The U.S. medical care boondoggle depends on hookwinking the physicians

The terms hoodwink and boondoggle are so appropriate. My comments here were inspired in large measure by Dr Michel Accad's Jan 2009 insightful  blog entry from which I quote:

'... beyond ignoring the obvious tension between the individual and the group,hoodwinking physicians into practicing "population medicine" is of course the essential  means to confuse practitioners into thoughtlessly carrying out sweeping intervention whose primary benefit is the profit of third parties."

 to this I add :  and the profit-not necessarily in monetary terms-of the academics whose writings give a scholarly veneer to this monumental hoodwinking enterprise.

See here for Dr. Accad's entire essay,

In this regard several terms and concepts are important:  population medicine, physicians as stewards of finite resources,cost  effectiveness research and  high value care. The key idea is to establish the notion that medical resources is a collectively owned resource and all are entitled to it by virtue of their existence. From this follows that the  utility of the aggregate matters and not that of the individual and that  some one has to manage this collectively owned resource and the elite medical progressives are the self nominated candidates for that job.

The medical  progressive's claim  to being egalitarian advocates of social justice is contradicted by their advocacy for a utilitarian approach to the allocation of these finite resources. Utilitarianism is not a subset of egalitarianism.A leading egalitarian, John Rawls accurately characterizes utilitarianism as being inattentive to the separateness of individuals and treating people merely as means for the achievement of some aggregate or social end. The medical progressives claim to promote social justice in the abstract but operationally sponsor utilitarian calculus in which some individuals may suffer to further  some alleged statistical benefit to the collective. The progressives play the social justice card frequently in their polemics profiting from this polymorphic notion's lack of generally agreed upon specificity - the term social justice is loose , vague and indeterminate.

The medical progressives causally dismiss the notion of rationing by their unilateral re-definition  which excludes the limiting of "low value" care from their universe  of rationing. Rationing according to this formulation means only limiting high value care and they presume they will be the arbiters of what value is high and what value is low. 


Another linguistic trap is to speak of a given medical expenditure as a "cost to the system" rather than an exchange.  So when someone goes to the ER with chest pain or severe headache that is considered to be a cost to the system or even more ridiculously a drain of resources rather than providing a service for a fee and the transfer of funds as part of various exchanges that are part of the ER medical encounters.

 When someone goes to a car repair shop to replace a radiator or visits a barber for a haircut why do we not speak of draining the car care industry's resources or depleting the finite hair care resources?It is because to a large degree we are paying for the medical care with someone else's money It is the third party payers and their academic facilitators that have accomplished a monumental hoodwinking of the public and most of the medical profession by distorting the language of medical care and shifted the emphasis from a long standing  oath based imperative to care for the patient to one of limiting care the effect of which is to benefit the third party payers

 The language of medicine has been transformed into the language of medical collectivism and the third party payers owe a large debt to the efforts of the collectivists in medical academia and to some of those individuals in influential leadership positions of certain professional medical associations.

In support of the claim that many physicians have been hoodwinked is the amazing amount of support  from professionals medical organizations for the passage of the so-called "doc-fix" or MACRA which mainly replaced one centrally planned system of price controls with another such system , one that placed even more control of medical care in the hands of federal planners and administrators and some "thought leaders" who have arisen from the leadership of various national medical organizations with important input from the lobbyists from the "Bigs" (big pharma,big hospital, big insurance,etc)


In closing I quote Dr. Accad again with this masterful summary:

" But beyond ignoring the obvious tension between the individual and the group, hoodwinking physicians into practicing “population medicine” is of course the essential means to confuse practitioners into thoughtlessly carrying out sweeping interventions whose primary benefit is the profit of third parties.  Only clever sophistry can claim to reconcile the needs of patients with the profit margin of insurance companies, the bottom line of hospital administrators, the end-of-the-month income of practitioners, the annual reports of employers, the promises of legislators, the zeal of government regulators, the self-importance of academics, the confused intentions of voters, and the pocketbooks of taxpayers.  The term “society” simply conceals the myriad of interest groups that partake in the boondoggle we call the health care system."

endurance exercise and the right ventricle-some thoughts

The issue of the effect(s) of endurance exercise on the right ventricle bothers me from time to time and I have blogged about it before.(see here)

A number of studies have shown that endurance exercise, marathons,triathlons, etc,  may result in transient changes in right ventricular function  (increased volume , decreased ejection fraction), while such changes in the left ventricle are typically not the case although some transient changes have been documented..But an important question is- do repeated episodes of prolonged exercise lead to some deleterious changes in the right  ventricle  which could include a predisposition to ventricular tachycardia or worse.Is there an exercise induced clinical picture of ARVD in someone who does not have the recognized genetic profile for ARVD?(see below).After thinking about it again and reading more about it,I think maybe but it does not seem to happen very often.

J. Ector and co workers studied right ventricular  (RV) function  in a group of  22 endurance athletes who had experienced episodes  of ventricular arrhythmias and concluded "Endurance athletes with arrhythmias have a high prevalence of right ventricular structural and/or arrhythmic involvement." ,the implication being the repeated endurance events predisposed to the rhythm problems (Eur Heart J. 2007, Feb 28 (3),345-53)

LaGerche studied 39 endurance athletes, see here, immediately after an endurance event,and one week later with echocardiography and Magnetic resonance Imaging. with gadolinium. Transient RV function changes noted immediately after  the event resolved by one week but 5/39 demonstrated  late deposition of gadolinium (delayed gadolenium enhancement or DGE) in the interventricular septum.The authors seemed to assume that the MR findings were fibrotic lesions and were causally related  to multiple bouts of endurance exercise but the actual cause of the late deposition of gadolinium has not been determined but it is true that  in some contexts ( maybe most) the histologic basis of the delayed gadolenium uptake is fibrosis.

Arrhymogenic right ventricular dysplasia (ARVD)-also called Arrhymogenic right ventricular cardiomyopathy) is an inherited condition primarily involving the right ventricle with replacement of cardiac muscle with fibrous tissue and fat, leading to decreased  right ventricular function and predisposition to arrhythmias including ventricular tachycardia and ventricular fibrillation.. Typically it is inherited as an autosomal dominant and involves several mutations in the genes that code for the desomsomal adhesive proteins which function to help bind muscle cells together.

ARVC is much more common in Italy and naturally there is more awareness in Italy and more more published research. The most common cause of sudden cardiac  death in the young in Italy is ARVC accounting for 22% of deaths versus 7 % from hypertrophic cardiomyopathy (HCM) in contrast to  HCM being the most common congenital problem found in sudden deaths in young athletes in the United states.See here for details of the long standing cardiac screening program in Italy.

While it seem reasonable to conjecture that a person with one of the ARVD gene patterns might hasten the clinical manifestations of ARVD by endurance exercise , is it possible/likely that a person could bring about an  ARVD-like clinical picture by repeated endurance training and endurance events in the absence of the Italian or other recognized  genetic patterns ?

Earlier work in 2009  by Breuckmann et al ( see here ) also demonstrated some marathoners with delayed gadolenium enhancement (DGE) but in a different distribution that seen in LaGerche's subjects. Of 102 marathon runners age 50-72 who had run at least five marathons in the preceding 3 years,12 showed a DGE .Of those, 5 had a "coronary artery disease" pattern along the distribution of the left anterior descending coronary artery while 7 showed a "predominantly midmyocardial patchy pattern".Could these midmyocardial patches of presumed fibrosis be the earliest lesions of a endurance athlete's cardiomyopathy, which to my knowledge, except for arguably ARVC , has not been reported. Have autopsies been done on Tarahumara runners?

Standard maximal heart rate prediction formula may result in an underestimate

For stress tests purposes ( regular treadmill and nuclear exercise imaging) physicians  typically use the formula : Maximal heart rate =220-age.

Another formula is the Tanaka formula; Maximal heart rate =209-.7age

More recently based on a Norwegian study by Nes  and co workers the following formula is suggested :

Maximal heart rate= 211-.64 with an error term of +/- 10.8. See here for reference.

For the three formulas applied to a 75 year old we get maximal heart rate predictions of
145,156 and 163 . (Standard,Tanaka,Nes)

Frequently stress tests are terminated at when the patient reaches 85% of the predicted max heart rate.
For the three formula we get :

123
132
138.

The validity of a stress tests depends in part on having the patient exercise to a high enough level to induce some degree of stress into the stress tests and use of 220-age formula would seem to make  false negative tests more likely.This is not breaking news, Tanaka said as much in his 2001 article in the American College of Cardiology Journal  but still some  stress test facilities still use the 220 formula . See here.

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

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

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

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

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

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


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

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

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

Is the doc-fix bill worse than SGR?

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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


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


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

MACRA will go a long way to achieving that proposal.

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

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

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

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

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

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

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

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

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

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

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

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

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


Dr.Berwick went on the be the  head of CMS for a while and Dr. Brennan went on to be the chief medical office of Aetna insurance company and then CVS Caremark.Sometimes the line between the Baptists and the Bootleggers gets a bit blurry.

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

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

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

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

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

" CMS, which has the ultimate negotiating position in the form of reimbursement for Medicare services, could only accept negotiated bundled charges. It could also refuse payment for non-compliance with the Choosing Wisely recommendations."...ABIM could require candidates to achieve a perfect score on questions related to costs and redundant care as a requirement for admission to secure exams for initial certification or MOC." (This would seem to be a rather severe penalty for not complying with a "recommendation" which Benson thinks should be an edict.)

Consider how important the Choosing Wisely rules would be if  Benson's wishes were enacted.Consider how much of a target the Choosing Wisely decisions would be to various lobbying groups.Third party payers would relish such a situation.


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

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


minor spelling and punctuation corrections made on 3/31/15 and 4/21/16

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

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

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

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


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

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


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

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

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


H/T Dr Wes

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

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

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

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

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

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

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

As the destroy fee for service movement ramps up just remember there is no perfect compensation mechanism

 The Obama administration is ramping  up the campaign against medical  fee for service and claiming they want to pay for quality not quantity of care. See. Dr.Paul Hsieh (of the blog We Stand Firm)  remarks about that issue here. It is really about cost control.

Quoting the economist, Arnold Kling:

"Keep in mind that there is no perfect system for compensating doctors. For example, if you pay them a fixed amount of money per patient, then their incentive is to see a lot of healthy patients and avoid the sick ones. If you pay them a fixed salary, their incentive is to work short hours. If you pay them for “quality care,” that means that a central bureaucracy, comparable to IPAB, has to define the meaning of quality."   

Of course it is all about incentives.

And remember Goodhart's Law- when a measure become a target it looses its value as a measure.Further many of the so-called quality targets do little to enhance patient care and some can be harmful,remembering the four hour pneumonia rule.

The various rent-seeking special interest groups  and certain members of the progressive medical elite have considerable control of the current narrative and we will hear more about the horrors of fee for service and nothing about the incentives physicians face in a capitated system or as employees of large vertically integrated health care conglomerate..

Are patients pawns on the chess board of population medicine?

They would seem to  be at least so it appears to be in the presentation of the "population medicine approach" of by Dr. Harold Sox,former editor of the Annals of Internal Medicine, former president of the American College of Physicians (ACP) and former chair of the U.S. Preventive Services Task Force, offered in the November 13 ,2014 issue of  the Journal of the American Medical Association (JAMA).

Here is my thumbnail summary of what Dr. Sox wrote in describing how the population medicine approach would work.The major important diseases would be identified as would methods for their prevention. With that knowledge in hand , then funds could be transferred across patients and disease processes so that the maximal overall health benefit could be achieved.In this process it might well be that sometimes funds would be diverted away from the testing and treatment of some so that the preventive measures could be funded and then  " in a few generations" the benefit would be fully realized.He is explicit regarding the fact that in the short run some people would be harmed although he does not seem to explain why it would be only the short run as would not new preventative measures always be formulated and have funds diverted to their execution.The population medicine advocates claim the approaching of each patient strictly as a individual is "obsolete" and  are promoting a statistical medicine that claims to be capable of provided the greatest health benefit to the greatest number.Practicing physicians know how difficult it can be to recommend what might be best for the individual patient,the "populationists" glibly claim to know what is best for everyone.

In chess, pawns or for that matter any piece, might be sacrificed in executing a strategy of placing the opponent 's king in checkmate. Is it the case that individuals might be sacrificed in executing a strategy of maximizing the health of the specified population as measured by some metric such as quality adjusted life years  (QALY) per dollar spent ? After careful study and  multiple re-reads of Dr. Sox's article my answer to the question posed in this commentary's title is yes.The patients are the pawns on the chess board of population medicine.

Maybe the health care supply curve slopes upwards and more ACA bait and switch

See here for a review of a recent NEJM article that supplied data indicating that the temporary increase in Medicaid fees which was part of ACA  may have increased access to medical care.So as Medicaid professional fees increase more services are supplied.

From Nov 2012 to July 2014,

" [t]he availability of primary care appointments in the Medicaid group increased by 7.7 percentage points, from 58.7% to 66.4%, between the two time periods. The states with the largest increases in availability tended to be those with the largest increases in reimbursements, with an estimated increase of 1.25 percentage points in availability per 10% increase in Medicaid reimbursements (P = 0.03). No such association was observed in the private-insurance group. During the same periods, waiting times to a scheduled new-patient appointment remained stable over time in the two study groups."

So now that the Medicaid fee increase has elapsed and fees will be cut should we not see a decrease in availability? The specter of more folks on Medicaid and fewer docs likely to see Medicaid patients is part of why this article talks about the great bait and switch of ACA.We see more of a distorted version of social justice emerging from Obamacare.

Is Maintenance of Certification (MOC) part of ACA and who put it there?

The short answer is :

Yes, MOC  has been implanted into the legislative structure of ACA and for many (most?) practicing physicians this is really breaking news and for those of us who oppose the ABIM's MOC program, may mean  bad news.

 Dr. Wes explicates how the Maintenance of Certification has been made part of Obamacare in his recent blog entry in which he questions the viability of an alternative "Board" to challenge and hopefully replace the ABIM's widely criticized MOC program.Does the letter of the law with its establishment of MOC in some aspects of Medicare preclude the replacement of ABIM's MOC with some less onerous process by a rival organization?  


"The Affordable Care Act (ACA) modified Sections 1848(k) and 1848(m) of the Social Security Act which defines how CMS pays physicians for their services.  Section (k) is the section that defines how a "Quality Reporting System" is to be set up (with subsection (4) requiring the "Use of Registry-based Reporting") and Section (m) defining physician incentive payments physicians might receive if quality reporting occurs properly. (Sadly, those CMS incentive payments do not cover the cost of participating in MOC for most of us.)

Section (k) was modified by the ACA to include the ABMS MOC program as a "physician registry."  The registry was "defined" as requiring all four parts of the MOC program created by the ABMS, including the much-maligned "practice improvement modules" that have been described by the physician community as overly time-consuming, irrelevant ...."


After re-reading of the relevant sections, it is not clear to me exactly what penalty a physician would incur by forgoing MOC. I welcome any input regarding that.

ABMS's MOC program is part of the law and what ever alternative organization set up to do some version of less onerous MOC is not part of the law and IMO the political clout of the rank and file real physicians is likely not up to the task of changing the law.


Dr. Wes, see here, raises interesting questions about possible collusion between principals in certain organizations  and CMS, those certain organizations being some of the ones which would  benefit financially  from the statutory establishment of MOC in ACA.

 Medical certification boards would obviously profit from the MOC process being quasi mandatory  or tied in in real ways to a physician's compensation.  Dr. Wes focuses on two physicians with ties to ABIM and ABIMF and CMS and the National Quality Forum which incidentally receives significant funding from CMS.

[An interesting aside is that a member of NQF's Board is Liz Fowler, currently a VP at Johnson and Johnson and someone who  played a major role in the drafting of ACA. See my earlier commentary entitled  "Who Wrote Obamacare and where is she now?") Ms. Fowler has been described , accurately in my opinion, as the poster girl for the revolving door in regard to government and major health care players.It seems that some of the prominent medical elite know how to open the doors as well.}

Quoting Dr. Wes:

"Troubling concerns of collusion of ABIM board members with the Center for Medicare and Medicaid Services (CMS) and the National Quality Forum (which receives the bulk of its revenues from grants supplied by CMS) exist. Christine Cassel, MD, who is the current President and CEO of the National Quality Forum, was President and CEO of the ABIM from 2003 to 2013 and ultimately responsible for the $2.3 million dollar luxury condominium purchase by the ABIM Foundation in December, 2007....."

Dr. Wes then chronicles the job history of the current ABIM CEO, Dr. Richard Baron who was associated with ABIM and then left to be a full time employee of CMS from 2011 -2013 and came home to his current ABIM's six figure salary.

Again quoting Dr. Wes:

"Which leads to the question: how much influence did the ABIM leadership have in establishing a continuous money stream for itself and its Foundation during the writing and mark-up of the Affordable Care Act? (see pages 247 and 844-845 of this large pdf). Clearly, there should be public record available to this effect and physicians should inspect this record before creating an alternate MOC pathway"

The fact that the term "professionalism" is found in ACA may be significant.. ABIMF has been promoting their particular version of professionalism for several years such promotion being the major stated goal of that organization. Unlike traditional medical  ethics the ABIMF professionalism embeds the obligation of social justice and an obligation for physicians  to act not only for the individual patient but for some collective,which operationally could be a given ACO or HMO. Has or will ACA make the ABIMF's sea change professionalism "the law of the land"?

Statutory language does not appear by a random process.Public choice theory tells us to look at who might profit from a given law or regulation and often you will find who was responsible for it.  Cui bono.

If you wondered what the American Board of Internal Medicine Foundation was all about...

I have asked more than once on this blog why does the American Board of Internal Medicine (ABIM) have a foundation ( the ABIMF).Why did one non-profit set up another one?

 Dr. Westby Fisher, writing  on his blog "Dr. Wes"  provides an eye-opening and in my opinion, shocking narrative about what is happening at the ABIM and ABIMF.This detailed expose about the ABIM and the ABIMF should be required reading not just for internists but for all physicians .

This entire article should be read and shared with colleagues.Here are some highlights and excepts as well as some of my comments.

The ABIM established the ABIMF  and  is its major source of funds. (I am aware the the Robert Wood Johnson Foundation gave the ABIMF 5 million dollars for its Choosing Wisely campaign, but most comes from ABIM)

The ABIM's source of funds is mainly from testing internists for certification and more  recently for maintenance  of certification (MOC) testing. It seems that if you subtract their operating expenses from their money flow from testing and certifying and re-certifying internists there is a lot left over to give to the ABIMF.

The principal activities  of the ABIMF are promotion of the new medical professionalism and   the Choosing Wisely Campaign while the ABIM is pushing its maintenance of certification (MOC) program.. Choosing Wisely  began as an apparently reasonable, mom and apple pie  program but may well be morphing into more than that or at the least a number of policy wonks ( and the former CEO of ABIMF) want it to be more controlling than the simple "conversation" between  physician and patient that is was originally purported to be.See here for a commentary about remarks made by the former CEO of the ABIMF ( Dr. John Benson) on the ABIMF 'blog  and by Dr. N, Mortin writing in the NEJM. Both speak of enforcement of the ABIM's edicts recommendations.

So, internists take tests for the which the costs and requirements continue to increase and the "profits" (at least cash in minus expenses) or a significant percentage of it is funneled to the ABIMF where it is spent on   promotion  of the seemingly ever expanding Choosing Wisely campaign as well as the medical  ethics game changing new professionalism.

Quoting Dr. Wes:'s introduction:

"Is it "medically professional" for a non-profit organization to use physician testing fees to "choose wisely" a $2.3 million luxury condominium complete with a chauffeur-driven BMW 7-series town car? In my view, obviously not. To most people such an action would conjure up images of hypocrisy, waste, and corruption.
Yet, after a review of public and tax records, it appears to me this is exactly what has happened."

Hypocrisy,waste and corruption are strong words.Dr. John Mandrola, writing on his blog "Dr. John M:" uses the words, hubris,overreach and tone deafness. in regard to the ABIM's MOC efforts.

I think  Drs. Fisher and Mandrola are if anything too restrained in their characterizations of the activities of ABIM and ABIMF.

The greater uproar and push-back from practicing internists is  directed at, understandably, the egregious and over reaching MOC program but I am afraid that the promotion of the new professionalism and the  linked political agenda may be even more dangerous to the practice of  medicine-all emanating from the ABIM-ABIMF conjoined twins.

Addendum: 1/26/15-Much deserved kudos to Dr. Wes ( AKA Dr.Wesby G Fisher,EP cardiologist) for pulling back the curtain revealing at least some the back stage activities of the ABIM-ABIMF.

Fewer hospital readmissions,the seen and the unseen and Goodhart's Law

One of the multiple provisions of the Affordable Care Act (ACA) is something called the Medicare Hospital Readmission Program.This provision links provider payments to 30 day readmission rates for three conditions-heart attack,heart failure,and pneumonia.More medical conditions are scheduled to be added to the list including chronic obstructive lung disease (COPD).

Writing in the December 4,2014 issue of the  NEJM Dr. Christine Cassel claims success for this program quoting that national readmission rates decreased from 19% to 17.5%.

 The French economist,Frederic Bastiat writing in 1850 advised his readers that a good economists not only looks as the visible effect,the seen, but needs to consider the unseen or what comes next.

What is seen here is the results of the reporting, what is unseen is the reason(s) for the decrease.

Did more patients end up in nursing homes, did more patients die at home,were more patients treated in ERs and not readmitted,what restraints , if any, were placed on ER doctors to not readmit folks recently discharged,.If someone was admitted to a different hospital did that count in the statistics?.What actions did hospitals take in a effort to minimize the likelihood of patients being readmitted?

The patients who were not readmitted are not seen. What  happened to them? Does this reported decrease in readmission rate reflect better care or just less care in the hospitals? Did more people die at home?Were more patients prematurely placed in a hospice care setting?

Thomas Sowell tells his readers that in the real world of limited resources and virtually unlimited desires that  most of times we are involved in trade offs and not solutions.What are the trade offs in this reported decrease in admission?

Has the hospital readmission program managed to be an exception to  Goodhart's'aw?

Charles Goodhart,a professor at the London School of Economics,wrote in a 1975 paper that when a measure becomes a target it ceases to be a good measure.

Although not discussed explicitly  as a example of Goodhart's law, Dr. Cassel also reviewed the ill advised six hour rule for the administration of antibiotics in patients with community acquired pneumonia.It turned out that ER personnel were too profligate in the administration of antibiotics so as to not get cited for poor care. They were like school teachers who "teach to the test".

Dr. Cassel said that the data validated the readmission policy approach. Can you claim that without knowing the mechanism(s) for the fewer readmissions? Do we know if the decrease helped or harmed patients? There was less expenditures from CMS in the hospitalization category but what costs were incurred and by whom?

Does a JAMA viewpoint essay by Dr. Harold Sox reveal what population health really means?

Dr. Harold C. Sox writing in the November 13,2013 issue of JAMA in an article entitled  "Resolving the tension between Population Health and individual health care" says:( my bolding ).

"Perhaps the de facto organizing principle for US health care,,approaching each patient strictly as an individual is obsolete.The population health approach is an alternative."

This sentence seems structured to allow for escape mechanisms. He hedges by beginning with "perhaps" and then says that" approaching each patient strictly as an individual " , so he could later claim that, of course ,treat the individual but you also have to consider the interests of society.

The money quote is :

 " Must the Population health approach compromise the needs of the individual to benefit the community?"

It will take several generations to realize the full benefit of investments in disease prevention . In the short run,the investments may draw resources away from tests and treatment for some sick people.In the long run, disease prevention and better low cost technology could reduce the outlay for treatment.In the interim, skillful clinical decision making can make the most of limited resources"

He is answering  his introductory question in the affirmative by giving an example of how an individual would suffer for the allegedly benefit of a group  and incredibly does not express any concern about sacrificing the individual to some hypothetical future benefit to the community or society.In fact and amazingly  the only benefit he actually mentions is "reduce the outlay for treatment".

 Sox continues:

 " Are the needs of the individual and the population reconcilable?
Using the same method of value and the same decision making principle for patients and for populations would be an important step toward a system that fairly allocated resources between the healthy many and the sick few"

The traditional role of the physician has been the care of "sick few".Are they now being asked to allocate some of the resources away from the sick to the "healthy many"?

But the principles involved in treating patient who requests help from a physician and  and proposing preventive measures for a population are not the same. The population has not requested help and may have not even authorized the "treatment"  A key principle in treating the individual is to respect his/her values. How can one determine the values of a population? Do all member of the population have to agree.? Is disease prevention is only principle to value, do liberty, and avoidance of coercion not matter? Who is to judge what is the fair allocation? Is disease prevention more important than treating the sick which historically is what physician basically did ?What about the possible harms of a preventive program?Should the population members have to agree to the preventive measures? Is informed consent not to be part of population medicine?

The coruption of medical practice

Drs Hartzband and Groopman hit another major home run..See here .

This husband and wife physician team  from Harvard Medical School have published cogent thoughts before  regarding serious issues in  current day medical practice.See here for their critique of the concept of quality adjusted life year (QALY) and here .

They contend that  medical care is being corrupted by the actions of several groups-insurers,hospital networks and regulatory groups.I would add that philosophical (ethical ) cover is provided by health policy experts who are attempting to change medical ethics from one in which the  physician has a strong,primary fiduciary duty to her individual patient to one in which the physician is obligated to act in the alleged benefit of the group.This attempt is exemplified by the New Professionalism initiative which is spearheaded by the American College of Physicians (ACP) and the American Board of Internal Medicine (ABIM and its foundation (ABIMF) and the Robert Wood Johnson Foundation (RWJF). Additionally, the movement for a "Population Medicine " approach  depends heavily on this sea change in medical ethics.Simply put- the population medicine approach is dead in the water unless physicians reject their traditional fiduciary duty to their patient.

Quoting the authors from their NYT article:

" Insurers, hospital networks and regulatory groups have put in place both rewards and punishments that can powerfully influence your doctor’s decisions.Contracts for medical care that incorporate “pay for performance” direct physicians to meet strict metrics for testing and treatment. These metrics are population-based and generic, and do not take into account the individual characteristics and preferences of the patient or differing expert opinions on optimal practice."

and later

"When a patient asks “Is this treatment right for me?” the doctor faces a potential moral dilemma. How should he answer if the response is to his personal detriment? Some health policy experts suggest that there is no moral dilemma. They argue that it is obsolete for the doctor to approach each patient strictly as an individual; medical decisions should be made on the basis of what is best for the population as a whole

We fear this approach can dangerously lead to “moral licensing”"

"Obsolete" is actually  the term  used by Dr. Harold Sox, former , long time editor of the Annals of Internal Medicine in his JAMA commentary  of  11/13/2013: I quote:

"Perhaps the de facto organizing principle for US health care approaching each patient strictly as an individual is obsolete.The population health approach is an alternative." [my bolding]

  

A NEJM opinion piece  by Victor  Fuchs carries further the theme of treating the collective. Quoting myself from an earlier posting:

In his closing paragraph, Fuchs tells us that when a physician works in a health care collective in which there is a fixed annual budget the physician resolves the dilemma [ the situation in which the cost effective option may not help or actually harm a given patient] by favoring the cost effective option. This according to Fuchs become "appropriate". ( Why does Fuchs use quotes marks?) So,the cost effective choice is the appropriate choice and also the ethical one. It is ethical in the moral calculus of Kant "because if all physicians act the same way,all patients benefit" .  Those comments by Fuchs are my candidate for the sophistry prize of the year in the health care category.

Does he really say that the medical ethical thing to do is to always choose the cost effective approach?Are there no other values worthy of consideration?In what sense does a patient deprived of care to further some alleged aggregate metric of a  group benefit?

addendum: 12/27/14.Minor spelling and punctuation corrections made and on 6/5/15

Does exercising efficiency decrease in cycists and walkers with aging but not runners?

The following will likely  only be of interest to older runners,walkers, cyclists and folks who like to talk about mitochondria.see here for a interesting commentary about muscular efficiency,aging and its effect of various kinds of exercise.

The mainstream current party line regarding the determinants of endurance exercise performance is that the major three factors are:

1Maximum oxygen uptake ( V02Max)there are conflicting data regarding whether regular endurance training over the years lessens that decrease with the older data supporting that idea.More recently Tanaka and others have shown that when expressed as per cent decrease from early adulthood, the rate of decline in VO2Max is not reduced in habitual aerobic exercisers.See page 58 reference no. 1.

2)Lactate threshold (LT).LT as a measure of the exercise intensity at which a person can sustain a high level of the maximal oxygen consumption.It is said to decrease with aging.Although data indicate that the absolute work rate or running speed at the LT decreases as a function of age, the LT does not change when expressed as a percentage of the 02 Max. Tanakia and Seals (ref 1) suggest that the decrease in LT is secondary to decreases in the 02Max.

3)Exercise economy .This is measured as the steady-state 02 consumption while exercising below the LT.A number of cross-sectional studies have shown that exercise economy does not change with aging.Most of the studies were done in runners but now we have a study that demonstrates a decrease in excise efficiency  in cyclists with aging.

Alex Hutchson in his Runner's World column,"Sweat Science", discussed several articles that demonstrated that older cyclists became less efficient with age but that deficit compared to the younger cyclists  was abolished by a several week period of quadriceps resistance exercises . In one study a 3 week training period increased leg strength by about 18% and cycling efficiency by about 16%. Possibly the old high school coach's comment "you are only as young as your legs might really be "you are only as old as your quads".Aging runners and cyclists can profit by adding quad resistance exercises to their exercise program.


As early as the 1980s there was experimental evidence that resistance exercise could increase mitochondrial bio-genesis and improve oxidative capacity even in a person habitually doing endurance exercise. 


1)Tanaka,H and Seals DR, Endurance exercise performance in masters athletes.
J Physio 586 1 (2008) pp 55-63


5/25/16 minor additions made regarding quadriceps exercise.

Eight high school football deaths from head or neck injury in 2014 equaling the number in 2013.

The Annual Survey of Football Injuries 1931-2013 (first author Kristen Kucera) was published in March 2014.See here for the full report.

The report distinguishes between direct death (basically brain or neck injury) and indirect death which includes a cardiac cause or heat stroke among others.

In 2013, there was 8 directs deaths ,all in high school, and nine indirect deaths seven of which were related to high school football. Of the direct deaths 6 were from brain injury and 2 were from neck injuries.There are approximately 1.1 million participants in high school football. So there were 16 death related to football in 2013 in that population.News report indicate that there have been 8 apparent direct deaths from high school football in 2014 .

Of the 8 direct deaths in 2013, 3 occurred in running backs, 2 in defensive backs and one  in wide receiver and one in line backer and the position of the eighth player was not known.

In 1976, a major football  rule change was put into place and review of the deaths tabulated by year indicates it was an important contributor to overall fewer deaths from head and neck injury but has certainty not eliminated them There were further rule changes in 2005 and 2007 designed to eliminate the use of the helmet as a weapon.. In 1976 it became illegal to make initial contact with head and face while blocking or tackling (so called "spearing").The decrease in cervical spine injuries is greater than that seen in fatal head trauma following that rule change and the increased emphasis of not hitting with the helmet.Still from 2003 through 2013, 23 high school players died from head or neck injuries and 103 died from indirect causes ( largely heat stroke and cardiac causes).

 What is thought to be the mechanism(s) involved in  the football related. fatal brain injuries . The likely candidates  are 1)acute subdural hematoma and 2)and those  of the second hit syndrome. See here for Dr. Robert Cantu's description of ten cases of the second hit  syndrome.The second hit syndrome is thought to be at least in part a disorder of cerebral blood flow auto regulation occurring acutely after a second blow to the head in a player who is still symptomatic from an earlier (perhaps unrecognized) concussion and may result in fatal herniation and brain stem compression which can occur within a few minutes of the second  head blow.

Better helmets,greater awareness of concussion and the efforts to restrict play for a concussed athlete and rule changes since 1976 are thought to have decreased fatal had  and neck injuries. Things did look like they have gotten better. From 1968 through 1971, 44 high school players died from head and neck injuries and 12 died in sandlot type football  and 12 died playing college ball and 2 died in pro and semi pro leagues.In that 4 year  time frame 70 people died from playing football .

 The reports states that data from the decade 1985 - 1994 showed reduction in those injuries.However, the data from 1995-2004 show an increase in brain fatalities over that in 1985-1994 ,namely 11 more deaths during 1995-2004 representing a 33% increase.In the latest nine year period  analyzed (2005-2013) 25 brain deaths have been recorded in high school players.

Football continues to be a sport in which there are high impact collisions which place the head and neck at a non trivial risk. It may be that the mitigating factors mentioned above (rule changes etc) have done what they can do but a very troublesome residual exists and young athletes continue to die while cheerleaders and family members gather on Friday nights to celebrate the rituals of high school football. Judo has been made mandatory part of  high school education in Japan and a number of athletes die every year as a result of head trauma associated with that sport. Understandably parents in Japan have raised  justified protests.Just imagine what protests would be raised if high school football were a mandatory part of high school education.

It has become common ( mandatory?) for an ambulance to be on hand at high school football games.I wonder if their presence is reassuring to parents or a troublesome reminder that medical tragedies continue to occur in spite of the considerable effort that has been made to avoid them.

The Great Health Information Technology Flim-Flam explained in plain english

Margalit Gur-Arie has hit another out of the park on her blog "Health Care Technology". Everyone should read her recent entry entitled "Technology for Onesies-Twosies". See Here.

Her comments are aimed at the almost one half of U.S. physicians who are still in private practice, most of which are in medium or smaller groups.The topic isthe government program to "help"private docs obtain and use electronic health records (EHRs) and its "Meaningful Use" Program which is a carrot and stick approach to get  recalcitrant physicians on the program.

Quote:

"Case in point: Meaningful Use is a voluntary program. The maximum incentive per Medicare physician is equivalent to seeing one more patient per week. The maximum penalty for a typical Medicare physician can be recuperated by seeing one more patient per week. The cost of using a Meaningful Use EHR, in both cash and physician time, far exceeds one weekly visit. Can someone please enlighten me on why there is no market (and trust me, there isn’t) for non-government sanctioned technology that is purposely built to serve doctors? Remember, you own more than half the market."

Bottom line- signing on to the government subsidy EHR program is not just a bad idea it is much worse than that. Note, the computer programs that are government sanctioned are for the most part not meant to help the physician practice medicine nor to help the patient receive better care.Read her entire article and find out who really benefits.Spoiler- it ain't the patients and physicians.

Does much of the blame for sarcopenia rest on the satellite cells of the fast twitch muscle fibers?

Well, at least some of the blame anyway.

Dr. LB Verdijk and coworkers at the Masstricht University in The Netherlands have published several articles contributing insights into at least some of what goes on with the age related loss of muscle size and strength.See here and here.

Their work deals with satellite cells (SC), so called because in their resting form they hang out on the periphery of skeletal muscle cells, wedged between the basement membrane and the sarcolemma.They are the muscle's stem cells. They are poised to multiply and to differentiate into myofibers when signaled by damage such as occurs with strenuous exercise.

Their 2007 publication  gives a good summary in the article's title, "Satellite cell content is specifically reduced in type II skeletal muscle fibers in the elderly" The authors performed muscle biopsies in the lateral thigh in 80 elderly subjects (age 76 +/- 1 yr) and 80 twenty year olds. The proportion and mean cross-sectional area of type II fibers was reduced in the elderly  as were  the number of satellite cells per fiber .A similar pattern was not noted in the slow twitch (type I) fibers.The type II fibers were smaller and fewer in number and contained fewer satellite cells per fiber .

Now for the sorta  good news.

A more recent article from the same  research group in the Netherlands reported that a 12 week program of resistance exercise training significantly increased both muscle fibers size and satellite cell count in type II fibers in elderly subjects. This was part of a more comprehensive study which examined muscle fiber type and satellite cell content in 165 subjects in various age ranges. 49 of which were 70-86 years of age.Also a subset of elderly subjects took part in a 12 week resistance exercise program .Muscle biopsies after the training program demonstrated increased type II fiber size and satellite cell content.

It seems plausible that the satellite cell awakening induced by resistance exercise was instrumental in muscle cell growth.There are , of course, many other factors in the muscle loss of aging including loss of sex hormones,increase in inflammatory cytokines,inactivity,poor nutrition and loss of anterior horn cells,among others. Resistance exercise in the setting of adequate protein intake  is not the fountain of muscle youth but so far it seems the best we've got.

A final word.writing as someone who has run more ( much more ) than can be justified  based on reasonable  concerns of improving health .Running will not prevent sarcopenia. While running on level ground the quadriceps does little more than stabilizes the patella. I suppose running up and down hills may activate some type II fibers but basic jogging will not prevent the age related loss of muscle size and strength.That requires resistance exercise and adequate protein intake.Apparently you need resistance exercise to mitigate the age related loss of fast twitch muscle fibers.

Can long standing endurance exercise training mitigate the of age related loss of compliance of left ventricle?

With more evidence available to generate legitimate concern about an increased risk of atrial fibrillation with  many years of endurance exercise and papers about long time endurance athletes and the  much less likely risk of developing arrhymogenic right ventricular dysplasia (ARVD), some good news for the crazy, old long distance runners was very welcome.

Here is a link to summary of the paper by Dr. Paul Bhella et al. entitled "Impact of Lifelong Exercise "dose" on Left Ventricular Compliance and Distensibility"

Here is the authors'conclusion :

" Low doses of casual, lifelong exercise do not prevent the decreased compliance and distensibility observed with healthy, sedentary aging. In contrast, 4 to 5 exercise sessions/week throughout adulthood prevent most of these age-related changes. As LV stiffening has been implicated in the pathophysiology of many cardiovascular conditions affecting the elderly, this "dose" of exercise training may have important implications for prevention of cardiovascular disease."

Is there an age related decrease in left ventricular compliance.  According to a 1984 article by Rodeheffet et al the aging heart may be able to maintain cardiac output in the face of an age associated decrease in maximal heart rate by increasing stroke volume. See here for link. The older person relies more on an increase in end diastolic volume and riding the beneficial part of the Starling curve, but if the left ventricle become less compliant, which it is claimed it does as a function of age that adaptation would only work for a while.

Is the decrease in LV compliance due to just getting old or might it be due to lack of vigorous physical exercise. Dr. Armin-Zaeh and coworkers at the Dallas Based Institute for exercise and environment medicine  believe  it is the latter. See here.  My personal bias is obviously to agree with them. Here are the conclusions from the above linked article.

"In conclusion, a sedentary lifestyle is associated with a decline of ventricular compliance, leading to higher cardiac filling pressures and lower stroke volumes for a given filling volume compared with age-matched athletes or young individuals. Prolonged, sustained endurance training preserves ventricular compliance with aging and may be an important approach to reduce the probability of heart failure with aging."


A partial,apparent  counterpoint to the  above studies can be found here in this 2003 article by  P E Gates and co-authors whose analysis and summary minimized the importance of one of their own findings  ( namely that a standard measure of diastolic function (the e/a ratio) was higher in endurance trained subjects) and instead emphasized the value of the decreased arterial stiffness noted in long term exercisers.Either way, a less stiff ventricle and/or a less stiff aorta, it is  good news to long term endurance exercisers.

addendum: 10/1/14 Correction made on title, "Stiffness" changed to "Compliance"
addendum-1/22/14 Title reworded to a less awkward version 

addendum; 10/4/15 An article by Daniel Forman  entiltted "Enhanced left ventricular filling associated with long term endurance exercise." The title tells their conclusion . The link below is just for an abstract so I cannot comment on the data or how well their summary captures the data. or how old the masters were. The authors state "Early ventricular filling indices in master athletes more closely resemble transmitral flow patterns of health young adults." (Journal of Gerontology 1992, 47 2)

Another chapter in "were you wrong then doctor, or are you wrong now?" this time regarding stenting of non culprit lesions.

The American College of Cardiology recently retracted one of its magic five "Choosing Wisely" recommendations.In 2012 ACC had advised that in the setting of an acute coronary event one should only revascularize the "culprit artery".This is the artery thought to be responsible for the event and if other obstructions are detected the ACC said that there was evidence that the fix everything approach might be harmful.This advice was based on non randomized trials. Here is ACC's official statement.

Now apparently two randomized trials  suggest one should fix (place a stent in ) the other obstructions. Here is quote from ACC:

 “over the last two years, new science has emerged showing potential improvements for some patients in their overall outcomes as a result of complete revascularization.”

Larry Husten,prolific medical journalist whose Forbes article on this subject is linked above, really nailed it , quote:

" It seems to me that the medical organizations that produce guidelines should freely admit this lack of evidence for most recommendations. Then, instead of getting their panties all in a bunch trying to defend the indefensible– as we saw recently with the salt guideline– they could advocate for better evidence...So if they want to make the case for more data they will have to first acknowledge their ignorance.

Acknowledging ignorance seems the last thing  likely to emerge from the guidelines generating organizations.

In 1728, the three verdict system arose in Scottish Criminal cases.The accused could be found guilty,not guilty or not proven. So guilty, not guilty or admitting their ignorance and admitting we just can't say.


Being  a guideline author seems to confer immunity for having to say you are sorry.  The individual physician strives to do what is the right thing for his patient and hopes that what he does is right, the quality rule makers are able to summon up sufficient hubris to  presume to know what is good for everyone. Of course they frequently do not. Remember the beta blocker fiasco.



 

Are pediatric football concussions different from high school and college head trauma?

It would be nice to think so and a 2012 study by Maugans et al provides some data ( see here for full text) which suggests it may be the case. Eight young football players  (in a study of 12 athletes ) were studied early post concussion and at two subsequent times.The football players ages were : two 12 year olds,one thirteen year old,three 14 years olds and 2 aged 15.

Multiple Imaging techniques were used . The diffusion tensor imaging (TDI) tests were normal  as were conventional MRIs,and proton magnetic resonance spectroscopy.

 This is in contrast to two studies in college and two studies in high school football players, none of whom experienced a concussion ,which showed decreased fractional anisotropy (FA) in certain white matter tracts and/or functional MR  abnormality in the dorso-lateral frontal cortex.See here for Talavage's article regarding functional MR changes in high school players.

Further ,one study (Bazarian,  (see here for full text)) showed persistence of the TDI changes six months after the college football  season ended. Here is the authors' summary:

" we have demonstrated that a single football season of RHIs  [ repeated head impacts]without clinically evident concussion resulted in WM changes on DTI. These DTI changes correlated with multiple helmet impact measures and persisted despite 6 months of no-contact rest. This lack of WM recovery could potentially contribute to progressive, cumulative WM damage with subsequent RHI exposures. If this relationship is confirmed in longitudinal studies, efforts to limit the development of RHI-related WM changes by monitoring helmet impact measures, and further elucidation of modifiable factors that may influence WM recovery, could mitigate the long-term risk of CTE [chronic traumatic encephalopathy]."

Maugan's group did demonstrate decrease in  cerebral blood flow ( CBF) in the concussed subjects which tended to return to normal over a few weeks.The authors' conclusion;

"Pediatric SRC [sports related concussion] is primarily a physiologic injury, affecting CBF significantly without evidence of measurable structural, metabolic neuronal or axonal injury.(I am still trying to figure out what a "physiologic injury" means.)
 
What might account for the apparent differences in brain scan results in the college and high school players and the younger athletes studied by Maugan?

Possibly the younger players have a  threshold for CNS symptoms given a head blow  that is lower that the  threshold for whatever tissue changes take place that are reflected in DTI findings.There are contradictory data regarding the question of whether younger brain are more or less susceptible to damage for head trauma.

While it has been shown that  some head  impact levels ( as measured by accelerometers in helmets) in  youth football may approach those demonstrated in high school and college they are on average lower.(see here for full text of article by Cobb, 2013 for detailed data of head impact forces ) Further, the total number of impacts in a season of high school or college practice and game time may be considerably more than in a season of youth football and it may be the cumulative effects is what drives the DTI changes and whatever underlying tissue changes that may occur.Also as the years pile up, youth football and then high school and then college and then for a few professional football the total  number of head impacts grows and it may be the long term cumulative effect of multiple sub-concussive plus the occasional concussive blow that  leads to CTE in a minority of football participants.A definitive link between the imaging findings on active players and the pathological changes seen in chronic traumatic encephalopathy has yet to be established.

Although parents may feel some reassurance from Maugan's research, there is little to be reassured about in  the brain imaging studies of high school and college football players following a concussion free season as well as those studies on players with concussions.There is certainly little reassurance offered in this lengthy and detailed  article from Rolling Stone.There is an increasing about of research on the effects of football related head trauma ( as well as ice hockey) .One pundit, a retired football  player,commented  that it is the parents who really need their heads examined.

Addendum : Minor alterations in syntax and spelling and grammar done on 9.24.14.The original, unfinished version was published on 9/19/14 by mistake .

Is the "triple aim of health care" analogous to the dual mandate of the Federal Reserve

Well, it can be argued that they are both unachievable and the execution of their aims and goals will require wise men such as the "Men of system" discussed by Adam Smith.

In 1977,  Congress, having accepted at least part of the theory of Keynesian economics, amended The Federal Reserve Act, with the passage of the Humphrey-Hawkins Act, stating the monetary policy objectives of the Federal Reserve as:

"The Board of Governors of the Federal Reserve System and the Federal Open Market Committee shall maintain long run growth of the monetary and credit aggregates commensurate with the economy's long run potential to increase production, so as to promote effectively the goals of maximum employment, stable prices and moderate long-term interest rates."

In other words, the Federal Reserve System is tasked by law to control inflation and maximize employment in spite of the fact, given the tools to which the system has access, that the two mandates might be incompatible.

Dr Don Berwick speaks of medicine's "triple aim"  ( as envisioned by the Institute for Health Care Improvement)  : Population health,the patient's experience and the per capita cost.The collective medicinal "we" should strive  to improve population health,the individual patient's experience and reduce the per capita cost.

I am reminded of a series of  articles in JAMA in 1994 by Dr. David Eddy ( "Rationing resources while improving quality" ) in which he promised to provide a means to improve quality of medical care and reduce costs. This was to be done by utilizing a utilitarian cost calculus.The idea was to do what was best for the group,the health care collective statistically, even though he admitted that in such a system there would be winners and losers but the utility to the former would out way the dis utility to the minority. Of course in this scheme quality had to be defined or redefined as  what is better for the aggregate. At least Eddy was candid about there being losers,in Berwick's utopian visions in the picture he paints there seem only to be winners.The population will do better, the individual patient's experience will improve and "we" will spend less money per patient. Everyone will do better and it will even cost less.What could possibly be wrong with that?

I believe that IHI's policy recommendations are basically Eddy's prescription adorned with a layer or two of management-speak verbiage dumped on the top to obfuscate what is really happening. When you claim to improve population health care or outcome and simultaneously  decrease per capital costs, you essentially are doing a cost effectiveness analysis based on a statistical benefit to some group ( e.g. those covered lives in an ACO or HMO) regardless of what determent might befall some other  individuals in the group making the third aim of improving the  patient's experience little more than a fraudulent claim. This is population medicine dressed up in polite euphemisms designed to flimflam the members of the health care collective.

Both Dr. Robert Berenson and Dr. Harold Sox,former president of the American College of Physicians, are  perhaps more candid about about their visions for medical care in the country.

Berenson writing in 1998 in the Annals of Internal Medicine said.

"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.

Berenson makes it clear that the individual's interest should be trumped by the group's interest.


Dr Harold Sox, former president of the American College of Physicians, in his commentary regarding "population medicine"  made it clear that in shifting funds from managing one disease to another would involve for at least a few generations a situation in which some patients might not receive  treatment so that others might enjoy some type of preventive measures.

Quoting Sox's  November 12, 2013 JAMA commentary:

 "Planning to optimize population health will mean determining the frequency,causes and consequences of he common medical conditions in a population and devising strategies for dealing with them over a lifetime. "...
resources must be allocated across program to prevent,detect and treat disease and its risk factors. "...One reasonable principle to move resources from groups of patients less likely to benefit to groups more likely to benefit...

With the application of this utilitarian calculus there will be winners and losers which Sox seems to admit implicitly the following paragraph.

"It will take several generations to realize the benefit of investments in disease prevention.In the short run, these investments may draw resources away from the tests and treatment of some sick people.In the long run, diseased prevention and better low-cost technology could reduce the outlay for treatment."

If Berwick's, triple aim is something other than  the utilitarian approach of Eddy,Berenson and Sox I wish someone would explain. It is the old wine in newly labeled bottles, this time labeled "enhanced patient experience" and the platitudinous "patient centered care" when really it is the greatest good for the greatest number as judged by cost effectiveness calculation and the real winners are the third party payers and their fellow travelers.


addendum: 12.8/2014.Some editorial changes made to clarify some points and correct spelling.

Is there convincing evidence that some high school football players develop traumatic brain injury without sustaining a concussion?

Traumatic brain injury (TBI) is classified as mild,moderate and severe based on mental status change and duration of loss of consciousness (LOC). Mild TBI  involves LOC less than 30 minutes and corresponds to  a Glascow Coma Scale rating of 13-15. For example, a football player who appears stunned and confused with only brief of no loss of consciousness would have a Glascow score of 14.

A major element of TBI is diffuse axonal injury thought to be caused by rotational and linear acceleration of the brain. Conventional MR imaging and CT images do not detect that type of changes. However, diffusion tensor imaging (DTI) can detect changes in fiber tracts reflecting changes in diffusion of water into nerve tissues.A DTI based measurement ,fractional anisotropy (FA) ,reflects water movement along the axons.In normal tissue FA is high ( approaches 1)

DTI abnormalities have been demonstrated in concussive cases of  mild TBI and the degree of abnormality correlates with the severity of post trauma symptoms.(see here). Typically FA increases acutely in TBI and later on values are decreased (see here ), although there is some inconsistency about the direction of change in this measurement  in the literature and there are case reports in which acutely FA decreases.

Football players  college,high school and professional, who have sustained concussions,have been shown to have abnormal DTIs.

There are  several publications  (1. Davenport et al,2.Talavage,3.Barzarian  4.McAllister )describing research involving college and high school football players that have shown similar DTI changes in athletes who did not have clinical concussions,These imaging changes seem related to multiple sub-concussive head blows.Some studies-but not all- have also shown that these DTI findings correlate with decrements in memory test results over the course of one season.Generally these DTI abnormalities correlate with measurements of acceleration forces of the skull detected by in- helmet accelerometers.

 1)EM Davenport and her colleagues from Wake Forest studied the cumulative effects of head impacts in a single high school football season in players without a recognized concussion.(Abnormal white matter integrity related to head impact exposure in a season of high school varsity football" J of Neurotrauma 2014 Jul 14, published ahead of print).

The authors' summary:

"We show that a single season of football can produce MRI measurable brain changes that have been previously associated with mTBI (mild TBI) .Finally, we demonstrate that these impact related changes in the brain have a strong association with postseason change in cognitive function." The cognitive function was noted in a verbal memory composite score which correlated with the magnitude of the MR findings.

 2) TM Talavage and coworkers studied 11 high school players with functional MRs (fMR),measures of head impact events and neurocognitive function testing. "Functionally detected cognitive impairments in high school football players without clinically diagnosed concussion." J of Neurotrauma. 31:327-338,Feb 2014)

 Unlike most of imaging studies of TBI this group found abnormalities in the frontal lobe with functional MR.DTI was not done.

 Quoting from the authors summary:

"Additionally, we observed players in a previously undiscovered third category, who exhibited no clinically-observed symptoms associated with concussion, but who demonstrated measurable neurocognitive (primarily visual working memory) and neurophysiological (altered activation in the dorsolateral prefrontal cortex [DLPFC])."

3 JJ Bazarian  studied 10 college football players over the course of one season. ( "Persistent Long Term cerebral White Matter Changes after Sports related Repetitive Head Impacts. Plos one 9(4),e94737)

 Head impacts were recorded and measured by helmet accelerometers and DTI was done preseason, immediately post season and six months after the end of the season.

 DTI abnormalities in white matter were noted in these players none of whom sustained a clinically evident concussion. The changes in most players,but not all, were also seen in the six month followup images. .. There was a positive  correlation between number of head impacts and DTI findings. The DTI changes were not correlated with changes in cognitive testing or tests of balance.

4)  TW McAllister's study involved 80 college football and hockey players ( "Effect of head impact of diffusivity measures in a cohort of collegiate contact sports athletes", Neurol. 10:1212/01Dec 11 2013.)
Quoting the authors:
"The magnitude of  [TDI] change in corpus callosum MD (mean diffusivity) was associated with poorer performance on a measure of verbal learning and memory."  Again these findings occurred in players with no recognized concussions.

The risk of concussion is greater in certain positions such as quarterback and wide receivers. Lineman , on the other hand have fewer concussions but most experience multiple head impacts during each game and each full contact practice session.See here for a detailed study on impact forces on various player positions.


Maugans and coworkers studied athletes younger than typical varsity high school players.These players were 12 to 15 years of age and DTI scans done fairly soon after the concussion did not show abnormalities in diffusion indicators including fractional anisotropy.

Dementia Pugilistica as a clinical condition in professional boxers was described as a clinical entity in a JAMA article in 1928.In 1973 the pathological findings were published. In 2005,Omalu et al published the results of an autopsy on an National Football League  player, Pittsburgh Steeler center,Mike Webster, on whom Dr. Omalu had performed an autopsy 3 yearns earlier.This was the first report of Chronic Traumatic Encephalopathy in a football player.

Zhang et al provided some data regarding brain changes in boxers who were symptoms free and who had a normal neurological exam. 47 professional boxers ( age 30 +/-4.5 years ) underwent conventional MRIs and DTIs.In 42 the conventional MRI was normal while 7 demonstrated some focal non specific white matter changes. The 42 demonstrated abnormal DTIs, with decreased fractional anisotropy in regions of the corpus callosum and internal capsule.Boxers have been the canaries in a coal mine.Their experience has made it clear that repeated blows to head can cause permanent progressive brain damage that is not immediately apparent but develops over a  variably long period of time.The question is to what extent does this apply to football in which the players wear helmets.For years it was believed that helmets were adequately protective but now that view is increasingly less plausible.

By 2013 the NFL agreed to settle a class action law suit brought about by former NFL players and their families  but the judge did not agree to the amount offered..Now the NFL has seemingly admitted that as many as one third of players will develop some sort of cognitive impairment and that they will have funds available to cover the agreement.

The distinction between a concussive and a sub-concussive head blow is on the margin indeterminate.  A player may experience a blow to the head and feel slightly dizzy or dazed and not report those symptoms to the coach or trainer. There may be social or peer pressures on players to not report symptoms as they would be benched and not allowed to play until they complete whatever concussion protocol is in place.So the distinction between a group of players with a concussion and a group with no history of reported concussion is  not one based on clear cut objective criteria,often relying on the voluntary reporting of subjective symptoms.So it should not be surprising that cognitive tests and brain imaging studies show similar findings in football players with and without a concussion history.

So in reply to the title question, yes I believe there is convincing evidence, But there has not yet been established a clear linage between the changes in cognitive tests and brain imaging studies  seen after a season of high school or college football  and the development of  chronic traumatic encephalopathy .