Are there growing hazards to your health when venture capital buys medical practices

The spread of corporatized medicine does not just pose threats to patient care but also to those delivering the care, most prominently the physicians and nurses.That harm has been labelled moral injury and is described in the book written by Dr Wendy Dean and Dr Simon Talbot after their ideas were introduced in a STAT article in 2018. Dr.Dean speaks of " a death of a thousand cuts" It is demoralizing to consider that the road to be a decsion maker in medicine is not med school residency and fellowship but an enginering degreee,and a business degree and to the brightest or best connected to get a chance to have a gig at McKensey and then on to venture capital. My rudimentary knowledge of venture capital is that the VC folks buy a business and then organize it to cut cost and make more money so that the business can be sold at a profit after a few years.Employees are a compnay's greatest cost so often employees are fired.It is hard to imaginin that at a medical practice undergoingthe venture capital dust up can be good for either the now employed physicans or the patients.

The attack on science and medicine makes more sense after reading Jason Stanley on Fascism

I was puzzled as to why someone would verbally attack Dr.Peter Hotez and threaten him with physical violence. What problem could they have with someone who co developed( along with Dr. Maria Bottazzi) a Covid vaccine ( Corbevax) and arranged to have it avaialble to millions of people . Two of Maga's big socialinflencers ( Steve Bannon and Roger Stone ) have attaced Hotez with Bannon's words triggering a wave of anti semetic attacks on the physician scientist who has been co-nominated for the Noble Prize for his work on a covid vaccine. What does all of that have to do with Professor Stanley work on fascism? Stanley tells us what fascism is all about. According to Stanley the right wing attack on the free press and the scientific community is stanard operating procedure for fascist movement sinceThe fascist leader needs to destroy the legitimacy of anyone who might oppose his views. From day 1 Trump attempted to denigrate the press.The attack on the scientific and the medical professions came a bit later. "fake news" has been the often repearted claim for anything the press says that runs counter to Trump's version.

Inflation is not just egg prices how about echocardiogram price hikes

Echocardiogram prices at at least one large megtropolitan hospital system in a large southern city,have accelerated impressively over the last year.
A family member had an echo last year and again recently. Last year's prices was $1461 and this year $4715 plus an $ 69 interpretation charge . Pulmonary function test at the same well known facility was $ 3871. Charges for outpatient imaging procedures are much higher than in imaging centers and echos are magnitudes cheaper in cardiologist offices, Several web sites that monitorcharges reported echo fees in cardiologist offices magnitudes lower than in the hostials echo labs, i.e. in the order of less than $500 in the same city as my family members fee of close to five thousand dollars. Several years ago Anthem insurance company said they would no longer pay for imaging procedures for outpatients done in hospitals.

What retired doc learned from economics

From Leamers book on Maco
humans are pattern seeking story telling creatures.

Economics cannot provide the level of certitude that the experimental sciences provide.The best it can do is look for patterns and then tell stories.

What if physics were like economics From Jim Manzi Uncontrolled:The surprising payoff of trial-and-error for business, politics and Society.

And how those stories vary-eg Milton Friedman and there is no free lunch versus the better than a free lunch claim that fiscal stimulus in an economy which has less than full employment will give a free lunch and will generate stillmore free lunches.(This from the advice that arose fromthe work of Lerner and Hansen taking Keynes thought and turning them into just about the coolest tool a politician or elected official could have ever received.)

It began with Ayn Rand and may have ended up on life support with Covid19 and how humans have reacted

It (my general political-philosophical set of beliefs) really did begin with Ayn Rand, first reading

"Capitalism, the Unknown Ideal " and then devouring Atlas shrugged and Fountainhead.

By late adulthood

my political-philosophical beliefs were fairly well settled in to be.

1)Strong belief in the importance of private property and rule of law and contract law and limited government and that central planning was for the most part a bad game plan

2)support for the kindergarten lesson of "don't mess with other people or their stuff". 

3)Individual freedom was important and the libertarian non-aggression axiom seemed like a good maxim;

4) The history of the 20th century made it quite clear that economic central planning as in communist USSR and China was a disastrous idea leading to the death of millions of people. 

I generally felt fairly comfortable in my self chosen set of reassuring voices in a my echo chamber

consisting of various blogs,books and podcasts and U tube sites until recently. 

 Coincident with the Covid pandemc,Some of the web sties, and  blogs which over the year s have been reliable dispensers of Austrian economic dogma  and general libertarian thought have with an alarming frequency published pseudo-scientific hogwash in regard to the covid 19 pandemic. 

One such posting denied the validity of current concept of viruses putting forth instead the bizarre notion that what are called viruses are actually waste products of cellular damage brought about by various type of  electromagnetic waves. All of the pseudoscientific is not quite as bat-sh**t

crazy as this denial of basic biologic knowledge but some are very close. For example, the claim that wearing a mask will lead to carbon dioxide retention and that mask wearing will lower your immune response , both claims lacking in scientific proof .

The covid pandemic has spotlighted the conflict between the common good and individual freedom.  

Nicholas Talib's comment seemed to an effort to  settle the apparent conflict when he said to remember that the principle underlying libertarian ,axiom , is the non aggression axiom

. If you believe that there is asymptomatic transmission of   a potentially serious  and potentially fatal disease the transmission of which can be significantly  mitigated by wearing a mask, then you need to wear a mask to conform with libertarian basic axiom if  you cannot socially distance .To not wear a mask with those assumptions in mind is to disregard or dismiss the non aggression  moral imperative as you are taking an aggressive act against strangers and or friends. 

However, it seems that there a number of vocal libertarian and libertarian leaning conservatives who do not agree with some or all of the following assumptions

1) There is a Covid 19 pandemic

2)Covid 19 is spread by respiratory droplets and aerosols and fomites

3) Masks will mitigate the spread of covid 19 

4)social distancing will mitigate the spread of covid 19

5) Viral vaccines have been shown to be safe and effective and have provided a "herd immjnity" for a a number of viral illnesses

 There is are a number of vocal libertarians and libertarian leaning conservative who believe or at least espouse some or all of he following:

1.The pandemic is a hoax

2 covid vaccine is a means of population control

can recent innovations in health care delivery be explained in the context of Baumol's disease

Note this blog post is the first of a joint authorship with chatgpt and me. Can recent innovations in health care delivery be explained in the context of Baumol's disease? the following is what chatgpt said in regard to the title question "While there is no single solution to address the cost disease in healthcare, several strategies have been proposed and implemented to mitigate its effects. Here are a few examples: Technological innovation and telemedicine: Advancements in technology, such as telemedicine and digital health solutions, can improve the efficiency and accessibility of healthcare services. Telemedicine allows for remote consultations, reducing the need for physical visits and lowering costs associated with in-person care. Task-shifting and delegation: Healthcare providers can optimize their workforce by delegating certain tasks to other healthcare professionals or utilizing non-physician personnel, such as nurse practitioners or physician assistants. This helps to improve productivity and reduce costs by efficiently utilizing the skills and capabilities of different healthcare professionals. Preventive care and chronic disease management: Emphasizing preventive care and proactive management of chronic diseases can lead to better health outcomes and reduced healthcare costs in the long run. By focusing on early intervention and preventive measures, healthcare resources can be allocated more efficiently, potentially mitigating rising costs associated with advanced or emergency care. Health information technology (HIT) adoption: Widespread adoption of electronic health records (EHRs) and health information exchange systems can enhance coordination and reduce redundancies in healthcare services. Efficient data sharing and interoperability can help healthcare providers make more informed decisions, reduce medical errors, and improve overall productivity. Payment reforms and value-based care models: Shifting from fee-for-service reimbursement models to value-based care models incentivizes healthcare providers to focus on quality and outcomes rather than the volume of services provided. These models promote efficiency, care coordination, and cost containment while aiming to improve patient outcomes. Collaboration and integration: Encouraging collaboration and integration among healthcare providers, such as forming accountable care organizations (ACOs) or healthcare networks, can improve coordination, reduce duplication of services, and streamline healthcare delivery. This integration can help optimize resource allocation and improve overall productivity. . Note chatgpt's strategies should be considered in most instances as aspiration. .

Covid 19 2022 101 -the basics

Three  basics emerge as we enter year three of a pandemic that has claimed 900.000 lives in the United States"

 Covid 19 is a respiratory virus that spreads by aerosols and there is asymptomatic spread as well as symptomatic spread and a significant amount oif the spread is from high spread events aa super spreader events 

1) Effective Masks prevent infection (N 95 or equivalent )

2)Vaccines prevent serious disease and death to a large degree but vaccines do not prevent infection.

3)vaccine effectiveness wanes over a period of months and booster are required as does immunity acquired by infection 

Corollaries. Vaccines do not prevent infection. To the extent masks prevent spread of infection they will naturally prevent death and serious illnesses. Mask effectiveness does not wane.

The protection afforded by vaccines and by contracting covid 19 wanes over time. Boosters are necessary.

Unless and until a vaccine that prevents infection is developed the human experience with covid will depend on the mutations that occur with covid and the development and availability  of safe and effective treatments given promptly after a rapid diagnosis. If covid mutates to a gentler affliction no more than a bad cold or mild to moderate severe flu,,, great.  But If the mutation history of covid continues as it has so far , we are not through with covid no matter how much folks pretend that is the case. Mutations will continue , infection and  surges will continue and boosters will be needed. Mutations may arise as they have so far that have varying degrees of  vaccine escape and varying degrees of virulence. 

The polio vaccine prevented infection by blocking GI tract mucosal invasions and until humans develop a vaccine that protects against covid invading the nasal mucosa or develop a vaccine that is effective against all corona viruses we are not going to say that we are through with covid.

New data on angio invasive follicular thyroid cancer necessitates change in ATA guidelines

With the publication of an article from Japan involving study of 303 cases of encapsulated angioinvasive FTC the current ATA risk classification of angioinvasive into those with four or more instance of angioinvasion ( deemed high risk) and those with three or less (deemed low risk) needs to be revised. The ATA risk classification is low, intermediate and high and the recommendations for each vary considerably.The current guidelines indicate that a patient with 4 or more angio invasions is high risk and a patient with 3 0r less foci of angioinvasion is consdiered low risk and therfore not needing remant ablation. Yamazaki et (1) reviewed 290 cases of FTC with angioinvasion (AI).These patients were free of metastasis at presentation and were seen at the Ito hosptial from 2005 to 2014. Disease free survival in those with one AI had a 94.9 % 10 year DFS while a patient with 4 or more had a 83% DFS, Those with AI of 1-3 had a DFS of 86.3 while patients with 4 or more had a DFS of 83.3 This is not statistically significant. Patients with angioinvasion of less than 4 are consdiered low risk by the ATA criteria Yamazaki' data show there is not a prognostic difference between a patient with three and a patient with four foci of AI . Yamazali et al Encapsulated angioinvasive follicular thyroid cancer.Prognostic impact of the extent of vascular invasion.Ann Surg Oncol 2022 feb 25

Thyrotrophin suppression to prevent thyroid cancer recurrence

Fron reading the Amercan Thyroid Association;s thyroid cancer guidlines I had assumed that the notion that TSH supression to reduce risk of cancer recurrence was both widely accepted and clearly demonstrated by underlying mechanistic studies and by emperical clinical data. The notion is widely accepted but a mechanistic rational is controversal with there being in vitro data that both support and deny the role of TSH in cancer growth and emperical data are contradictory. A 1998 report from the NTCTcs (Cooper DS,THyroid 1998)TSH suppresion was independly associated with disease progression in high risk patients but only in univariate analysis and not in multivariant models. A 2007 report from NTCTCS (Jonklass j, et al ) which was said by the authors to be the first to show superior outocme with THST They reported improved outcomes in high risk patients ( stage 111 and iv) The 2015 report (Carhill, AA etd al ) from NTCTCS recomended "moderate" but not " aggresssive therapy" Moderate was defined as a TSH level 2 -2.9 with aggresssive 1.0 to 1.99,.They found no additional benefit with the aggessive therapy and recommended at least three years of THST in high risk patients Kekebew et al have published data that challenged the paradigm which indicates suppressive therapy for thyroid cancer patients with either high or intermediate risk. The issue becomes a more high leverage decision ( a currently popular basevball jaron term ) in elderly patients as .as the cardiac risks are of concern and in women the bone loss issue .Basically TSH supression means the iatrogenic generation of subclinical hyperthroidism,a condition that is not comletely benign. Klubo-Gwiezdzinske et al studied retrospectively 1012 cases of DTC (41 with follicular) treated with near total thyroidectomy and remnant ablation and found no improvement in PFS ( authors state their study was under powered to detect a difference in OS) in intermediate and high risk DTC with TSH suppression.( Association of thyrotropin suppression with survival outcomes in patients with interemediate and high risk differentiated thyroid cancer. JAMA opoen network oncology 2019 2 (2) e 1187754

Was the old time medical ethics just an artifact of economics?

This is a redo of an earlier essay with minimal editorial change. I repeat it now with a nagging thought that "that ship has sailed some time ago" The concern I espressed several years ago has increased as medicine has become corporatized and a target for private equity. __________________ Can the traditional, medical-ethical prime directive of placing the individual patient's interest first survive in a financial environment in which physician autonomy is greatly diminished and income for most physicians is controlled by third party payers. not to mention the heavy hand of venture capital buying medical practices. More broadly put, Dr. Edmund D. Pellegrino asked in 1995 (JAMA,May 24/31,1995,Vol 273,no 20,) " Is medical ethics a social, historical, or economic artifact? Or are there some universal , enduring principles?" In 1988, Hall and Berenson writing in the Annals of Internal Medicine said that "the traditional [ethical ] ideal" was no longer compatible with the changed practice reality that "existing insurance contracts and manged care arrangements define for physicians." 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." Incredibly, the authors claimed that this shift in ethical focus would actually increase patient trust, an attribute that even in the late 80's was in decline as patients tried to live (sometimes literally) with the HMO's restrictions to medical care. Incredibly, they claimed that by not having the patient's interest as the prime directive there would be increased trust in their physician. The expected wave of letters to the Annals editors expressed the belief that advocacy for the individual patient was the prime directive and what it was all about and to replace it was to effectively do away with medical ethics as it had been known and practiced for a very long time. This is what would be expected from an audience of internists who had grown up medically inculcated with an ethic which was the polar opposite of what the authors proposed. Practicing internists at that time were reared to believe that the physician was completely and ultimately responsible for their patients and that their primary duty was to the patient. The average practicing internist if they read the article at all may have thought this was the contrived advocacy of someone who was attempting to make manged care appear ethical. All that was required was to turn medical ethics on its head.When I read that article I thought "you've gotta to be kidding me". A few years later ,I saw no one was kidding as the ACP, ABIM and the European Federation of Internal Medicine joined forces to formulate what was called the New Professionalism in which physicians were admonished to do more than maximize the health of all the patients in their HMO, which was as far as the Annals authors went. Now, physicians were told that they had an ethical obligation to strive for Social Justice. This joint effort by several medical organizations was said to be necessary as the "old ethic" needed to be revised to align itself with the new economic environment in which physicians now lived and "medicine's commitment to the patient was being challenged by external forces of change within our society". While the 1988 article's authors stopped short of suggesting physicians should conserve resources for others in society at large and not just concern themselves with their own HMO's population, the new ethics or professionalism as it was now called, headlined social justice raising it to the level of the big three ethical precepts-patient welfare, patient autonomy and social justice.More than one observer has asked does precept three conflict with precept one? The era from 1963 to about 1990 has been termed the time of "retail medical care". Physicians and patients enjoyed the situation in which a patient's insurance followed the patient so that he could choose any physician and the physicians' fees were not set by the insurer but largely were set by what the physician considered and the payer agreed to be "reasonable,customary,and prevailing". Things were good for physicians in those days as not only was physician autonomy largely unchallenged,but also Medicare had brought about a large influx of money to be spent largely at the discretion of the doctor and their patients and exciting new diagnostic and therapeutic tools were available. More could be done for your patients and more patients could afford medical care. Referrals could be based on the physician's knowledge of the area consultants and prescriptions were written without concern for some third party's list of permissible choices. But soon things were to change as the era of "wholesale medicine" replaced the old ways with the HMO now being a middleman-a very powerful middleman- and Medicare imposed wage and price controls on medical services. A series of articles was published in 1995 in JAMA authored by Dr. David Eddy that discussed the metrics and merits of decision analysis which he hailed to be a mechanism that could perform magic. The magic was to increase quality of medical care while reducing cost. But it was all merely playing with words and defining words to suit the argument. Eddy defined quality as the greatest medical good for the greatest number within the eco-medical collective (aka HMO). It did not go unnoticed to the skeptical reader that Dr. Eddy listed his affiliation as "Kaiser Permanente of Southern California") Pellegrino in 1995 also asked ...can physicians change the ethics of the profession at will ( as proposed by Berenson and Hall) or is there a more fundamental and universal foundation for the ethics of medicine in the special nature of the physician-patient relationship? Pellegrino's quotes are found in an article entitled "Guarding the Integrity of Medical Ethics-Some Lessons from Soviet Russia" . The subversion of medical ethics in Russia suggested to Pellegrino two lessons. 1) corruption will afflict any health system not designed with care of the patient as the its primary driving force. 2) medical ethics must be independent of political exigency. "... a morally responsive profession is an indispensable safeguard for the sick against the statistical morality of utilitarian politics, even in democracies." The statistical morality of utilitarian analysis seems to be increasingly unopposed as the group outcome derived data plays an increasingly large role in the decisions regarding the individual patient exhibited in part as guidelines executed by mid level practitioners as well as physicians. In this new day, the physician has more to worry about that just her patient, she must be concerned for everyone (as allegiance to social justice would demand) but at least she has been removed from the impossible role of being responsible for every aspect of his patient's well being as she is now (merely) a member of a team or perhaps the host of a medical home and part of a system of health care. It takes a village now to treat a patient. ______________ With increasing pressure for a single payer health care system and talk about a federal health board to determine what should/shall be done, the statistical morality of utilitarianism seems more and more on the ascendancy. As much as I do not want to believe it, more and more I am afraid that the old medical ethics may well have been and is now the "artifact of economics" about which Pelligrino speculated.

How reliable are tissue diagnosis of follicular thyroid carcinoma

In a study by Cipriani et al (1) in 2011 a pathology review of 66 follicular thyroid carcinoma (FTC) by three pathologists the diagnosis of 47 was changed (71 %).24 cases were reclassified to papillary carcinoma,18 to follicular adenoma, and five were reclassifed to poorly diffferentiated thyroid carcinoma ... A change from FTC to PTC (to follicular variant of papillary) is an order of magnitude less serious that changing the diagnosis from FTC to poorly differentiaed thyroid carcinoma.Further the change from Carcinoma diagnosis to thyroid follicular adenoma occured in 18 cases ,a change with obvious therapeutic implications.So in 23 cases (five plus eighteen ) the incorrect diagnoses have major and serious impact in almost half of the cases. FTC specific survival forthe reclassifed cases was 77% at ten years and 33.7 at 20 years. There are two major issues in which disagreement frequently occurs:1) whether or not there are areas of atypia as seen in papillary thyroid cancer and 2)whether or not there is invasion either of the capsule or angioinvasion. In some cases the reviewing pathologist believed that the invasion criteria used by some of the of pathologists were not sufficent and therfore the diagnosis was follicular adnoma. The cases were from well known and higly respected institutions ( MGH and University of Chicago) from 1965 to 2007 and all cases had undergone surgery and /or RAI treatment.The slides were reviewed by three pathologists from those institutions.You have to wonder what the error rate might be at the thousands of less pretigious institutions in the country and what the impact might be on patients whose diagnosis was wrong. .... If almost 3/4 of the diagnoses of FTC are on review found to be incorrect with with almost half being reclassified to papillary and around 10% being reclassifed to undifferentiated and about 30% not being carcinoma at all ( i.e. reclassified to adenoma) how accurate are the prognosis made on that basis and similarly how accurate are the data regarding effectivenss of various therapies. The recommendations of the American Thyroid Association as well as all other therapy recommending organizations begin with the implcit assumption that the diagnosis are correct, that is FTC is really that and not an adenoma with a excellent prognosis or a poorly differentiated carcinoma with a extremely bad prognosis regardless of therapy.You have to wonder how many patients with a benign adenoma underwent thyroidectomy and I 131 remnant ablation. If this study is representative of the general stratus of the pathological diagnosis of thyroid cancer how accurate could prognostic statements be ? 1 )Cipriani NA et al Follicular Thyroid carcinoma.How have histological diagnoses changed in the last half century and what are the prognostic implications? Thyroid, vol 25 number 11, nov 2015

I did not go to medical school to practice population medicine but maybe medical students do now

First do no harm,primum non nocere and do what what is right for the patient.Those were the core principles taught to me and my medical school classmates. In the more formal language of ethics, the driving principles were non-maleficence and beneficence.

Those were pillars of medical ethics and of the medical culture.

However, in recent years we have seen a major effort ,with varying degree of success, by prominent medical organizations and foundations  to change medical ethics and the culture of medicine.This is not just my interpretation of recent trends but direct quotes from leaders of several medical organizations say that is exactly what they wish to do.

While a number of organizations including foundations and think tanks have taken part in this effort my focus  in this commentary  is on two such organization-the American College of Physician (ACP) and the American Board of Internal Medicine (ABIM) and its affiliated foundation the ABIMF.

Basically the proposed change is the shift from the medicine of the individual wherein the physician acts in the interest of the patient ,that is  as his fiduciary agent to the concern for the health of the population or the collective which is referred to by its advocates in the less emotionally charged term "population medicine".

ABIM and ACP have orchestrated  two major initiatives; the Physician's charter and the Choosing Wisely Campaign.  the later of which I believe which functions as a Trogen horse.


The 2002 publication of Medical Professionalism in the New Millennium: A Physician Charter played a major role in the movement toward the practice of population medicine .It was the result of a collaboration of the ABIM Foundation,the ACP Foundation and the European Federation of Internal Medicine. The Charter described three fundamental principle of medical professionalism.
 Principle of primacy of patient welfare.
Principle of patient autonomy
Principle of social justice. Physicians must promote social justice in the health care system, including the fair distribution of health care resources.

Although the Charter said " physicians must reaffirm their active dedication to the principle of professionalism.".The third principle,social justice, had not been a feature of traditional medical ethics so it could hardly be reaffirmed. The authors gratuitously added a new principle to medical ethics and then in their concluding remarks pretend that physician must reaffirm a principle not previously part medical ethics .

The Charter also presented a "set of Professional Responsibilites", one of which was:
 

"Commitment to a just distribution of finite resources. While meeting the needs of individual patients, physicians are required to provide health care that is based on the wise and cost-effective management of limited clinical resources."

 Further in the same section of the paper physician are admonished to work to "minimize overuse of health care resources"

So under the rubric of " social justice" the authors instruct physicians  to provided health care that is wise,cost-effective and fair.The Charter was silent,however, in regard to how would the practicing make operation the principle of social justice . Later ACP and ABIMF would give instructions in that regard. Spoiler alert-it relates to following guidelines based on cost effectiveness criteria.


Since the Charter was proposing a sea change in medical ethics,voices were raised in opposition.
A particularly articulate critique was made by Dr. Richard Fogoros, who was blogging under the name DrRich  on the blog  The Covert Ratoning Blog . Quoting from his January 18,2010 blog commentary:

"The New Medical Ethics,...(Annals of Internal Medicine, February 5, 2002, vol. 136, pages 243-246), is deficient in the following ways:

• it undermines the foundation of the doctor-patient relationship,
• it threatens to fundamentally destroy medicine as a legitimate profession, and
• it places patients at grave personal risk whenever they encounter the healthcare system"

  Acceptance of the Charter by scores of other medical professional organization.

The second major initiative to change the medical culture began as what seemed to be a very reasonable and non controversial  suggestion. Physicians and their patients were encouraged to have a dialogue and discuss various tests and treatments as they applied to a given patient in regard to the elimination or at least reduction in the number that were thought to be unnecessary,possibly dangerous and costly. This initiative is known as the choosing wisely campaingn.

This quote for Wikiipedia summarizes the relationship between the Charter and Choosing Wisely :


...The charter states that physicians have a responsibility to promote health equity when some health resources are scarce.^[1] As a practical way of achieving distributive justice, in 2010 physician Howard Brody recommended that medical specialty societies, being stewards of a field, ought to publish a list of five things which they would like changed in their field and publicize it to their members.^[1][17][18] In 2011, the National Physicians Alliance tested a project in which it organized the creation of some "top 5 lists".^[1][19][20] Analysis of the National Physician's Alliance project predicted that the health field could save more than US$5 billion by cutting waste.<sup>[1][19][21]"


So the basic principles are : physicians are stewards of medical resources and that they need to work for health equity and that by cutting waste and saving money distributive justice would be furthered.</sup> 

Dr,Cassel in an August 2012 talk about Choosing wisely at Universality of California recalled that the CW program really begin a year earlier when she and others, including Dr. Berwick and leaders of  the not for profit publication Consumer rRports met.

Consumer Reports,though purportedly non political  supported Obamacare and the presidential appointment of Dr. Don Berwick to lead CMS.

Population Medicine as a form of utilitarianism based on on some nebulous impossible to quantify notion of utility or happiness based on the purportedly objective measure of QALY.

I did not go to medical school to work to maximize or optimize the overall health of some population  based on some metric and some ultimately subjective value judgment of a planner but times have changed and my generation of physicians is retiring and dying off.The dogs barked and the caravan moved on.

Will long term endurance exercise really keep a youthful heart

 Willl longtime endurance exercise really preserve ( help preserve) a compliant left ventricle (LV) and mitigate the age related stiffening of the LV and the aorta?

Is the only solid evidence for that thesis the extensive work of Dr. Ben Levine and his coworkers at the Institute for Exercise and the Environment?

Some longitudinal studies have shown that active exercise achieve grater preservation of 02 max than do sedentary people but there are  studies that contradict those findings.

Possible mechanisms by which long term exercise might preserve a compliant LV include:

animal work showing that rats with long time exercise develop elongated muscle fibers

improvement in calcium transport during relaxation 'increase in myocytes and improve fatty acid oxidation decreasing lipotoxicity  Bhella , Impact of lifelong exercise dose on left ventricular compliance and distensibiity J Am Coll Cardio. 2014 vol 64 no 12 

Beware- CHATGPT 's references sometimes are fabrications

In recent weeks there have been numerous internet compliants about ChatGPT.Some of them are regarding erroneous references or citations, I had an expereince with that. I was chatting with this system about a medical case of peripheral neuropathy.It said that distance running was a recognized casue of periphral neuropathy.I asked for references and three were provided. I tried to find the references on PUbMED and they were not found.I asked for three more references.Same result.I then asked ChatGPT if the refereces were made up. It replied that It was sorry for "misunderstanding my question" The six references given were all bogus.They had title and journal names that seemed real but the actual reference was bogus. Several people have made comments on various internet sites that the references or citations provided in a ChatGPT essay were fictitious.This behavior had been referred to a "hallucinations" More recently I questioned ChatGPT about certain aspects of conduction system cardiac pacing.The discussion seemed reasonalbe as least to the level of my non EP level of knowledge but one of the references could not be confired.I asked for another referece and this time the reference was correct-that is it was a real reference but not quite what I had asked far. So if it is the case that sometimes the references are valid and sometimes not may be even worse that if they were all fabrications.At least so far it did not try to lock me out of the space ship.

Here is how a physician can be a steward of health care resources

I knew from the first day of medical school that this doctor business was not going to be easy. We were told how many newwords and and concepts we had to master in the next few months,how some of us would not make it and how as physicians -if we even made it that far-would continues to have to work hard to continue to master new information and techniques.

As the years went by medical school, residency, fellowship all had their share of difficulty concepts to master and there was always something else to learn - always the perception that you needed to known all you could as you had people's health and lives in your hands.The rewards could be great but so were the challenges and the continuing obligation.

But then with the publication of the Physician Charter,the new medical professionalism,things seem to get even harder as a new daunting task appeared on the scene. Now doing your best for your patient to live up to your fiduciary duty was not enough, you also had to work for social justice and be a steward of society's finite medical resources.

Wow, that certainty didn't sound easy. In fact I had no clue as to how to live up to that new obligation nor understood  exactly what these those terms even meant and was it not the case that sometime an individual's best interests conflicted with those of society assuming that the later interests could even be appropriately defined.

It was years later when I finally realized how I could live up to these new ethical obligations an exemplify the traits expected and demanded of a professional in the new milimeum and now it seems very easy.

It is easy because the medical progressives,the elite,the thought leaders , the hierarchy of various medical professional organizations will make it easy for the rank and file medical practitioners in the field. These leadesr will determine what is of value not only to the patients but to society. So based on what is high value guidelines will be forthcoming and the field docs will only have to adhere to them to do what is right for the patient which will also be what is in the best interests of society.

 Any concern that I might have had about some conflict between the interests of the individual patient and society will vanish because as Victor Fuchs has told us what is good for the group will necessarily have to be good for your patient as well as he is a member of the group which is benefited. It gets better. The tests or procedures that you deny your patient is now understood to not be rationing at all. This is the case because some of the members of ACP elite has wisely redefined rationing as restricting the use of effective,high value care. So restricting lower value are is not by definition rationing at all.

This important role of determining what is high and what is not high value care is not the slam dunk that some members of the USPSTF task force said in regard to their pronouncement of no need to do any PSA screening. No this type analysis requires specialized expertise and training and is "typically performed by investigators", ( such as those writing the above referenced Annals article) 

How do we know what is right? Easy do a meta-analysis

After all the cochrane group says that in regard to establishing scientific truth the "systematic review of all relevant randomized clinical trials is the highest level of evidence."

What seems to be a different view is that the following characterization of the MA by Dr.Steven Goodman who explains that a MA is basically an observational trial in which the subjects are themselves clinical trials. In the traditional hierarchic of clinical evidence observational trials are not considered the top of the pyramid.

so what is it-the highest order of evidence or merely a lowly observational study?

What does "impaired relaxation" on echo report mean and what to do about it

Half of the patients labelled as having  heart failure are designated as "diastolic heart failure" or HFpEF,  the currently prefered medical jargon for heart failure with preserved ejection fraction. The other half of HF patients have heart failure with reduced ejection fraction or HFrEF.

Both categories are creatures of the echocardiogram.The ejection fraction or EF is the ratio of the stroke volume to the volume of blood in the left ventricle at the end of diastole.Diastolic dysfunction is defined by various combinations of other echo measurements, that relate to how easily blood flows into the left ventricle during the ventricular filling phase aka diastole and strive to be clinically useful indicators of an elevated left ventricular filling pressure (EDLVP)

It seems to be the case that as humans age the blood flow less easily into the left ventricle due to a number of related and as always in medicine or biology poorly understood factors.These include the capacity of the ventricle to relax after ejecting the blood in systole,how stiff or compliant the ventricle is,the geometry of the ventricle, how well " restoring forces"  (aka elastic  recoil) - THINK HERE OF COmPRESSING A TENNIS BALL AND THEN RELEASING THEFORCE AND BALL POPS BACK IN SHAPEwork and the restraint of the pericardium.The key distinguishing characteristic of an elite endurance athlete is impressive diastolic filling.

Ventricular  diastole flow is typically considered to have two phases-the early rapid filling phase and the later phase brought about the contraction of the atria.These stages can be visualized and quantitated by placing an echo probe of the the mitral valve and measuring the velocity of early flow  (the E wave) and the late wave (the A wave) and if we have two numbers someone will make a ratio.

The ratio of the early velocity to the late velocity ( E/A ratio) is a simple measure of diastolic function.With aging early flow decreases (  generally thought to be due  in early diastole to impaired relaxation and loss of elastic recoil) resulting in a lower E/A ratio. This is considered to be the earliest stage of diastolic dysfunction in which diastolic flow is decreased but cardiac filling pressures have not significantly increased. As ventricular filling become more impaired pressure builds in the left ratrium so that early flow increases as does the E/A  restoring a normal appearing a pattern labelled as "pseudonormal" ( this stage is now referred to as "stage one " in the 2016  American Society of Echocadiography and the older terms for the more severe stages of diastolic function,pseudonormal and restrictive have also been replaced with stage 2 and stage 3.)

Not only can diastolic flow across the mitral valve be measured by echo so can the movement of the supporting tissue of the mitral valve ( mitral annulus). The early movement , coincident with the E wave is labelled e prime and the late movement a prime.
But what to about echo reports that state impaired relaxation.Is it "normal for age" or a possible percursor to HFpEF.is there any role for aerobic exercise to lessen progression to HFpEF?

Is medical ethics a social,historical or economic artifiact?

The title question was raised in an article published in the Journal of the American Medical Association in 1995 by dr. Edmund D. Pellegrino (JAMA,may 24/31, 1995 -vol 273 no 20.)The article was entitled "Medicine and the Holocast:Learning more of the Lessons."

Pelegrino explains that the idea that the German war crimes perpetrated by physicians ( at least people with a medical degree) were the acts of only a handful was wrong. Many more physicians were involved in the what transpired under Nazi rule. He quotes historians who have demontrated how pervasive was the corruption and the degree to which German physicians "began to elevate service to the state above medical ethics"

Is the ACP's notion of value centuries behind current economic tought?

Is value subjective? Is value derived from the labor going into a good or service? Do business owners exploit their employee by stealing their "surplus value"? Why do diamonds cost more than water while water is necessary for life?

The value theory of value was promoted by David Ricardo and bought into and popularized by Karl Marx.

However, in the late 19th century three economists developed economic theory that became known as the marginal revolution. Value,they said was not something inherent in the object but value results from the subjective evaluation of the person and that evaluation is made at the margin. For example, if you have 20 apples you are likely to value the 21st apple less.

Tales of "corporate medicine"- care delayed may equate to care denied

 In this essay I will describe how the evaluation of a medical problem seems to work in at least one large not for profit big city hospital system and how that differs from how it used to be in a physician owned fairly large internal medicine practice in the same big city.

The basic events described are true but some non-essential details are altered in the following  narrative  to shield the identity of the innocent and the not so innocent. 

William G,a retired 78 year old accountant  has a routine annual visit with his primary care doctor who is a board certified ( and re certified ) internist.WG thought it was an annual exam but in reality, it was a modified Annual Wellness Visit (AWV) in which there was no physical touching involved between patient and physician. WG's red blood cell count was reduced from the previous year and the iron studies were done and they were consistent with ( but not diagnostic of) iron deficiency anemia. Based on his age a GI workup ( ie upper and low GI endoscopy) was in order and WG set off to get an appointment with a GI doctor in the same hospital system who had done a coloscopy for WG three  years earlier. Although he was an established patient it was 3 week before an office visit could be scheduled and the another 5 weeks before the endoscopy procedure could be scheduled, a frustrating 2 month delay.

When I was in internal medicine practice in the 1970s in a physician owned group the time from one partner having a patient needing a GI endoscopy to seeing one of the GI docs in the group would have been one or two days at the most and the procedure would have been scheduled in another one to three days at most. 

In the private practice group the clinic administrator worked  for the doctors and in the large big hosptial system to some degree it is the other way around.The staff who do the scheduling are hired by the hospital and work for the hospital 

Do the arguments of Kenneth Arrow and William Baumol forclose Market solution provison of health care

The overly long tittle  refers to Kenneth Arrow's information asymmetry argument against fee for service in health care? Does "Baumol's Cost Disease" lead to the conclusion that health care must be paid for by the goverment through taxes?

In regard to Baumol's disease, it is far from the case that his formulation is unchallenged. Baumol makes a number of simplifying assumptions and aggregations in his model most of which have been seriously critiqued. For example see here for an excellent detailed economic  analysis of his assumptions and his logic and analysis. But as usual the headlines are on page one and the clarifications and retraction are found buried much deeper in the paper in smaller type .

Still more ways to cook the clinical trial books

Clinical trials are concerned with efficacy and safety. There are statistical tricks and methodologic manuevers than can be used to either give the illusion of safety when that has not been proven by the data and/or likewise give the appearance of efficacy or equivalence with a comparison drug when the data does not really allow for that conclusion. Some of these methods are intuitively obvious-once they have been pointed out-others are more subtle and require a degree of sophistication not typically possessed by the average physician and at a level not likely to be taught to most medical students.

Here are some of the simple ones :

use a dose of the comparison drug that is too low(or too high) depending it you are trying to show equivalence or superiority or comparing side effects

in a comparison trials -keep the power low by have a relatively small trial

measure multiple endpoints but report only those that are favorable

use sub-group analysis to find a set of patients in whom there appears to be efficacy

arrange multi-center trials reporting those results from centers in which the right answer is found

cherry pick the subjects to minimize likelihood of side effects

report composite end point results when demonstration of efficacy is the aim and report individual safety outcomes when safety demonstration is the aim

Is the internist as the "doctor's doctor" no longer existence?

 In the days when I trained as an internist and for another 20 years or so after that medical folks talked about the doctor's doctor. This referred to an internist known for his meticulous history taking skills and performing a very complete physical exam that would at least sometimes find something others has missed, He (and it was not always a he) was the physician to whom other doctors would refer to when they or their family member had a serious or mysterious medical condition or maybe just for reassurance. 

However, as time went on the monetary compensation of the internists shrunk to a point (where for example they make only slightly more than a CRNA) and there was no time to take the time the oldtimey internist took because they could not afford to.Less compensation per patient lead to more patients per hour needed to be seen.

Recently I learned of an encounter a relative living in France had with his internist.At least there is one internist in France who seems much like that idealized internist that my fellow internal medicine residents and I hoped we could become.

My relative had been the victim of a missed acute appendicitis and was now several weeks post  percutaneous drainage of several abscesses secondary to a ruptured appendix and was awaiting a follow up appendectomy 

The internist took very detailed history and examined him and agreed with the need for follow up appendectomy and gave him the names and backgrounds of several surgeons.

Senior internists in France earn about $21200 per year only slightly less than US general internists but graduate from medical school without significant debt and have low malpractice premiums and are largely free of the major hassles of insurance approval for testing.Perhaps their practice styles allow them more time to be more like the stylized internist model of the past in the U.S.Alternately perhaps my relative's internist was an aberration.  

 

'I knew much more then than I do now"

A few years ago I spent some time doing "well baby" exam on employees and the executives of a large international company. The emphasis was on prevention or "preventative" (this had become a real word) medicine.

"Determining" the risk of a heart attack for an individual patient was routine.Determining  is in quotes because that seems to be a verb to use to magnify or exagerate the imporance or validity of what may be an educated or partially educated guess or even something less valid than that i.e. something you just make up.

do endurance athletes live longer beause of voluminous exercise or because their genes predispose them to high 02 oxygen uptake in later years?

If data show that endurance athletes live longer than non endurance athletes is it  so because of the life prolonging effects of endurance exercise performed over many years or is it the case that the endurance athletes genetic inheritance allows them to not only run long and fast but to survive longer. By survive longer I mean in part that for example  an octogenarian with an 02 maX of 30 is more likely to withstand the physiological trauma of septsis or major trauma better than an age cohort with an 02 max of 19.

A person',s maximal oxygen uptake(v02Max) is a strong predictor of life  expectancy. A major part of frailty in the elderly  is a low 02 max.

LGE in long time endurance athletes may not mean a potentially arrhythmogenic scar

 Late gadolinium enhancement (LGE) in long time endurance athletes may not mean scar tissue  (in the sense of replacement scar tissue ) and may represent a "benign" finding.All LGE may not mean  the same type of tissue alteration.That particularly applies to LGE at the insertion points of the right ventricle (RVIP).

 See Grogoratos,c clinical importance of late gadolinium enhancement at right ventricular insertion point Int J cardiovascular imaging 2020 .

  and Shambhag SM et al https://academic.oup.com/eurheartj/article/40/6/529/5185127

"... LGE at the RVIP ( right ventricular insertion points) has been proposed to represent focal plexiform fibrosis (associated with myocardial disarray rather than replacement fibrosis"  Bravo, PC, Late gadolinium enhancement confirmed to the right ventricular insertion points in hypertrophic cardiomyopathy an  intermediate stage phenotype, European heart journal cardiovascular imaging, 2016 Mar 17(3) 293  /// this article references the following as the source of the plexiform fibrosis pattern 

One key question is  does plexiform fibrosis pose the risk of inciting an arrythmia that does replacement fibrosis.  

 See also Moor, JC, The histological basis of late gadolinium enhancement in cardiovascular magnetic resonance imaging  in hypertrophic cardiomyopathy. Amer Coll cardio 2004 43 2260 

Does the classsification of atrial fibrillation need to be revised?

I think so , here is why,

 Paroxsymal atrial fibrillation  (APF) is currently defined a a spontaneous remitting episode of atrial fibrillation (AFIB) lasting less than seven days and resolving without intervention. Current U.S. guidelines recommend oral anticoagulation therapy (OAC) for patients with all types of afib based on the stroke risk estimate using  CHA2DS2-Vasc score.

Modern pacemakers (PM) can now record tracings continuously and store them for long periods of time. Several studies have analyzed these tracings and we have learned that commonly PM patients have short runs of Afib,( or more accurately  atrial high rate episodesAHRE-some of which are in fact  not AF)  varying greatly in duration and frequency .

It does not make sense to assume we should have the same prognostic concerns  and therapeutic recommendations   to someone with a episode of afib lasting one minute as to  someone with afib lasting  five days without good data validating that position.

Several studies have attempted to correlate these runs of afib with stroke  rate. With one exception data  (see footnote 1) have not been analyzed if these episodes last less than 5 or 6 minutes.These studies have shown that there is a  coarse grain dose response relationship  between duration or  "burden" of afib and stroke risk. Attempts have been made to determine an afib burden level above which there is a significant increase in risk worth of initiating anticoagulation  and no consensus has been reached.

Various investigations have yielded different burden levels .

The ASSERT trial is widely quoted as showing a two fold increase in stroke risk for episodes of afib last over  6 minutes. See footnote 2 for a discussion of the surprisingly and diametrically  different ways these results were described in medical publications.

Yet another article discussing ASSERT  claims that a fib greater than 24 hours does have increased risk of stroke but for shorter episodes no statistically significant relationship was shown.





footnotes:

 1. The Rate Registry study reported no increase risk of stroke for afib duration episodes less than 10-20 seconds.But what about those episodes between 20 seconds and six minutes?

2. Chin-Scarabellit et al including senior author K. Ellenbogen  describe the ASSERT trial simply as showing  an increased hazard ratio (HR) even though it was not statistically significant while Conn  et al  say "surprisingly,no correlation was found in the ASSERT between AHRE (atrial high rate episodes) and a history of stroke" and speculated that this might have resulted from the fact that the sampling period was only the first 3 months after PM implantation. A third spin on the ARREST was offered by Dr B P Knight (EPLab Digest March 2012) who said that only the  highest quartile of duration ( more than 18 hours) was statistically significant.He did not discuss the problems involving in relying on subgroup analysis to reach a conclusion regarding outcome validity less alone  making therapeutic decisions on that basis. Data is often hard to obtain but sometimes  the real difficulty is in finding agreement as to what the data signify.

The demise and possible impending death of internal medicine

I can remember when being an internist was a really big deal. You were consulted on complex ,complicated cases and frequently some of whom were critically ill. In the city where I practiced , lets call it Metropolis,internists  were frequently the physicians to whom general practice physicians in outlying cities would send their patients who were very sick when they did not know either what was wrong with them or what to do (or if it was Friday afternoon on the weekends whenyou were not on call)

We used to complain abaout the Friday afternoon late call about from Dr. Brown who asked if could transfer Mrs Jone to your hospital. We were specialists and in an earlier era we were called diagnosticians .

Thee once was a organization called the Metropolitan Society of Internal Medicine. In its day there were several hundred members and monthly meeting were very well attended, often approaching 100 attendees. Membership  was not open to anyone who called himself an Internist, you had to be Board Certified or Eligible to apply and there was a membership committee who oversaw the approval process.

I remember the last meeting I attended whee the members and guests were seated a one long table seating about 15 people. Today there is no such society.

I recently  scanned the County medical society bulletin and say many other societies listing their dates for meetings.The internists society was no longer listed.

Libertarians and egalitarians both favor equality of opportunity but have different concepts of opportunity

Some (many?) conservatives and libertarians seem to think that they favor equality of opportunity while the progressives or egalitarians favor equality of outcome. Not so, the egalitarians say that they too favor equality of opportunity not outcome.

 Their view of opportunity includes the following consideration. If someone is ill,or poor or has some disability then they cannot enjoy equality of opportunity. A chronically debilitated,poor person does not have the same opportunity to obtain employment or get health care insurance or buy nutritious good or decent housing. Just as the modern day liberals ( progressives) have co-opted  the term liberalism from the use of the word  as in classical liberalism (now libertarianism), they seem to have co-opted equality of opportunity to mean much more than equality under the law which is typically the sense in which libertarians and conservatives  use the term.

The egalitarian ethic is not just an abstract principle but an imperative to do something about the inequality of  opportunity. Charity would be one method of mitigation of inequality but while many sincere progressives and egalitarians volunteer and contribute to charities their broader solution is government enforced redistribution of resources to lessen whatever inequality that is of particular concern at that time.

Here , of course, is the area  in which conservative and libertarians and  progressives part company  and it becomes clear that the opposing groups do not seek the same rules of society.They both may favor equality of opportunity but mean different things by the word.


Now what about the term social justice?


To the progressives social justice means taking action to mitigate instances in which there is unequal access or unequal opportunity that is brought about by many societal factors , such as poverty  and poor public schools.



 The classical liberal concept of justice is the securing to individuals a domain in which they are protected from interference from others and from agencies of the state while Rawls et al  maintain  that limited view of justice does not recognize "that distributive shares ..are often determined by factors that are "arbitrary" from a moral point of view,eg the inheritance of certain factors, intelligence ,strength ,social advantage,wealth  that are just the luck of the draw and the recipients are not deserving of those advantages. even if they work hard and use those advantages well those accomplishments are still arbitrary from a moral point of view.As Hayek said, the term justice does not need a modifier.

The unexpected relationships between both high dose statins and high level endurance exercise and coronary calcification

 The jury  has been back for a quite a while. Statins decrease the risk of coronary artery events. The curvilinear relationship between exercise and coronary artery events is also apparently beyond debate.

So one would not predict that both statins and exercise could be too much of a good thing in regard to coronary artery disease. Remember coronary calcification is, by defintion,coronary artery disease. 

There are ample data demonstrating that long time and high dose statin use  may increase the development of coronary calcification.In addition,there are reports of increased coronary calcification in long time marathon runners and endurance athletes. 

So,how does this work? Exercise at least  up to some level (that  level has yet to be defined) decreases CAD risk but at some level increases coronary artery calcification which is a marker of CAD. Is the calcification different in endurance athletes? There is evidence that in endurance athletes who have coronary calcification that there are more of the dense variety and less of the mixed type which is thought to be more likely to thrombosis. 

Can internists keep up with medicine

 I have sampled four internists , two in active practice two retired more than 10 years earlier.Perhaps we can excuse the ignorance in the retirees.

All were woefully ignorant about the basics of the most common cause of anemia in the world,Iron deficiency anemia (IDA).

Case in point. A 78 year old man is noted to have a decrease of more than one gram in his hemoglobin from the previous annual "wellness meeting" which should not be confused with the annual physical exam which at least for some perhaps many Medicare patients is a thing of the past.Medicare will pay for an  annual wellness visit but not a real hands on physical exam.  The internist who  practiced in a practice group associated with a large "not for profit" hospital system recommend he take ferrous sulfate three times a day,

Note- there was not at the time a recommendation for the patient to have a GI tract evaluation, not even a stool Guiac was mentioned. In 2019 a influential often quoted article by Ganz and Weiss included a flow sheet indicating that older patients ( over fifty) undergo a upper and lower endoscopy to rule out a source of bleeding if their initial blood tests has a pattern consistent  with ( but not necessarily diagnostic of ) iron deficiency anemiaThe patient 's blood test fit that pattern. This  pattern was low serum iron and percent saturation and a ferritin less than 100. Possible iron defeciency anemia in a man over fifty certainty warrants an evaluation for GI tract bleeding.

As the case evolved the GI doc's ignorance re IDA was revealed when he commented that a subsequent increase in the patient's ferritin reflected increasing iron stores. These two internists apparently knew little or  nothing about the iron regulating hormone,hepcidin,   If they did they would know how to administer oral iron and how to use the ferritin  ( and other tests suh as the Ferritin index )to help differentiate between IDA and anemia of chronic inflammation and their combination.

Medicare Wellness Visit will not detect early disease but it is quick easy money for internist

 For the past five years I have taken part in a version of the Medicare Wellness Visit with the addition of a series of blood tests.During that time a thyroid cancer grew to the size of a very large egg ( 5.5 cmX 3.5X 3.5) before it was finally detected from a cervical spine CT. Medicare Wellness exam is reimbursed by Medicare reasonably well but Medicare does not pay for physical exams

My medical " care " during  a nine month period during which I was ostensibly  being evaluated for a mild anemia is notable for the following:

1.The entry of a number of errors in my medical chart ( which is recorded in a widely used electronic health record (EHR) My diagnosis included atrial fibrillation and diabetes neither of which do I have.The EHR continues  to admonish me that my diabetic eye exam  and diabetic foot exam are  overdue.

2.The ignorance of my primary care doctor and a GI specialist  in regard to the diagnosis and treatment of  the most common anemia in the world namely iron deficiency anemia was not reassuring. Both of their  knowledge gaps could have been quickly corrected  by spending a few minutes accessing Up T0 Date on their  electronic device.

3.The alarmingly long time lag between various elements of my diagnostic workup which took place in a nationally known and highly ranked medical care system AKA hospital system. For example from the time my  thyroid cancer was diagnosed by a fine needle aspiration (FNA) until the day of surgery was 43 days.

4.Entries in my record of several "phantom" medical exams. By phantom I mean description of exams that were in fact not done but still attested to by the physician's electronic signature. Why do some many physicians put their signature to a cut and paste exam that was not performed? Do they know what they will say if asked at a future deposition 'Doctor, did you actually do a exam on Mr.Jones on such and such date? Do you routinely lie on the medical record? .During a nine month period I was seen in the office by physicians 8 times and none of them apparently even looked at my neck let alone felt my thyroid gland  though on several occasions a normal thyroid exam was recorded in the chart  ( ie. the phantom exam).

5.My bone marrow aspiration and biopsy was done by a NP who told me she had been taught the procedure by a hematologist only some several  months earlier. A noteworthy thing about the BM exam was the price charged ($ 23,000 ) by the hospital.

6.The thyroid mass was detected by a CT of the cervical spine ordered by a neurologist who never did notify me of the abnormality. Fortunately I was able to access the report and read of the finding myself. An earlier chest CT report did not mention a thyroid mass although it was clearly visible. 

7.Astonishingy an ENT specialist who did a fiberoptic office exam of my throat for evaluation of a cricopharyngeal bar recorded a normal neck exam including the comment that the thyroid was free of nodules did not  perform an exam of the thyroid at all. One week later the cervical CT showed a thyroid mass 5.5 cm in its largest dimension. I had to wait 6 weeks for that ENT appointment.

8.The pathology report of the surgical specimen of the thyroid tumor has a number of syntactical and transcription errors,likely representing inconsequential errors but IMO reflecting an alarming lack of proofing and professionalism.

(9 The attending surgeon and the consulting endocrinologist both  either misread the pathology report or did not understand the significance of the reported findings and both told me that it was a very low risk variation but after the case was presented to the tumor board both amended their evaluation and recommendations accordingly based on the microscopic findings.

Iron deficiency is common in endurance athletes

 Iron deficiency is common in strenuous exercise i.e in  endurance athletes.

In runners "GI iron loss"is frequently mentioned as a possible cause of the iron deficiency frequently observed in runners but those publications rarely describe or explain exactly what they mean by GI  iron loss. 

Do they mean that the incidence of well recognized causes of GI bleeding (colon cancer,polyps,peptic ulcer etc) are common in runners. I find little evidence of that.Perhaps the reference is to some  type micro bleeds. Or do they mean there is some physiological mechanism by which there is GI iron loss without gross GI bleeding  namely occult GI bleeding ( ie. normal stool color with a positive hemoccult test).

Actually there are data indicating occult GI iron loss  with at least  one  study with positive  guaiac tests post marathons and another  pre and post marathon  upper endoscopy study showed some small lesions in the stomach that could possibly cause small amount of blood loss.

There is a physiologic mechanism by which runners ( and other endurance athletes) loose blood in the GI tract.The mechanism is the sloughing off of iron loaded duodenal luminal lining cells (aka enterocytes) Actually this is a physiologic process that happens in everyone but is believed to be significantly increased in endurance athletes particularly runners because they may have more exercise induced hemolysis which in turn leads to more iron loss due to duodenal cell sloughing which is intensified by hepcidin release for exercise which traps the iron in the duodenal cells and the macrophages. Enteroyctes have short ( about 3 day) life span.

Here is an "as if"  story of how that might work. Strenuous exercise leads to the release of IL6 which in turn stimulates the release of hepcidin, the hepatic hormone that is the master regulator of iron absorption and transfer and storage. (The putative release of hepcidin by IL6 is not crucial to  the story  it is the release of hepcidin that is important ).Hepcidin blocks the release of iron from the enterocytes and from macrophages slowing down the transfer of recycled iron to the bone marrow. 

  The Assocation of iron deficiency and running is well discussed in the sports medicine literature and in the lay runners press but much less so the hematology journals.

Are the Strauss criteria for diagnosis of LBBB best to predict outcome of CRT

 Are the Strauss criteria for LBBB diagnosis best suited to predict favorable outcome for CRT ?

Jastrzebsi et al have published data suggesting that the answer to that question is yes. The authors compared four EKG criteria for the diagnosis for LBBB and then compared the outcomes of CRT of patients defined as having LBBB by the various criteria. Patients with Strauss defined LBBB did better than the patients with LBBB defined by other criteria.

This study supports the notion that LBBB defined by Strauss detects so called "true LBBB" with delayed activation of the lateral left ventricular wall and the abnormal inter-ventricular septum motion which can be detected by the "septal flash" on cardiac echo exam. In other words the Strauss EG patterns seems to detect patients whose conduction defect(s) is most likely to be corrected by CRT differentiating it from various  "non-specific intraventricular conduction defects".

Jastrzebski,M et al Comparison of fojr LBBB definitions for predicting morality in patients receiving cardiac resynchronization therapy. Ann Noninvasive Electro 2018 23 (c) e 12563

Smart phone apps for Medtronic pace makers good for patient?or good for company?

 My pace maker battery life is on the downslope  of available electrons.This week I had an in office PM interrogation and the company tech took the opportunity to promote their new option ( for some units) namely an app for a smart phone to replace the bed side transmission unit I have now. 

I personally believe the patient  should  have full access to all of the information typically displayed on the interrogation reports.What Medtronic seems to offer to the smart app holder is the battery voltage reading and the expected battery lifetime and the daily activity.   You will need to use your app to send in the interrogation to the Medtronic mother ship from which your physician or the third partly interrogation report reader company can access the report.

So  now it seems that  gathering the data from your Pace Maker and transmitting  it to Medtronic falls upon the patient and his internet connection and his modem/router. while previously all of that was done by the hardware and software supplied by the pace maker company. You did not need an internet  connection or even a phone line which in the past was a means of sending in data to the company/

My thinking is that the current bed side system works well and I see no reason for me to take on the responsibility of the care and feeding of the electronic mechanisms and hardware to transmit the interrogation.When and if the bed side unit fails or wears out Medtronc will send you another without charge.When your smart phone dies you will replace it .

In 2013 the Heart Rhythm Society published a position  paper on the issue of remote interrogations (RI) and remote monitoring  (RM) of CIEDs ( cardiac implantable electronic devices).  As pointed out in the HRS paper, RI and RM are often used interchangeably with RM being used " colloquially for both" 

   

Libertarian takes on covid vaccination mandates and anti mandate mandates

 Robert A Levy of the Cato Institute discusses some aspects of the recently announced covid 19 mandates on the Septembers 1 Bob Harden Show podcast. 

Interestingly  Levy did not specifically use the term which is   the so called prime directive of libertarianism. The non aggression axiom. If one believes that the world is in the throes  of a pandemic involving a respiratory virus that spreads by aerosol transmission and that this  disease is very contagious and that vaccinated and of course unvaccinated can spread the disease and that masks mitigate the risk and that vaccination mitigate the risk then not wearing a mask in public in an area in which the disease is spreading should be considered an aggressive act.Therefore not wearing a mask under those conditions is about as un libertarian a thing as there be.  

 Governors Abbott and DeSantis have through their executive actions and/or legislation they sponsored acted to limit the private property rights of business owners in their states. Business owners have the right to set the terms and conditions of their employees and the terms of business arrangements of their customers. Both governors have prohibited  businesses from utilizing a de facto vaccine mandate regarding their customers. Conservatives have long favored a " no shirt,no shoes no service" business approach. which they now discard in an effort to what they seemingly believe to   gain approval of  a minority of Republicans who are perceived to be strongly anti  mask and anti covid vaccination under the faux banner of preserving freedom while actually abrogating the property rights of business owners. 

My "journey " with a pacemaker and His Bundle Pacing

 In October  2015 I was implanted with a pace maker which used a His Bundle (HB) lead.Every thing it seems now is thought of or written about as a journey so I tell my journey.

Since I developed a high grade second degree heart bock that was precipitated by exercise and a left bundle branch block (LBBB) also,I was a candidate for a pacemaker (PM) and cardiac resynchronization therapy  (CRT) which at the time was synonymous with bi-ventricular pacing (BI-V) .

BiV has been  accomplished by atrial pacing,right ventricular pacing and left ventricular pacing which was done by inserting a pacing lead into a vein of the epicardial surface of the left ventricule (LV) .which was accessed by placing a catheter into the coronary sinus in the right atrium and threading it into a LV epicardial vein.

My EP cardiologist had a different approach. He implanted a lead in the right atrium and placed the ventricular lead near the bundle of  His in the interventricular septumThe third  lead was placed in  a vein on the surface on the left ventricle.This bi-V approach  is done in cases of heart failure (HF) in which there is significant desynchrony of the left ventricle (LV) which reduces cardiac output and leading to significant deleterious cardiac remodeling. 

The LV lead was to be a back up lead and  in the first five years was not needed as during implantation the Right ventricular catheter recorded a His Bundle signal  which captured the Purkinje System and provided a narrow QRS complex replacing the LBBB. The HB pacing was considered to be "non-select" HB pacing as both the His Bundle and a portion of myocardium was stimulated giving an EKG with a delta wave resembling the EKG of an anteroseptal preexcitation pattern.

Non select HBP is thought to be as effective as select HBP ( in which there is only capture of the His Bundle and the EKG has an isoelectric  interval between the stimulus and ventricular capture signal) in terms of cardiac output.

HBP typically has requested a higher capture voltage than does right ventricular apical capture and has a greater incidence of need for lead replacement and may have a lower r wave. HBP has also required a longer implantation time and higher incidence of  failure to capture rate. All of those issues have become much less of an issue as operator experience has increased and better catheters have become available with procedure times being shortened, capture threshold lower, and fewer cases of that require a  lead replacement. 

The post implantation period was not without drama. The first night the chest pain was severe and frightening and I felt lightheaded. I had been NPO from midnight of the day preceding the procedure day  and although the procedure was scheduled for 7 am , because of an intervening emergency it was after one pm before I went into the cath lab by which time I was likely moderately volume depleted. 

This lead to a situation in which I had chest  pain and a low blood pressure.My wife also a physician were able to convince, badger and intimidate the rookie nurse to run in more fluid.The fluid and a shot of morphine  relieved the pain and volume depletion  correction alleviated the weakness. 

 3 days later I developed left sided pleuritic chest pain,a heart rate of 150 (shown to be atrial flutter on EKG) and an emergency Pulmonary CT angio was interpreted as showing several pulmonary emboli in the left lung and a peripheral pulmonary infiltrate in the same area. 

 Symptomatic Pulmonary emboli after pacemaker implantation are uncommon.One  study using  V/Q lung scans demonstrated probable emboli in 15% of a small number of asymptomatic casesI had a repeat pulmonary CT scan following 3 months of apixaban which was normal .

Six years later my pacemaker battery was nearly end of service and I had a pacemaker replacement. No post op complications occurred this time.

 

 In 2006 ,Rafael Barba-Pichardo et al  from Spain published a series of cases of HBP which included a single case of using the His Bundle to pace a patient with heart failure in whom a LV vein could be assessed. This appears to be first case report of HB paced CRT/

In 2010  DL Lustgarten et al accomplished direct His pacing in 10 patients who were candidates for Biv pacing.  ( Lustgarten Dl Electrical resynchronization induced by direct his bundle pacing ..Heart Rhythm 7 , 2010 p 15 

In 2017 Rodney Tung from Chicago and Kalyanam Shivkumar from UCLAA (2) reported a series of 21 patients in a study the purpose of which to assess the feasibility of a His-bundle lead for CRT in place of the coronary sinus lead.

1)Barba-Pichardo, R et al , Permanent His Bundle Pacing in patients with infra-Hisian atrioventricular block. Revista Espanola de cardiologia, vol 59m553-558

2)Ajijola,OA et al Permanent HIs-Bundle pacing for cardiac resynchronization :initial feasibility study in lieu of left ventricular lead.Heart Rhythm2017,sept 14 (9) 1353-1361

Exercise level ,cardiovascular risk reduction and risk of atrial fibrillation

 Six years ago  after I had recovered from my pacemaker implantation and the subsequent complications  (pulmonary emboli and pocket hematoma)  I mentioned to my EP cardiologist that I believed that I could run a half marathon. I had abandoned thoughts of completing a full marathon  because for  the proceeding two years I had barely finished in under six hour which was the cut off time to be officially counted as a finisher. for the full marathon.

The EP doc said that is not a good idea and when asked why he mentioned the risk of atrial fibrillation. I thought he was wrong but let the mater drop. I did not doubt that there is a relationship between running and AF but felt sure that the level of exercise sufficient to train for a half marathon was not in the range where there would be worry about AF.

The irony of recently seeing the EP doc's picture posted by him on a social medium site showing him with the half marathon medal along with his finishing time  did not go unnoticed. 

This is a good time to review the current recommendation for exercise to reduce cardiovascular risk,at what level of exercise  does it becomes too much or a good thing,and at what level does there appear to be an increased risk of atrial fibrillation. 

Currently the widely accepted view  and the WHO recommendation is that as a minimum one should exercise at a  level of 8 met hours per week.This is equivalent to 1/2 hr of moderate exercise for five days a week. Moderate is defined at a 3-6 Met level.8 met hours per week can also be achieved by vigorous exercise ( defined at greater then 7 mets) for 1.25 hours per day for five days  per week.

8 met hours per week is good but it is widely believed that at least a bit more is better, for example exercise at twice the minimum level would be better in term of cardiovascular risk reduction.This would be exercising at a moderate intensity for one hour a day for five days a week. 

So it seems in terms of cardiovascular risk reduction more is better but there must be limits to that.Is there a level of exercise beyond which there is no further improvement in risk reduction?

Eisvogel's data analysis suggest that that level is around 41 met hours per week. That is five times the minimum or 2.5 hours of moderate exercise per day five times a week . Interestingly the risk reduction exercise volume curve flattens out at a much lower level for vigorous  exercise, at 11 Met hrs per week according to Eisjvogels analysis data from Wen and from Aren.    

At what level of exercise can we expect an increased risk of atrial fibrillation?

Data from Ricci 2018 suggests that level may be about 55 met hours per week or 7 times the minimum recommended dose which would be 3.5 hr moderate exercise per day five times a week 

The level of exercise sufficient to train for a half marathon is definitely less than the estimated threshold for increased risk of atrial fibrillation. Check out any of the numerous half marathon training program and you will see the volume suggested is much less than 7 times the minimal WHO recommended exercise level.

 

Automatic threshold capture proven to work well for apical pacing but not for His pacing

 The thresholds for capture of the ventricular muscle may change over time with changes in the myocardial excitability which may be related to disease progression , electrolyte variation ,exercise,temperaturre etc. 

With the development and proven effectiveness and safety of automatic threshold determinations pacemakers were able to have longer battery lives and  there was more assurance of ventricular capture than was possible with in office threshold determination every 3 or six months as was the practice.  Automatic capture management (ACM) s have clearly been a useful development in PM technology.Patients' threshold levels could be measured daily. 

Various pacemaker manufacturers have developed their own automatic capture management systems and have become commonplace..

However since the increasing use of conduction system pacing in the form of His Bundle pacing,problems have become evident with  ACM algorithms.

Journal articles by Haran Burri and P. Vijayaraman have described the problems with HBP and ACMs. In regards to ACM issue details vary with what port on the PM is the His lead attached and whether there is selective or non-selective His pacing.

The story of left bundle branch block from interesting anomaly to a electrophysiologic fixable condition

In the beginning the EKG pattern of LBBB was an interesting phenomenon . William Einthoven in 1925 presented a case with a tracing that had also been recorded 31 earlier in the same patient. No one knew what the tracing signified and Dr. Einthoven remarked that the patient with this finding seemed to not be bothered by any heart symptoms.

As time went on it was realized that the pattern represented a "block" or conduction delay in the left branch of the Bundle of His and became established as a reliable sign of heart disease, it being often associated with ischemic heart disease,hypertensive heart disease and various cardiomyopathies.

Occasionally LBBB was noted in patients without obvious structural heart disease and the effect(s) of the cases of "lone "LBBB  on cardiac function was not initially appreciated.

 However, as early as  1979  physiologic studies  (1) on "lone LBBB" demonstrated significant septal and left ventricular  wall motion abnormalites associated with decreased left ventricular function and impaired relaxation. Later numerous studies on LBBB have detailed  the pathophysiology of the electrical and mechanical dyssynchrony of LBBB as well as molecular perturbations and deleterious ventricular remodeling.

In 2005 and 2013 reports from France described a cardiomyopathy that occurred with variable latency periods from the onset of LBBB that was to varying degrees reversible by cardiac resynchronization therapy (CRT) . Think about that for minute. LBBB may cause a cardiomyopathy that is possibly reversible by CRT.

Recognition of the role of a prolonged QRS and decreased cardiac function and the role of ventricular dyssynchrony in HF lead to idea of cardiac resynchronization therapy (CRT) in which there was pacing of  both the right ventricle and the left ventricle( with a pacing lead in  a coronary vein accessed via the coronary sinus)  in an effort to restore synchrony between the septum and the ventricular free wall.

From 2001 through 2009 there were several randomized clinical trials that demonstrated the efficacy of CRT in improving cardiac function, lessening  symptoms and in reducing mortality in heart failure patients.

As CRT was increasingly used to treat refractory heart failure (HR) it was realized that patients with a LBBB pattern were more likely to respond favorably and that CRT was essentially a treatment for LBBB.

Risum has published data from speckle tracking echo studies that suggest that the LBBB patients with HF who  respond favorably to CRT are those with a particular contraction pattern consisting of early septal activation and bulging of the lateral left ventricle followed by contracting of the LV with peak contraction occurring after aortic valve closure.

Will morphing physicians into health care providers destroy their placebo-witch doctor power

Thoughts catalyzed by lecture by Dr. Olshansky on the placebo effect  at Methodist Cardiology Rounds.

In out ancestral, tribal- based behavior maybe there is some DNA driving us to seek out and follow leaders, strong wise individuals who can shepherd us through tough times- societal and even personal as in health care matters.

Knowing as much as I know about doctors and medicine and clinical trials and  fragile and contradictory  guidelines  and the utter impossibility of being able to keep up with every thing even in  your own  subspeciality  and the temporal fragility of medical advice I think I have largely lost the capability to benefit from the placebo- witch doctor -effect when -I absolutely have to see a doctor HCP.

The question I am raising here is will HCPs without MD degrees pack the same placebo power as physicians for those who are not as skeptical as I am of the physician's ability.

Does what goes on behind the anesthesiologist drapes stay behind the drapes?

 At least some of what occurs behind the anesthesiologist drapes stays there not  being completely captured by the surgeons op note.  This is the case because the surgeon does not know what goes on in real time focused as he should be on the details of the procedure.

The story

I have a pacemaker, a dual chamber  in DDD mode with the right ventricular lead placed in close proximity to the Bundle of His.Typically this is referred to as non select His Bundle pacing, I was to have surgical procedure with the operative field to be within a few centimeters of the pacemaker .

It is common practice to deactivate the sensing function of the PM since the cautery typically used in surgery can emit electromagnetic energy  ( electromagnetic interference (EMI )) that can damage the PM or change its function with variable clinical consequences.

The sensing function of the PM can be disabled by the application of a magnet over the PM.This converts a  PM in DDD mode to one in D00 mode in which the atrium and ventricle are paced typically at a rate of 85. This is called asynchronous pacing and referred to as magnet mode .

This eliminates the risk of EMI but at the cost of limiting the heart ability to increase cardiac output and poses the risk of ventricular tachycardia or ventricular fibrillation if a pacing spike should occur at the vulnerable phase of repolarization. If the patient has a functioning sinus node and  intact electrical transmission  there will be two competing rhythms .  

The operative record include a series of Blood pressure recordings all of which in my case were normal.Yet the medication record includes levophed which would have only been used if the blood pressure has decreased significantly. So that fact must have stayed behind the drapes.

Could the presumed blood pressure drop be due to the magnet mode not allowing an intrinsic increase in cardiac output assuming there was a valid reason for the use of levophed?

 

Can we define the level of high volume endurance exercise above which mortality risk increases?

Can the level   of high volume endurance exercise above which mortality risk increases be defined.

An important study with data from the Cooper Clinic in Dallas provides some information on that question.

Defina  et al (1) presented data from a large cohort of men ( 21,758) with ten years of more of followup. In the group there were 432 men with  an  exercise history of equal to or greater than 3000 met-min per week .This is approximately equivalent to one hour of vigorous activity per day ( at a level greater than 7 Mets  which is the oxygen uptake required to finish Stage 2 on the Bruce protocol).This is a level of exercise about 6 times the minimal level of vigorous  ( greater than 7 Mets) exercise per week recommended by the 2018 guidelines.

Men in this group had a greater risk of having a coronary calcium score of 100 or greater but their risk for cardiovascular mortality (CVD) and all cause mortality was not greater than men exercising at lower levels and was lower than the least active men  in that cohort. This was the case even though they had higher CAC scores which generally predicts a higher cardiovascular risk.

Franklin and co-authors (2) said this about the DeFina study:

" These finding refute the notion that high-volume endurance activity ( greater than one hour/day) increases mortality regardless of CAC level"

The issue in the De Fina article  was the signficance of increased CAC in long time endurance exercisers on cardiovascular mortality but it also  provides some information regarding the title question .

1)DeFina,LF et al Association of all-cause and cardiovascular mortality with high levels of physical activity and concurrent artery calcification. JAMA Cardiology 2019 42 (2) 174

2)Franklin, BA Exercise related acute cardiovascular events and potentially deleterious adaptations
following long term exercise training. Placing the risks into perspective-An update A scientific statement from the American Heart Association. Circ 2020 Feb 26 PMID 32100573