Apparently the roofers union believed the administration's claim that if you like your health care insurance plan you can keep it. Now they finally seem to have realize the bogus nature of that pre ACA passage ploy.
See here for the union leaders statement asking for repeal of at least some of ACA.
" I am therefore calling for repeal or complete reform of the
Affordable Care Act to protect our employers, our industry, and our most
important asset: our members and their families.”
addendum: My apology. This post clearly is old news .In reviewing my store of unfinished drafts of posting I must have hit the publish button my mistake.5/31/16
Monday, May 30, 2016
The determinates of the stiff aging heart and what if anything can be done
Diastolic heart failure had been for the most part a diagnosis of exclusion.Symptoms and physical signs of heart failure (Hf) and an elevated natriuretic hormone level in the face of a normal ejection fraction (EF) as determined by echocardiography or gated myocardial perfusion imaging are the elements of the diagnosis.More recently echo studies of flow through the mitral valve opening have allowed a diagnosis of inclusion based on various indicators of diastolic flow and ventricular filling but evidence of diastolic dysfunction is not sufficient to make the diagnosis of diastolic heart failure with preserved systolic function abbreviated as HFpEF.
In the classic physiology text book's 70 kilogram man the stroke volume is 70 ml and the volume of blood poised in the left ventricle at the end of diastole is 120 ml, and the volume at the end of systole is 50 ml giving a EF ( 70/120) of 0.58 ( 58%)) where EF = EDV-ESV/EDV, Clinicians like to use the term pre load. Pre load is the end diastolic volume.
But the percentage ejected per beat is not even close to whole story of cardiac pump function because first the ventricle has to fill and it has become apparent than at least as many patients have filling problems as have lower ejection fractions. The HF from filling problems is known as diastolic failure or in the jargon HFpEF ( heart failure with preserved ejection fraction) as opposed to HFrEF (heart failure with reduced ejection fraction)
Of course all patients with HFrEF also have diastolic dysfunction., i.e.failure of normal filling of the ventricles.
Echocardiography has become the major tool to diagnose diastolic dysfunction. Doppler techniques measure blood flow early and late in diastole.In the healthy compliant heart most the flow occurs early and that phase is is designated the A phase and the second phase is the E phase and the E.A ratio has become a useful indicator of diastolic dysfunction. As the ventricle become more stiff , for whatever reasons,the ratio of E to A decreases and diastolic filling relies more on the atrial kick phase.
A model or stylized working hypothesis concerning the heart stiffness has been proposed in which two major elements. are considered: 1) reduced compliance which is defined a change in volume/change in pressure in the left ventricle The relevant pressure is the difference between the left atrial and left ventricular pressure and 2) ventricular muscle relaxation.
Compliance is assessed to some degree and imperfectly by the E and A and E/A ratio and the E/E prime ratio while the relaxation is measured by the isovolumic relaxation time of the left ventricle (IVRT) This is the period after the closing of the aortic value and before the opening of the mitral valve.An increased value denotes poor relaxation.The E/A ratio can be deceptive because as diastolic function decreases,the left atrial pressure may rise to help push the blood into the ventricle which tends to increase the E/A ratio that may have become depressed in an earlier phase of filling problems resulting in a "pseudo-normal" pattern.
To help sort out normal and pseudo normal ratios, tissue Doppler Imaging (TDI) can be helpful. TDI measures the movement of the mitral annulus as it move upwards as the ventricle fills and is designated as E prime.
It has been recognized that the e/a ratio decreases with aging and some cardiologists recommend using an age adjusted set of value to determine if a value is abnormal just as values for lung function test indices are age adjusted. So is it normal or is it the case that everyone get a bit of diastolic failure as they get older or for that matter a little bit of lung impairment.It has been suggested than the aging lung is a bit like early COPD.
Several groups of researchers have taken the optimistic view that regular endurance type exercise over the years can help prevent at least some of the age related stiffness of the heart. There are data that suggest that is the case as at least some groups of older long time endurance athletes have better e/a ratios than their otherwise apparently healthy more sedentary cohorts. However the IVRT does not differ between the two groups, so the impaired relaxation of the myocardium that accompanies aging does not seem to be mitigated by regular endurance exercise.
The putative underlying cellular mechanisms for increased stiffness and the sluggish myocardial relaxation are topics for another day.Basically the narrative is that myocardial cells die with aging (apoptosis) and the surviving cells hypertrophy plus subendocardial fibrosis develops and maybe long time regular aerobic exercise might mitigate that process a bit.
addendum:5/30/16 Hitting the wrong key lead to publishing a uncorrected version. I think I fixed most of the typos ,etc now .
.
In the classic physiology text book's 70 kilogram man the stroke volume is 70 ml and the volume of blood poised in the left ventricle at the end of diastole is 120 ml, and the volume at the end of systole is 50 ml giving a EF ( 70/120) of 0.58 ( 58%)) where EF = EDV-ESV/EDV, Clinicians like to use the term pre load. Pre load is the end diastolic volume.
But the percentage ejected per beat is not even close to whole story of cardiac pump function because first the ventricle has to fill and it has become apparent than at least as many patients have filling problems as have lower ejection fractions. The HF from filling problems is known as diastolic failure or in the jargon HFpEF ( heart failure with preserved ejection fraction) as opposed to HFrEF (heart failure with reduced ejection fraction)
Of course all patients with HFrEF also have diastolic dysfunction., i.e.failure of normal filling of the ventricles.
Echocardiography has become the major tool to diagnose diastolic dysfunction. Doppler techniques measure blood flow early and late in diastole.In the healthy compliant heart most the flow occurs early and that phase is is designated the A phase and the second phase is the E phase and the E.A ratio has become a useful indicator of diastolic dysfunction. As the ventricle become more stiff , for whatever reasons,the ratio of E to A decreases and diastolic filling relies more on the atrial kick phase.
A model or stylized working hypothesis concerning the heart stiffness has been proposed in which two major elements. are considered: 1) reduced compliance which is defined a change in volume/change in pressure in the left ventricle The relevant pressure is the difference between the left atrial and left ventricular pressure and 2) ventricular muscle relaxation.
Compliance is assessed to some degree and imperfectly by the E and A and E/A ratio and the E/E prime ratio while the relaxation is measured by the isovolumic relaxation time of the left ventricle (IVRT) This is the period after the closing of the aortic value and before the opening of the mitral valve.An increased value denotes poor relaxation.The E/A ratio can be deceptive because as diastolic function decreases,the left atrial pressure may rise to help push the blood into the ventricle which tends to increase the E/A ratio that may have become depressed in an earlier phase of filling problems resulting in a "pseudo-normal" pattern.
To help sort out normal and pseudo normal ratios, tissue Doppler Imaging (TDI) can be helpful. TDI measures the movement of the mitral annulus as it move upwards as the ventricle fills and is designated as E prime.
It has been recognized that the e/a ratio decreases with aging and some cardiologists recommend using an age adjusted set of value to determine if a value is abnormal just as values for lung function test indices are age adjusted. So is it normal or is it the case that everyone get a bit of diastolic failure as they get older or for that matter a little bit of lung impairment.It has been suggested than the aging lung is a bit like early COPD.
Several groups of researchers have taken the optimistic view that regular endurance type exercise over the years can help prevent at least some of the age related stiffness of the heart. There are data that suggest that is the case as at least some groups of older long time endurance athletes have better e/a ratios than their otherwise apparently healthy more sedentary cohorts. However the IVRT does not differ between the two groups, so the impaired relaxation of the myocardium that accompanies aging does not seem to be mitigated by regular endurance exercise.
The putative underlying cellular mechanisms for increased stiffness and the sluggish myocardial relaxation are topics for another day.Basically the narrative is that myocardial cells die with aging (apoptosis) and the surviving cells hypertrophy plus subendocardial fibrosis develops and maybe long time regular aerobic exercise might mitigate that process a bit.
addendum:5/30/16 Hitting the wrong key lead to publishing a uncorrected version. I think I fixed most of the typos ,etc now .
.
Friday, May 27, 2016
Has medical care reached a near Fubar condition because of the Answering machine?
I argue it may have.
Being a physician and knowing what I know about physicians , the good and the less good, I absolutely hate to go to a doctor. For most of my life I have not had to -now that I have to. I am past being appalled at the near impossibility of having meaningful or for that matter any communication other than face to face in the office.Some of this failure to communicate is due to the answering machine.
An illustrative real life case.
After the implantation of a pacemaker I experience several somewhat uncommon complications. One week post procedure my heart rate suddenly jumped to 150 . My pacemaker came with a bedside device that enabled me to send data to the PM center at the hospital .I sent a signal, called the number and was informed by the tech that it looked like I had atrial flutter. Calls to my EP doctor office were answered by a machine and the only relevant choice was to leave a message for his nurse. No call back in one or two hours and heart rate continues at 150, a value that exceeded the number that was sent to the PM center earlier. Knowing that atrial flutter is not a real call 911 situation did not keep my anxiety level from mounting.
Finally , knowing this was my ep doctor's clinic day my wife and I decided to go to the office and insist on seeing the physician . As it turned out the flutter has stopped by the time I saw the doctor.
The answering machine has turned into a situation in which the patient is given two options-leave a message and hope that you will get a reply sooner than the next or call 911 (or head directly to the ER on your own) .
Being a physician and knowing what I know about physicians , the good and the less good, I absolutely hate to go to a doctor. For most of my life I have not had to -now that I have to. I am past being appalled at the near impossibility of having meaningful or for that matter any communication other than face to face in the office.Some of this failure to communicate is due to the answering machine.
An illustrative real life case.
After the implantation of a pacemaker I experience several somewhat uncommon complications. One week post procedure my heart rate suddenly jumped to 150 . My pacemaker came with a bedside device that enabled me to send data to the PM center at the hospital .I sent a signal, called the number and was informed by the tech that it looked like I had atrial flutter. Calls to my EP doctor office were answered by a machine and the only relevant choice was to leave a message for his nurse. No call back in one or two hours and heart rate continues at 150, a value that exceeded the number that was sent to the PM center earlier. Knowing that atrial flutter is not a real call 911 situation did not keep my anxiety level from mounting.
Finally , knowing this was my ep doctor's clinic day my wife and I decided to go to the office and insist on seeing the physician . As it turned out the flutter has stopped by the time I saw the doctor.
The answering machine has turned into a situation in which the patient is given two options-leave a message and hope that you will get a reply sooner than the next or call 911 (or head directly to the ER on your own) .
Medicine and the first rule of economics and the first rule of poltics
Thomas Sowell tells us that the first rule of economics is:
We live in a universe of scarcity and there will be trade-offs. and
The first rule of politics is to ignore the first rule of economics.
In this column by Thomas Sowell we see examples of how the economic rule is ignored by offers of pie . I suggest there are offers of pie in the sky in regard to medical care and financing.
Can we have decreased medical cost and increased quality? No problem- all we need in a governmental single payer.(Interestingly the Medical Home advocates sometimes make that same promise although recent analysis from the Congressional Budget Office concludes they really can't tell if it will cost more or less.) Also more recently we are told if were pay for value not volume the same miracle will occur.
I first read about the notion of increasing quality while decreasing cost or at least containing cost in medical care in a series of article in JAMA by Dr. DM Eddy over ten years ago. The bait and switch trick here was for Eddy to redefine quality as the greatest good for the greatest number. Eddy's series of articles seemed mainly to deal with the topic of decision analysis, an area that Eddy had apparently specialized in after foregoing a surgical career but his major thesis was/is that the goal of a health care system should be to maximize the health of the group and individual physician's concern about individual patients is misplaced.Eddy seemed to claim there would be no trade off , we would have both higher quality and lower cost., by simply redefining quality.Of course he is suggesting a system with its own major dangerous trade-off, namely the nebulous,loose and ambiguous good of the collective ( which will be in the eye of the elite in charge of the medical enterprise) over the much more easily discerned good of the individual.
Enter the decision analyst who can determine what is maximal health and how best to allocate or cost shift to achieve the maximal health of the group. He spoke of health care as a closed system and that it was a "zero-sum"game where for the good of the collective some patients may well be worse off, but although regrettable that is necessary for the greater good the details of which will be worked out by competent decision analysts.
This was an early proposal by the progressive medical elite for a overt rationing of care that self identified very smart people would be able to devise for the greater good of the herd. Eddy may well deserve a role in that group of smart people. The rationing that is part of the Independent Advisory Board ( IPAB) which was part of PPAC but not yet activated would be, I think, more of the covert rationing variety wherein there would be no explicit announcement of a utilitarian mandate but the board would rather simply say what was effective and ultimately what would be paid for by the third party- government and that would be leaped upon also by the third party private insurers. DrRich ( in a no longer active blog ) had a lot to say about that , see here.
Eddy's polemic is now more than ten years old and rarely read but others have forged ahead in his footstep. Enter the folks and ABIM , ACP and ABIMF and their program to change medical ethics ,make physicians be considered stewards of a collectively owned medical resource base and nudge and if necessary coerce physicians to dutifully follow guidelines that should boost the bottom line of the third party payers .
We live in a universe of scarcity and there will be trade-offs. and
The first rule of politics is to ignore the first rule of economics.
In this column by Thomas Sowell we see examples of how the economic rule is ignored by offers of pie . I suggest there are offers of pie in the sky in regard to medical care and financing.
Can we have decreased medical cost and increased quality? No problem- all we need in a governmental single payer.(Interestingly the Medical Home advocates sometimes make that same promise although recent analysis from the Congressional Budget Office concludes they really can't tell if it will cost more or less.) Also more recently we are told if were pay for value not volume the same miracle will occur.
I first read about the notion of increasing quality while decreasing cost or at least containing cost in medical care in a series of article in JAMA by Dr. DM Eddy over ten years ago. The bait and switch trick here was for Eddy to redefine quality as the greatest good for the greatest number. Eddy's series of articles seemed mainly to deal with the topic of decision analysis, an area that Eddy had apparently specialized in after foregoing a surgical career but his major thesis was/is that the goal of a health care system should be to maximize the health of the group and individual physician's concern about individual patients is misplaced.Eddy seemed to claim there would be no trade off , we would have both higher quality and lower cost., by simply redefining quality.Of course he is suggesting a system with its own major dangerous trade-off, namely the nebulous,loose and ambiguous good of the collective ( which will be in the eye of the elite in charge of the medical enterprise) over the much more easily discerned good of the individual.
Enter the decision analyst who can determine what is maximal health and how best to allocate or cost shift to achieve the maximal health of the group. He spoke of health care as a closed system and that it was a "zero-sum"game where for the good of the collective some patients may well be worse off, but although regrettable that is necessary for the greater good the details of which will be worked out by competent decision analysts.
This was an early proposal by the progressive medical elite for a overt rationing of care that self identified very smart people would be able to devise for the greater good of the herd. Eddy may well deserve a role in that group of smart people. The rationing that is part of the Independent Advisory Board ( IPAB) which was part of PPAC but not yet activated would be, I think, more of the covert rationing variety wherein there would be no explicit announcement of a utilitarian mandate but the board would rather simply say what was effective and ultimately what would be paid for by the third party- government and that would be leaped upon also by the third party private insurers. DrRich ( in a no longer active blog ) had a lot to say about that , see here.
Eddy's polemic is now more than ten years old and rarely read but others have forged ahead in his footstep. Enter the folks and ABIM , ACP and ABIMF and their program to change medical ethics ,make physicians be considered stewards of a collectively owned medical resource base and nudge and if necessary coerce physicians to dutifully follow guidelines that should boost the bottom line of the third party payers .
Some of the reasons why (at least some) older runners have decreased heat tolerance
Stimulated by my own frustrating inability in recent years to run as far on my weekend "long runs" as I could just 3 or 4 years earlier I began to search for some physiological reasons. For years I would run a slow 18-20 miles on Saturday or Sunday throughout the years but in last 2 years I have basically crashed around 14-15 miles and was generally wiped out the rest of the day loosing weight from a pre run of 160 to a post run of 152 to 154 in warm to hot weather conditions and having a postural BP decrease indicative of volume depletion.
So far I have found evidence in the literature that at least 4 factors might play a role
1.A age related decreased in nocturnal ADH ( Arginine vasopressin) may cause a nocturnal polyuria.
2.Increased rate of glycogen utilization in older runners.
3.Lower levels of body water in older people.
So that my body water in the morning was lower to begin with as more water lost in the evening preceding the run and my glycogen stores were more rapidly depleted even after some efforts at glycogen loading leading to some limiting level of dehydration and glycogen depletion.The relatively meager liver glycogen stores are used during sleep.
4.Decreased V02 max with aging. The carbohydrate (CHO)/fat mixture changes as a person exercises more intensely and at some percentage of 02 max ( often quoted as about 60%) fuel source shirts to mainly CHO and little fat so that CHO stores ( glycogen) are more quickly depleted).So maybe in a misguided effort to run a bit faster than I should be,I get glycogen depleted quicker, i.e. after fewer miles have been run. So lower V02 max leading to quicker glycogen depletion.
Dehydration in the older runner likely leads to to lower blood pressures post long hot run as the stiffer ventricle and central arteries respond to decreasing blood volume with exaggerated blood pressure changes- sort of a Starling curve thing. This of course is an effect and not a cause of volume depletion.
So far I have found evidence in the literature that at least 4 factors might play a role
1.A age related decreased in nocturnal ADH ( Arginine vasopressin) may cause a nocturnal polyuria.
2.Increased rate of glycogen utilization in older runners.
3.Lower levels of body water in older people.
So that my body water in the morning was lower to begin with as more water lost in the evening preceding the run and my glycogen stores were more rapidly depleted even after some efforts at glycogen loading leading to some limiting level of dehydration and glycogen depletion.The relatively meager liver glycogen stores are used during sleep.
4.Decreased V02 max with aging. The carbohydrate (CHO)/fat mixture changes as a person exercises more intensely and at some percentage of 02 max ( often quoted as about 60%) fuel source shirts to mainly CHO and little fat so that CHO stores ( glycogen) are more quickly depleted).So maybe in a misguided effort to run a bit faster than I should be,I get glycogen depleted quicker, i.e. after fewer miles have been run. So lower V02 max leading to quicker glycogen depletion.
Dehydration in the older runner likely leads to to lower blood pressures post long hot run as the stiffer ventricle and central arteries respond to decreasing blood volume with exaggerated blood pressure changes- sort of a Starling curve thing. This of course is an effect and not a cause of volume depletion.
Thursday, May 12, 2016
Snake oil salesmen and politicians
When Chinese railroad laborers in the 19th century used snake oil they consider it a legitimate and p useful product. The story goes that the laborers brought over with them oil from the Chinese water snake which they believed to be useful to relieve muscle and joint aches and pain from long hard days laying track on he US railroads making their way to the west coast.History provides us no record of randomized clinical trials.
A business man named Clark Stanley began to peddle what he purported to be rattlesnake oil said to have marvelous medical purposes. Following the passage of the 1906 Federal Food and Drug act a suite was brought against Mr. Stanley for "misbranding", as the ointment did not actually contain any snake oil. Whether it had any therapeutic value was apparently not at issue. So originally the term snake oil had no negative connotation but later became another word for con job or flim flam or mildly put -deceptive advertising.
Dr. Roy Poses of the blog Health Care Renewal expounds on the exploits of a modern , until now, unsuccessful politician currently leading the Republican race for president which involved a multi level market scheme for selling vitamin tablets that were purportedly customized to the individual customer based on a urine test. Ultimately the higher links in the multi level apparently could not pay their bills and the Trump Network's contract with the vitamin company lapsed and the Trump Marketing engine moved on to better pickings.
(the article that apparently was first on this story was the NY magazine in 2011)
The term snake oil salesmen morphed into a synonym for hucksters or con men or film-flame artist -terms that are not uncommonly used to describe politicians.
If a politician found he had cannibals among his constituents, he would promise them missionaries for dinner. H.L. Mencken
A business man named Clark Stanley began to peddle what he purported to be rattlesnake oil said to have marvelous medical purposes. Following the passage of the 1906 Federal Food and Drug act a suite was brought against Mr. Stanley for "misbranding", as the ointment did not actually contain any snake oil. Whether it had any therapeutic value was apparently not at issue. So originally the term snake oil had no negative connotation but later became another word for con job or flim flam or mildly put -deceptive advertising.
Dr. Roy Poses of the blog Health Care Renewal expounds on the exploits of a modern , until now, unsuccessful politician currently leading the Republican race for president which involved a multi level market scheme for selling vitamin tablets that were purportedly customized to the individual customer based on a urine test. Ultimately the higher links in the multi level apparently could not pay their bills and the Trump Network's contract with the vitamin company lapsed and the Trump Marketing engine moved on to better pickings.
(the article that apparently was first on this story was the NY magazine in 2011)
The term snake oil salesmen morphed into a synonym for hucksters or con men or film-flame artist -terms that are not uncommonly used to describe politicians.
If a politician found he had cannibals among his constituents, he would promise them missionaries for dinner.
H. L. Men
Read more at: http://www.brainyquote.com/quotes/authors/h/h_l_mencken_2.html
Read more at: http://www.brainyquote.com/quotes/authors/h/h_l_mencken_2.html
If a politician found he had cannibals among his constituents, he would promise them missionaries for dinner.
H. L. Men
Read more at: http://www.brainyquote.com/quotes/authors/h/h_l_mencken_2.html
Read more at: http://www.brainyquote.com/quotes/authors/h/h_l_mencken_2.html
If a politician found he had cannibals among his constituents, he would promise them missionaries for dinner. H.L. Mencken
Monday, May 02, 2016
Retired doc celebrates 1000 + commentaries with some self referential rehases.
Happy anniversary to self.
About ten years and now slightly over one thousand blog commentaries have passed by since I started a blog about the same time I retired .
Here are some of my favorites topics , a few of which have had a few thousand hits which is a lot for a backwater blog with minimal general interest and too much inside baseball talk.
1)I have written about so called "high value" medical care more than once. Here is my favorite in which I suggest that while modern mainstream economic thought is very diverse and has many areas in which there is marked disagreement, most agree that demand curves slope downwards and value is subjective. The now widely talked about notion of high value medical care seems to contradict that second principle.Simply put- the question is high value according to whom.
Another commentary on a related issue is here . Value=quality/cost as a pseudo-equation used to pretend that cost containment is really all about quality and has nothing to do with third party payers enhancing their profits by lowering costs, i.e. paying less for medical care.
2)Meta Analysis is a topic I have written about for ten years with my basic grip being that meta analysis should not be enshrined at the tip top of the evidence based medicine pyramid.See here .
I quote from from an important essay by Dr. Steve Goodwin .
3)The issue of how to apply population data , as in for example a randomized clinical trial, to a real life individual patient, is a topic I wrote about in 2005 quoting heavily from an important paper by Kravitz,Duran and Braslow in one of a series of blog entries that were facetiously labeled suggestions for a medical school curriculum. (Facetious because I had no role whatsoever in curriculum planning)
4) Another "curriculum suggestion" dealt with education about the transformation of Nazi physicians to Nazi killers.This quoted liberally from a book ( The Nazi Doctors) by Robert J Lifton,M.D. Lifton said - That according to the Nazi medical credo the physician was to be concerned with the health of the Volk and was to overcome the old individualistic principle of the right to one's own body and the embrace the duty to be healthy and the physician duty was to the collectivity.( a paraphrase not a direct quote). Scary ideology that did not die out with the end of World War II and what happened and how it happened in Germany is an important thing for current physicians to know about.
5)A theme I have hammered away on perhaps too much is that of the progressive medical elite,the medical arm of the progressive mindset who believe that ordinary citizens are just not qualified to mind their own business and that the elite must mind it for them , ideally by persuasion but if necessary through coercive means.Here is a sample. Some might use the term" medical clerisy" to refer to this group.
6) Little seems to be written now about the Complete Lives System promoted by Dr. Zeke Emanuel that caused a bit of a controversy in 2009 . My critical commentary received more hits than most of my efforts as well a number of supporting letter echoing the concern I had.Here I suggest what Hayek might have said in regard to the complete lives system.
7) Physicians, like all humans, deal a lot with uncertainty One framework that can be used to consider uncertainty divides it into two types- stochastic or random and epistemic i.e. one based on lack of knowledge. Dr. Steve Goodwin offered a useful metaphor or story about the difference between random or stochastic versus deterministic. I wrote about that here.
8)Hoodwinking the medical profession ( and the public) to further the boondoggle that medical practice is becoming was the topic of a blog for which I borrowed heavily from a very insightful commentary by another blogger , Dr. Michale Accad. The Baptist and Bootlegger metaphor is applicable here as well.
9 )The New Professionalism as envisioned by a subset of folks at the American Board of Internal Medicine and the American College of Physicians with editorial and financial assistance from the Robert Wood Johnson Foundation represents an effort to reformulate traditional medical ethics from which in which the physician has a primary fiduciary duty to his patients to one in which a nebulous duty to be a steward of society's medical resources assumes a major role and social justice is appended to the traditional medical ethical precepts.Here I comment on the relationship between social justice and the rule of law and here I write about Thomas Sowell's Conflict of Visions
as related to the old and the new medical ethics.
Enough for one posting-maybe I reminisce about some others latter.
About ten years and now slightly over one thousand blog commentaries have passed by since I started a blog about the same time I retired .
Here are some of my favorites topics , a few of which have had a few thousand hits which is a lot for a backwater blog with minimal general interest and too much inside baseball talk.
1)I have written about so called "high value" medical care more than once. Here is my favorite in which I suggest that while modern mainstream economic thought is very diverse and has many areas in which there is marked disagreement, most agree that demand curves slope downwards and value is subjective. The now widely talked about notion of high value medical care seems to contradict that second principle.Simply put- the question is high value according to whom.
Another commentary on a related issue is here . Value=quality/cost as a pseudo-equation used to pretend that cost containment is really all about quality and has nothing to do with third party payers enhancing their profits by lowering costs, i.e. paying less for medical care.
2)Meta Analysis is a topic I have written about for ten years with my basic grip being that meta analysis should not be enshrined at the tip top of the evidence based medicine pyramid.See here .
I quote from from an important essay by Dr. Steve Goodwin .
3)The issue of how to apply population data , as in for example a randomized clinical trial, to a real life individual patient, is a topic I wrote about in 2005 quoting heavily from an important paper by Kravitz,Duran and Braslow in one of a series of blog entries that were facetiously labeled suggestions for a medical school curriculum. (Facetious because I had no role whatsoever in curriculum planning)
4) Another "curriculum suggestion" dealt with education about the transformation of Nazi physicians to Nazi killers.This quoted liberally from a book ( The Nazi Doctors) by Robert J Lifton,M.D. Lifton said - That according to the Nazi medical credo the physician was to be concerned with the health of the Volk and was to overcome the old individualistic principle of the right to one's own body and the embrace the duty to be healthy and the physician duty was to the collectivity.( a paraphrase not a direct quote). Scary ideology that did not die out with the end of World War II and what happened and how it happened in Germany is an important thing for current physicians to know about.
5)A theme I have hammered away on perhaps too much is that of the progressive medical elite,the medical arm of the progressive mindset who believe that ordinary citizens are just not qualified to mind their own business and that the elite must mind it for them , ideally by persuasion but if necessary through coercive means.Here is a sample. Some might use the term" medical clerisy" to refer to this group.
6) Little seems to be written now about the Complete Lives System promoted by Dr. Zeke Emanuel that caused a bit of a controversy in 2009 . My critical commentary received more hits than most of my efforts as well a number of supporting letter echoing the concern I had.Here I suggest what Hayek might have said in regard to the complete lives system.
7) Physicians, like all humans, deal a lot with uncertainty One framework that can be used to consider uncertainty divides it into two types- stochastic or random and epistemic i.e. one based on lack of knowledge. Dr. Steve Goodwin offered a useful metaphor or story about the difference between random or stochastic versus deterministic. I wrote about that here.
8)Hoodwinking the medical profession ( and the public) to further the boondoggle that medical practice is becoming was the topic of a blog for which I borrowed heavily from a very insightful commentary by another blogger , Dr. Michale Accad. The Baptist and Bootlegger metaphor is applicable here as well.
9 )The New Professionalism as envisioned by a subset of folks at the American Board of Internal Medicine and the American College of Physicians with editorial and financial assistance from the Robert Wood Johnson Foundation represents an effort to reformulate traditional medical ethics from which in which the physician has a primary fiduciary duty to his patients to one in which a nebulous duty to be a steward of society's medical resources assumes a major role and social justice is appended to the traditional medical ethical precepts.Here I comment on the relationship between social justice and the rule of law and here I write about Thomas Sowell's Conflict of Visions
as related to the old and the new medical ethics.
Enough for one posting-maybe I reminisce about some others latter.
Saturday, April 30, 2016
Transformation from "layperson" to physician
In the ten years since I began blogging much of what has been written about medical professionalism, I find alarming. The New Professionalism as promulgated by the American College of Physicians and the ABIM attempts to transform the basic medical obligation of the physician to the patient to a nebulous,operational vague co-duty to serve society by conserving resources and furthering social justice.
The following is taken from an earlier blog entry with light editing and additions.
Dr. Lawrence G.Smith, writing in the April 3, 2005 issue of the American Journal of Medicine speaks of this transformation. from lay person to physician. Professionalism has been written about extensively as it relates to doctors. Smith maintains the core of professionalism is the "personal transformation of self that takes place in stages during the early years of medical training and practice" When transformed the person now interacts with society in a new and different manner ).Dr. Smith was not speaking of professionalism in terms of being a steward of collectively owned resources,that distortion of basic medical ethics was not then widely written about.
I have no doubt that transition happened to me. I can still remember comments made by teachers now over 50 years ago which were part of that process. I remember the attitude of respect and seriousness that was passed to me from the professors of gross anatomy as it related to behavior to the cadavers and behavior in the lab. I remember the pathology professor who told us that when we saw patients at night in the hospital how important it was for us to look and behave like physicians.I remember the chief of surgery who insisted that his residents wear shirts and ties in the hospital and clean coats and that his definition of a surgeon was a physician who knew how to operate.I remember how the clinical faculty typically treated the patients in the county hospital always with courtesy and respect, even though at times residents might have not.
Soon after I completed residency and fellowship training I was doing a locum tenens and had the occasional to call the chief of medicine, with whom I had trained, to see a private patient at 3 am. She had end stage lupus and he had seen her several years before and her parents insisted that he see them. I called him at home and he arrived soon after .. He was well shaven and well dressed in a suit and tie.. He spent over a hour with the patient and family,taking a detailed history and ding a physical examination , completed a page and half note and spent another 10 minutes with me.The family was greatly relieved that all that could be done was being done. I was greatly relieved and felt that the chief had taught me another lesson;how a physician can do things the way that should be done in the real world.
These are just a few snap shots of the many events and attitudes that lead to my transition from a college kid who really had no idea what to expect in med school or beyond to a person who felt he was trained to do serious, often difficult, important work and that it all was a privilege and a great obligation and that doing the right thing for the patient was what it was all about. Much of what my high school friends had done while I was in training, I had missed and in the years of training much of transpired in the world I had also missed. And much of the everyday concerns of relatives seemed to be so much less important.I believe part of that transformation process is the isolation from the daily events of the world that seems required by the intense study and training lasting for years past the usual time an adult joins the work force. Part of that transformation occurs because most of your waking hours are spent with other physicians and professionals doing what doctors do and talking about things doctors talk about.Role models are everywhere.
I might add my classmates and I made that transition with the "benefit" of the trophies- for- everyone -before- the- game white coat ceremony.
As Dr. Smith said, once the transformation occurs you cannot think of being a physician as just a job.And it is difficult to think of yourself as any thing but a physician.
And because of that transformation it becomes very hard for a physician to retire or to be forced to leave practice because of illness. Are you transformed back into a lay person or are you still a physician who ...?
The following is taken from an earlier blog entry with light editing and additions.
Dr. Lawrence G.Smith, writing in the April 3, 2005 issue of the American Journal of Medicine speaks of this transformation. from lay person to physician. Professionalism has been written about extensively as it relates to doctors. Smith maintains the core of professionalism is the "personal transformation of self that takes place in stages during the early years of medical training and practice" When transformed the person now interacts with society in a new and different manner ).Dr. Smith was not speaking of professionalism in terms of being a steward of collectively owned resources,that distortion of basic medical ethics was not then widely written about.
I have no doubt that transition happened to me. I can still remember comments made by teachers now over 50 years ago which were part of that process. I remember the attitude of respect and seriousness that was passed to me from the professors of gross anatomy as it related to behavior to the cadavers and behavior in the lab. I remember the pathology professor who told us that when we saw patients at night in the hospital how important it was for us to look and behave like physicians.I remember the chief of surgery who insisted that his residents wear shirts and ties in the hospital and clean coats and that his definition of a surgeon was a physician who knew how to operate.I remember how the clinical faculty typically treated the patients in the county hospital always with courtesy and respect, even though at times residents might have not.
Soon after I completed residency and fellowship training I was doing a locum tenens and had the occasional to call the chief of medicine, with whom I had trained, to see a private patient at 3 am. She had end stage lupus and he had seen her several years before and her parents insisted that he see them. I called him at home and he arrived soon after .. He was well shaven and well dressed in a suit and tie.. He spent over a hour with the patient and family,taking a detailed history and ding a physical examination , completed a page and half note and spent another 10 minutes with me.The family was greatly relieved that all that could be done was being done. I was greatly relieved and felt that the chief had taught me another lesson;how a physician can do things the way that should be done in the real world.
These are just a few snap shots of the many events and attitudes that lead to my transition from a college kid who really had no idea what to expect in med school or beyond to a person who felt he was trained to do serious, often difficult, important work and that it all was a privilege and a great obligation and that doing the right thing for the patient was what it was all about. Much of what my high school friends had done while I was in training, I had missed and in the years of training much of transpired in the world I had also missed. And much of the everyday concerns of relatives seemed to be so much less important.I believe part of that transformation process is the isolation from the daily events of the world that seems required by the intense study and training lasting for years past the usual time an adult joins the work force. Part of that transformation occurs because most of your waking hours are spent with other physicians and professionals doing what doctors do and talking about things doctors talk about.Role models are everywhere.
I might add my classmates and I made that transition with the "benefit" of the trophies- for- everyone -before- the- game white coat ceremony.
As Dr. Smith said, once the transformation occurs you cannot think of being a physician as just a job.And it is difficult to think of yourself as any thing but a physician.
And because of that transformation it becomes very hard for a physician to retire or to be forced to leave practice because of illness. Are you transformed back into a lay person or are you still a physician who ...?
Friday, April 29, 2016
Quality adjusted life years is not even argued about any more-
We don't debate the merits of quality adjust life year determinations any longer, we just do them.
But, there was a time a few years ago when there was thoughtful criticism of the concept of quality adjusted life years (QALY) but the dogs barked and the caravan moved on.
One such analysis appeared in 1990.I (JAMA 199:263(21):2917-2921), John LaPuma et al said that the QALY concept was :
"founded on six ethical assumptions:
quality of life can be accurately measured and used, utilitarianism is acceptable, equity and efficiency are compatible, projections of community preferences can substitute for individual preferences, the old have less "capacity to benefit" than the young, and physicians will not use quality-adjusted life-years as clinical maxims."
In their article they offer valid critiques of each of those assumptions.
Now it seems that the notion of QALY is firmly established in the practice of " determining" the cost effectiveness of medical procedures and treatments. Why is the word determining placed in scare quotes? Because my argument is that the idea of determining QALY is, in the words of the founder of utilitarianism, which is what QALY is all about, a fiction.
Jeremy Bentham did not discuss QALYs since the term was not invented in his day but he did consider the idea of adding up individuals happiness or utility as it was essential to his philosophy.
Bentham's famous principle is "the greatest happiness of the greatest number is the foundation of morals and legislation". To him happiness was the balance of pleasure over pain and this would be summed up somehow for everyone affected by the policy proposal and was known as the principle of utility and is the essence of utilitarianism.
Those who favor a utilitarian approach to public policy issue will not be pleased to learn than Bentham himself admitted that summing happiness or utilities or some measure of quality of life did not make sense. Bentham wrote:
"Tis vain to talk of adding quantities which after the addition will continue distinct as they were before,one man's happiness will never be another man's happiness:a gain to one man is no gain to another;you might as well pretend to add 20 apples to 20 pears,which after you had done that could not be 40 of any one thing but 20 of each as there were before. This addibility of the happiness of different subjects , however, when considered rigorously it may appear fictitious, is a postulatum without the allowance of which all political reasoning is at a stand.."
So Bentham realized that adding up everyone's happiness did not make sense (when considered rigorously) but we need to do it to make policy.
The economist, Anthony de Jasay ,said that scientifically speaking aggregating the utilities of different persons, e.g. to subtract from the gains of some the losses of others,is just as nonsensical as taking four apples out of seven oranges.So nonsense that is "useful" for some analysis is still nonsense.
Cost effectiveness analysis as applied to medical procedures does not exactly sum happiness over many individuals but sums instead quality adjusted life years. The QALY ( or the simpler concept of life years) is foundational in the current efforts to determine cost effectiveness.
John Rawls' A Theory of Justice proposes a redistribution scheme different from utilitarianism about which he said "[it] ( utilitariansim )does not take seriously the distinction between persons".Thomas Nagel,a critic of utilitarianism said of it that it treats the needs and satisfactions of multiple individual beings as if they were the features of some hypothetical mass person.
Nonsense or not it is a handy tool for the elites who would make their value judgments determinative of what the rest of us are allowed to have in terms of medical care.
Woody Allen tells the following joke. A guy walks into a psychiatrist' office and say "doc, my brother is crazy, he thinks he is a chicken." The doc replies you should get him in a mental hospital.The guy say I should but we really need the eggs.
The third party payers and their fellow travelers need the eggs.
note: Minor editorial tweeks made on 8/16/12 and joke and other addtions made on 4/8/16
Thursday, April 28, 2016
The Tenth Commandment and Hayek were right about envy
Quotes for the day From FA Hayek and PJ O'Rourke bring a year-end message about envy and social justice.
Quoting the economist, Anthony de Jasay quoting Hayek.
"No effort to make society drabber will make it drab enough to relieve envy. Hayek,invoking Mill, pleads that if we value a free society, it is imperative 'that we not countenance envy, not sanction its demands by camouflaging it as social justice, but treat it.. as the most anti-social and evil of all passions' "
PJ O'Rourke, whose scholarly credentials include having actually read Smith 's Wealth on Nations in the original English, has this to say about the envy and coveting things:
"The Tenth Commandment sends a message to all the jerks who want redistribution of wealth, higher taxes, more government programs, more government regulation, more government, less free enterprise, and less freedom. And the message is clear and concise: Go to hell."
References:
Page 198. The State, Anthony de Jasay
An Alternative Inaugural Speech" (18 January 2005) by PJ O'Rourke
Quoting the economist, Anthony de Jasay quoting Hayek.
"No effort to make society drabber will make it drab enough to relieve envy. Hayek,invoking Mill, pleads that if we value a free society, it is imperative 'that we not countenance envy, not sanction its demands by camouflaging it as social justice, but treat it.. as the most anti-social and evil of all passions' "
PJ O'Rourke, whose scholarly credentials include having actually read Smith 's Wealth on Nations in the original English, has this to say about the envy and coveting things:
"The Tenth Commandment sends a message to all the jerks who want redistribution of wealth, higher taxes, more government programs, more government regulation, more government, less free enterprise, and less freedom. And the message is clear and concise: Go to hell."
References:
Page 198. The State, Anthony de Jasay
An Alternative Inaugural Speech" (18 January 2005) by PJ O'Rourke
The authoritarian coercive aspect of the progressive medical elite
George Will has commented on the recent authoritarian activity of of attorneys general and the justice department to go after climate change "deniers", (a derogatory term to suggest a similarity to round earth deniers and Holocaust deniers.)
Will talks about the authoritarian facet of progressives. I submit the subset of progressives in the medical elite has the same frightening characteristic.
Here are some examples;
1) Dr Robert Benson ,former CEO of the ABIMF,writing on the blog of the ABIMF is explicit about what he desires in regard to the Choosing Wisely initiative of the ABIMF. ( It should not go unnoticed that the funding for this program , the motive of which I have ranted about before, comes largely for fees charge to internists for their certification and recertification exams and for other time consuming programs that have been made part of their MOC ( Maintenance of certification program).
Benson wants the Choosing Wisely
quoting Dr. Benson : boldings added
" 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."
2) Like minded thoughts are expressed in the NEJM by Dr. Nancy Morden of the Dartmouth Institute for Health Policy and Clinical Practice:
"..linking the lists ( of tests and procedures not to do ) to specialty specific maintenance of certification activities such as practice audits and improvement tasks could also advance their dissemination and uptake at very low cost."
"...Choosing Wisely items should also be incorporated into quality-measurement efforts such as Center for Medicare and Medicaid Services Physician Quality Reporting ...linking low value service use to financial incentives ( translate penalties ) .. should accelerate ...into practice changes."
3) Drs Don Berwick and Troyen Brennan in their book "New Rules" are not subtle in the following quote:
"Today, this isolated relationship[ 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.
When one talks about constraining and reformulation and "rules with authority" , the coercive aspect is obvious. Of course the progressive medical elite is authoritarian, they are progressives.
Tuesday, April 26, 2016
The ethics of the medical progressives
Hubris is the belief that one is intellectually superior to his fellow human being.That can be manifest as just an air of superiority , sort of a know-it-all who might offer gratuitous advice.Such folks tend to be irritating but not necessarily dangerous.. Add that mind set to a belief that folks of that statue should be in charge of well most everything and you have the two basic principles of the progressive mind set and then things can get to be dangerous.Add to that mindset the notion that if folks do not accept your blindingly brilliant plans there should be some mechanism of enforcement of your wisdom.
Cui Bono. Follow the money or who profits. Ask the question who profits form what appears to be a sea change in medical ethics in the last decade? What is the sea change? The change is from a basic fiduciary duty of the physician to the patient to the physician now ethically tasked with both doing what is best for the patient and somehow conserving "society's medical resources". One master less chance of conflict- two masters conflict lurking much of the time and loss of trust.
The new medical ethics is the ethics of the progressive. I call the medical progressive the medical progressive elite. In Joe Kotkin's taxonomy found in his book America's New Class System they would be a subset of the clerisy who function to provide cover for the oligarchs and for the ever growing and increasingly powerful governmental bureaucracy.
The progressive ethic is that much of society's affairs ( meaning an individual's affairs) should be managed by an elite.Medical decisions that in the past have been the bailiwick or purvey of the patient in consultation with his physician will in the world of the new medical ethics become decisions that will be made by wise leaders with ideas who pass their wisdom down in the form of guidelines adherence to which is now an ethical imperative. Here we have the merging of the high sounding ideals with the narrow self interests of the third payer payers.Does this not resonant with the notion of the Baptist and the Bootlegger?
Dr. Paul Hsieh discuses certain aspects of the new medical ethics here on PJMedia Blog.
Interestingly this 2012 article by Mark Daniels which reviews certain historical development in medical ethics and discusses various categorical approach to ethics in general ( duty based versus utilitarian etc) makes no mention of a duty of the physician to be a steward of society's medical resources.
The new ethics has been promulgated and promoted by the American Board of Internal Medicine and its foundation and fellow travelers in the American College of Physicians a number of whom have held positions in both organizations. This new duty is manufactured out of whole cloth largely by these two organizations.Their Choosing Wisely campaign and the Medical Processional for the New Millennium publication have served as vehicles to bamboozle both the medical profession and the public.
Who profits? the third party payers and a number of the progressive medical elite who have positioned themselves to be the movers and shakers in the governmental and quasi governmental
structure that aims to control the practice of medicine and importantly attempt to control (i.e. minimize) the expenditures of the private and public third party payers.
Former ACP presdient asks "must the population health approach compromise the needs of the individual"
Dr. Harold Sox in a JAMA viewpoint commentary ( see here for link) addresses three questions regarding 'Population health approach" which he defines as " a aim to improve and maintain health across a population"
1.Can the population health approach improve the outcome of US health care? 2.For this approach to succeed ,must it reconcile the need of the individual with the community 3.How might these needs be reconcilable?
"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,these investments may draw resources from tests and treatments 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. "
This IMO is an incredible paragraph on several grounds .First of all the author admits that some sick people may be harmed as funds are diverted to prevention programs.So the answer to the question that introduces the paragraph is "yes" and is presented in a matter of fact manner. The distinction between short run and long run seems spurious. If limiting funds for treatment for some sick people is used to for prevention, why would that be a one time occurrence. Would not funds continue to be used for prevention as the expense of some sick people if there is some purported advantage to that based on the currency of QALY? One can only guess what "skillful clinical decisions" might be that somehow mitigates the issue of denying treatment to some for some purported future aggregate benefit from a prevention program? Here putative preventive measures trump the need to treat a sick person which for centuries has been the essence of the physician's activity.Oh well to make a omelet..The omelet here would be improved health of the community as judged by some aggregate statistic and judged by some central entity.
Earlier in the article Sox speaks of making decisions regarding allocation of resources across patients and programs.The program that would be favored at the expense of another would be based on comparison of QALY ( quality adjusted life years). "One reasonable principle is to move resources from groups of patients less like to benefit to groups more likely to benefit" The author does not specify who it is that will "move resources" and whose permission, if any, would be necessary for such rationing. or who will make that type decisions.This shift of resources might involve removing resources of value to some for putative somehow measured greater benefit to others.
Individuals make trade-offs in many areas of their lives including health care. This utilitarian approach is based on a third party making trade-offs between lives. It treats people as means of reaching some social end, in this case "maximizing health" and in the process fails to respect the "discreteness of the individual"
Earlier in the commentary the author says :
"Planning to optimize population health will mean determining the frequency,causes and consequences of the common medical condition in a population and devising strategies for dealing with them over a life time" Wow, no hubris there.
Sox speaks of the health care system and the public health care system planning together, as if the health care system is a unitary entity capable of acts appropriate to a sentient being,such as planning and cooperation. and could cooperate with another abstraction as if it were also a sentient entity.He seemingly realizes something major will be required to force this cooperation and the answer is "global spending limits".This will "force the community to cooperate in deciding how to maximize the health of the people?"
It is hard to make sense out of that last quote so riddled as it is with reifications , regarding abstractions as concrete existential entities capable of thought and action.Are you forcing the community which is the people to decide how to maximize their own health? How will that decision making process be carried out? Voting,town hall meetings for every one in the country? What measure of health maximizing would be used? Who would decide? Does this conflate community or society with with government? The two are not the same.
A number of members of what I call the progressive medical elite have apparently received the memo that says to push the concept of "global medical spending limits:. In the same issue of JAMA, Dr. Don Berwick and Dr. Zeke Emanuel both recommend very specific limits. eg.for medical spending to increase no more than the increase in the GDP.
So are the needs of the individual and the population reconcilable? They are in the specific sense in which he uses the term, i e reconcilable in the sense of " using the same metric of value (QALY) and the same decision making principles.
But the answer to the question "Must the Population health approach compromise the needs of the individual to benefit the community?" is yes as demonstrated in the example he offered.
As if to camouflage the brutal reality of the "draw[ing] of resources" away from the sick, Dr Sox closes with the platitude that the basics of patient centered care have not changed. The hell they have not changed-they certainly have in the population health world he envisions.
The progressives in general as well as subsets such as the medical progressive elite learned nothing from the history of the 20th century - nothing in terms of the outcome of central planning, nothing in terms of the slippery slope of sacrificing the individual to the collective.
1.Can the population health approach improve the outcome of US health care? 2.For this approach to succeed ,must it reconcile the need of the individual with the community 3.How might these needs be reconcilable?
"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,these investments may draw resources from tests and treatments 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. "
This IMO is an incredible paragraph on several grounds .First of all the author admits that some sick people may be harmed as funds are diverted to prevention programs.So the answer to the question that introduces the paragraph is "yes" and is presented in a matter of fact manner. The distinction between short run and long run seems spurious. If limiting funds for treatment for some sick people is used to for prevention, why would that be a one time occurrence. Would not funds continue to be used for prevention as the expense of some sick people if there is some purported advantage to that based on the currency of QALY? One can only guess what "skillful clinical decisions" might be that somehow mitigates the issue of denying treatment to some for some purported future aggregate benefit from a prevention program? Here putative preventive measures trump the need to treat a sick person which for centuries has been the essence of the physician's activity.Oh well to make a omelet..The omelet here would be improved health of the community as judged by some aggregate statistic and judged by some central entity.
Earlier in the article Sox speaks of making decisions regarding allocation of resources across patients and programs.The program that would be favored at the expense of another would be based on comparison of QALY ( quality adjusted life years). "One reasonable principle is to move resources from groups of patients less like to benefit to groups more likely to benefit" The author does not specify who it is that will "move resources" and whose permission, if any, would be necessary for such rationing. or who will make that type decisions.This shift of resources might involve removing resources of value to some for putative somehow measured greater benefit to others.
Individuals make trade-offs in many areas of their lives including health care. This utilitarian approach is based on a third party making trade-offs between lives. It treats people as means of reaching some social end, in this case "maximizing health" and in the process fails to respect the "discreteness of the individual"
Earlier in the commentary the author says :
"Planning to optimize population health will mean determining the frequency,causes and consequences of the common medical condition in a population and devising strategies for dealing with them over a life time" Wow, no hubris there.
Sox speaks of the health care system and the public health care system planning together, as if the health care system is a unitary entity capable of acts appropriate to a sentient being,such as planning and cooperation. and could cooperate with another abstraction as if it were also a sentient entity.He seemingly realizes something major will be required to force this cooperation and the answer is "global spending limits".This will "force the community to cooperate in deciding how to maximize the health of the people?"
It is hard to make sense out of that last quote so riddled as it is with reifications , regarding abstractions as concrete existential entities capable of thought and action.Are you forcing the community which is the people to decide how to maximize their own health? How will that decision making process be carried out? Voting,town hall meetings for every one in the country? What measure of health maximizing would be used? Who would decide? Does this conflate community or society with with government? The two are not the same.
A number of members of what I call the progressive medical elite have apparently received the memo that says to push the concept of "global medical spending limits:. In the same issue of JAMA, Dr. Don Berwick and Dr. Zeke Emanuel both recommend very specific limits. eg.for medical spending to increase no more than the increase in the GDP.
So are the needs of the individual and the population reconcilable? They are in the specific sense in which he uses the term, i e reconcilable in the sense of " using the same metric of value (QALY) and the same decision making principles.
But the answer to the question "Must the Population health approach compromise the needs of the individual to benefit the community?" is yes as demonstrated in the example he offered.
As if to camouflage the brutal reality of the "draw[ing] of resources" away from the sick, Dr Sox closes with the platitude that the basics of patient centered care have not changed. The hell they have not changed-they certainly have in the population health world he envisions.
The progressives in general as well as subsets such as the medical progressive elite learned nothing from the history of the 20th century - nothing in terms of the outcome of central planning, nothing in terms of the slippery slope of sacrificing the individual to the collective.
Monday, April 11, 2016
The alleged demise of the internist-is it just the money?
A blog entry, now several years old,by one of my favorite medical bloggers, DB aka Dr. Robert Centor, offered an important insight into some of the current problems with the specialty of internal medicine which include few medical graduates opting for general internal medicine and the low level of general satisfaction of many internists.It is clearly not your grandfather's internist anymore.
Dr. Centor was commenting specifically on the suggestion by one of his colleagues that the training of internists needed to be revamped with more emphasis on outpatient issue and less on inpatient matter.He seemed to believe and I agree that that was not the answer. Rather DB's key message,in regard to the decreasing popularity of general internal medicine as a choice of medical students, I believe was the following:
"...I believe the problem is money – and that has impacted everything else."
As long as the internists "reimbursement" was what was known as "reasonable, customary and prevailing" the classical internist type practice thrived and "those were the days my friend and we thought they would never end" but they did. The beginning of the end of that type practice can be traced to the imposition of price controls on physician fees by Medicare. Soon after the other third party payers clamped down as well in part with the largely now defunct mechanisms subsumed under the rubric "managed care" whose effects still linger although the programs were rejected by the patients.
With managed care the collegial and self reinforcing relationships that grew up in the pre-managed care era disappeared. Now longer could the internist refer to the physician of his choice it was typically necessary to refer only to someone on the patent's plan.No longer could the family practice physician or the surgeon or ObGyn send a patient to the internist she knew she could trust to take good care of the patient.
With the new payment system ( ever decreasing fees from governmental and non-governmental payers) and the breakdown of the old informal, ad hoc but very useful referral systems, satisfaction for the internists began to fall.Importantly,with decreased fees per patient encounter the incentive was to increase patient encounters and spend less time with each patient.
Further, internists 's practices gradually became a game not of his choosing. Guidelines proliferated and the internist's attention turned more the care of the worried well and a check list practice evolved making sure your patient flossed,wore seat belts and had her colonoscopy and five fruits and veggies a day. Much of it became trivialized to the point where it really began to actually make sense for an assistant (PA nurse practitioner) to do much of what somehow had become expected. And then there is the "existential angst" brought about by the conflict of the old with new medical professionalism.See here for my earlier rant on that and for DrRich's very similar views in his comment to the post.
With decreasing fees per patient encounter it became harder and harder for the traditional internist to care for patients in and out of the hospital and see patients after hours in an emergency room and make the ends of his practice meet with enough left over to make it all seem worthwhile. The notion of a hospital-only practice with regular hours offer many discouraged and burning out internists an out and for younger internist to spend their time taking care of sick patients, i.e. the complex problems that traditionally internists dealt with.
Of course, there is more to the origin of the hospitalist than the angst of the internist and the dwindling pay schedules but I still marvel a bit at the readiness of the internist to change roles to become a physician whose stock and trade was episodic care with little if any chance for the type of long term care through the course of a chronic illness that was once typical of an internist's practice .
So even though the internist turned hospitalist gained more time off, probably better income, and less business type hassles and a chance to deal with the type of serious , complex, medical problems that internists train to manage, but it was only part (although a major part) of what an internist used to be. And of course, the internist who remained with a truncated medical practice had to forgo much of what his training was all about. More and more, I am convinced that the type practice that an internist had was largely dependent on the economic environment of the times and when that environment changed so did the internist and to the degree the new professionalism is the currency so has the medical ethics.
addendum: typo corrected 4/12/16
Dr. Centor was commenting specifically on the suggestion by one of his colleagues that the training of internists needed to be revamped with more emphasis on outpatient issue and less on inpatient matter.He seemed to believe and I agree that that was not the answer. Rather DB's key message,in regard to the decreasing popularity of general internal medicine as a choice of medical students, I believe was the following:
"...I believe the problem is money – and that has impacted everything else."
As long as the internists "reimbursement" was what was known as "reasonable, customary and prevailing" the classical internist type practice thrived and "those were the days my friend and we thought they would never end" but they did. The beginning of the end of that type practice can be traced to the imposition of price controls on physician fees by Medicare. Soon after the other third party payers clamped down as well in part with the largely now defunct mechanisms subsumed under the rubric "managed care" whose effects still linger although the programs were rejected by the patients.
With managed care the collegial and self reinforcing relationships that grew up in the pre-managed care era disappeared. Now longer could the internist refer to the physician of his choice it was typically necessary to refer only to someone on the patent's plan.No longer could the family practice physician or the surgeon or ObGyn send a patient to the internist she knew she could trust to take good care of the patient.
With the new payment system ( ever decreasing fees from governmental and non-governmental payers) and the breakdown of the old informal, ad hoc but very useful referral systems, satisfaction for the internists began to fall.Importantly,with decreased fees per patient encounter the incentive was to increase patient encounters and spend less time with each patient.
Further, internists 's practices gradually became a game not of his choosing. Guidelines proliferated and the internist's attention turned more the care of the worried well and a check list practice evolved making sure your patient flossed,wore seat belts and had her colonoscopy and five fruits and veggies a day. Much of it became trivialized to the point where it really began to actually make sense for an assistant (PA nurse practitioner) to do much of what somehow had become expected. And then there is the "existential angst" brought about by the conflict of the old with new medical professionalism.See here for my earlier rant on that and for DrRich's very similar views in his comment to the post.
With decreasing fees per patient encounter it became harder and harder for the traditional internist to care for patients in and out of the hospital and see patients after hours in an emergency room and make the ends of his practice meet with enough left over to make it all seem worthwhile. The notion of a hospital-only practice with regular hours offer many discouraged and burning out internists an out and for younger internist to spend their time taking care of sick patients, i.e. the complex problems that traditionally internists dealt with.
Of course, there is more to the origin of the hospitalist than the angst of the internist and the dwindling pay schedules but I still marvel a bit at the readiness of the internist to change roles to become a physician whose stock and trade was episodic care with little if any chance for the type of long term care through the course of a chronic illness that was once typical of an internist's practice .
So even though the internist turned hospitalist gained more time off, probably better income, and less business type hassles and a chance to deal with the type of serious , complex, medical problems that internists train to manage, but it was only part (although a major part) of what an internist used to be. And of course, the internist who remained with a truncated medical practice had to forgo much of what his training was all about. More and more, I am convinced that the type practice that an internist had was largely dependent on the economic environment of the times and when that environment changed so did the internist and to the degree the new professionalism is the currency so has the medical ethics.
addendum: typo corrected 4/12/16
Wednesday, April 06, 2016
Federalization of MOC program and Choosing Wisely is moving closer to reality
Dr. Wes on his blog gives an update on the alarming progress ABIMF and fellow travelers have made in their program to exert control of medical practice.
The folks associated with ABIMF have told us what they want to do and now it looks like they are making alarming progress towards those goals.
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On the ABIMF blog ,former CEO of ABIMF, Dr. John Benson made these comments,telling us what they want. ("The Necessity of Stewardship"Feb.20.2014)
"The time is well past exhortation. The issue has been recognized for decades. Hard choices and penalties must go beyond training the next generation. 2020 is closing in."
He continues
" 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." (note the current President of ABIM and ABIMF is Dr. Richard Baron who left a post at CMS through the revolving door to assume his duties at ABIM and ABIMF)
and it gets worse
" 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." (Maintenance of Certification)
Benson seems to want Choosing Wisely to literally become the law of the medical land and recent events at the federal level should give him satisfaction.Very alarming developments.
Tuesday, April 05, 2016
Statistical independence does not mean causal
An article in the Jan 24, 2005 issue of the Archives of Internal Medicine(vol. 165 p138-145) made important points regarding the concept of "independent risk factors". Basically, Dr. Brotman and co-authors remind (or more likely inform) the readers that ( my bolding): statistical independence does not mean causality, is context dependent ( ie in that particular data set) and risk factors may be causal even if not statistically independent. Independence is a statistical concept relying on a particular statistical model.
I once downplayed the significance of elevated triglycerides as a risk factor for coronary disease because I had read triglycerides were not an independent risk factor. Now, or course, clinical studies have shown the opposite- at least for now. The point is that a risk factor can be "significant" i.e. important whether or not a medical publication's analysis indicates that is an "independent risk factor" .
Articles like this can be are important antidotes to the faith that we tend to have in the black box magical output of multivariate analysis as well as less familiar techniques ( eg propensity score matching and,instrumental variables methods which purport to make observational studies more like randomized trials). Few physicians have plowed through the pen and paper process of doing a multivariate analysis or even understand generally what it all about.I don't claim to. That exercise might give one a real sense of what is being done and perhaps how small variations in data input can alter the answer- changing an independent risk into one that is not and vice versa.
In regard to heart disease, the authors assert that as more variables are linked to disease, no study will be able to properly model all the risk factors to enable them to say that X is an independent risk factor. This problem of residual confounding limits medicine's search for the causes and might make us more circumspect when we make pronouncements to patients about what causes what and what we should do about it and we cannot just rely on whether a particular study did or did not show statistical independence.
William Barrett In his book "Illusion of Technique"(Anchor Books, 1979) says that Logic is the only modern science that has shown its own limits by showing the limits of formal systems(through the work of Godel and others).
We might tend to forget when we read " X is an independent risk factor for disease Y" that we are dealing with "provisional conclusions " extracted from "fragmentary" data and working within a particular statistical model with a particular data set.
Some have make a distinction between "faith based" medicine with "evidence based medicine". Considering the faith required to believe the output of mysterious mathematical models about which most physicians readers know little , this distinction begins to fade away.Maybe we need a medical version of Godel's theorem as an antidote to hubris or faith based believe in technique. I eagerly await more articles,such as Brotman's,pointing out the limits of medicine's knowledge generating techniques.
note: This theme appeared in comments in a different venue by me about ten year ago and have not appeared before on RDT and has been lightly revised and edited.
Thursday, March 31, 2016
Population Medicine is faith based - without logic or emperical support
Here are the comments of Apu,owner of the Kwik e Mart after Homer Simpson quite his job there:
"He slept,he stole,he was rude to the customers.Still, there goes the best damned employee a convenience store ever had. "
In a way a free , market based society is something like that. With freedom and capitalism , property rights and rule of law , there are booms and busts, there are demonstrable inequalities among various parameters,there is information asymmetry, externalities, and apparent market failures. Still it is the best damned economic, social system a country ever had.
The economist and historian,Dierdre McCloskey,put it this way:
"How do I know that my narrative is better than yours? The experiments of the 20th century told me so. It would have been hard to know the wisdom of Friedrich Hayek or Milton Friedman or Matt Ridley or Deirdre McCloskey in August of 1914, before the experiments in large government were well begun. But anyone who after the 20th century still thinks that thoroughgoing socialism, nationalism, imperialism, mobilization, central planning, regulation, zoning, price controls, tax policy, labor unions, business cartels, government spending, intrusive policing, adventurism in foreign policy, faith in entangling religion and politics, or most of the other thoroughgoing 19th-century proposals for governmental action are still neat, harmless ideas for improving our lives is not paying attention."
The proponents of a population medicine approach have not been paying attention.
The population medicine approach is a faith based movement whose rhetorical support is largely gratuitous assertion and is strikingly lacking in logic and empirical support. It takes a great act of faith to believe that very wise medical leaders will be able to determine what medical conditions should be treated, what preventive measures should be carried out and how in the "era of limited resources" of which they speak the correct allocations of resources will be made.
Population Health Approach (PHA)or more concisely population medicine is the antithesis of individual medicine which is and has been for centuries the interaction of the individual patient with a physician whose fiduciary duty is to the patient acting to the best of his ability and judgment in that patient's best interests . It is the medicine of the individual versus the medicine of the aggregate or the group..It pits the sanctity of the individual against the alleged aggregate benefit of some group.
It is the tension of Plato and Aristotle.
It is basically the fable story tale saga of the baptist and the bootlegger. the bootlegger being the third party payers. The baptists are various members of the progressive medical elite lobbying for a system in which the elite can decide what is best for the rest of us, this time in terms of medical care.
Let's look at some of content of the sermons .The bootleggers usually leave the rhetoric to the baptists but there may be the occasional exception.See the final paragraph below.
A revealing and amazingly explicit explication of some of the principles is found in this sermon by one of the preachers of the religion of population medicine. Dr. Harold Sox expresses the view of the doctrine espoused by the Church of the ACP and ABIMF,( Reference: JAMA November 13,2013 vol 310 number 8).
"Throughout history,codes of professional conduct have called on clinicians to make each patient's interests their highest priority.If resources becomes limited,clinicians will find themselves unable to adhere to that standard of practice for all patients.In 2002a new code of conduct ,the Charter for Professionalism ,addressed this conflict by calling of physicians to consider the needs of all when treating the individual. While meeting the needs of individual patients,physicians are required to provided health care that is based on wise and cost-effective management of limited clinical resources.The provision of unnecessary services not only exposes patient to avoidable harm and expense but also diminishes the the resources available to others."
This remarkable passage indicates that the physician has an ethical imperative to balance the needs of the individual patient with the needs of society.With this foundational principle of the population health approach, the Charter, in effect calls on clinicians to allocate resources. However, it does not provide specific advice. Recent programs such as the American Board of Internal Medicine Foundation's Choosing Wisely campaign, are beginning to fill this knowledge gap, as do some practice guidelines."
It is an astonishing passage ,filled with both hubris and naivete, as it seeks to completely overturn centuries of medical ethics in which the physician had a fiduciary duty to the patient and rewrite the role of the physician and shift the decision making process from the patient and her physicians to central planners..
A sometimes evoked fable in the religion of the medicine of the collective is that of the Medical commons. A example of that type sermon is found in JAMA in a joint effort by Drs. Troy Brennan and Christine Cassel in which the authors urge both physicians and patients to forgo their own limited self interest and work together for the good of the group.At the time of the publication of this 2007 article, Dr. Cassel was an officer of the American Board of Internal Medicine (ABIM) and Dr. Brennan was a executive at Aetna Inc. (Managing Medical Resources,return to the commons, JAMA June 14 2007,vol 297 p 2518
addendum:Reference added 5/30/2016
Wednesday, March 30, 2016
The progressive medical elite-nothing wrong with P4P that being smarter (and learning the latest buzz words)- won't fix
The professional medical elite have had to admit that yes, sometimes in the past the P4P projects haven't worked out very well but we can all learn from past mistakes and with a fresh set of administrative buzz words and by being really smart this P4P thing will work really well regardless of what past experience and human nature tell us.
That seems to be the view expressed by a spokesman for the American College of Physicians (ACP) who is masterful in his fluency of medical management buzz words the use of which along with being really smart, and catalyzing cooperation between the various stake holders will lead to a new enlightened era of amazing P4P rules abrogating Goodhart's law and revoking human being's strong tendency to respond to incentives.
Quoting from The ACP Advocate Blog written by Bob Doherty,VP of governmental affairs for the ACP in regard to rules for P4P
"..we should figure out what works to help physicians achieve the Triple Aim, including better ways to organize and deliver care, and then judiciously apply a core, harmonized, and improved set of measures to track progress, while always being on the look-out for unintended adverse consequences." Also we need to "reimagine" things. Why does that remind me of Will Roger's solution to the German U-boat problem?
It is always good to throw in the bogus feel-good and pious Triple Aim phrase and "harmonizing" has a nice vague group think ring to it and who is the "we" to which Doherty refers.There was once a time when there were only two people in the exam room that could be considered stakeholders, the patient and the physician. Now the way medical care is discussed and is practiced seems to find others in the exam room who have some stakes to hold. These invisible stake holders include , of course, the third party payers and now more than ever the health care entity that employs the physician .
Dr. Christine K. Cassel, formerly head of the ABIM and the ACP and the National Quality Forum (NQF), expressed her opinion in the New England Journal of Medicine ( "Getting More Performance from Performance Measurements" Cassel, CK et al , NEJM 371,23 2014). I quote.
"All stakeholder groups are now invested in getting more performance out of measurements ,which should ultimately drive the care improvements that patients need and deserve."
Two professors from the University of Zurich, Frey and Osterloh present four major arguments against the use of P4P ( see here for a summary).I quote some excepts:
"It would be naïve to assume that the persons subjected to variable pay-for-performance would accept the respective criteria in a passive way and fulfill their work accordingly. Rather, they spend much energy and time trying to manipulate these criteria in their favour.( Ed:This is one of mechanisms underlying Goodhart's Law).
......Variable pay-for-performance tends to crowd out intrinsic work motivation.".
Don''t look to the opinion pieces by Cassel or Doherty for cogent analysis of these and other critiques of P4P.Boil the oceans.
That seems to be the view expressed by a spokesman for the American College of Physicians (ACP) who is masterful in his fluency of medical management buzz words the use of which along with being really smart, and catalyzing cooperation between the various stake holders will lead to a new enlightened era of amazing P4P rules abrogating Goodhart's law and revoking human being's strong tendency to respond to incentives.
Quoting from The ACP Advocate Blog written by Bob Doherty,VP of governmental affairs for the ACP in regard to rules for P4P
"..we should figure out what works to help physicians achieve the Triple Aim, including better ways to organize and deliver care, and then judiciously apply a core, harmonized, and improved set of measures to track progress, while always being on the look-out for unintended adverse consequences." Also we need to "reimagine" things. Why does that remind me of Will Roger's solution to the German U-boat problem?
It is always good to throw in the bogus feel-good and pious Triple Aim phrase and "harmonizing" has a nice vague group think ring to it and who is the "we" to which Doherty refers.There was once a time when there were only two people in the exam room that could be considered stakeholders, the patient and the physician. Now the way medical care is discussed and is practiced seems to find others in the exam room who have some stakes to hold. These invisible stake holders include , of course, the third party payers and now more than ever the health care entity that employs the physician .
Dr. Christine K. Cassel, formerly head of the ABIM and the ACP and the National Quality Forum (NQF), expressed her opinion in the New England Journal of Medicine ( "Getting More Performance from Performance Measurements" Cassel, CK et al , NEJM 371,23 2014). I quote.
"All stakeholder groups are now invested in getting more performance out of measurements ,which should ultimately drive the care improvements that patients need and deserve."
Two professors from the University of Zurich, Frey and Osterloh present four major arguments against the use of P4P ( see here for a summary).I quote some excepts:
"It would be naïve to assume that the persons subjected to variable pay-for-performance would accept the respective criteria in a passive way and fulfill their work accordingly. Rather, they spend much energy and time trying to manipulate these criteria in their favour.( Ed:This is one of mechanisms underlying Goodhart's Law).
......Variable pay-for-performance tends to crowd out intrinsic work motivation.".
Don''t look to the opinion pieces by Cassel or Doherty for cogent analysis of these and other critiques of P4P.Boil the oceans.
Friday, March 25, 2016
Population medicine-the poster child for the hubris of the progressive medical elite.
Note: the core ideas expressed below originally appeared in a blog post published 1/16/15 under the title " Are patients pawns on the chessboard of population medicine?"
So are patients the 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" 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 Dr. Sox's description of 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
If that does not exemplify the mega-hubris and naive utopian view of the progressive mind set possessed by someone who somehow knows what is best for everyone,I do not know what does. First they determine what the important diseases are,then they glibly state they can discern how to prevent them and then they presume to have the wisdom, authority and power to "transfer" funds for one patient treatment to another person's prevention program so that the overall benefit is maximized though some pawns may have to be sacrificed.
.The population medicine advocates claim the approach to 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.Individual freedom and autonomy also is obsolete in this world view. Of course,the presumption of the knowledge of what is best for everyone,irrespective of the wishes and autonomy of the alleged beneficiary of that betterment, is characteristic of the progressive ( AKA modern liberal).The medical progressive elite is just a subset of the larger category of progressives.
In chess, pawns or for that matter any piece ( except the king), might be sacrificed in executing a strategy of placing the opponent 's king in checkmate. In the case of the population medicine approach the individual patient 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 ?
I closed another earlier article on Dr Sox's frightening essay with this paragraph:
"...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? "
I know- I have written about this more than once before but I find the concept so antithetical to hundreds of years of traditional medical practice and ethics and to basic concepts of individual freedom and individual autonomy that I cannot get over those ideas being given voice in one of the country's major medical journals and few voices raised in opposition.
Monday, March 07, 2016
Is transient increase in pulmonary artery pressure one reason why older runners take a while to "warm up"
Most older folks who jog,run or cycle probably experience a sluggish,hard to get going period when they first start out on their exercise session.
Dr.SP Wright and colleagues have published data demonstrating that in the group they studied (men and women age 55+-6 years ) there was transient increase in pulmonary artery wedge pressure (PAWP) pressure as determined by right side heart characterization.
PAWP increased from baseline at 11+-3 to 22+- 5 with light exercise.and then declined back to 17+-5.
This information needed to be considered in light of what was already known about pulmonary artery and pulmonary artery wedge pressure at rest and on exercise.Kovacs et al reviewed data from 1187 subjects who underwent right heart catherterization at rest and with exercise.( ref 1 below). ( I continue to be amazed at the number of people who agree to let doctors put catheter is the veins and snake them through the heart chambers and into the pulmonary artery)
Current guidelines state that pulmonary artery hypertension (PAH) can be diagnosed when PAP exceeds 25 mm hg at rest or 30 with exercise. However exercise levels of pulmonary artery pressure increase with age while pressure levels at rest do not and as is discussed below the 30 cutoff may be misleading in older patients..
During low levels of exercise in subjects less than fifty years of age the PAP was 19.4 +-4.8 while in those greater than fifty pressure were 29.4 +-8. So in older apparently normal subjects the PAP may exceed 30 .( In one review 20/97 normal subject over 50 years of age exceeded the pulmonary artery hypertension diagnostic threshold of 30 . There will be a number of false positive diagnosis of pulmonary artery hypertension if the exercise30 mm hg criterion is used.
So in older humans the exercise pulmonary artery pressure is higher and then increases further with the onset of exercise but then returns to lower levels after about 5-10 minutes of exercise.
This transient increase in the wedge pressure could explain how some of us breath a little heavier when we first start to run. Further this transient increase should be considered when doing clinical research work regarding pulmonary artery pressures. So why is this transient increase occurring?
Although Wright's subjects were considered normal it is possible that they had some degree of exercise induced diastolic dysfunction ( their resting echocardiograms were said to be normal). Impaired ventricular relaxation and decrease in left ventricular compliance seem part of the aging process.But if the transient increase in pulmonary artery related pressure is an indirect manifestation of diastolic dysfunction , why is it transient?
references:
1) Kovacs, et al "Pulmonary arterial pressure during rest and exercise in healthy subjects: a systematic review"European respiratory Journal , vol 34, issue 4 ,Oct 2009
2)Wright,SP et al. "The pulmonary artery wedge pressure response to sustained exercise is time-variant in healthy adults"Heart 2016, Mar 102(6) 438
Dr.SP Wright and colleagues have published data demonstrating that in the group they studied (men and women age 55+-6 years ) there was transient increase in pulmonary artery wedge pressure (PAWP) pressure as determined by right side heart characterization.
PAWP increased from baseline at 11+-3 to 22+- 5 with light exercise.and then declined back to 17+-5.
This information needed to be considered in light of what was already known about pulmonary artery and pulmonary artery wedge pressure at rest and on exercise.Kovacs et al reviewed data from 1187 subjects who underwent right heart catherterization at rest and with exercise.( ref 1 below). ( I continue to be amazed at the number of people who agree to let doctors put catheter is the veins and snake them through the heart chambers and into the pulmonary artery)
Current guidelines state that pulmonary artery hypertension (PAH) can be diagnosed when PAP exceeds 25 mm hg at rest or 30 with exercise. However exercise levels of pulmonary artery pressure increase with age while pressure levels at rest do not and as is discussed below the 30 cutoff may be misleading in older patients..
During low levels of exercise in subjects less than fifty years of age the PAP was 19.4 +-4.8 while in those greater than fifty pressure were 29.4 +-8. So in older apparently normal subjects the PAP may exceed 30 .( In one review 20/97 normal subject over 50 years of age exceeded the pulmonary artery hypertension diagnostic threshold of 30 . There will be a number of false positive diagnosis of pulmonary artery hypertension if the exercise30 mm hg criterion is used.
So in older humans the exercise pulmonary artery pressure is higher and then increases further with the onset of exercise but then returns to lower levels after about 5-10 minutes of exercise.
This transient increase in the wedge pressure could explain how some of us breath a little heavier when we first start to run. Further this transient increase should be considered when doing clinical research work regarding pulmonary artery pressures. So why is this transient increase occurring?
Although Wright's subjects were considered normal it is possible that they had some degree of exercise induced diastolic dysfunction ( their resting echocardiograms were said to be normal). Impaired ventricular relaxation and decrease in left ventricular compliance seem part of the aging process.But if the transient increase in pulmonary artery related pressure is an indirect manifestation of diastolic dysfunction , why is it transient?
references:
1) Kovacs, et al "Pulmonary arterial pressure during rest and exercise in healthy subjects: a systematic review"European respiratory Journal , vol 34, issue 4 ,Oct 2009
2)Wright,SP et al. "The pulmonary artery wedge pressure response to sustained exercise is time-variant in healthy adults"Heart 2016, Mar 102(6) 438
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