Thursday, April 23, 2015

Do we neeed to worry about the right ventricle in endurance exercise?

Is the right ventricle the Achilles heel of endurance exercise? I wrote briefly about this subject in 2007 .

In that regard there is more data now about which to fret.  A 2011 article by researchers in Australia and Belgium  gives reason to believe that endurance exercise affects the left and right ventricles differently and possibly  not in a good way .Could endurance exercise induce chronic changes in the structure of the right ventricle such that it is vulnerable to ventricular arrhythmias, similar to those related to an inherited cardiomyopathy (arrhythmogenic right ventricular cardiomyopathy).  See here. ARVC is very uncommon in the US but more commonly seen in Europe particularly in Italy where it is said to be the most common cause of sudden cardiac death in young athletes.

 The authors studied 40 well trained endurance athletes before an event , immediately afterwards and 6-11 days later.Echocardiograms were done at all three times and cardiac MRs were done at baseline. 

 Immediately post race, right ventricular ejection fraction was reduced  and RV volume was increased while comparable   changes were not present in the left ventricle. RV function did recover by one week except for an echo derived index  called "global strain".(In echo lingo strain means deformation which can be determined by tissue Doppler techniques)

Five of the 39 athletes demonstrated delayed gadolinium enhancement (DGE) in the ventricular septum. These changes believed to represent fibrosis were more common in the athletes who had  been competitive endurance athletes longer  and the authors suggested that the areas of  fibrosis noted on the gadolinium scan were in the area of the septum which bulges into the left ventricle as a result of the tissue deformation noted  in the right ventricle.


As the authors stated, the long-term clinical significance warrants further study.Will there be re-modelling of the RV in such a way as to predispose to ventricular arrhythmias?

Another publication by some of the same authors  had previously examined the prevalence of gene mutations in athletes with complex ventricular arrhythmias. Specifically they looked for desmosomal gene mutations of the type typical of ARVC ( Arrhythmogenic  Right Ventricular Cardiomyopathy). Desmosomes are complexes of protein that function to facilitate cell to cell adhesion. In 20 of the 47 cases no desmosome gene mutations was identified.A suggestion was made that prolonged endurance exercise could bring about remodeling of the right ventricle which would predispose to ventricular arrhythmias  even in some athletes who do not have the recognized desmosomal gene mutation..I wrote in more detail about this study here.

The right ventricular issue may well be worth worrying a bit about but the small but consistently  increased incidence of atrial fibrillation in long term exercisers has a more robust data base in its support









Wednesday, April 22, 2015

Is the doc-fix bill worse than SGR?

Here is what Dr. Scott Gottlieb has to say in his Forbes column on 3/19/15:

"The current Medicare reforms being put before Congress ( he was writing before the bill was passed) are better than the existing scheme, the so-called sustainable growth rate or SGR. But the new measures sill envisions Medicare actuaries and  at the center of a price setting process. Now they will also have the authority to mandate clinical practice standards. That this woeful development stands as an improvement to the status quo is a measure of how much our current approach has corroded so many aspects of medical care."

That is I believe the worse and most important part of MACRA. The folks at Medicare will mandate clinical practice standards that it turn will drive physicians compensation.Some well intentioned physicians working within various medical societies sincerely believe they can inject rationality into those yet to be written standards.Those well intentioned few are up against the lobbying powers of the various crony capitalists,the bureaucratic inertia of the administrative state, and the bully pulpit power of a subset of the leadership of professional organizations who either sincerely or cynically advocate for the purportedly calculable  good of the collective over the individual patient.

Yes, of course it is good that physicians no longer have the threat of a 21% immediate reduction in fees and to receive a slight increase (less than the rate of inflation) but after you look past that the slight and temporary  gains made now will seem like a Pyrrhic victory and I believe that Dr. Gottlieb may have been overly optimistic in his comments.

One of the reasons allegedly for the widespread support of MACRA was  that the impending 21% cut would force many physicians to opt out of Medicare. I submit that once the Merit Based Incentive Payment System (MIPS) is implemented and understood by practicing physicians it will be likely that even more physicians will leave Medicare.

Will well meaning  physicians somehow find the time,money and energy to fix the heretofore inadequate or harmful quality measures replacing them with better ones?  Will the CMS quality "metrics" some how escape  the inescapable  reach of Goodhart's law?  A measure of something looses its value as a measure when it become a target. With quality measures as will be defined by CMS and resource utilization embedded into MICRA  more and more medical decisions will be made in Washington and physicians will be less and less able to act as the fiduciary agents of their patients with trust in physicians and reliance on evidence based medicine fading away.

For a detailed and frightening analysis of what MACRA contains please read this commentary by Dr. Arvind Cavale. See here.

There is so much to fret about that is explained by Dr. Cavale  not the least of which is the move to have your physician share the insurance risk with the insurance company. Have a nice day.



Friday, April 17, 2015

The Doc Fix, prayers of the progressive medical elite have been answered and then some



In regards to the passage of the doc fix bill (known now by the acronym MACRA) John Goodwin said it well: " it locks in Obamacare's vision of the relationship between physicians and the state." ... Now, doctors and patients will have to get used to a new reality where the federal government and beltway lobbyists’ priorities are more deeply embedded in physicians’ offices than ever."

Further the exact details and degree of the embedding will not be made known  until  phase three of new payments system. Remember we have to pass the bill to see what is in it?

The changes made in physicians payments are in three phases and from the years 2015 -2020 there will be a 0.5% increase in physician CMS fees and from 2020 -2026 the increase will be zero.

Phase 1 is the "lull-docs-to-sleep" phase in which all physicians will "enjoy"  increases in the payment schedule  (that do not keep pace with inflation) and for a while not worry about the always impending threat of a SGR imposed fee cut. This is the deal that is too- good- to -pass-up phase which typically  occurs in the early stages of a scam.This phase runs from 2015 to 2019.Docs who are part of an APM )(see below) will receive an extra 5%.

Phase 2 is what I call the the devil is in the details phase.Physicians will be reimbursed based on a formula that takes into account  four buzz word filled metrics.The categories of metrics are 1)quality 2)resource utilization 3)meaningful use of electronic health record. 4) clinical practice improvements. This phase runs from 2019 through 2025 and the overarching   buzz word  is MIPS (Merit based incentive payment system).
 CMS will play the major role is setting physician payment.Note the meaningful use requirement will likely have more teeth and there is reason to believe that the much reviled MOC has received more statutory authority,although there are conflicting claims as to whether MOC is explicitly in Doc Fix or if it was already part of ACA or not in either.The National Quality Forum (NQF) is contracted by CMS for three years to provide advice and make suggestion regarding quality issues.It should not go unnoticed that the CEO of the NQF is the same Christine Cassel who was CEO of ABIM during the time that MOC was implemented.

Whoever the rule makers will be will be targeted by lobbyists stake holders to try and mold the rules to suit their particular concern.

Phase 3 is the everyone-work- for- the-man final phase  in which physician pay will be dictated by their involvement in a "alternative payment model", examples of which would be an ACO or a medical home or some sort of scheme involving large vertically integrated health behemoths.This phase begins in 2026.

Medical decisions will be shifted even more than they are  now to Washington and the wishes of Don Berwick and Troyen Brennan that they expressed in their book  New Rules are much closer to being realized. I quote from their writing:

"Today, this isolated relationship[ he is speaking of the physician patient relationship] is no longer tenable or possible… Traditional medical ethics, based on the doctor-patient dyad must be reformulated to fit the new mold of the delivery of health care...Regulation must evolve. Regulating for improved medical care involves designing appropriate rules with authority...Health care is being rationalized through critical pathways and guidelines."


The Doc Fix also moves forward the recommendation of Dr. Robert Berenson that he and a co-author made in a 1998 Annals of Internal Medicine Article ( p 395-402):


"We propose that devotion to the best interests of each individual be replaced with an ethic of devotion to the best interests of the group for which the physician is personally responsible."

MACRA will go a long way to achieving that proposal.










Friday, April 10, 2015

After 18 years and randomized trials with 25,000 men ,the relationship between 5 ARs and prostate cancer is still ??

This commentary from JAMA give a good summary of where we are with 5 ARs ( Five alpha reductase inhibitors) and prostate cancers.Large randomized clinical trials (PCPT trial and the REDUCE trial have been done with  finasteride (Proscar) and dutasteride (Avodart).

My take is that  the 5 ARs seem to reduce the risk of developing low grade prostate cancer but may increase the risk of higher grade prostate cancer. However, a reasonable argument can be made that the 5 ARs do not in fact increase the risk of high grade cancer but just make the cancers more easily detectable but we probably will never know because is is unlikely that many further studies will be done and  I doubt further analysis of existing data will be convincing.

One can also argue that a 5 AR driven decrease in the occurrence of low grade prostate cancer may not translate into fewer prostate cancer deaths. Most every diagnostic or therapeutic  decision involves a tradeoff, but here exactly what the tradeoff here is remains unclear.The drugs clearly decrease prostate size but in regard to prostate cancer there is much lingering doubt.

As hard as answers are to come by in preventive medicine issues ( think the changing panorama of suggestions for healthy diets and aspirin use, glucose control in diabetics, etc), it is astounding that the population medicine folks think that they can discern what preventive measures "should" be done and would be willing to recommend  that some should have to forgo treatment  so some in the future would be the beneficiary of some greater aggregate good. See here for Dr. Harold Sox's plan for just that policy.Hubris-city.

 I used to spend considerable time giving preventive medicine advice in the context of a corporate wellness program. As I think back on what I said then ( with more certainty that the data warranted ) I have more than a few doubts now about what I said then. The only thing I am more sure about now is that for the most part regular exercise is a good thing. I am much less sure about the advice I gave about aspirin and statins for primary coronary disease prevention and for PSA screening and screening for bone density. It may well be that randomized clinical trials are the best we can do in terms of discerning medical management plans but it not uncommon to do RCTs  and still the answer(s) remain undetermined as is the case of the reductase inhibitors.

The old plaintiff lawyer meme of "Doctor, were you wrong then or are  you wrong now" continues to hit home, particularly in the enterprise of preventive medicine.


Tuesday, March 24, 2015

The medical progressive's fear-that someone,somewhere is deciding with his physician's input what his health care should be

H.L. Mencken defined Puritanism as that haunting fear that someone,somewhere may be happy.

The Medical Progressive Elite's haunting fear is that someone,somewhere is making their own medical decision with input from their private physician.This fear is shared by the third party payers. In recent years,there appears to be considerable progress in alleviating their fear.

The last thing that the third party payers and the medical progressive elite want is that medical decisions be made  a physician- patient "dyad".This situation is ripe for a classic Baptists and Bootleggers scenario,the medical elite sincerely believing that medicine is too complex and expensive to be left to the judgment of patients with advice from their physicians and the third party payers striving to decrease the cost of doing business and increasing profits share holder value.

This medicine-is-too important-to-be left-patients-and-their- physicians view  is made crystal clear in the following quote from the book,"New Rules"  written by Drs. Don Berwick and Troyen Brennan:

"Today, this isolated relationship[ they are speaking of the physician patient relationship] is no longer tenable or possible… Traditional medical ethics, based on the doctor-patient dyad must be reformulated to fit the new mold of the delivery of health care...Regulation must evolve. Regulating for improved medical care involves designing appropriate rules with authority...Health care is being rationalized through critical pathways and guidelines. The primary function of regulation in health care, especially as it affects the quality of medical care, is to constrain decentralized individualized decision making."


Dr.Berwick went on the be the  head of CMS for a while and Dr. Brennan went on to be the chief medical office of Aetna insurance company and then CVS Caremark.

Destroying the physician patient dyad or relationship  has been a strategic goal of the progressive elite for years and a major initiative to that end was the 2002 publication "Medical Professionalism in the New Millennium:A physician charter".That was a joint effort by the ACP Foundation,the ABIM Foundation and the European Federation of Internal Medicine. The project chair was Troy Brennan and, in my opinion, importantly in terms of future funding and  promotion of the "charter" a member of the project was  Dr. Risa Lavizzo-Mourey of the Robert Wood Johnson Foundation.The RWJF has been a major source of funds for the ad campaign for the Professionalism project.  She has been the CEO and President of the RWJF since 2002. Dr. Harry Kimball ,president of ABIM from 1991 to 2003 was also a project participant.

The Professionalism 's theme is to downplay the fiduciary role of the physician to the patient and insert a nebulous co-duty of  the physician to be a steward of society's limited medical resources and to work for social justice. A particular political agenda was inserted into medical ethics. For physicians who wondered how that role was to be played out, later the ABIMF clarified  things by explaining that one could be a steward of the [collectively owned] medical resources  and social justice would be achieved by providing efficient health care.In one document the authors changed the nature of traditional medical ethics and  also rewrote the meaning of social justice which was now efficient care as opposed to the widely accepted meaning of social justice as redistribution.  In a bait and switch move they have redefined social justice as efficient health care attempting to aggregate the values that individuals might place on a treatment with some collective metric allegedly representing the greatest good to the greatest number.They then further simplified things for the practicing internists (actually all physicians) by gratuitously asserting that following guidelines would be the road to social justice.

Disappointingly, the AMA went along with this flim flam sophistry of the physicians as stewards of society's collectively owned medical resources.See here.

In the ACP-ABIM world no longer would the patient and the physician  be the primary determiners of a test or treatment value but value would be designated as high or low  primarily on a cost effectiveness calculus.Rather than treating each patient as an independent moral agent an aggregate utilitarian metric would be imposed  in which "high value care" is not in the eye of the patient but rather defined by a third party and expressed in  quality adjusted life years per dollar spent The only or at least determinate value is economic efficiency.

Of course, the medical professional elite is a subset of the larger progressive community whose operational credo is that most things are too complex and complicated  to be left to average people and if they will not listen to the delivered wisdom they should be compelled  while the progressive's polar star and major talking point is  to fight against inequality. The poster child for the stick approach has be the comments of Dr. Robert Benson Jr.,the emeritus president of ABIMF,writing on the blog of the ABIMF:

" CMS, which has the ultimate negotiating position in the form of reimbursement for Medicare services, could only accept negotiated bundled charges. It could also refuse payment for non-compliance with the Choosing Wisely recommendations."...ABIM could require candidates to achieve a perfect score on questions related to costs and redundant care as a requirement for admission to secure exams for initial certification or MOC."

 If you want to know what the ABIM and its foundation are about, just read  the ABIMF blog.

The combination of mega hubris and libido domini spells trouble in health care as it does pretty much everywhere.


minor spelling and punctuation corrections made on 3/31/15







Thursday, March 12, 2015

Newsweek article echos practicing internists concerns about the ABIM and the ABIMF

 Rising criticism about the American Board of Internal Medicine and its twin, the American Board of Internal Medicine Foundation is getting wider coverage.

The leadership at the ABIM-ABIMF cannot be happy with this recent article in Newsweek by Pulitzer :Prize winning investigator journalist, Kurt Eichenwald.

Most of the article highlighted the activities of the ABIM but he did say the following about the ABIM Foundation:


"And there is another organization called the ABIM Foundation that does...well, it’s not quite clear what it does. Its website reads like a lot of mumbo-jumbo. The Foundation conducts surveys on how “organizational leaders have advanced professionalism among practicing physicians.” And it is very proud of its “Choosing Wisely” program, an initiative “to help providers and patients engage in conversations to reduce overuse of tests and procedures,” with pamphlets, videos and other means."


As to the growing opposition to the actions of the ABIM and questions about what the ABIMF is all about , I wonder if Dr Benson,emeritus CEO of ABIMF  might wish the following comments had not been published on the AMIF's blog: I have added the bolding.


" CMS, which has the ultimate negotiating position in the form of reimbursement for Medicare services, could only accept negotiated bundled charges. It could also refuse payment for non-compliance with the Choosing Wisely recommendations."...ABIM could require candidates to achieve a perfect score on questions related to costs and redundant care as a requirement for admission to secure exams for initial certification or MOC."

Apparently , in Dr. Benson's eyes the Choosing Wisely pronouncements are ( or should be) more that a few talking points that physicians and patients can focus on as they discuss what might be "the right treatment for the right patient at the right time" .There should be requirements for Medicare payments and demonstration that a ABIM exam candidate has mastered them before they would even be "allowed" to take their "secure examination".  Comments such as these suggest more is going on at ABIMF than harmless mumbo-jumbo. It is worthy of that  other medical policy wonks are sending up trial balloons for proposals  giving Choosing Wisely regulatory teeth. See here.

The more light shined on the folks and activities at ABIM-ABIMF the less likely they will be able to preserve their phoney-baloney,self appointed positions. 


H/T Dr Wes

Addendum Walter Bond on his blog asks will the ABIM board members, present and the recent past,defend what they did or argue that they fought against all the bad stuff and blame as much as possible on Dr. Christine Cassel.See here


Monday, February 16, 2015

Defensive backs at greatest risk for serious head and neck injuries from football.

This article from AANS regarding traumatic brain injury (TBI) data from 2012 discusses sports related concussions and the more serious brain injuries and injuries to the cervical spine.

Defensive backs in American football are at the greatest risk for both fatal head injury and serous cervical spine injury. Quoting the report:

"The majority of catastrophic injuries occur while playing defensive football. In 2012, two players were on defense and one was in a weight lifting session. Since 1977, 228 players with permanent cervical cord injuries were on the defensive side of the ball and 55 were on the offensive side with 44 unknown. Defensive backs were involved with 34.6 percent of the permanent cervical cord injuries followed by member of the kick-off team at 9.2 percent and linebackers at 9.5 percent."

Spending even a small amount of time watching high school,college and professional football on TV makes it clear that the vast majority of high impact collisions occur in the defensive zone involving defensive backs and either runners or receivers and on kickoffs.Quarterbacks receive many hits with the helmets impacting the ground and have a significant risk of concussion but apparently have  lower risk of fatal injury or injury leading to permanent disability.Offensive linemen may receive more sub-concussive head blows over a game or a season and whatever the long term consequences of that may be but seem less likely to regularly  be involved in high impact collisions and therefore less at risk for serious brain or cervical spine injury

Don't let your babies grow up to be defensive backs