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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 ...

Wednesday, January 17, 2018

Mayo study: higher cardiorespiratory fitness associated with lower risk of atrial fibrillation

Data and analysis continues to address the issue of exercise level and risk of atrial fibrillation (AF)-sometimes referred to as the U-shaped curve controversy.

Hussain et al (1) did a follow-up study on 14,094 selected subjects who had been referred to Mayo Clinic for exercise stress testing. These were from a much larger group from whom those with a history of heart failure, atrial fibrillation or flutter or stroke were excluded.The average follow-up was 14 years and the outcomes of interest were incident atrial fibrillation ,stroke and death.
They divided the subjects into 4 groups based on functional cardiorespiratory capacity as estimated by their performance on the Bruce protocol stress test.

Those subjects in the highest exercise performance category showed no increase in the risk for AF.

The authors concluded:

"...better cardiorespiratory fitness is associated with lower risk of incident AF, stroke and mortality. Similarly risk of stroke and mortality in patients with AF is also inversely associated with cardiorespiratory fitness."

They also commented that the reduction in these risks with increasing exercise capacity  "may be a direct physiological effect of exercise and physical activity or a consequence of a lower burden of cardiovascular risk factors" I would add "or both".

This is  another coarse grain study which will not settle the U shaped curve argument.I think often these "controversies " just dwindle away rather than get settled. The etiology of AF and stroke with AF involves a complex array of numerous possible input variables and here we look at the effect of  only one such variable ( exercise capacity-as a surrogate for exercise level) on the outcome (s) but at least  long time endurance exercisers may find some solace here. Critics can justifiably point out that a number of potentially confounding variables were not available  for analysis including, smoking history,alcohol use,and actually exercise habits.

Again quoting  Simon (2) ".. a man hears what he wants to hear and disregards the rest"

1) Hussain,N Impact of cardiorespiratory fitness on frequency of atrial fibrillation , stroke,and all cause mortality. AJC Jan 1, 2018. vol 121 issue 1, p 41-49

2) Simon, P .Lyrics from the song ,The Boxer, 1969

H/T "notes from DR RW"

Monday, January 15, 2018

Not your father's internist any more

This a very lightly edited version of a commentary that I made 12 years ago. Nothing has happened in the last 12 years to change my views and from the point of view of a very over the hill internist, things are even worse and are not likely to get better.

"The current data are clear.There are fewer docs going into general internal medicine.Lower pay, less prestige are two of the reasons offered and an increasing amount of onerous,often counter productive computer driven requirements may for some be the final straw.

A  "op-ed" like piece in the ACP Observer by the President D. Anderson Hedberg is entitled "Finding the Art within the science of internal medicine". My gut reaction to it is " wouldn't it be nice if it were [still] true.?"The internist he portrays does resemble the internist I thought I was training to be. But I doubt if it is possible to be that type physician today.(see end note )

Dr. Hedberg quotes a 1998 article by Dr. Robert L. Wortmann, chair of IM at the U. Of Oklahoma in Tulsa. Dr. Wortman said the four distinguishing characteristics of internists are: 1) the ability to be a diagnostician ( internists were once called that) who can practice the deductive scientific process that leads to therapy. 2) the ability to provide care of complex acute and chronic problems. 3) the ability to be a consultant for generalists, specialists and subspecialists and 4) curiosity. One comment he made re "curiosity" does resonate with my IM training. He said that to the internist it is important to consider the "links between disease and pathophysiology as well as between the therapy and its mechanism of action"

These comments definitely had more currency at a time when: 1) there was no competition in primary care save for GPs. and there was a clear distinction between GPs and internists. There were no family doctors-from whom the distinction between them and internists is harder now to draw- and no competitor from nurse practioners. 2) there was the reasonable likelihood of being able to spend enough time with a patient to play out those characteristics and patients did not have to be seen every 10-15 minutes to either meet the clinic or HMO quota or generate enough income to keep the practice going. 3) there was no need to worry and try and determine if the recommended therapy was approvable by the HMO, Insurance company or pharmacy management company.4) there was no hospitalists to compete with you. You were the hospitalist. 5) there was time and opportunity to pursue efforts to satiate your curiosity.

Only about 25 % of internists consider themselves general internists and more and more subspecialists refer back to the general IM doc or the FP problems not clearly linked to their subspeciality.Hospitalists are growing in numbers and the arrow points in the direction of at least some general IM docs pulling back from their roles in the hospitals making them more like FPs than internists.

In short, in today's environment how realistic are the comments of the two physicians quoted above? I think not very. I am afraid their comments were more relevant in an earlier era.It is hard to say what are the distinguishing characteristics of internists in the current practice of medicine.
I believe it is a confluence of factors and forces that are leading to the demise of the general internist.

Another major determinative factor is the following:A few decades ago the internist (there was no "general" preceding the designation) was the recognized expert in diseases of the heart, lungs, and kidneys as well as the expert in endocrinology and hematology. Tremendous growth and development of the subspecialist domains of expertise has changed the landscape. Cardiologists are now called in to treat coronary syndromes, pulmonary docs for respiratory failure, etc etc. Oncologists take care of the cancers, kidney doctors the ESRD cases and it is the rheumatologists now giving the disease modifying treatments for rheumatoid arthritis .When emergent or semi-emergent medical issue arise after hours the patient is likely seen in the ER by an ER doc and if hospitalized, then seen by a hospitalist who more likely than not calls in specialists.In short, the areas in which the internist was the expert have largely disappeared and the experts are the IM subspecialists.

To a large degree many internists are left with office treatment of the same conditions managed by FPs and nurse practitioners ( hypertension, type 2 diabetes,annual check ups, elevated cholesterol,URIs etc, annual "check ups" )

How many internists would want their myocardial infarction treated by an internist? I want a cath cardiologist.

end note: I do not deny there are exceptions. I have been a big fan of the blog ," db's medical rants" by Dr. Robert Centor,an academic internist who as best  I  can tell from his writings continues to function in the manner described by Dr. Worthmann.However he does not seem to  work primarily  in a private practice setting the landscape of which , in the last few decades ,has become a completely different game.

Saturday, January 13, 2018

LBBB associated non ischemic cardiomyopathy -more favorable remodeling if CRT started early

 An article by the electrophysiology group at the University of Pittsburg highlights the importance of early CRT in cases of left bundle branch induced non-ischemic cardiomyopathy with heart failure.

 First some background:

The effect of LBBB on ventricular function has been recognized at least since the 1980s and abnormal septal movement  described as  early as 1973 (4). See here for my review of the abnormal cardiac function observed in LBBB.

LBBB induced cardiomyopathy and its potential reversibility by CRT was described at least as early as 2005 in an article by Jean-Jaques Blanc(1). In 2008 Blanc co-authored a chapter on that topic in Barold and Ritter's book  "Devices for Cardiac Resynchronization" (pg 139-145)

In 2013, Vaillant et al (2) described 6 patients with so-called isolated LBBB who developed heart failure and in whom a marked improvement in cardiac function was documented following the institution of CRT.

Wang and Saba et al (3) from Pittsburg studied 123 patients with LBBB-associated idiopathic non-ischemic cardiomyopathy. About half were treated with CRT in less than 9 months after diagnosis and half received CRT after 9 months.

Improvement in left ventricular ejection fraction to greater than 35% was more likely in those who received earlier treatment. The author concluded in part " Delaying CRT may miss a critical period of halt and reverse progressive myocardial damage"

I suggest the importance of this paper is not that earlier is better than later (which seems expected) but rather that,to my knowledge, this is the first paper describing a  large number of patients with  LBBB induced cardiomyopathy   and their response to CRT.Only a handful of patients had been described previously and this article should perhaps serve to make this entity better recognized.

The patients were treated with CRT which, so far, has been virtually synonymous with bi-ventricular pacing (Bi-V). Now , however, more patients are being paced with His Bundle pacing. There is some developing evidence that His Bundle pacing is equivalent in terms of efficacy to Bi V pacing. His bundle pacing certainly seems more physiologic. His bundle pacing is capable of making the abnormal LBBB QRS complex normal or nearly so in the majority of  cases.Alberti et al  (5) from the University of Florence make the case for His Bundle pacing as an alternative to Bi-ventricular pacing in CRT and note the ongoing clinical trial (the HOPE_HF trial)  using His Bundle pacing in CRT eligible patients.Actually in 2015, Lustgarten et al(6) demonstrated an equivalent CRT response
of Bi-V pacing with His Bundle pacing in 29 patients.

All of Wang's patients were treated for 3 months with the  standard heart failure regimen but responded poorly and then with CRT. What about patients who develop "lone" LBBB and have a history of decreased exercise tolerance but ejection fractions still within the normal range? Should the patient be required to have overt HF and poor response to medication before  CRT is considered?

Again a personal note in this regard.  Two years ago  I developed LBBB and my exercise capacity decreased immediately . My echo showed a EF in the normal range ( lower limit) and mitral Doppler flow indicated impaired relaxation and stress echo showed abnormal septal movement. I had also developed an exercise induced high grade second degree heart block and on that basis was a candidate for a pacemaker. I was fortunate to have an EP cardiologist who was doing His Bundle pacing (few were at that time ) and after a series of  uncommon post procedure complications was able to enjoy a return to a level of exercise ability indistinguishable from my pre conduction problems status and I believe avoided the likelihood of a progressive LBBB induced cardiomyopathy.
Three cheers for His Bundle pacing.

1)Blanc J, Evaluation of left bundle branch block as a reversible cause of non-ischaemic dilated cardiomyopathy  with severe heart failure . A new concept of left ventricular dyssyncrhony-induced cardiomyopathy Europace. 2003  7 (6) 604-610

2)Vaillant et al. Resolution of left bundle branch block induced cardiomyopathy by cardiac resynchronization therapy.JACC 2013 vol 61 no 10  pg 1089

3)Wang,NC et al New onset left bundle branch block-associated idiopathic nonischemic cardiomyopathy and time from diagnosis to cardiac resynchronization therapy. The NEOLITH II study PACE 2018 Jan 4

4)Breithandt,G. Left bundle branch block,an old-new entity.J. Cardiovas Tranal Res2012 ,Apr 5 2 107. (authors reference the work of Curtius and of McDonald.

5)Alberti, L Hemodynamics of His bundle pacing. J of electrocardiology 50 (2017) 161-168

6)Lustgarten DL et al His-bundle pacing in cardiac resynchronization therapy patients.a crossover design comparison.Heart Rhythm 2015;12 1548-57

Wednesday, January 10, 2018

The ABIM Foundation, "a foundation dedicated to what?"

Following a revealing blog post regarding the ABIM  by DRWes, a  comment was made by Keith:

" This is what happens when a non profit organization loses site of it's true mission and becomes more focused on the dollars. Looks like they are generating so much loot from their plundering of physicians that they needed somewhere to hide it. Why not create a foundation (the ABIM Foundation) dedicated to what ????"

 So what is it dedicated to?

The key document which outlines the purported current missions of the  ABIMF is the 2002 publication of "Medical Professionalism in the New Millennium:A Physician Charter" .

According to the ABIMF's website: "The Fundamental principles of the charter are primacy of patient welfare,patient autonomy and social justice. "

The first two are long established principles of medical ethics about which there is little controversy  ,but the third is another matter

From a tactical point of view the use of term social justice" has a number of selling points.First, while everyone who would consider themselves progressive (or modern liberals) would support social justice, many of a conservative or libertarian mind set would not. The term social justice is loose and indeterminate and therein again lies is rhetorical value. To many social justice connotes helping the disadvantaged.and  conservative and libertarians are not going to be speaking out against helping the poor etc but differ from progressives in the permissible techniques to bring that about.But to the founders of the Charter helping the disadvantaged  may not be  the driving force.

 We are told that new new medical professionalism is about a "fair and equitable distribution of finite medical resources" and that physicians have an obligation to move toward that goal. At this point readers of the charter might well wonder how, as practicing physicians, how would they accomplish that move.  Well, we are told that physicians can practice cost effective medicine and that may well be best done by following guidelines.In that way they can be the stewards of the finite resources.So it seems that " fair and equitable" corresponds to "cost effective" which for an individual physician that translates to " follow the guidelines"

So  now the bait and switch, the bait is a obligation to promote social justice and the switch is to follow guidelines which is claimed to bring  about  fair and equitable distribution of resources.

Yet you have to ask is this striving for purported social justice the reason for the existence of the ABIMF or  is it to save money for third party payers?ABIM accumulated a significant amount of money by testing internists for board certification and found themselves holding many millions of dollars . This was profit in the sense of receipts greatly exceeding their costs but a non profit does not make a profit by definition even if their monetary intake greater exceeds their monetary output. ABIM itself is a non profit.

Monday, January 08, 2018

Long term trend of where and how decisons are made exemplified is in the House bill health "reform" bill

I continue to be impressed by the depth of the insight found in Thomas Sowell's "Knowledge and Decisions".

Here is my attempt to discuss some part of it that.

One of the major constraints facing human is lack of knowledge for making the many decisions they have to make in the business of living and just getting by.But decisions have to made and analysis of how and where these decisions are made offer meaningful insight into a lot of which transpires.

We can speak of decision making units (DMU) ( my abbreviation) and attempt to examine the processes involved .Much can be learned about that by looking at the incentives and constraints under which the DMUs operate and the extent to which their (its?)decisions and actions are subject to feedback.The DMUs also may vary in the extent to which they engage in incremental trade offs as opposed to categorical solutions.Sowell correctly emphasis that for analytic purposes one should not look at an organization's purported "mission statement" but rather at their incentives and constraints

Sowell contends that over time in the United States there has been a shift in the locus of the decision making.There has been a shift from decisions traditionally made in the home to the school, from businesses to various governmental agencies and to the courts. Further, within government there has been a major shift from decisions made by the legislative branch,concerning which voters have at least the chance of influencing the decisions, to the executive branch with its too numerous to list agencies and departments which are much more immune to the power of the vote and more insulated from public feedback and often given much difference by the courts.

These administrative entities  have  " .... political initiatives and its own external constituencies developed as a results of initial mandate, constantly pushing for an expansion of its activities and benefits." ( from page 318 Sowell, "Knowledge and Decisions" Basic Books, 1980,)

Medical decision making has also migrated from the decisions made by the individual patient physician "dyad" to more central decision making directly and/or indirectly by insurance companies,large medical  practices, pharmacy management companies and HHS.

Sunday, January 07, 2018

"..how little they really know about what they imagine they can design" -Mega medical hubris

Frederick Hayek was talking about the "curious task of economics " That sentiment can as easily be applied to the central planners of medicine. Dr. Donald Berwick has written about the need medicine has for "[wise] leaders with plans".

Five years ago I blogged about the need for a lecture for medical students to underline the dangers of hubris.The type of hubris exhibited by the recently minted expert typically is a self limited affliction as growing experience overwhelms earlier exaggerated estimates of one's knowledge and medical expertise.

Nowhere is hubris more highlighted than it is in those intellectuals who profess to know what it best for others, everyone.This is not the  usually limited hubris of the novice but rather a permanent more exuberant hubris typical of the self appointed philosopher leader who profess to know what is best for everyone as is the case with the spokesmen for population medicine.

The notion of wise leaders with plans ( for others) finds historical precedence in Plato and his advocacy of philosopher kings.

Friday, January 05, 2018

Echocardiography in the elite athletes of the NBA

The stylized athlete's heart is described as having an increased left ventricular end diastolic volume,a thickened left ventricular wall and increased  left ventricular mass.

Electrocardiograph studies have been reported in soccer players and cyclists largely from Europe.It has been recognized for years that different patterns of cardiac remodeling result from various forms of athletic activities typically depicted as the dichotomy between patterns described in  endurance athletes and in  resistance trained athletes.

Recently (1) a large amount of data has been published on US professional basketball players.These were players on the active rosters of all the NBA teams from the 2013-2014 and 2014-2015 seasons. Testing was done at several locations and sent to the cardiology department at Columbia for analysis.

That publication should be of value to cardiologists faced with issues involving cardiac evaluation of basketball players as regards HCM and Marfan's Syndrome.  Sudden cardiac death is most common among basketball players and HCM is the leading cause.

1) Engel , DT Athletic cardiac remodeling in U.S. professional basketball players.JAMA Cardiology 2016:1(1), 80-87