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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 ...

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.
https://practicingphysician.org/


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?


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.

Thursday, July 05, 2018

Is the Choosing Wisely campaign a giant flim flam benefitting the thrid party payers?

Is the choosing wisely initiative (CW) just a clever ploy to save money for the third party payer?
 or Is it just about a sincere effort by physicians who really care to eliminate to the extent feasible fraud and waste?

Is CW an extension of the New Professionalism movement?

I  argue that CW is a flim flam and a power grab jointly shared by the third party payers and the medical progressive elite who provide the academic cover and propaganda. I  argue that it is in fact about much more that elimination of fraud and waste and that it is a logical outgrow of a major element of the change in medical ethics that the New Professionalism movement is attempting to bring about.

It is a story about the ACP the ABIM and a foundation ( the ABIMF) established with money obtained from internists taking certifying exams whose fees greatly exceeded any reasonable cost of providing those examinations and about  another foundation  , the Robert Wood Johnson Foundation (RWJF)

I  argue that it is not just the CW ad campaign funded by ABIMF and RWJF but it is larger namely The New Professionalism-Choosing wisely-high value care flim flam.

The New Professionalism authored by folks from ACP,ABIM and the RWJF  provided the cover or alleged philosophical foundation for CW and the push for high value care.The follow the money rule continues to have great explanatory value.


Wednesday, June 27, 2018

Why did the greatest "ancient marathoner" slow down signficantly in his 70s?

Why did the greatest ancient marathoner of all time slow down so much in the decade of his 70s?

At age 73 Ed Whitlock finished a marathon in 2:54:48. Twenty-five years earlier he ran a marathon in 2:31:23. In a quarter of a century his marathon time decreased by only 23 minutes. See here for the blog Cannute's Efficient Running Site 's tribute to Whitlock.

Whitlock's 02 max was measure at 52.8 ml/kilo/min when he was aged 70 and 11 years later at age 82 a measured Ox max was essentially unchanged ( 54 ml/kilo/min).

A person's maximal oxygen consumption ( 02 Max) decreases with age. The per decade decrement is generally said to be between 5 and 10 Percent. The jury is still out regarding if the rate of decline in endurance athletes is more,less or the same as more sedentary humans. There is good evidence indicating that the rate of decline increases around age 70 and values as high as 15 % percent per year or more have been reported. Assuming the 02 Max measurements are correct, Whitlock's 02 max was essentially unchanged during his running trek through his  70s but his marathon times decreased significantly.

As commented on by Cannute, Whitlock in his 40s was a very good marathoner but was not setting world age marathon records . At age 48 he ran a marathon in 2:31:23- a very good time for age-actually any age- but not the record.  Ye,t by age 70 he was setting marathon records for age and continuing setting records until a few months before his death at age 86.He set the age 85plus marathon record in Toronto clocking in a 3:56:33

So what was his secret? Obviously his genetic endowment included a high 02 max. His marathon times did decrease between age 70 and age 80. He was running sub four hour marathon at 80 plus while running sub 3 hour at 70 plus while his measured 02 max seemed constant over that time period.

Of course there is more to running marathon than 02 max.

Whitlock's training in his 70s and 80 did not follow the current generally accepted marathon training  principles. He did no speed work except in races. In his 70s he is said to  have run up to 3 hours a day , almost every day at a very slow pace, described as a slow shuffle. He carried the LSD (long slow distances) program to a extreme.

Tim Noakes, noted exercise physiologists and long time endurance athlete, believes that a major reason than marathon times decrease markedly in the decade of their 70s is that most older runners cannot maintain the hours of training necessary to perform well in the marathon  in part because  there are too manyminor ( and major injuries), too many aches and pains. The muscles endure better than the "connectors", i.e the structures and tissue connecting the bones to the muscles and joints.

Yet it may be that even in the absence of significant injury or a nagging series of minor injuries a human's running speed for distance decreased significantly during the 8th decade of life. (about 25% decrease in marathon running speed for the world's greater old timer marathoner.) One suspect to consider is  muscle loss of "spring function" and the spring function of tendons and the arch of the foot. You figuratively and maybe literally loose the "spring in your step".









Monday, June 25, 2018

Bundle of His Pacing an overnight game changer fifty years in the making may have reached tipping point

Benjamin J. Scherlag,PhD, is credited as the first person to demonstrate an intra cardiac tracing of  His Bundle (HB) electrical activity In1967 he demonstrated ventricular pacing from the bundle of His.

In 1970 OS Narula and Scherlag demonstrated the feasibility of temporary HB pacing in humans.

 In a 1978  article in Circulation, Scherlag,El-Sherif,Lazzara and others presented clinical and experimental data demonstrating the normalization of bundle branch blocks  ( right and left) with HB pacing.

Thirty years after Narula's work, Deshmukh's 2000 publication reported his experience in placing    permanent His Bundle pacing leads in   18 patients with dilated cardiomyopathy,poorly rate controlled atrial fibrillation and narrow QRS complexes who  underwent AV node  ablation. He  later published a larger series with 3 1/2 year follow-up on patients with supra-Hisian AV block.Although results were encouraging, the time for more widespread use of HB pacing has not yet quite arrived. The procedure was thought  to be  too challenging and  commercially designed equipment which would facilitate the procedure was not yet available . It required   a separate mapping catheter and higher pacing thresholds and it was not clear  exactly what subset of patients would be benefited by this method to a degree greater than obtained by the simpler apical right ventricular pacing in regard to which data suggesting the harmful effect of RV pacing were not yet fully appreciated. So HB pacing was not perceived as being ready for prime time.

From 2006 through 2012 work from Kronborg from Denmark and Zanon and others from Italy   strengthened the case for more widespread application of HB pacing.In 2011 Zanon reported the experience from  multi-institutional data using the Medtronic Select Secure system describing 307 patients implanted in the His zone with 87 having direct HB pacing and 220 with indirect or "Para-Hissian" pacing.

Two important papers from the United States were published in 2015:

A series of 98 HB paced  patients was reported by electrophysiologists from the Geisinger Clinic.
 with a longer follow reported by the same group in 2017.Also Lustgarten reported on a cross over trial comparing Bi-ventricular pacing with HB pacing in patients  receiving Cardiac Resynchronization Therapy (CRT).

Both papers indicated that the procedure was less difficult than previously thought due in part to newer specially designed sheath and leads,required lower pacing thresholds than earlier reports and follow-up data regarding stability of leads was encouraging and left ventricular function improved at least as much brought about by Bi-V pacing. Further the Geisinger data , while not a randomized trial,indicated that long term follow-up showed no decrease in left ventricular function while a parallel group who had the standard right ventricular apical pacing did  decrease left ventricular function  and a 22% incidence of pacing induced cardiomyopathy was reported.

In EP cardiology, as in most things, there are tradeoffs. The HB paced patients had , in the Geisinger data, twice as many lead revisions after five years( 6.7% vs 3%) and significantly more generator changes when compared with the RV paced group ( 9% vs 1%) . In additional the procedure time was slightly longer as were  fluoroscopy times.

The Geisinger HB registry data was updated and published in 2018.This article was one of  several recent articles describing experiences with HB pacing in a variety of clinical settings and we may have reached a "tipping point" in terms of EP Cardiologist's attitudes re HB pacing.

Francesco Zanon from Rovigo Italy ,an early adaptor of HB pacing, published data on 147 patients referred with a variety of PM indications and various types of bundle branch block. 80 % of patients experienced disappearance of the BBB . 90% of the  patients had effective HB pacing with a mean follow up of five years. He spoke of a "new philosophy of how we pace".

 One of the fathers of electrophysiology, Benjamin Scherlag,has called for a randomized trial comparing HB with BiV pacing for CRT and Dr. Kenneth Ellenbogen has also commented on the need for  RCTs and wrote an editorial suggesting that possibly HB pacing was the Holy Grail of  pacemaker therapy .









Tuesday, June 12, 2018

age related decline in exercise capacity is not just decrease in 02 max

It has been suggested that the study of the physiology (pathophysiology?) of aging might be informed by the study of aging athletes.

Analyzing information about Ed Whitlock,thought by some to be the greatest "ancient marathoner" ever, may offer some interesting insights.See here for more regarding Whitlock.

02 max measurements were made on Whitlock at age 70 (52.8 ml,/kilo/min)) and age 81 (54ml/kilo/min).

At age 72 he ran a 2:54 marathon and at age 82 his marathon time was 3:41.So his running time decreased significantly from 6.62 minutes per mile to 8.4 minutes per mile.His speed decreased from 9 miles per hour to 7.11 miles per hour, a 20% decrease.  Yet during that same time period his measured maximal oxygen uptake was unchanged. We also know from  published interviews  that his training did not significantly diminish. So what was the cause(s) of his decreased running speed?

The decade of the the 70s is generally said to be one in which the age associated decrease exercise capacity seems to accelerate. and 15 to 20% decrement per ten years have been reported.A reasonable assumption is that a major factor in that decrease is decrease in 02 max. Yet Whitlock's 02 max was unchanged while his running speed decreased in the range typically said to occur in normal humans.

Similar data on other runners have demonstrated that running speed for distance running decreases proportionally greater than the temporal decrease in 02 max.However, in cyclists a different pattern is seen with the 02 max and speed decreasing more proportionately .

It is tempting  to evoke the role of the pounding of the legs in running versus cycling. The long time distance runner and exercise physiologist, Tim Noakes ,has opined about the long term effect of "pounding" on decline in exercise capacity.The constancy of Whitlock's 02 max and the 20% decrease in marathon times from early 70s to early 80 reminds one of the high school coach's aphorism "you are  only as young as your legs".

Could some answers be found in study of titin and its isoforms?Titin (aka connection) is the body's largest protein and is said to act like a spring for muscles, recoiling the sarcomere after it is stretched.

There is a short,stiff isoform ( N2B) as well as other more elastic isofroms ( e.g. N2BA ) . The phosphorylation of titn results in a post translational modification of titin with production of more elastic isoforms. Beta adrenergic stimulation may increase the phosphorylation of titin.

The stiffer ventricular muscles of patients with diastolic heart failure have less of the more elastic titin isoform and more of the shorter stiffer titin isoform.

Titin may or may not play a role -probably more than one factor conspire by a number of mechanisms to cause runners in their seventies to loose much of the "spring in their steps."even if their cardiac output changes little  even though a constant cardiac output over that 10 years period is likely very far out on the curve.






Friday, May 11, 2018

Is ablation better than drugs for A FIb? What did CABANA trial show?

The results of the Cabana trial were presented at the Heart Rhythm Society meeting in May 2018. The full results will be published later. Here is Larry Husten's reporting in Forbes.

The intention-to-treat (ITT) analyses indicated there was no statistically significant difference between ablation and drug treatment in regard to the primary outcome which was the total of death,disabling stroke, serious bleeding and cardiac arrest.

On the other hand the per-protocol analysis (PPA) gave different results indicating  an advantage to the ablation group.

It got down to a battle of the Packers. Dr Doug Packer,who presented the data,said that the per protocol analysis should trump the ITT, while Dr. Milton Packer seemed to think that venerable epidemiologic principles would be violated if one did not follow the ITT analysis.

There is already talk of the need for a sham trial  and EP cardiologists talking about sub-group analysis (ablation maybe better in those under 65 years of age and in those with heart failure) and touting the quality of life benefits of ablation .

One obvious problem (many more will likely be talked about) was the drug treatment group was not homogenous-it  included both rate and various rhythm  control strategies.  

Since there seems to be a battle between the ITT folks and the PPA supporters ,for those who might want to drive deeper into the issue , here is a place to start.

Thursday, May 03, 2018

Argument for aerobic exercise in patients with Parkinson's disease.

There ae no randomized clinical trials that demonstrate the benefit of regular aerobic exercise in delaying the progression of Parkinson's disease  (PD) nor in the decrease in the risk of development of dementia.However the Mayo Clinic has published an excellent review of the literature regarding  the beneficial effect of exercise on various brain areas and functions. See here.

Quoting the authors : "This aggregate literature provides a compelling argument for regular aerobic exercise and cardiovascular fitness attenuating PD progression."


h/t to Dr. Robert Donnell at his blog "Notes from Dr. RW" .


Monday, April 09, 2018

People who are more fit have less atrial fibrillation and less strokes if they develop AF


Individuals who are more fit ( have a higher functional aerobic capacity) are less likely to develop atrial fibrillation (AF) and if they do develop AF they are less likely to have a stroke or die.

These are the conclusions from a long , large study from Mayo Clinic.See https://www.ncbi.nlm.nih.gov/pubmed/29221502. ref 1

The final study cohort included 12043 patients referred for a treadmill exercise test and were followed for a median time of 14 years (9-17).They were classified into four groups based on functional aerobic capacity (FAC) .Each 10% increase in FAC was associated with an decreased risk of incident AF ,stroke and mortality by 7 %.

Was the decreased risk observed in the more fit due to a direct physiological effect of exercise or a result of the reduction in the standard risk factors observed in the more fit individuals  or is that a distinction without a difference?

Folks who may be accused of exercising too much may find some satisfaction in the data revealing no level of fitness above which there was an increased risk of AF.In other words they found no "U-shaped curve" regarding level of exercise ( or more properly of fitness as this study did not measure exercise level) and AF risk.




1)Hussain, N, Impact of cardiorespiratory fitness on frequency of atrial fibrillation,stroke and all cause mortality. Am J Cardiol 2018, Jan 1, 121 41-49

Thursday, April 05, 2018

More on the "lying"or at best really stupid electronic medical record

My medical record at a well known medical center -which shall remain nameless-has labelled me as having atrial fibrillation and it seems to be written in indelible electronic ink refractory to my attempts to erase it.

It came about because of two computers conspiring  together. The first was the computer inside of my pace maker.Its algorithm to detect atrial fibrillation detected signals which were interpreted at "AT/AF", meaning atrial tachycardia/ atrial fibrillation. It was a false positive call , tricked by a Pacemaker phenomenon called far field sensing. This occur when the sensing lead in one cardiac chamber senses activity in the other chamber and miscounts it. Ultimately the Medtronic tech recognized it and adjusted the atrial lead sensitivity so that the double counting would not occur. Problem fixed but..

The second computer, my electronic medical record (EMR) latched on to the "diagnosis of atrial fibrillation and will not let go. I have written my "patient portal" with a full explanation indicating that my EP cardiologist concurred.

Recently, I met with my new primary care internist and we discussed my Blood pressure, my pacemaker and no mention was made of AF.He never said the words atrial fibrillation.I gave him two of my old EKGs which did not show atrial fibrillation . Yet when he gave me a copy of my patient visit summary my current health issues were said to be 1.pacemaker 2.atrial fibrillation.

Did the computer write the second diagnosis on its own. Did the doc see it, did he even read what was printed out? I cannot believe he even saw it. I cannot believe a board certified internist of over 25 years experience would not have asked why was I not taking an anticoagulant as my CHADS2-VASc score of 3 would warrant anticoagulation according to all guidelines.In the days of the paper medical record can one imagine an internist handing a patient a report that said he had atrial fibrillation when he was aware of no evidence that he in fact had AF?

Of perhaps less significance, my printout also listed a physician who I had never seen, never heard of before and apparently is a pediatrician not even affiliated with the hospital.

The computer systems with which physicians try to make "meaningful use" were  designed to assist coding and quality reporting and have little to do with really improving patient care and often have the opposite effect and not infrequently are harmful.




Tuesday, March 20, 2018

If endurance exercise is the fountain of youth how much do you have to drink?

The arc (s?) of the normal aging heart -

One of the stories told  by physiologists and cardiologists regarding the age related downhill course of cardiac function is something like this.

One way to simplify  cardiac function is to consider the two parts of the cardiac cycle,1) contraction and ejection of blood and 2) relaxation and the refilling of the ventricle.

There are data indicating that the first signs of an impending problems are seen in the filling phase ie. diastole.From extensive echocardiographic and invasive physiologic measurements in humans the following sequence can be sketched out.

First there is impaired relaxation following by decreased elastic recoil and later diminished  compliance ( which is to say increased stiffness) and then -at least according to work from the EEM group- remodeling of hearts with thicker walls and smaller ventricular volumes).Simply put a sedentary ageing  lifestyle leads to a small stiff heart and long time endurance exercise leads to a larger more easily filled heart.The contractile function of the heart is well preserved with ageing , at least as indicated by measurement  of the ejection fraction.

This is largely consistent with the mainstream echocardiographic model which proposes a predictable,progressive process beginning with impaired relaxation,followed by decreased compliance and ultimately- as a compensation- elevated filling pressures.This model describes three phases of diastolic dysfunction indentifiable by combination of echo findings believed to reflect  how well or poorly blood flows into the ventricles from the atrium. This model recognizes that the various indices ( e.g E/A ratio, IVRT,maximal E wave velocity and the time constant of isovolumic pressure decay (Tau) change with age so that what would be abnormal in a 20 year old is normal in a 75 year old.It is thought that that filling pressure can be estimated by use of this model. NOTE-see end note 1 for reference to data that challenges the mainstream model by in part  providing data that cardiac cath measurements of left sided pressures do not regularly correspond with the three echo defined stages of diastolic dysfunction)

Now we look at what I have labelled as the "Dallas or EEM theory" of cardiac ageing. see end note 2

A series of articles from the University of Texas Southwestern Medical School and the EEM have provided extensive invasive and noninvasive data regarding cardiac function at various ages and the effect of longtime endurance exercise versus sedentary ageing on  cardiac structure and function.

Levine et al first demonstrated that lifelong endurance athletes ( 25 years or more of running a lot) had left ventricular compliance virtually identical to those of sedentary 20-30 years olds. Then they compared ventricular compliance in four groups of 25 each of people who exercised at various levels over a 25 years period. These were all subjects over the age of 64 and were screened to excluded pre-existing heart disease.Group 1 was sedentary people who exercised no more than one session per week. Group 2 were labelled "causal exercisers" and exercised 2-3 times per week. Group 3 (Labelled as committed exercisers}worked out 4-5 times per week and the "competitive" group trained 6-7 times per week and regularly raced.The racers had the most elastic ventricles while group 3 was "very close" in terms of ventricular compliance while groups 1 and 2 has significantly stiffer hearts.

Next Levine studied a group of 70 year old subjects  and an exercise program was unsuccessful in improving the reduced compliance observed in that group. Next a study was able to show that middle aged subjects with a year long exercise program ( that involved in part high intensity interval training) was able to increase their ventricular compliance.


My main question in this regard is "how much exercise "is sufficient to maintain a healthy compliant left ventricle." Levine's amazingly compliant  (pun intended) subjects not only stuck with program for a full year but after the first 6 months participated in a hig intensity interval program using the 4X4 workout program that involves 4 minutes of exercise at 95% of maximal heart rate followed by 4 minutes of rest done four times.


End note 1. Grant et al (Grant A, Grading diastolic function by echocardiography:hemodynamic validation of existing guidelines.Cardiovascular Ultrasound 2015 513 :28) compared echocardiography results with  left heart catherization data in 460 patients.The data demonstrated that there were no differences in regard to left ventricular pressures between patients with normal diastolic function and those with grade 1 or 2 diastolic dysfunction but there were differences between normal and grade 3 diastolic dysfunction in patients with reduced ejection fraction.In those patients with preserved EF, there is no statistical difference between normal and any grade of diastolic dysfunction. (see figure 5 of their article which graphically illustrates the lack of the "predictable, progressive process "which characterizes the  current paradigm.)If the detection of elevated LV pressures which generally correlates with exertional shortness of breath is in part the goal of echo studies of diastolic function it appears to not be reached based on Grant's data.

end note 2. Dr Ben Levine is the founder and director of the Institute for Exercise and Enviromental Medicine (EEM) housed at the Texas Health Presbyterian Hospital Dallas and professor at University of Medicine Southwestern. His group have done a series of comprehensive physiological studies on subjects recruited from the Dallas Heart Study, a population based sample of 6100 subjects in Dallas .
In a nut shell the concept is that everyone with aging develops some degree of diastolic dysfunction related to impaired relaxation and loss of diastolic suction,Later aging (particularly sedentary ageing) is associated with loss of ventricular compliance ( AKA increased stiffness). A long term endurance exercise program is capable of mitigating the changes in compliance but not the decrement in relaxation and diastolic suction. EEM's studies  further indicate that a sedentary lifestyle may lead to a small stiff heart which may be the precursor to heart failure with preserved ejection fraction (HFpEF) ) and the Dallas group suggest that an appropriated amount of endurance type exercise begun no later than early middle age may play an important role in the prevention of HFpEF.

"Humans are pattern-seeking story -telling animals and we are quite adept at telling stories about patterns, whether they exist or not".Michael Shermer.
In 2008, Shermer coined the term "patternicity" -the tendency to find meaningful patterns in meaningless noise. I am not suggesting that the extensive,very carefully done research referenced above is meaningless noise.I just really like the quote but I certainty hope the "Dallas hypothesis" ( my term) proves to be of significant value, having spent a lot of time running a lot over the years.

Sunday, March 18, 2018

Mitochondrial function in octogenarian endurance athletes

Scott Trappe from Ball State University and colleagues from the Karolinska Institute studied 9 lifelong endurance athletes 80 years of age or older  with 6 healthy 80 years olds who did no regular exercise. Aerobic capacity and muscles biopsies -done to measure levels of oxidative enzymes- were compared between the two groups.

The muscle biopsies showed high levels of citrate synthase and beta hydoxyacyl-Co A dehydrogenase in the athletes said to reflect the oxidative potential of the mitochondria. These values were similar to those from untrained young subjects.Quoting the authors: " It is important to note that mitochondrial function normally declines with age and this decline does not appear to be reversible with endurance training in sedentary adults greater than 80 yr old or very old animals." This implies that one has to start earlier and maintain some level of regular aerobic exercise to keep your muscle mitochondrial young.

I have commented  before on the impressive aerobic capacity of select elite older athletes.see here.Trappe'sathletes had measured maximal oxygen uptakes of 38 +/- 1 while the healthy controls averaged 21+/1/ .(O2 max in the range seen in the athletes would roughly correlate to the levels seen in someone able to run a 26.2 marathon in 4 to 4/1/4 hours,A 21 02 Max should allow someone to finish stage 1 of the Bruce treadmill protocol and into the second stage but likely not to completion of Stage 2.)Stage 1 Bruce protocol corresponds to 5 Mets roughly equivalent to walking a 15-16 minute mile and  to be able to finish Stage 2 corresponds to 7 Mets roughly equivalent to jogging a 15 minute mile.

Trappe's article is entitled "New Records" but as amazing as these guys were aerobic wise an Englishman transposed to Canada is one rung above on the aerobic scale. Ed Whitlock at age 80 finished the Toronto Marathon in 3 hours and 15 minutes.Using table 2.3 from Tim Noakes's book ,4 th edition The Lore of Running this time would correspond to an estimated  V02 Max of 50-55! See end note 1





1) Trappe S Et al New Records in aerobic power among octogenarian lifelong endurance athletes.J. Applied Physiology 114.3-10 2013.

End note 1.Rather than considering estimated 02 max from a table we can see actual measured values done on Ed Whitlock on two occasions. From the excellent blog entitled "Canute's efficient Running Site" we learn that just before his 70th birthday Whitlock's measured V02 max was 52.8 and at age 81 it was measured at a physiology lab at McGill to be 54!. Assuming that the difference between 52.8 and 54 was just normal test-retest variation, Whitlock seemed to loose no aerobic capacity over a ten year period. Conventional   wisdom and more than a little data indicate that the 70-80 decade is typically a time period in which there is an accelerated decline in 02 max,perhaps twice that of the 10 % per decade decline than is widely quoted. Whitlock did not get the memo.The VDOTvalues that are referenced on Canute's website and found in detail on Jack Daniel's VDOT Running Calculation web site appear to give more realistic estimates of running times that those that I have been using for comparison with exercise testing comparison that those  found on Noake's table.


addendum: End note 1 was completely redone after discovering Canute's web site.

Tuesday, March 06, 2018

What does reduced ejection fraction in elete athletes mean?

Some NBA  and  professional European cyclists (1) have been shown to have reduced cardiac ejection fractions (EF) and some NFL players(2 )have EFs in the lower range of normal. In regard to the cyclists this observation has , at least in one review, been used to bolster the argument that "too much exercise" is harmful , i.e. support for the  "U-Shaped" curve theory."Too much " exercise certainty can be harmful  (maybe that is what "too much" means) but reduced resting EF in elite . athletes is not proof of that contention.

The "wisdom of the body "may dictate that maintenance  of stroke volume a priority and not EF. These athlete have large preloads ( aka end diastolic volumes) so that a smaller percentage can be ejected to maintain the resting stroke volume. These basket ball players had a normal increase in stroke volume  and EF with exercise as did the NFL players.I believe the exercise EF was not measured in the cyclists.



1.Abergel, E. Serial left ventricular adaptations in world -class professional cyclists.J AM Coll Cardiology July 2004.
2. Abernethy,WB Echocardiographic characteristics of professional football players.JACC Jan 2003 p 280
3)Engel,D Athletic cardiac remodeling in U.S. professional basket ball players. JAMA Cardiol 2016, (1) 80-87 

Monday, March 05, 2018

Reversing cardiac aging-maybe some but it isn't easy

More about cardiac aging and aerobic exercise  from the Institute for Exercise and  Environmental Medicine  is found  the January 2018 issue of Circulation. Howden et al(1) report the results of a two year trial of a vigorous exercise program on various physiological measurements.

They were able to show some improvement in cardiac compliance ( i.e. a decrease in myocardial stiffness) in a group of middle aged,otherwise healthy subjects over a 2 year period but the exercise required was considerably more than frequent brisk walks or slow jogs around the park.Rather , part of the exercise program involved a vigorous high intensity interval program using the "4 by 4 " Norwegian Skier technique twice a week and later in program only once a week.

Dr. Ben Levine, the Director of the Institute, and his team seemed to be able to recruit subjects who would persevere in a demanding exercise program over a 2 year program  and   to also permit right heart catheterizations which were done to give the investigators a index of compliance of the left ventricle.The bottom line is that they were able to demonstrate a reduction in cardiac stiffness with their exercise program .

This study is the most recent in a series of publications which have demonstrated that there is some level of prolonged endurance exercise that can at least to some degree mitigate the age related loss of cardiac compliance . Previously they had attempted to improve cardiac compliance in older subjects (in their 70's) and were unsuccessful. In this study they hoped they could find a "sweet spot", a time frame in which it was not loo late to reverse the age driven stiffness and they seemed to have , at least to some measurable degree, succeeded .

Levine characterizes the sedentary heart as a "small, stiff heart" versus the endurance athlete's heart as larger,slightly thicker and more compliant.

Levine describes the stages in the aging of the heart :1) loss of relaxation ,2) stiffening ( beginning in middle age), and finally 3) remodeling. The hope is that adequate exercise might mitigate  or significantly delay stage 2 which may be the precursor or  a prerequisite for heart failure with preserved diastolic function. Years of endurance exercise does not seem to prevent the first phase but Levine's data suggest that exercise may counteract the stiffening and remodeling.




1) Howden EJ et al Reversing the cardiac effects of sedentary aging.A randomized trial.Circulation,2018 137; (full text available on line without firewall)

Wednesday, February 21, 2018

diastolic heart failure-do we need a two (or more) hit theory?

Warning The following represents the musings of a non-cardiologist,clearly unqualified by training to speak with much credibility on this subject.

The earliest recognizable phase (s) of diastolic dysfunction seems to happen to everyone if they live long enough and late middle age may be long enough. This phase is labelled, in the jargon of echocardiography, as "impaired relaxation" and  according to the latest expert guidelines technically as " E/A ratio less than or equal to 0.8 and E  wave velocity less than or equal to 50 cm/sec."These values are obtained by measuring blood flow with Doppler technique across the mitral valve. Relaxation occurs simultaneously with elastic recoil (aka restoring forces) from which there is no current method to distinquish it.Authors addressing this topic seem fond of the spring analogy and it has been suggested that the world's largest protein molecule,titin,functions like a spring.

 To perhaps overly simplify a complex process,let us consider diastole or ventricular filling as a three phase event, pre-early, early and late.See end note 1 Pre-early is the phase after the aortic valve closes and before the mitral valve opens (the isovolumic relaxation phase),early is the phase when blood flow rapidly into the ventricle ( as  depicted by Doppler technique as the E wave) ,late is when blood is pushed from the atrium by contraction and represented a the A wave. In the young E is greater than A and remains so probably until about late middle age.when the E wave is no longer higher than A, the echocardiographer  now usually says "impaired relaxation"

The party line current theory describes the early phase of diastole as being driven by relaxation and diastolic suction. Extensive data show that several indices of  diastolic function change in the process of healthy aging. The ventricle takes longer to relax which is signaled   by a prolonged isovolumic relaxation time or IVRT. There is also slowing of the early flow across the mitral valve  depicted by a lower E wave velocity and a lower E/A ratio.

The early mitral velocity of blood flow decreases and the IVRT lengthens- changes believed to represent impaired relaxation and is reported as such on echo reports. (Even though it is generally agreed that there is no way to partition the relative effects of relaxation and diastolic suction as they occur at the same time.)  Simplistically diastolic suction function can be thought of elastic recoil,the release of the stored energy created by contraction. This is also referred to as restoring forces.  The late phase of diastole is influenced by the stiffness or compliance of the ventricle and the contractility of the atrium.

One of the missions of echocardiography is non-invasively estimate the "filling pressure" of the left side of the heart. Filling pressure is the  pressure at the end of diastole also referred to as preload.
Elevated filling pressure can be used to confirm or support the diagnosis of heart failure (HF) and is believed to correlate strongly with shortness of breath on exercise.

Since every one is thought to develop  a decrease early diastolic function but everyone does not develop diastolic heart failure ,could those patients with decreased ( or more decreased) ventricular compliance-which exerts its effect in late diastole- be the HFpEF candidates?

The story of the changes detected in the aging heart as depicted by the Group from Southwestern (1) goes like this:

Early on there is impaired relaxation.Left ventricular stiffening occurs during the transition period between youth and middle-age and "become manifest between the  ages of 50 to 64", This is followed by left ventricular volume shrinkage and remodeling ( wall thickening) after age of 65. So the sequence is impaired relaxation, stiffening and then remodeling.

There are data indicating that about 1/4 patients with stage 2 or 3 diastolic function    progress  to HF.(Impaired relaxation is stage 1, as ventricular stiffness builds up so does the pressure in the atrium and this is reflected with an increase in E ,and E/A increases , a pattern often referred to as pseudonormal (although the most recent ASC guidelines no longer use that term) , as things get worse the LA pressure increases more and values change appropriately earning the designation of restrictive pattern (again this is the older terminology banished by the 2016 revised guidelines)

So maybe a second hit is needed. One such hit could well be prolonged hypertension and the resultant concentric hypertrophy of the heart leading  to decreased ventricular compliance, or at least "ventricular chamber compliance".Left ventricular myocardial changes seen in obesity and diabetes could also represent a second hit and could contribute to both diastolic dysfunction and systolic dysfunction.

Myocyte apoptosis occurs with aging is accompanied by hypertrophy of the surviving myocytes and increase in fibrosis, all of which could conspire to stiffen the ventricle  as well as impairing relaxation.

The group from  Dallas (2) has presented data that a sedentary lifestyle can cause concentric cardiac hypertrophy and that prolonged aerobic exercise  ( at levels as least twice that of the standard exercise prescription which would be about 5 hours of moderate exercise per week) if started by early middle age may prevent the age related loss of ventricular compliance It should be noted that there are data and interpretation of data that contradict that hypothesis. See here  and here for commentary regarding the observations that more aerobic exercise is required to prevent diastolic heart failure that is sufficient to decrease the risk of coronary artery disease.

Diastolic heart failure is a well recognized companion of diabetes .Several possible second hit suspect mechanisms  have been described  in diabetes including deposition of glycation products and increase in myocardial cell tension.

Of course there is much more to it than that. Normal healthy aging per se has been associated with apoptotic loss of heart muscle cell,compensatory hypertrophy of remaining muscles cells and fibrosis leading to some stiffening of the ventricles with the only apparent "hit" being aging. But again that seems to happen to everyone and everyone does not develop diastolic heart failure.Maybe a second hit is needed and again according to the Dallas group a sedentary lifestyle may be one such second hit second hit.See here for commentary on effect of sedentary lifestyle on cardiac remodeling .

In broad, non specific terms the "second hit" is anything that increases cardiac stiffness.





1) Fujimoto,N. Effect of ageing on left ventricular compliance and distensibility in healthy sedentary humansThe Journal of Physiology2012 590 (pt 8)1871 (see end note 2)

2) Dr Benjamin D Levine N Fujimoto Paul Bhella and others have published extensively examining the effect of ageing,exercise and the lack of exercise on various aspects of cardiac function and age related impairment. They posit that long term endurance exercise begun at lest by middle age may prevent the loss of compliance that is common in sedentary human evens in the absence of the usual suspect heart problems (HBP,diabetes,obesity)


end note 1.I know there are "really 4 stages" I left out "diastasis"
end note 2. If anyone can explain to me the difference between compliance and distensiblity please comment.

Addendum 3/16/18 A few more additions to try and get this thing right.




Monday, February 05, 2018

Might meta analyses and meta data dreging gaslight everyone



Two dueling meta-analyses come to mind. There was a widely quoted meta analysis regarding Vitamin E which concluded it increased the risk of death. Soon after that article appeared in the Annals of Internal Medicine , letters to the editor claims that using a different statistical technique on the same data base, there was no increase in death risk.

Large data bases and multiple comparisons between outcomes and variables seem to always show that some factor becomes a risk factor for something often with relative risk values less than 2 and often less than 1.5.RR.Values in this range are unlikely per se to  unearth a causative factor.This activity is sometimes referred to as "data dredging"  or looking for a positive correlation to rush to print and press releases.

The prudent researcher usually emphasizes that these finding are "hypothesis generating" and not game changing breakthroughs although  the less prudent and the lay press and astro-turf propaganda outlets may suggest the latter. When apparently contradictory data then appears in the medical (and then the popular) press what is one to believe. This seems to be a cousin of "gas lighting" even though no one is plotting to make anyone doubt their ability to reason and analyze medical  data but  tons of data and sounding alarms on the findings of many  of them may have a similar effect of "not knowing what to believe".













Friday, January 19, 2018

Has the modern electronic medical record made many physicians accomplices to lying?

In the last few  years I have the opportunity to read my medical records  and those of  some extended family members. After reading these documents, I wondered- has the electronic medical record (EMR)  made doctors liars? When they sign off on a record that filled with erroneous statements and claims that something was done and it was not done and the physician knew it had not been done ,why would not lying be an accurate description ? I suggest it would be.

When I reflect back on the emphasis of the importance of accurate medical records that was  embedded into my nascent physician  mind as a medical student and house officer and  as I read the repetitive useless information, erroneous entries and pages of useless cut and past repetitions  and even fabrication of what transpired I cannot believe what the medical recored has become. So in some ways this is one of the saddest and most disillusioned  blog entries I have ever posted. In some cases the medical record has been useless and misleading and often inaccurate garbage and certainly potentially capable of harming the patient and likely a fertile field for plaintiff attorneys.

I read the medical records ( fairly easily obtained through the clinic's patient portal). I read that the patient had a physical exam ( describing normal finding for various parts of this phantom exam which she never had). No one listened to heart or lungs. Reading the medical history I find that she was said to have hyperthyroidism ( she had hypo) said to be on Armour thyroid  ( she is not) .Reading another orthopedics record ( again from the patient portal ) I learn that the summary sheet described the wrong leg bone as having the issue of concern i.e. tibia rather  than femur.

A few years ago I read on my own  colonoscopy report that my physical exam was normal. This was another phantom exam, this was being signed off by one of my former partners.

So would it be fair to describe this type things as publishing a false medical record or simply put lying. Court room scene. Doctor, your records on Mrs X indicate you performed a physical exam prior to her endoscopy?. Did you in fact do such an exam? Mrs X has testified that she did not have such an exam.


Do the physicians even know what is contained in the medical record that they sign? Is that any excuse if they sign the record?


Addendum:  2/8/18 Still more. Having  a pacemaker in place I take part in a "remote interrogation" of the PM every three months.This includes a summary done by a PM tech at the PM center at a local hospital. Each report ends with "the patient had no complaints". At no step in this process has anyone ever asked me how I am doing.

addendum 5/6/18 After remote interrogations every 3 months for two and one half years,at last the technician actually asked me how I was doing  and if I was having any problems.

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) published 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 competition 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 and it is the ER docs and hospitalists who sort out the problems of sick patients summoning subspecialists as needed.

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.

Addendum: 2/9/18 My own internist who is also my former partner finally decided to find a internist for his medical care.The one he chosen has an excellent CV board certified,good med school,good residency site etc. He said he liked him, he seemed nice  but it was "sorta funny" that he did no physical exam at all.

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. To my knowledge ,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  at least 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

The long term trend of how and where decisions are made

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.


addendum: 1/20/18 The title was changed. The title was appropriate for a much earlier version of the post written in regard to a particular piece of legislation ,reference to which was deleted in the final version. My apologies for sloppy editing.







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

Wednesday, January 03, 2018

How traditional medical ethics got highjacked and why?

For as long as the dominant medical ethical precept and prime directive was do what it right for the individual patient,third party payers were challenged to control medical costs to the degree they desired because they could not control the folks whose hands were on the cost levers. That just might be the answer to the why.

Traditional Medical ethics stood in the way of the third party payers efforts to control costs and in regard to the private health insurers  to maximize profits.

With the why out of the way, lets move on to the how.

First, we look at an early trial balloon of the plan to disabuse physicians of what to the third party payers was a very dangerous notion namely that the physicians had a fiduciary duty to their patients.

The following gives a flavor of several publications from major medical publications that launched the trial balloon and does not claim to be an exhaustive literature review of medical article promoting that theme.


In 1988 Dr. Robert A. Berenson and M. Hall, a law professor, writing in the Annals of Internal Medicine said that "the traditional ideal" [the traditional doctor patient relationship in which the doctor's duty was to the patient] was "not compatible with the role that existing insurance contracts and manged care arrangements define for physicians."

They were explicit when they said : (my bolding)

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.

The authors were saying that insurance companies and managed care companies were defining the physician's role and that physicians needed to simply change their ethical precepts and get with the program.Some may recall that one of the characteristics of a profession (which medicine once was) was that it defined its ethics not an outside party. So the old ethics just does not work any longer.


Berenson and Hall proposed a complete revision or negation of the medical ethics that existed from hundreds of years.This fiduciary duty to the individual patient should be replaced by a nebulous co- duty to medical collective to which the individual patient belonged. As outrageous as that appeared to someone trained in the traditional medical ethics, an obligation to serve the greater needs of society and to balance that against the individual patient's welfare has subsequently appeared to be widely accepted ( at least by many medical society  leaders and spokesmen) by various medical organizations. See here the New Professionalism as promulgated by the American College of Physicians. But I get ahead of the narrative.

Dr. David Eddy authored a series of articles in JAMA ( Eddy DM. Rationing resources while improving quality.How to get more for less.JAMA.1994:272,817-824) promising to teach physicians how they could increase quality and save money at the same time.

The trick was the utilitarian imperative-do the greatest good for the greatest number. In his moral calculus it was not only appropriate but it was ethically demanded that, for example, one would not waste money by for example offering yearly mammograms to women between 40 and 50 if a greater bang for the buck could be achieved by offering smoking cessation session to pregnant women. Cost effectiveness analysis was to guide what was offered to the group It was the health of the collective that mattered and that was true even if the collective was a thrown together bunch of strangers whose employers happened to sign up to a given HMO. The traditional fiduciary duty of the doctor to the patient as well as the legal manifestations of that relationship and the aspect of human nature that says I want what is best for my health and my family's health not for some alleged aspect of a fictional collective would have to moved past.

Doctors were admonished by Eddy to not be "hoarding resources" for their patients.Note his approach went past cost effectiveness concerns and even past comparing the cost and benefits for alternative approaches to the same disease. He was suggesting making judgment about what disease money should be used for and what sub-group of members of the collective should benefit and which should not.

Another significant shot across the old medical ethics bow was offered by Dr. Donald Berwick and Dr. Troyen Brennan with their book, "New rules" published in 1996. The authors were as explicit as was Dr. Berenson when they wrote:


"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
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 later received a recess appointment to head CMS while his co-author later become CMO and VP for Aetna (2006-2008) and subsequently CMO and EVP of CVS Caremark.Dr. Berenson has held several positions in federal government icluding vice chair of the Medicare Payment and Advisory Committee (MED PAC).


Next we look at the charter for the New Medical Professionalism which was published in the Annals of Internal Medicine in 2002 as internists on both sides of the Atlantic offered a faux solution to the problems that medical practitioners faced in the new century .Dr. Brennon played a major role in that effort.

The authors listed various problems facing physicians and then gratuitously offered the mother of all non sequiturs namely that presumably these multiple problems (a barrage of new drugs and technology,changes in market forces,etc) could be solved by physicians working for social justice and an equitable distribution of society's medical resources as well as working to promote and respect patient autonomy and the principle of the patient's welfare.Social justice was bundled with the other two non controversial principles. Think about that "solution", to mitigate the myriad of problems the proposal was to maintain principles physician had upheld for a long time and add on an obligation to work for social welfare. As if physicians did not already have have enough to do. This was not an ethics handbook ( that would come later ), rather this was a "charter" , a set of commitments for medical professionalism which they defined as the basis for medicine's imaginary contract with society.

In 2007 the same or very similar theme was played again , this time by Dr. Brennan , who by this time had become VP of Aetna in an article entitled "Managing Medical Resources, A return to the Medical Commons" , coauthored by the then President of ACP Dr. Christine Cassells.(JAMA,June 13,2007,Vol 297,#20,pg 2518.



Here,the authors speak of an abstract, hypothetical " medical commons" and lament that the current emphasis by the physician for the welfare of the individual patient will spoil the commons much as the farmer who selfishly grazes his cattle on public land without regard for depleting the resource will destroy the resource.Physicians are implored to "reconstitute the medical commons" and think in terms of resource conservation and allocation so at the end the greatest medical good can be done for the greatest number of patients.They admit there is not currently such a commons. There never has been so I am unsure how a return is possible.

The medical commons figure of speech seems particularly lame.While a grassy knoll for the villager's sheep can be defined by a specific surveyor description, the "medical commons" is a extremely large amorphous array,the elements of which almost defy enumeration, and every changing, with some elements growing ,others contracting and innovations cropping up constantly.There is no easily defined entity called "medical resources";it is an amorphous abstraction.Further, to speak of allocation means some one or some elite group will be the "allocator in chief ". Decisions will not be made by thousands of individual physician-patient pairs.

Cassell and Brennan assert that a market based or a regulatory approach will allocate resources without the caring and wisdom that clinicians can bring to the endeavor. In their analysis the only choice is a medical commons with physicians and patients moving hand in hand willing to put aside the petty concerns of the individual when necessary for the greatest good of the group.

This is not the only publication wherein an officer of a large insurer found a friendly home either with a ACP officer as co-author or in a ACP journal to espouse a similar theme.

The journal of the American College of Physicians (ACP), the Annals of Internal Medicine, in 2006 featured a five page article in which the former CEO, and then current board member of Aetna, Dr. John W. Rowe, pontificated on the "moral basis for physicians..to participate in...[P4P]." I commented on that article at the time and noted that Aetna's reputation among practicing physicians was such that Dr. Rowe might not have been the most credible witness to present the case for P4P , a movement which the ACP has tended to favor. In a comment to my blog entry Dr. Roy Poses pointed out more details concerning Dr.Rowe's association with Aetna , namely that he owned 6 million shares and that he was actually chairman of the board of Aetna and that , of course, Rowe has a fiduciary duty to act in the interests of the company.


Then in 2012 came the new ethics manual of the American college of Physicians ( Published as a supplement to the Annals of Internal Medicine Jan. 2012,
American college of Physician ethics Manual, sixth edition;) Here is one quote:

Physicians have a responsibility to practice effective and efficient health care and to use health care resources responsibly.


In this document there was no longer dancing around the edges or causing the reader's eyes to glaze over with absurd fairy tales of patients and physicians working together for some nebulous common and conservation of commonly owned resources. Now we are told doctors need to conserve medical resources and get over the archaic obligation to the be patient's advocate.

quoting from Table 1 ( pg 74) Principles that Guide the ACP Ethics Manual recommendations

principle description

Beneficence The duty to promote good and act in the best interest of the patient
and the health of society

Non Maleficence The duty to do no harm to patients

Respect for patient The duty to protect and foster a patient's free uncoerced choice
autonomy

Justice The equitable distribution of the life-enhancing opportunities
afforded by health care

Quoting from page 74 of a supplement to the Annals of Internal Medicine, entitled "American college of Physicians Ethics Manual,sixth edition.


Comment: Right at the beginning the ancient bedrock of medical ethics is quietly altered. Now Beneficence is expanded beyond its traditional meaning altered to include "the health of society"
How has the term been used in the past.

Wikipedia states:
The term beneficence refers to actions that promote the well being of others. In the medical context, this means taking actions that serve the best interests of patients. However, uncertainty surrounds the precise definition of which practices do in fact help patients.

James Childress and Tom Beauchamp in Principle of Biomedical Ethics (1978) identify beneficence as one of the core values of health care ethics. Some scholars, such as Edmund Pellegrino, argue that beneficence is the only fundamental principle of medical ethics. They argue that healing should be the sole purpose of medicine, and that endeavors like cosmetic surgery, contraception and euthanasia fall beyond its purview.
.


Considerations of justice must inform the physician's role as citizen and clinical decisions about resource allocation. The principle of distributive justice requires that we seek to equitably distribute the life-enhancing opportunities afforded by health care. How to accomplish this distribution is the focus of intense debate.More than ever,concerns about justice challenge the traditional role of physician as patient advocate.

A box insert is found on page 87 of the manual:

Box 4  "Patients first and stewardship of resources.

The physician's first and primary duty is to the patient.

Physician must base their counsel on the interests of the individual patient, regardless of the insurance or medical delivery setting.

This physician's professional role is to make recommendations on the basis of the best evidence and to pursue options that comport with the patient's unique health needs,values and preferences."

Ed. OK so far no problem but now

"Physicians have a responsibility to practice effective and efficient health care and to use health care resources responsibly.Parsimonious care that utilizes the most efficient means to effectively diagnose a condition and treat a patient respects the need to use resources wisely and to help ensure that resources are equitably available."

In 2002,  a major offensive against the old ethics appeared in the form of the "Charter for the New Professionalism in the New Millennium "Then things are firmed up in the ACP's new ethics manual

June 2012 AMA joins the bandwagon.

Dr.Richard Fogoros said the following: on his blog the Covert Rationing Blog:

To summarize, by the turn of the millennium doctors were being coerced to withhold healthcare from their patients at the bedside, and thus to violate their time-honored primary professional directive. The intent of the 2002 Charter on medical professionalism was to repair the problem (i.e., to cure the “frustration”), not by confronting the forces of evil doing the coercion, but rather, by simply changing medical ethics to make bedside rationing OK. And that’s just what the document did, though only after careful re-editing to make this radical change to medical ethics sound as benign as possible.

Here we had the great non sequitor which was that  physicians are frustrated by many current forces and situations so to relive their angst we propose they not only worry about the welfare  of their individual patients but they also are responsible for everyone's welfare and the conservation of society's resources.

But how to do that-simple- later we are told simply follow the guidelines.