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 ...?
Saturday, April 30, 2016
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.
\
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
Wednesday, February 24, 2016
At least something is still true,giving too much 02 to COPD patients is not good
Since at least the 1960s pulmonary physicians were preaching not to give high flow 02 to COPD patients because they would "hypoventilate" and maybe even hypoventilate to a respiratory rate of zero. Campbell and other emphasized that important therapeutic principle
We talked about elevated carbon dioxide levels suppressing the brainstem systems to drive breathing so that it was only the hypoxia drive that was left and that would be to varying degrees taken away by being given excessive oxygen. In that era it was not uncommon for ambulance drivers ( there were no EMTs in the old days)to give COPD patients 4-6 liter flow O2 only to arrive at the hospital with the patient barely breathing.Those days thankfully are long gone.
This article from Emergency Medic Blog give a good summary review of this topic
H/T to Dr Robert Donnell and his blog for his continuing impressive effort to "keep up" with medical stuff while still practicing medicine as a hospitalist.
We talked about elevated carbon dioxide levels suppressing the brainstem systems to drive breathing so that it was only the hypoxia drive that was left and that would be to varying degrees taken away by being given excessive oxygen. In that era it was not uncommon for ambulance drivers ( there were no EMTs in the old days)to give COPD patients 4-6 liter flow O2 only to arrive at the hospital with the patient barely breathing.Those days thankfully are long gone.
This article from Emergency Medic Blog give a good summary review of this topic
H/T to Dr Robert Donnell and his blog for his continuing impressive effort to "keep up" with medical stuff while still practicing medicine as a hospitalist.
Tuesday, February 09, 2016
Bring an advocate if you have to go to hospital
Bring an advocate with you if you have to go to the hospital,if possible a physician.My two recent times in the hospital made it clear how valuable that can be.
My first stay was for a pace maker implantation which though considered as outpatient procedure actually takes place in the hospital and typically involves an overnight observation stay.
My advocate was my wife, an also retired hematologist.She was first helpful in trying to help the person who pushed in a large portable computer apparatus and attempted to take a medical history which was made laughable by her almost complete lack of knowledge of medical terms and then trying to spelling them for entry into the computer. It took her 3-4 minutes to finally enter the fact that I had an allergy to ceftin ( cefuroxime) She was the first of 4 or 5 folks who asked me if I had any allergies who then dutifully recorded that in the electronic medical record , but for the good it did a handwritten note later thrown in the trash would have been as effective.See below.
Once I was wheeled into the cath lab for the procedure, I was on my own. I saw someone ( nurse, tech, nursing assistant ?) hanging up an IV bag and asked what it was.I was told it was Ceftin!. That is right, after telling 4-5 people I had an allergy to that medication, that it exactly what they planned to give me.,the last of which was not more than 5 minutes before when I was in the waiting area for the cath lab.She consulted with the cardiologist and she said vancomycin was substituted. A few minutes later one of nurses set up a barrier over my face to protect the operative field.Had that been set up earlier I would have not inquired about the contents of the IV bag.
Interestingly, I noticed on my hospital bill that I was charged for a dose of IV Ceftin as well as the vancomycin.Maybe you get charged if they get the medication from the pharmacy,whether or not it is used.
More drama with vancomycin when I was preparing to be discharged the following morning. The resident had seen me and was writing the discharge orders. Apparently he made a comment to himself or perhaps to whomever was in ear shot that they had used vancomycin rather than the routine ceftin. Somehow the nurse interpreted whatever he said to mean that I was to receive another dose of vancomycin before discharge and was in the process of making that happen when my advocate-wife-physician asked why she was doing. After a few minutes of arguing my wife cornered the resident and confirmed that he was discharging me on minocycline orally and there was no order written or given verbally for the vancomycin.
My first stay was for a pace maker implantation which though considered as outpatient procedure actually takes place in the hospital and typically involves an overnight observation stay.
My advocate was my wife, an also retired hematologist.She was first helpful in trying to help the person who pushed in a large portable computer apparatus and attempted to take a medical history which was made laughable by her almost complete lack of knowledge of medical terms and then trying to spelling them for entry into the computer. It took her 3-4 minutes to finally enter the fact that I had an allergy to ceftin ( cefuroxime) She was the first of 4 or 5 folks who asked me if I had any allergies who then dutifully recorded that in the electronic medical record , but for the good it did a handwritten note later thrown in the trash would have been as effective.See below.
Once I was wheeled into the cath lab for the procedure, I was on my own. I saw someone ( nurse, tech, nursing assistant ?) hanging up an IV bag and asked what it was.I was told it was Ceftin!. That is right, after telling 4-5 people I had an allergy to that medication, that it exactly what they planned to give me.,the last of which was not more than 5 minutes before when I was in the waiting area for the cath lab.She consulted with the cardiologist and she said vancomycin was substituted. A few minutes later one of nurses set up a barrier over my face to protect the operative field.Had that been set up earlier I would have not inquired about the contents of the IV bag.
Interestingly, I noticed on my hospital bill that I was charged for a dose of IV Ceftin as well as the vancomycin.Maybe you get charged if they get the medication from the pharmacy,whether or not it is used.
More drama with vancomycin when I was preparing to be discharged the following morning. The resident had seen me and was writing the discharge orders. Apparently he made a comment to himself or perhaps to whomever was in ear shot that they had used vancomycin rather than the routine ceftin. Somehow the nurse interpreted whatever he said to mean that I was to receive another dose of vancomycin before discharge and was in the process of making that happen when my advocate-wife-physician asked why she was doing. After a few minutes of arguing my wife cornered the resident and confirmed that he was discharging me on minocycline orally and there was no order written or given verbally for the vancomycin.
Wednesday, January 27, 2016
How I aced a college physics course while learning almost no physics
The basic game plan for the pre-med students was to get good grades and get into medical school.In some ways, many ways, getting a education was secondary, perhaps a side effects of getting the grades.
My college physics course was in some ways rather idiosyncrasy- there were weekly tests that consisted of several problems which were graded on a no partial credit basis. It the correct answer was 17.5 seconds 17.3 got no credits. There was instance feedback on the results. You took the paper to the Prof who quickly graded it and you knew the results.
The prof had taught for over twenty years and his pattern was to repeat questions .So that if you had access to an "Old test file" to which all fraternity members had access and somehow the non-frat folks also had access You could review the type of problems that were in the files that related to the lecture material for that week and focus on those.
It was matter of learning how to solve each type problem,recognizing the patterns,and practicing the steps so you could set the problem up quickly,go through the steps and have amble time to recheck the math ( remember it was no partial credit).
An example problem was someone drops a rock in a well and hears the splash n seconds later, how deep is the well. (It is amazing how often that and other " well posed " problems come up in the daily practice of medicine)
This trip down memory lane was stimulated by a blog entry by the ever interesting and insightful Dr. Scott Aberegg on his blog ,Status Iatrogenicus.
He discussed the difference between intelligence and common sense and how often the two are not well correlated. The physics course "success" was due to the application of the basic mechanisms that underlie the "intelligence" tested on such things as the SAT and ACT. Pattern recognition, learning the rules or technique of solving the particular problem and practice practice practice.The latter of which is the well recognized way to Carnegie Hall , It was clearly the way to ace the course and finish with a grade significantly higher that the rest of the class ( number 2 was not even close) all of whom were hand picked by the prof who seemed to enjoy giving pre med students a hard time.
This story can also be thought about in terms of Goodhart's Law.When a measure become a target it looses its value as a measure. I remember that the most common question asked by the medical school classmate who was first in the class was "Will that be on the test?"
h/t to and a firm recommendation to read and think about Dr. Aberegg's essay entitled "Book Smarts and Common Sense in Medicine " . It is more than well worth the time spent. See here.
My college physics course was in some ways rather idiosyncrasy- there were weekly tests that consisted of several problems which were graded on a no partial credit basis. It the correct answer was 17.5 seconds 17.3 got no credits. There was instance feedback on the results. You took the paper to the Prof who quickly graded it and you knew the results.
The prof had taught for over twenty years and his pattern was to repeat questions .So that if you had access to an "Old test file" to which all fraternity members had access and somehow the non-frat folks also had access You could review the type of problems that were in the files that related to the lecture material for that week and focus on those.
It was matter of learning how to solve each type problem,recognizing the patterns,and practicing the steps so you could set the problem up quickly,go through the steps and have amble time to recheck the math ( remember it was no partial credit).
An example problem was someone drops a rock in a well and hears the splash n seconds later, how deep is the well. (It is amazing how often that and other " well posed " problems come up in the daily practice of medicine)
This trip down memory lane was stimulated by a blog entry by the ever interesting and insightful Dr. Scott Aberegg on his blog ,Status Iatrogenicus.
He discussed the difference between intelligence and common sense and how often the two are not well correlated. The physics course "success" was due to the application of the basic mechanisms that underlie the "intelligence" tested on such things as the SAT and ACT. Pattern recognition, learning the rules or technique of solving the particular problem and practice practice practice.The latter of which is the well recognized way to Carnegie Hall , It was clearly the way to ace the course and finish with a grade significantly higher that the rest of the class ( number 2 was not even close) all of whom were hand picked by the prof who seemed to enjoy giving pre med students a hard time.
This story can also be thought about in terms of Goodhart's Law.When a measure become a target it looses its value as a measure. I remember that the most common question asked by the medical school classmate who was first in the class was "Will that be on the test?"
h/t to and a firm recommendation to read and think about Dr. Aberegg's essay entitled "Book Smarts and Common Sense in Medicine " . It is more than well worth the time spent. See here.
Wednesday, January 20, 2016
Does the two-phase concept for treatment of Thromboembolic disease make sense?
Dr. Clive Kearon,from McMaster University, has suggested the concept of a two-phase anticoagulant treatment of of vein thrombosis and pulmonary embolism.See here. A full text version can be accessed from J Thromb Haemostis 2012;19: 507-511 entitled A conceptual Framework for two phases of anticoagulant treatment of venous thromboembolism.
Kearon , and his coworkers at McMaster University in Canada are accomplished researchers in the field of thromboembolism and his thoughts deserve serious attention.
Kearon proposes that four observations provide strong support for this two-phase concept:
1.Treatment for less than 3 months is associated with a higher recurrence rate
2.Treatment for 6 months has the same recurrence risk as treatment for 3 months.
3.The recurrence after too short a treatment predominately occurs at the site of the original thrombus.
4.The recurrence after too short a treatments typically occurs immediately after stopping treatment.
These observations suggest to the author that at first the anticoagulant therapy treats or somehow"turns off" the acute thrombotic process and prevents extension of the clot and reduces the risk of a pulmonary embolus. This theory is consistent with his observations listed above as 3 and 4.
Kearon's two phases are :
1. active treatment phase during which there is a rapid decrease in the risk of recurrence
2.secondary prevention phase, which is as long as the anticoagulation is continued.
Obviously the two phases overlap.
In some patients there are recurrence DVTs when anticoagulant therapy is stopped, whether it be at 3 months or 6 months or several years.So now the way of thinking is changing from should we treat for 3 months or 6 months to three months or extended anticoagulation with periodic reassessment of risks versus benefits, a process that is at best often a semi-educated guess with with broad error terms and is euphemistically described as "determining". Maybe followup D-dimer testing has some role here.
Kearon , and his coworkers at McMaster University in Canada are accomplished researchers in the field of thromboembolism and his thoughts deserve serious attention.
Kearon proposes that four observations provide strong support for this two-phase concept:
1.Treatment for less than 3 months is associated with a higher recurrence rate
2.Treatment for 6 months has the same recurrence risk as treatment for 3 months.
3.The recurrence after too short a treatment predominately occurs at the site of the original thrombus.
4.The recurrence after too short a treatments typically occurs immediately after stopping treatment.
These observations suggest to the author that at first the anticoagulant therapy treats or somehow"turns off" the acute thrombotic process and prevents extension of the clot and reduces the risk of a pulmonary embolus. This theory is consistent with his observations listed above as 3 and 4.
Kearon's two phases are :
1. active treatment phase during which there is a rapid decrease in the risk of recurrence
2.secondary prevention phase, which is as long as the anticoagulation is continued.
Obviously the two phases overlap.
In some patients there are recurrence DVTs when anticoagulant therapy is stopped, whether it be at 3 months or 6 months or several years.So now the way of thinking is changing from should we treat for 3 months or 6 months to three months or extended anticoagulation with periodic reassessment of risks versus benefits, a process that is at best often a semi-educated guess with with broad error terms and is euphemistically described as "determining". Maybe followup D-dimer testing has some role here.
Tuesday, January 19, 2016
Pulmonary emboli after pacemaker implantation -symptomatically rare maybe more commonly silent
Case reports of pulmonary embolism following pacemaker implantation are rare.
One 1986 paper reported a "15% incidence of asymptomatic perfusion defects on V/Q lung scans". Forty patients were studied after PM implants. 20 were given low dose heparin and twenty were not. In the non-heparin treatment arm there were 3 asymptomatic cases of high probability positive studies, normal ventilation,normal xray and decreased perfusion. In other words, the typical pattern of a pulmonary embolus on lung scan. So the number of 15% of silent PE post PM implantation is typically quoted in the literature on the basis of this single, small study .
A prospective study of 150 consecutive was published ,apparently a thesis at the University of Turku in Finland. There were five cases of PE. The abstract doesn't indicate if these were symptomatic or not.
My understanding is that routine post procedure anticoagulation is not widely done because of concern of pocket hematomas which is turn increases the risk of an infection.
Full disclosure-my interests in this stems from having pulmonary emboli, clincally manifest six days after the implantation of a bi-ventricular pacemaker and after being treated for a pulmonary embolus with apixaban I developed a pacemaker pocket hematoma.
A physician can learn a great deal about a condition when he develops that condition.Talk about generating limbic valence.
One take home message I discovered was how variable radiologists' reading of CTPA
can be. A recent American Journal of Radiology article claimed that as many as 26% of CTPA are "false positive". In my case, the "official" reading indicated segmental emboli in the lingula and in the medial basal and anterior basal segments of the left lung.A second "unofficial" reading came from a friend, who is recently retired radiologist -no clots seen. Another unofficial reading done by a radiologist from the same institution as the EP cardiologist who was treating me was read as showing some artifacts and "one or two emboli". Three radiologists produced three significantly different readings and a 4th radiologist ( from another institution reading a 3 months follow up CTPA said of the earlier film there were some equivocal findings of possible subsegmental emboli.
addendum : 7/30/19 some comments and reference to new data added.
Mayo Clinic did a retrospective review of 5646 pacemaker implantation done between 2000 and 2010.There were 88 cases of diagnosis of clinical PE which is 1.6% most of whom had a predisposing factor such as post of surgery status,DVT,immobility etc.
Ref: Nolteria, Amit, Pulmonary emboli in patients with transvenous cardiac implantable electronic device leads. Europace 2016, Feb 18 (2), 246-252
So clinical PE seems rare and one small study suggested a 15% incidence of asymptomatic PE.
One 1986 paper reported a "15% incidence of asymptomatic perfusion defects on V/Q lung scans". Forty patients were studied after PM implants. 20 were given low dose heparin and twenty were not. In the non-heparin treatment arm there were 3 asymptomatic cases of high probability positive studies, normal ventilation,normal xray and decreased perfusion. In other words, the typical pattern of a pulmonary embolus on lung scan. So the number of 15% of silent PE post PM implantation is typically quoted in the literature on the basis of this single, small study .
A prospective study of 150 consecutive was published ,apparently a thesis at the University of Turku in Finland. There were five cases of PE. The abstract doesn't indicate if these were symptomatic or not.
My understanding is that routine post procedure anticoagulation is not widely done because of concern of pocket hematomas which is turn increases the risk of an infection.
Full disclosure-my interests in this stems from having pulmonary emboli, clincally manifest six days after the implantation of a bi-ventricular pacemaker and after being treated for a pulmonary embolus with apixaban I developed a pacemaker pocket hematoma.
A physician can learn a great deal about a condition when he develops that condition.Talk about generating limbic valence.
One take home message I discovered was how variable radiologists' reading of CTPA
can be. A recent American Journal of Radiology article claimed that as many as 26% of CTPA are "false positive". In my case, the "official" reading indicated segmental emboli in the lingula and in the medial basal and anterior basal segments of the left lung.A second "unofficial" reading came from a friend, who is recently retired radiologist -no clots seen. Another unofficial reading done by a radiologist from the same institution as the EP cardiologist who was treating me was read as showing some artifacts and "one or two emboli". Three radiologists produced three significantly different readings and a 4th radiologist ( from another institution reading a 3 months follow up CTPA said of the earlier film there were some equivocal findings of possible subsegmental emboli.
addendum : 7/30/19 some comments and reference to new data added.
Mayo Clinic did a retrospective review of 5646 pacemaker implantation done between 2000 and 2010.There were 88 cases of diagnosis of clinical PE which is 1.6% most of whom had a predisposing factor such as post of surgery status,DVT,immobility etc.
Ref: Nolteria, Amit, Pulmonary emboli in patients with transvenous cardiac implantable electronic device leads. Europace 2016, Feb 18 (2), 246-252
So clinical PE seems rare and one small study suggested a 15% incidence of asymptomatic PE.
Friday, January 15, 2016
New ACCP guidelines on VTE-stockings out, NOACs solidly in -outpatient treatment of pulmonary emboli for some patients
The American College of Chest Physicians (ACCP) has issued its tenth set of recommendations regarding venous thrombo embolic disease (VTE) .See full free text.
Noteworthy is the solid recommendation for the New (or novel) oral anticoagulants (NOACs) over the old favorite Warfarin which was the oral anticoagulant of choice (the only one in the U.S.)) for over fifty years.NOACs were first approved by the FDA for treatment of non-valvular atrial fibrillation and more recently for DVTs and PEs.
Recommendation wise the four NOACs currently approved are not created equal. Rivaroxaban and Apixaban can be used without pre treatment with a parenteral anticoagulant,typically low molecular weight heparin, while dabigaran and endoxaban cannot.
The ACCP panel lead by Clive Kearon of McMaster University rescinded their earlier recommendation for the use of compression stocking to prevent the post thrombotic syndrome.
The outpatient treatment of some patients with PE is a game changer or sea change or whatever the current cliche of choice is for major changes in medical practice.Prior to the NOACs the standard of care was several days in the hospital overlapping with heparin until the patient was safely anticoagulated with a reasonably stable INR . Now patients who are hemodynamically stable with a suitable home environment can be either discharged after a brief time in the hospital or sent home from the ER on either rivaroxaban or apicaban with a double dose for the first week.
The distinction between provoked and unproved continues to be emphasized. With provoked DVT or PE three months seems to be the standard of care , while for unprovoked- reassessment at the end of three months is recommended at which time the nebulous balancing of bleeding and clots risk is somehow determined.
The problem of pulmonary emboli in the subsegmental pulmonary arteries is addressed without a clear cut definite recommendation being made .Watch and wait with follow up testing or treat-for patients with a subsegmental embolus and a negative leg vein study.
Subsegmental emboli are often asymptomatic and also are CT angiogram are more likely to be false positive and subject to varying readings when the study is interpreted by more than one radiologist
The argument of 3 months versus six months of anticoagulation has morphed into three months versus extended anticoagulation.
Noteworthy is the solid recommendation for the New (or novel) oral anticoagulants (NOACs) over the old favorite Warfarin which was the oral anticoagulant of choice (the only one in the U.S.)) for over fifty years.NOACs were first approved by the FDA for treatment of non-valvular atrial fibrillation and more recently for DVTs and PEs.
Recommendation wise the four NOACs currently approved are not created equal. Rivaroxaban and Apixaban can be used without pre treatment with a parenteral anticoagulant,typically low molecular weight heparin, while dabigaran and endoxaban cannot.
The ACCP panel lead by Clive Kearon of McMaster University rescinded their earlier recommendation for the use of compression stocking to prevent the post thrombotic syndrome.
The outpatient treatment of some patients with PE is a game changer or sea change or whatever the current cliche of choice is for major changes in medical practice.Prior to the NOACs the standard of care was several days in the hospital overlapping with heparin until the patient was safely anticoagulated with a reasonably stable INR . Now patients who are hemodynamically stable with a suitable home environment can be either discharged after a brief time in the hospital or sent home from the ER on either rivaroxaban or apicaban with a double dose for the first week.
The distinction between provoked and unproved continues to be emphasized. With provoked DVT or PE three months seems to be the standard of care , while for unprovoked- reassessment at the end of three months is recommended at which time the nebulous balancing of bleeding and clots risk is somehow determined.
The problem of pulmonary emboli in the subsegmental pulmonary arteries is addressed without a clear cut definite recommendation being made .Watch and wait with follow up testing or treat-for patients with a subsegmental embolus and a negative leg vein study.
Subsegmental emboli are often asymptomatic and also are CT angiogram are more likely to be false positive and subject to varying readings when the study is interpreted by more than one radiologist
The argument of 3 months versus six months of anticoagulation has morphed into three months versus extended anticoagulation.
Tuesday, December 29, 2015
Is sacubitril a "game changing" breakthrough or approved on basis of a stacked deck trial or something in between?
A number of medical commenters and pundits have claimed game changer status for sacubitril but also the trial that lead to its approval has been accused of being not a fair test. Two general types of the tricks of the trade that can be employed to make a comparison between treatment better than it really is are 1) stack the desk and 2) cook the books (AKA various sometime obscure statistical slights of hand)
In this instance I cannot comment on the second but others have suggested that there was at least a little bit of deck stacking.
Lets look and what was compared with what.
The drug that the FDA approved is named Entresto and is a combo pill consisting of a first in class drug named sacubitril and valsartan which is a well proven Angiotensin receptor blocker which has been proven effective in the treatment of heart failure (HF), Sacubitril inhibits neprilysin which in turn is a inhibitor of natriurectic hormones .The new combination pill is named Entresto.
Entresto was compared with the ACE inhibitor,enalapril.
If someone wanted to determine if the addition of sacubitril to valsartan was safe and effective and better than valsartan alone why not compare that combination with valsartan ?. Why choose a drug from a different class than valsartan?
In the ParadigmHF trial, 8442 patients with class 11-IV NYHA heart failure with ejection fractions less than 40%. were treated with either Entresto or with Enalapril at a dose of 10 mg twice a day.
So how big was the difference between the two treatment groups? 26.5 % of the control group versus 21.8% of the enalapril treatment group were hospitalized for heart failure. A difference to be sure but enough of a difference to be heralded as a game changer?
But there is as usual more to the story- now there are expressions of concerns about some unusual potential side effects of the breakthrough medication involving some breakthrough complications in the eye and the brain.see here
Also see here for a JAMA commentary about the concern of a potential increase risk of Alzheimer disease by inhibiting the action of neprilysin in its putative role in amyloid degradation. Not to worry though- a projected trial to look into that issue should be ripe for publication circa 2022. See here for a further discussion of some criticism of the trial including how externally valid is it (how well does it represent real life treatment of HF) and how representative was the dose of the comparative drug.
Larry Husten comments on the number of "game changers" in cardiology in 2015 in his posting entitled " 2015 the year we finally cured heart disease".
In this instance I cannot comment on the second but others have suggested that there was at least a little bit of deck stacking.
Lets look and what was compared with what.
The drug that the FDA approved is named Entresto and is a combo pill consisting of a first in class drug named sacubitril and valsartan which is a well proven Angiotensin receptor blocker which has been proven effective in the treatment of heart failure (HF), Sacubitril inhibits neprilysin which in turn is a inhibitor of natriurectic hormones .The new combination pill is named Entresto.
Entresto was compared with the ACE inhibitor,enalapril.
If someone wanted to determine if the addition of sacubitril to valsartan was safe and effective and better than valsartan alone why not compare that combination with valsartan ?. Why choose a drug from a different class than valsartan?
In the ParadigmHF trial, 8442 patients with class 11-IV NYHA heart failure with ejection fractions less than 40%. were treated with either Entresto or with Enalapril at a dose of 10 mg twice a day.
So how big was the difference between the two treatment groups? 26.5 % of the control group versus 21.8% of the enalapril treatment group were hospitalized for heart failure. A difference to be sure but enough of a difference to be heralded as a game changer?
But there is as usual more to the story- now there are expressions of concerns about some unusual potential side effects of the breakthrough medication involving some breakthrough complications in the eye and the brain.see here
Also see here for a JAMA commentary about the concern of a potential increase risk of Alzheimer disease by inhibiting the action of neprilysin in its putative role in amyloid degradation. Not to worry though- a projected trial to look into that issue should be ripe for publication circa 2022. See here for a further discussion of some criticism of the trial including how externally valid is it (how well does it represent real life treatment of HF) and how representative was the dose of the comparative drug.
Larry Husten comments on the number of "game changers" in cardiology in 2015 in his posting entitled " 2015 the year we finally cured heart disease".
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