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Is the new professionalism and ACP's new ethics really just about following guidelines?

The Charter ( Medical Professionalism in the New Millennium.A Physician's Charter) did not deal with just the important relationship of ...

Thursday, September 13, 2018

The impressive and alarming success of the American Board of Internal Medicine Foundation

The American Board of Internal Medicine Foundation (ABIMF) is not the largest,most heavily endowed nor the best known of the many non-profit organizations who  function as advocates for various aspects of health care and medical practice. However, its success in promulgating concepts and influencing medical practice and health care seems disproportionately greater than one might expect based on its size. ABIMF's "greatest" achievement is the development and promulgation of the notion of Medical Professionalism and its major tenets: patient welfare,patient autonomy and social justice. The insertion of the later tenet into medical ethics is a major departure from traditional ethics and is destructive to the physician patient relationship

The first two tenets were long standing pillars of medical ethics and practice and dealt with the relationship between the physician and patient but in 1992, their efforts along with the ACP Foundation and a European Group proclaimed that part of medical professionalism included what they believed was the proper relationship between the physician and society

This  manifesto was published in the Annals of Internal Medicine in 1992 in a paper entitled Medical Professionalism in the New Millennium-A Physician Charter. The ABIF has continued after the 1992 paper to promote the primacy of patient welfare,patient autonomy and social justice and to advocate for "a just and cost effective distribution of finite resources".

 The notion of a co-duty,one to the patient and one to society,was not previously a part of western medical ethics.The 1991 edition of the AMA ethical code did not mention social justice or stewardship of society's resources. Cost effective care is the major thrust of the foundation's recent initiative called "choosing wisely" .  By 2012 over 100 other medical professional organizations had signed on to the Charter and education along those lines apparently is taking place in a number of medical school according to a 2012 article in the Annals of Internal Medicine.

It is the ABIM's MOC  ( Maintenance of Certification program ) that has caused the most angst for internists and reliable reports of its very questionable financial activities have triggered an unprecedented uprising  which surprisingly has had more than a little success.( Much credit for this is due to Dr. Wesby Fisher who on his blog has reported activities of the ABIM and the ABIMF that are  egregious and arguably illegal.)

Yet the sea change in the discussion about medical ethics and professional behavior importantly driven by the same folks who gave us MOC  may in the long run be even more damaging.

Thursday, September 06, 2018

Is the minimal level of recommended exercise sufficient to decrease the risk of heart failure?

In January 2017, I posted a blog commentary entitled " The minimum exercise levels of  the 2008 guidelines won't prevent heart failure". See here.

The gist of that commentary   was that the adherence to the minimal exercise levels indicated by the guidelines had been demonstrated by ample epidemiologic studies to reduce the incidence of cardiovascular disease (CVD) but  exercise at that level had not been demonstrated to reduce   heart failure (HF) incidence and that a higher amount of exercise was needed.

Since then I have more carefully studied a 2015 epidemiologic paper  by Pandy,which I had read before but obviously not with adequate attention , and a detailed physiologic comparison of cardiac function by Bella et al  in 4 groups of healthy subjects who varied  in their long term exercise levels to which I also had not paid appropriate attention. 

These considerations   resulted in a major revision my 2017 headline to " Adherence to the 2008 guideline will reduce HF incidence but more exercise will reduce HF risk significantly more"

Note: I have added an addendum to the 2017 posting  stating the headline is simply wrong 

So now to try and clean up the earlier erroneous  commentary .

First a review of some background:

The 2008 US and WHO guidelines recommend a minimum of 150 minutes of moderate exercise per week or 75 minutes of vigorous exercise. This corresponds to 500 MET minutes  per week or 8.3 MET hours .The US panel also said that further gain could be made by increasing that level to twice that amount. Moderate intensity was defined as requiring between 3 and 5.9 METS and vigorous greater than 6 METS.Note-the panel was addressing the risk of cardiovascular disease in general and not heart failure risk per se .

There is universal agreement that aerobic exercise will decrease heart disease risk ( and according to some studies-dementia,some cancers and type 2 diabetes) but there is disagreement as regards how little exercise  might be  sufficient to reduce cardiovascular risk  and how much exercise might be harmful. I leave those 2  questions  to another time.

In regard to HF:

Patel et (1) published a 2013 review of 5503 subjects age 65 and older from the Cardiovascular Health Study .They divided participants into inactive ,low level exercise ( 1-499 METS),Medium (500 to 999 METS )and high was defined as  greater than 1000 METS 

The hazard ratio (HR) for the low group was a non-statistically significant 0.87 (0.71-1.06,p=0.170.
The medium groups HR 0.68 (0.54-0.85)p=0.001
The high group HR 0.60(0.49-0.74, p=0.026<0 .001.="" p="">

Note that  the low and medium groups overlap the 500 level so  no conclusive verdict regarding HF risk reduction with 500 MET level can be made. You can say that the lowest exercise group enjoyed no reduction in HF risk but we do not know how many subjects were closer to the 1 than to the 500 level. We can say that the medium and high level  did demonstrate a HF  risk reduction but can conclude  nothing about the value of exercising at the 500 MET min level,which is the minimal level recommended by the 2008 panel. 

However, from Pandy's 2015 meta-analysis (2) that there demonstrable risk reduction  in HF in a group of subjects exercising at the 500 MET level. The authors examined data that included over 20 thousand HF events among 370 thousand participants in some 12 prospective cohort studies. 

The 500 MET-min  per week group had a reduction in HF risk ( HR-0.9 (0.81-0.92). However, a greater risk reduction was found in the 1000 MET Min per week group ) HR-.81 (0.77-0.86) and even greater reduction 0.65 (0.58 -0.73 ) in the group at the 2000MET min per week which corresponds to 10 hours of moderate exercise per week or 4 times the minimal amount suggested by the 2008 guidelines.

So the epidemiology  data indicate  that the lower level of recommended exercise will cause a measurable decrease in HF risk but in that regard more does seem to be better.Now to consider Bella's (3) physiological data which is consistent with Pandy's analysis.

 The following  2 paragraphs are copied from my earlier blog commentary.

" Dr Paul Bhella and his  associates  did extensive physiological studies on four groups of healthy volunteers over the age of 64. Four groups were designated   on the basis of their exercise history for the preceding 25 years. (not a typo) 1) sedentary-no more than one exercise session per week  2) casual exerciser-2-3 session per week 3) "committed" exercisers-4-5 session per week and 4)competitive master level athletes -6-7 session per week and competed regularly.  All had normal systolic function ( as defined by a normal resting ejection fraction) but groups one and two has decreased left ventricular compliance while the committed and competitive groups had left ventricular pressure volume curves and left ventricular masses similar to young healthy controls. ( see here for my  further comments and a few caveats regarding this paper including reference to Tanaka's work that challenges the notion that long term endurance exercise  does in fact preserve  ventricular compliance)

Quoting Bhella ". . at least 30 minutes of dynamic exercise per session for 4-5 days per week over a lifetime can  sufficiently prevent most of the decreases in LV compliance and distensibility observed with sedentary aging"

It appears that training at triathlon or marathon levels is not necessary to decrease long term risk of heart failure but the exercise has to be persistent. The term "lifelong "used by Bella may be an exaggeration but his subjects had a 25 year history of regular aerobic exercise.

Bella's data seems to confirm the notion that the 2/12 hours per week recommendation just might decrease the risk of HF with the caveat " if done over a long period of time". The same  group has subsequently published data showing that beginning a  more intense exercise program in a person's 60s or 70's will not result in improved left ventricular compliance but , of course, one would expect  health benefits.

I quote a key paragraph from Bella:

"This study's key finding is the novel observation that at least 30 minutes of dynamic exercise per session 4  to 5 days per week over a lifetime can sufficiently prevent most of the decrease in compliance and distensibility observed  with sedentary aging.This finding holds important implications for global health as ventricular stiffening has been implicated in the pathophysiology of many common CV conditions affecting the elderly.

Contrary to my earlier commentary the minimal levels of exercise may well be enough to decrease the risk of HF but exercise at about twice that levels is likely to bring about a more significant reduction. Note that Bella's comment of 30 minutes 4-5 days a week corresponds to the minimal recommendation of 150 minutes of moderate exercise per week.

1)Patel,K et al Prevention of heart failure in older adults may require higher levels of  physical activity than needed for other cardiovascular events.Int j Cardiol 2013 1905,-1909.

2)Pandy, A Dose Response relationship  between physical activity and risk of heart failure.A meta-analysis. Circulation 2015 132 1786-1794

3)Behlla,P Impact of lifelong exercise "dose"on left ventricular compliance and distensibility. JACC 64 1257-1267 2014  

Wednesday, September 05, 2018

Does the notion that people have a duty to be healthy shatter traditional medical ethics

First lets define what we mean by traditional medical ethics.This would include the medical ethical precepts that constituted medical ethics before the announcement of the "New Professionalism" by the ACP and others. Basically and stating it informally it is that the physician has a fiduciary duty to the patients, and he should place the patients interests before his and of course first do no harm.

Keeping those precepts in mind, consider the following statement which is typical of a growing trend in medical commentaries .

People ( patients) have a duty to be healthy ( practice "healthy behaviors" and eschew "unhealthy behaviors") and comply with medical advice for the good of healthy population.

Drs. JF Wharam and D. Salmasy, writing in the Jan. 14,2009 issue of JAMA. In their discussion of P4P arrangements they state:

...policy makers, health care executives,disease advocates, and scientists with clinical or epidemiological expertise effectively choose population-level goals and thus impose obligations in a manner that
might ( my italics) infringe on patient and physician autonomy. Without fair deliberation,such goals, however wise, cannot claim legitimacy

I suggest that the word "might" be deleted from the above quote. It will infringe. Further, it is not clear what would constitute "fair" deliberation.When someone begins to talk about being fair,watch out.So with "fair deliberation " such claims ( if wise) are , according to the authors therefore  legitimate.

When physicians get some of their income by meeting certain population based goals( e.g. have x% of patients with a hemoglobin A1c under some number) patients who might seem to eat too much or not always take their medicine or whatever else might  be perceived  by the physicians as getting in the way of the population based goals and keeping  the doc from her bonus.Again it is issue of serving two masters,the real life patient in the exam room  versus some insurance based collective construct.

Friday, August 10, 2018

Many Kudos for the anti-MOC warriors and glimmers of hope

Dr. Wes Fisher ,an EP Cardiologist from the Chicago area, has waged what was  for a long while a
one man crusade about the questionable activities of the American Board of Internal Medicine and its own foundation the ABIM foundation and the harmful effects of  their maintenance of certification  (MOC) program. I have blogged a bit about that before and now a number of other physicians have joined in the fray.

Now it seems his prodigious work in that area is beginning to pay off.He recently took part in a very instructive  podcast with Dr. Michel Accad. Fisher is now working with a law firm doing preliminary work hopefully leading to a law suit against the ABIM possibly involving anti trust  issues and fraud.

Money is need for the litigation to move forward.To aid in that effort , Dr. Accad has offered a copy of his brilliant book, "Moving Mountains" to folks who contribute to a fund for the litigation.

Go to the pod cast to learn in details about the antics of the ABIM that catalyzed Dr. Fisher's efforts. See  this link for episode no. 17 of the Accad and Koka Report and links are available there for a GoFundMe link for Fisher's law suit and to the organization he founded, Practicing Physicians of America.

Incidental note. For the last 2 days I have been unable to link to Dr. Fisher's website. I enter drwes.blogspot.com and am diverted to www.widgetserver.com .I was able to backdoor into his site from his Twitter feed.Has his web site been hacked? Coincidence? Addendum , two days later Dr. Fisher's web site was up .

Thursday, July 12, 2018

How well do the Echo guidelines work to estimate cardiac filling pressures ?

Elevated filling pressure is thought to define heart failure as it is thought to be the driver for exercise intolerance and shortness of breath.

Filling pressures can be invasively determined by catheters in either the pulmonary artery wedge position or in the left ventricle.

One of the major aims of echocardiography is to provide reliable estimate of filling pressures .It is generally accepted that echocardiographic indices are more effective in determining  filling pressures in patients with reduced ejection fraction (EF) and is more problematic in patients with preserved EF

The 2009 echo guides  for determination of diastolic function were revised in the 2016 guidelines and both  have been the target of some criticisms.

IMO a 2015 article ( 2) from the Cleveland Clinic offers data that raises reasonable concerns about the estimation of filling pressure in patient with preserved EF.It should be noted that the classification system of degrees of diastolic dysfunction (DD) used by the authors is not the exact system proposed by the 2016 guidelines. but rather those of the 2009 guidelines.(1) and the authors' criticism relate specifically to the 2009 system.However I believe their conclusion ( see below) regarding the basic underlying paradigm holds regardless of tweeks made to the 2009 guidelines.

The authors reviewed 460 consecutive patients who underwent echocardiography within 24 hours of elective left heart catheterization.

Their figure 5 plots left ventricular diastolic pressure (LVEDP) against normal and the 3 grades of DD in patients with EF greater than 50 % and those with EF less than 50%.In both groups there was no difference in LVEDP between normals and those with Grade 1 and Grade 2. The only statistically significant difference was that between normals and those with grade 3  DD who had EF less than 50%.

The authors conclude: "the findings of this study question the notion that DD is a predictable, progressive process beginning with impaired relaxation followed by reduced compliance and increased filling pressures. The prognostic value of echo graded DD may relate more to its reflection of intrinsic properties of the left ventricle, or to exercise hemodynamics  than to its correlation with resting hemodynamics alone. "A Mayo Clinic study  of 467 patients ( 3) by Kane et al found  no higher pulmonary artery systolic pressures at rest  or on  exercise in those patients with the echo diagnosis of impaired relaxation.

 1) Nagueh, SF Recommendations for the evaluation of left ventricular diastolic function by echocardiography. J Am Soc Echo 2009, 22, 107

2) Grant A, Grading diastolic function by echocardiography:hemodynamic validation of the existing guidelines. Cardio Vascular Ultrasound 2015.

3)Kane, GC et al Impact of age on pulmonary systolic pressure at rest and with exercise.Echo Research and Practice, 2016,3(2) 53-61

addendum 8/1/18 spelling errors corrected and several poorly worded sentences revised.

Sunday, July 08, 2018

The great social justice bait and switch courtesy of ACP,ABIM and RWJF

Certain members of the leadership of the American College of Physicians,the American Board of Internal Medicine and the Robert Wood Johnson Foundation authored a manuscript designed to permanently change the physician patient relationship.The paper is entitled "Medical Professionalism in the new millennium: A Physician Charter.",.which I will refer to in this commentary as "The Charter" .  It was a project of  the  foundations of the ABIM and ACP and the European Federation of Internal Medicine.See here for the document.

The documents simply asserted that physicians are the stewards of a [collectively owned] store of medical resources and that physicians have a professional obligation to work for social justice. While they did not explicitly deny the fiduciary role of the physician to the patients in effect  they declared that there was a co duty to conserve the "limited" medical resources as well as the duty  to the individual patient.Contrary to the biblical warning about serving two masters the Charter's authors urge a stewardship of medical resources which subsequent publications by ACP,ABIM and others  said will best be made operational by physicians  following guidelines.

In my opinion this publication is a poster child for the use of gratuitous assertions.

Quoting from the Charter" essential to the contract [medicine's contract with society] is the public trust".

The Charter was published in the Annals of Internal Medicine  and Dr. Harold Sox, the then editor of the Annals of Internal Medicine, offered an introductory commentary. He said in part "the condition of Medical Practice are tempting physicians to abandon their commitment to the primary of patient welfare....the Charter call physicians to promote fair distribution of health care resources"

 I suggest that the choice of the words "primacy of patient welfare" is significant in the omission of the modifier "individual" in front of the word patient. Subsequent promotion of the Charter has made it clear that patient welfare will be defined in terms of the aggregate not in terms of the individual patient.  A subsequent publication ( JAMA: November 13,2013) by Dr. Sox advocating  "population Medicine " made it clear what type of patient welfare Dr Sox favored. See here.

A brief quote from Sox; "

"Perhaps the de facto organizing principle for US health care,approaching each patient strictly as an individual is obsolete.The population health approach is an alternative." (I have added the bolding)

Dr. Sox makes explicit what is hinted at and glossed over in the charter,namely the sacrifice of the individual to the group, the individual patient to the aggregate, or at least  to some aggregate metric claimed to represent the good of the group.

 The charter promised social justice and operationally that has been translated to following guide lines based on alleged aggregate benefit.

Friday, July 06, 2018

Medicine is increasingly dominated by collectivist ideology.

This commentary title is an truncated and slightly altered version  of the following quote from the brilliant essay by Dr. Michel Accad. "Medicine today is dominated by the collectivist ideology" . See here for the reference to his 2009 contribution. 

This is a theme I have thought and fretted about far too much.Many of the thoughts I have mulled over and occasionally expressed in this blog are far better expressed in Dr. Accad's essay. Here is a sample;

"In the broadest sense, medical collectivism is the belief that medicine cannot be left to voluntary and unrestricted transactions between individual patients and individual healers but must be improved, directly or indirectly, by the hand of government."

and another.

" Individuals and populations ,patients and society are conveniently conflated as a matter of fact."

And here is the real money quote.

"..hoodwinking physicians into practicing population medicine is of course the essential means to confuse practitioners into thoughtlessly carry out sweeping interventions whose primary benefit is the profit of third parties."

Docs who were trained in my era ( I know that was a long time now-MD-64) learned that the principle ethical precept was do what was right for the patient and there was ,with few exception.s no other obligations.  What was definitely not on the table was the notion that physicians had an obligation to conserve the nation's medical resources. Social justice was not on the table.

I believe the metaphor of the Bootlegger and the Baptist captures an important aspect of what is happening in  medical practice in the United States.

I do not envision a wide spread plot or conspiracy of third party payers and academic physicians and leaders of major medical professional organizations meeting regularly to further their long term dream of finally taming the physicians and disabusing them of their traditional role as a fiduciary of their patients. However, the third party payers certainty welcome the efforts of the academic medical elite in that regard and some times welcome them into their ranks .

The Baptists in this conception are those physicians who sincerely believe that in the age old conflict between the interests of the individual and those of society as a whole that the trump card would be held by society.The Bootleggers are the third party payers whose bottom line increases in proportion to the acceptance of those views.