Wednesday, June 30, 2010

Cardiology Fellows as "Experts"

Either we're not paying our cardiology fellows enough, or they have too way much time on their hands:
Consulting Services:
As a member of the Intota consultant network, Expert is a specialist who provides technical consulting to corporate, legal and government clients. Expert provides professional consulting as a Cardiology Consultant. Expert may consult as an independent consultant or as a member of a consultancy, consulting company, or consulting firm. Consultants service will be covered by a consulting contract. Ask an expert initial screening questions and ask the experts services particulars, by simply submitting an expert request.

Expert Witness:
Intota experts can serve as expert witnesses or litigation consultants offering expert testimony, expert advice, litigation support, forensic services, and related expert witness services. Expert can serve as an expert witness or litigation consultant in intellectual property (patent, trademark, trade secret, copyright), product liability, and insurance matters. Expert may provide forensic expert witness testimony, litigation consulting services, forensic investigation, and forensic testing if appropriate in litigation areas as a Cardiology Expert Witness. Intota provides attorneys and legal professionals the opportunity to ask an expert initial screening questions and ask the experts services particulars by submitting an expert request.
I bet Expert wishes he never advertised for this.


Tuesday, June 29, 2010

How I Saved My Patient $53 per Month

She came to me for a refill for metoprolol succinate (Toprol XL) at $60.61 for 50 tablets (slower release, taken once daily). Note that the linked webpage does not offer a generic equivalent suggestion, even though this one exists:
Metoprolol tartrate $7.18 for 100 tablets (25 mg are taken twice daily)
With all the fancy smancy multi-million dollar electronic medical record and e-prescribing systems out there, the ability of these systems to suggest cheaper drugs for our patients should be requirement for systems going forward. I'm willing to bet most patients wouldn't mind taking a pill twice a day if it saved them over $600 per year.


Monday, June 28, 2010

Why Lawyers Will Get Every Heart Test Known to Man

... because if you don't predict the unpredictable, they sue:
A doctor failed to see that former Tompkins County District Attorney George Dentes had heart disease, and this professional negligence led to Dentes' fatal heart attack in October 2006, his widow is alleging in a medical malpractice suit starting in county court this week.

Dr. Jonathan Mauser of Cayuga Cardiology Associates P.C. improperly interpreted Dentes' April 2005 stress echocardiogram, failed to suspect that Dentes had coronary artery disease and failed to recommend or perform a cardiac catheterization to confirm it, Elsie Dentes claims in the suit. Mauser and Cayuga Cardiology Associates are named as defendants.
Remember, the doctor did not give this patient heart disease, God did.

While I do not know the circumstances surrounding the case in question, it is clear that our society increasingly accepts that all diseases are preventable, life is limitless, and all tests we perform perfect. Of course, none of these are true. Yet when something doesn't follow the Western psyche's playbook, someone has to pay. All too often, that someone is the doctor.

This, my friends, is why doctors will continue to order every test known to man... as this case exemplifies, there is simply no incentive to do otherwise.


Why Did Dick Cheney Develop Heart Failure?

Years ago, when I was indoctrinated as a fellow in to American College of Cardiology, Dick Cheney - then a former secretary of state, was the keynote speaker at our commencement ceremony. His keynote speech reflected on what it was like to watch his father die following a massive heart attack, comforted only by morphine, oxygen, bed rest. By then, Mr. Cheney, already a recipient of two bypass operations, made a point to thank the cardiovascular community for helping him.

Many years later, Mr. Cheney's complicated yet remarkable cardiovascular history reads like a social studies timeline - one with heart attacks, arrhythmias, blood clots, and now, congestive heart failure. (Of course, political spin meisters want to make sure we call it "fluid retention" rather than congestive heart failure, since "failure" is not an option when speaking of all things political).

Congestive heart failure is nothing more than an insufficient pumping of blood to meet the body's needs. As a result, the kidneys detect the decreased perfusion pressure and trigger the release of a cascade of hormones to increase the blood pressure to maintain perfusion of the tissues. Some of the hormones help retain fluid in the vascular space. If this fluid becomes too excessive, the fluid can spill into the lung resulting in a sensation of shortness of breath, usually worse when lying flat. One of the main drugs used to fool the kidneys to release the accumulated fluid are diuretics - the most common being furosemide (Lasix).

There are a number of things that may have contributed to the development of Mr. Cheney's heart failure. Since HIPAA knows no bounds with disclosing Mr. Cheney's heart history, we can use this opportunity to tease apart a few possibilities.

First, dead meat don't beat.

It doesn't help that Mr. Cheney has had many heart attacks in the past. With the progressive loss of healthy muscle cells to to the heavy lifting of contraction, the ejection fraction falls. At first, the heart compensates by recruiting other, non-injured segments of heart muscle to take up the slack, but with each successive heart attack, the reserve heart muscle dwindles. Lose enough muscle and the heart must rely on increasing the rate at which if contracts to increase output, but for hearts already with limited blood flow this might lead to futher shortage of oxygen to the heart muscleto When this happens, the heart rate kicks up just a bit to increase cardiac output. If it kicks up too much, the heart can outstrip it's own oxygen supply, resulting in additional injury to the heart. This is part of the reason medication that slow the heart rate (beta blockers) can be helpful adjuncts to preserving heart muscle function and slowing the progression of worstened heart failure.

Second, Mr. Cheney's atrial fibrillation.

The loss of coordinated pumping of the top chambers (atria) just before the lower pumping chambers (ventricles) can lead to 10-20% drop in effective cardiac output in some patients. The irregularity of the heart's rhythm while in atrial fibrillation also causes a loss of coordinated closing of the normally one-way valves that direct the flow of blood through the heart, further compromising the heart's pumping ability. Rate control of atrial fibrillation or the restoration of normal sinus rhythm in the heart are often important adjuncts to the treatment of atrial fibrillation.

Third, is the presence of Mr. Cheney's defibrillator.

Although we do not know for sure, it would not be surprising if many of Mr. Cheney's heart beats are being supplied by his defibrillator's pacemaker feature. Excessive pacing the right ventricle can cause a dis coordinated beating of the lower pumping chambers, resulting in a subtle, but real, fall in cardiac function during paced heart beats compared to beats that are not paced and normally conducted from the top to bottom heart chambers. At some point in the future, Mr. Cheney might benefit, in appropriate circumstances, by adding extra pacing wire to his existing defibrillator system (so-called biventricular pacing) to re-coordinate the contraction process of his heart chambers above and beyond that which can be achieved with medications alone.

Finally, might he have new portions of heart muscle lacking sufficient oxygen?

Not all coronary arteries that might be partially blocked can be revascularized during surgeries or angioplasties. As a result, some segments of heart muscle might not have enough blood flow to maintain proper function, yet have just enough to survive intact. Many of our medications help lower blood pressure to decrease the work the heart has to perform on a beat-to-beat basis, dilate blood vessels to improve coronary blood flow, and work to decrease the negative affects that excessive adrenaline-like compounds can have on the heart's remaining muscle cells. The very fact that his doctors did not feel further invasive procedures were necessary suggests Mr. Cheney's revacularization options are limited at this point.

So given his current setback, what should we expect regarding his prognosis?

Hard to know. But given what I know about the successful management of heart failure these days, I wouldn't count him out quite yet.


Can You Lower Your Health Care Bill?

From the Chicago Tribune:
Get multiple quotes in writing. Before your procedure, shop around to various doctors to find out how much they charge and how much they expect insurance to pay. Get those price quotes in writing, with a name, title and signature, so that you have a paper trail if you end up getting charged more later. Remember to cover all the costs associated with the procedure and every doctor in the room: lab costs, the anesthesiologist, the radiologist, etc.

You may want to consult the "Healthcare Blue Book" beforehand ( It's a medical pricing guide that states the average compensation that medical providers accept from insurers for services ranging from surgery to dental and eye-care procedures.

It's especially helpful for those with high deductibles or who are paying out of pocket.

"Healthcare Blue Book is a great tool," Hicks said. "We're actually partnering with them, and will have a service in place for our members this summer that will let them click a few buttons to access local medical costs so they can find fair prices and save money. We'll rely on Healthcare Blue Book to provide that information."
I would add a word of caution about promoted in this article: some of the data are simply not accurate.

For instance, I looked up the costs for placing a permanent pacemaker and for a cardiac defibrillator, and the costs quoted by the site for the two different devices were identical: $4275. Further, there is no differentiation made regarding the type of pacemaker or defibrillator (such as single, dual, or biventricular devices).

Still, it's a start and the other points made by the article are worthwhile. Just don't be surprised if the medical billing office won't come close to matching some of the prices they quote online.


Saturday, June 26, 2010

Fellowship Graduation

Dr. Wes with Colleagues and Friends
Cardiology Fellowship Graduation,
National Naval Medical Center, Bethesda, MD

I'm not sure there's ever a time in medical training where one is so happy to get on with their careers as the day you complete your fellowship training. For a few very intense years, a special bond forms between you and those who work beside you - you've seen tough cases, sad cases, spectacular cases, together.

Fellowship was a chance to focus on the science and art of a very narrow segment of medicine. In my case, it was cardiology and (later) cardiac electrophysiology. I was glad I was able to retrieve the picture above, taken just before I completed by cardiology fellowship training. I wonder where all those magnificent people are now, and marvel at the young faces, the tennis shoes, the film canisters above the image intensifiers that are now obsolete, replaced by fancier digital acquisition systems.

It was with some poignancy that I saw another graduating class in hail the efforts of the graduating cardiac electrophysiology fellows on Friday.

There they are, surrounded by friends, staff members, family members, and a whole host of support personnel (nurses, technicians, education administration, etc.) They are, for now, at the peak of their game - as ready as they can possibly be for working independently (we hope). They look back. Remember all the good times and bad. They get gifts to wish them well. They get signed momentos. Joy - pure, nervous joy.

And that's the paradox of such moments when we part ways, isn't it? We leave our friends and closest colleagues to head off on our own and make a mark. What lies ahead, we haven't a clue...

...because despite all the hours and effort, that's when the learning really starts.


"Reasonable Consumers" Unite! Kill Drug Ads

It seems the FDA is looking for input on how drug companies explain the side effects of their drugs in direct-to-consumer advertising.

But the pharmaceutical industry is requesting that only "reasonable consumers" need to be addressed about those side effects. Anyone that doesn't act "reasonably," well, so sorry.


About the only reasonable thing that can be said about direct-to-consumer advertising are three things:
  1. They are horribly expensive, with the US shunting over $2 billion dollars annually per pharmaceutical company to the advertising industry.

  2. It should also be noted that the FDA has a huge conflict of interest with the pharmaceutical industry, since it receives large sums from them to review their new drug applications.

  3. Note, too, that only two countries in the world permit these ads: the US and New Zealand.
I find it interesting that I can't get a $0.10 pen from the drug companies any longer, but our patients can get billions of dollars in advertising given to them "free" without any concern about what this is costing our health care system.


Friday, June 25, 2010

When Hospitals Divorce Their Doctors

As doctors increasingly become physician-employees, there's no longer a need to share resources with University specialists:
Three University of Virginia cardiologists have been told by the Augusta Health board they will lose their hospital privileges next week, impacting the 2,500 patients the doctors serve.

Augusta Health officials told the doctors in a letter that they won’t be able to treat their patients in emergencies or otherwise at the hospital in Fishersville.

. . .

Crow’s statement said the board is limiting cardiology department participation to doctors “under contract to Augusta Health.”

Augusta Health has four cardiologists on staff, and will soon have a fifth, he said.

Limiting cardiology participation to the hospital’s own doctors will allow Augusta Health “to build a strong and financially viable community-based cardiology program,” Crow said.
Universities have a long history of exporting their clinical expertise in the hopes of capturing more complicated surgical cases from their imbedded specialists. With more and more health systems consolidating (note the three-for-one swap above), the days of collaboration and shared resources between health systems are ending and patients are finding access to doctors more challenging.


Addendum 26 Jun 2010 @ 05:45am: It seems procedures, not patients, are what's at stake:
"“Twenty-five hundred [patients] is significant, but is not going to generate that many procedures on a yearly basis,” he said.

Sometimes Lab Staff Can Be So Helpful

... and even a bit creative when you've misplaced your reading glasses:

Click image to enlarge

How to Balance Health Care Budgets: Close Hospitals

It appears Cook County has a plan to make their struggling health care system solvent - close hospitals:
Most controversial in the new strategic plan is a proposal to convert Provident Hospital and Oak Forest Hospital into large outpatient centers, a move that could endanger jobs at the two underused medical centers and that has drawn strong union opposition.

"Our concern is that people won't have access" to needed hospital care, said Christine Boardman, president of Service Employees International Union Local 73, which represents 1,500 workers in the health system.

The situation surrounding Provident Hospital — a pioneering African-American hospital with deep roots on the South Side — is especially complex. If negotiations under way over a possible relationship with the University of Chicago Medical Center are successful, the institution would remain largely intact.

But those talks have been rocky. If they fail, the proposed strategic plan would significantly scale back services at Provident, which would keep its ER open and retain a few dozen hospital beds for patients who need to stay overnight.

The county began the process of closing Oak Forest's long-term care unit several years ago. The fewer than two dozen patients who remain would be placed in nursing homes and rehabilitation facilities under the plan; the facility's ER and hospital beds would close.

"That concerns us because this is an area where medical needs are growing," said William McNary, co-director of Citizen Action/Illinois.

Foley acknowledged that to take care of county patients, "we would really need to build relationships with other hospital providers" on the Far South Side.
Granted, hospitals lose money, and while closing hospitals will save money, it is interesting to note where the patients at those hospitals are planning to be sent:
The county began the process of closing Oak Forest's long-term care unit several years ago. The fewer than two dozen patients who remain would be placed in nursing homes and rehabilitation facilities (emphasis mine) under the plan; the facility's ER and hospital beds would close.
Further, there might be a little flaw in the logic about cost savings with moving to the more lucrative outpatient service model:
"There will be considerably greater convenience for most patients," said David Dranove, professor of health industry management at Northwestern's Kellogg School of Management. But costs don't necessarily plummet when a hospital is converted to outpatient care, he said.
What we're seeing is a planned shift of moneys from the state government dole to the nation's government dole as plans are underway to offload state's health care obligations to the US government as a whole.

The only problem is, when too many patients leave the local government's hospitals for greener pastures, those cornerstones of public health will struggle to survive as patient volumes (and US government payments for services via Medicare and Medicaid) dwindle:
Hundreds of thousands of poor, uninsured adults — the county health system's core clients — will gain insurance cards and the ability to choose medical providers for the first time in 2014. If large numbers of people elect to leave the county health system, that could prove devastating. "We've got to improve our services and improve our infrastructure or we'll lose a large part of our patient base," Foley said.
Which all goes to show: quality, quality, or low cost of healh care - pick any two.


Thursday, June 24, 2010

When Lightning Strikes

... it can make some pretty dramatic video. Here's what happened in Chicago last evening: simultaneous strikes of (left to right) The John Hancock Building, Trump Tower, and the Willis Tower (formerly the "Sears" Tower):

From Craig Shimala on Vimeo.


Wednesday, June 23, 2010

Cool SVT Animations

For medical students and others who want to see some nice animations of various forms of supraventricular tachycardias (SVT) in living color, be sure to checkout the free SVT animations at (requires Adobe Shockwave player available from the site).


h/t Vijay Sadasivam, MD via Facebook and Ves Dimov, MD via Twitter

Tuesday, June 22, 2010

It's Official: Guidelines for Care Are Now Mandates for Care

Want a pacemaker or defibrillator on your dying UnitedHealthcare patient with complete heart block? Sorry, in many states you must first ask permission from the insurer beginning 1 July 2010:
UnitedHealthcare claims this protocol is not a pre-certification, pre-authorization program or medical necessity determination. A notification number must be obtained in accordance with the Cardiology Notification process prior to perform EP implant procedures. Failure to complete the notification process will result in an administrative denial. All procedures require notification regardless if they are elective or emergent. (Emphasis mine)

Prior notification may be obtained online, by telephone or fax:

■Online: (User ID and password are required)
■Telephone: +1 (866) 889-8054
■Fax: 1 (866) 889-8061
Cardiology Notification process? WTF? Where, exactly, do we place this "notification number" in patient patient's chart? In their operative report?

I can see it now as P waves are dancing across the screen:
"Hold on there, Ms. Smith! Just trying to place this temporary pacing wire... Um, give me a minute, okay.... Uh, which insurance do you have?.... er, please ma'am, don't talk right now - I might hit your lung.... It wouldn't be Unitedhealthcare, would it? Wait, don't talk.... okay, which one? Yes? Does anyone have UnitedHealthcare's Cardiology Pay-to-Play number???..."

"Okay, Ms. Smith... Ms. Smith????... Ms. Smith???...."

(gurgling noises hard in background)
And will the service will be 24/7/365?

Of course not!
If notification is required on an emergent basis or notification cannot be obtained because it is outside of UnitedHealthcare’s normal business hours, the service may be performed, and notification can be requested retrospectively. Retrospective Notification requests must be made within 14 calendar days of the service. Rendering physicians should follow the same notification process outlined for a standard request. Documentation must include an explanation as to why the procedure was required on an emergent basis or why notification could not be obtained during UnitedHealthcare’s normal business hours. If a claim is submitted prior to the Retrospective Notification Process being completed, it will receive an automated denial for lack of notification; however, the claim will be reprocessed if Retrospective Notification is received within 14 calendar days of the date of service, and it meets criteria as an emergent procedure.
Just think how many hours upon hours of doctors' time will now be spent holding online waiting for a college dropout to tell us our notification number!

Damn, what a waste of resources.

This is our "guidelines" for care are now mandates for patient care and will be used against us in our new era of health care reform.

Deviate from them and your patient will pay...

... and pay dearly.


Addendum: Dr. John Mandrola, another EP, shares a similar story, even before these new mandates go into effect.

Monday, June 21, 2010

Wide and Thin or Narrow and Thick

Get your mind out of the gutter. We're talking about defibrillators here.

There's a great picture comparing the size of implantable defibrillators for the management of ventricular arrhythmias and heart failure (and a nice article on the not-so-new wireless telemetry features) over at the New York Times today.

Here's the question:
If you needed a new defibrillator and assuming all implantable devices had identicle capabilities, which would you rather have: (1) a wide and thin device (a la the "Cognis 100-D" device of Boston Scientific's), or (2) a thicker and slightly narrower device (sported by Medtronic's Consulta CRT-D and St. Jude's EPIC-HF devices)?
Go ahead and place your vote in the comments section.

For fairness, here's a side view of the three devices arranged left-to-right as in the prior picture:

(Click to enlarge)
Left: St. Jude; Middle: Boston Scientific; Right: Medtronic

(Industry reps needn't vote. Thanks.)


The Microbiology of Trophies

Remember "cooties" in grade school? You know, the germs or disease that girls gave boys or boys gave girls in grade school if they touched? Well, it seems they're becoming an an epidemic (video).

So thank goodness someone checked for "cooties" on the Stanley Cup:
The NHL champion Blackhawks' beloved trophy stopped by the Chicago Tribune newsroom Thursday, and so we took the opportunity to do something the Cup's keeper said had never been done: We swabbed it for germs.

We sent the samples to the Chicago lab EMSL Analytical, which found very little general bacteria and no signs of staph, salmonella or E. coli.

"It's surprisingly clean," lab manager Nancy McDonald said.

Just 400 counts of general bacteria were found, she said. By comparison, a desk in an office typically has more than 10,000.
No staph species detected?


Me thinks there was a sampling error...


Sunday, June 20, 2010

Pensions and the Challenge to Health Care

I am not a finance guy, but was struck by what I read in the New York Times this morning:
Despite its pension reform, Illinois is still in deep trouble. That vaunted $300 million in immediate savings? The state produced it by giving itself credit now for the much smaller checks it will send retirees many years in the future — people who must first be hired and then, for full benefits, work until age 67.

By recognizing those far-off savings right away, Illinois is letting itself put less money into its pension fund now, starting with $300 million this year.

That saves the state money, but it also weakens the pension fund, actually a family of funds, raising the risk of a collapse long before the real savings start to materialize.

“We’re within a few years of having some of the pension funds run out of money,” said R. Eden Martin, president of the Commercial Club of Chicago, a business group that has been warning of a “financial implosion” for several years. “Funding for the schools is going to be cut radically. Funding for Medicaid. (emphasis mine) As these things all mount up, there’s going to be a lot of outrage.”

Joshua D. Rauh, an associate professor of finance at Northwestern University who studies public pension funds, predicts that at the current rate, Illinois’s pension system could run out of money by 2018. He believes the funds of other troubled states — including New Jersey, Indiana and Connecticut — are also on track to run out of money in less than a decade, unless they make meaningful changes.

If a state pension fund ran out of money, the state would be legally bound to make good on retirees’ benefits. But paying public pensions straight out of general revenue would be ruinous. In Illinois’s case, it would consume about half the state’s cash every year, bringing other vital state services to a standstill.
Of course, Illinois hospital systems know this. They are, after all, some of the largest and most lucrative employers in our state and are very savvy when it comes to the money of medicine.

As a result, large hospital systems purchase credit default swaps to hedge against the collapse of the Illinois bond market. Just this week, the price for those "swaps" (derivatives) just exceeded those for the state of California and are approaching the swap price for Greece.

All because the current union members want their pensions, some as early as age 55.

This presents very real problems for Medicaid patients:
Of the 32 million uninsured Americans expected to gain health coverage under the new law, as many as 20 million will be insured by Medicaid, experts estimate. Asset tests will be largely eliminated, so workers who lose their jobs can get health coverage even if they own their homes or have money saved for retirement. (Illegal immigrants will not be eligible.)

Absorbing that many people into the system will not be easy. The program is administered and partly financed by the states, which are now racing to figure out how to carry out the necessary changes and simplify enrollment even as they struggle to cope with severe budget cuts and staff shortages.

Many residents don’t realize they will be eligible, and it will be up to the states to let them know. And the program has long been haunted by questions about quality of care.
But why worry? Who cares if the states can't pay their Medicaid tab. The federal government will pay for the pension shortfall, right?

And it won't cost a thing... really...


Friday, June 18, 2010

The Day After

It's rainy outside.

The dog's hungry and needs to be let out.

I still need to shave and shower.

And yes, I'm going to work today.

They tell me the doctor Medicare cuts went through. You mean the AMA, with all their sound and fury signifying nothing, failed to influence our Congressional leadership?

Gee, who knew?

Folks, this was the plan. The cuts were supposed to go through. So look at it on the bright side. Our government just saved $250 billion!

And quietly, practices will downsize their nicest employees or close all together. Many others will speed up their flight to be bought by big hospital systems - but these hospital systems will be more selective when deciding who they admit to their ranks. Inner city hospitals, struggling for survival, will look to the government for more subsidies to meet their demands for survival. Government will comply to protect themselves. Big hospitals and health systems with lots of doctor-employees will point to the decreased revenue by their doctors, tighten their belts a bit more by maintaining their months-long hiring freezes indefinitely, and fail to give those productivity bonuses to their workers as their construction contracts for their additions continue to get paid as they get ready for the "Big Wave."

In business, nothing changes quickly. Especially big, money-hungry, bureaucratic machines. But the paranoia will grow amongst the administrative and medical supplier ranks as senior leadership looks to cut back. You see, doctors are just the first.

And then there's the patients. If you're in a big town, you won't notice the difference. That's because in the operating rooms, there will still be one nurse where there had been two. In the ICU's, your nurse will visit you a bit less, but thanks to electronics, she'll still be watching or listening for you. You might notice it's harder to understand the foreign accent of your doctor, but he or she will be pleasant. At least until the next doctor arrives on the night shift.

But for the rural patients. Best of luck. Hope you've got frequent flier miles or low mileage on your car. You're going to need it. I have no doubt that you'll be able to get a telemedicine doctor to see you, provided you have more than a dial-up connection and a new computer with a videocam. What, you can't afford one? Better ask the government for a computer, then, okay? And while you're on the phone, ask them how possible acute appendicitis will be handled, will you?

Fortunately, if you're below 65, you'll see the effects a bit later. But if you're over 65, better tap into your savings a bit, so you can pay to have a doctor.

That's just the way it's going to be.


Addendum: Some earlier takes here and here.

Thursday, June 17, 2010

The Politics of Black Boxes

It's been several months since the black box warning on clopidogrel (Plavix) appeared and most cardiologists I know have not changed their practice as a result. I asked them to write about this on this blog, but because of the potential future legal ramifications of admitting as much, they politely declined.

For those unfamiliar, this black box warning, added to the drug's package insert by the FDA in March of this year, tells doctors who use this drug:
  • Effectiveness of Plavix depends on activation to an active metabolite by the cytochrome P450 (CYP) system, principally CYP2C19.

  • Poor metabolizers treated with Plavix at recommended doses exhibit higher cardiovascular event rates following acute coronary syndrome (ACS) or percutaneous coronary intervention (PCI) than patients with normal CYP2C19 function.

  • Tests are available to identify a patient's CYP2C19 genotype and can be used as an aid in determining therapeutic strategy (and to)

  • Consider alternative treatment or treatment strategies in patients identified as CYP2C19 poor metabolizers.
When you ask interventionalists what they think about this genetic testing to assess who might be a "poor metabolizer" you get a blank stare and many reasons why no one does it, like:
  • That black box was warning based on a single non-published crossover trial on 40 subjects:
    A crossover study in 40 healthy subjects, 10 each in the four CYP2C19 metabolizer groups, evaluated pharmacokinetic and antiplatelet responses using 300 mg followed by 75 mg per day and 600 mg followed by 150 mg per day, each for a total of 5 days. Decreased active metabolite exposure and diminished inhibition of platelet aggregation were observed in the poor metabolizers as compared to the other groups. When poor metabolizers received the 600 mg/150 mg regimen, active metabolite exposure and antiplatelet response were greater than with the 300 mg/75 mg regimen. An appropriate dose regimen for this patient population has not been established in clinical outcome trials.
  • Presence of a gene does not mean it is expressed clinically.

  • There are no data to demonstrate that outcomes have been effected by the use of genetic testing in a large cohort of patients, only a retrospective analysis of outcomes reported in the New England Journal of Medicine.
Forty prospective patients. Non-peer-reviewed data. Retrospective studies. And a black box warning, the FDA's most severe.

We know that there is a political push by President Obama and his NIH director, Francis Collins, MD, PhD (a geneticist) to use "personalized medicine" (read: genetic tests) as a way to come up with recommendations for medical care:
"As we learn more about individual's risk – from family history to DNA testing to understanding of environmental exposures – we ought to be able to come up with recommendations that are more personalized. I think people are ready for that. I think they're hungry for that. I think they are more likely to be responsive to that, but we have a long ways to go in terms of preparing people for that kind of individualized approach to medicine."
Ironically, Dr. Collins admitted:
Today, "you can get fancy DNA tests for hundreds of dollars," Collins told The Endocrine Society meeting - but your better bet for now may be a simple family tree of health, checking what ailments Mom, Dad and Grandpa had to predict your own future. "That's a free genetic test of great power."
So we should ask ourselves why a 40-patient crossover trial and retrospective analysis of outcomes qualifies as top-notch research on which to base a black box drug warning that also supplies no dosing recommendations to doctors if such a test is positive.

It wouldn't be the money generated by genetic testing for companies (see here and here) and hospitals who stand to make a pretty penny on them, would it?


Addendum 18 Jun 2010: They just won't quit, and admit:
"The challenge is to deliver the benefits of this work to patients. As the leaders of the National Institutes of Health (NIH) and the Food and Drug Administration (FDA), we have a shared vision of personalized medicine and the scientific and regulatory structure needed to support its growth. Together, we have been focusing on the best ways to develop new therapies and optimize prescribing by steering patients to the right drug at the right dose at the right time."
Look for more black boxes applied to more drugs with no understanding of the legal ramifications of their use. Is this the caliber of scientific rigor we are to expect from our government's reform agendas?

Addendum 29 Jun 2010 @ 14:38PM: reports on the ACC and AHA's recommendations regarding the black box warning.

Tails You Win, Heads You Lose

Looks like they picked heads - 40-60 of 'em:
Gruesome and equally bizarre cargo is causing some serious controversy after a Southwest Airlines employee opens a package and finds a shipment of human heads.

A shipment of human heads bound for Fort Worth, Texas, remained in Little Rock, Ark., Thursday after a Southwest Airlines employee opened the package and called police.

The Fort Worth medical-research company where the heads were expected, Medtronic, said the 40 to 60 heads are for educational purposes.

It's not unusual for an airline to ship bodies, or body parts, for medical research.

The problem was the heads were not properly packaged or labeled.

Southwest Airlines said a courier showed up with the package and claimed to not know the contents.

The Southwest employee looked inside the package and found the heads.

The airline called police, and the department turned the package over to the county coroner, who has plenty of questions.

"In our discussion with the health department, we've come to the conclusion that there is a black market for body parts out there. We just want to make sure these specimens aren't part of that underground trade," Pulaski County Coroner Garland Camper said.
Looks like heads are going to roll!...


Normal Echocardiogram Reading Error Rate 0.2% - By Technicians

In a "study" that is unlikely to ever be repeated again, we find that echocardiogram technicians are pretty good at screening normal echos, and have, according to credentialed cardiologists, a 0.2% reading error rate:
Harlem Hospital Center has completed an investigation of 7,000 heart tests going back five years, most of which had never been reviewed by doctors, a spokeswoman for the hospital said on Wednesday.

The investigation found that 14 patients might have been misdiagnosed because their tests had not been handled properly, said the spokeswoman, Ana Marengo. Twelve of the patients had been contacted, and none of them were found to have suffered adverse effects from the failure to properly read their tests, Ms. Marengo said."
Recall that the echocardiogram technicians were only sending abnormal tests for cardiologists to review, and only presumed normal tests were never read (or signed) by a certified cardiologist.

I wonder what the "normal" echocardiogram reading error rate is for board-certified cardiologists?


Wednesday, June 16, 2010

The Incidence of Self-Reported US Heart Attacks by Age

As told by Gallup survey:

Click image to enlarge

Gone Fishing

It was early and the sun just creeping over the horizon. The air was cleansed by the rain the night before, the grass still wet. He walked bent down below the cedar tree and pulled on the large rock at its base, revealing its underside. There, tucked neatly in a slime-lined dirt corridor was a large nightcrawler, unaware of its predicament. He reached down to snatch his quarry as the worm thrashed to and fro between his digits, lubricating his grip with clear, oleaginous slime.
For more than two decades, internist Lee Antles has treated Medicare patients at his practice in Olympia, Wash. Last month, he started turning them away.

What pushed him over the edge was Congress's failure to end the looming threat—which no one expects to be carried through—of a 21% payment cut for doctors who participate in the seniors' insurance program. Last year, he and his wife, Margie, who manages the office, took home $55,000 before taxes, he said.
He changed hands with the creature and wiped his dominant hand on his trousers, then reached up to grasp the monofilament just short of the shiny iridescent hook. His fingers slid down the line to control the hook as he pondered the location to impale the juicy allurement. "Better to have the worm wiggle," he thought as the hook pierced the skin just proximal to the worm's lighter-colored citellum.
At Dr. Antles's practice in Olympia, Medicare pays him $95 for a visit that covers six organ systems. By comparison, Aetna Inc. pays $129 and Uniform Medical Plan, which covers state workers, pays $140. To bridge the patchy reimbursements, Margie Antles has taken out four loans and borrowed money from her parents.
The worm wriggled and slimed, its caudal portion curling back on the embedded metallic foreign body. The man grasped a second spot a bit further down the worm's length, curling its body so it could be impaled again. The folded portion of the worm was now firmly secured while the ends kept flipping to and fro as a half-red and half-white sphere was clipped a bit higher on the line.
For seniors, the tussle in Washington could make it more difficult to find a doctor, especially if they're switching doctors. Medicare pays physicians at a lower rate than private insurers, and they complain of too much paperwork.
Suddenly, with little hesitation, the line was cast and worm, hook and bobber flew effortlessly to land on the water's surface.

Ostuni and other delegates are upset a Medicare payment formula was not a permanent part of the new health reform law. Because it was not in the law, the AMA now has to lobby Senate Republicans for another temporary payment fix to avert the scheduled cut.
The bobber sat motionless on the water's surface. A light fog hung just above the water. A damselfly landed on the bobber only briefly before it moved. A tiny movement at first, radiating ripples on the water's surface from the bobber's location. A pause. Then another tiny jiggle and more ripples. Suddenly, the bobber disappeared. The man gave a hefty jerk to the line, but sadly, line came easily. "Damn, too hard," he thought, and reeled in the line to find his nightcrawler gone.
Dr. Antles is considering quitting medicine and moving to Chicago, so his wife can return to a sales job that pays at least twice that much. "It just causes me such angst," he said, who would become a stay-at-home father to the couple's six-year-old daughter. "It leaves 1,000 Medicare patients. Where do they go?"

Tuesday, June 15, 2010

You Know You're a Doctor When...

They had been married for over 35 years, both successful ophthalmologists who had entered retirement after selling their practice. The kids had grown and their house was just too big for them now, so they decided to downsize to a condominium.

After many days of searching, they toured a lovely place and were excited to make a deposit, but the husband first wanted to inspect the building from the outside before committing. As he rounded the building with his wife beside him, he looked up, struggling to find the unit they were interested from the ground.

"Which one is it dear?" he asked.

"The one on the right, third floor."

"I don't see it," he said.

His wife saw where he was looking.

"No sweetheart, not that one," she said directing him to the right side of the building, "It's the one over there, on the patient's left side."


Medicine to Social Media: Get Over Yourself

I have noticed an interesting psychodynamic to most medical bloggers, social media enthusiasts, and internet-savvy individuals use social media:

... we all are narcissists.

We love our blogs, our posts, our "wall," our "followers," our "subscribers," our "friends", and our "unique visitors." Just look at people constantly checking their Blackberry's and iPhones at the dinner table. We are, after all, creating a 'community' of sorts all around us that never stops. We know that without others liking our comments or content, we receive no viewer traffic. Without noticeable traffic, we die.

Really, that's as deep as social media gets.

Of course it takes some gonads to say this. It is far easier to say that I give up my time, energy, and insights selfishly so the world can share my brilliant (and not-so-brilliant) exposés. That would sound far "cooler" and more hip in today's "e-mo-tional" electronic world. While I would hope there might be a modicum of usefulness for others when I participate in social media, the reality is that I've found I like to write. I like to find the story behind the story. I like to make friends. And I like to feel I'm adding a physician's voice, however small, to the increasingly overcrowded health care internet din. I realize that like it or not, for our younger generation who have grown up comfortable with this online world, to not have an internet presence is to not exist.

Now before I have the world of social media descend upon me like a hoard of locusts, let me say public sharing of information may not be a bad thing. There are times when we need companions. There is even quite a bit of useful information out there. For patients, the value of this information or of having "friends" in a time of crisis is incredibly important. Some feel it's so important that the enthusiasm for social media has spawned and entirely new internet breed: the socially-empowered "e-patient." And thousands of commercial interests are more than happy to facilitate their empowerment.

But I find it funny that social media "experts" continue to ponder why doctors don't "engage" more in social media. After all, it's the rage, right? Come on guys, get with the program! What are you really like? You need an online presence in today's internet world. So frenetic is the trend that nearly every major (solvent) hospital and hospital system is paying large sums of money for their public relations and marketing departments to employ social media "specialists" to develop Facebook pages, live-tweet the day's events, and engage their patient communities in the daily news at the hospital. Come join the latest web-chats, tweet-a-thons...whatever. Marketing plans. All to keep their patients coming back for more.

But for doctors, they understand that medicine is an intensely private affair. There is no place for narcissism during a patient visit. Medicine is also very ugly at times: bloody stools, discharges, lesions and psychiatric issues come to mind. Not that these ailments can't be found on YouTube. They can. And sometimes these not-so-pretty issues present very real challenges for diagnosis and treatment for doctors. One might think that the instantaneous communication afforded by social media would be the perfect place for "on-line collaboration." Yet in reality, using social media, even doctor-limited online forums, might be the worst place a doctor could ask for advice, especially when uniquely identifiable issues specific to an patient are discussed with others in such a potentially public, legally-discoverable way. For many doctors, the legal, ethical and political climate is simply not conducive to permitting patient-specific discussions on the internet.

Nor should it be.

And this doesn't even begin to address the issue of time. Participating in extra discussions outside of patient care takes time, and for people who create original content rather than link-bait, it takes lots of time. Worse, few of us can type, so even the requirement to enter five passwords at five different sites presents challenges for those already struggling to get their paperwork done before heading home.

So as we move forward in this increasingly connected internet-facilitated medical world, the limitations of social media will continue to present challenges for doctors and the developers who strive to develop niche sites catered to them. No matter how you parse it, doctors don't avoid the internet and social media because they're simply Luddites, they avoid the internet because they enjoy the benefits of anonymity, privacy, efficiency and legal protection that comes with dropping off the grid.

Now excuse me while I check my Sitemeter stats again.


Sunday, June 13, 2010

Even Thoracic Surgeons Can Do CPR

If you have to collapse during your workout, make sure you do it near two nurses and a thoracic surgeon.

What's interesting, though, is outside the hospital, doctors and nurses are just like anyone else who might come upon such a scene:
“We do this every day, but we’re surrounded by our colleagues and the equipment,” she said. “To do it out in the field was just surreal..."
And it's even more surreal when the patient does so well.

Nice work, guys!


Friday, June 11, 2010

Underwear To Monitor Your Pulse

You just can't make this stuff up:
The underwear project, spearheaded by the nanoengineering professor, was funded by the U.S. military and its effectiveness will likely be tested on the battlefield.

"This specific project involves monitoring the injury of soldiers during battlefield surgery," Wang told Reuters. "The goal is to develop minimally invasive sensors that can locate, in the field, and identify the type of injury."

Ultimately, the waistband sensors will be able to direct the release of drugs to treat the wounded soldier.
I wonder what other creative uses our men in uniform will find for this?

I can hear it now: "It's not the size of the device, honey, it's the metronome that's in it!"



Fellowships and Visas

I saw this updated webpage this morning from Dartmouth Hitchcock Medical Center on how to apply to their EP fellowship program. It contains this statement at the end:
Special note for foreign national physicians: You must have a currently valid certificate from the Educational Commission for Foreign Medical Graduates (ECFMG) to be eligible for application to a GME-accredited clinical training program. We accept applicants with J1 visas. We will assist H1-b visa applicants with their paperwork but are not able to absorb any of the cost involved with their transfer.
Why do foreign applicants get a "Special note?"

For those not familiar, J-1 visas require the applicant to return to their country of orgin for two years before being eligible to return to the US. There are exemptions to this requirement to return to their country that can be granted, including a "No Objection Statement" from their government or the "Conrad Program." The Conrad Program is a waiver issued for a foreign medical graduate who has an offer of full-time employment at a health care facility in a designated health care professional shortage area or at a health care facility which serves patients from such a designated area.

H1-b visas are a 6- to 10-year visa permitting employers to temporarily employ foreign workers in specialty occupations, like medicine.

Each year, scores of applicants apply for these cherished specialty and subspecialty fellowship spots. Subspecialty medicine is already an incredibly competitive venture owing to the pyramid structure already inherent to programs with limited fellowship training positions.

But there is another aspect to selecting fellows that few (if any) programs will openly admit: they don't want to train their competition.

It is well-known that following their training, many fellows tend to prefer to stay at or near their training hospital - often because it is simply easier (and less expensive) to stay locally to work if possible. Many hospital programs know this - especially ones in upper-crust communities with more than one competing hospital system. As such, there is a bias toward hiring foreign-trained fellows in fellowship programs because programs don't have to worry about oversaturating their market. This, then, skews competition for fellowship programs toward accepting foreign applicants in lieu of US-born applicants.

Others will argue that no such bias exists - that application processes are careful to cull only the best and brightest. After all, they are "equal opportunity employers" that promise " provide equal opportunity to all qualified persons without regard to citizenship, race, color, creed, religion, sex, age, sexual orientation, national origin, disability, handicap, veteran or other legally protected status." Still others will say, "get over it," it's an international market for health care providers now.

No one can deny that there are benefits to cultural exchange that occurs when non-US physicians enter programs and that there are benefits to other countries when these doctors do return. But could medical schools inadvertantly be turning their backs on US-born medical students who have paid nearly $300,000 for their medical education just so they can avoid local competition and discrimination claims? Might there be a better way to offer health care to underserved areas in the US and abroad besides hiring foreign physicians for fellowship?

With the increased pressure to shrink subspecialty medicine in favor of primary care with health care reform, perhaps it is time we re-visit the J-1 visa issue for our US medical schools and fellowship programs. Maybe we should require all of our new graduates to work for two years in underserved areas before settling in their chosen community.

Then again, better to keep it politically correct and not discuss these issues, right?


A Sad Day for Cardiology

... courtesy of a drunk driver:
Sixty-nine-year-old Dr. Morton Arnsdorf, who lived in Beverly Shores, was killed when his car was engulfed in flames. Arnsdorf was a doctor at the University of Chicago Medical Center.

At about 5:32 p.m., a Dodge Neon was heading east on U.S. 20 when it rear-ended Arnsdorf's Saab, as it was slowing down to make a left turn onto County Road 300E.

The impact caused the Saab to cross into the westbound lanes of U.S. 20, and it was hit by a Mercury.

Arnsdorf's Saab was engulfed in flames, and he was trapped inside the car.

The driver of the Neon, a 17-year-old man from Michigan City, was airlifted to a South Bend Hospital.

The passenger in the Neon, Travis Pagels, 18, of Michigan City, and the driver of the Mercury, John Merrell, 62, of Portage, were transported to Saint Anthony Memorial Hospital in Michigan City for treatment.

Porter County police believe that alcohol was a contributing factor in the crash. Investigators were waiting on the toxicology results from the driver of the Neon. The investigation is continuing.
My condolences to the family.


Addendum 12 Jun 2010 09:42 - The summary of Dr. Arnsdorf's remarkable career.

Thursday, June 10, 2010

A Cornucopia of EKG Tracings

Trying to learn EKG's? Here's a great resource.

(Hey, if it's free, it's for me! I especially like the search engine page.)


The Next EMR/Ablation/Treadmill Workstation

Don't laugh. I'm not kidding. Just add this plus this.

Yep, this would take afib ablation to a whole new level!


Wednesday, June 09, 2010

Dissin' Short People

From the Associated Press to the supposedly authoritative WebMD, short people (we are told) are more likely to die of heart disease.

This all stems from an article, no doubt released to the wire via a press release (ed. note: see below), from the European Heart Journal based on a review of the literature and meta analysis of 52 studies. It seems the reporters felt that this was so important to disclose to the world because the authors concluded: "The relationship between short stature and CVD appears to be a real one."


Meta-analyses and literature reviews of a large group of disparate studies culled from "MEDLINE, PREMEDLINE, and All EBM Reviews as well as from a reference list of relevant articles" could NEVER claim to reach such a conclusion, since just about every type of study bias known to man is introduced by such an approach. About the only thing that can be concluded from this so-called "analysis" is nothing more than maybe we should consider studying if this association actually exists.

In my view, the authors (and maybe even the editors of the European Heart Journal) have should explain what they have against short people in reaching their so-called "conclusion."

-The 5' 11", Wes

Addendum 1700 CST 9 June 2010: The European Heart Journal's press release:
Embargoed: 00.05 hrs London time (British Summer Time) Wednesday 9 June 2010

Short people are more likely to develop heart disease than tall people

Short people are at greater risk of developing heart disease than tall people, according to the first systematic review and meta-analysis of all the available evidence, which is published online today (Wednesday 9 June) in the European Heart Journal [1].
The systematic review and meta-analysis, carried out by Finnish researchers, looked at evidence from 52 studies of over three million people and found that short adults were approximately 1.5 times more likely to develop cardiovascular heart disease and die from it than were tall people. This appeared to be true for both men and women.

Dr Tuula Paajanen, a researcher at the Department of Forensic Medicine, University of Tampere, Tampere, Finland, said that over the years there had been a number of studies that had provided conflicting evidence on whether shortness was associated with heart disease.

“The first report on the inverse association between coronary heart disease (CHD) and height was published in 1951 and, since then, the association between short stature and cardiovascular diseases has been investigated in more than 1,900 papers. However, until now, no systematic review and meta-analysis has been done on this topic. We hope that with this meta-analysis, the association is recognised to be true and in future more effort is targeted to finding out the possible pathophysiological, environmental and genetic mechanisms behind the association, with eyes and minds open to different hypotheses,” she said.

Due to the many different ways that previous studies have investigated the association between height and heart disease, Dr Paajanen and her colleagues decided to compare the shortest group to the tallest group instead of using a fixed height limit.

From the total of 1,900 papers, the researchers selected 52 that fulfilled all their criteria for inclusion in their study. These included a total of 3,012,747 patients. On average short people were below 160.5 cms high and tall people were over 173.9 cms. When men and women were considered separately, on average short men were below 165.4 cms and short women below 153 cms, while tall men were over 177.5 cms and tall women over 166.4 cms.

Dr Paajanen and her colleagues found that compared to those in the tallest group, the people in the shortest group were nearly 1.5 times more likely to die from cardiovascular disease (CVD) or coronary heart disease (CHD), or to live with the symptoms of CVD or CHD, or to suffer a heart attack, compared with the tallest people.

Looking at men and women separately, short men were 37% more likely to die from any cause compared with tall men, and short women were 55% more likely to die from any cause compared with their taller counterparts.

“Due to the heterogeneity of studies, we cannot reliably answer the question on the critical absolute height,” write the authors in their study. “The height cut-off points did not only differ between the articles but also between men and women and between ethnic groups. This is why we used the shortest-vs.-tallest group setting.”

The findings have clinical implications. Dr Paajanen said: “The results of this systematic review and meta-analysis suggest that height may be considered as a possible independent factor to be used in calculating people’s risk of heart disease. Height is used to calculate body mass index, which is a widely used to quantify risk of coronary heart disease.”

It is not known why short stature should be associated with increased risk of heart disease. Dr Paajanen said: “The reasons remain open to hypotheses. We hypothesize that shorter people have smaller coronary arteries and smaller coronary arteries may be occluded earlier in life due to factors that increase risk, such as a poorer socioeconomic background with poor nutrition and infections that result in poor foetal or early life growth. Smaller coronary arteries also might be more affected by changes and disturbances in blood flow. However, recent findings on the genetic background of body height suggest that inherited factors, rather than speculative early-life poor nutrition or birth weight, may explain the association between small stature and an increased risk of heart disease in later life. We are carrying out further research to investigate these hypotheses.”

Dr Paajanen said that it was important that short people should not be worried by her findings. “Height is only one factor that may contribute to heart disease risk, and whereas people have no control over their height, they can control their weight, lifestyle habits such as smoking, drinking and exercise and all of these together affect their heart disease risk. In addition, because the average height of populations is constantly increasing, this may have beneficial effect of deaths and illness from cardiovascular disease.”

In an editorial on the research published at the same time [2], Jaakko Tuomilehto, Professor of Public Health at the University of Helsinki, Helsinki, Finland, welcomed the study, writing: “The systematic review and meta-analysis on this topic . . . is well justified 60 years after the first observation and the hundreds of other papers which have been published since then on this topic. The results are unequivocal: short stature is associated with increased risk of coronary heart disease. This meta-analysis provides solid proof for this, but, as the authors conclude ‘The possible pathophysiological, environmental, and genetic background of this peculiar association is not known’.”

He suspects that environmental events affecting growth before and after birth may be involved. “Socio-economic adversity in childhood is . . . associated with delayed early growth and shorter adult stature. The so-called catch-up growth during the first years of life among children who are born small has negative health effects in adulthood; much of the early growth is due to greater fat accumulation. Thus, it is most likely that short stature is the link to coronary heart disease, and that tallness is not a primary factor in preventing the disease, although it indicates healthy growth. Short stature seems to be a marker for risk.”

While more work is needed to understand the exact nature of the mechanisms at work, he writes that information on height can be used now for the prevention of heart disease and other chronic diseases linked to shortness. “Full term babies who are born small are likely to be short as adults. They should receive preventive attention early on. The primordial prevention of chronic diseases should start during foetal life, and health promotion should be targeted to all pregnant women with the aim of health development of the foetus. Low birth weight and some other birth characteristics can reveal potential problems during this period of life. After that, in babies with low birth weight, it is important to avoid excessive catch-up growth, i.e. early-life fatness.”

In adult life it becomes more difficult to discover best practices, but Prof Tuomilehto, thinks it is likely short adults would benefit from more aggressive risk factor reduction.

He concludes: “Most of us know approximately our own height ranking, and, if we are at the low end, we should take coronary risk factor control more seriously. On the other hand, tall people are not protected against coronary heart disease, and they also need to pay attention to the same risk factors as shorter people.”



[1] “Short stature is associated with coronary heart disease: a systematic review of the literature and a meta-analysis.” European Heart Journal. doi:10.1093/eurheartj/ehq155.

[2] “Is tall beautiful and the heart healthy?”. European Heart Journal. doi:10.1093/eurheartj/ehq183

Pdfs of the full research paper and the editorial are available before the publication date from Emma Mason or at:

The European Heart Journal is the flagship journal of the European Society of Cardiology ( It is published on behalf of the ESC by Oxford Journals, a division of Oxford University Press. Please acknowledge the journal as a source in any articles.

The European Society of Cardiology (ESC) represents more than 62,000 cardiology professionals across Europe and the Mediterranean. Its mission is to reduce the burden of cardiovascular disease in Europe.

Contact: (media inquiries only):

Emma Mason: Tel: +44 (0)1376 563090
Mobile: +44(0)7711 296 986

ESC Press & PR Office (for independent comment):

Tel: +33 (0)4 92 94 86 27. Fax: +33 (0)4 92 94 86 69. Email:

Patient Parking: Another Hospital Revenue Stream?

The British health care system is making a go at it:
Using data from 126 Freedom Of Information requests, Epsom and St Helier University Hospitals NHS Trust came top for clamping.

Over a year the hospital clamped 1,671 cars and made nearly £2m profit.

Leeds General Infirmary issued the most parking tickets - over 10,000, generating £142,000 profit.

The Royal Derby was the target of the most criticism - it received 82 complaints in 2008-09.
I wonder what US hospitals are bringing in? When a hospital owns 4,734 spaces, I bet they're doing pretty well.


Tuesday, June 08, 2010

Colbert: Innovative Physician Payment Reform

... with chickens:

The Colbert ReportMon - Thurs 11:30pm / 10:30c
Indecision 2010 Midterm Elections - Sue Lowden
Colbert Report Full EpisodesPolitical HumorFox News


h/t: K. Sarpolis, MD

When Atrial Fibrillation Recurs

... as told this morning in the Washington Post:
"I was amazed at how quiet my heart was," says Currier, a 69-year-old resident of Springfield. But the benefits of the treatment, called catheter ablation, didn't last. Soon her heartbeat became erratic again, forcing her to ask: What should I do?

That's the dilemma facing more than 2.2 million Americans who have atrial fibrillation, the most common heart arrhythmia and one of the most vexing to control. While treatments ranging from medication to surgery are proliferating -- and often are marketed aggressively by hospitals -- no one can say with certainty which will work best for any individual patient. And each treatment has side effects, some of them serious.

"We don't have great evidence to help patients and doctors make a fundamental choice among the treatment options, which differ dramatically," says Steven Pearson, president of the Institute for Clinical and Economic Review, which evaluates medical treatments and is affiliated with Harvard Medical School.

That makes A-fib, as it's commonly called, a top candidate for comparative effectiveness research, say Pearson and other experts. Congress set aside $1.1 billion last year for this type of research, which involves head-to-head testing of drugs and treatments to determine which work best, and for which types of patients. Advocates say such research will improve health care and help get costs under control.

More information about A-fib therapies, for instance, would allow doctors to customize treatment for specific patients, says Harold Sox, a prominent internist who headed an Institute of Medicine committee advising Congress on how to spend the comparative effectiveness research funds. The committee issued a report recommending that atrial fibrillation should be a top candidate for such funding when it is given out by the government in the coming months.
So I found it interesting that while the above article alluded to, but did not mention by name, the multi-center, prospectively randomized pivotal trial ongoing now called the CABANA trial (Catheter ABlation versus ANtiarrhythmic drug therapy for Atrial fibrillation). So far, only 46 patients of nearly 3000 patients needed to complete the study have been enrolled. It is anticipated that over 140 centers around the world will participate.

Yet despite the widespread prevalence of atrial fibrillation, the study has been slow to enroll. We should ask ourselves "why?"

Let me count he ways.

First, is the public and referring doctors are not aware of the study and the pivotal trial is just getting underway. (This morning's article should help a bit.)

But there are other issues...

... like the media and other doctors' pre-conceived understanding of the procedure - "I-hear-that-ablation-stuff-is 90-98% effective, so just go in there and get your afib ablated and you'll be fixed" attitude. Patients have seen the glowing early results of catheter ablation, touted by some early on with "85 percent" success rates (which, quite frankly, are hogwash, unless we count people who continue to take antiarrhythmic drugs following their ablation - hardly a comparison of the two approaches).

But other early trials that only looked only at the time to first afib recurrence have had glowing press coverage as well, potentially biasing recruitment efforts for the CABANA trial.

Finally, there's the complexity of recruiting patients. Patient's usually prefer a "guick-fix" and many might be less inclined to participate in the CABANA trial's five-year duration. Also, gathering the vast quantities of information required for such a comprehensive evaluation of these two widely-disparate treatment approaches involves numerous medication, heart rhythm, and patient evaluations throughout the study's course. When one tries to capture every single warfarin medication adjustment or palpitation on event recorder, the manpower needs and time required to complete such a "comparative effectiveness research" trial in the era of manpower constraints being imposed on hospital systems limits enthusiasm for conducting such large trials. Are we to assume doctors who are already taxed with ever-growing clinical responsibilities can easily pick up the slack? That's why centers with higher research nurse-to-doctor ratios will be the centers most likely to recruit faster.

Which leads other less well-endowed medical centers to wonder if the results of these types of trials will really reflect "real-world" clinical medicine.

Probably not.

But when you don't have much else to go on, and the money for research is increasingly showered on large health care systems, it might be the best we can do as a country. What this might mean to smaller, more rural health care delivery as the government applies the results of this trial across the nation remains to be seen.


Disclaimer: I am the principle investigator for CABANA trial at our institution and yes, we have one research nurse dedicated to this trial.

Sunday, June 06, 2010

Leading By Example or Intimidation?

Two cardiologists, two very different approaches.

One is this:
He’s an early riser, to say the least — up between 4 a.m. and 4:30 a.m. every day.

First thing on his morning agenda is a cup of green tea. Settling into his home office, he quietly checks his e-mails and reads for about 30 minutes. This is his quiet time, when he prepares himself for the day.

From 5 a.m. to 5:30 a.m. he writes grant proposals, clinical research papers and the like. “It’s amazing how much you can accomplish in the early morning,” he said.

At 5:30 a.m., he’s on his way to the medical branch Field House, which is five minutes from his East End condo. There, he swims laps for 30 to 40 minutes (on an empty stomach) and then showers to head back home.

While he used to enjoy a quick jog in the mornings, a knee injury keeps him away from high-impact exercise.

At 6:30 a.m., it’s finally time for a heart-healthy breakfast at home with his wife, Tamami.

The meal is always the same: salad. But it’s not the salad you’re typically served before a meal.

It’s a special salad he spent years perfecting and includes lettuce, seafood, wasabi, eight kinds of vegetables, ginger, olive and sunflower oils, vinegar, whole jalapeños and mozzarella cheese.

“Every morning, I know I’m getting at least one excellent and nutritious meal in for the day,” Fujise said.

“I never know how the rest of the day will go, but I can feel good about my morning knowing I had the perfect breakfast.”

From 7 a.m. to 7:45 a.m., Fujise responds to more e-mails at home and tends to his department’s administrative work. By 8 a.m., he’s in his office on the medical branch campus.

As the head of cardiology, Fujise frequently is called into business lunches and dinners, which can make it difficult for him to maintain his heart-healthy lifestyle.

His compromise is to order appetizers instead of entrees, a house salad with vinaigrette or grilled fish.

If he’s fortunate enough to not have a lunch meeting, Fujise enjoys a lunch he brings from home.

His preference is one piece of dark chocolate (76 percent cocoa), one box of raisins, a handful of mixed nuts, some tofu and green tea.

While not advisable for everyone, Fujise and Tamami engage in “calorie restriction,” whereby they restrict their caloric intake by 20 percent to 30 percent.

Comfortable at 156 pounds and 5 feet 10 inches tall, Fujise aims to eat no more than 2,000 calories each day. He gains weight fast, he said, and must monitor the scale daily to keep himself in check.

“My wife does an outstanding job of handling my meals and pushing me to exercise,” he said. “Like everyone else, some days I’m weary, but she pushes me to the door and encourages me every morning.”

Fujise does not eat sugar because of metabolic syndrome concerns, although he will have Splenda on occasion, nor does he partake in office doughnuts or cakes or any fried foods.

If he hosts a lunch meeting, he makes sure there are healthy food options.

“I don’t want my young medical students getting accustomed to fried foods. My goal is to promote heart health,” he said.

Coffee also is absent from his heart-healthy list, although he understands why many people must have their jolt in the mornings.

He used to be a coffee drinker himself, but he found the caffeine in coffee to be equivalent to that in green tea but without the jitters that often come with coffee. Plus, green tea has been proven to help fight cancer, he said.
... and the other is this:
He was the most respected man in our training program. The oldest cardiologist at our institution, gruff, never afraid to shy away from a four-letter word to make his point, and with the uncanny ability to diagnose critical aortic stenosis (pulsus tardus et parvus) or insufficiency (bisferiens pulse) by placing his hands on his patient’s pulse. No echocardiogram was necessary. His incredible knack for inductive reasoning of associated diagnoses was unparalleled. His breadth of clinical experience and expertise unequalled. I had always held him in my highest esteem – a real model to follow.

So after returning to that institution of higher learning after fellowship training and getting settled in my new routine as a young staff physician, I headed to lunch with an entourage of medical students and residents. It was then that I saw him, my medical idol, in line with a burger and fries, and a tall Coke.

“Hello, Dr. B., how have you been?”

“Hell, just fine, Wes.” It was then I noticed his tray.

Smiling, I quipped, “Dr. B., aren’t those things bad for you?”

“Well, shit, Wes,” he smiled with a twinkle in his eye, “... I look at this way. I have a 50-50 chance of dying of cancer or heart disease... and I’d much rather die of something I understand!”
Here's the question:

Which cardiologist would you chose to be your doctor?


Friday, June 04, 2010

The Initial Impressions of The Vanishing Oath

Here's a very brief video (2:45 min) of some portions of the Q&A session and viewer comments that followed the showing of The Vanishing Oath, a physician-directed documentary highlighting the challenges for physicians today. I apologize the the sound quality, but it was recorded by my son with our hand-held video camera:


Helping Doctors and Nurses to Communicate - Maybe

... with a push-to-talk device.

One of our super-cool residents

This little badge-gizmo-on-a-lanyard from Vocera is being tested in our ICU's to facilitate communication between doctors, nurses, pharmacists and other care providers there.

Each nurse picks up one of these devices each shift and "signs in" on the company's website, where the name is associated with the ID number of the device. Push a button, and the device responds "Vocera" meaning it's ready to receive your command. You then say "Call Wes Fisher." The device uses it's voice recognition software and responds "Calling John Sheridan." The nurse quickly pushed the button to cancel the page.

Oops, seems I was not signed in for the system.

So I had them call someone who HAD signed in that shift and it worked pretty well. There was need to drop what they were doing to find a phone. Also, the person on the receiving end did not have to touch the device to respond and the communication was just like talking to each other on a loud speakerphone. One nurse mentioned that conversations could be overheard if family is near, but they could say "Transfer call to extension 1-2-3-4" (for instance) and the call will be automatically transferred to a different phone extension for a more private conversation. They also liked the ability to say "Call ICU pharmacist" without having to leave the patient's room to clarify an electronic order.

Interesting stuff. We'll just have to see how it works when folk's voice commands compete with the overhead intercom calling for a "Code Blue."


Note: I have no commercial interest in the technology described above.

Thursday, June 03, 2010

Receptionists Beware

... your days are numbered.

This little gizmo was placed in one of our facility's lobbies this week. (No, it's not being used to get your boarding pass on your way to the airport, but it is amazing the parallels health care is taking with the airline industry):

Click to enlarge

Instead, it's used to check in patients presenting to have their blood drawn for prothromin times.

Click to enlarge

Just swipe your credit card, confirm your appointment, sign your name, and away you go!

On seeing this, one doctor exclaimed, "But INR checks are my patient's only chance to get out and socialize!"

Fortunately for now there are still helpful assistants there to help them learn how to use the device.


Wednesday, June 02, 2010

End-of-the-year Lectures

Some things never change - like sitting in the back of the lecture hall.

I just wonder if they know how good they've got it.


Providing Health Care Will Get You Investigated

When I started medical school if someone had told me that providing health care to my patients would be grounds for a Department of Justice inquiry into the care I delivered, I would have laughed in their face. But the government's desperate financial times require desperate measures. From the Report on Medicare Compliance:
Both the Department of Justice (DOJ) and the Recovery Audit Contractors (RAC) are focusing investigations on Medicare billing for implantable cardiac defibrillator (ICD) surgery. The reimbursement rate for ICD surgery is one of the higher dollar Medicare Severity Diagnosis Related Groupings (MS-DRG). The DOJ’s investigation is focusing on both medical necessity and MS-DRG coding validation issues, while the RACs are currently only conducting MS-DRG validation reviews. According to the CMS national coverage determination (NCD), Medicare pays for ICD implantation for eight specific conditions. However, there are many circumstantial limitations to coverage in these conditions that often lead to CMS not covering the implantation. For example, the beneficiary must not have had an acute myocardial infarction within 40 days prior to surgery. If a hospital being investigated by the DOJ performed the implantation despite this condition, the DOJ is requiring them to justify why they thought the surgery was medically necessary. The DOJ is sending out document production requests, requesting all documents related to ICD implantation coding, billing, payment, reimbursement, payment denials and ICD-related appeals by all payers. Additionally, RACs are conducting coding and validation reviews of MS-DRGs related to ICD surgery. When conducting validation reviews, the RACs are looking at the beneficiary’s medical record, specifically the diagnostic and procedural information and discharge status, to determine whether the ICD surgery MS-DRG code listed is supported by the proper documentation.
Consider yourself warned, criminals.

Remember that malpractice litigation we were worried about? What were we thinking?

Those were the good ol' days.


Reference: “Justice Dept. Investigates Hospitals for Cardiac Billing in New Spin on RAC Risk.” Report on Medicare Compliance Vol. 19, No. 15. 26 Apr. 2010; 1, 5.

Tuesday, June 01, 2010

DOJ Takes Aim at Doctors

... as conspirators:
This case is a watershed for two reasons:

First, until now the Federal Trade Commission, not the Justice Department, has taken the lead in prosecuting physicians. Since 2000, the FTC has brought about three dozen cases against physicians (all but one of which settled without any trial). But the FTC only has civil and administrative jurisdiction; the Antitrust Division has civil and criminal jurisdiction. The Sherman Act makes no distinction between civil and criminal “price fixing,” so in a case like this, it’s entirely a matter of prosecutorial discretion whether to charge the doctors with a civil or criminal offense.

Based on the descriptions in the Antitrust Division’s press release, there’s certainly no reason they couldn’t have prosecuted the doctors criminally and insisted upon prison sentences — and there’s little doubt such threats were made or implied to obtain the physicians’ agreement to the proposed “settlement.”

The second reason this is a landmark case is that the Justice Department has unambiguously stated that refusal to accept government price controls is a form of illegal “price fixing.” (Emphasis mine)

The FTC has hinted at this when it’s said physicians must accept Medicare-based reimbursement schedules from insurance companies. But the DOJ has gone the final step and said, “Government prices are market prices,” in the form of the Idaho Industrial Commission’s fee schedule. The IIC administers the state’s worker compensation system and is composed of three commissioners appointed by the governor. This isn’t a quasi-private or semi-private entity. It’s a purely government operation.

What’s more, the Antitrust Division has linked a refusal to accept government price controls with a refusal to accept a “private” insurance company’s contract offer. This lives little doubt that antitrust regulators consider insurance party contracts the equivalent of government price controls — and physicians and patients have no choice but to accept them.
Read the whole thing to understand the implications of this settlement. Given the 21% cut to Medicare payments that occurred today (but CMS is 'holding claims' for ten days to allow for another stop-gap measure to be implemented), ask yourself two questions: (1) "Where was the AMA?" and (2) Are you ready to be a government employee?"