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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 ...

Monday, May 30, 2016

At least one labor union fails to recognize the social justice of Obamacare

Apparently the roofers union believed the administration's claim that if you like your health care insurance plan you can keep it. Now they finally seem to have realize the bogus nature of that pre ACA passage ploy.

See here for the union leaders statement asking for repeal of at least some of ACA.

" I am therefore calling for repeal or complete reform of the Affordable Care Act to protect our employers, our industry, and our most important asset: our members and their families.

addendum: My apology. This post clearly is old news .In reviewing my store of unfinished drafts of posting I must have hit the publish button my mistake.5/31/16

The determinates of the stiff aging heart and what if anything can be done

Diastolic heart failure had been for the most part a diagnosis of exclusion.Symptoms and physical signs of heart failure (Hf) and an elevated natriuretic  hormone level in the face of a normal ejection fraction (EF) as determined by echocardiography or  gated myocardial perfusion imaging are the elements of the diagnosis.More recently echo studies of flow through the mitral valve opening have allowed a diagnosis of inclusion based on various indicators of diastolic flow and ventricular filling but evidence of diastolic dysfunction is not sufficient to make the diagnosis of diastolic heart failure with preserved systolic function abbreviated as HFpEF.

In the classic physiology text book's 70 kilogram man the stroke volume is 70 ml and the volume of  blood poised  in the left ventricle at the end of diastole is 120 ml, and the volume at the end of systole is 50 ml giving a EF ( 70/120) of 0.58 ( 58%)) where EF = EDV-ESV/EDV, Clinicians like to use the term pre load. Pre load is the end diastolic volume.

But the percentage ejected per beat is not even close to whole story of cardiac pump function  because first the ventricle has to fill and it has become apparent than at least as many patients have filling problems as have lower ejection fractions. The HF from filling problems is known as diastolic failure or in the jargon HFpEF ( heart failure with preserved ejection fraction) as opposed to HFrEF (heart failure with reduced ejection fraction)

Of course all patients with HFrEF also have diastolic dysfunction., i.e.failure of normal filling of the ventricles.

Echocardiography has become the major tool to diagnose  diastolic dysfunction. Doppler techniques measure blood flow early and late in diastole.In the healthy compliant  heart most the flow occurs early and that phase is is designated the A phase and the second phase is the E phase and the E.A ratio has become a useful indicator of diastolic dysfunction. As the ventricle become more stiff , for whatever reasons,the ratio of  E to A decreases and diastolic filling relies more on the atrial kick phase.

A model or  stylized working hypothesis concerning the heart stiffness has been proposed in which  two major elements. are considered: 1) reduced compliance which is defined a change in volume/change in pressure in the left ventricle The relevant pressure is the difference between the left atrial and left ventricular pressure and 2)  ventricular muscle relaxation.

Compliance is assessed to some degree and imperfectly  by the E and A and E/A ratio and the E/E prime ratio while the relaxation is measured by the isovolumic  relaxation  time of the left ventricle (IVRT) This is the  period after the closing of the aortic value and before the opening of the  mitral valve.An increased value denotes poor relaxation.The E/A ratio can be deceptive because as diastolic function decreases,the left atrial pressure may rise to help push the blood into the ventricle which tends to increase the E/A ratio that may have become depressed in an earlier phase of filling problems resulting in a "pseudo-normal" pattern.

To help sort out normal and pseudo normal ratios, tissue Doppler Imaging (TDI) can be helpful. TDI measures the movement of the mitral annulus as it move upwards as the ventricle fills and is designated  as E prime.

It has been recognized that the e/a ratio decreases with aging and some cardiologists recommend using an age adjusted set of value to determine if a value is abnormal just as values for lung function test indices are age adjusted. So is it  normal or is it the case that everyone get a bit of diastolic failure as they get older or for that matter a little bit of lung impairment.It has been suggested than the aging lung is a bit like early COPD.

Several groups of researchers have taken the optimistic view that regular endurance type exercise over the years can help prevent at least some of the age related  stiffness of the heart. There are data that suggest that is the case as at least some groups of older long time endurance athletes have better e/a ratios than their otherwise apparently healthy more sedentary cohorts. However the IVRT does not differ between the two groups, so the impaired relaxation of the myocardium that accompanies aging   does not seem to be mitigated by regular endurance exercise.

The putative underlying cellular mechanisms for increased  stiffness  and the sluggish myocardial relaxation are topics for  another day.Basically the narrative is that myocardial cells die with aging (apoptosis) and the surviving cells hypertrophy plus subendocardial fibrosis develops and maybe long time regular aerobic exercise might mitigate that process a bit.

addendum:5/30/16 Hitting the wrong key lead to publishing a uncorrected version. I think I fixed most of the typos ,etc now .

Friday, May 27, 2016

Has medical care reached a near Fubar condition because of the Answering machine?

I argue it may have.

Being a physician and knowing what I know about physicians , the good and the less good, I absolutely hate to go to a doctor. For most of my life I have not had to -now that I have to. I am past being appalled at the near impossibility of having meaningful or for that matter  any communication other than face to face in the office.Some of this failure to communicate is due to the answering machine.

An illustrative real life case.

After the implantation of a pacemaker I experience several somewhat uncommon complications. One week post procedure my heart rate suddenly jumped to 150 . My pacemaker came with a bedside device that enabled me to send data  to the PM center at the hospital .I sent a signal, called the number and was informed by the tech that it looked like I had atrial flutter.   Calls to my EP doctor office were answered by a machine and the only relevant choice was to leave a message for his nurse. No call back in one or two hours and heart rate continues at 150, a value that  exceeded the number that was sent to the PM center earlier. Knowing that atrial flutter is not a real call 911 situation did not keep my anxiety level from mounting.

Finally , knowing this was my ep doctor's clinic day my wife and I decided to go to the office and insist on seeing the physician . As it turned out the flutter has stopped by the time I saw the doctor.

The answering machine has turned into a situation in which the patient is given two options-leave a message and hope that you will get a reply sooner than the next or call 911 (or head directly to the ER on your own) . 

Medicine and the first rule of economics and the first rule of poltics

Thomas Sowell tells us that the first rule of economics is:

We live in a universe of scarcity and there will be trade-offs.

The first rule of politics is to ignore the first rule of economics.

In this column by Thomas Sowell we see examples of how the economic rule is ignored by offers of pie . I suggest there are offers of pie in the sky in regard to medical care and financing.

Can we have decreased medical cost and increased quality? No problem- all we need in a governmental single payer.(Interestingly the Medical Home advocates sometimes make that same promise although recent analysis from the Congressional Budget Office concludes they really can't tell if it will cost more or less.) Also more recently we are told if were pay for value not volume the same miracle will occur.

I first read about the notion of increasing quality while decreasing cost or at least containing cost in medical care in a series of article in JAMA by Dr. DM Eddy over ten years ago. The bait and switch trick here was for Eddy to redefine quality as the greatest good for the greatest number. Eddy's series of articles seemed mainly to deal with the topic of decision analysis, an area that Eddy had apparently specialized in after foregoing a surgical career but his major thesis was/is that the goal of a health care system should be to maximize the health of the group and individual physician's concern about individual patients is misplaced.Eddy seemed to claim there would be no trade off , we would have both higher quality and lower cost., by simply redefining quality.Of course he is suggesting a system with its own major dangerous  trade-off, namely the nebulous,loose and ambiguous good of the collective ( which will be in the eye of the elite in charge of the medical enterprise) over the much more easily discerned good of the individual.

Enter the decision analyst who can determine what is maximal health and how best to allocate or cost shift to achieve the maximal health of the group. He spoke of health care as a closed system and that it was a "zero-sum"game where for the good of the collective some patients may well be worse off, but although regrettable that is necessary for the greater good the details of which will be worked out by competent decision analysts.

This was an early proposal by the progressive medical elite  for a overt rationing of care that  self identified very smart people would be able to devise for the greater good of the herd. Eddy may well deserve a role in that group of smart people. The rationing that is part of the Independent Advisory Board ( IPAB) which was  part of PPAC but not yet activated  would be, I think, more of the covert rationing variety wherein there would be no explicit announcement of a utilitarian mandate but the board would rather simply say what was effective and ultimately what would be paid for by the third party- government and that would be leaped upon also by the third party private insurers. DrRich ( in a no longer active blog ) had a lot to say about that , see here.

Eddy's polemic is now more than  ten years old and rarely read but others have forged ahead in his footstep. Enter the folks and ABIM , ACP and ABIMF and their program to change medical ethics ,make physicians be considered stewards of a collectively owned medical resource base and  nudge and if necessary coerce physicians to dutifully follow guidelines that should boost the bottom line of the third party payers .

Some of the reasons why (at least some) older runners have decreased heat tolerance

Stimulated by my own frustrating inability in recent years to run as far on my weekend "long runs" as I could just 3 or 4 years earlier I began to search for some physiological reasons. For years I would run  a slow 18-20 miles on Saturday or Sunday throughout the years but in  last 2 years I have basically crashed  around 14-15 miles and was generally wiped out the rest of the day loosing weight from a pre run of 160 to a post run of 152 to 154 in warm to hot weather conditions and having a postural BP decrease indicative of volume depletion.

So far I have found evidence in the literature that at least 4 factors might play a role

1.A age related decreased in nocturnal ADH ( Arginine vasopressin) may cause a nocturnal polyuria.

2.Increased rate of glycogen utilization in older runners.

3.Lower levels of body water in older people.

So that my body water in the morning  was lower to begin with as more water lost in the evening preceding the run and my glycogen stores were more rapidly depleted even after some efforts at glycogen loading  leading to some limiting level of dehydration and glycogen depletion.The relatively meager liver glycogen stores are used during sleep.

4.Decreased V02 max with aging. the  carbohydrate (CHO)/fat mixture changes as a person exercises harder and at some percentage of 02 max ( often quoted as about 60%)  fuel source shirts to mainly CHO and little fat so that CHO stores ( glycogen) are more quickly depleted).So maybe in a misguided effort to run a bit faster than I should be,I get glycogen depleted quicker, i.e. after fewer miles have been run. So lower V02 quicker glycogen depletion.

 Dehydration in the older runner likely leads to to lower blood pressures post long hot run  as the stiffer ventricle and central arteries respond to decreasing  blood volume with exaggerated blood pressure changes- sort of a Starling curve thing. This of course is an effect and not a cause of volume depletion.

Thursday, May 12, 2016

Snake oil salesmen and politicians

When Chinese railroad laborers in the 19th century used snake oil they consider it  a legitimate and p useful product. The story goes that the laborers brought over with them oil from the Chinese water snake which they believed to be useful to relieve muscle and joint aches and pain from long hard days laying track on he US railroads making their way to the west coast.History provides us no record of randomized clinical trials.

A business man named Clark Stanley began to peddle what he purported to be rattlesnake oil said to have marvelous medical purposes. Following the passage of the  1906 Federal Food and Drug act a suite was brought against  Mr. Stanley for "misbranding", as the ointment did not actually contain any snake oil. Whether it had any therapeutic value was apparently not at issue. So originally the term snake oil had no negative connotation but later became another word for con job or flim flam or mildly put -deceptive advertising.

Dr. Roy Poses of the blog Health Care Renewal expounds on the exploits of a modern , until now, unsuccessful politician  currently leading the Republican race for president which involved a multi level market scheme for selling vitamin tablets that were purportedly  customized to the individual customer based on a urine test. Ultimately the higher links in the multi level apparently could not  pay their bills and  the Trump Network's contract with the vitamin company lapsed and the Trump Marketing engine moved on to better pickings.

(the article that apparently was first on this story was the NY magazine in 2011)

The term snake oil salesmen morphed into a synonym for hucksters or con men or film-flame artist -terms that are not uncommonly used to describe politicians.

If a politician found he had cannibals among his constituents, he would promise them missionaries for dinner. H. L. Men
Read more at: http://www.brainyquote.com/quotes/authors/h/h_l_mencken_2.html
If a politician found he had cannibals among his constituents, he would promise them missionaries for dinner. H. L. Men
Read more at: http://www.brainyquote.com/quotes/authors/h/h_l_mencken_2.html

If a politician found he had cannibals among his constituents, he would promise them missionaries for dinner.   H.L. Mencken

Monday, May 02, 2016

Retired doc celebrates 1000 + commentaries with some self referential rehases.

 Happy anniversary to self.

About ten years and now  slightly over one thousand blog commentaries have passed by  since I started a blog about the same time I retired .

Here are some of my favorites topics , a few of which have had a few thousand hits which is a lot for a backwater blog with minimal general interest and too much inside baseball talk.

1)I have written about so called "high value" medical care more than once. Here is my favorite in which I suggest that while modern mainstream economic thought is very diverse and has many areas  in which there is marked disagreement, most agree that demand curves slope downwards and value is subjective. The now widely talked about notion of high value medical care seems to contradict that second principle.Simply put- the question is high value according to whom.

Another commentary on a related issue is here . Value=quality/cost as a pseudo-equation used to pretend that cost containment is really all about quality and has nothing to do with third party payers enhancing their profits by lowering costs, i.e. paying less for medical care.

2)Meta Analysis is a topic I have written about for ten years with my basic grip being that meta analysis should not be enshrined at the tip top of the evidence based medicine pyramid.See here .
I quote from from an important essay by Dr.  Steve Goodwin .

3)The issue of how to apply population data , as in for example a randomized clinical trial, to a real life individual patient, is a topic I wrote about in 2005 quoting heavily  from an important paper by Kravitz,Duran and Braslow  in one of a series of blog entries that were facetiously labeled  suggestions for a medical school curriculum. (Facetious because I had no role whatsoever in curriculum planning)

4) Another "curriculum suggestion" dealt with education about  the transformation of Nazi  physicians to Nazi killers.This quoted liberally from a book  ( The Nazi Doctors) by Robert J Lifton,M.D.  Lifton  said - That according to the Nazi medical credo the physician was to be concerned with the health of the Volk and was to overcome the old individualistic principle of the right to one's own body and the embrace the duty to be healthy and the physician duty was to the collectivity.( a paraphrase not a direct quote). Scary ideology that did not  die out with the end of World War II and what happened  and how it happened in Germany is an important thing for current physicians to know about.

5)A theme I have hammered away on perhaps too much is that of the progressive medical elite,the medical arm of the progressive mindset who believe that ordinary citizens are just not qualified to mind their own business and that the elite must  mind it for them , ideally by persuasion but if necessary through coercive means.Here is a sample. Some might use the term" medical clerisy" to refer to this group.

6) Little seems to be written now about the  Complete Lives System promoted by Dr. Zeke Emanuel that caused a bit of a controversy in 2009 . My critical commentary received more hits than most of my efforts as well a number of supporting letter echoing the concern I had.Here I suggest what Hayek might have said in regard to the complete lives system.

7) Physicians, like all humans, deal a lot with uncertainty One framework that can be used to consider uncertainty divides it into two types- stochastic or random and epistemic i.e. one based on lack of knowledge. Dr. Steve Goodwin offered a useful metaphor or story about the difference between random or stochastic  versus deterministic.  I wrote about that here.

8)Hoodwinking the medical profession ( and the public)  to further the boondoggle that medical practice is becoming  was the topic of a blog for which I borrowed heavily from a very insightful commentary by another blogger , Dr. Michale Accad.  The Baptist and Bootlegger metaphor is applicable here as well.

9 )The New Professionalism as envisioned by a subset of  folks at the American Board of Internal Medicine and the American College of Physicians with editorial and financial assistance from the Robert Wood Johnson  Foundation represents an effort to reformulate traditional medical ethics from which in which the physician has a primary fiduciary duty to his patients to one in which a nebulous duty to be a steward of society's medical resources assumes a major role and social justice is appended to the traditional medical ethical precepts.Here I comment on the relationship between social justice and the rule of law and here I write about  Thomas Sowell's Conflict of Visions
as related to the old and the new medical ethics.

Enough for one posting-maybe I reminisce about some others latter.