Wednesday, October 31, 2012

Today's Paperless Medical Office

Today's "Paperless" Medical Office
Oh, the irony...


h/t: A faithful follower of this blog.

Happy Halloween!

From our house to yours:

The Open-Heart-Gone-Bad Pumpkin

Close-up image of the gourd heart, pacemaker, and retracted (gourd-fragment) fat


Thursday, October 25, 2012

EKG Du Jour #29: Tangoing with Two

"Dr. Fisher, there's this middle-aged person in the Emergency Room with a funny EKG who's short of breath and pretty tachycardic. Would you mind looking at it?"

"No," I said, taking a moment from the surgery I was performing.   Here's what I saw:

Click image to enlarge

"Hmmm. Boy that's strange. Did you ... ?"

What did I ask? How would you sort this EKG out?


Construction of a Blog Post

How a blog post is constructed here, illustrated nicely by notes discovered in my lab coat pocket this morning:

Delightfully Old School.

Still, I can't type and sometimes I think English is my second language, so thanks for tolerating all of my typos and grammatical errors through the years.


Wednesday, October 24, 2012

The Limits of Lifestyle Intervention

Diet and exercise: they were supposed to be the answer to all that ails America's obesity and health care cost problem.  

Signs of this Utopian vision are everywhere.  From entire government departments encouraging healthy lifestyles through fitness, sports and nutrition, government websites that encourage "healthy lifestyles," and entire community efforts to partner with health care organizations to fight obesity with the hope of cutting health care costs.

What if, believe it or not, when it comes to people with Type II diabetes, diet and exercise don't affect the incidence of heart attack, stroke, or hospital admission for angina or even the incidence of death?

Suddenly, all health care cost savings bets are off.  Suddenly, we have to re-tool, re-think our approach, understand and appreciate the limitation of lifestyle interventions to alter peoples' medical destiny.  Suddenly we have to come to grips with a the reality that weight loss and exercise won't affect outcomes in certain patients.  Suddenly, there is a sad reality that patients might note be able to affect their insurance premiums by enrolling in diet and exercise classes after all.

These thoughts are so disruptive to our most basic "healthy lifestyle" mantra that few can fathom such a situation.  Nor would any members of the ever-beauty-and-weight-conscious main stream media be likely to report such a finding if it came to pass.

And yet, that is exactly what has happened. 

The Look AHEAD trial studied 5145 adults with type 2 diabetes who had a body mass index (BMI) > 25.  The purpose of the study was to compare the incidence of  nonfatal myocardial infarction (heart attack), nonfatal stroke, death, or hospitalization for angina between diabetics who received a rigourous weight loss and exercise program with education to just an educational approach alone.   Interestingly, the study failed to show any effect of weight loss and exercise over simple education about the disease in the incidence of these "macrovascular" endpoints.  In fact, the study was stopped early.

So disturbing were these findings to our basic understanding of disease prevention that the principle investigator recently appeared on Medscape in print and in video format to reassure the physician community:  "I can tell you from the outset that we were successful."

And yet, they were not: they did not affect the indicence of stroke, heart attack, death, or admission to a hospital for angina in overweight Type II diabetic patients one bit, even after 11 years of trying.

You see, it is uncomfortable to sit with the reality that exercise and fitness might not be as helpful as we had hoped at altering certain health care outcomes.  So we ignore these trials.  We don't report them in main stream media because we don't like to feel uncomfortable with the realization that there's much we still don't know or understand about exercise and weight loss at affecting health outcomes in medicine. 

Yet there is so much to learn from trials like this BECAUSE they fly in the face of conventional wisdom.

Maybe we should stop pouring money into fitness rooms and health clubs and promote other intellectual or spiritual pursuits instead.   Maybe we should reconsider the benefits of exercise and weight loss as psychologic more than physical.  Maybe we should de-fund all those government programs set up to promote exercise and fitness as our path to health care cost-savings.

Or at the very least, we should just eat some humble pie, stop fooling ourselves, and understand the limitations of lifestyle interventions like weight loss and exercise to improve medical outcomes or to reduce health care costs in America.

But be careful. 

Saying the truth is sure to get you banned from main stream media.



1.Look AHEAD Research Group, Wing RR. Long-term effects of a lifestyle intervention on weight and cardiovascular risk factors in individuals with type 2 diabetes mellitus: four-year results of the Look AHEAD trial. Arch Intern Med. 2010;170:1566-1575. (Pubmed)

Friday, October 19, 2012

The Growing Residency Squeeze

"Dr. Fisher, I'm applying to a cardiology fellowship - could I ask you to write me a letter?"

"Sure," I said, "To whom should I address the letter?"

"Oh, don't worry about that, I'll give your administrative assistant a list of the programs."
It sounded innocent enough until thirty-five addresses were forwarded to us for delivery.

While I have written about the challenges that medical students are having obtaining residencies before, it only seems to be getting harder for some.  This is, in part, because while medical schools have increased their medical school positions by about 30%, residency slots have only increased at a much slower rate of 8%.  Worse, because of funding shortages anticipated from the new health care law, Medicare funding cuts could even mean residents might have to pay for their residency, too: 

From Marketwatch:
Just as monumental as graduation day is “Match Day,” when medical school students get sealed envelopes that tell them what city and hospital they’ll be going to for training. But advocates say the number of grads could severely outnumber the amount of residency positions by 2015 — or sooner — if hospitals don’t substantially expand the number of residency positions they offer. While medical school enrollment is on track to grow by 30% by 2016 from 2002 levels, the number of residency training positions have only grown by 8% since 2002, according to the AAMC. Even as there’s an impending doctor shortage, “We’re worried we’re going to have a group of MDs that have studied but can’t practice because they can’t find a training spot,” says Grover of the AAMC. Part of the problem is that there’s a cap on the amount of Medicare dollars that can go to residency programs that has been in place since 1997, when some health experts predicted that there was going to be an oversupply of physicians in the U.S.

About 20% of the $13 billion spent annually on training 110,000 young doctors is provided by Medicare, down from roughly 30% a decade ago, estimates Grover. If Congress doesn’t act to allow Medicare to fund a larger number of positions, hospitals may need to find additional revenue to fill the gap, and some may need to reduce the number of positions they offer, he adds. At a time when the federal government is cutting Medicare spending and some hospitals are already seeing their budgets squeezed, finding additional revenue for new training positions will be tough, says Grover. It’s even possible that graduates might soon also be asked to pay for the training — an option that some insiders say would place an unreasonable burden on already debt-laden doctors — instead of the current model where they are paid while they work at the hospitals, says John Norcini, president of the Foundation for Advancement of International Medical Education and Research: "There's a whole series of possibilities."


Thursday, October 18, 2012

One Heck of a Halloween Cake

An Anatomical Wax Model cake based on the La Specola (Florence) museum collection of anatomical wax models from the late 18th century.


See all the photos at Conjurer's Kitchen on Facebook.


Smuggling Defibrillators to Save Lives

Street Scene - Mumbai, India
From The Annals of Internal Medicine doctors from the US have shown that ICDs can be safely resterilized and re-used for indigent patients in another country.  In their study, Pavri et al collected 106 ICDs with three or more years of estimated battery life from either deceased patients or patients having devices explanted because of "upgrades" or infection and implanted then in 81 patients in a single hospital in Mumbai, India.  From the Methods section of their paper:

We deleted all identifying patient information and lead information; programmed them to nonpacing mode, when possible, or lowered the outputs to the minimum possible values; turned off all sensing and therapies for ventricular tachycardia (VT) and ventricular fibrillation (VF); and deactivated all ICD alerts (auditory and vibratory). When a sufficient number of devices were collected, they were transported to India in batches. Transport was most often done by physicians (or friends and family members of physicians) who were  traveling from the United States. The devices were placed in checked-in baggage in a clear plastic bag, and 2 letters were placed in prominent view. The first letter was signed by the donating physician, stating that the devices were of no commercial value and that they were being donated for reuse in patients who could not afford such devices. The second letter was signed by the Chief Executive Officer of Holy Family Hospital, stating that the hospital was expecting the devices for donation to such patients. Contact information for all physicians was provided in the letters.

Attempts at sending explanted devices by courier or mail proved difficult; without precedent, it was simply not possible to describe the purpose and nature of the shipment to shipping authorities or to insure the contents. We finally resorted to carrying the devices during travel to India in our personal baggage, as described. Some difficulties (requiring lengthy explanations) were encountered during baggage screening and, especially, at Customs in Mumbai.
Device Resterilization Protocol in India 
Once received, the ICDs were removed from their bags and rinsed under running water. We cleaned the headers (lead ports) with pipe cleaners and inspected the seams and body for residual biological debris. We immersed the ICDs in hydrogen peroxide for 10 minutes and then in povidone-iodine for 2 minutes. They were then rinsed with running water for 2 minutes and dried with an air blower. Finally, we double-packaged the devices and sealed them with special indicator-marked paper for ethylene oxide gas sterilization in an automatic ethylene oxide machine (certified by Pest Control of India, Mumbai) at 38 °C. The protocol included 4 hours of ethylene oxide gas exposure followed by 6 hours of aeration, after which inspection confirmed that the package indicator label had changed from brown to lime green. The resterilized ICDs were aerated for at least 12 hours in an open, dry space.
The devices ultimately functioned well, but social and societal limitations caused six of 81 patients to be lost to follow-up.  No device infections occurred and three patients even received three such devices over their lifetime.

Appropriate shocks were delivered in 42% of patients. Antitachycardia pacing was delivered for ventricular tachycardia (VT) in 12.3% of patients. In total, 60.4% of the devices delivered appropriate therapy (shocks of antitachycardia pacing) in 54.3% of patients. In total, 22 patients received a second device and three patients received a third device after the initial ICD reached the elective replacement voltage. The average time before replacing a resterilized device was approximately 3.5 years.

As the authors noted, in the United States "pacemakers and ICDs are currently labeled as single use devices, and the U.S. Food and Drug Administration specifically prohibits reuse, referring to it as “an objectionable practice." The device manufacturers do not condone reuse and their warranty periods do not include it. Any complications associated with such off-label use could be grounds for legal action."

And yet, lives (and money) were saved, albeit not in the United States.

But this did not stop the critics.  In the accompanying editorial, Drs Paul Farmer and Gene Bukhman of the Harvard Medical School, suggested that the authors' efforts failed the quality test, reminding us that "Historians of medicine have shown that the gratitude of patients and their families, although not to be dismissed, is not always a reliable marker of high-quality medical care."

What the....?

Certainly such a practice is controversial, but in a world with such overwhelming medical waste that literally tons of perfectly re-useable medical equipment are discarded each month in America's hospitals, I feel these authors should be congratulated for their efforts to humanely break the status quo and forcing us to consider the obvious ethical implications of discarding life-saving, exceedingly expensive medical devices (and similar medical equipment) that could be used to help others less fortunate.

In our current global health care cost crisis, we need more innovation in the area medical areas like this, not less.



Pavri BB, Lokhandwala Y, Julkarni GV, Shah M, Kantharia BK, Mascarenhas D. ReUse of Explanted, Resterilized Implantable Cardioverter-Defibrillators: A Cohort Study. Ann of Intern Med 16 October 2012;157(8):542-54. 

Farmer P, Buckman G. Reuse of medical devices and global health equality. Ann Intern Med 2012; 157:591-593.

Computer Viruses and Bots "Rampant" on Medical Devices

From Technology Review:
In September, the Government Accountability Office issued a report warning that computerized medical devices could be vulnerable to hacking, posing a safety threat, and asked the FDA to address the issue. The GAO report focused mostly on the threat to two kinds of wireless implanted devices: implanted defibrillators and insulin pumps. The vulnerability of these devices has received widespread press attention (see "Personal Security" and "Keeping Pacemakers Safe from Hackers"), but no actual attacks on them have been reported.
Fu, who is a leader in researching the risks described in the GAO report, said those two classes of device are "a drop in the bucket": thousands of other network-connected devices used for patient care are also vulnerable to infection. "These are life-saving devices. Patients are overwhelmingly safer with them than without them. But cracks are showing," he said. (Fu was Technology Review's Innovator of the Year in 2009.)

h/t: Instapundit

Wednesday, October 17, 2012


There are so many changes in medicine these days, but it takes a bit of time away from the keyboard to appreciate them.

So glued have I become to looking at computer screens, it's been hard to pull my head from them any more.  Doctors lives are spent staring at these damn screens now.  I wonder how many of my youngest colleagues know how to start an IV, a foley, place a central line, or safely pass an nasogastric tube, let alone examine a patient.  Now we just click an order and things magically happen by a team of technicians.  Doctors are now the Masters of Click.  Clicks are now how doctors are measured, quantified, and sadly, actually valued.  If it wasn't clicked, it didn't happen.

The environment for doctors continues to change, too.  But it's even more evident now if we stop and look for a moment.  There used to be the Doctor's Lounge - a sacred inner sanctum in a hospital where doctors could congregate, get a small bit to eat - maybe an fresh apple - and find a few colleagues exhausted from the night before catching up on the news.  Now, there might be a coffee pot that dispenses come hot-water-concocted chemistry experiment it labels as "coffee" but takes like Drano.  Our space called the Doctors Lounge has become an antiquated mail room with long-forgotten names lying askew on a wall of drawers.  No one checks these boxes any more; we're too busy emptying our electronic in-boxes on the screens that replaced the chairs there.  And of course, the same thing's happening to the Doctors Dining room - if such a dining room exists at all any more.  Doctors rarely have a meal together to re-group and share our medical concerns with each other there.  Instead, most now eat in the employee dining room if they have time to eat at all between patients.

But there is an upside.  The hospital has never looked better.  We smile more and watch the Bears on Big Screen TV's with our patient-customers on weekend rounds to improve patient satisfaction scores.  Hospitals are officially in the hospitality business.  This is how those of us in the "business" are getting paid and measured now.

And finally, there's our new dress code.  The once heralded white coat donned as a medical student that later gives way to the once-heralded grey lab coat of an attending physician has lost its respected value, too.  Instead, the grey lab coat of the attending as been relegated to nothing more than a sign of the Responsible Physician.  Far grander now is the Brooks Brothers suit.  Or maybe a really nice sport coat and tie.  Or maybe, for the real Movers and Shakers, just a designer shirt, polished shoes, and tie.  These doctors are the new Leaders now.


There used to be a time where doctors rose above the administrative fray for the good of our patients.   Now, the new standard of "exceptional physician" is that of a keyboard operator and administrator.

Now, excuse me while I get back to clicking.


Monday, October 15, 2012

Pager Spam

As if call wasn't bad enough, here's some screen shots of a 02:30 am page received yesterday evening:


May the dung of a thousand elephants land on this advertised web page.

(*** WARNING *** Enter the web address displayed at your own risk. My antivirus software detected a possible computer threat.)


Tuesday, October 09, 2012

When We Mix Politics With Science

Today I opened an e-mail dated 4 October 2012 from the Heart Rhythm Society that announced the 2013 Keynote Speaker at the Heart Rhythm Society's Opening Plenary Session 8 May 2013 in Denver, Colorado : Former President of the United States, Bill Clinton.  Our society's justification for this speaker reads as follows:

"President Clinton remains an influential international figure. His passion for improving lives through innovation and activism positions him as the perfect complement to our program, as we celebrate how our pioneering past is shaping our promising future."

No doubt Mr. Clinton will improve the news coverage of the Heart Rhythm Society's meeting.  Controversy always does. 

But to present a political figure rather than a scientific figure as keynote speaker speaks volumes of how medicine has changed (and continues to change) in America.  Unfortunately, rather than offering a point-counterpoint discussion with Mr. Clinton, heart rhythm specialists who are already reeling from the DOJ's unusual intervention into our field will be treated to Mr. Clinton's views on "innovation" (and no doubt "arithmetic") in health care.

Perhaps the Heart Rhythm Society should offer another retired politician from the opposite side of the political aisle to debate Mr. Clinton and call the Opening Plenary Session in Denver "Debates, Part II."  At least then the audience there could weigh the opposing views on "our promising future" in health care and innovation independently and objectively.


The Affordable Care Act: A Retrospective

An excellent article reviewing how the Affordable Care Act came to pass appears today in the Los Angeles Times and Chicago Tribune. It is worthwhile reading to recall how the Patient Protection and Affordable Care Act law came to pass. 

An accompanying article reviewing how health care remains a "headache" for Mitt Romney also serves as important reading as voters prepare to head to the polls this November.


Wednesday, October 03, 2012

When Experts Speak Outside Guidelines

This morning, an article appeared in the Chicago Tribune that "revisits" Sudden Cardiac Arrest.  It is written by a local cardiologist, Dr. Joseph Marek, who advocates for EKG screening of athletes without discussing its downside and the fact that such a recommendation falls outside of our professional associations' guidelines on this issue.

While the intent of Dr. Marek's efforts are probably in the right place, we should all realize that testing (of any kind) that occurs on large segments of the population who are at relatively low risk for an ailment leads to a considerable incidence of false positive tests (in other words, abnormal findings that are ultimately found to be benign).  The cost and anxiety of the evaluation of these tests (consults, echocardiograms, even invasive angiograms) during such an evaluation can be considerable and might lead to real complications of their own.