Monday, October 31, 2011

Medicine's New Snow Shovel

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Image credit: Single-website personal license purchased for this blog from

Happy Halloween

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The Siren Song of Continuous Improvement

This is what medicine has become in the eyes of our regulators:

Federal health officials are seeking physicians and other health professionals for a program to develop leaders in health care innovation.

The Centers for Medicare & Medicaid Services on Oct. 17 announced the Innovation Advisors Program, which will accept up to 200 people in its first year. Advisers will develop projects and processes in their home regions that achieve the goals of bettering population health, improving health care delivery and lowering costs through continuous improvement. They will focus on Medicare, Medicaid and the Children's Health Insurance Program.
Continuous. Never-ending. Infinite.

As if money had no limits.

More. More. More.

More doctors-turned-administrators. More “projects” and more “processes” like Pay for Performance and Quality Measures. More keyboard entry time.

But note that this is continuous improvement but is limited to government programs: a fact that contradicts the word "continuous."

The implications to policy makers who use such trendy buzz phrases like “continuous improvement” is that doctors and current public policy workers aren’t already working to constantly improve our patients’ health. Instead, we are messy, doing expensive things that involve too much time and too much money.

So new programs must be developed and their processes measured to see if they work.

Isn’t this the point of "continuous improvement?"

So the government's answer for continuous improvement is to acquire 200 more Anointed Ones woven from the same cloth to help us all "improve." (Well, at least for the first year. No doubt more will be needed in the future. “Continuous,” remember?)

But there's another, better way.

It's a way that will save (literally) billions upon billions of dollars ffor our health care system and taxpayers of this great country. Best of all, it's simple, effective, and guaranteed to work:

Stop continuously improving projects and processes that don’t exist.


Sunday, October 30, 2011

For a Tear

Lovely dentist, so young, with fever.

Just a sore, you said, but alas, much more.

A swollen blitzkrieg over lip, cheek, eyes, then scalp,

Morning smile turned noontime nightmare,

Third nadir’s unfair haunting.

So hurry with tubes, drips, then a cycling whir,

In hopes a returning tear can anoint your brow.

Thursday, October 27, 2011

Medicine's Holiday Crunch

Like Christmas season advertising, the holiday crunch for procedural medicine is coming earlier every year.

Perhaps that's why the posting on this blog as suffered: we're busier than ever.

Why is this?

I suspect it's because of a variety of forces that are coming together to create the great procedural "perfect storm" this time of year.

Perhaps the most important contributor to the holiday rush is the patients themselves. Patients are feeling the effects of their higher health insurance costs like never before. Higher co-pays and annual deductible amounts are making them frantic to get their high-ticket procedures performed before year's end to avoid paying an even higher deductible amount next year.

Additionally, staff want to take vacation this time of year. This puts constraints on specialist's lab time availability. It's a supply-side bottleneck. To relieve the crunch, the same staff are finding themselves working longer and longer days already.

No doubt the government regulators and hospital administrators are enjoying the fruits of their regulatory victory. Seriously, how could it get better? More cases, same staff, lots of new "efficiencies."

Bada bing, bada boom!

But there's a catch. Maybe not now, but sometime soon. We've seen inklings of it - nothing big in the grand scheme of things, mind you, but inklings nonetheless: workers are getting frayed. Since hospitals work to keep overhead costs low in anticipation of still more cuts to government payments, hiring has slowed. Burnout of existing staff is a real concern. Not just with doctors, but ancillary staff, too.

So far, our new health care system has been engineered to take care of lots and lots of patients. To this end, they are succeeding. But as this holiday crunch continues this year and beyond, the pop-off valve to our new health care delivery system pressure-cooker remains the doctors, nurses, and other ancillary personnel workers who work tirelessly to Feed the Beast. Add to this the fact that our providers are increasingly regulated into forced behaviors without concern to the additional time that these regulations require. There seems to be more time spent on regulation requirements ("performance measures", and the like) in exchange for less time for patients and less time for home. As a result, all our direct providers of health care (nurses, doctors and ancillary staff) remain our new health care system's weakest and most vulnerable link.

And what happens when these worn out, burnt out, overbooked workers make an error as overstressed structures do?

We get more regulations.


Tuesday, October 25, 2011

When Siri is Asked for Medical Advice

The implications of artificial intelligence to health care delivery and marketplace referrals have just changed with the introduction of Apple's new iPhone 4S and it's new voice recognition software, Siri. Here's what I got when I asked my phone if I need a pacemaker:

... and here's where "she" sent me to get the answer:

Nice. Except that's not OUR pacemaker clinic.

Uh, oh. Better call our marketing department and have them change our clinic's web-searchable name.


Monday, October 24, 2011

Big-Time Medical Blogging

First, there was O Magazine, now Reader's Digest (next to Hugh Laurie, no less):

Yes, Virginia, it's medical blogging at its best!

(Thanks to my patient who clipped this for me!)



Nurse's Union Sets New Definition of 'First Aid'

The Occupy Wall Street protests continued in Chicago and the nurses unions are dispensing a new form of "first aid:"
Outraged by the arrest of two nurses and a union organizer volunteering at the Occupy Chicago protest over the weekend, National Nurses United is planning a protest at Mayor Rahm Emanuel's office Monday.

The group, the nation's largest union of registered nurses, is calling on its membership in Chicago to picket City Hall on Monday morning to demand that misdemeanor trespassing charges against the nurses and all of the protesters be dropped.

The two nurses arrested were among a larger group marching with Occupy Chicago protesters and later set up a tent to provide first aid.

"It was the wrong move," RoseAnn DeMoro, the group's executive director, said Sunday. "We were there to make sure if the occupiers get harmed, they have first aid."
But pictures from the event in Chicago and elsewhere where the group was protesting suggests another more subliminal story line. In this picture the Twitter stream from the National Nurses United union, the police appeared restrained and tolerant of the protestors:

So what kind of "first aid" was being rendered in their tent?

Here are a few pictures from the same group's "first aid" tent in San Francisco taken from the same Twitter feed:

Hmmm. Were there donuts were in those boxes?

Shucks. Maybe not:

Well, no donuts, but there sure was plenty of splashy red nurses union propaganda available for sympathetic protestors to consume as "first aid."


Friday, October 21, 2011

Changing Perspectives

Earlier in my medical career, I would have thought this idea was a good one: a little med-alert card a patient could carry in their wallet that would tell people they're on an anticoagulant:

But in the old days, I didn't give much of a thought as to what was printed on the other side of the card:

Now I have to think about if I'm giving away branded marketing material of "value." How much are these cards worth? Will this be considered a "gift" from the drug industry? Will my patients be unnecessarily influenced by industry or might their lives be saved by having such a card?

Worse, I have to wonder if the use of the use of such a card would expose myself to additional liability risks if I did not offer similar cards to my patients on other anticoagulants like warfarin, aspirin, or clopidogrel.

Seems strange, really, because when I first started medicine I never used to think about these things - I just wanted to help my patients.

Now, everything's changed.


Food Rating System Smackdown

The Institute of Medicine has just released it's recommendation that all foods be rated with an 'energy star' system: three stars = good, zero stars = bad:
The Energy Star system is a model because it’s simple and easy to use, and also because it’s gained traction with industry, which now develops products with the rating in mind, committee members said.
Except that this rating system hasn't gained traction with industry:
But the Grocery Manufacturers Association and Food Marketing Institute announced their own front-of-the-pack system, called Facts Up Front, in January. It gives information on calories, saturated fat, sodium and added sugars but doesn’t rate foods according to those components.

In a statement today, the GMA said it has “concerns about the untested, interpretive approach suggested by the IOM committee” and that “consumers have said repeatedly that they want to make their own judgments, rather than have government tell them what they should and should not eat.” The FMI said in an emailed statement that it believes the Facts Up Front program “utilizes the guiding principles recommended by IOM.”
This is a smackdown, ladies and gentlemen.

If this is what the wellness ivory towers are coming up with for America, imagine what other brilliant initiatives we can brace ourselves for as millions of dollars are shifted from grandma's pacemaker to expensive wellness campaigns such as this one.

But in small-town America where the corporate suits have herded, overregulated, and often micromanaged America's workers, ordering the "0 energy-star" food stuffs might be exactly the point:
Hey Mildred, can I have one of those '0-star' cherry pies for my breakfast? And while you're at it, grab a pack of Marlboro Lights, will ya?
Once again, Joe Worker fails to appreciate that the gurus at the institute and food industry are only trying to save him from himself.

When will our regulators get this? Studies have already suggested the futility of these attempts.

But I guess to a carpenter, everything looks like a nail.


Tuesday, October 18, 2011

A Shout-Out to Street Anatomy

One of the more interesting blogs to follow is Street Anatomy which "obsessively covers the use of human anatomy in medicine, art, and design."

On a recent trip to Portland, Oregon to attend a wedding, I noticed a bit of street anatomy there and immediately thought of their blog:

The above image was part of a much larger mural:

(Sadly, I was unable to find much about the mural but will leave it to my readers to think of a clever title.)

Shortly thereafter we walked over to the Saturday Market where tons venders market their goods by the riverfront. I stumbled on this piece by Jerry Grose, a retired bank chief operating officer who uses clay as his medium:

Click image to enlarge

The mosaic on the clay was created by applying strands of horse hair to the hot clay as it cooled. (No, those are not cracks). Nice stuff and not too expensive. I don't think Mr. Grose has a website, though, so you'll have to visit Portland's Saturday Market and tell him I sent you.

It's amazing what medical stuff you can find on the street if you just look for it. Thanks, Street Anatomy.


Bucking the Established

"Out with the old, in with the new!"

Who's your doctor? Do you have one?

If you have one, you aren't that interesting to them any longer because you're "established." This is not the fault of your doctor, but because of government rules for paying doctors: "new patient" visits pay better than "established patient" visits. "New patients" have a much better chance of needing new procedures, so they are even more special. Add to that the fact that more and more patients are going to need to become part of the "system" soon, and "new patients" quickly achieve the health care value trifecta.

Sorry. Those are the rules.

The higher payments made by insurers and government agencies for new patients was meant to offset the longer amount of time and cognitive challenges of dealing with a new patient that enters the doctors office. There is no question that there is more work to do when a new patient enters a medical facility: entering demographic data on a computer, actually taking a set of vital signs, performing a careful history and physical. But thanks to the explosion of ancillary health care assistants, imaging studies, the availability of the internet, and a constant push to do more in less time, doctors work differently today than they once did. Much of the data gathering is accomplished before the patient enters the office, imaging studies and baseline testing often occurs before a patient is even seen (remember those tests "required" for "quality" care?). Furthermore, because limitations for the frequency of testing has been imposed by government regulators, health care systems leap at the opportunity to "direct" doctors to order tests the moment the test might be needed. As such, "new patients" become particularly valuable to health care systems compared to "established" ones.

But are established patients really that tarnished? Should a doctor's time with them be valued any less than the time spent with a new patient? Is there value in that continuity of care? Or are we just creating a incentivized human funnel to our health care system that favors new patients over those with whom we might develop relationships? Is the doctor-patient relationship at risk as a result?


Just as it was intended.


Monday, October 17, 2011

Ready for Halloween

Found this gem while shopping at the Saturday Market in Portland, OR this past weekend. There should still be time for you to get yours if you act fast. While there's a few medical devices, the kitchen appliances (especially the meat cleaver) and the office supply devices (like scissors) were particularly popular. Shipping will set you back about $6.


Addendum: I have no commercial (only fun) interest in the Spoonman Creation's operation.

Sunday, October 16, 2011

When Doctors Occupy Health Care

As Occupy Wall Street protests spread across the nation, I can’t help but wonder if the same movement could occupy health care. After all, the basic tenants of the movement involve protesting against social and economic inequality, corporate greed, and the influence of corporate money and lobbyists on government. In the "Occupy" movement, there is a feeling there’s an inside game and the game is rigged.

It would seem, then, that our new health care law, written by corporate interests and heavily influenced by lobbyists, could become a ripe target for the movement. We are beginning to see patients and doctors asking some very powerful questions: Why does the retail price of a pill have to exceed $10? Why does a single IV infusion of a chemotherapeutic agent have to cost $5000? Why must we keep building hospital facilities that exceed $1 billion commonly, often in areas of extraordinary real estate prices? Why are insurance premiums consistently growing faster than inflation? Why are health care stocks and funds considered one of the best investments right now just as people are worried about affording health care? Why is health care reform making special interests happy while many doctors and patients are increasingly unhappy?

Must doctors accept the pervasiveness and intrusiveness of the inside game in health care? If they didn't, I wonder what doctors’ placards might say?


Wednesday, October 12, 2011

Joining the Fishbowl

It's a strange thing, this practice consolidation.

Imagine: one minute the guys over there are your competitors, then the next thing you know, they're part of your group.

Before, you were SURE you offered patients something better (at least that's what you told yourself). Now, they are us. How does one differentiate themselves any longer? Can we? Should we?

Before, you worked for your practice, them for theirs. People unhappy with them could come to you across town and vice-versa. Where will your patients have to travel for an independent second opinion now? Or will those second opinions just occur with another colleague? As it stands now, we all work for One Practice and The Man. If the new guys screw up, we all screw up. They do well, we'll do well. (At least that's what's promised, right?) And what if The Man screws up?

It can't be easy being the new kids on the block: do you trust them? Do they trust you? Were there incentives to join? Were there not? What deal was cut? There was a deal, right? An now: what will be the impact of their presence be on patient volumes? On pay?

Like formerly incompatible tropical fish, we're all being thrown in the same fishbowl together. We look and feel so pretty now, don't we? But you have to wonder: who will survive and who will die off when the fishfood is in short supply? And as the bowl gets more crowded, will there be enough oxygen to support us all?


Tuesday, October 11, 2011

Student's Sudden Cardiac Arrest Captured on School's Security Camera

She was only 12 years old when her sudden cardiac arrest was captured on a school security camera. Thankfully, she was saved by the quick actions of a few teachers and the school's automatic external defibrillator:

It's good to remember that sudden cardiac arrest is not just limited to the elderly.


Addendum: Oh, and I'm sure she had an implantable cardiac defibrillator installed after her event rather than just a more conventional pacemaker as mentioned in the article.

The Challenges of Gorilla Echocardiography

If you thought human echocardiography was tough, imagine what it's like to perform an echocardiogram on a gorilla while it's awake:
Using wooden sticks, Niehoff and Evans touch the bars where they want Kwashi to place his hands. The gorilla complies.

"Good boy," Evans says, slipping grapes into the gorilla's mouth.

Evans applies conductive gel to the tip of a small wand that emits high-frequency sound waves. Then, with grapes in his left hand, Evans moves the wand in his right hand toward Kwashi's chest, being careful not to place the instrument completely through the bars.

This is where an important part of Kwashi's training kicks in. The gorilla leans forward slightly until his chest rests against the bars. He holds that pose - and continues gobbling grapes - as the wand touches his chest.

A few feet away, Jenny Schaaf stands at a state-of-the-art cardiac ultrasound machine on loan to the zoo from Toshiba. The monitor shows the gorilla's beating heart, which Schaaf, technical director of the echocardiography lab at Christ Hospital, captures for later analysis.

"Tilt up a little bit," she says, directing Evans on how to position the wand. "Little bit more. That's perfect."

"Good boy!" Evans says, as Kwashi holds his pose.

A few minutes later, though, Kwashi grunts. Evans recognizes the sound as the "cough vocalization."

"That's a warning that, 'I don't like what you're doing.' He doesn't like his chest being touched."

Sunday, October 09, 2011

New Marchers, Old School

Seen at yesterday's "Occupy Chicago" march on State Street:

The entire US Defense budget for 2010: $685.1 Billion

In 2009, the United States federal, state and local governments, corporations and individuals, together spent $2.5 trillion, $8,047 per person, on health care. This amount represented 17.3% of the GDP, up from 16.2% in 2008 and health insurance costs are rising faster than wages or inflation.

Even if every sword was beat into scalpels, it wouldn't begin to pay for America's exploding health care bill. Worse, with our new health care reform law, the same old construct for health care delivery remains: burgenoning middle-man costs, pandering to special interests, and endless consumer expectations.


Friday, October 07, 2011

The Question

There they were, little maroon flags outside three patient exam room doors. You could almost hear the game show host ask the question:
Will it be Door #1, Door #2, or Door #3?"
So I asked the medical assistant, "Who's next?" and she pointed me to Door #2.

It was a new patient with a familiar problem, one I've seen probably a thousand times before. Another day, another case. Bada bing, bada boom. Nothing to it. You would think that all cases, and all people are the same in some ways. Certainly, those managing our health care system of the future would like us to believe it's so simple: just another case of heart failure (what can go wrong?) or supraventricular tachycardia (love that one, there's NOTHING hard about that!) or maybe a few PVC's (Check). Another day, another dollar.

I suppose it would be easy to classify patients that way, after all, I'm now just a "proceduralist for the heart electrical system" in the eyes of many these days. But there is something that I always find myself looking for with each new patient I see: The Question.

The Question is the query that irreversibly connects you with the patient. It's not the details of the history of present illness or the past medical or surgical history, rather, it's The Question that makes the patient look at you in a slightly different way. It's The Question that makes them realize you're human. It's The Question that let's them know you're interested. It's The Question that is outside the rubric of medical history taking. It's The Question that keeps you coming back for more, day in and day out.

The cool thing about The Question is it's usually different for every patient. In fact, it is invariably unique to a given patient. The challenge for every doctor is finding it. And the weird thing is, you might not know you found it at first. But when someone asks you about the patient, it's invariably The Question and its answer that you recall along side their health issue. It might be a simple, "What kind of work do (did) you do?" or "What's your son doing now?" or even "Nice shirt. Where did you get that?" Nothing complicated, mind you. You hear about the job, the kids, the passions: people being people, not just an algorithm.

And the best part?

There's always (and I mean always) something new to learn.


Wednesday, October 05, 2011


He wondered: why does the sound of footsteps in the lineoleum floor always sound louder post-call? He'd have get a change to buy new shoes, he thought - ones with better arch support and without those slippery leather soles. Maybe this weekend. Then, like a stroke patient noting faint hyperesthesias, he felt the sticky diaphoresis beneath a shirt worn too many hours in a row.

Can't forget to pick up the dry cleaning, too.

Day in, day out for a week at a time he marched this march, the end of a long week had finally come and he took a deep breath, hoping he hadn't forgotten anything. He entered the parking lot: where was his car again? Oh, that's right - wrong level. He changed course. More footsteps, more sweat. There it was. Opening the door he realized it needed a wash and a good vacuum, too. Couldn't worry about that now, she needed him home. Guests coming. What was he supposed to pick up again? Oh, yeah, a baguette. Wine, cheese. It is nice to reenter civilization, to forget about life for a while.

After his errand he headed home. Dusk settling. The soft glow of the porch lights showered the walk with a yellowish hue that accented the tint now visible on the autumn leaves. The squirrels continued on their risky suicide missions to bury their winter snacks. A solitary cricket gave it his last before the final quieting chill set in. Why should be more aware of these things than before?

Perhaps it is the quiet, the uninterrupted time to think, the lazy yet relentless pace of common life that offsets the days of schedules, commitments, and procedures. Better: it is the welcome expectation that these sounds will be unpunctured by the startling cry from his beeper.

But before his head could sink amongst the pillows, he had to rally once more. Game-face donned, he charged up the steps with baguette in hand. Things were in full swing. Welcome! Then a toast, a nice meal, then a goodbye as eyes quickly drooped. The dishes could wait, but the dog, unhurried, was oblivious: one more body with which to attend.

Then finally, with doors locked, the lights were extinguished. As the stairs were scaled, he noted the wood floors were warmer and softer than the linoleum. Noisier, too. No matter: it was home. And at long last he took a seat and reclined to his final encounter of the day ...

... with the calm, sweet darkness of the back of his eyelids.


Tuesday, October 04, 2011

Monday, October 03, 2011

One for the Price of Two

If you want to grow the expense of health care delivery in America very quickly, then create two government agencies to do the same job.

From the 28 September 2011 issue of the New England Journal of Medicine, we read about a small paragraph in our new health care law that created the Patient-Centered Outcomes Research Institute (PCORI). From that same article, here's the PCORI's mission:
PCORI responds to a widespread concern (eds note: emphasis mine. Really? What about the internet?) that, in many cases, patients and their health care providers, families, and caregivers do not have the information they need to make choices aligned with their desired health outcomes.

PCORI funding is set at a total of $210 million for the first 3 years and increases to approximately $350 million in 2013 and $500 million annually from 2014 through 2019. With more than $3 billion to spend between now and the end of the decade, PCORI will support many studies encompassing a broad range of study designs and outcomes that are relevant to patients, aiming to assist people in making choices that are consistent with their values, preferences, and goals.
We should recall that there is an agency in the federal government that already does this called the Agency for Health Care Research and Quality (AHRQ). The mission statement of this agency reads:
The Agency for Healthcare Research and Quality's (AHRQ) mission is to improve the quality, safety, efficiency, and effectiveness of health care for all Americans. Information from AHRQ's research helps people make more informed decisions and improve the quality of health care services. AHRQ was formerly known as the Agency for Health Care Policy and Research.

(From another page on the same website:

AHRQ Agency Staff: Approximately 300.
Fiscal year 2010 Budget: $372 million.
Fiscal year 2011 Budget Request: $611 million
Research: Approximately 80 percent of AHRQ's budget is invested in grants and contracts focused on improving health care.
Ahem. Could someone please tell me why there are two agencies doing the same thing and how on earth they're different?

Wouldn't cutting one of them be a good way to save about $500 million per year for America's taxpayers?


Sunday, October 02, 2011

The Vagaries of Atrial Fibrillation

I am always amazed at the different ways atrial fibrillation can present: sometimes with rapid heart rates, other times slow; sometimes it's continuous, other times intermittent; sometimes it occurs without symptoms, other times it occurs with major symptoms like palpitations, stroke, or a peripheral embolus.

Atrial fibrillation is a strange, troubling, and often difficult disease to manage.

And so, when a patient with known persistent atrial fibrillation with rapid ventricular rates presents with a funny sense of lightheadedness with exercise once a week or so, you tend to think you know what you're going to find: periods of super-fast heart rate associated with lightheadedness.

At least until you check the patient's heart rhythm with a recording device. Now I'm beginning to think anything's possible.

Here's why.

Increasingly, I have been reaching for a newer form of heart monitor that combines continuous monitoring with patient feedback but lasts much longer than our older 24-hour Holter monitors. It is compact, has no dangling wires, and gives a continous single-lead EKG tracing for up to 14 days. It has a button that the patient can press to identify periods when symptoms are occuring. Best of all, it's just a little flexible plastic patch that is applied to the surface of the skin. In that patch is a processor that records the surface EKG (even while in the shower) for the full 14 days. (Exercise has to be avoided to avoid sweat from dislodging the adhesive). After that time, the patient drops the device in the mail (provided the post office stays open!) and sends the device to a processing center where the stored 14-day EKG is processed and pre-categorized by heart rate range, rhythm, tachycardias, pauses, PAC's, PVC's and for the reviewing physician to overread. The data are then plotted and made available for clinical review on the company's website. Here's a few pictures of one of the earlier prototypes of this device (iRhythm - now a St. Jude Medical company) that I took:

So why is this important?

In my view, it's because of what I'm finding the patient doesn't perceive while wearing an event recorder. A more conventional event recorder is different than this patch-monitor because it relies on the patient to push the button when they experience symptoms and then stores the heart rhythm from a a minute or two before and after the button was pressed so it can be uploaded to a monitoring station for interpretation. As a result, asymptomatic arrhythmias can be missed. Historically, since patient symptoms were what we cared about we naively assumed this should be the best way to identify the patient's problem.

That was the "old days."

Here's a few representative tracings from the earlier patient when this person pressed the patch's button (denoted by the red circle) at the time of the patient's "symptoms:"

(Click image to enlarge)

As expected: nothing but atrial fibrillation with fairly rapid ventricular response. Certainly there's no real emergent concern with these findings.

But then came the spouses' addition to the patient's history as I called them with the patient's patch-monitor results:
"You know what's been strange? Sometimes at dinner he/she just looks down at the plate for a second and doesn't respond, then asks 'What are you yelling at me for?'"
Here's what the full-disclosure patch-monitor recording from Day 8 from meal time:

(Click image to enlarge)

Needless to say, over nine seconds of asystole is probably the reason the patient failed to respond to their spouse and is the most likely cause of the patient's rarely perceived periods of lightheadedness. Ten other pauses over three seconds had transpired at many times of the day amongst the 14-day recording, yet none were perceived by the patient.



But now I know it's not too unsual for the vagaries of atrial fibrillation.


(Disclaimer: I have no commercial interest in the ZioPatch, iRhythm, or St. Jude Medical)

Saturday, October 01, 2011

Big Brother to Attend the 2012 ACC Meeting in Chicago

Last year, I became concerned about using RFID tags to track doctors at our annual scientific sessions for "planning" purposes. In return, the ACC explained why (really) this was necessary and how they will "take your concerns in consideration" for future meetings.

Suffice it to say, this year, RFID tags will be used again. From the ACC Scientific Session registration page:
RFID badge scanning technology will be utilized at ACC.12 to better understand attendee/delegate educational interests and preferences to assist with future planning. No personal information is stored in the RFID badge, only an ID number. Exhibiting companies that choose to rent RFID readers to analyze attendee movement in their booth will NOT be provided with attendee names or personal contact information. Only organizational affiliation, clinical focus, and city/state/country information will be provided.
So don't be concerned. After all, this year there's something more that's even better!

Big Brother will be watching.

Yes, doctor, please enter your Medicare NPI number at the time of registration so the government can track you, too.

Why does the government need to do this? We're told:
A provision (Editor: Caution - 323 pages!) within the 2010 federal Patient Protection and Affordable Care Act (PPACA) requires healthcare companies to disclose any transfer of value to a healthcare provider to the U.S. Department of Health & Human Services beginning in 2012. The ACC requests its U.S. healthcare provider attendees supply their publicly-available NPI number so that companies may comply with the above provision.
So companies will have your individually-identifiable Medicare NPI number anyway. You, dear doctor, will be tracked, courtesy of the US government, RFID tag or not.

We should ask ourselves some probing questions about this activity:
  1. What in heaven's name is "affordable" to America's health care system about this action? Is it the development of a tracking database? Are our nation's doctors historically untrustworthy in their dealings with industry when attending educational scientific sessions?
  2. Is this action required because patients will be harmed or placed at risk by this educational activity?
  3. Will other professional and political conferences be similarly tracked?
  4. How much does this tracking cost the American taxpayer? Will it cost more to collect the data and analyze it than is saved by tracking meal expenses? In other words, is it cost-effective?
Oh, and one last question:
Are US taxpayers aware they are funding this type of activity?
Well if they weren't, they certainly are now.


The Open Country of a Woman's Heart

A map from the early 1800's of some very complicated terrain:

Click image to enlarge