Heart Failure Therapy Inappropriately Bashed

People who stretch the limits of science need to be called out.

Especially when their intent appears to be to change therapy recommendations based on conclusions from a retrospective meta-analyses. Meta-analyses are nothing more than selectively-pooled studies aggregated by statistical pseudoscientific hand-waving and data manipulation fraught with so many examples of bias that we have to wonder if the intent of the lead author's comments about such a study to the media were not focused on whether their hypothesis was an appropriate topic for future study, but rather if some just had another axe to grind.

Repeatedly this week we have seen the lead author of the meta-analysis that attempts to determine if QRS width can predict future responders to cardiac resynchronization therapy (CRT) promulgate opinion in the name of science. In fact, the study's lead author, Ilke Sipahi, MD leaps to such amazing conclusions about the study's findings that the mind just boggles. From the Wall Street Journal, to Consumer Reports and now, that bastion of scientific reporting, the New York Times, his comments resulted in a main stream media feeding frenzy on the technology. His conclusion?

"In this in-depth analysis, we found that pacemaker patients with less severe electrical disturbance in their hearts did not receive any benefit whatsoever from these expensive and potentially risky implants. Given the abundance of data showing lack of efficacy in this patient population, current treatment guidelines should be changed."

Wow. I'm speachless. Cause and effect to change medical practice from a meta-analysis! Since when?

Since never.

And how did the mainstream media interpret the study?

Here's a sample comical passage from a Consumer Reports article entitled "Many Heart Failure Patients Don't Benefit from Pacemakers:"

Current American Heart Association guidelines say that patients with a QRS (the measurement of the activity of the heart's left and right ventricles) of greater than 120 milliseconds should be treated with CRT (Cardiac Resynchrtonization Therapy). But the study found that patients with a QRS between 120 ms and 150 ms—38 percent of the participants—received little to no benefit from CRT. In contrast, the 60 percent of people who had a QRS of 150 or higher did benefit.

Said another way, 38% (about 40%) of patients with QRS widths between 120-150 had no benefit to CRT pacing, and 40% of patients with QRS widths greater than 150 also had no benefit to CRT pacing. (Yet a remarkably large 60% of these very sick patients with or without wide QRS complexes - most NYHA Functional Class III - benefitted from the therapy.)

Yep. That's the real data: pre-procedure QRS width does not predict who will respond to biventricular pacing therapy clinically. Some will. Some will not. Truth is, we can't predict a priori which patients will respond to this form of pacing therapy for heart failure. To suggest (suddenly and miraculously) that QRS width can predict response from these poor data aggregations when numerous other studies have failed to show such an effect is an irresponsible leap.

Now, please guys, can we stop bashing the best form of heart failure therapy for patients with wide QRS complexes above and beyond our maximal medical therapy and move on to more important issues like bathing salt bans extolled by our AMA leadership today?

Now there's science!

-Wes

P.S.: (For a much calmer evaluation of the trial and the media's response, see Dr. John Mandrola's blog.)

Reference: Sipahi I, Carrigan TP, Rowland DY, Stambler B, Fang JC.
Impact of QRS Duration on Clinical Event Reduction With Cardiac Resynchronization Therapy - Meta-analysis of Randomized Controlled Trials
Archives of Internal Medicine Published online June 13, 2011.

Disclaimer: Dr. Fisher is on the speaker's bureau for the medical device companies Medtronic and Boston Scientific and earned $2000 from each company in the past year for that teaching. Also, he often cares for real patients with heart failure and, yes, earns a portion of his living implanting CRT devices as a board-certified cardiac electrophysiologist.

How the Housing Market Is Affecting Doctors

Six years ago:

Low-interest loans, virginal credit records, an MD degree.

Need a home, doctor? No problem! How about one of these super-duper snazzy townhomes in a nice neighborhood. Just sign here!

Now:

A marriage, a young family. Perhaps time to buy a new place?

Oops. They can't. The townhome next to them is priced for a short sale at 60% of their purchase price and hasn't had an offer in a year.

Can you say, "under water?"

"Walk away from the mortgage!" many say. "It's not worth it!"

Until they realize they won't have any credit for about, oh, nine years.

Or maybe they could try one of these options.

It's not just about higher medical education expenses and lower salaries for our younger doctors. Like many others in today's economy, it's about the housing crisis, too.

-Wes

Small Miracles

There are very few things that qualify as electrophysiology emergencies, but recurrent ventricular tachycardia with subsequent implantable cardiac defibrillator shocks is one of them. Especially when it continues despite your best efforts to quell the arrhythmias with our most potent antiarrhythmic medications. The options are few at that point: attempt a ventricular tachycardia ablation, refer the patient for possible transplant, or turn the device off and move the patient to hospice care.

For patient's in their mid-70's, the options wean to two of those - do or die - literally.

So after long discussion with the patient and his family, the young electrophysiologist booked the case, knowing full-well it's difficulty but hoping to locate the focus of the predominant ventricular tachycardia in hopes of buying a bit more quality time for the patient free from the painful mechanical hourly disruptions.

Things progressed well at first: The patient was anesthetized and device deactivated. Access was reasonably easy. Monitoring lines were placed without difficulty. A complicated array of sophisticated mapping equipment was installed into the various chambers of the patient's heart. Before long and a few ventricular extrastimuli later, several forms of ventricular tachycardias were easily induced. Regretfully, these were not the clinical arrhythmia. But with perserverence and a few more extrastimuli, there it was: sustained monomorphic ventricular tachycardia just like the patient's clinical arrhythmia - a moderately fast, tough-to-pace-terminate beast.

"Burst at 360." (our lingo for pacing at a 360 millisecond cycle length, or 167 beats per minute)

Nothing. The arrhythmia continued.

"Burst at 320."

Still nothing.

"Burst at 300."

"Doctor, his blood pressure."

"Okay, let's shock him."

The defibrillator charged and delivered the life-saving jolt across the patient's chest. And there it was. A paced rhythm. A moment of relief. Then,

"We've got no pressure!"

"Give him a second." Pacing was fine, just no mechanical movement.

"Still nothing!"

"Start CPR! How about some EPI! Anything? Check the airway! Call for an echo, stat! I'm deflating the mapping array.... Continue CPR. Anything?"

"Got a little pressure with CPR..."

And on and on it went. Seven minutes that felt like a lifetime. Finally, a pressure without CPR. An exhausted staff. An anxious anesthesiologist. An uncertain electrophysiologist.

Thoughts flooding: "Will he be okay? Did I do the right thing? What went wrong? I never had that happen before. Such a nice guy..."

The hours after passed quickly as the patient was transferred to the ICU, pressors infusing, the patient still asleep under the merciful mix of general anethetics as the ventillator moved his chest up and down. The walk to the waiting room. The discussion about what happened, the uncertainty of how the patient would fare. Then returning to compose the note that could never captivate the sense of helplessness of the moment while still not knowing what had happened. No effusion, heart looking as it had, the chest x-ray unchanged.

Finally, after rounding on several of other patients that had been left neglected during the kerfuffle he returned home, exhausted both physically and emotionally, questioning his ability, his career choice, his resolve. Did he do the right thing? Would he ever do that again?

He parked his car, then walked inside and collapsed on his sofa, just wanting to escape for a brief moment to peace, quiet and solitude for a moment all his own.

Then he felt it, a tiny hand upon his cheek.

He turned, and there was is 18-month old son, with outstretched hands peering up into his flooded eyes, grinning with a fragment of mascerated Goldfish cracker in his lips and holding a fist-full more in an attempt to feed him.

And in a flash, as if sent by God himself, all was right with the world.

-Wes

Tag, You're It

It's in your inbox: the results of a nasal swab for MRSA that you never ordered.

Tag, you're it.

Scores of monthly INR results for patients from the past 10 years of care. They're now cared for by "your" nurse practitioners. Has someone addressed all these?

Tag, you're it.

The ER with "your patient." The one you saw once in consultation back in 2004.

Tag, you're it.

A pneumovax given that you nevered ordered. A patient who's angry with a bill.

Tag, you're it.

An EKG result you've already read. And signed. But that's not enough. It's scanned in to the computer now so please click on it to "sign it," will you?

Tag, you're it.

Confirmation of an e-mail message that you sent to your patient. Click again, please, so the computer knows that you know that you sent it.

Tag, you're it.

You didn't call her with her results within 24-hours?

Tag, you're it.

It's astonishing: the speed, the volume, the ability to recall information today from days, weeks, even years before. Like a overspun conveyor belt with information packages coming at you from everywhere spinning faster, faster, faster still.

Someone has to be responsible for all the mandated care, the results, and the labs tests ordered behind physician's backs in our new era of electronic medicine.

So doctors: tag, you're it.

But here's a little secret from the IT department: just highlight them all, then right click. It's so much faster.

See?

Then a knock at your door.

A summons.

Tag, doctor, you're it.

-Wes

The Double-LVAD

There's a nice picture of a paired left ventricular assist devices (I guess to serve as left and right ventricular assist devices) over at Wired magazine:

Kind of cool.

Of course it would be nicer if it wasn't a post-op chest xray with four chest tubes...

-Wes

Addendum: h/t to @rlbates on Twitter to pointing me to this nice piece from NPR about this case.

What If Obamacare Were Found Unconstitutional?

Health care is a sensitive issue politically.

And as things would have it, it now is a sensitive issue legally.

So my thoughts now are not meant to be partisan, but rather a "ground-floor" perspective on what would happen if the Patient Protection and Affordable Care Act were found entirely unconsitutional.

What would happen?

Would a bunch of post-college aged kids ages 21-27, promised insurance beginning this year, suddenly no longer be eligible for care? Probably not. Most insurance policy constructs last a year, so changing coverage would take a while. Still, there will remain a need for some type of insurance coverage for this group outside of classic employer-based insurance since jobs are few and far between for this group. Irrespective of whether the PPACA is enacted or not, employer-based insurance is becoming a thing of the past.  (Update 26 Jun 2012: the nice insurance industry has found this provision to be both popular and highlly profitable since young folks rarely get sick, hence they will continue this provision, even if the PPACA is struck down)

Would doctors who sold their practices lock, stock, and barrel to large health care organizations be able to disband from these large health care organization superstructures (and their associated non-compete clauses) to restablish independent practices? No way. For doctors who performed imaging procedures in their offices at a discount to what hospitals charge, CMS claimed "self-referral" incentives for these procedures, and stopped paying for them in the outpatient setting (but interestingly, not for hospitals). Consequently, by banning payments to doctors for these services, independent physician practices no longer were viabile, except those in affluent neighborhoods where concierge medicine could establish a foothold. The employed physician model and more hospital consolidation seems inevitable going forward irrespective of the outcome of legal challenges to the PPACA.

What about people with pre-existing conditions? It would seem that care would be delivered as it is now for this group. Charitable care, ER care, Medicaid programs would likely have to expand putting even more pressure on our state budgets. But then, isn't this why many states are concerned about the PPACA in the years ahead anyway?

Will the electronic medical record and electronic prescribing, the cornerstone of purported cost savings and efficiencies under the PPACA suddenly disapppear? Of course not. The EMR has been wedging its way into medicine since at least 2004 (that's the last year we had paper inpatient charts at our institution). Newly minted doctors today have never manually written inpatient orders, have never had to walk to radiology to "pull the films" to see a chest x-ray, or go to the microbiology lab to review culture results. They are wired. They expect instant test results. They expect to be able to read outpatient notes. They expect to be able to find another responsible doctor in the care history of a patient. In fact, novelty patients now are those who have never had an entry in their electronic medical record: "Gee, no one's seen this guy before!" Bottom line: an unconstitutional PPACA won't derail the electronic medical record.

It has been estimated by the CBO that repealing the PPACA would cost $210 billion dollars if this occurred between 2012 and 2021. What that money would be used for is anyone's guess (legal and political PR fees?). We have to wonder. But common folk like most of us are not privvy to the intricacies of government self-serving budget-making.

So what if the PPACA is found unconstitutional?

It. Won't. Matter.

Irrespective of the outcome of the pending legal battles for or against the PPACA, we continue to have a huge cost of care crisis in America. Our problem (hate to say it) was never a need for "insurance reform." It remains a problem of costs. And the PPACA does little to help us understand where cost savings would be realized. Why is this?

The legislation was authored by powerful interest groups who were "brought to the table" to feast on the last vestiges of fee-for-service health care. To date, they continued to gorge themselves. I'm not seeing a concern about costs. I'm seeing a consolidation of monster health systems accross our land. Much as the insurance industry found profits by eating their own before, so now are hospitals. Bigger, more doctors, more huge facilities gobbling up their competitors until the last Great Health System can claim the "Too-Big-To-Fail" prize. And why not? Our jobs and economy depend on it. We continue to want the best of care without compromise (though there are responsible rumblings out there about end-of-life care.) Bigger systems running more smaller systems. Not only will it be bigger, more efficient, but safer, too! Our wonderful Utopian vision of the future. Costs be damned. We've got to build for the future and the influx of newly-eligible health care customers!

There is no interest in shrinking the middle man.

Instead, our entire system is cloaked in financial secrecy as we continue to build our Health Care Hindenburg under the auspices of the PPACA, or not.

-Wes

Deception

This came in the mail today:

Click image to enlarge

Any idea what it's for?

-Wes

PS: The "little bit of everything" is on the reverse side, for those who must know.

When the Stuff Hits the Fan

Easy case.

Seen it a hundred times.

Old guy (or gal).

Comes into ER.

Found "down."

"Hey doc, looks like his hearts goin' slow. I think he (or she) needs a pacer."

"On any meds that might do this?"

"Nah."

"How's his (her) potassium?"

"4.3, normal."

And like lots of times, you head in. Glad you can help. Call-team's on their way, thanks to you. Called the device rep to make sure they can be there just in case, too. Cool as a cucumber. Nothin' to it. Been here, done this.

You arrive to a guy (or gal) that looks pretty good. Maybe has one or two medical problems. Heart rate's better thanks to the atropine and the fluids they gave him (her) on arrival. The intraosseus line in the tibia is impressive, too. ("At least he (she) wasn't awake when that happened," you think.)

So you review, examine, plan your approach. EKG on presentation? Ouch, heart rate agonal. Wide complex rhythm of right bundle branch rhythm. Look at the monitor: "lots more right bundle branch rhythm there, thank goodness, P waves, too." you secretely notice.

Seems he (or she) is willing (how many times does he (or she) want to pass out at home?), understands what lies ahead, that the crew's on their way. "We'll be taking you over in just a few minutes. Any other questions?" There are none.

Perfect.

And after a while the crew arrives, assembles the poor guy (or gal) on the table and ships him (or her) over to the cath lab area. Chest is prepped, equipment assembled, antibiotics given, monitors connected...

... damn we're good. Smooth operators.

So the local anesthetic is injected and the incisions made. Dissection to the pre-pectoralis fascia just above the breast muscle accomplished, even the wires passed easily into the vein using ultrasound guidance. Even having a nice chat with the guy (or gal).

Poetry in motion.

Sheaths placed in the vein over the guidewire, pacing leads placed through the sheath. Until, from the control room...

"We lost our EKG."

You glance up. Nothing on the monitor. Brain shifts from 33 rpm to 78 rpm, then higher....

"Okay, boys and girls, let's find the problem. Device rep? Turn on pacing from your PSA." You fluoro. No heart motion. Curved stylette goes into the longer lead.

"I've got the airway," the nurse shouts. "Should we start CPR?"

"Not yet, moving the lead to the ventricle..."

"Crap, he's (or she's) moving. Seizing. Sh%^#t! Hold him on the table! Need... him... under... flouro.... just... one... more... second..."

"There! Turn on pacing!"

You look up. Pacing has begun. EKG shows capture. Your sphincter relaxes. A bit. Until beneath the surgical drape, thrashing ...

"It's okay sir (or madam)! You just passed out. Don't try to get up off the table. You're in surgery, remember?"

Calm ensues.

Suddenly flat line on the monitor again....

"What the?..."

You step of the flouro pedal again. Lead looks good. Moving.

"He's still with us," the nurse shouts. "Still got a pulse ox reading. Must had knocked off the EKG lead..."

"Come on, guys! How many changes of underwear do I need to bring for these cases? Sheesh! ... Sir (or Ma'am), you doing okay?"

"Uh, yeah, doc. What... happened?..."

"You passed out again on us. Just like you did at home. It's all good now, we got that lead in place."

And so, as dusk settles over the horizon on another thrilling ride in the EP lab, you stop to reflect on just how lucky you and the patient were that day. By the grace of God you had access to the vein already, the lead in the right atrium, and the presence of mind and experience to position the lead to the ventricle in the nick of time.

You know others before you weren't so lucky. You know that others, despite their best efforts, had the patient die. You know how terrifying those seconds were. You wonder if they got sued.

No fault of their own. Just fate.

So you vow from that day forward that you'll always place a temporary pacing wire from the leg before you start an emergency case like this on the weekend.

It's all about having control.

And reducing your underwear cleaning bills...

-Wes

The Making of a Doctor

... or mad scientist:

7th Grade Frog Dissection (Click to enlarge - if you dare)

Some say my tongue's still out when I do pacemakers... just hard to see behind the mask...

Heh.

-Wes

So Much For Paying Me for Keeping You Healthy

Okay, America. Stay healthy. Eat only two thousand calories per day, exercise five times a week, don't smoke, keep your body mass index at an appropriate level and for goodness sakes, don't let me find your hemoglobin A1C over 6.5, ya hear? I demand it.

Okay, Mr. Hospital-Employer, I did my part, now pay me, okay?

What? You won't? What do you mean when you say I haven't DONE anything?

I have just broadcast to the world (via the internet, no less) exactly what I should be doing to keep people healthy. Isn't this payment-for-keeping-people-healthy thing supposed to be our new payment model going forward? We're all in this together, right? You know, one big happy Accountable Care Organization. Accountable for the quality of care we provide and for our ability to keep people out of our doors. What's better than preventing illness for lowering our costs to the health care system?

What's that you say?

What do you mean I have to work nights and weekends now? I've been your stalwart foot-soldier! I've done everything our administrative directors and the government has asked me to do: click questionnaires, completed my charts, looked at patients in the eye when I care for them, even went above and beyond to blast sincere public service announcements on your behalf!

What's that? They're getting sick anyway?

No way. They can't! They've done everything right! They've followed my every message! People don't just get cancer! We can STOP that, darn it. Maybe we can issue a few more sincere press releases and policy ideas...

Yes, sir. Sorry, sir. I'll try to do better. No problem going to another hospital that you bought. Really. No that's fine. What's a few more RVU's, right? Yes, sir, I understand.

* pause * (Reaching for his cell phone)

"Honey, I'm going to be a bit late tonight. Looks like I have to see a few more consults..."

-Wes

On FDA's Simvistatin 80 mg Tablet "Label Change"

For those of you who may have missed it, the FDA came out with a "label change" recommendation for simvastatin 80 mg tablets yesterday. In short, doctors, stop using this dose.

Now what I find interesting is not the recommendation, but the background for it.

This recommendation comes for a drug (ahem, the ONLY) generically-available statin (read, "cheap") for our patients who don't have the cadillac drug benefits many folks still have. It also heralds not from a late-breaking clinical trial, but a clinical trial from.... (drum roll, please) ... two-thousand and EIGHT. (What the *$%^#$*?) Yep, that's when the SEARCH Trial on 12,000 patients comparing the LDL-lowering effects of simvistatin with high- (80mg) versus low-dose (20mg) doses of simvastatin was published.

Realize that the SEARCH Trial showed a trend toward reduced heart attacks and death from higher dose simvastatin but did not reach statistical significance, yet had a higher incidence of rhabdomyolysis in patients on the high-dose simvastatin therapy.

So where has the FDA been the past three years? Why now? Why not a similar advisory on the 80-mg dose of Liptor? Or high-dose Crestor? Might it be because higher-dose statins might actually save more lives and reduce stroke? Or should we be more concerned about rare side effects like rhabdomyolysis which, last time I checked, while can be life threatening, is often reversible when recognized.

Further, this is on one of our most widely prescribed statins out there. The recommendations proposed have impacts that span far and wide for our patients. The FDA recommendations go beyond the results of the SEARCH trial to include additional recommendations regarding dosage adjustments for other well-recognized simvastatin-drug interactions. Worse, their recommendations conflict with their earlier drug-adjustment recommendations and are far more restrictive. (Data, please?)

For instance, earlier, the FDA wanted us not to use more than 20 mg simvastatin for our patients on Amiodarone. These new recommendations tacitly cut the recommended maximum dose in half to 10 mg. Why? Just because? Or are they now more concerned about rare side effects than they are about the number of heart attacks and strokes our patients might have on the lower dose of medication?

Additionally, where are the recommendations and compensation for making changes to our patient's medication regimens? Our electronic medical records do not have the ability to query medication dosages, time taken, interactions readily available. Oh sure, someone can probably build one at great expense, but does that mean we need to contact all of these patients and make the changes? Are we negligent for not doing so now?

Merck has published a website called "simvastatininfocenter.com" where patients can get more information so the company can to cover their derrières.

Doctors have no such means for a mea culpa.

Won't be long before we see the website MuscleAchingOnSimvastatinSoSueYourDoctor.com.

Thanks, FDA.

-Wes

The Rise of Specialty Hospitalists

It started as just a figment of the hospitalist movement years ago when I saw an ad in Florida advertising for a cardiology hospitalist. Now it seems the trend is continuing to other specialties like neurosurgical, orthopedic, OB-GYN, and ENT hospitalists.

In the new construct of health care reform ahead, will specialists evolve to mere proceduralists?

If so, should we insist our hospitalist colleagues obtain additional specialty training and board certification in their chosen "specialty" fields? Or is a mere "label change" of the hospitalist title enough to assure quality care for our patients?

This trend toward lower-cost, less-trained individuals subsuming titles of "specialists" so hospitals can meet their bottom lines leaves me lukewarm regarding patient care quality. Yet ironically, I suspect that 90% of things we do day to day in my field will be managed fine by this construct.

It's just the other 10% of cases that aren't routine that I remain concerned about. It's like that old Harry Callahan line spoken by Clint Eastwood in the movie Dirty Harry:

I know what you're thinking. "Did he fire six shots or only five?" Well, to tell you the truth, in all this excitement I kind of lost track myself. But being as this is a .44 Magnum, the most powerful handgun in the world, and would blow your head clean off, you've got to ask yourself one question: Do I feel lucky? ... Well, do ya, punk?

-Wes

The Government's Research Double-Standard

If you want to sell a new drug or therapy in America, you must perform a prospective, randomized clinical trial to prove its safety and efficacy. Further, if that trial does not reach one or more pre-specified clinical endpoints, you can't advertise or publish the trends found.

But if you want to limit costs in medicine, it seems the government is intent on looking the other way:

At stake in the Harkonen case is a much broader debate over the standard for drawing clinical conclusions from scientific data. FDA typically requires two forward-looking or prospective trials, in which patients are randomly picked to get either an experimental drug or a placebo. That might be an appropriate standard for FDA approval, but it's an excessive burden for private firms that merely want to share their truthful research conclusions with doctors. The restrictions may also violate the First Amendment; Dr. Harkonen is appealing on those grounds to the Ninth Circuit.

At the same time government is limiting what private companies can legally communicate about their drugs, it has set a much lower standard for federal health agencies. President Obama has created new institutions with the sole mandate of running trials based on softer statistical standards. Retrospective studies will be the core occupation of a new "comparative effectiveness" research agency that has $4.1 billion to conduct government studies on medical products. The results will be used to inform federal treatment guidelines, as well as Medicare's payment policies.

At least $100 million of that $4.1 billion is being spent on promoting research results. The Agency for Healthcare Research and Quality recently paid $26 million to the PR firm Ogilvy to "market and promote the adoption" of the findings.

And it doesn't stop there.

Our clinical treatment "guidelines," now number some 2,766 for physical and psychiatric treatments according to the government's "Guideline Clearing House" (even, ironically, one for "Wandering"). These prescripts for care use a cornucopia of non-scientific methods, including opinions and case studies to formulate their recommendations, stating:

"Research findings and other evidence, such as guidelines and standards from professional organizations, case reports, and expert opinion were critiqued, analyzed, and used as supporting evidence."

So when scientific rigor is given only lip-service by our government regulators, what will happen to the quality of care provided to our patients?

Maybe government recommendations should come with a food-label like disclaimer:

-Wes

Regulations Gone Wild

We certainly have seen regulations upon regulations appear for health care over the past several years, and this letter to the editor of the Wall Street Journal (1 June 2011) from the Commissioner of the Consumer Product Safety Commission, Nancy A. Nord, should cause us all to pause:

As a commissioner at the U.S. Consumer Product Safety Commission (CPSC), I can attest that no such (regulatory reform) activity is happening at this agency. We certainly have not combed through our regulations to eliminate those that are "out-of-date, unnecessary, [or] excessively burdensome," as he suggests is being done across the government. Instead, we are regulating at an unprecedented pace and have pretty much abandoned any efforts to weigh societal benefits from regulations with the costs imposed on the public.

In health care, we have seen an unprecedented rise in regulations for in-hospital MRSA screening while little data have been forthcoming about its patient benefits. Doctors are under increased administrative burdens to complete Pay for Performance questionnaires without any evidence of their benefit to patients. Burdensome and costly re-credentialing programs have never been shown to improve health care quality. In fact, we're seeing so many regulations on how we provide care foist upon us without any clear indication that patient outcomes have benefited that we have to wonder if, like the CPSC, common-sense regulation will even get a head nod as well.

How doctors will work to free themselves of these administrative burdens while maintaining the clinical care volumes in the years ahead now that they are increasingly beholden to a larger health care management organizations remains to be seen, but I suspect once patients encounter problems with access to their own care, there might be a chance for effective reappraisal of which regulations really are in their best interest.

Until then, with more centralized control of health care, look for more and more regulations heaped on providers to control costs, safety and improve efficiencies "just because."

-Wes

Twitter at Scientific Sessions

Bryan Vartabedian, MD over at 33 Charts has an interesting post on his blog today: Should Twitter be Restricted at Scientific Meetings? I encourage all to read it.

Increasingly, scientific sessions (many of which have heavy corporate sponsorship) have evolved from scientific endeavors to those of marketing and media endeavors. While there are benefits to pharamceutical and medical device representatives gaining "access" to "key opinion leaders" to explore ways to further innovate in medicine, there is also a chance that these interactions will influence and bias.

Doctors know this. So do device and pharmaceutical reps. As do the media.

But at most of the recent Scientific Sessions that I have attended, there is usually a sign at the door of the meeting telling us photographs are prohibited. And yet, without exception, I have seen people snapping pictures of slides and posters and friends, among other things.

Who are we kidding? The ubiquious nature of cell phones capable of snapping a picture and sending it around the world in seconds exists on nearly every attendee at these meetings. Yet somehow I haven't seen anyone wrestled to the ground to surrender their cell phone to authorities to date.

And most of these scientific meeting sponsors have welcomed social media as part of their marketing efforts, publishing updates on sessions underway, not to mention encouraging companies to market their wares at the meeting as well. Should doctors, then be restricted? We're not talking censorship of the scientists are we?

So should we restrict the use of Twitter at scientific sessions?

My thoughts on this: if you've invited the media to cover the event, then by default, you've invited Twitter.

-Wes

The Case of the Missing Pager

It happens to every doctor at some time in their busy career: the missing pager. Usually, discovering the locale of the digital disrupter is quite simple: you simply page yourself provided, of course, that the contraption is not on "vibrate" mode.

And so it was with me some time ago.

The scene was a familiar one: rushing off to work, heading out the door while contemplating the upcoming caseload of the day with my mind wandering off to great medical thoughts when, suddenly, I reached to my hip to find that I had forgotten my pager.

Dang.

So back to the house I go and scramble for the telephone. My wife, hearing the door opening calls back from upstairs: "Something wrong, dear?"

"No, just forgot my *@#$&#*& pager. No biggie."

So I called the paging number and waited. (Why it takes so long for electrons to travel to space and back is beyond me.) Some time later I heard in the distance:

* Bleeep, bleeep, bleeep *

"Whew," I thought, "at least it's not on vibrate mode."

I turned and proceeded to the bedroom, ready to corner my prey. I looked and looked and still, no pager.

So I paged it again. Fingers tapping and frustration growing, I wait. Finally:

* Bleeep bleeep bleeep *

"Shoot, it's in the other room," I think. "No wonder." So I proceed to the office accross from my bedroom, sure I'd find the little bugger on the desk beneath some papers. So I move everything in sight. Under here? Nope. How about here? Nope. Oh, COME ON! Where can that stupid thing be. I retrace my steps, check my pockets, my waist band, pull out my car keys just to make sure it's not hiding with them: nothing. So I page again.

* Bleeep bleeep bleeep *

There you go! It's not in the bedroom or the office, it's in the hall! Probably fell off my pants. Or maybe it's in the laundry hamper... Clothes removed, checked, piles quickly scanned: still nothing.

By now I feel my temperature rising. How can I be this thick-headed? Five more pages, fifteen more "bleeeps," and back and forth from room to room, all with the same result.

And then it dawns on me....

Could it be?....

There, right smack dab in the middle of the back of my waistband it hung, well out of way of my usual reach as it dutifully bleeped and projected its sound to the room that was always behind me.

Ugh.

Stupid is as stupid does, I suppose. (I guess it could have been worse.)

-Wes

Double Dare Leads to Cardiac Scare

Remember, pointing a pellet gun at your boyfriend's chest and pulling the trigger, even when he dares you to, may not be the smartest thing to do. Fortunately for this guy, he was saved by extensive right coronary artery collaterals and a very capable surgeon:

“He is a miracle case because so many things went in his favor,” said Dr. Nicholas Namias, Jackson Ryder Trauma department director and one of the surgeons who operated on him last week.

Most miraculous was the rare anatomy of Mendigutia’s heart. The bullet caused a blockage in the left anterior descending artery, the heart’s main artery. But because of his heart’s “very rare” anatomy, blood was able to flow through the opposite side of the artery.

Also, in this type of case, the pellet could have affected his aorta, esophagus and/or trachea, said Namias. In this case, it missed all three.

Mendigutia was airlifted to Ryder Trauma at midnight May 23 with cardiac tamponade, which means blood was filling up in the space between the myocardium (heart muscle) and pericardium (outer covering the heart). This prevents the ventricles from expanding and can cause a heart attack.

“Gabriel had a right coronary artery that supplies the left anterior descending distribution. He had a blockage, but rare anatomy allowed blood to flow backwards to area of injury, “said Namias, who doubts any other area hospital would have been able to save his life.

-Wes

Addendum 6 June 2011: The man's post-op picture and follow-up story here.

The Unintended Consequences of Free Medical School

Don't it always seem to go,
That you don't know what you've got 'til it's gone.
They paved paradise,
And put up a parking lot."

- from "Big Yellow Taxi" by Joni Mitchell

An opinion/policy piece appeared two days ago in the New York Times entitled "Why Medical School Should Be Free." Hey, why not? If it's free it's for me!

After all, such a system the rage in many other socialized medical systems.

But rather than focus a critical eye on why medical school has become so exorbitantly expensive, the authors choose to offer a proposal to make it free. By doing so, the authors suggest there is no need for introspection about the antiquated and costly system of medical school education that exists today. There's no need to reconsider the academic tenure system and it's burden to state budgets. There's no need to consider that many university programs are already crumbling under large debt loads and struggling to meet the training and case-load demands of their students, farming them out to private institutions to assure they meet their requisite number of cases.

Heck no. Better to perpetuate the current system and make it free! Students would no longer object to schools that could finally crank their tuition higher! (Trust me, *wink wink,* taxpayers won't know the difference!)

And don't worry about the broad-based specialist shortages that exist today. Heck no. It's all about primary care. Have a hernia and need a surgeon? Or a bypass? Ooops. Not seeing much in this piece to correct our current shortcomings. What's another $50,000+ per year of education for for those employed specialists-to-be making $37,000 per year as residents?

Mere chump change.

For those military and National Health Service Corps recruiters out there, you'd better start thinking of another incentive program to recruit doctors since offering free medical education in return for a few years of service to your country no longer looks like such a good deal.

Beyond these things, we should also ask: has there been a benefit to patients when medical school's compete to attract the best and brightest doctors?

Certainly.

Look, it'd be nice if no one had to pay for medical school. (It would be nice if I didn't have to pay for college education either for that matter.) But let's not forget the real issue here: doctors are losing all autonomy and ability to advocate for their patients' needs above those of their employers, be they public or private. Since someone will now be paying a doctor's tuition, someone else will decide a doctors' work and level of expertise. Someone else will decide their hours and of course, someone else will decide their pay. As a result, will this new medical school curriculum model shun individual ingenuity in favor of health care budgetary imperatives? When a doctor has little monetary skin in the game, how will such a system assure an adequate work ethic from doctors going forward? A suppose time clocks would work.

Bottom line: there never has been and will never be a free lunch for anyone without some very big strings attached.

-Wes

Kevin Pho, MD gives his reasoned take on the same New York Times article from the primary care perspective.

For Memorial Day

-Wes

Could Your Car Detect a Heart Attack?

Should car companies be in the medical business? Well, Ford Motor Company seems to think so. First the bluetooth-enabled glucose meter and now the ECG-enabled bucket seat:

AACHEN, Germany, May 24, 2011 – Ford Motor Company's advanced research engineers have developed a prototype vehicle seat that can monitor a driver's heart activity and could one day reduce the number of accidents and fatalities that occur as a result of motorists having heart attacks behind the wheel.

Engineers from Ford's European Research Centre in Aachen, Germany, working closely with Rheinisch-Westfälische Technische Hochschule, Aachen University, embarked on the project to address an often overlooked traffic safety issue – accidents triggered by drivers who experience heart problems.

The prototype Ford seat employs ECG (electrocardiograph) technology that monitors the heart's electrical impulses and detects signs of irregularity that can provide an early warning that a driver should seek medical advice, because he might be impacted by a heart attack or other cardiovascular issues. Whereas a normal ECG machine in a doctor's office requires metal electrodes to be attached to the skin at various points on the body, the Ford ECG seat has six built-in sensors that can detect heart activity through the driver's clothing.

So I wonder what the car will actually do when it detects a heart attack? Will it pull off to the side of the road and stop? Maybe it'll activate the car's OnStar system? Or maybe a few more electrodes could be applied to the seat that could deliver a corrective defibrillation jolt? (One false positive arrhythmia detection and you can bet that car will never sell, though).

Sheesh.

Next week, look for the pulse-oximeter-enabled steering wheel that drops oxygen masks from the car's ceiling when driver's oxygen level drops too low.

-Wes

New York's Dress Code Proposal for Doctors Doesn't Go Far Enough

From AMA Medical News:

New York physicians may have to take off their neckties, jewelry, wristwatches and long-sleeved white coats when caring for patients if a bill under consideration in the state legislature becomes law.

The bill, proposed in April in the state Senate, calls for a "hygienic dress code council" within the New York Health Dept. to consider advancing a ban on neckties and requiring physicians and other health professionals to adopt a "bare below the elbow" dress code in an effort to slash hospital-acquired infections.

Even though there's no data that this does anything to reduce hospital acquired infections.

But that doesn't matter.

So why stop there? I say, doctors should do the ultimate for their patients: the Full Monty.

-Wes

A Variant of "Where's Waldo?"

For doctors, there's a new game they can play at their next professional society's scientific meeting: "Where's the RFID Scanner?"

See if you can find them in this picture from this year's earlier Heart Rhythm Society Scientific session:

Click to enlarge

-Wes

Atrial Fibrillation Ablation - Marketing Through Scientific Publications?

Circulation, a major cardiology medical journal, just published an article on atrial fibrillation ablation, complete with extensive video - all available for free online. It's an informative piece, but I found myself wondering why this piece was "unlocked" and available to the public for free when the most of the rest of the journal is locked. In the video, the atrial fibrillation magically disappears - I'm not sure how. Was it by ablation? Or did a cardioversion occur that we didn't see? And where is the discussion of potential complications? Should they be mentioned? The viewer is left to wonder if we're watching a promotional video rather than a truly balanced perspective on the technology. Might industry have supported this publication? Or maybe it was the hospital system's marketing department?

It isn't that the article doesn't have value. I just wonder if a new form of critical scientific review or additional disclaimers are warranted when video supplements are added to journal articles now that print-media is nearly obsolete.

-Wes

The Offer They Won't Refuse

"Hello, Doctor Johnson, this is Madam Secretary."

"Nice to hear from you Kathy. What can I do for you?"

"I enjoyed our last get-together, Dr. Johnson. May I call you William?"

"Please do."

"Thank you. You know, William, we've appreciated your contributions to our various health care initiatives over the many years and we've reviewed your public policy statements on the cost of Medicare and the waste inherent to the system. Brilliant work, really. Seeing that you're a tenured professor at the University of Greatness with such national prominence we thought we could turn to someone with such an impressive set of credentials and publications. Add to that, your contributions to the President's campaign haven't gone unnoticed."

"Thank you, Madam Secretary."

"William, let me cut to the chase: we're in need of like-minded individuals like you that see the value in preserving Medicare as we know it. Thanks to your efforts in the past, the President and I thought you'd be a perfect candidate to sit on our Independent Payment Advisory Board for the next nine years to help guide us to better health care with lower costs."

"Seriously? Me? Oh. My. Goodness!"

"Yes, William, that's right. And this position, as you and I both know, will make your tenured position at the University of Greatness look like relative chump change. Press releases, life-long consultancies, the works! And your salary? How does a million bucks a year with annual cost-of-living adjustments, coverage of your travel and moving expenses, and guaranteed unrestricted health care for you and your family for the rest of your lives grab you?"

"Seriously, Kathy? I had no idea that the conversation that last cocktail party would come to this! I'm looking forward to shifting our emphasis from providing so many options to people that are so expensive to standardizing care. Like all those drug-eluting stents in cardiology when bare metal ones can do the same job..."

"It'll be your chance to shine, William. And best of all? No. One. Can. Touch. You. No independent or judicial reviews. You won't have to take any more crap from anyone! And Congress? If they fail to act on any of your recommendations, bang-oh, they're enacted. (Snickering now) When was the last time you saw Congress agree on anything? (Laughing together) That, sir, is power personified! We're making this offer to only fifteen people, William, and with all of your impressive credentials, you are one of 'em!"

"But Madam Secretary, to be fair, I don't know anything about most of the other specialty fields out there. I'm just a pediatrician - and one that hasn't been practicing clinical medicine for the past 10 years... What will my colleagues say when I take a position on stents? I mean, I respect doctor Frigamafratz's position on the need for less stent thrombosis..."

"William, don't worry, you can still make them part of a special 'Presidential Advisory Panel.' You know the drill: put 'em on a panel and let him feel all important - like he's part of the solution! But it will still be you making the call! Get it? And as far as the other regular cardiologists out there are concerned, how are they going to compete with your presence next to a podium with an American flag and the symbol of Asclepius emblazoned behind you on TV?"

"Heh. Yeah. I love the way you think, Kath! What was I thinking? Very efficient, really. A fantastic board with national impact almost instantly! Amazing. When can I start?"

-Wes

What Not To Say in a Medical School Interview

Years ago, I was fortunate to have been selected as a medical school representative for our medical school Admissions Committee. As such, I had the opportunity to see, first hand, the admission process and partake in interviews with prospective medical students. Most candidates had already made the MCAT score / grade cutoffs requisite for medical school and were then asked to come for an interview with members of the Admissions Committee. (At the time, the interviews conducted by student representatives were weighted equal to the interviews of more senior members of the admissions committee.)

Reflecting on those days, I recalled two students' responses that prevented them from being a medical student at our school.

First, when responding to the predictable, broad open-ended question "So why do you want to be a doctor?" it's never a good idea to answer with a blank stare, long pause, and then, "Gee, that's a good question!"

Second, no matter how great your MCAT scores and grade point average might be, when asked "Five years from now, what would you like to see yourself doing?" it's probably a good idea not to answer as follows:

"Let's see, it's Wednesday. I guess I'd like to be out on the golf course right about now."

While the response garnered a good chuckle from the Admissions Committee, he never stood a chance.

-Wes

Our Tenuous Medical Homes

It was just a visit to manage her paroxysmal atrial fibrillation. She was long overdue for the visit. So she arrived as she had so many times before: with little fanfare and folderol. She sat patiently after her weight was obtained, vitals recorded, and medications verified. Clutching her purse, whe sat patiently as the examination door opened.

"Hello, Ms. Smith, how have you been doing?"

"Wonderfully, doctor. I haven't had any more problems with my heart rhythm." She leaned sideways to put down her purse on the floor next to her.

"Any dizziness, lightheadedness, shortness of breath, cough?..."

"No, I'm doing fine, thankfully," her eyes glistening.

I proceeded to complete her history and catch up on a few details with her, then moved on to the physical examination. I watched as she got up on the exam table and noted her moving a bit more slowly than I had recalled.

"Is your strength doing okay?"

"Oh sure. Never better. Just slowing down a bit is all. But I'm not sure how well I'd be doing if it weren't for my daughter."

"How's that?"

"Oh, well, I'm her caregiver. Diabetes, you know. She's blind now, lost a the lower part of her leg... horrible disease, really. But she's my reason to keep going..."

I realized I had been caring for her almost ten years, but had forgotten an important detail: "How old is she now?"

"Fifty-eight."

"Is there anyone else who could help you?"

"Not really. My brother lives quite a ways away. He's been urging me to move, and I'm sure it'd be easier if ithere weren't two stories there, but it's our home! I just don't think I could bear moving ..."

I completed the examination, discussed her management, then refilled her prescriptions. As I completed her final paperwork I had to decide when to see her next.

I paused, not sure of the time interval to propose for her to return.

A month? Three months? Or maybe six? It's hard to decide when you're seeing such a remarkable ninety-one year old.

"Six months would be perfect, doctor," she said. "I hope I can see you then."

-Wes

Health Care Business Terms for Dummies (Like Medical Students)

Since starting this blog I have had the opportunity to stumble across interesting business terms currently in use in health care. As a service to our graduating medical students and residents entering our evolving world of medicine, I thought I'd assemble a reference source of important business terms for their use. This list is by no means complete and I would welcome other definitions readers might add to this ever-expanding list:

Term	Translation
Accountable Care	Care provided by those who only know how to subtract
Health care consumer	Patients - If your patients are alive, they cost the system money
KOLs (Key Opinion Leaders)	"Yes" Men and Women for Industry - I was first going to call these individuals "industry whores" but not all of them accept fees from industry for their opinions. The opinions of KOLs, however, uniformly jive with the industry interests they speak about.
Lean Six Sigma	Reducing staff-to-patient ratios as low as possible - and substituting kiosks for them instead.
Quality Measure	An order you seem to have forgotten that makes people money.
Meaningful Use	A measure of one's ability to use a keyboard - To suggest another definition is silly since no one will be paid to deliver care in the future unless they have purchased a very expensive computer system tells you what to type and when to type it.
Wellness Initiative	Health Data Collection Opportunity - Remember, "wellness" is not the opposite of illness.

Hope this helps!

-Wes

When Medical Devices Speak to You

Could your implanted medical device soon speak to you?

Perhaps.

Two unlikely corporate partners, Ford Motor Company and Medtronic, are partnering on an interesting new "application" using continuous glucose monitors: a car that "speaks" to you:

The two companies announced Wednesday that they have developed an in-car prototype system that connects Ford’s Sync technology to a Medtronic glucose-monitoring device via Bluetooth—which then displays the driver’s glucose level on the car’s dashboard display. If a driver’s glucose level become too low, an alert sounds or a signal appears on the dashboard display.

Low blood sugar can cause confusion, clumsiness, dizziness, difficulty speaking, and a variety of other side effects that are potentially dangerous to drivers. Those side effects can typically be treated by eating or drinking glucose-rich foods or beverages.

The partnership between the two companies is part of a larger health and wellness initiative that Ford launched that is aimed at helping people with chronic illnesses or medical disorders—including diabetes, asthma, and allergies—manage their condition while on the go.

Very clever! A GPS system for your blood sugar!

Think of the possibilities...

A diabetic patient, equipped with their bluetooth-enabled continuous glucose meter sits behind the wheel and drives for about three miles when, quietly and non-obtrustively, a sultry voice behind the dashboard states:

"Prepare to turn unconscious... in... 0.2 miles..."

Or if a similar technology is developed for patients with implantable cardiac defibrillators:

"Pardon me for disturbing your tranquil drive, but your defibrillator has detected a rhythm disturbance and will begin therapy in approximately 400 ft.... 200 ft ... 50 ft....

*ka-blam!*

Please proceed to your planned route..."

But best of all, once they perfect implantable drug delivery systems we might hear from the dashboard of our cars:

"If your erection lasts over four miles..."

-Wes

Stifling Fun in Medicine

I wonder if we're in danger of stifling fun in medicine.

Certainly there are still fun things to do in medicine (ablating a pesky accessory pathway safely, for instance). But as I watch the newly-minted medical school graduates emerge from their long, sheltered educational cocoon, I wonder what their attrition rate will be from medicine once they see our new more-robotic form of health care community.

There is a social camaraderie in medicine when you train. Maybe it's the "misery loves company" syndrome. In medical school you stick together through thick and thin because few others understand what you're going through. You strive for the day when, collectively, you earn the designation of "doctor of medicine." There's a strength in numbers.

But as our work flows become regimented, our geographic coverage areas more dispersed, and our hours more fragmented, I've seen the loss of the collegiality of the doctor's lounge being replaced with the coldness of e-mail blasts. I've seen the loss of summer picnics with my colleagues' families replaced with "Doctor Appreciation Day." After work get-togethers that included our spouses and kids are have long since gone - most of us just want to get back home to re-group for the next day ahead.

As medicine continues on its inevitable cost-contraction course of doing more with less, I hope there continues to be a way to keep the psychological well-being of our health care workforce and their families in mind. Otherwise, the historically long-term career of physicians might become much shorter.

-Wes

A Blood-Powered Hydroelectric Turbine?

From IEEE Spectrum:

"The heart produces around 1 or 1.5 watts of hydraulic power, and we want to take maybe one milliwatt," Pfenniger explains. "A pacemaker only needs around 10 microwatts." At the Microtechnologies in Medicine and Biology conference in Lucerne, Switzerland, earlier this month, Pfenniger presented results from a trial in which a tube is designed to mimic the internal thoracic artery, a millimeters-wide vessel that doctors sometimes cannibalize for surgery because it is redundant. The most efficient of the three off-the-shelf turbines he tested produced around 800 microwatts, which could run devices much more power hungry than today’s pacemakers.

Pretty interesting. But the body is a formidable hydroelectric plant; they still have to work out the clotting and hemolysis potential of these devices...

-Wes

What Does Propublica Want?

It's an healthy question to ask after Propublica's recent exposes on the Heart Rhythm Society and SCAI. So I turned to the internet to find this piece published previously in Slate:

What do the Sandlers want for their millions? Perhaps to return us to the days of the partisan press. The couple made their fortune, which Forbes estimates at $1.2 billion, at Golden West Financial Corp. In recent years, they've spent millions on politics. The Federal Election Commission database shows the two of them giving hundreds of thousands of dollars to Democratic Party campaigns. In 2004, Herbert Sandler gave the MoveOn.org Voter Fund $2.5 million, again according to the FEC database. The Center for Responsive Politics Web site reports donations of $8.5 million from Herbert and Marion to the 527 group Citizens for a Strong Senate, in the 2004 cycle. CSS was formed by "a group of strategists with close ties to former North Carolina Sen. John Edwards," writes the washingtonpost.com's Chris Cillizza. American Banker reported in 2005 that Herbert also gave $1 million to the California stem cell initiative and that the pair have also funded the progressive Center for American Progress.

While I do feel there's a need for healthy disclosure of industry ties with physician groups, it's helpful to keep in perspective the origins of the recent investigative reporting. Is it meant to beat down doctors further into submission in the health care debate to make us cogs in the corporate wheel rather than innovators in care?

It's low-hanging fruit to take shots at the sources of funding to doctors' societies. I wonder if Propublica will perform similar reporting for the sources of funding for members of our Judiciary?

-Wes

Humor in the Cardiac Catheterization Laboratory

From patient to porn star, thanks to a "landing strip:"

Just prior to the tap into my right femoral artery at the groin to insert the catheter, a creative prep nurse with razor and wicked sense of humor shaved and left a landing strip where a forest primeval once thrived.

Those nurses are getting creative!

-Wes

What Quality Means Now: Checkboxes

With the news that Wellpoint, one of the largest insurance companies in America, will cut off annual 8% payment increases to about 1,500 hospitals if they fail to "test" high enough on 51 quality measures, they have officially defined "quality" health care as checkboxes.

Yep, checkboxes.

You see how do insurers know if we offer each of our patient's nutritional guidance or exercise counseling?

Well, they check to see of doctors have clicked on a yellow warning box advising we do this. If we have, then not only is that doctor a fine, "quality" doctor, but the hospitals (and it's computer system and scores of administrative staff that compile and submit this data) are real, fine, "quality" hospitals.

That's all there is to it.

Never mind if we don't have time to actually perform the counseling.

* click * * check * * click *

Simple as pie. Efficient, too.

Beautiful bureaucratic quality.

Good luck with that.

-Wes

Skynet is Here

I saw this and could help but wonder how similar technology might be applied to atrial fibrillation ablation some day:



From IEEE Spectrum:

Being able to do this is all about communication, as Professor Nathan Michael discussed today at the IEEE International Conference on Robotics and Automation (ICRA) in Shanghai. As he and fellow researchers Matthew Turpin and Vijay Kumar have discovered, the robots have to not just know exactly where they are, but they also have to broadcast that information to their neighbors to maintain the integrity of the formation. This processing is all done on each individual quadrotor, so there's no all-seeing computer watching everything and telling each robot where to go. The accuracy is impressive: 50 percent of the time the quadrotors are within a mere two centimeters of where they should be.

Well, these robots haven't been miniaturized nor tested in blood so they're not ready for atrial fibrillation ablation yet, but it's still fascinating to see what creative minds can develop.

"Thinking" robots.

Uh, oh.

Then again, maybe I'm just reminded of scrubbing bubbles.

-Wes

Fading or Evolving?

Perhaps its a natural evolution of a blogger on the internet: starting out strong, then fading. Perhaps it's a realization that you've said what you wanted or needed to say and newer content is harder to find. Perhaps it's the changing times or the changing of priorities. Perhaps it's because newer, faster ways have developed for doctors to communicate with the outside world, like Twitter.

Perhaps, it's all of these.

Whatever it is, my blogging frequency has slowed considerably since I started:

Will this trend continue to reach its inevitable asymptote of zero?

I suppose.

But as long as there are things that are interesting, bothersome, unique or funny to share, I'll continue - maybe not as a thoroughbred with as many posts per day, but an old mule who can occasionally give a good ride. (Whether that ride will be rough or smooth remains to be seen...) Still, as long as it remains fun to do, I'll keep her goin' for now. While it's taken a while to garner a faithful following of all six of you, I continue to be amazed at the impact one guy's blog can have. Thanks to all of you who have taught me, scolded me, praised me, and educated me along this wild journey.

A few other reflections at this juncture.

I feel a bit guilty that I cannot always post the comments left here in a timely fashion. I can assure you I read them all and appreciate the perspectives shared. But my day job requires that I perform procedures that happily remove my brain from the internet. I get to them when I can - hence why idle back-and-forth chat will never be my "M.O." And try remember to keep your comments clean, respectful of others, concise, and on message. (Remember, your mother's watching.)

By the way, to those that leave those "love your blog" comments with a link back to your overseas drug distribution, vibrator sales site, or similarly dissociated website: rest assured your comments will continue to be hastily labeled as "spam" for the great gods of Google to feast upon.

So happy Friday-the-13th and thanks for checking in from time to time. It's been a ball.

We'll now return to our regularly (yet less frequently) scheduled programming...

-Wes

Agglutination

Today, another large Chicago hospital joined forces with one of the largest remaining local physician groups:

Naperville-based Edward Hospital said Tuesday it has formed a joint venture with the fourth-largest doctors group in the Chicago area.

The venture, which would treat as many as 100,000 patients, initially will focus on health maintenance organization patients of both the 309-bed hospital and Downers Grove-based DuPage Medical Group, which has 320 doctors and revenue of $363 million in 2010, according to Crain's annual ranking of physicians groups.

As the health care law winds its way through the courts, its effects are already profound. Each day we see the consolidation of the health care "market" as doctors groups are swallowed whole by large hospital systems as part of the "Accountable Care" organizational construct mandated by the Affordable Care Act. Now we see the west side of the Chicago suburbs are fortified.

For patients, there's little to notice at the present time since very little immediate change to care delivery will occur. (This was the intention.) But as payment screws tighten to these newly-agglutinated partners and the newly-insured flood the system in the years ahead, there still will be a woeful lack of physicians to absorb the influx of patients. Access to care for patients with insurance will remain challenging - likely more so.

The shortage of specialists continues, too. Our newly-minted specialists from the current training pool are finding it hard to find jobs because of these consolidations. Newly-formed large groups are reluctant to add new hires as they join forces with large health care systems because of concerns they are already joining many other doctors competing for the same pool of patients already. Since their new employment contracts will likely contain productivity clauses, who in their right mind would want to hire now?

So while many are paying attention to primary care shortages, specialist shortages are likely to be even more severe going forward.

But then, specialists cost a lot of money to our health care system, don't they?

And now you know why they call it the "Affordable Care Act."

-Wes

How to Optimize Your Care While Hospitalized

It was interesting lunchtime conversation. A lone doctor listening to some highly experienced and capable nurses, reflecting on their work:

"If the patient's nice, it's a lot easier to want to go back in that room with them. Their reputation travels at the nurses station. But if they're mean, well, it's not as easy to go back in there, so I might not stop by as often."

"I agree, it's easier to catch flies with honey than vinegar."

Words to live by.

-Wes

Challenging Times for Health Care Law

The Affordable Care Act (interesting that it's no longer called the Patient Care and Affordable Care Act by the White House) will continue its march toward the Supreme Court this week:

President Obama's healthcare law faces a series of challenges in three appeals courts starting Tuesday as Republican lawyers from 27 states will urge the courts to strike down the law as unconstitutional.

In a sign of the high stakes and the partisan divide, one case will feature a rare courtroom clash between the Obama administration's top appellate lawyer and his counterpart from the George W. Bush administration.

At issue is whether the government can require virtually all Americans to have health insurance by 2014 or pay a small tax penalty. Democrats said the mandate was needed to make sure that all who could afford to do so paid for medical insurance. Otherwise, they said, freeloaders would force hospitals and taxpayers to pay for them if they were badly injured or came down with crippling diseases.

Republicans who opposed the law called the mandate an unprecedented government meddling in private lives. It "would imperil individual liberty" and "sound the death knell" for the Constitution if the government can "compel" people to buy products, Paul D. Clement, the former Bush administration solicitor general, said in a brief last week.

Given the partisan divide, I would anticipate that there will be some cases for, some against, like before. Still, the prequel playing out in Massachusetts warrants heeding challenges ahead if this bill is ultimately upheld:

A new survey released yesterday by the Massachusetts Medical Society reveals that fewer than half of the state's primary care practices are accepting new patients, down from 70% in 2007, before former Governor Mitt Romney's health-care plan came online. The average wait time for a routine checkup with an internist is 48 days. It takes 43 days to secure an appointment with a gastroenterologist for chronic heartburn, up from 36 last year, and 41 days to see an OB/GYN, up from 34 last year.

-Wes

The Power of a Wheelchair

Touring the Birmingham (Alabama) Botanical Gardens

I noticed something magical about a wheelchair this past week.

First, getting a loved one out of a chair or bed away from four dark walls does wonders for their psychological well-being and self-confidence.

Second, without exception, every person my mother and I encountered while roaming the streets and parks in this chariot could not have been more generous, thoughtful, patient and kind.

No longer forward nor behind
I look in hope and fear;
But grateful take the good I find,
The best of now and here.

- John G. Whittier

Happy Mother's Day!

-Wes

Will Doctors Have to Take Out Loans to Pay for (Re-)Certification?

I have recently realized that if I want to remain board certified in cardiovascular disease and cardiac electrophysiology, I must begin the lengthy process to re-certify now. No longer are doctors board certified for life; the process must be repeated very ten years. For me, it won't be long before I'm taking the tests for the third time and I carry two board certifications that are subject to this every-10-year requirement.

But while preparing for this gauntlet again, I was struck by the fees I must pay just for prep-courses and registration fees: well over $10,000.

CV Board Review Course	$998.00
EP Board Review Course	$1420.00
Maintenance of Certification (MOC) Fee - CV Disease	$1810.00
MOC Fee - EP (with 2nd MOC discount)	$760.00
Board Certification Fee - EP	$2785.00
Board Certification Fee - CV Disease	$2165.00
Test Center Fee - Board Cert	$500.00
Test Center Fee - MOC	$500.00
TOTAL:	$10,938.00

Realize these costs don't include transporation and housing costs that might be required, not to mention the costs incurred from time off from work.

I realize that it's expensive to prepare, review, monitor and regulate this testing, but these costs are growing at a ridiculous rate - I hate to think what new doctors saddled with significant educational loans must endure just to get started.

Hey, I think I have a new idea for a business: a loan company that funds doctors to help doctors pay for their certification fees!

Oh wait: it already exists.

-Wes

Addendum 5/9/2011 08:45 AM CST - I received this follow-up e-mail from Lori B. Slass, VP for Communications at the ABIM, with the following clarification of their fees for dual-boarded individuals like myself:

"As the VP for Communications at ABIM I did want to clarify some of the fees you presented today.

As someone who is already board certified in CV and EP, your costs to recertify would be $1,810 + $760 for the 2nd (EP) exam. Total cost is $2,570 – good for ten years.

So it is about $250 a year to maintain certification for someone like yourself who is dual certified. I agree this is not an insignificant amount, and many physicians take review courses to prepare and that does add to the costs, but it is much less than you highlighted in your post. The test center fees you note are only for international candidates.

It is also worth noting that the fee includes all the modules you need for both certifications, and over the course of ten years, even after you complete the MOC requirements you can complete modules for CME credit at no extra cost.

The ABIM Board of Directors are very careful in establishing fees. We are a non profit and to a great extent, the key determinant of the fee for MOC is the direct cost of developing and administering the program. Costs associated with the examination have also risen with the introduction of Computer Testing Centers. We have found, and our candidates confirm, that computer based testing has important advantages over the older method of testing. Hope this is helpful."

I have provided links to the published ABIM fees in my post. It states clearly that the examination fee (alone) for EP is $2,795. I have asked for additional clarification.

Addendum #2 9 May 2011 09:43AM CST: Additional clarification is now provided:

"We will try to make it clearer on our website, but you do not have to repay certification fees once you are certified. Only the MOC fees – total cost for you $2570 for Card and EP (covering two exams) and you correctly noted that you do not have to maintain IM, only those certifications relevant to your practice.(emphasis mine) We also like to think the free CME for 10 years is a nice addition."

Heart Rhythm Society Responds to Scrutiny Over Industry Ties

Tomorrow professional medical societies will be looking long and hard at how they disclose industry ties in response to an article published this evening by ProPublica (and co-published in USA Today) entitled: "Financial Ties Bind Medical Societies To Drug and Device Makers." The investigative reporting by Charles Ornstein and Tracy Weber examines the medical conference trade and the associated funding sources, focusing on the Heart Rhythm Society 2011 meeting underway in San Francisco. The report includes an interactive graphic, and slideshow of "promotional opportunities" available for purchase from the Heart Rhythm Society. The authors also organized the responses of 33 other prominent medical societies to an inquiry of Senator Charles Grassley's regarding funds they receive from the pharmaceutical and medical device industries. There is much for the public to learn here.

But what should not go un-noticed, however, is the Heart Rhythm Society's willingness to "bear all" about their practices. In fact, they answered, head-on, questions posed to them by the ProPublica reporters. In this respect, they should be commended for pulling back the curtain on the sources of funding for these scientific sessions and their operations.

It will be interesting to see if other medical societies are as forthcoming as the Heart Rhythm Society has been. What is clear is that as dollars get tighter and tighter for health care, the scrutiny of these practices and their potential to influence doctors will only continue to intensify.

-Wes

Irony: Aetna Asks People to Sit and Use Computer Game to Obtain "Wellness"

“Considering that Americans are spending over $200 billion a year on healthy living products and services, but the rates of chronic health conditions and obesity continue to rise, the time is right for a new approach to engaging people in achieving better overall health,” said Kyra Bobinet, MD, medical director of health and wellness innovation at Aetna. “We think the Mindbloom Life Game will provide a fun, rewarding and effective way for Aetna’s members to make lasting improvements in their physical and emotional well-being.”

Yeah, you filthy Americans! What do you think you're doing? Look at you! $200 billion just so you can get fatter and sicker!

Here, we have the answer to America's obesity problem. The "time is right" for us to "engage" you. Sit down, play this online computer game while we collect some important information on you and you'll be guaranteed to obtain the ever-elusive concept, "wellness."

Oh, how much did this cute game cost to develop?

Look, we're trying to look after your best interests. Don't bother us with such trivialities!

By the way, have you paid your insurance premium yet?

-Wes

h/t: The Medical Quack

World's Smallest Medical Camera

From FastCompany.com:

The world's smallest medical camera was unveiled this week by Israel-based biotechnology firm Medigus. The camera is .99 millimeters wide and boasts a resolution of 45,000 pixels--not high resolution by any means, but a shocking degree of clarity from a camera of that size. Because the camera is disposable, it will significantly cuts down on prep time for surgeries and endoscopic procedures thanks to being pre-sterilized. Even more importantly, the camera will significantly lower the cost of endoscopic diagnostic procedures. Reusable medical cameras require highly specialized, expensive sterilization procedures whose cost is often figured into patients' and insurance providers' bills.

Cool.

-Wes

Buttons

Buttons are threatening health care.

A moderate number of years ago, a new innovation came to my field: radiofrequency energy delivery to burn (ablate) tiny areas of the heart. The lesions created with this form of energy were more uniform and controllable compared to the direct current energy we had used before. As a result, doctors quickly migrated to this form of energy to perform their heart procedures. In turn, manufacturers of the machines to deliver radiofrequency energy rushed to develop sophisticated devices that measured power, impedance, and the temperature achieved at the catheter tip within the heart. All of these measurements were used to assure safety of the procedure and with these machines came buttons, knobs, dials, digital displays, and analog displays galore.

It was an engineer's playground, but a technician's nightmare.

But as the years went by, I noticed something interesting. The device that ultimately gained the largest market share was the one with the fewest buttons. It was easy.

And also, safe.

Lately, I have notice a disturbing trend in the development of our electronic medical records: there's no more room for buttons (or menus) on our computer screens. Increasingly, I find I have to scroll up and down or find buttons in drop-down menus as I care for patients. Buttons and more buttons, many of which I don't use.

* Click Click Click *

* Scroll *

* Click Click * "Damn, where is it?"

Before people think this post will devolve into a screed against the electronic medical record (EMR), relax. I am not a non-believer.

But I am a realist.

One only has to look at the complexity of today's TV remote controls to understand the problem.

Electronic medical records are rapidly being developed to replicate exactly what we are currently doing to medicine to make sure the entire team of health care providers (doctors, nurses, technicians, secretaries, scheduling personnel, supply officers - EVERYBODY) do things in it a certain, pre-defined (and regimented) way as we care for patients. As they get more intricate, we see the integration, and the associated complexity, and are awed.

But as I step back and look at these systems from 50,000 feet, the engineer-doctor in me becomes concerned. That's because of several very human realities that we must accept:

1. First is the shear number and volume of information we are asking our staff to enter for procedures. Electronic medical records are morphing from the classic written chart to supply systems, safety systems, billing systems and care systems incorporating every governmenal regulation known. Patient here? Entered. Timeout? Entered. By whom? Entered. Surgical sight? Entered. Groin prep? Entered. Type of prep agent? Entered. Duration of prep? Entered.
   
   Buttons. Buttons. Buttons.
   
   As more and more eyes are glued on the computer screen, fewer and fewer eyes are directed toward our patients.
2. Second and perhaps more concerning, buttons are static. Because they are hard-wired, buttons replicate the status quo and deter innovation. What happens, for instance, when a new button is needed because of a new development in medicine? Will systems be able to be easily adapted by end-users or will a programming change (and the ripple effects to other programs) be required, debugged, and tested before they can be safely implemented? What about the risks to safety as more and more hospitals want to implement other button changes system-wide? Will programmers be reluctant to make changes because of the impact (and re-training costs) required? What if a simpler way is found to deliver care that removes the need and cost of all these tedious checks and balances, will we be able to change?
3. Third, there will never be enough buttons to account for every variable seen in medicine. Free text will still be needed in data fields. Button-ology has limits.
4. Finally, buttons are getting expensive. There are so many buttons now that scribes are increasingly being employed for data entry as doctors struggle to free themselves from their burden. For every person hired for data entry, the reliance upon (and cost of) our button-filled systems mounts. Might these additional personnel soon be requirements for successful EMR implemenation?

Our new EMR reality is this: programming developers better be careful.

Otherwise doctors and administrators might find the most cost-efficient way to perform data entry might evolve back to pen and paper.

-Wes

Bristol-Myers Squibb Issues 5 mg Coumadin Tablet Recall

From the FDA today:

Bristol-Myers Squibb initiated a voluntary recall of one lot of 1,000-count bottles of Coumadin (warfarin sodium) Crystalline 5 mg tablets. Company testing of tablets from a returned bottle found a tablet to be higher in potency than expected. The lot number affected in the U.S. is 9H49374A with an expiry date of September 30, 2012. A decrease of active ingredient may increase the risk of clots which could lead to heart attack or stroke, and if there is too much active ingredient, there is an increased risk of bleeding.

So what should patients who take 5 mg tablets of Coumadin do?

Here's the FDA's recommendation from the same notice:

Patients who may have 5 mg tablets should not interrupt their therapy but should seek advice from their pharmacist to see if they have tablets originating from the affected lot and if so, should consult their physician for appropriate medical advice.

In short: call your pharmacist first. If the pharmacist where you picked up your 5 mg Coumadin tablets did not fill your prescription from the affected lot, no change in management is required.

But this is where this FDA advisory stops short. What are doctors going to recommend to patients who are taking 5mg Coumadin tablets from this lot?

If it were me, I would probably advise my patients to exchange tablets at their pharmacy for tablets from a non-affected lot and have a blood thinning level (prothrombin time or INR) checked to make sure their blood is not excessively thinned.

But, hey, that's just me.

-Wes

In Pakistan: Cardiologists Threaten Suicide

As America awakened to news of Osama Bin Laden's death in Pakistan, conditions for cardiolists in Pakistan sound dire:

Dr Zaheeruddin, while talking to The Express Tribune said, “After waiting for so long, for our salaries and to get our services regularised, we have been left with no other option but to protest and commit suicide along with our families.”

The reach of social media was exemplified by the inadvertant live-tweeting of the attack on Bin Laden. I wonder if these cardiologists have considered using social media to amplify their message before resorting to suicide.

-Wes