Friday, October 31, 2008

Should You Have Blogging Insurance?

Digital Pathology Blog contemplates his liability needs as a blogger. I would encourage this given my experience, particularly if "whistle-blowing" or ranting occurs on your blog. Some offerings for bloggers insurance are mentioned here. I'm still shopping options and readers will likely see advertising creep in to my blog to offset expenses.

I'd also encourage all bloggers to understand the legal definitions of defamation, slander, and libel.



My Problem: "Bloggers Beware"
Where I try to decide if I should continue blogging: "So Now What?"
From the Daily News / Opinions: "Bloggers Must Learn A New World Order to Win Fans, Respect"
Electronic Frontier Foundation Cyberslapp Website

Wednesday, October 29, 2008

In Politics, Money Matters

When it comes to driving policy for health care in the upcoming election, money matters. I thought just before the election it would be interesting to see how different groups supported the presidential candidates.

From the Chicago Tribune's website on the 2007-2008 presidential campaign contributions, I punched in some search terms for the occupations of various donors, and this is what I found:

Click image to enlarge
In every category, whether it be doctors, lawyers, nurses or hospitals, Obama's fund raising machine received more contributions and more dollars toward his campaign from health-related occupations.

But to keep today's health care costs in perspective, if we assume that the average family's annual insurance coverage costs $13,000 per year, Obama's total fund raising tab amongst the above groups would cover only a few more than 2300 families.


Anyway, don't let all of this money go to waste - get out and vote on Tuesday.


Halloween Picture Caption Contest

Here's the picture. Now go on over to Happy's place and add your suggestion. As he says: "All humor accepted. Leave no stool unturned..."


Devices Finished? I Don't Think So

If only biotechnology could deliver on its promises:
“You can’t keep stuffing gizmos into people to treat end-stage disease,” the keynote speaker said. “When biotechnology gets right, we’re finished. Because it’s restorative, not palliative as devices are.”
Biotechnology for pacemakers? Not yet. Biotechnology for treating tachyarrhythmias with stem cell injections? Not yet.

Maybe Mr. Osterle knows something that I don't know, but for now, I'm gonna keep "stuffing in" his company's devices. I just haven't seen the Fountain of Youth from biotech spring forward for my patients.

But heck, why not dream?


Tuesday, October 28, 2008

Round Three - One More Time

To paraphrase an insurance letter from Blue Cross Blue Shield I received today from another disgruntled patient:
Dear Doctor,

We regret that we cannot pay your claim despite the letter we requested and the copy of the chart you sent us before. Please send us the information one more time so we may reopen the file for consideration and have it reviewed by our medical reviewer.


Blue Cross Blue Shield Delay Payment Squad

PS: We'd really appreciate you taking your time to comply with this letter as we earn more interest on the money your patient has already paid us - you're the best.
I can't tell you how many of these letters I'm getting now with the economic downturn. And the sad thing is, everyone knows it's happening but noone's doing anything about it.

Welcome to third party payment schemes 101.

Now, anyone want to talk about "never events" with the insurance industry?


29 Oct 2008 10:45 AM CST Addendum: An example of one of many such letters.

One wonders, in this era of electronic medical records, if all the computer infrastructure and endless piles of documentation are worth anything in situations like this. But, alas, it's just another example of covert rationing.

Freedom of Choice for Health Care Delivery Options

Interesting take from George Will today on Arizona's Proposition 101 before its populace on Election Day:
On Election Day, Arizonans can give the nation the gift of a good example. They can enact a measure that could shape the health care debate that will arrest or accelerate the nation's slide into statism. Proposition 101, "The Freedom of Choice in Health Care Act," would put the following language into Arizona's Constitution:
"Because all people should have the right to make decisions about their health care, no law shall be passed that restricts a person's freedom of choice of private health care systems or private plans of any type. No law shall interfere with a person's or entity's right to pay directly for lawful medical services, nor shall any law impose a penalty or fine, of any type, for choosing to obtain or decline health care coverage or for participation in any particular health care system or plan."
I'm betting this passes...

... at least I hope so.


Another Iteration of Artificial Heart

With the rising number of uninsured, the incredible cost of end-of-life care that already exists, the economic crisis, and the growing public awareness of the cost of healthcare, can we really afford to splurge on artificial hearts any longer?

I wonder.

But this new device does look cool. But if it's really like the real thing, as the article suggests, could someone explain what the blue thing hanging off the pump correlates to in man?


Monday, October 27, 2008

The Oldest Functional Body Part on Record

... and it's lasted 123 years.


via Instapundit.

Challenges Ahead for Specialty Care Doctors

As the election nears, both political parties have plans for leaving "no person left behind" when it comes to health insurance even though the costs will be exorbitant:
If the victorious candidate presents his health-care plan to Congress, such optimistic projections will face a stern test at the Congressional Budget Office, Congress's fiscal scorekeeper. The office's estimate of the actual cost of the plans would form the basis for debate, and legislators would face a huge barrier approving any plan assigned a $1 trillion-plus price tag over 10 years. (emphasis mine)
I just returned from a strategic planning committee of the Heart Rhythm Society in Dallas that was tasked with trying to anticipate the impact of the current economic and health care crises on our specialty. The mood, needless to say, was somber. The threats to our subspecialty (and I'm sure of many others) are keen as Congress moves to increase expenditures to primary care at the expense of specialists and subspecialists. One dean of a medical school even commented this weekend, "When the Congressional Budget Office knocks on my door and approaches me about where they can cuts and shift costs given a budget-neutral environment, which is easier, cutting funds to a subspeciality with 1600 members nationwide or cutting the funds from the many family practice or internists out there?"

So while most doctors will appreciate the near flat Medicare payment schedule secured by Congress this year, specialists still have to worry that change is in the wind.

Only by understanding the value of specialists and subspecialists in terms of expertise, safety and patient care outcomes are subspecialist services likely to survive, or even thrive, in the current climate. The onus will be on each subspecialty's lobbies to define such things as competencies, safety, and outcome records and present them for consideration to governing bodies. Clearly for smaller subspecialites, this is a particularly expensive and time-consuming endeavor as each subspecialty fights to maintain some portion of the Medicare payment pie.

Americans, however, will continue to demand subspecialization in medicine for the foreseeable future since they recognize that subspecialists play an important role in their health care delivery. It is impossible for general practice and primary care physicians to understand and implement subspecialty care in today's complicated and litigious health care environment. But as efforts continue to shift dollars from subspecialist to primary care, there exists a potential for losing subspecialists. In fact, 10% of electrophysiology training positions were left unfilled this year. What will this mean to patients? What does this mean to hospitals who are counting on electrophysiology to be their piñata of Medicare dollars to fund their next wing expansion? Why are doctors not committing to the rigors of our subspecialty? Is the market saturated or is this an aberration?

It is unclear.

But one thing is clear, you can't rob Peter to pay Paul without an impact to speciality care delivery. With the expanding elderly population, existing subspecialists will be stretched to maintain service expectations and their lobbying clout. Young doctor professionals will wonder if all those years of delayed gratification to gain expertise are really worth it. And as the cost of training increases and reimbursement to specialists decline, look for a consolidation of subspecialty care in America while new doctors reconsider their career trajectories.


Sunday, October 26, 2008

The E-Schnozz

This is kind of interesting. Only thing is, the presence of bacterial odor may not necessarily imply that pathology exists since the patient might just be colonized with the organism.


Saturday, October 25, 2008

Ten Times the Fun

According to the bureaucrats, if you want to impose "cost saving measures" to correct our complicated health care system, do everything in your power to make it more complicated.

In fact, make it at least TEN TIMES more complicated.

Take for instance, our current coding scheme for classifying diseases called ICD-9 codes. (ICD-9 stands for the ninth revision of the "International Statistical Classification of Diseases and Related Health Problems"). These codes are required on every insurance claim to justify a payout on behalf of the patient. If a procedure code does not match the appropriate disease code on an insurance claim.... BOOOIIINNNNGGGG, the insurance claim is denied, and Medicare and the insurers save money.

These codes are a picture of clarity. I mean, let's hear it for 427.0! Oh, baby, I can get my head around that code, can't you?

What, you don't know what that means?

Why, "SUPRAVENTRICULAR TACHYCARDIA!" I mean, I knew that, why didn't YOU? Sheesh! Any REAL doctor knows THAT code. After all, it makes so much sense, right? And 427.1? Why heck, any well-respected doctor should immediately be able to intuit that the code is used to denote VENTRICULAR TACHYCARDIA! What, you're lost? How can that be? I mean, it's so CLEAR!

And on and on it goes, some 17,000 codes for 17,000 kinds of ailments.

But for bureaucrats, 17,000 codes are not enough. They want MORE! Many, many more. And so, ladies and gentlemen, they have announce the introduction of...

... drum roll, please ...

... ICD-10!

Yep! Welcome to the world of the soon-to-be-enacted NEW AND IMPROVED 10th revision of the ICD codes with a staggering 155,000 codes to be implemented on 1 October, 2011!

Imagine, 290 codes just for diabetes! Yeeeee haaaaa! Diabetes with foot ulcers on the right foot gets one code, diabetes with foot ulcers on the left foot gets another code, diabetes with foot ulcers on both feet, but not involving the shins gets another code... I mean, a new code for every nuance of disease! You get the drift! Isn't this SPECIAL? Just think of the COST SAVINGS those clever bureaucrats have found!

Oh, wait.

Someone actually looked at the cost to implement this "cost-saving" coding scheme for doctors, and here's what they found:
The total estimated cost for a 10-physician practice to move to ICD-10 would be more than $285,000. These expenses include:
  • Training expenditures are estimated to total $4,745

  • New claim form (superbill) software $9,990

  • Business process analysis $12,000

  • Practice management and billing system software upgrades $15,000

  • Increases in claim inquiries and reduction in cash flow of $65,000

  • Increased documentation costs $178,500

For a small, three-physician practice, the total cost to implement ICD-10 is estimated to be $83,290, for a large, 100-physician practice the estimated costs to implement ICD-10 is more than $2.7 million.
Heck, I'm on board, aren't you? Especially since most stand-alone physician practices can't even afford yesterday's electronic medical record that will be obsolete before it's installed. Look, for instance, at this comparison of a family practice doctor's current 2-page "superbill" that will expand to a 9-page "superbill" using the newly proposed coding scheme.


But lets not fool ourselves. This is exactly what the government wants: more complexity and bureaucracy in the name of lower "costs." One only needs to see how the government calculated their "cost" savings for justifying the massive increase in complexity to the coding scheme:
Benefit Assumption 1: Based on the data provided in a recent AHIP report the percentage of pended claims was assumed to be 14% of total claims.

Benefit Assumption 2: Pended claims will be reduced by 0.28% (minimum) to 0.7% (maximum). Using the research and interviews, it was assumed that the pended claim percentage, currently 14% (Benefit Assumption 1), would be reduced through standardization.

Benefit Assumption 3: Reduced manual intervention will reduce the costs for providers by $3.20 per call and for plans by $1.60 per call. Manual intervention is required to resolve pended claims and both Healthcare providers and Health Plans incur these operational costs.
Yep, there you have it. CMS has justified the most massive expansion of electronic coding so "providers" and massive health systems can get their money without having to pick up the phone.

But just in case doctors aren't too keen about the complexity and expense of electronic medical records for their office due to the carefully-planned obsolescence of new systems, doctors are also being forced to e-prescribe next year in order to gain 2% more of their Medicare payment they were due.

My friends, soon we will see that the Beast has won. Independent stand-alone physician practices will soon be a thing of the past, brought to their knees by overbearing electronic billing and prescribing regulatory requirements. In their place will be physician-employees of major health care systems that are capable of purchasing computers, personnel and electronic reimbursement software upgrades annually, while they are subject to data-mining algorithms to assure "efficiencies" and "effectiveness" and "quality," all in the name of cost-savings.

Too bad its the patients who will ultimately have to bear the costs for this.


Friday, October 24, 2008

Managing Atrial Fibrillation in Heart Failure

When the number of authors on a paper approach the number of patients in one arm of a prospective, randomized trial... heads up.

I have just finished reading an article that appeared yesterday in the New England Journal of Medicine (Khan MN et al., "Pulmonary Vein Isolation for Atrial Fibrillation in Patients With Heart Failure" N Engl J Med 2008; 359: 1778-1785) regarding the PABA-CHF Trial (Pulmonary Vein Antrum Isolation versus AV Node Ablation with Biventricular Pacing for Treatment of Atrial Fibrillation in Patients With Congestive Heart Failure). It was an ambitious trial that compared atrial fibrillation ablation to biventricular pacing with AV nodal ablation for the treatment of heart failure. At least 29 investigators from 17 different centers randomized a mere 81 heart failure patients with weak heart muscles (ejection fractions <40%) into two treatment groups: 41 for atrial fibrillation ablation and 40 for AV nodal ablation and implantation of a biventricular pacemaker. The pre-specified endpoint was a composite one: improvement on a 6-minute hall walk, improvement on the Minnesota Living with Heart Failure Score, and improvement in ejection fraction. After showing remarkable results favoring ablation in terms of these three measures, the authors concluded that "pulmonary vein isolation was superior to atrioventricular-node ablation with biventricular pacing with heart failure who had drug-refractory atrial fibrillation."

Those are powerful words, especially when they are published in the New England Journal of Medicine.

Given that atrial fibrillation is the most common arrhythmia in man and occurs in probably 10% of the population over 80 years of age and heart failure, too, is an incredibly common disorder, we have to ask ourselves why so few patients were enrolled in this important trial? Was it tough to find appropriate patients willing to submit to the trial? Why were so many centers involved? Might the results have been skewed by sampling error or selection bias?

These are not small questions, especially for a trial studying such an economically and therapeutically important topic.

There are important distinctions between the two procedures studied that were conveniently ignored by the authors. First, atrial fibrillation often requires the use of an anesthesiologist and an impressive array of personnel and equipment (3D mapping systems, ablation equipment, etc) to perform. The average procedure time in many centers averages 4-5 hours and is labor-intensive. Further, earlier studies reporting on the world-wide experience of atrial fibrillation ablation in a much larger group of over 8000 patients demonstrated that 27.3% of patients required more than one procedure to render patients "cured" of their atrial fibrillation and only 52% of patients were rendered free of antiarrhythmic drugs. Further, there was a 6% incidence of major complications from atrial fibrillation ablation when performed in a larger cohort of presumably healthier patients.

Not to say that pacing and AV junctional ablation isn't potentially expensive, too. It is. But usually only one procedure is required. Further, the use of a biventricular pacemaker in these patients with ejection fraction under 40%, rather than a defibrillator, is puzzling since several trials have demonstrated a survival advantage for biventricular defibrillator therapy over biventricular pacing therapy in similar heart failure patients (SCD-HeFT, COMPANION). Were these patient's not really as sick as the authors suggest? Further, was 6 months' follow-up really enough? Why were there no deaths in such a sick patient population in either arm of the trial? Are the data reported in the new trial representative of a more representative population of patients with atrial fibrillation in heart failure?

I worry about studies like this that fail to drill down on such important issues and are published front and center in journals with the impact factor of the New England Journal. While this trial might have profound implications that urge us to delve further into catheter ablation as a means to treat heart failure, to claim that catheter ablation of atrial fibrillation is "superior" to biventricular pacing and AV nodal ablation with such limited data and only 6-months of follow-up is overreaching and might miss important morbidity and mortality endpoints.


Wednesday, October 22, 2008

Never Events to Affect Doctors Pay?

"Never!" says Buckeye Surgeon.

He offers a great essay on the absurdity of the notion and takes aim at the journalistic naiveté underway.


From Five Stars to One

How does Healthgrades rate hospitals?

An article on one hospital's fall from grace from a 5-star ranking to a one-star ranking cites two possible methods Healthgrades, the "industry standard" company that rates hospitals, obtains their data. On one side, we hear this from their spokesperson, Todd Van Fossen:
"To arrive at its ratings, Fossen said, Health Grades used Medicaid and Medicare data from 2004 through 2007."
But what kind of Medicare data? It's interesting to note that rating hospitals makes money (and plenty of it) for Healthgrades. In fact, Healthgrades is projected to make $10.42 million in Quarter 3 of this year. So does it come at any surprise that Decatur Generals' Dr. James Gilmore was less than pleased about their sudden drop in their CV surgery's status from five-star to one-star, stating that Healthgrades used a financial means of rating hospital surgical programs, claiming:
"Speaking before the program shut down, Gilmore said Health Grades uses billing data instead of clinical data to arrive at its ratings and that its primary responsibility is to its stockholders."
Could this be true? Given the lag time required to process Medicare claims data, we are left to wonder, do they use billing data or clinical data to "grade" hospitals? Could financial conflict of interests be swaying rankings?


What It Means to Be "Board Certified"

The American Board of Internal Medicine issued this press release yesterday regarding scam medical boards. I reported on this last October and notified the ABIM about this ploy: pay a few hundred bucks and you can have plenty of alphabet soup after your name and you get an authoritative "certificate" without taking any test.

I applaud them for protecting the value of the term "board certified" and states that have not already done so should enact legislation to protect this term. Patients and doctors alike should feel confident that the term "board certified" conveys special mastery of knowledge and skill in medicine rather than just paying to own a "certificate."


Tuesday, October 21, 2008

A Palliative Grand Rounds

... is up over at Pallimed:
Welcome to another edition of Grand Rounds (v 5.5), the best of the medical blogosphere. Below I have taken the liberty to edit down to what I considered the most provocative, most interesting, or most literary posts published in the last week.

Monday, October 20, 2008

The Disjointed Servers of Health Care

Here's how we serve health care in 2008:
Need to read an echo? Sign on to the KINETDX echo server.

Need to read an EKG? Sign on to the MUSE EKG server.

Need a cath report? Sign on to the APOLLO server.

Need to read a chart? Sign on to EPIC.

Need to check a pacemaker? Sign on to the PACEART server.

Need to read an Xray? Sign on to your local PACS system.

Need to check your e-mail? Sign on to the in-house intranet.

Need to read your e-mail from home? Sign on to the CITRIX server.

Need to sign your charts? Log on to the Electronic Patient Folder server.
And that's just the beginning.

* Sigh *

It's no longer an "electronic medical record" we're using but rather a sea of electronic medical servers.

Now let's see, what was that password again?


Sunday, October 19, 2008

Health Care and Cronyism

I picked up the New York Times this morning and saw the front page story entitled "Building Flawed American Dreams" and expected to find a story about American health care. Instead, I found it was really a front page story about Henry Cisneros and his involvement in the backroom-dealings of the housing industry - the subprime mortgage deals that led to our current economic crisis. The story chronicles the myriad of regulators, financial institutions, and cronyism that created this crisis, unfettered by transparency, free market competition or disinterested oversight. Somehow, I couldn't help but think that the story was about health care after all.


Because the parallels to our proposed health care system of the future are, I'm afraid to say, remarkably similar:
Homeownership has deep roots in the American soul. But until recently getting a mortgage was a challenge for low-income families.
Homeownership's roots in our soul pales in comparison to our own health care needs. Additionally. many families can no longer afford health care, or even the insurance policies that are supposed to be our saviour. "What do you mean we can't have health care for all? Of course we must! It is our moral imperative!" This is emotional manipulation - appealing to our most primal fears -a roof over our heads is primal, mortality more so.

So we stand on this slippery slope.

Enter the money.

We've gotten to the point where even our own presidential candidates have espoused health care as a "right" for every American. As we consider this entitlement, we must now ask ourselves how, exactly, the government will implement this initiative to make healthcare a "right." Can the government really supply the facilities, the doctors, the finances to make this happen? Or will they, like the housing industry, turn to private corporations to lead the charge? Who will get the contracts? What special legislation will be enacted to make it happen? Importantly, what business deals will be struck? What back-room deals and shennanigans will be cooked to make this impossible-to-finance system continue? Or will the parallels be as Mr. Cisneros said:
"I'm not sure you can regulate when we're talking about an entire nation of 300 million people and this behavior becomes viral."
"Health care for all" has already become "viral." The entitlement attitude for affordable health care has become the cornerstone of healthcare policy in America. So can we expect to regulate a bloated system of bureaucracy that, like the housing industry, has its own set of self-interested parties?

If the housing crisis is any indication, I doubt it. The HUD-insured subprime mortgage party lasted through both the Clinton and most of the Bush administration. The private and public organizations that fed at the government trough have taken their money elsewhere. Or perhaps they are waiting in the wings for nationalized health care - follow the money. When will we ever learn?

And when the propped up government funded health-care system fails, then what happens?


Credit Crisis Affecting Healthcare

From hospitals unable to find funding for continued operations, to medical device companies unable to secure a second round of funding to continue clinical trials, the credit crisis is affecting health care and might be the most effective force yet to help land our healthcare Hindenburg.

It sure isn't going to be our clueless politicians.


Friday, October 17, 2008

Heliport Concerns Rise Again

In the wake of yesterday's helicopter crash in Aurora, IL that killed 4, the safety of having a heliport on top of the newly proposed Children's Memorial Hospital in the heart of downtown Chicago is being brought into sharp focus this morning:
""My feeling is this accident rate is epidemic," said Jim Hall, a former chairman of the National Transportation Safety Board.

Investigators have just started looking into Wednesday's crash and have not reached conclusions on what factors played a role. But the accident put a new spotlight on a disturbing trend. Lax government regulation and fierce competition for customers have created a disincentive for helicopter transport companies to invest in advanced pilot training and safety equipment to protect flight crews, medical personnel and patients, the aviation authorities said.
The concerns for the safety of people in the highly congested downtown Chicago area have been voiced previously. The statistics are staggering:
The first step to improve safety on medical helicopters should be to immediately require two pilots on all medical helicopter flights to end a chain of accidents—15 so far this year, experts said. The safety board has called on the Federal Aviation Administration to implement reforms over the last decade, including a two-pilot requirement.


Like Wednesday night's crash, 90 of the 193 accidents occurred between 10 p.m. and 6 a.m., a period that authorities call the "back side of the clock" when fatigue is often a mitigating factor. In addition, 47 of the accidents involved the helicopters hitting obstacles, according to the database, which is drawn from government and industry records.
In light of these data, the question now becomes what safety requirements will the FAA and City of Chicago impose for helicopters landing on rooftops in the highly congested downtown area?


Wednesday, October 15, 2008

Cheney Has Afib Again

Just heard Vice President Dick Cheney had another arrhythmia - seems his atrial fibrillation has kicked in again. Since he's probably already on warfarin for his deep venous throboses, if he ate breakfast, they might administer Ibutilide to pharmachologically cardiovert him, or if he was without food for a sufficient period of time, consider cardioversion.


Addendum 1300 CST - From "Later this afternoon, the vice president will visit George Washington University Hospital for an outpatient procedure to restore his normal rhythm." Translation: He'll go to the hospital four hours after his last meal, be sedated, then have his defibrillator shock him back to normal rhythm, be monitored briefly, then return to the Vice Presidential mansion.

Tuesday, October 14, 2008

Superbugs and the Police State

Imagine folks: breach hand hygiene rules and hospitals could be fined up to £50,000 in England.

I can just see it now: undercover agents ("watchdogs") with clipboards slapping overworked doctors and nurses with tickets for "Failure to Wipe" or "Soap dispenser dysfunction." Or slipping a little fine into already underfunded hospitals. Criminey. Are these guys serious? As if patient's wouldn't have to ultimately pay the bill.

Look for similar rules here in the US as the government looks for ways to pay off the mortgage crisis and fund healthcare for the uninsured or maybe for Hilliary's new bureaucratic "Wellness Trust" bill introduced recently before the Senate.

I mean, what is "Wellness" anyway?


h/t: Gooznews

Grand Rounds is Up

... over at Notes of an Anesthesioboist:
Today I've organized Rounds into six major sections (each preceded by a self-indulgent little nod to a movie from my personal list of favorites)...


Father Knows Best

Welcome to the next episode of Father Knows Best entitled, "Best Practice Alerts:"
Have a diabetic without a HbA1c?
* Ding Ding * You get a best practice alert!

Have a patient without an mammogram in the last year?
*Ding Ding* You get a best practice alert!

Haven't had your colostomy colonoscopy and over age 50?
*Ding Ding* You get a best practice alert!

Haven't counselled you patient about their smoking each year?
* Ding Ding * You get a best practice alert!

Haven't had your cholesterol checked?
* Ding Ding * You get a best practice alert!

Didn't screen your patient over 18 for depression?
* Ding Ding * You get a best practice alert!

Didn't know that there 134 potential alerts for 2008?
*Ding Ding * You clearly need a best practice alert!
"Best Practice Alerts" are computer algorithms triggered from diagnosis codes.

"Best Practice Alerts" are an Electronic Medical Record's (EMR) means to assure that the "voluntary" Physicians Quality Reporting Initiative is undertaken. Never mind that failing to comply means certain discrimination between physicians. Just remember, it's voluntary! Really.

"Best Practice Alerts" force doctors to cross tacit specialty treatment boundaries and risk alientating referral doctors.

"Best Practice Alerts" drive testing and procedures, and therefore costs, to our health care system.

"Best Practice Alerts" are encouraged by those with a stake in health care.

"Best Practice Alerts" remove judgement from medical care in favor of mandates.

"Best Practice Alerts" are disruptive to doctor-patient interactions, consuming precious clinic time as "why" or "why not" must accompany each alert response.

"Best Practice Alerts" have not been shown to improve patient outcomes over more conventional care.

So how, then, are we to assume such alerts represent "Best Practice?"

Well, it's simple: because Father knows best.


Image reference:

Sunday, October 12, 2008

What's More Stable Than Money?

In these trying financial times, it's nice to know there's something more stable than money...

... like a 1996 McDonald's Hamburger:


h/t: Mark's Daily Apple.

Saturday, October 11, 2008

"Oh, and Doctor, One More Thing..."

It's the line no doctor wants to hear at the end of their examination, but it's the line that cuts to the chase:

"Oh, and doctor, one more thing..."

Doctors plan on adding at least 30 minutes to their clinic visit time for that line.

My favorite instance of this line came many, many years ago. I was in my internal medicine residency.

He was 82, a stalwart, congenial gentleman who was always prompt and a pleasure to manage. He decided to bring his wife to the appointment, since she knew all of his medications, dosages, and procedures that he could never recall. Plus, he needed a walker and she helped open the doors.

They shuffled into my office and were situated in their chairs. I reviewed his overall condition, addressed his concerns, and reviewed his extensive medical problem list: diabetes, hypertension, hyperlipidemia, coronary disease, osteoarthritis, and hip replacement. He had no significant complaints that day, so we refilled his prescriptions, ordered some basic labs to assure his diabetes and renal function were monitored and was ready to send them on their way, when his wife said:

"Oh, and doctor, one more thing..."

I braced myself. I couldn't imagine what would come next. I sheepishly asked: "Yes?"

"Well, I'm worried about Herbert." (not his real name.)

"Why's that?"

She looked down at her feet, then stared at me with conviction. I could tell she was struggling.


Her face was a bit red, but she was worried and bound and determined to make sure I knew her concern:

"Well, Herbert doesn't want to have sex with me each night any more. Is that okay?"

Now it was my turn. I was speechless. Dumbfounded. I glanced over and saw Hercules Herbert smiling.

"Uh, seriously?"

(God what a pathetic response, but it was all I could muster at the time.)

"Seriously. He just keeps wanting to fall asleep."

I looked at Herbert's med list again. Beta blockers, ACE inhibitors, statin, aspirin, angiotensin receptor blocker, glucophage. Nothing new. I couldn't help but wonder how this man had been so lucky. God, every night? Heck, I'd have to rest, too! I considered calling my wife. "Honey, I just wanted you to know that there's a guy here, well, you know, every night!" But I reconsidered. She was obviously concerned about Herbert. I asked to see his medications.

She pulled out a handful of pills.

I arranged them on the table and paired them with his med list:

"Now which is the beta blocker?"

She pointed to atenolol.

"And the glucophage?"

She pointed to the pill.

And on and on it went, until there was one left over.

"What's this?" I asked.

"Oh, that? Just a little medicine I gave him for his arthritis that bothered him at night."

"What's it called?"

"Serax. It worked great for me."

I reminded her that Serax was an anxiolytic and could cause drowsiness. She blushed, realizing her mistake.

She thanked me profusely as they left the office. I struggled to catch up with clinic and rushed home. When I got home I told my wife the story in confidence.

Needless to say, she wasn't impressed.


Wednesday, October 08, 2008

So Now What?

Given the events of late, there are questions I have to address, the biggest of which only I can answer: should I continue this blog? Certainly from an economic standpoint to date, this blog has been more of a liability than an asset. So now I have to be realistic and really ask myself, why continue?

I’m not sure. There are many arguments to support blogging as a physician: marketing yourself or your practice, advertising and making a buck, education (both for yourself or your patients), working with an online community of like-minded souls, or creating an online presence getting your voice heard on a national and international level. It all sounds so great, doesn’t it? I mean, I had it all figured out when I started! (Not.)

But blogging, as I’ve found, also exposes one to malicious verbal attacks and subpoenas. As such, it is risky. There is no question that placing one’s online self in the world for all to see adds vulnerability and potential liability. When I told a colleague Friday about my recent predicament he responded, “Why the hell would anyone want to blog?”

Good question.

I hope my experience makes every physician consider this question carefully.

But perhaps the question is not as simple as that. Perhaps physicians who choose to blog should ask ourselves how best we should maintain our increasingly economically important online presence while minimizing our risk to do so. In that vein, what rules for commenting should physicians impose? Should only anonymous commenters be restricted? What would that do to the quality and content of information discussed? Should all comments be reviewed before publishing them, risking the perception of censorship? Or should a blog be pulled underground, accessible only by registration? Should one blog anonymously or non-anonymously? How important are these blogs, really, to patients? All I know is that patients have found me repeatedly because of my online presence, but I have to question if the vitriol demonstrated by a few makes it worth it.

I’d appreciate the blog-o-sphere’s suggestions and commentary. I am certain that what is here will stay in its current form. But as I move forward to my next iteration, whatever that might be, it’d be helpful to hear your thoughts – even from anonymous commenters, although now, unfortunately, comments will be reviewed before posting.


Tuesday, October 07, 2008

An Even Bigger, Better CT Scanner?

Toshiba's Aquilion ONE with some bold assertions:
"LIVES will be saved, hospital admissions slashed and heart patients diagnosed more quickly with a powerful new scanner that has put Melbourne on the medical map.

The $3.5 million machine, unveiled at Monash Medical Centre yesterday, is the most advanced model in the world and five times more powerful than conventional scanners."
Never mind that there's no data regarding these claims for this new CT scanner, the radiation received, or the real costs in terms of false positives admitted or direct costs to patients. Certainly, overtesting is creating a huge financial burden on American healthcare. How much will this new technology add to our medical device arms race in cardiology?

But the technology is interesting and demonstrates how fast imaging technology leapfrogs payers' ability to know how to pay for it:
For the first time, physicians can see not only a three-dimensional depiction of an organ, but also the organ's blood flow and dynamic function. Unlike any other CT system, the Aquilion ONE can scan one organ — including heart, brain and others — in one rotation because it covers up to 16 cm of anatomy using 320 ultra high resolution 0.5mm detector elements.
So rest assured, it will all be good. Real good.

Trust me.


Treating Our Patients to Death

An excellent essay on futile care by Joseph Sacco, MD appears today in the New York Times.


Saturday, October 04, 2008

Bloggers Beware

Dear Blog-o-sphere:

I was going to tell you about a little problem I had in June that concluded last Friday, but I have reconsidered. This has been one of the hardest things I have had to do since starting this blog, since there's nothing more that I would like to do than to go public about this and let the individual who subpoenaed me suffer a little Streisand Effect in return for the considerable legal costs I have incurred.

I can tell you I was subpoenaed for a discovery deposition about one of my posts on this blog. I was not named as a party in the suit occurring in Cook County Circuit Court here in Illinois, mind you. Rather, the plantiff thought for sure that I knew one of the anonymous commenters on my blog. I did not. They insisted that I take down the post on my blog. I have not. They asked that I remove the comments identifying individuals on my blog. I have not and will not. They wanted me to take down an image I posted on my blog. It still stands.

After three trips for my lawyers before the Cook County Cicuit Court in late summer and fall of this year at considerable expense, my motion to quash the subpoena was rendered "moot" after the suit upon which it was based was dismissed in court.

So why do I let you know this?

Because of the circumstances that took place are important for bloggers to be aware of their potential for such legal actions, not dissimilar to that suffered by Karen Seidel of, just on the basis of anonymous commentary on your blog. The implications of this are chilling.

But I am also aware that I reside in Illinois, sometimes jokingly referred to as the "Land of Lawyers" rather than the "Land of Lincoln." Regrettably, I have no formal legal background and am therefore at a distinct disadvantage in court proceedings should the individual cry foul if I went public and drag me back to court again crying about some defamation claim. Sure, sure, my post is written and contains all kinds of documents pertaining to the suit and the other individual's prior activities, but it just ain't worth the potential hassle right now.

Rather, I'm going to let these guys handle it. I gave them all my info. Including the contents of that other blog post.

Trust me, that's going to be a lot more fun to watch.


Friday, October 03, 2008

Keyboard Residues

... from hospital hand disinfectant gels?


PS: I wonder what that stuff would grow?...

EKG Du Jour - #11: Tombstone Alternans

0400AM: "Uh, Dr. Fisher, we're having a little trouble. She keeps having this strange rhythm and loses her pressure."

Me: "Could you send me her EKG?"

Them: "Sure. We're sending it now:"

Click image to enlarge."

One of my Top Ten ugliest EKG's with some amazing findings.

How many can you find?


Thursday, October 02, 2008

End of Life ICD Issues

Anyone dealing of end-of-life issues should review the case study nicely discussed over at Pallimed.


The Mysterious Human Heart

A nice three-part award-winning documentary on the heart, funded in part by AtraZeneca, Mars, and Medtronic, can be viewed at the PBS website:
Peter Libby, MD, conceived, obtained funding for and served as senior medical advisor for “The Mysterious Human Heart,” a three-part documentary that earned executive producer David Grubin an Emmy Award for Outstanding Science, Technology and Nature Programming last month.
I like episode two, personally. ;)


My Favorite Kind of Patient

... one with a great sense of humor.

Today, as would have it, the cases were backed up in the lab. My ever-clever patient brought a book with him and wanted to show an exerpt describing what he was sure was a distant relative of mine. The exerpt came from David Lindley's paperback entitled "Degrees Kelvin: The Tales of a Genius, Invention and Tragedy" (John Henry Press, 2004):
"One man in particular became a crucial and outspoken booster (to the liquid-filled nautical compass). John Arbuthnor Fisher, born 1841 in Ceylon (now Sri Lanka), became a midshipman in the Royal Navy at the age of 13, having passed the entrance examination that consisted, his biographer reported, of "writing out the Lord's Prayer, and jumping over a chair, naked, in the presence of the doctor; after which he was given a glass of sherry as evidence of his having become a naval officer."
Yep. Sounds like a relative to me.


Cardiologists vs Electrophysiologists

It seems in cardiology, things are so tiny: tiny angioplasty balloons, itsy bitsy guidewires to snake down the smallest of coronary arteries. Heck most things they deal with are measured in millimeters: need I say more? Now electrophysiologists, well, I've already had my say.

But Dr. Val, today's guest blogger who transitions from her old space at Dr. Val and The Voice of Reason at Revolution Health to her new site at Getting Better With Dr. Val, notes a new trend in medical marketing to these marvelous medics of the miniature:

Heh. Dare I say it?... Click picture to ENLARGE...