowly to head to my car, too, mind scrambling still.

“Oh Doc?”


“Tom Kelly, remember?” (Not his real name.)

“Uh, sure! God luck to you, Mr. Kelly.”

Despite my best efforts to conceal my ignorance, he knew all along. And yet, even so, he confided in me his deepest, most personal concerns at time he was most vulnerable, just because I had treated an unrelated problem for him years ago. I cherish this part of what it means to be a doctor and I will always be honored and humbled by such remarkable interactions.

Thanks, Mr. Kelly.


Saturday, September 06, 2008

On Time, Technology, and The War of the Worlds

War of the WorldsIt seems so sudden, this shortening of the days.

It is dark now where it was once light, yet the days remain fixed at 24 hours. You reflect, and think about time: time for light, time for leisure, time for family, and time for work.

Time for doctors is the incessant foot soldier, marching relentlessly as one day moves to the next. Increasingly, doctors (especially proceduralists like myself) are compensated, in part, based on productivity. Such a model is limited by the time available, by its vary nature. So in order to remain income-neutral as insurance payments have dwindled, doctors historically have been pressed to do more in less time. In most instances we have managed, but the margins for doing more within the same fixed 24 hours of time has reached its limits.

Consequently, I wonder what my profession will look like in five or ten years.

It is interesting to see the promotion of atrial fibrillation ablation and cardiac resynchronization devices for heart failure begin to take the forefront of cardiac electrophysiology. But these more complicated procedures also take much more time to perform than a comparable catheter ablation procedure for supraventricular tachycardia or a standard pacemaker for heart block. Not surprisingly and likely in large part due to the push by government payers to limit expenditures to proceduralists like myself, a serious discussion is now being had across the country by subspecialists: offer more complicated procedures which pay much less per hour spent, or funnel these cases to specialized centers in favor of cherry-picking the simpler procedures.

Such a strategy also plays into the hand of high-tech developers in my field nicely. Increasingly, we have seen a large marketing push to promote either the stiff-cathetered Hansen Medical steerable sheath in the heart or blood vessels, or the spaghetti-noodle-soft catheter of the Stereotaxis system which is steered within the heart using a super-magnet and driver motor. But what I have been noticed is these technologies have not launched to the level I would have expected if they had delivered a true paradigm shift to the way we ablate arrhythmias.


While these technologies are fascinating and make for great promotional material for hospitals, they address a problem few electrophysiologists feel they have a problem with: steering a catheter. Unlike the 3-D mapping systems like Biosense Webster's Carto system, or St. Jude's Ensight system that help us understand the anatomy and physiology of arrhythmia processes (and therefore have value-added benefit to the electrophysiologist), catheter-moving robotic technology has so far added little to the ability of electrophysiologists to correct the underlying rhythms being treated. Additionally, cost has been a barrier to market entry, with Hansen's system costing somewhere in the neighborhood of $600,000 US and, Stereotaxis's system costing significantly more since special construction and non-magnetic equipment is required to install their system.

But there's still a more pressing barrier to entry for these technologies now: time.

These devices take time to set up, time to train personnel, time to wait for the anesthesiologist, time to move the other non-robotic catheters used in the case, and more time to move the robotic catheter from point A to point B. As such, they have not yet delivered on the promise to be more efficacious or expeditious than our manual ablation techniques. They have not simplified our complicated procedures but rather complicated them.

This is not to say that ablation cannot be performed with these robotic systems. Certainly they can. But to the average electrophysiologist interested in getting their work done well and getting home in time to see their kids before bedtime, or to the hospital administrator interested in increasing their productivity in an existing lab, these devices have yet to deliver improved efficiencies or effectiveness compared to manual procedures. I even heard one hospital administrator snicker that they're aware of more than one specially-constructed laboratory sitting idle as doctors resist its use in favor of a conventional facility. Does this mean for doctors whose hospitals purchase these systems that they'll be forced to used them? Will the companies push Medicare to developing a reimbursement code to that there will be an economic incentive to use them?

In H.G. Well's War of the Worlds, a simple, unappreciated bacterium ultimately destroys invading powerful alien creatures that arrive in London. For these robotic catheter-driving technologies, time, especially procedural time, has become the simple under-appreciated bacterium that might affect their survival as well. While any new technology carries a learning curve, unless they offer improved time or outcome efficiencies, they will be bypassed for more conventional approaches. What is clear, is that few hospital administrators will want to purchase them if they're just doing to store these expensive technologies in a closet.


Image reference: Wikipedia.

Thursday, September 04, 2008

Software Coming to Help Detect Medtronic Sprint Fidelis Lead Fractures

Sometime next week, we should be receiving software, called the "Lead Integrity Alert" that can be uploaded into existing Medtronic implantable cardiac defibrillators (ICDs) to help detect lead fractures from the recalled Sprint Fidelis (Model 6949) defibrillator leads. This software was approved by the FDA today and can be uploaded into the Medtronic's Marquis, Maximo, Virtuoso and Concerto ICD models non-invasively during a routine office visit. It is thought that such programming changes can reduce the number of patients who receive an inappropriate shock from a lead fracture before it is explanted by 38 to 40%. While not perfect, it might alert both the patient and physician earlier to a avoid unnecessary shocks should a lead fracture.

How the Software Works

There is a so-called Sensing Integrity Counter that usually trips an alert if there are greater than 300 counts of non-physiologic sensed intervals by the device. This software will lower this number to 30 or more to trigger an alert. Further, if there are an excessive number of very short "non-sustained ventricular tachycardia" sensed intervals, this also could trigger an alert. The software also allows an automatic adjustment of the "number of intervals to detect" to be automatically incremented to the next-higher detection ratio in hopes of averting a shock, while beeping six times a day (rather than once) to improve the chances a patient will notice the new alert state if tripped.

What to Do

Patients with the advisory leads will have the software automatically installed during their next routine office device check, but those who want it installed earlier should contact their doctor and inquire if the software could be installed earlier.

Realize this software only affects Medtronic ICDs. St. Jude and Boston Scientific devices are NOT affected.


11 Sep 2008 Update: Medtronic's Info on the Lead Integrity Alert.

Change of Shift Is Up

... the best of the nursing blog-o-sphere is up "Pulp Fiction-style" over at Nurse Ratched's Place.


Wednesday, September 03, 2008

ICD Shocks - A Blessing or a Curse?

It's all across the media: ICD shocks predict impending death!

Thanks. My patients appreciated these headlines, I'm sure.

But if we're going to tell the 234,000 people who have implantable cardiac defirillators (ICDs) that they're going to die in less than a year after their first shock, shouldn't the media attempt to exercise even a modicum of discernment before going public with these headlines?

First, these findings come from analysis of the Sudden Death in Heart Failure trial (SCD-HeFT) - a well-designed prospective multicenter randomized trial in adults over age 18 which randomized over two thousand patients between three therapeutic treatments for heart failure: (1) conventional medical therapy, (2) converntional medical therapy plus Amiodarone, and (3) conventional medical therapy plus a single chamber, shock-only ICD therapy. The main finding of the SCD-HeFT Trial, in its original form, was that medical therapy (be it with o without Amiodarone), mortality in this group of patients was 7.2% annually. In other words, our best antiarrhythmic at the time, Amiodarone, failed to effect patient mortality. The addition of an ICD for primary prevention of sudden death is this sick population, actually reduced mortality (to 5.5% per year in patients followed for 5 years - a 23% reduction in mortality compared to medical therapies).

So now, is it any wonder that patients who have received an ICD to prevent death on a preventative bases, might just get a shock as their condition deteriorates?

When you can take fairly sick individuals and implant an ICD in them as primary prevention (i.e., they never had an arrhythmia before) and then look at those who develop arrhythmias suddenly, it seems intuitive to me that those patients would be sicker or have had a change in their clinical situation.

The data from the study support this theory. Therefore, evaluating for the development of worsened heart failure or additional ischemic burden might be prudent in these patients, since these causes seemed to be the largest culprits resulting in ICD shocks. Additionally, the study found that patients with either appropriate (shocks for ventricular arrhythmias) or "inappropriate" (shocks for rapid heart rates from non-ventricular causes, like atrial fibrillation onset) have a poorer prognosis compared to those who did not receive shocks, but this also might be a way to risk-stratify the sicker patients of the overall implant population. Does this mean the patients should not receive devices to live longer? Of course not. But there has to be balance to recommending ICDs in the sickest patients, since recurrent shocks can impact the patient's quality of life if they occur frequently. Infrequent shocks, interestingly, did not seem to convey a worse quality of life in this same group as reported (ironically) in the same issue of the New England Journal of Medicine.

Remember that all mortality curves of different therapies that divert favorably from one therapy, will again meet with the alternate therapy some time in the future, since none of us are immortal. ICD's reduce mortality in sick patients with heart failure, but an ICD shock might suggest that, of the group implanted, those patients with shocks have a better indication for the device, since their mortality is higher. It is important, however, to keep in mind who was NOT studied in this paper:

The patient population studied did not include children.

The patients studied did not have cardiac resynchronization devices.

The devices were not programmed for antitachycardia pacing and did not have dual chamber devices which are better capable of detecting atrial arrhythmias.

So before our patients go out to buy funeral plots, let's keep the issues of the risks and benefits of ICD therapy, and the benefit or curse of their shocks, in perspective.


Reference: Poole, JE et al, "Prognostic Importance of Defibrillator Shocks in Patients with Heart Failure," New England Journal of Medicine Sep 4, 2008 Vol 359(10):1009-1017.

Our Most Expensive Typing Pool

With the advent of the Electronic Medical Record, the world's most expensive typing pool has been born.

Just look at all of the nurses, medical students, residents, pharmacists, social workers, physicians' assistants, nurse practitioners, and attending physicians from all corners of the medical globe tic-typing away each morning, noon and night. Sit at a table next to this remarkable typing pool and all you'll hear is: "click-click-click-click-click-click-click-click-click-click-'sh*t'-click-click-click-click-'dammit'-click-click-click-click-click."

Each morning, without fail, there's one or two individuals circling the computer terminals waiting for access to these electronic monetary portals, like children waiting to grab the last chair when the music stops.

But what are they typing?

Here's an example (actual typing in bold):

.id (name, sex, age entered automatically from what clerk has entered at Central Registration) referred for (enter your chief complaint here).

.pmh (At least four pages of Past Medical History spits out when this is typed - the original work was completed by the patient's poor primary care physician, neatly organized, but never to be updated again - hey thanks, Dude!)

.psh (Another page of Past Surgical History is dumped into the note in a fraction of a second, the information kindly entered by a newbee medical student or overachieving resident, or in some rare cases, that gracious primary care physician - hey, you guys are the best!)

.cmed (Another page and a half of the current medications, their dose, prescribing physician, half of which come from self-generated 'CYA' hypoglycemia orders are also self-generated in the interest of 'safety')

.all (The patient's allergy list)

.soc (The patient's Social History regurgitated in detail, with helpful information like "wears seat belts," "does annual self-examinations", and "coffee consumption" all, of course, provided by the patient's primary care physician pain-stakingly entering this highly critical information for the purposes of satisfying "quality initiatives" and Medicare billing requirements - I mean, aren't primary care physician's the best?)

.fam (One line of "Mother died of CA" automatically spits out (previously entered by the hospitalist - bless their soul - so that billing to Medicare can go from Level 4 to Level 5 for the rest of the health care team. Way to be team players!)

.ros (Spits out a canned review of systems, always appended with "All other systems negative.")

.vs (Automatically enters vital signs here, automatically generated by automated pneumatic blood pressure cuffs, digital thermometers, and pulse oximetery machines)

.exam (Enters doctor or nurses's pre-canned exam, edited as needed to they can remember what the patient looked like - unfortunately, this portion of the typing takes the most time and requires the person to surrender their precious computer terminal to actually talk to the patient and examine them.)


EKG: (Put your best guess here)

Cut and paste CXR results here.
Cut and paste echo results here.

And here, some erudite proclamation of an interpretation of the problems is carefully typed. This, you see, is the only thing people will read. The rest above is for Medicare and has been added repetitively and identically by countless other individuals, all whom enter the same content to assure achieving the maximum amount billed by law for their services. Not that any of it is read, mind you, but it'd better be there, lest the Medicare auditors descend on your facility.

Plan: The other portion of what is really read. This takes a bit longer to enter, too, since the doctor spends much of the time scrolling back up the note to see if the medication recommended will interact with the multitude of medications spit out by the ".cmed" dot-phrase.

I wonder what the effect of such automatic generation of notes will have on the next generation of doctors. Will they actually process what is entered, or merely become highly-efficient typists and plagiarists in the never-ending quest to become more "efficient" health care providers?