Featured Post

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, May 16, 2019

Does a high coronary calcium score in long time endurance athletes mean greater mortality

Another article (2)  has  been published regarding the proposed relationship between high level endurance exercise and coronary calcification.

 We get this comment from the chief science officer and CEO of the Cooper Institute , Dr. Laura DeFina :

" The key question addressed in the present study was whether the presence of a high CAC associated with high levels of exercise training as typically practiced by masters marathon runners is associated with greater mortality.For this question,the answer is clearly no"

During times when I am influenced by Lily Tomlin's observation (1) I tend to think - perhaps unfairly-of studies such as these as coarse-grain,multi-comparison, big "n" small "RRs" fishing trips.

It is big n  study with 21,758 men followed for about ten years. The significance of n size is that with large numbers,small differences may be statistically significant but not clinically important. The point of saying multi-comparison is that sometimes researchers will do many regressions that may or may not be mentioned in the article searching for a p value of statistical significance. ( I ,of course, am not accusing authors of this article with that practice.)This article cannot be considered fishing as earlier work has suggested that high or very high levels of endurance exercise are associated with more coronary calcification but no increase and possibly a decrease in cardiac disease mortality.This article seems consistent with that notion.

We also get this quote from Dr. Carl Lavie : " Despite the fact that this type of high volume physical activity and exercise may promote calcific coronary atherosclerosis, it appears to still be associated with safety and possible lower mortality risks" Dr. Lavie has written several articles with Dr. James O'Keefe arguing that some relatively low level of exercise described as "excessive" would increase one's risk of death but has subsequently softened views what is excessive.

The analogy with the more potent statins and more coronary artery calcifications and lower C-V mortality seems obvious

1) Lilly Tomlin: No matter how cynical you become its never enough.

2)DeFina, LF et al ,"Association of all cause and cardiovascular mortality with high levels of physical activity and concurrent coronary artery calcification. JAMA Cardiol 2019 4 (2)174

Saturday, May 11, 2019

Is it possible for experts to determine objective high value health care

Is value objective or subjective?

A common, though oversimplified and exaggerated view,  is that Adam Smith was the father of economics. His views were published in 1776 in his Wealth of Nations.He along with several other early giants of classical economists,David Ricardo,John S. Mill, promoted the Labor theory of value. Karl Marx continued that line of thinking in 1867 in his magnum opus Capital  in which he said " If a pair of shoes usually takes twice as long to produce as a pair of pants,for example then..the competitive price of shoes will be twice the price of pants."

Lawrence H, White , in his book The Clash of Economic Ideas talks about what he describes as the fundamental flaw in the labor theory of value is "its supposition that the price of a good reflects an intrinsic feature of the good,...rather than something in the minds of its buyers". The belief was that input costs determines the selling price rather than the reverse.

It was not until 1871 that the labor theory  of value was displaced by what is known as the subjective or marginal utility theory of value. Karl Menger one of the three co-founders of this idea,who worked independently, said in his Principles of Economics , "Goods always have value to certain economizing individuals and this value is also determined only by those individuals."

Simply put the value of a good or service is the subjective evaluation of the buyer.

In fact,it is this subjective value that underlies exchange-Fred values the apple more than dollar he give the grocer who in turn value the dollar more than the apple.Both party typically thank each other as exchange is mutually beneficial.

So since the late 19th century economists of almost all stripes have agreed that value is subjective.
If this is the overwhelming consensus views of economists what is the rationale or justification for organizations such as the American College of Physicians and others to  claim to be able to determine which medical procedures and treatments are "high value". Are they claiming that value is objective,that they can determine scientifically the real value,and further determine which value are high enough to merit the designation "High value"

First how is value determined by health outcome experts and how is a value determination judged to be "high". Is the process objective and scientific all the way down or is it the case that at some point someone's subjective value is inserted .

Through clinical research it is possible to determine if the outcome of treatment X versus treatment Y is better in terms of survival.So one could talk about life years saved by treatment X versus treatment Y-this is clinical effectiveness research.X is better-more effective than Y in terms of simple survival. But to determine value cost has to be injected into the analysis.How much did X cost versus how much did Y cost.,then one could look at life years saved per dollars and compare X  and Y in that way.

Obviously  years lived  per se is not the only relevant outcome to consider.How one lives (pain,mobility,level of cognition etc) are all important and those and other elements are lumped under the heading "quality of life" (QOL). Measuring quality to transform life years into quality adjusted life years is a difficult and ambiguous slippery  area and we will defer a discussion about whether than can ever be done for later but for discussion we'll assume that something called quality adjusted life years(QALY) can measured. (I seriously doubt that it can be measured  because in part I do not believe you can aggregate quality of life.I doubt that it is meaningful to add Frank and Fred life quality of life and transform that some aggregate of quality years.)

After the QALY are determined for procedure X and Y then in theory one can sum the cost of the two procedures and then derive a ratio of QALY s per dollar spent. Ignoring for the moment the difficulties and ultimately the arbitrary nature  of teasing out cost from charges in the context of what is certainty not a free market unencumbered by price control  but rather one whose costs exist behind a veil of various variable negotiated prices between providers groups and third party payers with an even more opaque series of subsidies and discounts.

When you brush past the bewildering display of statistical artifacts and step to view the overall landscape what you see is another utilitarian procedure. Some new wine is there but the bottles are stamped underneath with the imprint  "utilitarian analysis" A joint resurrection of Benthams "greatest good for the greatest number." in the form of a cost benefit analysis done in the tradition of and with the tools of Neo-classical economics.

Tuesday, April 09, 2019

Has the movement to debase medical ethics become a done deal now

In 2013,  when I posted the essay found below in a slightly revised version found ,there was still considerable resistance to the "New Medical Professionalism" which had been introduced in 2002 by the American College of Physicians and the European Federations of Internal Medicine. and published in the Annals of Internal Medicine in an article entitled  "Medical Professionalism in the New Millennium: A Physician's Charter." Numerous medical blogs protested and there was some public debates.Now I find little comment or concern about what I believe was a effort to destroy traditional medical ethics.
Here is my earlier essay entitled "The Great Linguistic Coup of 21Th Century Medical Ethics"

"George H. Smith in his book "The System of Liberty" in the chapter entitled "Liberalism,Old and New" discusses how the concept of liberalism and its advocates were victims of a linguistic coup in the latter part  of the nineteenth century.

 The classic liberals considered freedom as the absence of coercion.They championed   limited government whose function was to secure the rights of individuals.Enter a group of thinkers who proposed a " new liberalism" , one that would,in their view, correct this inadequate,limited definition of freedom.To the newcomers liberty without equality was freedom in name only  and true freedom involved equal opportunity and power to enjoy one's life. They wanted to replace the idea of "negative freedom" of the classical liberals with what would become  the focus  of  the welfare state.True freedom in their view was more than mere removal of compulsion or coercion.  The new liberals were paternalistic and believed  the state should do much more than secure the people from internal and external predators but rather protect them from the effects of their own uncoerced actions.The classic liberals defended their position in part by asserting that the new liberalism was old wine in new bottles, with the wine being advocacy for a paternalistic government.The new liberals continued to dispense rhetoric that seemingly supported liberty but they had redefined the word liberty.

The new liberals won the day and the old or classic liberals lost much influence  but re-appeared in the 20th century with a new label, libertarian. The new liberals were simply known as liberals and later referred to by some as progressives.

I argue analogously that the traditional ,classical medical ethics and its advocates ( physicians themselves) were victims of a similar linguistic coup. Throughout most of the 20th century and earlier the core of medical ethics was primacy of patient welfare and respect of the autonomy of the patient,the later gradually replacing an older paternalism of medicine.Physicians were considered to have a fiduciary duty to the patient.

At the end of the 20th century and the early years of the 21th century a new medical ethics emerged,one in which -while  its proponents claimed nothing had really changed-there was a radical sea-change in regard to the duties of the physician.This was accomplished by nothing more rhetorically solid based  or intellectually justified  than a simple gratuitous assertion.The notion of social justice was simply declared to be part of medical professionalism and medical ethics.The degree to which this bogus concept has been accepted and endlessly repeated in medical publications is a tragic shame.The victims of this linguistic coup are the physicians themselves but to a greater degree the patients are the real losers as they have lost their advocates at a time when they may need them the most."

Monday, March 25, 2019

Will the quality crusade be the final corruptor of the medical record?

 File this under "The corruption of the medical record".

  The topic today is the " After visit summary"(AVS).

In my case this was a collection of mistakes,misstatements and falsehoods all neatly printed out in a manner that  may facilitate the physician getting credit for various quality measures.  After reading the AVS I asked myself do I really want a serious medical problem that I may develop to be  overseen by someone who signs off on such a pile of crap.

Recently I saw my primary care physician (PCP) for an annual check up.

Several aspects are worth a blog entry. Today it is the "After visit Summary" (AVS) which was available the next day on the practice's web site .Actually it is the hospital web site's patient portal,
This group of internists is "hired" by the hospital under the guise of being a practice group somehow affiliated with the hosptial.

Mt particular  AVS is a sleek  , multicolored document replete with little icons by such entries as your weight (icon of a dial),pulse ( icon of a valentine style heart). etc.

Under the "Today's Visit" we see small head shot photo of the physician and a listing of the addressed issues.This was a collection of mistakes,misstatements and outright falsehoods which are now part of my permanent record.

I was said to have atrial fibrillation. I do not have AF. The diagnosis of AF was erroneously placed on the  chart by the EP clinic but was later ( 8 months) corrected and removed from by problem list. I mentioned to my PCP that do not have AF and that the earlier entry was the results of a error in the EP clinic.This was the second time I explained about the diagnosis of AF to him and his scribe.

I was also said to have "osteopenia of both hips" .WTF. I have had no imaging of my back or hips at that facility .

I was said to have "hypercalcemia"  and "hypergammaglobulinemia "When  first seen by this PCP one issue was a metabolic profile done by my previous PCP that was stuffed with errors, namely elevated, calcium,elevated K and elevated globulin ( all likely the results of hemolyzed blood sample). These were all repeated and found to be normal but some how the diagnosis of hypercalcemia and elevated globulin level remain.

Nevertheless, on my AVS I was told that those issues were addressed.

What is the AVS all about? it is about "meaningful use".It is one of the eligible professional meaningful use core measures. It all began in 2009 with the HITECH act that was designed to "encourage physicians" to use an EHR.There were monetary carrots and sticks. Neither of which seem to me to be much more than chump change particularly after considering the care and feeding of a EHR .

Kaiser Health News and Fortune Magazine have a detailed article describing what a utter disaster the EHR has become.The title is "Death by A Thousand Clicks"

Monday, March 18, 2019

Recent changes in AHA/ACC atrial fibrillation guidelines

One of my favorite EP cardiologists, Dr. John Mandrola,gives his thoughts regarding the 2019 focused update on  atrial fibrillation (AF)  from the AHA/ACC ,Heart Rhythm Society task force.

Here are some of the highlights and the entire article by Mandrola (full text is available) is recommended.

Aspirin is no longer recommended for low risk AF patients. As Mandrola says , just like that, without much of an explanation .

Both the FDA and CMS have approved percutaneous left atrial appendage closure with the Watchman device  and the panel gives it. a class 11b recommendation. Apparently, the panel did not see fit to comment on the 4% risk of device associated thrombosis reported with Watchman.

DOACs now is  officially preferred over warfarin. Not mentioned by Mandrola is the observation that the fewer strokes with DOACs versus warfarin is driven by the fact there  are fewer hemorrhagic strokes with DOAC while there is little if any difference in the number of ischemic strokes.

The task force stated that female sex alone is no longer considered  a risk factor  for stroke in an AF patient per se.

The guideline writers gave a class 11 b (additional studies are need-procedure may be considered) recommendation for AF ablation in heart failure.Mandrola believes the data supporting AF ablation in HF patients is sufficient for the panel to have given a higher recommendation quoting the positive results of the CASTLE-AF trial that showed a 12% absolute risk reduction in death and in heart failure admissions in the ablation cohort.

Mandrola shares my views on the CHA2DS2VASc score . It is "simple to use , but at its core distills a decidedly continuous risk for a future event down to an integer." He references D. R. Quinn's 2017 review of 34 studies of AF ( reference can be found in Mandrola's review) that illustrate the large variation in the baseline risk of stroke in untreated AF patients. Quoting Mandrola " Translation: We have no idea of the risk in untreated patients.",and yet every day cardiologists and other docs crank out the CHA2DS2VASC and mater-of-factly tell their patient that they have x% annual risk of stroke and suggest how much that risk will be reduced by oral anticoagulation.

I have written about Quinn's study before and quoting from Quinn's article "' The majority of cohorts did not observe stroke rates that would indicate a clear expected net clinical benefit for anticoagulating AF patients with a CHA2DS2-VASc score of 1 or 2."

Monday, March 11, 2019

Left anterior fascicular block-comments on epidemiology and ventricular function

Left anterior fascicular block (LAFB) was previously known as left anterior hemiblock (LAH) .The earlier designation can be attributed to the widely accepted   writings of Maurico Rosenbaum whose work ( 1967) seemed to indicate that in humans the left bundle divided into a left  and   a right branch.

This "trifascicular" concept (right bundle branch and the two branches of the left bundle) was widely accepted and persisted  even though  work in 1972 by Demoulin and Kulbertus  make it clear than there was also frequently a septal branch of the left bundle and more importantly that the anatomy of  left bundle is much more complex that simply consisting of two (or three) branchs, i.e. more of a spiderweb or fan.There is great variation in the interconnections and  in few of the 49 careful dissections by Demoulin can a simple pattern of 2  or even 3 fascicles be seen. (the patterns can be seen on page 283 of reference 1, full text is available)

Realizing that all models are wrong but some are useful ( George Box, circa 1978),it may be that the LAFB model has some value.

LAFB is diagnosed on EKG when the frontal plan axis is between minus 30 and minus 90 with QRS duration less than 120 msec and the patient does not have an inferior wall myocardial infarction,LVH  or WPW syndrome.So, typically LAD equals LAFB in the EKG reading context.

Mandyam et al ( 2) from UCSF studied long term outcomes in patients with LAFB who at the beginning  of the data collection did not have evidence of heart disease. Using data from the Cardiovascular Health Study (CHS), they compared 39 subjects with LAFB with 1625 patients without LAFB over a 19 year period.The average age of the control groups with 71.4 and the age of LAFB group was 74.9

They report LAFB was significantly associated with atrial fibrillation (AF) Heart failure(CHF) and death with the following p values-AF .02,CHF .02, and death .001.

This was a small  ( 39  patients),coarse grain study.The authors point out that although CHS tries to exclude preexisting disease on entry to the program hypertension or asymptomatic coronary artery disease may have been missed. The authors referenced no corroborating studies .

This UCSF article received considerable medical press coverage in part as it offered some suggestion that the previously accepted notion that LAFB was a  "benign" finding might not be correct but within a year their findings were seeminly contradicted by research from Copenhagen.

JB Nielsen (4) studied the cardiovascular outcome of 222,227 subjects with a 5.7 year  follow-up period. They did find a statistically significant correction between LAFB and AF, HF and both all cause and cardiovascular mortality. However, after adjusting for age and gender only the all cause risk retains statistical significance.

Quoting the authors: "current EKG definition of LAFB is not always clinically important marker of cardiovascular morbidity and mortality beyond what can be expected by age and sex."

What is the effect of LAFB on left ventricular function?

Leeters and colleagues from The Netherlands studied 28 patients  with RBBB,LAFB and heart failure with 2D speckle tracking regional strain measurements as well as healthy controls and 28 LBBB patients. This is not a study of "lone LAFB" as the patients had RBBB and HF and a number of them had scars detected by CMR. Since the RBBB per se would  not affect Left ventricular activation sequence it is reasonable to assume the delay in activation of the anterior LV is due to the LAFB.The study indicated wall motion abnormalities between the anterior wall and inferior wall of the LV analogous to the classic pattern of septal and lateral LV wall dyssynchrony characteristic of LBBB but apparently less disruptive of cardiac function.

1) Fisher,JH Hemiblocks and the fascicular system:myths and implications. J. Of Interventional cardiac electrophysiology 2018 52: 281-285

2)Mandyam, ML Long-term Outcomes of left anterior fascicular block in the absence of overt cardiovascular disease, JAMA 2014 309 (15)1587

3)Leeters IP, et al Left Ventricular regional contraction abnormalities by echocardiographic speckle tracking in combined right bundle branch block with left anterior fascicular block compared to left bundle branch block.J Electrocardiol 2016 49 (3) 353

4)Nielsen, JB et al Left anterior fascicular block and the risk of cardiovascular outcomes.
JAMA Int Med June 2014, 174(6),1001-1003

Tuesday, February 19, 2019

More data on lifelong exercisers-this time from Ball State

Scott Trappe and colleagues (1) from Ball State Human Performance lab  studied 7 women and 21 men all in their 70's who were lifelong ( fifty years or more) exercisers and compared them to elderly,apparently healthy sedentary  subjects and to heathy young exercisers (average age 25)

The lifelong exercisers exercised 5 days/week with a weekly hourly total of 7 hours. for the past 52 =/- 1 years.

Maximal oxygen uptake was measured on a maximal cycle test and muscles biopsy done to determine a "muscle aerobic profile" (MAP for short). MAP refers to the degree of capillarization and metabolic enzymes eg. Citrate synthase,B-HAD and glycogen phosphorylase  were determined by muscle biopsy in the lateral thigh.

While the MAP was the same as in the young exercising controls the 02 max  of course was not .The set of long time exercising women was small, but rounding up women who have exercisers for fifty years is no small feat.

Comparing the 02 max in young women,exercisers and elderly control women we find: 44,26 and 18 .

The authors conclude : " the data suggest that skeletal muscle metabolic fitness may be easier to maintain with lifelong aerobic exercise than the more central aspects of the cardiovascular system."

The authors mention the fragility index and quote that the value for men is 17.5 ml/kilo/ min and make their educated guess about what it is for women giving 14 ml/kilo/min as the value. I am not sure why women would have a lower number since the index is corrected for weight. Folks fortunate to have values well above those numbers are said to have more physiologic reserve to withstand and survive various homeostasis challenges whose frequency is a function of age.

This index should not be confused with another fragility index which gives an indicator of how robust are the results of a clinical trial.See here for more on that.  (A clinical trial would have an FI of 1 if the hypothetical movement of one patient from the success column to the failure column would make the study no longer statistically significant ( at the p of 0.05 level)


1) Gries,J et al Cardiovascular and skeletal muscle health with lifelong exercise
JAP 125: 16736 2018 (full text available on line)