Monday, December 28, 2009

When Cardiologists Sue

It's sad that cardiologists have had to sue as their last resort to save their practices:
"Heart specialists on Monday filed suit against Secretary of Health and Human Services Kathleen Sebelius in an effort to stave off steep Medicare fee cuts for routine office-based procedures such as nuclear stress tests and echocardiograms.

The lawsuit, filed in U.S. District Court for the Southern District of Florida, charges that the government's planned cutbacks will deal a major blow to medical care in the USA, forcing thousands of cardiologists to shutter their offices, sell diagnostic equipment and work for hospitals, which charge more for the same procedures.
Perhaps other professional organizations will be forthcoming with similar suits as private doctors and their patients pay dearly for the reform efforts underway. Meanwhile hospitals continue to build. Pharmaceutical and medical device companies stocks rise. But did we really think the government's promise to find nearly $500 billion in "wasteful spending" from Medicare and Medicaid to resolve the fiscal realities of the ridiculously expensive legislative reform efforts could happen any other way?

No doubt the suit will bring this issue to the forefront for patients. It will be interesting to see how this plays out. Perhaps a compromise. Perhaps a further delay.

But make no mistake. specialists are first in the sights of the health care reformers. They and their technology are the bad guys. They are expensive. Innovation is evil. And while the American College of Cardiology may have significant resources to fight this fight and have a legitimate gripe, the government's legal purse is infinite. Eventually, the ACC's finances will be worn thin.

And so all the great reform efforts underway, America will have "primary care" for most of its citizens lucky enough to find a primary care doctor and specialist care only for those living close enough to a hospital to receive it.


Thursday, December 24, 2009

Our Senatorial Gift

As the Senators vote to pass their bill to extend insurance to thirty million more people while failing to address malpractice or physician payment reform, we can all only hope and pray that it's worth it in the end.

On thing's for sure, 2010 is shaping up to be one heck of a year.

Merry Christmas.


Chart source.

Wednesday, December 23, 2009

A LIttle Holiday Cheer

From our lab to yours, complete with a heart, pacemaker and defibrillator ornaments, defibrillator pads, pacing-lead tinsel, and an ablation catheter tree-topping:

Click image to enlarge

Wishing you a happy holiday season and very Merry Christmas!


Tuesday, December 22, 2009

Small Miracles

They sat, huddled together beneath the brightly lit Christmas tree, giggling as they described to their new found friend how they'd never seen snow before. Slowly as the week progressed, it melted, but not before the snowfight, the tree purchased, the shops invaded, the parties attended, and the tours taken. Their high school exchange program was soon to end, but not before they reflected on their visit, sharing one last set of digital pictures.

They sat, huddled together, working on tomato soup. There's has been an incredible journey: from childbirth, to grade school to college and beyond. There were seemingly endless Christmas's spent tearing through packages before, but now it is quieter. Other things are more pressing. "Would a chocolate shake taste good?" She is weak, but smiles. "I love chocolate shakes," she says. She calls and asks if she should add Ensure. She sleeps more now and good news comes in small bits: her white count's normal and she only needed two liters of fluid IV this week. "Mom, Mom? Mom, we're heading home now. You going to be okay, Mom?" She drifted back to sleep while her husband, exhausted, looked on.

I woke this morning and discovered that another blanket of snow had arrived overnight. Undisturbed, its perfect lumninescent contours served to soften even the most jagged of nature's edges.

It's a wonder how the peace of the holiday season can be found in the most unlikely of places.


Friday, December 18, 2009

The Rule of Twenties

Heard from a local independent gerontologist tonight who does not accept Medicare or other insurance payments in our state:
"When it comes to geriatrics, it's the rule of twenties:
20 problems
20 medications
20-minute phone calls
20 minutes to take their clothes off
20 minutes to put their clothes back on.
With the initial physical exam, three follow-up visits, and one EKG that Medicare pays for, I would receive only $360 in total. I pay $40,000 per year in malpractice, yet have never had a judgement against me. Think how may patients I'd have to see to cover just that expense. (editor's answer: 111)

You wonder why I am not a Medicare provider? I'd never survive at that their payment rate. And Blue Cross? They're no better and often pay less.

Funny thing is, Medicare was only too happy to have me opt out, because to them, I'm no longer part of their problem."
And the reason every primary care doctor's not doing this???...


Beware of Voice Recognition Software for Reading Chest X-Rays

You might get something like this:
"Single view.

There are no prior studies for comparison. The heart is mildly enlarged. The ovarian veins are engorged area.

"The increased density in the medial portion of the right base may be parenchymal or due to vascular structures. The remainder of the lungs is air. No effusion."
Um, did I miss something in medical school?



We Interrupt This Blog

... to do a bit of self-promotion. Cafepress, our distributor for our medical t-shirt website,, is offering a free upgrade in shipping until midnight tonight so t-shirts ordered for yourself or a loved one can arrive by Christmas eve. For overseas and non-US territories, today's the last day to have orders received in time for Christmas via express delivery.

Remember, 10% of proceeds from the shirts helps support plenty of worthy charities.


Can a Website Teach CPR?

The American Heart Association, in conjunction with a $1 million dollar grant from the Medtronic Foundation, thinks it can, especially if schools can win a thousand bucks for their effort promoting the idea:
Through the Be the Beat campaign, the Medtronic Foundation is providing $1,000 grants for school staff to help fund CPR and AED training outreach programs within their school or community. The deadline for application is January 15, 2010. More information is available in the “Teachers and Administration” section of the Be the Beat Web site, engages 12- to 15-year-olds to learn the basics of cardiopulmonary resuscitation (CPR) and how to use an automated external defibrillator (AED) through interactive games, videos and songs on the Web.
Sadly, the music selections that play at 100 beats/minute, (like "Stayin' Alive" and "Another One Bites the Dust") aren't available for download, but a expanded list of songs that play at that rate is included. Songs like U2's "I Still Haven’t Found What I’m Looking For" or Simon and Garfunkle's "Cecilia" (yep, "Celilia, you're breakin' my heart, I'm down on my knees, beggin' you please, to come home, to come home!" made the list. This alone is sure to be a source of endless entertainment, though I'm not sure about the appropriateness of singing ABBA's "Dancin' Queen" during CPR...)

And while the games kids are expected to play on the website are right up there in challenge level with the first iteration of "Pong," the concept of getting a broader, younger demographic to even think thirty seconds about CPR and how to use an AED is a novel one.


Wednesday, December 16, 2009

Are We Seeing the Death Spiral of Conventional Medical Conferences?

I think so.

It was apparent to me at the Heart Rhythm Society Scientific Sessions meeting and now a similar trend was noticed by Dr. Steven Sedlis at this year's American Heart Association meeting:
It felt like a ghost town. I ran into Ira Schulman, my medicine resident at Bellevue when I was a third year medical student; we looked at one another and simultaneously blurted out “where is everybody?”
. . .

There are probably numerous reasons for plummeting attendance at AHA. The economy, the on-line publication of trial results prior to presentation, the ubiquity of conference calls, e-mail strings and yes blogs that keep one in regular contact with colleagues throughout the country and the world without the need for face-to-face encounters are just some of the obvious causes.

The scaling back of industry support may be another major factor at play here. Certainly there are fewer exhibitors and the exhibits are far less lavish. As Muhamed Saric pointed out when I met him on the floor of the exhibit hall there were no Siemens or Philips exhibits, and in fact I could not find any cath lab manufacturers presenting their products at the AHA. The need to diminish the influence of industry on the medical profession and the need to avoid conflicts of interest were brought up at many of the presentations at the session by leaders of the AHA and other thought leaders in academic medicine, but one unintended consequence of this well-intentioned effort seems to be less financial support for the meeting itself.
I've always enjoyed the socialization and camaraderie that comes with medical conferences, but with the uncertainty of the current health care climate for doctors, the rising costs of these conferences for attendees, and the increased comfort doctors have for receiving medical information via the internet and social media, the need for traveling to medical conferences has quickly become obsolete. While medical device company or pharmaceutical reps might still find these venues moderately entertaining, without their ultimate customers in attendance, the medical scientific session conference marketing circuit will slowly fade away.


Scientific Medical Journals and the Media

The article appeared yesterday in the Wall Street Journal: "Study Shows Older Patients Benefiting From Defibrillators."

One would think a doctor might like to read the article, especially one dealing with defibrillators.

So I checked late last night and wouldn't you know, no such article was on-line. Then I checked again early this morning. Still no reference on line. I checked Google. I checked Circulation: Heart Failure's website. I checked for the press release on the American Heart Association's press release web page.

No such article.

But Reuters had seen it (I think) (or at least they saw the American Heart Association's press release about the article, I really don't know).

And so I waited and waited, only to find that the article was finally posted on-line publically on the Circulation: Heart Failure's website at about 12-1PM CST, almost a full 18 hours later the manuscript was reported upon by the main stream media.

The article certainly has plenty to comment upon, but I will forgo that for the moment and instead focus on this disturbing trend of media releases pitched to journalists before the scientific community.

Given that this study was funded by GlaxoSmith Kline and the journal Circulation: Heart Failure is published by the American Heart Association who acknowledges multimillion dollar funding from the pharmaceutical and medical device companies we have to wonder: why are physicians being left out of the opportunity to critically review scientific publications before mainstream media broadcasts information to our patients and the public? Might it be that the sponsors of these trials might not like what certain doctors might say about the study? Or are such press releases being more like classic TV ads hoping to prod patient's to "Ask Your Doctor" about study's findings? What potential implications might these press releases have on public policy mandating doctors to "Get With the Guidelines" for the treatment of heart failure going forward?

I find the feeding of jounalists these manuscripts before the very scientists who subscribe to the these journals troubling at best and potentially subversive and manipulative at worst.


Tuesday, December 15, 2009

Grand Rounds Is Up

... with a Charlotte's Web theme over at Florence dot com:
Welcome to this holiday edition of Grand Rounds! It's the time of year when friends and family gather, when stories are told and memories are made. But the winter weather and short days here in the northern hemisphere seem to prompt brevity in our everyday comings and goings. It seems like the right time to combine storytelling and brevity and channel Charlotte, one of the most masterful storytellers I met during a childhood spent with my nose in a book.


Monday, December 14, 2009

Live on TV: An Implantable Cardiac Defibrillator Fires

As implantable cardiac defibrillators (ICDs) are increasingly ubiquitous in society, it is not suprizing that their effects might be caught on television. We've already seen the remarkable benefit of an ICD correcting ventricular fibrillation in the professional Belgian soccer player, Anthony Van Loo, but when it happens to a conscious scientist at the 2009 Coppenhagen Climate Summit, it certainly turns heads:

Danish physicist Henrik Svensmark was attending the Coppenhagen Climate Summit '09 and had three repetitive ICD firings recorded on live television. Reportedly he was rushed to a hospital and his condition stabilized.

Implantable cardiac defibrillators fire when the ventricular heart rates exceed a pre-determined heart rate that is sustained for a predetermined number of heart beats. It is unclear if his heart rate was elevated from a lower heart chamber (ventricular) arrhythmia (the most likely cause) or a racing upper chamber (atrial) heart rhythm abnormality that drove the lower chamber too fast. Unlike Mr. Van Loo, Dr. Svensmark heart rate was probably not fast enough to cause him to lose consciousness. Nonetheless, when the defibrillator fires, it delivers the equivalent of approximately 830 volts in a tenth of a second, causing the muscles of the chest, heart, vocal coards and diaphragm to contract forcefully, occassionally resulting in the "yelp" heard at the just before the video ends.

Communicating with the patient's ICD with a programmer after such an event helps doctors determine the cause of ICD firings and assure the device was working as expected. Based on that information, medication therapies or device adjustments can be made to help prevent future firings.

It should be noted that this event was NOT a "heart attack," or a sudden disturbance of the blood flow that supplies the heart, but rather an implantable cardiac defibrillator treating the sudden onset of a potentially lethal heart rhythm disturbance. As such, because the defibrillator responds so quickly, heart muscle function is usually preserved.


h/t: A faithful reader.

Sunday, December 13, 2009

US Health Care Reform Photoshop Contest Winner

My wife and I would like to thank all those who contributed to the first (and perhaps only) US Health Care Reform Photoshop Contest. Polling for the favorite finalist stopped at 11:59 PM on 11 Dec 2009 and, like American Idol, the blog-o-sphere tallied the most votes for "Taking Care of the Healthcare Pest," submitted by "Elisabeth" of Peidmont Healthcare.

Congratulations and Merry Christmas!


Rural Versus Urban Primary Care Wars

As the primary care crisis grows, it seems rural areas are seeing their competitors snatch up primary care doctors who were supposed to return to their community after training:
Competition for physicians pits rural communities against each other, and many of those “may, in fact, be losing out to urban hospitals,” said Creighton's Frey. “Unless some major changes occur in the physician work force, the future is very frightening.”

Marvin Neth, administrator of Callaway District Hospital in central Nebraska, said he believed he had a doctor signed up through a federal loan-forgiveness program a few years ago.

But a bigger hospital recruited the physician away, most likely by agreeing to pay the loans and the penalty for not fulfilling the physician's obligation to the rural health care program, Neth said.
Addding to the crisis is the fact that some primary care doctors quickly find the workload and lifestyle untenable and decide to specialize:
Rural areas have battled the health care access problem for a long time. Many rural physicians have patient volumes that are too high and are on call too much to make that lifestyle appealing to young physicians.

Dr. Matthew Johnson joined a North Platte, Neb., group of several internal medicine physicians about four years ago. As a young newcomer, he was to gradually take over the patients of a physician who was easing into retirement. But the physician retired immediately.

“The clinics were full,” Johnson, now 34, recalled recently.

He was swamped and frequently worked 80 hours a week. He saw patients in his office, in the hospital and sometimes in the aisles at Walmart, where they would complain that they couldn't get in to see him and went to the emergency room instead.

Johnson recalled thinking: “I can't do this for 30, 35 years.”

Johnson said he neglected his wife and two children and grew irritable. “I'd treat my patients better than I'd treat my family.”

Last year, Johnson left that practice to study at UNMC to become a heart specialist. He knows he'll work hard as a cardiologist, but not 80-hour weeks, and he'll make more money.

“Cardiology's been all that I expected,” he said.
"The grass is always greener...", I guess.


Thursday, December 10, 2009

Controlled Drug E-Prescriptions: Policy Versus Practice

"Hello, Dr. Fisher?"

"Yes, this is Dr. Fisher"

"This is Sam Smart, pharmacist at Walgreens over in East Elsewhere."

"Yes, sir, how can I help you?"

"Well it's about that prescription you gave to Mr. Pacertoday for Norco."

"What about it?"

"Well, it's not printed on the right controlled drug presciption paper."

"But that's how we've been issuing prescriptions. I haven't seen any of that special printer paper with that squiggly-lined paper for months. I know we're 'sposed to use in that kind of paper, but it's never in the printer and there's no special printer for controlled drugs, so we just use regular paper. It has my signature, right?"

"Well, there's a signature, but I really can't tell if this is an authorized signature without the proper paper..."

"But you're talking to me, right?"

"Uh, yeah."

"And you called my office phone number, right?"

"Uh, yeah."

"So can you fill the prescription now that you've verified that I'm the one who wrote the prescription?"

"Well, I'm really not supposed... Well, I will this time. But in the future, make sure you use the right paper, okay?"

No, not okay.

Doctors, nurses, and secretaries do not have time to fill special paper in printers to write prescriptions for controlled drugs, yet this is what our fabulous regulators require in order to prevent Medicare fraud. Practically speaking, this isn't happening for the simple fact that it's impractical.

How about just allowing us to send our controlled drug script electronically, like all of the other prescriptions we send? Or maybe add an encoded PIN number?

Using fully implemented e-prescribing would likely have much less potential for fraud and abuse...

..unless, of course, our electronic medical record systems aren't as secure as the bureaucrats say they are.


Reference: "Frequenty Asked Questions Concerning the Tamper-Resistant Prescription Law (Section 7002(b) of the U.S. Troop Readiness, Veterans’ Care, Katrina Recovery, and Iraq Accountability Appropriations Act OF 2007), Center for Medicare and Medicaid Services.

When Politics Get Local

... suddenly, things become very real for both cardiologists and patients.


Tuesday, December 08, 2009

Difficult Case? Ask Dr. Obama!

... and you can have instant access to him in your lab, too!


Coming Full Circle in the Health Care Reform Efforts

It's like rain on your wedding day
It's a free ride when you've already paid
It's the good advice that you just didn't take
Who would've thought... it figures

Well life has a funny way of sneaking up on you
When you think everything's okay and everything's going right
And life has a funny way of helping you out when
You think everything's gone wrong and everything blows up
In your face

-Alanis Morissette, "Ironic"

Isn't it ironic that here, months and months after starting the health care reform efforts to correct the fiscal insolvency of Medicare, a system that has proven itself incapable of reining in health care costs, that Congress is now in discussions to expand that same program to people ages 55-65
Negotiators Monday were considering a proposal that would open Medicare to people ages 55 to 64 if they couldn't find coverage elsewhere. The proposal would allow them to buy insurance coverage at subsidized rates under Medicare, though the subsidies wouldn't be as great as those for people 65 and over, said congressional aides and lawmakers.
How much money have we spent to get to this point?

I'm seeing a health care cost savings, aren't you?


Monday, December 07, 2009

Getting Ready for the Cardiology Cuts

There are potentially plenty of ways cardiologists will see their payments decline next year: from the loss of Medicare inpatient consultation code payments to the 2010 physician fee final rule issued last week by the Centers for Medicare & Medicaid Services (CMS) which threatens to cut to cardiology practice procedural payments an average of 27 percent.

For those who want to calculate the potential impact to their practice, the American College of Cardiology has prepared a nifty Practice Impact Calculator that contains two worksheets: one for your practice and the other for the impact that loss of consultation codes will impart. Just enter this year's volumes and the calculator will do the rest.

Try not to get too depressed filling it out and consider sending your results to the ACC.

Oh, and more good news: please keep in mind that the proposed 2010 payments shown on the spreadsheet do not include the across the board 21.5% cut to the Medicare conversion factor that will take effect on January 1 if Congress fails to prevent it. Also, remember that this spreadsheet shows only the impact on Medicare payments. Many private payers follow along with Medicare’s payment trends, so reduced Medicare payments could be only the beginning.


Photo credit.

The New American Medical School Challenge

Nature abhors a vacuum.

And no where is this more clear than residency slots in Internal Medicine.

Today, I learned some interesting statistics that should alert medical students applying to residency programs across the country.
  1. Surprisingly, applicants to our categorical residency program is up 15% this year.

  2. The number of foreign medical graduate students to this year's applicant pool has increased 50% over last year.
In short, the medical marketplace for doctors is becoming a global one, and the need to support current salary levels is likely to erode in the not-so-distant future.


Sunday, December 06, 2009

The Inefficiency of Medical E-Mail

I am fortunate to work at an institution that has a fully deployed electronic medical record (EMR) system that incorporates outpatient physician notes and inpatient notes under one umbrella. By and large, patient care is facilitated since both outpatient and inpatient notes appear simultaneously in the patient's chart, along side telephone messages and clinical results. While there are plenty of kinks to work out, most of us have to admit that there are huge patient care advantages to such a system.

The system also promotes a secure e-mail service for patients to e-mail their physician and a mechanism to have their results forwarded directly to them. With the ability to empower patients directly, many would consider this as the Utopian model for heath care delivery of the future.

And what could be better? Patients get virtually unlimited access to their health care provider, 24-7. Results are whisked to the patient. Speed. Efficiency. "Green." It's all good, right?


At least until a complicated health care situation occurs.

Then the four-page e-mail is sent, asking for clarification. A lengthy reply is made attempting to answer every question. The response is quickly followed by questions. More answers. "What do you mean?" "But what I thought you said..." More responses. More questions. "But have you considered ...?" "But I have to be in New York that weekend. Do I really need it?" "I've been thinking..." "What about....?" "Like I said..." Back and forth. A constant stream of electronic anxiety.

Then a pause.

"Doctor, why haven't you answered my question, doctor? I sent you three mesages today and haven't heard from you. Doctor? Your nurse practitioner wrote that you'd ... I don't understand why there's such a disconnect...."

Hours and hours of back and forth, pounding on a keyboard producing the cold, hard blandness of text. Broken streams of communication. No emotion. No visual cues. No empathy. No give and take.

Just text.

* Click clack, clack click. *

It's about as inefficient as it can get, absorbing huge amounts of physician and nursing time.

Granted, it doesn't happen often. Most patients are sensitive to this mode of communication and e-mail's inherent limitations. But occassionally there are the highly computer-saavy patients who live online, over-use the service, and expect their answers instantaneously. The reality is that few doctors type well, are still putting their hands on and in patients, and do not continuously reside at a computer screen (despite what the hospital administration wants you to believe). That being said, there are still many times where it is far more efficient to see the doctor in person when tough treatment decisions have to be made.

That is, of course, as long as the doctor can pull his face from the computer screen during the office visit.


Photo credit.

Friday, December 04, 2009

ICD Implantation, Hugh Hefner-Style

Well, at least it's one way to make a former tattoo three-dimensional:

Just putting the sexy back... :)


Photo used with patient permission.

Boston Scientific Issues 'Soft' Defibrillator Advisory

Boston Scientific recently issued a new device advisory for their current line of Teligen ICD and Cognis CRT-D automatic defibrillator devices. The advisory affects only those devices that are implanted beneath the breast muscle (subpectorally) on the chest wall. It seems two (2) devices implanted (of 77,000 total devices implanted worldwide) in this location experienced weakening of a header bond caused by significant forces applied to the header by the pectoralis muscle to the rib. This resulted in altered lead impedances and the introduction of noise to the defibrillator sensing lead that might inhibit pacing or result in inappropriate tachycardia therapies (shocks).

The submuscular implantation location is an uncommon location to implant the devices. It is estimated that only 5% (3850) of the 77,000 devices implanted, were implanted in the subpectoral location.

From Boston Scientific's "Dear Doctor" letter:
Boston Scientific has determined that the bond between the header and case could be weakened by significant forces associated with a subpectoral implant procedure or when a device in a subpectoral position is pushed against a rib during contraction of the pectoralis muscle. A weakened header bond may alter lead impedance and introduce noise that may inhibit pacing therapy or initiate inappropriate tachy therapy. Additional mechanical stress applied to a weakened bond may eventually cause header connection wires to fracture, resulting in loss of therapy.

. . .

Rate of Occurrence
The implant orientation of devices is not reported to Boston Scientific, making it difficult to provide rate of occurrence and prediction information. We have received two (2) reports worldwide of subpectoral implants with weakened header bonds. We estimate that 5% of approximately 77,000 COGNIS and TELIGEN devices worldwide have been implanted in a subpectoral location.

The following factors may also impact the risk of failure if implanted in a subpectoral location:

• Exact location of the patient’s ribs relative to the device
• Body size and/or muscle mass of the patient (risk may increase for larger/muscular patients)
• Activity level and/or occupation of the patient (risk may increase for more active patients)


For future implants:
• Boston Scientific recommends that subpectoral implantation of affected COGNIS CRT-Ds or TELIGEN ICDs (Table 1) be avoided until improvements to header bond strength are available for devices in your geography.

For affected devices (Table 1) implanted in a subpectoral location:
• Follow patient at least once every three months as recommended in device instructions for use.
• Consider advising patients to contact their physician or clinic if they receive shocks, in order to ensure timely review of associated electrograms and other device data via in-clinic or remote interrogation.
In summary, the devices need to be followed as usual (every three months), but are not recommended for removal unless they begin to develop erratic behavior. The warranty and unreimbursed medical expenses "may" be honored in "certain geographies."


Reference: Boston Scientific's webpage with more information as well as links to the Dear Doctor and Dear Patient letters

Thursday, December 03, 2009

Coronary Stent Gift Cards for the Holidays

Target has them.

Walmart has them.

Best Buy has them.

Just about every retailer has them for the holidays.

So why not get a gift card worth more than $1000 given to you by your friendly neighborhood coronary stent dealer?
Sign up today and you could:
  • Save up to $30 each month for six months on prescription antiplatelet (anticlotting) medication.

  • Participate in a personalized reminder service for your antiplatelet (anticlotting) medication.

  • Save up to $30 each month for six months on three cholesterol medications from Abbott Laboratories.

  • Through the FreeStyle Promise Program*, receive one FREE Freestyle Lite or FreeStyle Freedom Lite blood glucose monitoring system, save up to $50 every month (or up to $600 per year) on test strip co-pays, and have access to personalized health expertise by certified educators and ongoing product support.
To enroll, simply call 1-800-547-4386

To sign up for this program, you'll need your XIENCE V Patient Care Program card. You received this card from the hospital following implantation of a XIENCE V stent. When you call you'll also need your stent's product lot number. The product lot number can be found on the stent implant card. You received this card in your patient materials following the implantation of a XIENCE V stent. The stent implant card is purple and white, and has a color photo of a heart on it. If you do not have or have lost your XIENCE V Patient Care Program card or your stent implant card, be sure to contact your physician or the hospital.
Hey, what's a few perks among friends?

I've got mine (from our rep, mind you, not because I have a stent):

How about you?


PS: Oh, if you have Medicare, Medicaid and these things are covered, you can't use the card! (In other words, it's just a bad joke...)

Wednesday, December 02, 2009

Could the Stethoscope Gain on the Echocardiogram?

Some seem to think it could:
Early tests of the (stethoscope) system suggest that it could eliminate more than eight million unnecessary echocardiograms and cardiologist visits a year, saving some $9.4 billion and, even better, catch more of the dangerous murmurs. For doctors, and anyone with a heart, this stethoscope’s upgrades are well worth the two-century-long wait.
One thing's for sure, the crappy plastic yellow stethoscopes in the rooms of isolation patients have to go.


h/t: Matthew Bodish, MD

US Health Care Reform Photoshop Contest: The Vote

Okay, the entries for the 2009 US Health Care Reform Photoshop Contest are in and it's time to vote! The idea was to create a single picture using your snark, your wit, your creativity to encapsulate your feelings about the US Health Care Reform efforts underway in a single photograph.

We appreciate the efforts by all of those who made to effort to submit an entry, but only one lucky winner will receive an iTouch in time for the holidays. So here are the entries one more time, in random order:

1) "Healthcare Budget":

2) "Health Care Cat" (in the spirit of LOLCats):

3) "Gonnorrhea for Rationed Health Care"

4) "Taking Care of the Healthcare Pest":

So think carefully, and vote. Please, no voting he "Chicago-way," okay? One vote per person, please. Polls close 11 Dec 2009:

Which is Your Favorite Health Care Reform Photoshop Picture?

The Problem With Making Medical Devices Look Hip

With the advent of trendy-looking insulin pumps and event recorders that look like hip MP-3 players or cell phones, there might be a downside, like theft:
School officials say it's inconclusive whether the pump was "misplaced or taken." Police say they're still investigating.

But Raube and her parents believe someone stole it: Maybe they mistook the tiny shiny pink pump with cords wrapped around for an iPod. Maybe they knew what they were stealing.

Tuesday, December 01, 2009

The Electronic Medical Record and The Challenges Ahead

For those who have not seen it, one of the better discussions on the achievements, limitations, and future challenges of the adoption of the Electronic Medical Record can be found at the blog of Howard Luks, MD, The Orthopedic Posterous in a guest blog by R. Vaughn, MD. Be sure to read the comments from some very informed patients, IT experts, doctors and even, yes, yours truly.

Although long, you'll learn something.

Not bad for an ortho guy...



Monday, November 30, 2009

EKG DU Jour #19: A Case of Obtundation

A 60 year-old man was found obtunded, unable to ambulate or communicate at home by a house cleaning service. He was brought to the emergency room and found to by hypotensive, bradycardic and was intubated emergently due to poor ventillatory effort. His initial potassium was found to be 7.6 meq/L and a slow junctional escape rhythm of 40 b/min. He was administered calcium, insulin and glucose, and the EKG, shown below, improved a bit.

Click image to enlarge

An astute observer glanced at the EKG and posed an important question to the ER staff.

What was the question?


Addendum 18:45 CST - The EKG image was updated to permit better enlarged viewing.

Text Paging Health Information

I saw this in a recent nursing note:
Urine noted to be bloody without clots.
Text message sent to 2290 (trauma pager) about hematuria.
Patient denies any pain at this time.
No doubt patient identification or their room number, was sent to identify the patient (I'm not sure which). I suppose a record of the physician covering the trauma service that night is discoverable.

But I wonder, in the world of cyberspace with electronic communication carrying such an important role in health care delivery lately, is HIPAA really enforceable or will it just be used to extract huge fines from care providers now that the new HITECH policy expands HIPAA's reach.

Since text pages are neither encoded nor retained as an official audit trail of care delivered, it seems to me care providers are vulnerable, even when they are doing the right thing for the patient.


Sunday, November 29, 2009

Primary Care's Problem: Putting the Sexy Back

Hugh Laurie can't do it. (We need to cut back on over testing, doctor, and those pills!...)

Marcus Welby can't do it. (Who? You mean that OLD guy?)

8% pay raise through cost shifting can't do it. (And you want me to fill out how many forms?...)

Calling their clinic a "medical home" and flooding it with angry people who can't get an appointment won't do it.

So how do you do it?

How does one go about putting the "sexy" back in primary care?

This is one of health care reform's biggest problems and right now, just about every piece of legislation promised to further overwhelm primary care doctors with more hoop-jumping than ever before. From ICD-10 with it's 150,000 billing codes, to mandates to purchase expensive medical record systems that, so far, have proven their worth to administrative collection agents in their protected silos well before they have proven their worth to our nation's health. Or to pay for performance, a form of least-common-denominator medicine that forces compliance before enabling innovation in health care efficiency. Primary care is no longer sexy, it's becoming cookbook. So much so that nurse coordinators have become the new buzzword for primary care - not exactly a reason to enter four long years of medical school and three more years of residency training. Who wants to go to school of become a doctor only to find out that you're really going to school to become a nurse manager?

And then there's the academic mega-centers' disdain for private practice care. The not-so-subtle elitist attitude that private doctors in the community aren't nearly as good as the academic megacenters' specialist care, while they, themselves, have never set foot outside their pearly gates to work in the trenches lest their white coat become soiled.

Primary care is not about medical robots, waterfall lobbies, big screen TV's and marble floors. But those things are sexy. And we all know that Americans, like bugs, are drawn to bright and shiny objects. We love the whizbang, the big buildings, the nice decor. We scream for the latest and greatest hospital additions with computer technology and the latest robots, only to turn around the next day to scream about our hospital bills. God forbid we put two and two together.

Primary care doctors are up against all of this and the marketing efforts they employ. No wonder they cannot compete.

Putting the sexy back in primary care will involve anything but more bureaucracy and oversight. Congress does not get that these aren't sexy. To them, the tombs of legislation are what's sexy ("See all the work we did?")

But what's sexy to doctors is using independence and entrepreneurism in medicine for the patient's benefit. That's sexy.

And unless our legislators get that, primary care will go the way of the dinosaurs and the great paucity of care providers imposed by bureaucratic doctrine, will continue unabated.


Addendum: Today we find that general surgeons are way ahead of primary care doctors in bringing sexy back to their profession.

It seems some are leaving the drab of emergency room call to fill SWAT teams in a "national movement" to embed medical professionals "so that help is at the ready should something go wrong."

Pitty the poor ER patient who finds the general surgeon is out on a drug bust.

Saturday, November 28, 2009

US Health Care Reform Photoshop Contest on Its Final Stretch

Just a reminder: there's a little over 24 hours left to submit your entries to the US Health Care Reform Photoshop Contest where a single tastefully doctored photograph that summates your feelings about the health care reform efforts underway could win you an Apple iTouch. Entries are due by 11:59 PM CST and should be e-mailed to wes - at - medtees - dot - com. Full contest rules can be found here.

Good luck!


When a Nurse Contracts Malaria

In 2008, Dawn Dubsky was a nurse at Children's Hospital in Chicago when she took a trip to Ghana, where she contracted malaria and all its complications. In a two part series, the Chicago Tribune chronicles her story. The results, in many ways, were profound:


Tuesday, November 24, 2009

Putting the "Happy" in Thanksgiving

Who said hospitals can't have fun? Provident St. Vincent Medical Center, Oregon shows us how as they support breast cancer awareness:

Only one question: where were the adminstators?

Happy Thanksgiving!


Some Thoughts for Thanksgiving

I thought I'd share this list that was published on this blog before:
I am thankful for the teenagers who are complaining about doing chores -- that means they are home and safe.

... for homework. It means we live in a country where education is valued and encouraged for all.

... for the taxes I pay; it means I have income.

... for the mess that I have to clean up after parties, because it means I am surrounded by friends.

... for the clothes that fit a little 'too snug' because it means I have enough to eat.

... for the lawn to mow, windows to wash and gutters to clean; it means I have a home.

... for the parking spot I found at the far end of the parking lot, because it means I am capable of walking and am blessed with transportation.

... for my huge heating bill, because it means I am warm.

... for the person behind me in church that sings off key, because it means I can hear.

... for the pile of laundry and ironing, because it means I have clothes to wear.

... for all the complaining I hear about the government; it means we have freedom of speech.

... for the alarm that goes off early in the morning because it means that I am alive!

Author unknown
And one other thought: be sure to visit Paul F. Levy's blog, Running a Hospital, to learn about the Engage With Grace program to how you can engage in a conversation with your loved ones about their (and your) end of life wishes.

Now, especially, is a good time to reflect on what we can do for others.


Monday, November 23, 2009

When Insurers Dominate Market Share

Prices rise:
One factor that could be driving larger increases locally: Blue Cross & Blue Shield of Illinois, which historically has used its dominant 50%-plus marketshare to undercut competitors' prices, has been more aggressive with rates this enrollment season, brokers say.

"Blue Cross is the one company that is consistently coming in with higher renewal increases," says Rob Wilson, an insurance broker and president of Westmont-based Employco Group.

A Blue Cross spokeswoman declines to comment.
Funny that when hospital systems coalesce and raise prices to remain "competetive," the FTC cries foul, but when the insurance industry does the same thing, the FTC can't be bothered.

But then, the government knows what's best for patients, right?


Sunday, November 22, 2009

Code Blue, Then and Now

11:30 pm - Cackling though the overhead intercom system:
“Code Blue, Three East, Room 236”

A thunderous herd of medical students, residents, anesthesiologists, cardiologists, social workers, security personnel descend on the scene. Arriving, the chief resident is in charge at the foot of the bed. IV’s have been started, some young well-muscled individual is bobbing up and down on the unseen’s chest, brow glistening with sweat, but focused. An anesthesiologist, noting the agonal rhythm, works to secure the airway, then a central line. Nurses administer drugs, bring line kits. Airway secured. “EKG? Where’s the EKG?” Electrode replaced. “Story? Who’s got the story?” Ten. Twenty. Thirty. The minutes pass. Finally, silence, as the monitors removed and the group departs. Like sound and fury, signifying nothing.
11:30 pm – The pager sounds:
* bleep bleep bleep *
A digital image appears on the screen: CODE BLUE, Room 2001

I was not on call, but I wondered, “Was this a patient of mine?” “Did I forget someone?” I raised my head from the pillow and strolled in to the accompanying room where my outdated computer sat and waited while it booted. “What might have happened?” “Is it someone old or young?” Thoughts spun just as the disk drive. Waiting. I typed by keyfob’s codes, I entered by password twice, I waited some more then the electronic medical record appeared and I checked the name next to the room number. For the first time, the number meant something: a person, 88 yrs old, yet someone I did not know. The scene appeared from miles away.

I sat back and perused the chart. Heart attack, conservative management, hypotension, fluid bolus given, then nothing more.

A few more keystrokes and the computer went black.

Then sleep came poorly once again.

Saturday, November 21, 2009

Want To Opt Out of Medicare?

Here's how, courtesy of Mayo Clinic Family Medicine - Arrowhead (Arizona):
The discrepancy between what Medicare pays and our cost of providing care acutely impacts the sustainability of our primary care practice. Medicare reimbursements do not cover our actual costs of providing care, and therefore we have recently had to make some difficult decisions that will impact the Arrowhead Family Medicine practice. Effective January 1, 2010, the physicians at Mayo Clinic Family Medicine - Arrowhead will opt out of participating in Medicare, meaning that Medicare will no longer reimburse for the services they provide....
With the $500 billion dollars of cuts to Medicare spending in the new health care bills proposed, will we see more of this in more affluent areas?


Friday, November 20, 2009

Early Health Care Reform Photoshop Entries Are Up

Early US Health Care Reform Photoshop Contest entries are available to view here. (I did the one at left - sorry, it's ineligible). There's still plenty of time to submit your entry. Entries will be still be accepted until 30 Nov 2009 at 23:59 pm CST!


Wednesday, November 18, 2009

As Hospitals Gain Cardiologist Employees, Private Cardiologists Are Shunned

An interesting story has developed in Missouri where a private group of cardiologists was asked to no longer see their patients at the local hospital. It seems the hospital hired it's own group of cardiologist-employees. Things grew so contentious according to the video accompanying the report, when the cardiologists asked for an OR lite, they were told to use a flashlight (the hospital disputes the claim).

As the cardiologist shift to adjust for the economic realities that confront them, they have much more to lose from their patient relationships as its the patients that are inevitably affected the most when these shifts occur.


Tuesday, November 17, 2009

Sebelius: Talking the Talk or Walking the Walk?

Here's a bit of the transcript from Kathleen Sebelius, Department of Health and Human Services Secretary, speaking to the Wall Street Journal's CEO Council (approximately 2 min, 45 sec into video) about saving health care costs:
... There are lots of features of the House Bill and that are already in the Senate bill that change that (the way doctors are paid). We are beginning to move away, particularly in Medicare, from traditional fee-for-service pay that I would suggest not only causes redundancy but doesn’t encourage innovative, high quality, low cost practices to moving toward a system that exists in pockets, exists in Mayos, Geisinger, (Inter-)Mountain Health Care. We know what it looks like. It isn’t how medicine is practiced it isn’t the the hospitals and providers are paid, so "bundled payments," "medical care homes," "accountable care organizations" – all buzzwords for really providing financial incentives and eventually financial penalties for appropriate medical protocols and appropriate outcomes - stopping the system now where one out of every five who’s released from the hospital is back in 30 days having never seen a health care provider, reducing or eliminating hospital-based infections, which are now one of the top 10 leading causes of death in America. We know exactly the system that can be done to stop it. It doesn’t take any capital investment It doesn’t require any new technology.”
I wonder what she means by "... eventually financial penalties for appropriate medical protocols and appropriate outcomes?"

Why penalize people for adhering to appropriate medical protocols? Or maybe she just needs some sleep...

And then there's this quick fact check:

Septicemia: #10 in 2006 (1.3% of deaths) CDC list for death in America and was #11 in 2004 (1.4%) but is substantially better than rates in 1997 (2.4% of deaths).

(Just keeping it real.)


Medical Bloggers' Grand Rounds Is Up

... this week over at Colorado Health Insurance Insider.


Compensating Doctors for After-Hours Call Coverage

Should there be a premium added to physician compensation for on-call coverage after hours, or are Medicare rates enough?

This appears to be the central question between two competing hospitals in Longview, Texas where a $300,000 stipend was paid to a cardiology group by one hospital and not the other for cardiology on-call coverage.

Guess which one the doctors are promoting now?
Banos said the Diagnostic Clinic cardiologists recently approached Good Shepherd "demanding hundreds of thousands of dollars in compensation from Good Shepherd for providing call coverage to the patients of Good Shepherd."

"This is in addition to whatever money they are able to bill and collect from patients and their insurance companies for the services they actually provide when they are called in to perform a procedure," Banos said in his e-mail to Good Shepherd employees.

Banos said he believes the demands for compensation were "veiled threats to move their elective procedures to Longview Regional if we did not pay." He added Good Shepherd's stand is that meeting the compensation demands would "not be fair to the many other physicians on our medical staff who selflessly and without any expectation of pay [from the hospital] provide call coverage to our patients each day as part of their commitment to the community."

"We cannot meet the needs of our community and pay doctors for doing something that they are already obligated to do as a part of their community obligation" Banos said.

Banos said he believes Longview Regional agreed to pay the cardiologists more than $300,000 a year for on-call coverage.

"We do not believe that it was by chance that it was only after this agreement was reached that these physicians touted Regional's 'commitment to quality care' and announced their 'choice' of Longview Regional for their patients." Banos said. "We knew that taking a stand could result in these physicians moving their elective cases to Longview Regional, and it did."
Before condoning the cardiology groups' actions strictly on the basis of greed, we should note that there is a precedent for higher pay for employees working after hours in industry. Hospitals, too, have resorted to paying "nocturnists" (night-shift hospitalists) higher salaries than their daytime hospitalist counterparts as they struggle to find staff willing to work the night shift managing inpatients. These salaries are not covered strictly by funds received from the paltry Evaluation and Management payments paid by Medicare, rather, they are subsidized by the hospital system.

Threatened with unprecedented pay cuts from Medicare, look for this trend to continue as doctors use their only remaining asset, patient referral clout, to negotiate their compensation going forward.


Monday, November 16, 2009

How Not to Consent a Patient for Angioplasty

"Honey, all you need to worry about is if I am going to listen to opera or Steely Dan during the procedure."

P.S. I told you "Honey" was bad.

Sunday, November 15, 2009

US Health Care Reform Photoshop Entries

Last updated 24 NOV 2009 @ 06:00 AM.

Early entries for the US Health Care Reform Photoshop Contest are shown below in the order they were received. Remember, the deadline for entries is 11:59 CST 30 Nov 2009. This post will be updated from time to time as new entries arrive.

(Editor's note: We're putting the entries up as they're sent. Remember, you'll ultimately be the judge.)

1) "Health Care Cat" (in the spirit of LOLCats):

2) "Gonnorrhea for Rationed Health Care"

3) "Healthcare Budget":

4) "Taking Care of the Healthcare Pest":

US Health Care Reform Photoshop Contest

In the spirit of the upcoming holiday season and to make sure something on health care reform gets done before the end of the year, Dr. Wes and his wife, Diane, would like to propose the first (and perhaps only) US Healthcare Reform Photoshop Contest.

Bring us your snark, your wit, your creativity about the health care reform efforts encapsulated in a single photograph. Photographs in support or against the current efforts will be equally considered, and you, dear internet devotees, will be the final judge. The winner receives an iPod Touch.

Rules: No more than one photo entry per household, please. Create a single photo using Photoshop or other equivalent photo-editing software that encapsulates the essence of health care reform as you see it. Photographs must be G, PG, or PG-13 rated and family-friendly (R or X-rated photographs will be enjoyed, but not eligible or posted). An example image we created is shown above. Please do NOT use copyrighted photos.

E-mail your entries to me at wes - at - medtees dot com (please keep file sizes under 100K) with your name, address and e-mail contact information and I'll post the vetted entries on a webpage on this blog in the order they are received. If the response is overwhelming, we reserve the right to limiting the images posted to our discretion.

Depending on the number of entries, our highly distinguished referees (my wife and I) will choose the five or six photographs that will serve as the finalists by no later than 11:59 PM on 30 November 2009. On 2 December 2009 or so, the chosen finalists will be displayed and the polls will open for you to choose the winner. The photograph with the most votes tallied will receive an 8Meg iPod Touch. Voting on the finalists will close 11 Dec 2009 at 11:59 PM. This way, we hope there's plenty of time for our prize to reach the winner before the holidays and final health care reform vote. In the unusual event there is a tied vote, we will chose the winner between the two favorites.

So get going, be creative and most of all, have fun!

Happy holidays!

- Wes and Diane

P.S.: Please spread the word!

FTC Disclaimer: No advertising sponsors are supporting this contest.


Health Care Reform Photoshop Contest RulesIf you'd like to help promote this contest on your blog by placing this tacky button on your sidebar, just copy the HTML in the textbox below and add it to the your blog's sidebar code:

The entries so far can be viewed here.

Friday, November 13, 2009

Problems With Low-Energy External Defibrillators?

Seems the FDA wants to know more:
FDA is investigating energy levels in (automatic) external biphasic defibrillators (AEDs) with shocks ≤ 200 J. FDA has received reports of 14 events since 2006 in which a 200 J biphasic defibrillator was ineffective in providing defibrillation/cardioversion therapy to a patient, whereas a subsequent shock from a different 360 J biphasic defibrillator resulted in immediate defibrillation/cardioversion. The majority of events occurred during attempts at cardioversion of atrial fibrillation, but there was at least one instance with defibrillation of a ventricular arrhythmia as well. FDA is seeking additional information in order to interpret the significance of these events, and to determine whether FDA activities are advised.
I haven't seen this, but others may have, so let 'em know.


Waiting, and Hoping, For a Heart

A patient, recently listed for cardiac transplantation, tells his story about being rejected, then accepted, to the cardiac transplantation list:
Next week, I'll check into Mayo, one of the world's premier hospitals, to undergo additional treatment in preparation for receiving a new heart. Since my brain tumor turned out to be benign and my prostate cancer has responded to treatment, doctors there said those issues no longer should disqualify me as a candidate for a heart transplant.

Now that I'm on the list, I am on an around-the-clock standby alert. I have to be ready to be on the operating table within four hours once a compatible heart becomes available. The fact that Chicago is 331 miles from Mayo, in Rochester, Minn., complicates things since I don't have my own charter jet. But the Mayo Med Air charter service could assist me if a commercial flight can't get me there quickly enough.

The challenge now is the wait. The heart I need will become available only when the donor is declared brain-dead and his heart can be taken from him and implanted in me within four hours. I am told the fact my blood type is B positive increases the chances of me getting a transplant quicker, though there are other patients ahead of me.

I had wanted it all to happen at the University of Chicago Medical Center, where world-renowned Dr. Valluvan Jeevanandam, who performed a triple-bypass on me in 2001, has done more than 1,000 transplants. But that hospital takes a more conservative approach to the fact my prostate cancer still is in remission. They wouldn't put me on the transplant list until I had been using an implanted heart pump ''for several years.''

Fortunately, the Mayo Clinic and Northwestern Memorial Hospital feel I have progressed enough in my recovery from the slow-growing prostate cancer to be eligible for a heart now.
With the competetion for patients underway as the large health care system land-grab extends across state lines and overseas (See here and here), have the selection criteria for transplant patients remained a form of rationing or really become a form of marketing?

I wonder.


Thursday, November 12, 2009

How to Find the Arrhythmia Patient's Room

When it's 1:00 AM and you're not sure where the patient with incessant ventricular tachycardia is located in the ICU, just turn to the telemetry strips:

Click image to enlarge


Need a New Medical School?

... just be a holdout on the vote to approve the House health care bill:
In a statement, Costa said he succesfully negotiated funding for a UC Merced medical school.

"I am voting for HR 3962 because the choice of doing nothing was not an option. During my negotiations to help improve the bill for our Valley, I was able to achieve funding for a medical school in the Valley, with studies at UC Merced and residency in Fresno, as well as additional incentives to bring health professionals to our Valley. Increased funding in this bill for programs ranging from nurse training to health career opportunity programs to community health centers and increased reimbursement rates for low-paying Medicaid will go a long way in strengthening our health system in the Valley," Costa said.

The bill, HR 3962, passed the House of Representatives with a vote of 220-215.

Cardoza said the bill directs $167 million in health care funding to hospitals in his 18th district alone. The district includes parts of Fresno and Madera counties. But Cardoza said he still has concerns about the cost of the bill.
I love the last sentence: "... and he still has concerns about the cost of the bill."

Yeah, right. And if you believe that, I've got some oceanfront property in Arizona I'd like to sell you...


Frontloading Surgical Performance

I must say, in all the years I have been practicing medicine, I have never seen a "thank you" gift delivered before surgery, but recently, our team got delivered this:

Click image to enlarge

Needless to say, I was floored.

But then I read the note, which was priceless:

Click image to enlarge

Fortunately, all ended well, and no "oops" were had.

But talk about the pressure to perform well!



Wednesday, November 11, 2009

The House Health Care Bill and Bureaucratic Duplication

I don't mind health reform. In fact, I believe we need it. But when reform bills fund projects that already exist, or fund special projects for other non-health care professionals, like lawyers, I have to wonder what Congress is doing.

The recently passed House bill (H.R. 3962 pdf) contains a multitude of grants and "demonstration projects." I wasn't sure what some of these grants were meant to support, so I looked them up. I was surprised to find that many of the grants duplicate programs or departments already in place. While this list is by no means comprehensive, I thought I would provide a few comments on a few of these grants shown in italics):
  • Grant program for "community-based collaborative care"
    (Seems this is really a grant to fund telemedicine programs and HL-7 hospital coding standards so computers can talk together. While ultimately this should be a good thing, the grant actually has little to do with collaboration of health care in the community right now.)

  • Grant program to develop infant mortality programs
    (Why is more money needed when a department already exists for this?)

  • Grant program for reducing the student-to-school nurse ratio in primary and secondary schools
    (Forget teachers, stick with nurses for schools I guess)

  • Grant program so "No Child is Left Unimmunized Against Influenza"
    (And yet, I'm sure we'll soon have a Pay for Performance measure for that)

  • Grant program to implement medication therapy management services
    (Once again, never mind this has already been done)

  • Grant program for community-based overweight and obesity prevention
    (been there, done that, but it seems we can never get enough of this.)

  • Sec 2221 (pg 1246) Grant program for nurse-managed health centers
    (APN's doing "primary care." Can't help wonder why the AMA loves this bill. Where's there support of what we do?)

  • Grant program to support demonstration programs that design and implement regionalized emergency care systems
    (already being done in certain communities. The natural question is how much money is anticipated for the multitude of communities in need.)

  • Grant programs to prepare secondary school students for careers in health professions
    (What ever happened to "Career Day?")

  • Grant programs for community prevention and wellness research (What is "wellness" anyway?)

  • Grant program to promote positive health behaviors in underserved communities
    (Sounds like attitude adjustment training: "Don't worry, be happy," I guess. Interesting that Senate Bill 319 already addresses this for women and children. Men, it seems, don't matter.)

  • Grant program for state access programs (These grants already exist, too!)

  • Grant program for national independent monitor pilot program for skilled nursing facilities and nursing facilities
    (What is this? An independent monitor to "oversee" large chains of skilled nursing facilities for some defined period of time. What about Medicare's Nursing Home Compare program?

  • Grant program for training in dentistry programs
    Already exists

  • Grant programs for innovations in interdisciplinary care (Yep, got this in place already, too)

  • Grant program for health insurance cooperatives
    (Helpful cash for insurance interests

  • Grant program for wellness programs to small employers
    (I can hear it now: "Don't drink, eat or smoke too much..." and place some nice posters on your wall...)

  • Grant program to disseminate best practices on implementing health workforce investment programs
    (A bill already exists on the House floor: H.R. 2810)

  • Grant program for national health workforce online training
    (looks like medical schools might be in trouble!)

  • Grant program for state alternative medical liability laws
    (a grant to see if liability reform might work - fair enough - but will it change anything?)

  • Grant program for public health infrastructure
    (um, don't we already have an Office of Public Health and Science?)

But the "demonstation project" that was created specifically for lawyers: Section 2537 (pg 1464) - a demonstration project of "grants to medical-legal partnerships" was most concerning.

What's this you ask? Is it for health care?

Not really. It's actually a grant just for lawyers who practice poverty law so they can "assist patients and their families to navigate health care-related programs and activities" for the next five years. Never mind that's why we have doctors, nurses and social workers.

Bottom line, there are plenty of places this bill could (and should) be cut to save costs.

But hey, when it comes to health care reform, it seems there's something for everyone when the taxpayer's paying!


Tuesday, November 10, 2009

Quiz of the Day: The Distance Traveler

Q: What's a hundred years old and has traveled over 5 million miles?

A: Would you believe a basketball?


Where Treatment Guidelines Fall Flat

... when cases don't follow the rule book:
All of the planned means of tackling Stellan's SVT today during his ablation failed initially. Heart block was induced each and every time from each and every angle they tried to ablate. Dr. A and his team were left with little choice but to ablate Stellan's AV node in order to get rid of his accessory pathway. But before they did, one of Dr. A's colleagues threw out a wild idea.

"Let's try to go through his aorta."

Not in the plan. Not even in the possible or hypothetical plans. Not considered safe or feasible or wise on a 10 kilo baby. But with few options left before destroying Stellan's node, they decided to risk it.

To be honest, I'm glad I didn't know about it at the time.

So from his groin, they threaded the catheter up into his aorta, down into his atrium and through his valve toward his ventricle. From that angle, even though Dr. A said they were in the exact same spot as they'd tried ablating earlier, there was a money shot. He tried cryoablation. It started to zap his SVT with no heart block. So he tried a little more cryo. Again, no heart block.

So Dr. A pulled out the big dog. The radio frequency ablation catheter. His ultimate goal was to get 2 to 3 seconds of ablating done, even if it destroyed his node.

1 second. 2 seconds. 3, 4, 5.

From that angle, through the aorta, Stellan's AV node remained untouched.

Unbelievably, Dr. A was able to crank up the wattage and ablate Stellan's extra pathway for one solid minute before declaring his pathway dead on arrival.

And his AV node is as happy as the day is long.
Certainly this case didn't "Get With the Guidelines" and might not be the approach most would take in this circumstance. Huge risk was involved for the pediatric electrophysiologist: a higher incidence of stroke for the child, unknown long-term affects to the aorta, a potential to injure the coronary arteries, and a large risk to one's professional career if anything went wrong.

At yet, the doctor considered all other options and did what he thought was best for the child given the circumstances...

... then hit a home run.

And judging by the picture of the child in the referenced blog's sidebar, it looks like the doctor did a pretty fine job.


h/t: A faithful reader.

Sunday, November 08, 2009

Bloggers Can Make a Difference on Veteran's Day

Meet the Eleven Eleven Campaign -- a nationwide campaign by to change the way America honors its Veterans by hoping to raise $11 from 11 million Americans beginning (when else?) but November 11th.

To learn more about the campaign and how you can help make this November 11th a day when bloggers come together to support our Vets, join the conference call Monday, November 9th at 8 pm ET/7 pm/CT/5 pm PT.

Please RSVP to the conference call here:

Dial-in Number: 1-213-289-0500

Participant Access Code: 4670471


h/t: Glenn Reynolds at Instapundit.


House Bill 3962 passed by the narrowest of margins.

I find it interesting that when others parse the implications of the bill's passage, doctors aren't mentioned.

Kind of says it all.


Saturday, November 07, 2009

Criminal Penalties For No Insurance Possible Under Pelosi Bill

From a letter from the the non-partisan Joint Committee of Taxation from Rep David Camp to explain penalties for not carrying insurance under the Pelosi Bill (H.R. 3962):
Americans who do not maintain “acceptable health insurance coverage” and who choose not to pay the bill’s new individual mandate tax (generally 2.5% of income), are subject to numerous civil and criminal penalties, including criminal fines of up to $250,000 and imprisonment of up to five years.
Is this what American's want, criminal penalties including jail time?

If not, I'd suggest you call, fax, or e-mail your Congressman today.


Reader Poll: Should House Health Care Bill Pass?

With the US House of Representatives set to vote on the ‘‘Affordable Health Care for America Act’’ (H.R. Bill 3962) this weekend, should the bill pass?

Vote in the sidebar and feel free to leave any comments you'd like to make below.


P.S. I'm not tracking URL's nor marketing - promise - just interested what others who read this blog think.

Friday, November 06, 2009

Cardiology Consolidation Continues

This time, in Kansas City:
Cuts of the magnitude envisioned by Medicare, Holkins said, would present “a significant problem for the revenue side of our business model.”

The 14-physician practice, which has roughly 80 employees, has been independent since its founding in 1975.

So, Holkins said, the decision to affiliate was not taken lightly.

“I have really liked the idea of being independent,” he said. “But I also like to be able to pay our employees well and have enough left so our physician partners make a comparable salary to their peers in Kansas City, and I saw that as something I would not be able to do going forward.”

Reading the Fine Print of Government-Run Comparative Effectiveness Research

This week, the New England Journal of Medicine published the comparative effectiveness research trial "ROOBY" comparing conventional cardiac bypass surgery to off-pump bypass surgery. The study was conducted at VA medical centers and randomly enrolled 2203 patients between conventional bypass and off-pump bypass surgeries. The study concluded "At 1 year of follow-up, patients in the off-pump group had worse composite outcomes and poorer graft patency than did patients in the on-pump group. No significant differences between the techniques were found in neuropsychological outcomes or use of major resources." Excellent reviews of the trial (with associated surgeon commentary) are provided at and at

What I found interesting was the fact that over half of the operations in the trial were performed by surgical residents. (Admitedly all surgeons had to have a minimum experience of 20 off-pump procedures, but the median off-pump experience by surgeons in the trial was 50 procedures.)

I wonder, where were the senior surgeons at the VA?


Thursday, November 05, 2009

Cancer's Miracle

It's a strange thing, cancer.

It renders the greatest intellect impotent.

Families coalesce, grapple, then muster their courage to confront the reality, their angst cloaked in platitudes and favors. Certainly there must be something we can do!

Slow. Gradual. Relentless. And yet it's moving too fast.

I wake at night to my wife's restlessness, the thoughts of her mother circulating. Why her? Why now?

A sniffle, a sigh. There is little I can do.

The relentless march goes on, the cadence quickening.

We realize now what's important; her mother's gifts to us a gem.


One Special Operation

Real life is so much better than Grey's Anatomy.


A Cardiology Fellow Saves a Life on the Subway

Dr. Sonia Tolani, 32, a first-year cardiology fellow at NewYork-Presbyterian/Columbia, notches her belt with another save after 20 minutes of CPR on the subway...

"Stayin alive, stayin' alive, ah ah ah ah..."

Nice work!


Do the Ends Justify the Means?

John Cassidy of the New Yorker thinks so:
So what does it all add up to? The U.S. government is making a costly and open-ended commitment to help provide health coverage for the vast majority of its citizens. I support this commitment, and I think the federal government’s spending priorities should be altered to make it happen. But let’s not pretend that it isn’t a big deal, or that it will be self-financing, or that it will work out exactly as planned. It won’t.

Many Democratic insiders know all this, or most of it. What is really unfolding, I suspect, is the scenario that many conservatives feared. The Obama Administration, like the Bush Administration before it (and many other Administrations before that) is creating a new entitlement program, which, once established, will be virtually impossible to rescind. At some point in the future, the fiscal consequences of the reform will have to be dealt with in a more meaningful way, but by then the principle of (near) universal coverage will be well established. Even a twenty-first-century Ronald Reagan will have great difficult overturning it.
Regretably, this analysis is where we're heading: who cares what it costs, just enact it!

God help us when the check comes due.


Wednesday, November 04, 2009

Health Care Insurance Gift Cards

... for Florida residents, they're just in time for the holidays!
Starting this month you can find these gift cards at any Winn Dixie and in November you can find them at CVS pharmacy stores.

There are two types of gift cards available. One is called "the blue health care card" It acts like a temporary health insurance. For $59.00 it gives you health insurance coverage for one to 2 1/2 months based on your age. Here's how it works. You buy the gift card at the store, and the person receiving the card activates it. Then they enroll in a variety of plans offered. After that, you'll receive a package in the mail with a member id card.

You can use the temporary insurance gift card to see a doctor, a dentist, at the pharmacy, or for lab work.

The other gift card is called the family blue discount card. It's $19.00 but unlike temporary insurance, this one gets you 3 months worth of discounts on dental, prescriptions and vision services.
Just be sure you know when you're going to get sick!


Are Pharmacies Getting Flu Shots Before Doctors?

From the Chicago Tribune:
"I am a pediatrician in suburban Cook County. We signed up to receive the vaccine, and have yet to get it. I hear it is going to go to local pharmacies before we get it. They only vaccinate children 9 and above. ... Who is going to ensure that infants and asthmatics get vaccinated?"
The response from the Illionois Department of Public Health's spokeswoman Kelly Jakubek was telling:
"We currently are only placing orders for hospitals and health departments, which we consider the front line of health care," she said.

Chicago vaccine providers are under a similar system in which the first shipments go to places that serve the most at risk, said Dr. Julie Morita, medical director of the Chicago Department of Public Health. Her department places the orders and selects the providers to get the first H1N1 vaccine shipments.

"Our priority is to get the early vaccine to high-risk providers," Morita said, "and once the majority have gotten vaccinated, then it can go to retail providers. We can't guarantee a limitless supply, so there may be breaks in supplies for a time, and then get orders filled later on."
It is difficult to know whether Dr. Morita bases her decision on places that have a high incidence of the disease (the frequency of development of a new illness in a population in a certain period of time), or a high prevalence (current number of people suffering from an illness in a given period of time). Pediatricians offices might have a high incidence, but very low prevalence, of flu relative to large chains stores, and if prevalence is what matters to the health department (and politically this would seem so), then pediatricians might be last in line for the shots.


Tuesday, November 03, 2009

A Little Electronic Health Record Satire

SEEDIE (The Society of Exhorbitantly Expensive and Difficult to Implement EHR's) (the same organization that certified Extormity) issues it's definition of "meaningful use:"
"What is meaningful use?" asked executive director Sal Obfuscato at a recent SEEDIE executive retreat in Belize. "We believe the question is the answer, as man has always struggled to find meaning in this world."

This insight led SEEDIE to suggest that certified EHR vendors should embed quotes from well known philosophers in their applications. This approach will prompt physicians and other caregivers to actively seek meaning as they document patient encounters.

"When I am treating a patient, a thought-provoking quote from Jean Paul Sartre or Voltaire is far more valuable than the ability to e-prescribe or adhere to evidence-based guidelines," said Dr. Timothy Farragut, a Vermont pediatrician and SEEDIE board member. "You get so caught up in diagnosing a condition that you forget to ask yourself the important questions - why am I here, what does it all mean, can I still make my tee time?"

These recommendations are part of a SEEDIE effort to be designated as an ARRA certification body. "Unlike certification organizations that focus on subjective functional requirements, our innovative approach to meaningful use is focused on a much deeper meaning of the word meaning," said Obfuscato.


EP Woo: Electrohypersensitivity Syndrome

Do you have headaches, difficulty concentrating, insomnia, heart irregularities and headaches, fatigue, poor short-term memory, difficulty sleeping, skin problems, tinnitus, nausea, and dizziness? You might have electrohypersensitivity syndrome, a variant of "cell-tower blues!"

Yep, conclusive data gleaned from a study of twenty-five whole patients out of 100 to be studied has discovered at least one example of a "DECT" (aka Digital Enhanced Cordless Telecommunications in the 1.9-2.4GHz band) cell phone causing increased heart rate and irregularities!

Never mind that actual signals are not included in the data, but only a graph of "R-R intervals."

(Um, in case you were wondering, noise will cause variations in surface EKG signals and shortening of RR intervals.)

But don't pay attention to details. It is now clear that electrohypersensitivity syndrome clearly affects a significant proportion of America's teenagers...