Perfecting Social Graces

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!”

Brilliant, as always.

So now when I have a burger or steak with friends at a social gathering and am confronted by the competitive guest eager to restate to me the risk factors for heart disease ad nauseam, my response is simple: “I’d much rather die of something I understand.”

Thanks, Dr. B.

--Wes

FDA Warns Against Some Online Canadian Drugs

If you've thought about getting your drugs online from Canada, beware of counterfeit drugs that have appeared in the market:

The U.S. Food and Drug Administration (FDA) is advising consumers not to purchase prescription drugs from websites that have orders filled by Mediplan Prescription Plus Pharmacy or Mediplan Global Health in Manitoba, Canada following reports of counterfeit versions of prescription drug products being sold by these companies to U.S. consumers. FDA is investigating these reports and is coordinating with international law enforcement authorities on this matter.

The link above includes some of the websites using Mediplan drugs. Several cardiovascular drugs were found to be counterfeit, including Lipitor, Crestor, Zetia, Diovan and Hyzaar, among others.

--Wes

Primary Care: The 'Brewing Storm'

An outstanding job of depicting the current crisis for primary care physicians in America today is nicely described by Thomas Bodenheimer, M.D. in tomorrow's New England Journal of Medicine. The full text is here. Take a minute and read this. It will help you understand why folks are becoming so dissatisfied with their primary care physicians, why young doctors are fleeing from this field of medicine, and where the impediments to correcting the problem lie. In effect, it is a perfect "brewing storm."

--Wes

Celebrex Stops Recurrent Adenomas

Two new studies (one here and the other here) from tomorrow's New England Journal of Medicine have demonstrated a reduction in the recurrence of colonic adenomas following polypectomy in folks treated with celecoxib (Celebrex), a COX-2 anti-inflammatory medication manufactured by Pfizer. Unfortunately in both reported studies, the incidence of cardiovascular events in the two studies were increased in the celecoxib-treated groups in a dose-dependent way (Relative risk 1.3-3.4). Bottom line:

"These findings indicate that celecoxib is an effective agent for the prevention of colorectal adenomas but, because of potential cardiovascular events, cannot be routinely recommended for this indication."

--Wes

Another Problem With Pay for Performance

Pay for performance initiatives are likely to generate the wrong incentives, as this attempt to measure "quality measures" by Medicare has demonstrated. If you make money collecting data, expect financial incentives to exceed health care incentives.

I wish our government officials at CMS made the New York Times bestseller, Freakonomics, required reading. This is a classic example of the wrong incentive being supplied...

--Wes

Medtronic Introduces New Pacer Line

Medtronic announced a new pacemaker line publically. From what I can tell, the new feature on these devices is "atrial capture management (ACM)." ACM is where the device can auto-adjust the output of the atrial lead voltage output to assure capture. The devices do have the cool AAI (atrial or upper chamber-only pacing) to DDD mode(upper and lower pacing as needed pacing) switching capability available in their former Enrhythm line of pacemakers to avoid excessive ventricular pacing. I'll see if I can find out other features soon to share them with the blog-o-sphere. I haven't heard of any REALLY new features that will make me switch to these pacemakers... but even Medtronic's website still does not have info on these devices quite yet.

Although the names of the devices are a bit fluffy in my view (I mean Adapta, Versa and Sensia?!? - these sound like some cologne or sex aid, perhaps!), ", at least they avoided the "sound-alike" problem I commented upon regarding their last product line. I guess I was looking for some of the macho names like stents get to have: like "Cobra", "Cypher", "Taxus", "Multilink Ultra", for instance.

:)

Now, the cost? I'm sure they'll be at the top of the spectrum for now....

-Wes

11:03 AM CST Addendum: For the non-EP folks, sorry about the technical speak, but here's what I've learned about the new line of pacers: the Sensia line will replace the old Sigma and Kappa pacemaker product lines, the Versa will replace the Enpulse product line (it will have the "Search AV" feature but NOT the "mimimum ventricular pacing (MVP)" feature), and the Adapta product line will become their "top-of-the-line" pacemaker similar to the Enrhythm pacemaker (i.e. will have the MVP feature) but will NOT have the anti-atrial tachycardia features of the Enrhythm pacemaker. Also the Adapta pacemakers will be capable of accomodating unipolar leads as well as bipolar leads (the Enrhythm device MUST use bipolar leads). Hope this helps!

--Wes

My New Wedding Song

When I was married many, many moons ago, we had Pachelbel's Canon in D Major played for our wedding. Ah, such a lovely song.

But with the years and more of reality stepping on my idealism, I think I'll have this version played when I renew my vows. It speaks volumes.

--Wes

It's Tuesday - Must Be Grand Rounds

Vol 2, No 49 of (Medical Blogger) Grand Rounds is up at Protect The Airway.

"WELCOME TO THE ED …

From here, a patient could end up just about anywhere in the hospital, and besides the frontline healthcare workers in the ED, it seems there is never a shortage of supporting healthcare personnel passing through. All of this makes for a hectic and confusing environment, so let PTA show you the way."

Check it out.

--Wes

Red Cross One Year Later

On the anniversary of the Katrina, Rita and Wilma hurricane disasters, I was sent the one-year progress report from the Red Cross after our t-shirt website, MedTees.com donated a dollar a shirt over three months (almost $500 dollars total) to the Katrina relief effort. Although the Red Cross has been rocked by significant scandal at its local chapters, they still remain an important US-based relief organization and have done remarkable good for millions of victims of these (and other) natural disasters. Hopefully now they can spend some of that money to clean up their own disasters to continue serving the millions of needy individuals during such crises.

--Wes

Medtronic: Could Direct-to-Consumer Advertising Backfire?

For the past week, there have been reports about Medtronic's direct-to-consumer (DTC) advertising campaign to promote automatic implantable defibrillators, devices costing about $20,000-$30,000 that detect and treat rapid, abnormal heart rhythms that can be potentially fatal in people with abnormal heart function.

The company announced plans to spend $75 million to $100 million to improve sales of implantable defibrillators, which have been hurt by doctors concerned about recalls and by worries about proposed sharp cuts in Medicare reimbursement for the devices.

The campaign will include Medtronic's first large-scale advertising aimed directly at patients. Such ads are common for prescription drugs but have been a rarity in the medical device business.

But could such a DTC campaign backfire? Physicians have typically been the individuals to recommend such expensive, life-saving technology to their patients based on recent studies demonstrating a survival benefit to many patients with significantly compromised heart muscle function. Will doctors become frustrated by every patient with normal heart function or no heart diease at all (and hence are not appropriate candidates) calling their clinic to see if they might be candidates for expensive ICD's or who demand immediate appointments because they might fear "sudden unexpected death?" Are doctors' offices prepared for the emotionally-charged ads of people whose lives have been saved by these devices that then ask: "Are you protected?" (or something like this?). Will doctors feel coerced to act, especially when the implication of not acting might be perceived by their patients as not doing enough to protect them, at all costs? Doctors are not oblivious to these marketing tactics, especially in lieu of the "ask your doctor" pharmaceutical campaigns that have preceeded the medical device industry's proposed campaign.

The indications for appropriate referral for ICD's are complicated. Not all patients need them. But some do. The real question is separating the wheat from the chaff - and no advertising campaign can do this. Such a campaign might raise unnecessary fears in our patient population and subsequently cross an important line that shouldn't be crossed: recommending health care for financial incentive rather than by actual need. Oh sure, it might pay off on the short run (some doctors might enjoy the increased volume of patient visits) and their actions with this ad campaign couched in the "feel good" guise of "saving lives." But it might also alientate the very physicians in whom Medtronic relies to recommend their devices, tacitly implying they are incapable of appropriately recommending such therapy to their patients.

But Medtronic is savvy. No doubt this upcoming campaign has been thoroughly vetted by consumer focus groups. But were doctors part of those focus groups? I doubt it.

--Wes

Could Bioengineered Pacemakers Become Reality?

With this report, bioengineered pacemakers might soon become reality.

"In the current study, the researchers delivered a gene encoding a bioengineered cell-surface protein to heart muscle cells of pigs. This protein mimics the combined action of several proteins called HCN ion channels, which play a critical role in maintaining a normal, evenly paced heartbeat. These channels control the flow of sodium and potassium ions in and out of cells that regulate the electrical impulses of the heart."

Many barriers remain before applicable to man, but with the improved understanding of the inner workings of the heart and genetics, who knows?

--Wes

Atrial Fibrillation Ablation Update

One of the better reviews of atrial fibrillation ablation's current state of the art was recently reviewed by John D. Fisher (no relation) and colleagues from Montefiore Medical Center's section of Cardiology in PACE (Pacing Clin Electrophysiol. 2006;29(5):523-537). A link to the online version of the article can be found via Medscape (registration required). It's a worthwhile read full of good basic information and an objective compillation of the reported studies to date.

--Wes

Heparin vs. Enoxaparin for Venous Thrombosis

Perhaps the biggest piece of news in cardiovascular circles this week was the JAMA article demonstrating the equivalency of unfractionated heparin to low-molecular-weight heparins, like enoxaparin (Lovenox) in treating patients with deep venous thrombosis (blood clots in the legs). This study spells trouble for Sanofi Aventis, the maker of Lovenox. Why? Because of hospitals' concerns over pharmaceutical costs. One dose of 5000 units of heparin costs $1.15, where one dose of a 40mg syringe of Lovenox costs hospitals about $24. Granted the usual starting dose of heparin in this study was about 26,000 units (320 U/kg), with 20,000 units (250U/kg) given twice a day, whereas the average daily dose of Lovenox was 8290 units, but this still represents a significant cost savings for hospitals if this drug substitution is widely adopted by the medical community. And since this study was performed without the requirement for follow-up assessment of the partial thromboplastin time (or PTT) blood levels and demonstated an equal safety record, it likely will be adopted in future guidelines for anticoagulation therapy for deep venous thrombosis.

It would be interesting to re-run all of the retrospective studies funded and eventually marketed by Sanofi Aventis with the newer, more aggressive heparin dosing guidelines adopted by the authors of the currrent JAMA article to re-evaluate costs.

Look for more studies comparing plain ol' heparin at higher doses to enoxaparin for other indications (like pulmonary embolus, acute coronary syndromes and the like) in the future.

--Wes

A New Medical Blogger

Please take a moment to welcome Dr. Kannan, a new contributor to the medical blog-o-sphere, with whom I have had the priviledge to mentor and from whom I continue to gain insights on this complicated field called medicine. His thoughtful prose and insights will be most welcomed.

But I'm afraid he's an internet nerd like me.

--Wes

08:20 AM CST Addendum: The link was fixed. Sorry. --Wes

The Cost of Health Care Education

From the Wall Street Journal today via FinAid.org: the average cumulative debt of doctors after Medical school in 2003-2004 dollars was $113,661 with 95% of medical students borrowing money to fund their education. Compare this to law grad students (LLB or JD) whose average debt was $70,933 (87.7% borrowing) or doctorate degree students($49,007 with 51% of students borrowing) and you get an appreciation for yet another financial pressure our young physicians experience when they complete school. Given these price pressures, how on earth can we justify decreasing reimbursements to physicians? But it's likely to happen. Fortunately, it appears the expected cut in reimbursement to doctors of 4.4% will been repealed this year and reimbursements will be held at 2005 levels, but realize with inflation, this "freeze" still represents a pay cut. So it adds insult to injury when one finds that Medicare has decided to roll over reimbursement to the next fiscal year as a budget-balancing tactic and delay reimbursements to doctors by nearly two weeks this September. From the American Academy of Neurology's website:

A brief hold will be placed on Medicare payments for all claims for the last nine days of the Federal fiscal year, September 22, 2006 - September 30, 2006. These dates do not refer to the dates of service, but to the dates that you would have normally received the actual payments if you filed a clean claim. Claims held as a result of this one-time policy will be paid on October 2, 2006, with no interest or late penalty paid to an entity or individual for any delay in a payment by reason of this one-time hold on payments.

This delay of payments will cause a deferment of $1.3 billion to be paid beginning in October 2006 which marks the beginning of government’s 2007 fiscal budget year. The policy applies only to claims subject to payment and does not apply to full denials and no-pay claims. These payment delays are mandated by section 5203 of the Deficit Reduction Act of 2006.

Times are gettin' tough in medicine on everyone, but especially young doctors. And you can bet these young physicians' bankers will still expect payment on their loans without a 9-day lag.

--Wes

Quackery Gone Wild: Laser and Smoking Cessation

I was driving to clinic yesterday and heard an advertisement by Laser Associates of Chicago to promote their laser therapy for smoking cessation. I nearly crashed my car. "What the heck is that," I thought. So I did some research.

Low-level laser light (the stuff coming out of laser pointers) is red light that when reportedly applied to "acupuncture" sites, stimulates the release of endorphins - specialized neuroreceptors in the brain, that by some incredible circumstance, this helps you stop smoking! Wow! It's Star Trek in real life!!!

But closer inspection demonstrates the sinister plot developing. You see, this "clinic" is a "doctor-directed" clinic, so the web site says. I have no clue who is really running it or the exertise of the "therapists." Closer review demonstrates that the "clinical director" is a chiropractor named Thomas E. Newell. According to the Illinois Department of Professional Regulation's license look-up web page, Dr. Newell had an active chiropractor license from 12/20/1960 through 7/31/1996 and failed to renew the license since that time. It seems Dr. Tom has decided to promote a form of smoking cessation that is not based in fact and aims to defraud people out of $299-$399 per "treatment." Similar clinics have popped up in Las Vegas and Detroit. The citizens' action group Public Citizen has made efforts to petition the FDA to stop fraudulent advertising by these clinics. But one of the firms, Freedom Laser Therapy has offered a weak retort to Public Citizen's claims citing their "IRB" (or Investigational Review Board) is on top of the data-gathering. But who sits on their Investigational Review Board? Are they all stock-holders in Freeedom Laser Therapy? Do they REALLY have the patients' best interests at heart? Are patients given informed consent BEFORE therapy? Is that consent signed and dated by the treating unlicensed doctor?

So please, beware. Avoid this scam. Save your money, or if you must spend your hard-earned $299 in cash somewhere, send it to the American Cancer Society to find a cure for cancer, or to Public Citizen to shut these guys down.

--Wes

100th Medical Blogger Grand Rounds

In case you missed it, Dr. Charles did a wonderful job "reporting" on the state of the 100th Grand Rounds yesterday while I was away. Thank you, Dr.C.

--Wes

Time Out

Ah, our quiet respite from the hussle and bussle of everyday life was refreshing. Although not truly "primitive" by purists standards, the time away from electronics and cell phones to camp with fire and tents was a welcome invitation to slow down and discover that conversations can still occur without the aide of technology, and the world is indeed a beautiful place. Our first night was a lovely bed and breakfast where we had our own cabin and woke to a lovely foggy morning in the mountains on a busy dairy farm.

Next we went 26 miles on the Elroy-Sparta Bike trail with the kids.

We followed this with a 12-mile canoe ride down the Kickapoo River the following day.

And managed to stop and enjoy the small things along the way.

-Wes

Time Well Spent

I won't be blogging for the next four days. For the first time in many months, all of the kids are here at home. We've decided to take some time together in the boonies. No cell phone, no computer, no electricity. (What will the kids do?... heh, heh).

This "back-to-school" season reminds me of the frenetic pace the squirrels exhibit as they prepare for the upcoming winter months. But kids grow so quickly. Before you know it they're up and gone. So although short, I know our time together will be time well spent.

--Wes

Sterile Technique in the Cath Lab

A New York Times article today discusses high rates of coronary stenting noted in doctors in Elyria, Ohio realative to the rest of the US. What was more interesting to me was the article's picture: a cardiologist performing a heart catheterization procedure without a hat or mask, while the radiographic technologist at least has a protective face shield. While I am aware of the low incidence of infection from these procedures, potential risk to the operator and patient still exists. Universal Precautions to eliminate infections to the operator from blood borne pathogens are needed, especially in bloody procedures like this. Also, I remain concerned about the potential for infection risk to our patients with indwelling prosthetic valves or who receive implanted devices like stents, vascular closure plugs, and PFO closure devices. Policy is clear on this:

Since the incidence of infections related to procedures in the cardiac catheterization laboratories is low, it is unlikely an adequately powered randomized study of caps and masks will ever be performed. However, the consequences from such infections are significant while the risk of using these precautions is nonexistent. Therefore, it is the recommendation of these guidelines that the use by the operator(s) of a cap, mask, and eye protection be strongly considered, if not mandatory, for all procedures performed in the cardiac catheterization laboratory for the protection of the operator.

If an operator does not use a cap and mask routinely, they should at least be used for procedures in patients who are at increased risk for both an infection as well as for a serious complication, should one develop. Such patients include those with native valve disease or intracardiac prostheses, arterial access performed through a femoral arterial graft, prolonged catheter or procedure times, prolonged use of an in-dwelling sheath following the procedure, intra-aortic balloon pump insertion, per-Infection Control Guidelines cutaneous valvular procedures, and the use of implantable devices such as stents, septal closure devices, and/or VCDs. It may not always be known at the start of the procedure if one of these higher-risk situations will occur. Accordingly, each facility should consider the best policy for their laboratory, with patient safety given the highest priority.

Issues related to blood-borne pathogens are real, especially in today's highly-interventional cath labs, and proper sterile technique improves safety for the patient AND cardiologist. After all, most of our technicians follow the physicians' lead.

--Wes