Navigating Healthcare – Patient Safety and Personal Healthcare Management

ACA debate in the Supreme Court – Join Me as I talk with Sam Bierstock at 2:30pmET #voiceofthedoctor

Posted in Uncategorized by drnic on March 29, 2012
Cited as the “most important debate of our time” and the hottest ticket in Washignton DC this week the healthcare debate kicked off a record setting 6 hours of arguments over a period of three days. You can listen to proceedings here. You can download Monday (pdf transcript), Tuesday (pdf transcript) and Wednesday Part 1 (pdf) and Part 2 (pdf).

Tomorrow I will have the pleasure of talking with Dr Sam Bierstock, MD BSEE on Healthcare RadioNow in what will be my regular radio podcast spot for Voice of the Doctor 2:30pm ET. We will be discussing our initial thoughts on the proceedings and the potential impact this will have on healthcare and in particular clinicians. It should prove to be a lively debate as Sam and I have opposing views. We will be discussing the Affordable Care Act (ACA) (full text in pdf form) and in particular the Supreme court debate that centered on four questions

1) Threshold Question (Monday)
The justices must decide whether an 1867 law called the Tax Anti-Injunction Act prevents the court from even considering this bill right now. (A provision dating back to 1867 to prevent every man and his dog from challenging and holding up any taxation by challenging it as unconstitutional, refusing to pay it till the courts make a hearing and tying up the government in court rulings and bankrupting them in the process.

Under the regulation there are no penalties until 2015 so the argument is that there is no case because nobody has paid the penalty or suffered any financial injury yet.

The debate was lively and provided much fodder for various interpretations and views of possible outcomes. It seems unwise to attempt to divine the tea leaves – what does seem to be generally agreed is that healthcare has to change. On its current trajectory with the aging “baby boomers” who will get sicker and require more care and a current cost per head of population far higher than any other developed country, healthcare is on life support and not doing well.

2) Individual Mandate
The regulation requires everyone to have health insurance. Challengers assert that this is the first time the federal government 

Central to this requirement is the need to spread risk to allow for the other provisions in the regulations that mandate affordable coverage for everyone with no discrimination based on previous medical conditions, and a requirement to charge people in the same age groups the same rates.
The government counters that everyone consumes health care and that the only question is when. without the requirement to have health insurance the people who get healthcare without insurance are forcing everyone else to pay for it predominantly in the form of cross subsidization in the pricing

No matter who pays for healthcare there is an increasing focus  on value based purchasing. In fact e-patient Dave blogged on his most recent attempts to be a responsible engaged patient and his frustrations at the lack of transparency in fees, bills and the ultimate cost of the care and tests we receive. 

3) Striking down all other provisions
Is the mandate is truck down should this apply to all components and if not do some remain while others are struck down. Much of this is tied up with the concept fo shared risk. If there is no requirement for everyone to have health insurance then only those that are sick will buy healthcare coverage making the health insurance unaffordable and uneconomic

In this point there is mostly agreement – the government agreeing that the insurance companies could not sustain a business model with out the shared risk and the opponents arguing that all components are so inextricably intertwined that everything would have to be invalidated.

It does seem that without putting *everyone* in the pool the other principles of extended coverage are unfunded and likely non-starters. The underlying question seemed to be could the Supreme court carve this bill up or was this really a job for congress. Given the 2700 pages and the push back from the justices of going through this item by item if the individual mandate falls so goes the rest of the elements.

4) Is the Expansion of Medicaid Unconstitutional
Is coercing the states into participating in the program where the states share 50% of the costs for the poor and disabled. States have the option of opting out (none have done so to date). As set out in the regulations the costs of the big expansion of coverage are covered by the federal government for 3 years but this shifts to the states over the following years rising to 10% by 2020. The opt out is an all or nothing proposition – they can’t opt out of just the expansion, and must either opt out of the whole program or take it plus the expansion and increased costs

My simple take on this – the states are happy to take the hand outs and have become increasingly dependent on federal funds but balk at the idea they might be required to extend the coverage…. or as one justice put it

“It’s just a boatload of federal money for you to take and spend on poor people’s health care”

There are three ways to tune in:

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An emergency room story to make anyone ill

Posted in Uncategorized by drnic on March 27, 2012
rifleman at 7:30 AM March 25, 2012

I had to go to an ER in Tennessee for an irregular heartbeat (a-Fib). I was there for three hours & all they did was an IV (there’s that dreded IV charge) and an EKG. After 3 hours my heart corrected itslef and I left. One doctor/intern (somebody wearing a white coat) came in and graced me with his presence and told me what I already knew. I have group insurance which pay 80%.

My part of the bill (20%) was a little over $1,000. Just my part. The bill was so vague I asked for a detailed statement and when it came it was equally vague. “Lab tests” doesn’t tell me squat! They use these deliberately confusing terms and codes hoping you’ll just cave and pay. Also, if you haven’t paid the FULL balance within 30- 45 days they’re ready to turn you over for collection.

Hospitals should be required to give you a detailed bill explaining what they did. We don’t tolerate car mechanics billing us this way (I hope). Can you see a charge on your tune up for “wires” without some explanation?

One of the major problems for parents, relatives and anyone who uses the medical service judiciously and with good intention – unknown fees.
Attending an ER for a tummy ached for a parent who went in knowing costs can be high and argued over inclusion of unnecessary tests and treatments (an IV saline drip for example) tell a worrying take

“I kept asking, ‘Is this really necessary?’ ” said Moser, who first questioned the emergency room staff about the need for an IV drip to administer a saline solution.

THis avoiding an “accidental” inclusion of $158 charge. But the fees for the other services can mouth up exponentially.

The cost for just walking in the door of the emergency room? That came to $1,288. The ultrasound nicked him an additional $1,135. A comprehensive metabolic panel (blood analysis) was billed at $1,212.

Moser was also charged $158, accidentally, for the saline solution he had turned down. The total came to $4,852.55, not counting separate bills that would arrive later and total nearly $1,000, including $540 for pathology and $309 for the doctor.

Seems that hospitals need to publish their fees so patients (and doctors) can make informed decisions? Next time you are at the ER ask for a fee list and to know how much each of the suggested investigations and treatment s will cost you before you agree

Facebook May Not Be So Friendly For Those With Low Self-Esteem : Shots – Health Blog : NPR

Posted in Uncategorized by drnic on March 26, 2012
<blockquote class=’posterous_short_quote’>Facebook May not be so Friendly</blockquote>

Facebook connects us but for those who struggle with social interactions the connections can amplify disconnects with main stream society. In an interesting piece on NPR featuring research from Ontario in Canada researchers found that:

People with low self-esteem posted far more negative updates than those with high self-esteem. Forest says they described a host of unhappy sentiments, from seemingly minor things like having a terrible day or being frustrated with class schedules to more extreme feelings of rage and sorrow

The effect was compounded by the perception of others on Facebook who disliked the type of negative comments, worsening the isolation. What does not appear in the piece but is in the actual broadcast with an interview with one student who had deleted his post he made a telling point, especially relative to middle school and high school age students. As he put it, at a time when children are moving away from the family, friends are more important and Facebook amplified isolation. It was not just about being “friended”. The simple action of being tagged in a picture highlighted to you (and your peers) that you were “there”. And for those that were not that they had not been invited. It used to be occasional discovery of exclusion from events – now your appearance, or more importantly lack of appearance, highlighted to the world your exclusion further disconnecting you from your peers.

So that makes me wonder how great an idea is for younger children in their formative years – is the age limit (ignored and certainly not policed) of 12 high enough?

Cholesterol Drugs May Slow MS

Posted in Uncategorized by drnic on March 26, 2012
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In an interesting development the Statin cholesterol lowering group of drugs is showing some effect at reducing the progression of MS suggesting that MS may be linked to lipid metabolism?

It included 81 patients with early-stage MS randomly selected to take either 80 milligrams a day of Lipitor (atorvastatin) or a placebo. After 12 months of treatment, 55.3 percent of patients taking the drug had developed no new brain lesions, compared with 27.6 percent of those who took the placebo.

While early results needing more study it does offer some promise of a treatment

Cholesterol Drugs May Slow MS

Posted in Uncategorized by drnic on March 26, 2012
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In an interesting development the Statin cholesterol lowering group of drugs is showing some effect at reducing the progression of MS suggesting that MS may be linked to lipid metabolism?

It included 81 patients with early-stage MS randomly selected to take either 80 milligrams a day of Lipitor (atorvastatin) or a placebo. After 12 months of treatment, 55.3 percent of patients taking the drug had developed no new brain lesions, compared with 27.6 percent of those who took the placebo.

While early results needing more study it does offer some promise of a treatment

Neglecting the patient in the era of health IT and EMR

Posted in Uncategorized by drnic on March 21, 2012

Neglecting the patient in the Era of Health IT

Not to see what lies dimly in the distance but to do what clearly lies at hand

Dr Verghese from Stanford who has authored several books make the point that the doctor patient interaction is the most important aspect of healthcare

Here he talks about the importance of being present during the exam, in an era with so many distractions threatening to erode the vital relationship between doctor and patient. This interview was introduced by CEO Jonathan Bush and then appeared in two parts on the

And I commented on this back in 2008 in this piece
Doctor Please look at me not Your EMR that featured my own family experiences at the doctors office that I personally as excited about but my then 10 year old pointed out to me that all the attention was not eh technology not the patient

BUt it would seem that some clinicians are able to manage th challenges of time

One of my heroes is a physician who trained at Harvard and came from a small community in Laredo, Texas. He trained at Harvard and went back to Laredo and practices now, even in his 80s. And he has this ability to walk into a room and sit on the patient’s bed and create the illusion that he has all kinds of time and nowhere else he needs to be. And paradoxically by being so completely in the moment he manages to spend less time with patients than many of us who are hurrying to get on to the next thing.

So if there was some advice for busy clinicians today from the famous Scottish historian and critic Thomas Carlyle:

Not to see what lies dimly in the distance but to do what clearly lies at hand

Seems that this is good advice not just for healthcare but life in general given all the distraction we face

A Maverick’s Lonely Path in Cardiology – alternative view on cardiac intervention

Posted in Uncategorized by drnic on March 20, 2012

Essay 28

Bernard Lown, MD

As I have just passed my 90th birthday, writing this essay reminds me of Machiavelli’s admonition when he was receiving final Communion on his deathbed. “Renounce the devil and embrace the Lord,” intoned the priest. A long silence. Then came Machiavelli’s whisper: “This is no time to make new enemies.”

Let me start with a confession: I not only harbored dangerously unorthodox views during my career; I practiced them. Being allowed to voluntarily retire from the practice of medicine in 2007, rather than having had my medical license revoked decades earlier, was either an egregious establishment oversight or an act of divine intervention. Though my medical transgressions were never obfuscated or hidden, few are aware of them.

My deviant behavior consisted of sharp departures from the accepted norms of medical practice. I deemed such behavior an act of civil disobedience, for which I was ready to accept punishment. Yet sadly no one in or out of authority took note.

So what is this all about? If you are not in the health profession, I urge you nonetheless to wade through the swampy terrain of medical jargon. (The endnotes aim to clarify some obscurities of medicalese.) This essay addresses the onrushing industrialization of health care, a critical issue for the long-range well-being of the United States.

Forty years ago I stopped referring most patients with stable coronary heart disease (CHD) for cardiac angiography.(1) This procedure permits visualizing the extent of obstructed coronary arteries. What occasioned my deviation? The problem was that nearly all those undergoing angiography ended up having surgery, namely, coronary artery bypass grafting, or CABG (pronounced “cabbage“).

What could be wrong with improving blood flow to the heart by unblocking an obstructed or narrowed artery? Such a seemingly commonsense approach would have had the approval of every plumber who encounters a blocked faucet.

But, first of all, the heart is not a plumbing fixture. When a coronary vessel is narrowed or blocked, the heart has a built-in defense mechanism: It develops a collateral network of small vessels to compensate for the diminished delivery of nutrients and oxygen.

Overcoming an anatomic obstruction by surgical tinkering, or later with stents, may actually not be of benefit. Whatever the convictions of clinicians, all practice must be legitimized by evidence. Without evidence, medical practice lacks scientific sanction. Therein resides a second objection for the rush to CABG. No evidence existed that CABG improved both survival and the quality of life more than the optimal medical treatment for patients with stable coronary artery disease.(2)

Without such evidence the common resort to coronary artery surgery rested on a thin reed of presumption rather than on a solid foundation of unimpeachable data. This was not a “six of one, half a dozen of another” choice. The consequences of intervention were sobering. CABG was not an innocuous procedure. It carried an upfront mortality as well as significant incidence of serious complications. In addition it added substantially to the cost of health care. Some years later coronary angioplasty and coronary artery stenting were introduced for the same purpose, again without supportive data.

So why did these procedures become so instantly popular? It must not be left unsaid that for some patients these interventions are miraculously life saving. But because they are extraordinarily beneficial for some with coronary artery disease, is it sound to infer that they benefit all comers?

Coronary interventions

Coronary surgical interventions were the first radical approach for overcoming obstructed coronary arteries resulting from atherosclerosis, the so-called hardening of the arteries. In 1967, the Argentine surgeon Dr. René Favaloro, working at the Cleveland Clinic, successfully used a vein graft to bypass an obstructed coronary vessel. Like Edmund Hillary and Tenzig Norgay, the first climbers to reach the summit of Mount Everest, or Roger Bannister, the first to run a four-minute mile, Favaloro opened a terrain deemed beyond human reach. In coronary artery vascular surgery he sundered the barrier to the seemingly impossible. Within ten years 100,000 patients were subjected to coronary bypass operations in the U.S.; by 1990s the number had quadrupled.

The rush to interventions multiplied still further with introduction of the far-less-invasive coronary artery angioplasty, wherein a thin balloon-tipped catheter is inflated at the site of a vascular narrowing. This percutaneous approach did not require anesthesia or opening the thoracic cavity. Soon came the further innovation of positioning a metallic stent, a veritable metallic scaffolding, to dilate and keep open a narrowed segment. At present more than one million stents are implanted annually in the U.S. A majority of newly minted cardiologists have become adept interventionists. They spend full time in the catheterization laboratory, a place for experimenting with novel, challenging technologies and a veritable gold mine for hospital and doctors.

I am racing ahead of my story. In the 1970s coronary bypass grafting was the only available approach for directly dealing with an obstructed vessel. CABG, as already stated, was not innocuous. It carried a 2 to 5 percent operative mortality. The grafts tended to clot and obstruct. Ten years after the operation a majority had reoccluded. Reoperation was then associated with double-digit mortality. Nearly 10 percent of patients undergoing CABG experienced some complications. Blood clots dislodged during the operation resulted in strokes and heart attacks. Undetected by cardiologists for many years was the impaired intellectual function afflicting many. It manifested in subtle memory losses and mild depression. I missed these complications until alerted by several spouses of patients.(3) As one succinctly stated, “My husband is physically normal, but he isn’t the guy I married.” Surprisingly it took a decade or longer for these disabilities to be recognized. A published study on magnetic resonance imaging found that 51 percent of those who had CABG demonstrated some brain damage.(4)

Fear facilitates medical interventions

One might wonder why patients acquiesced to undergoing a painful and life-threatening procedure without the certainty of improving their life expectancy. I have long puzzled at such acquiescence. Surprisingly, patients not only agreed to the recommended intervention but commonly urged expediting it. Such conduct is compelled by ignorance as well as fear. Patients are readily overwhelmed by the mumbo-jumbo of medical jargon. Hearing something to the effect of “Your left anterior descending coronary artery is 75 percent occluded and the ejection fraction is 50 percent” is paralyzing.(5) To the ordinary patient such findings threaten a heart attack or, worse, augur sudden cardiac death.

Cardiologists and cardiac surgeons frequently resort to frightening verbiage in summarizing angiographic findings. This no doubt compels unquestioning acceptance of the recommended procedure. Over the years I have heard several hundred expressions, such as: “You have a time bomb in your chest” and its variant “You are a walking time bomb.” Or, “This narrowed coronary is a widow maker.” And if patients wish to delay an intervention, a series of fear-mongering expressions hasten their resolve to proceed: “We must not lose any time by playing Hamlet.” Or, “You are living on borrowed time.” Or, “You are in luck — a slot is available on the operating schedule.” Maiming words can infantilize patients so they regard doctors as parental figures to guide them to some safe harbor.(6)

The power of such verbiage was brought home to me in the early 1970s by a Florida couple. The wife, Marjorie, did all the talking. It was quite evident that her husband, Bill, was too disabled to provide a coherent story.(7) The right half of his body was limp, his mouth sagged and drooling, his speech an incomprehensible jabber. Marjorie, a youthful-looking woman in her 60s, stumbled over words in a hurried animated outpouring of staccato sentences. She was impatient to bring me quickly into the loop as though I could offer a magical remedy for her disabled husband.

Bill had been in vibrant good health. Two years earlier, having reached age 70, he retired and devoted much time to long-neglected hobbies. Preeminent among these was playing 18 holes of golf twice weekly with former business friends. One Friday morning Marjorie was taken aback to learn that Bill was heading for a cardiovascular checkup to a world-renowned medical center that had recently established an outpost in Florida. Bill denied any symptoms. The reasons he offered for scheduling this appointment were that he had never had a heart checkup and the flood of advertisements from the new center made him realize that prevention was far preferable to coping with a heart attack or worse. He discouraged Marjorie from “schlepping along,” certain that he would be back by lunchtime.

When Bill had not returned by noon, Marjorie’s anxiety mounted. She telephoned the medical center but was shuttled between prerecorded messages. At two o’clock she received a call to come immediately to the clinic. She arrived at the cardiologist office more dead than alive. Her husband, normally outgoing, was silent and contemplative, and greeted her with a wan smile. The doctor explained that Bill “failed the exercise test,” but was fortunate that there had been an opening in the catheterization laboratory, where he underwent an emergency angiogram. As the doctor had suspected, he had serious multivessel coronary artery disease.

For Marjorie the afternoon is buried in a deep haze. On a view box the cardiologist demonstrated the findings. These looked to Marjorie “like white strings knotting and suffocating the heart.” She inquired as to the urgency of the condition. The cardiologist responded that this type of anatomy was associated with an “impending heart attack or worse” and advised early CABG. Marjorie pleaded with the doctor to arrange the operation as soon as possible.

The doctor scheduled bypass surgery for the next morning. He again congratulated Bill for his good fortune, there being an opening in a tight surgical schedule. Everything went as planned except that interoperatively Bill sustained a massive stroke.

Deeply upset by her tale and knowing full well that there was no remedy to reverse the brain damage, I posed a question that was both insensitive and dumb. I asked, “Why didn’t you seek a second opinion?” She leaped from her chair shouting, “That is a stupid, stupid question, Doctor. When your house is on fire, you do not ask for a second opinion! You call the fire department.” She was absolutely right on all counts.

Medical records of Bill’s clinic visit in Florida showed that he was able to exercise for ten minutes adhering to a standard treadmill protocol. The coronary angiogram demonstrated only moderate multivessel narrowing. He had been completely asymptomatic and physically unlimited prior to the operation. These findings indicated that Bill could have been managed medically with the likelihood of a nearly normal life expectancy.

Why foster fear?

Why do cardiologists indulge in fear mongering? The reasons are multiple. One factor, I believe, relates to control. With the medicalization of society and patients’ growing awareness of overtreatment, doctors are no longer regarded as impartial counselors deserving complete trust. To protect themselves, patients engage in a number of maneuvers to gain medical know-how. They forage the endless medical pastures of the Internet, peruse extensive health information from a variety of sources, and shop for second opinions.

A physician soon learns that a “realistic” formulation shuts off questioning and saves time. “The cyst on the CT scan may be cancerous” or “one of the main coronary arteries is 50 percent obstructed” dissipates doubt about a doctor’s expertise. Cardiologists are aware that the medical technology in a catheter laboratory is awe inspiring. The resulting angiogram is like Mosaic holy writ emanating divine authority. The doctor so armed need no longer brook doubt or contradiction. Even obstreperous patients acquiesce and grow lamb-like.

Another reason doctors counsel patients to undergo interventions is that, invariably, they are true believers of what they communicate. Often, though, they think like plumbers rather than like scientists. A blocked pipe has to be unblocked. In the case of the heart, the sooner the better. Such medical opinions, though seemingly propelled by common sense, are not supported by clinical evidence.

When a coronary artery completely obstructs, it causes either loss of viable heart muscle or sudden death. It is reasonable to assume that a coronary artery 90 percent narrowed is at greater risk for occluding than an artery with a less restricted lumen. Such a view persuades doctors to recommend interventions to improve flow. However, human logic does not accurately reflect cosmology or biologic processes. It commonly turns out that the vessel responsible for a heart attack is but modestly, if at all, narrowed. Surprisingly, when a 90 percent obstructed vessel totally occludes, it may neither inflict further heart muscle damage nor provoke symptoms.

What has been learned is that the cause of an acute coronary event is the inflammation and rupture of the thin covering of an atherosclerotic plaque. When this covering ruptures, the plaque empties, provoking clotting and abruptly obstructing a previously widely patent vessel. The heart is unprepared for such an abrupt denial of nutrients and oxygen. By contrast, a slowly obstructing vessel promotes the formation of a network of small collateral vessels. These provide alternate routes for blood flow, thereby protecting heart muscle viability when a diseased artery finally occludes.

The above is not merely theory. Clinical angiographic studies have found that arteries with minimal disease may obstruct, leading to a heart attack. When two coronary angiograms were carried out before and after a heart attack, the culprit vessel was not severely diseased in the first visualization. This was observed in 85 percent of heart attack patients!(8a,b) One would surmise that the lumen of vessels widened or grafted are not the ones that later cause mischief. It stands to reason therefore that coronary interventions in those with stable CHD might protect only a minority against either a heart attack or sudden cardiac death.

The major factor that seduces clinical judgment toward interventions, I am persuaded, is economic. Cardiologists’ income has skyrocketed since advent of interventionist coronary procedures. During the 1980s a cardiologist income grew by more than 50 percent, while that of internists stagnated. The two leading interventionist cardiologists in New York City based at the Mount Sinai Hospital and Presbyterian Hospital currently earn around $3 million annually.

At the very same time that procedures were rampant and growing, medical treatment was profoundly changing. A host of risk factors for CHD could now be reversed by lifestyle changes and new pharmaceuticals.(9)

The “unethical” study

During the early 1970s I was impressed by new therapeutic possibilities presented by preventive strategies and agitated by the increasing resort to halfway technologies. The adverse human consequences of overtreatment troubled me far more than the economic costs. Many patients were forfeiting their well-being and even their lives. For a small subset of patients with coronary artery disease, a surgical intervention was necessary for assuaging symptoms and prolonging life. But for the majority available medical measures could provide a nearly normal life expectancy of unencumbered living.

Visualizing the coronary anatomy was a prerequisite for CABG. Angiography is regarded as a seemingly innocuous procedure. One soon learns in doctoring that medical interventions are never complication-free. Shaping my clinical judgment were several patients I had encountered who experienced devastating consequences from coronary angiography.

I was distressed by one patient in particular. G.B. had been a successful professor of dentistry with stellar accomplishments. One day while playing tennis he experienced oppressive chest discomfort. He dismissed this as due to a strained muscle, reasoning that at 48 years of age, without a family history of heart disease and without cardiac risk factors, the discomfort was best ignored. When he related what happened to his wife, she grew agitated and insisted that he consult a cardiologist. A brief workup indicated that the episode was most likely heart related. A cardiac catheterization with coronary angiography described to him as “absolutely without risk” was scheduled a few days later. During the catheterization he suffered a massive cerebrovascular stroke. He was left with markedly impaired speech and an abrasive personality. His professional life was ended.

I first saw G.B. as a patient twenty years later. He was now afflicted with severe angina pectoris, but had not seen a cardiologist since the traumatic episode. He raged against the medical profession. Living out of state, he came once or twice annually. I dreaded his visits. I was not spared his bursts of anger against doctors. Often G.B. expressed a wish to have died at the time of the stroke. Episodes of angina grew in frequency and were unresponsive to nitrates and a panoply of other drugs. I was certain he needed bypass surgery preceded by coronary angiography. I lacked the courage to raise this until gaining his trust as a human being and physician. It took five years before we were friends. Eventually G.B. was persuaded to undergo CABG. The operation was successful, but his life continued to be charged with frustration and rage.

Dealing with the growing tide of interventions, most of which I regarded as unwarranted, was morally challenging. To remain silent was complicit. To speak out was to invite confrontation with a powerful and unforgiving establishment. One pressing question was, how could we identify the subset of coronary patients that did well without surgical treatment? To determine how to proceed entangled me in a welter of contradictory views and emotions. One thing was certain, something needed to be done.

Sometime in early 1972 Lown Clinic patients undergoing coronary angiography at the Peter Bent Brigham Hospital (PBBH) were set to be randomized either to medical or surgical treatment. The study was aborted before it began. Every patient opted for CABG operation. We could have anticipated such an outcome. Once the angiographers and medical house staff reviewed with patients the cardiac catheterization findings, coached in the lurid prose then and now in use, the trajectory of further care was unalterably fixed. Not a single patient agreed to participate in the randomized study. My words hit a brick wall.

It became evident that angiography was a funnel, a way station to a predetermined goal. Its prime purpose was to guide surgeons to narrowed or obstructed coronary arteries. To diminish the use of CABG for patients with stable CHD required bypassing coronary angiography.

We therefore determined to study stable CHD patients having advanced disease without subjecting them to angiographic investigation. Without viewing the coronary anatomy, how could we be certain that the selected patients had advanced disease? An extensive cardiovascular literature affirmed that the capacity to exercise on a motorized treadmill and the ensuing electrocardiographic changes indicated the severity of coronary vessel obstructions.

Patients selected for the study adhered to a distinctive medical program. Risk factors were punctiliously attended to. Hypertension control was high on the therapeutic agenda. We prescribed the free use of sublingual nitroglycerine for managing angina pectoris.(10) We discouraged early retirement from productive and satisfying work. We openly discussed with both patient and spouse the threat of sudden cardiac death that haunts a majority of those afflicted with coronary heart disease. We were unequivocally reassuring on this score.(11) We addressed social and family problems and opened dialogues about significant psychosocial stresses. We minimized shuttling patients to specialists and kept procedures and interventions to a minimum. Foremost, doctors spent much time listening, thereby fostering trust and an adherence to prescribed lifestyle changes. We aimed to be holistic practitioners, not merely heart doctors. In short, we did as much as possible for the patient and as little as possible to the patient. Above all we avoided medicalizing our patients, so instead of living for their disease, they continued to live fully despite their disease.

We aimed to identify early warning symptoms and signs of changes in disease status, allowing ample time for appropriate interventions. The paramount question was whether medical management affected adverse outcomes of coronary heart disease such as sudden cardiac death, heart attacks, or the development of congestive heart failure. At the same time we were not Luddites. When the coronary condition changed, appropriate interventions, including CABG, were undertaken.

As the study got under way and participating patients multiplied, I became increasingly concerned about malpractice suits. In the climate of our time it was easy to conjure all types of adverse scenarios resulting in a class action suit launched by a bevy of aggressive attorneys. Not abiding by the prevailing standard of care was tantamount to negligence, a major factor in litigation. It would take but a single case of sudden death or a heart attack in a patient denied coronary angiography and CABG to launch a nightmare. If several of our patients were so afflicted, one could conceive a public scandal with dire results, including the forfeiture of hospital privileges and a license to practice medicine. There would be no shortage of plaintiff witnesses from esteemed institutions around Boston.

In the early hour of morning, when sleep denudes reason of reasonableness, I was haunted by the likelihood of incarceration for manslaughter. These perturbing ruminations were not helped when a cardiology colleague accused me of indulging in unethical medical practice. He asked, “How would anyone regard a doctor who denied a chest X-ray to a patient coughing up blood because of some cockamamie theories?” I imagined he was accusing me of criminal negligence behind my back.

Results only a Pangloss would believe

We had no difficulty in recruiting patients for the study. Many who had been urged to undergo bypass surgery were seeking a second opinion. In the first of four studies we carried out over the ensuing thirty years, we recruited 144 consecutive patients with advanced coronary artery disease.(12) These were followed for an average period of nearly five years, during which time 11 patients died, for an annual rate of 1.4 percent. We referred only 9 patients for CABG (1.3 percent annually). These results were better than the best outcomes being reported for those undergoing CABG. We concluded that resorting to cardiac surgery was infrequently indicated for patients with stable CHD.

Our sense of achievement was short-lived. Leading medical journals refused to publish these findings. The study was faulted for lacking angiographic data. It was averred that without such information about the coronary artery anatomy our results were uninterpretable. A number of medical journal reviewers suggested that the reported favorable outcome indubitably reflected the selection of patients with mild or no heart disease. This notwithstanding that a majority of the study population had suffered heart attacks, experienced angina pectoris, and developed profound electrocardiographic changes during exercise stress testing.

It took four years before the New England Journal of Medicine published our findings. A flurry of angry letters followed with the recurrent motif that without coronary angiography our conclusions were invalid. For the first time in my medical career I received phone calls from outraged physicians accusing me of abandoning science or of setting cardiology back to the Dark Ages.

To address the major criticism of our first study, we launched a new investigation limited to patients with angiographically confirmed severe multivessel coronary artery disease. Though an Herculean task, it was made possible by the fact that medical insurance companies were beginning to demand second opinions before reimbursing for CABG. This was intended to contain the surge in costly cardiac operations. We recruited a small population of 88 patients, of whom 63 had significant narrowing of all their major coronary arteries. During twenty-eight months of follow-up we encountered no deaths and referred only 14 patients for CABG (7 percent annually). These results, though published in a leading medical journal(13), gained no attention in the mainstream media and evoked no interest among cardiologists or in the health policy community.

Introduction of percutaneous transluminal coronary angioplasty in the 1980s wrought a revolution in treating obstructed coronary arteries. This procedure involved threading a balloon-tipped catheter through a peripheral artery to the narrowed coronary segment. Inflating the balloon widened the lumen, thereby reducing the blockage.

Angioplasty was a wondrous technical achievement with substantial clinical advantages over CABG. It avoided surgery with its many potentially adverse byproducts resulting from anesthesia and thoracotomy as well as perioperative complications, a longer hospitalization, and a slower recovery. The salutary cardiac outcomes were similar. As with any medical intervention, angioplasty was associated with rare fatalities and some complications, a few of which were disabling. Troublesome was that the dilated vessel frequently reobstructed with adverse consequences.

The competition between angioplasty and CABG roused a turf war between cardiovascular surgeons and interventionist cardiologists. The competition contributed to lowering the threshold for interventions. New syndromes were devised justifying a rapid transit to either a catheterization laboratory or an operating suite. The shibboleth diagnoses became either “unstable” or “intractable” angina pectoris. In the new climate of market medicine, a complaint of chest discomfort or the use of an extra nitroglycerine was sufficient for a diagnosis of “unstable angina” and for being routed to the catheter laboratory.

Interventionist cardiologists were so charged with conviction of their benefactions that many largely asymptomatic men, merely on suspicion, had their coronary anatomy surveyed. Of course the outcome was preordained. Most middle-aged Americans have coronary artery narrowing. The rush to procedures was spectacular. By mid-1980s 30,000 patients had undergone percutaneous angioplasty. Within five years the procedure grew tenfold. With the introduction of coronary artery stenting, procedures reached a million annually.

In an era of mega-interventionist cardiology, it was essential to reexamine the comparative robustness of a medical-management approach. For the third study(14), the Lown Clinic recruited 171 second-opinion patients, previously counseled to undergo an intervention. During four years of follow-up, outcomes were identical to our earlier reported results. Once again our findings were dismissed as meaningless due to a small sample size.

We were determined not to be silenced. From 1992 to 2000 we screened 2,598 patients, of whom 693 were eligible and consented to participate. Their mean age was 67, the oldest reported group.(15) Half of these patients had been urged to undergo a revascularization procedure. During an average follow-up of 4.6 years, the cardiac event rate was extraordinarily low, with an annualized mortality of merely 1.4 percent, identical to the outcome we had reported twenty years earlier. Referral for interventions, namely CABG and coronary stenting, was 6 percent annually, a tiny fraction of the massive traffic for costly and unwarranted procedures.

Four decades of persistence, some would call it pigheadedness, availed us not a whit in gaining visibility for an approach that we believed improved health care and substantially contained medical costs. Notwithstanding the prevailing widespread concern with runaway health care costs, neither the media nor the health care establishment evinced any interest. No one came knocking at the door to examine our practice or our outcomes.

The challenges we were posing were not merely clinical and economical. Ultimately the issues we raise are profoundly ethical. A new treatment, whether involving drugs or procedures, is improper without indubitable supporting evidence of benefit. The patients’ well-being must not be compromised by imagined good when countervailing interests are at the same time being served. Our forty-year struggle essentially concerned medicine’s first and inviolate principle, primum non nocere. “First do no harm” is the litmus test sanctioning the privilege to practice medicine.

Notes

1. The large majority of patients have stable CHD. Generally a middle-aged man experiences chest tightness while engaging in excessive exertion or exhibits electrocardiographic changes when undergoing diagnostic exercise testing. When coronary risk factors are addressed through lifestyle alterations and with appropriate medications, the patient may anticipate a long survival.

2. The first randomized study was published in the leading cardiovascular journal in 1983, sixteen years after Favaloro’ s description of CABG (Coronary Artery Surgery Study (CASS), Circulation 1983; 69:939-950). This study found no difference in outcome between medically and surgically treated patients except in a small subset of around 10 percent. This important publication did not rein in interventions, and CABG procedures continued to escalate.

3. See my blog essay 26, “Wives Yes; Husbands No,” September 19, 2011.

4. Knipp SC, Matatko N, Wilhelm H, et al.: Cognitive outcomes three years after coronary artery bypass surgery: relation to diffusion-weighted magnetic resonance imaging, Ann Thorac Surg. 2008; 85 (3): 872-9.

5. In someone without symptoms ,such findings do not warrant any intervention. They do mandate a well-structured medical program focused on lifestyle changes to reduce CHD risk factors.

6. This subject is dealt more extensively in The Lost Art of Healing, Chapter 5, “Words That Maim.”

7. This case is reported in the Lown Forum, titled “Harm of Unwarranted Tests, Procedure and Treatments,” October 2010.

8a. Little WC, et al.: Can coronary angiography predict the site of a subsequent myocardial infarction in patients with mild to moderate heart disease? Circulation 1988; 478:1157-68.

8b. Ambrose JA, et al.: Angiographic progression of coronary artery disease and the development of myocardial infarction. J Am Coll Cardiol. 1988; 12:56-62.

9. Reducing salt intake and taking antihypertensive drugs reduce blood pressure; lowering dietary fat consumption, along with a host of new drugs, reduced blood cholesterol; diabetes was also better managed. A revolution in therapy was afforded with the introduction of beta-adrenergic-blocking drugs that damped sympathetic nerve traffic to the heart.

10. Encouraging the free use of nitroglycerine puts the patient in control, thereby diminishing uncertainty as well as anxiety. My great teacher, S.A. Levine, commented that the patient who uses nitroglycerine freely and abundantly outlives his doctor.

11. We found that patients who showed no advanced forms of arrhythmia during 24-hour heart monitoring and who were able to exercise more than eight minutes adhering to a standard protocol without evoking heart rhythm abnormalities, experienced no sudden cardiac death during the ensuing year! This provided a basis for optimism to be communicated to patient and spouse.

12. Podrid PJ, Graboys TB, Lown B: Prognosis of medically treated patients with coronary‑artery disease with profound ST‑segment depression during exercise testing. N Engl J Med. 1981; 305:1111‑16.

13. Graboys TB, Headley A, Lown B, et al.: Results of a second‑opinion program for coronary artery bypass graft surgery. JAMA 1987; 258 (12):1611‑14.

14. Graboys TB, Biegelsen B, Lampert S, et al.: Results of a second-opinion trial among patients recommended for coronary angiography. JAMA 1992; 268 (18):2537-40.

15. Jabbour S, Young-Xu Y, Graboys TB, et al.: Long-term outcomes of optimized medical management of outpatients with stable coronary artery disease. Am J Cardiol. 2004; 93:294-99.

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In a compelling and thoughtful essay by Bernard Lown, MD he describes his journey over the last 40 years combatting the rising tide of intervention in cardiac care

Balking the prevailing view of intervention and coronary artery bypass grafting (CABG) he details several studies demonstrating the consequences of over treatment. As he puts it
>>>>For a small subset of patients with coronary artery disease, a surgical intervention was necessary for assuaging symptoms and prolonging life. But for the majority available medical measures could provide a nearly normal life expectancy of unencumbered living.

In the design of our healthcare system his resistance and position feels very much like the identification and reporting of Helicobacter Pylori by Barry Marshall and Robin Warren in 1982 as the causative agent for stomach ulcers and cancer. They were met with the same derision as Dr Lown appear to have been as evidenced by the challenge to get his papers published and the general criticism and rejection of the idea that for 40 years have been largely ignored

>>>>Four decades of persistence, some would call it pigheadedness, availed us not a whit in gaining visibility for an approach that we believed improved health care and substantially contained medical costs. Notwithstanding the prevailing widespread concern with runaway health care costs, neither the media nor the health care establishment evinced any interest. No one came knocking at the door to examine our practice or our outcomes.

It would seem that any patient considering cardiac care, angiography and possible interventional treatment would want to at least explore these issues and understand in detail what alternatives might exist together with the risks associated with aggressive intervention. I know I would/will.

Brain imaging, behavior research reveals physicians learn more by paying attention to failure

Posted in Clinical Decision Making, EBM by drnic on March 14, 2012

ScienceDaily (Nov. 24, 2011) — Research on physicians’ decision-making processes has revealed that those who pay attention to failures as well as successes become more adept at selecting the correct treatment. The researchers also found that all the physicians in the study included irrelevant criteria in their decisions about treatment.

When seeking a physician, you should look for one with experience. Right? Maybe not. Research on physicians’ decision-making processes has revealed that those who pay attention to failures as well as successes become more adept at selecting the correct treatment.

“We found that all the physicians in the study included irrelevant criteria in their decisions,” said Read Montague, Ph.D., director of the Human Neuroimaging Laboratory at the Virginia Tech Carilion Research Institute, who led the study. “Notably, however, the most experienced doctors were the poorest learners.”

The research is published in the Nov. 23 issue of PLoS One, the Public Library of Science open-access journal, in the article, “Neural correlates of effective learning in experienced medical decision-makers,” by Jonathan Downar, M.D., Ph.D., assistant professor of psychiatry at the University of Toronto and Toronto Western Hospital; Meghana Bhatt, Ph.D., assistant research professor at Beckman Research Institute, the City of Hope Hospital, Duarte, Calif.; and Montague, who is also a professor of physics in the College of Science at Virginia Tech.

The researchers used functional magnetic resonance imaging (fMRI) to look at the brain activity of 35 experienced physicians in a range of non-surgical specialties as they made decisions.

The doctors were instructed to select between two treatments for a series of simulated patients in an emergency room setting. “First they had a chance to learn by experience which of two medications worked better in a series of 64 simulated heart-attack patients, based on a simplified history with just six factors,” said Bhatt.

Unknown to the test subjects, of the six factors, only one was actually relevant to the decision: diabetes status. One medication had a 75 percent success rate in patients with diabetes, but only a 25 percent success rate in patients without diabetes. The other had the opposite profile. The physicians had 10 seconds to select a treatment. Then they were briefly presented with an outcome of “SUCCESS: (heart attack) aborted” or “FAILURE: No response.”

“After the training, we tested the physicians to see how often they were able to pick the better drug in a second series of 64 simulated patients,” said Bhatt. “When we looked at their performance, the doctors separated into two distinct groups. One group learned very effectively from experience, and chose the better drug more than 75 percent of the time. The other group was terrible; they chose the better drug only at coin-flipping levels of accuracy, or half the time, and they also came up with inaccurate systems for deciding how to prescribe the medications, based on factors that didn’t matter at all.”

In fact, all the doctors reported including at least one of the five irrelevant factors, such as age or previous heart attack, in their decision process.

“The brain imaging showed us a clear difference in the mental processes of the two groups,” said Montague. “The high performers activated their frontal lobes when things didn’t go as expected and the treatments failed.” Such activity showed that the doctors learned from their failures, he said. These physicians gradually improved their performance.

In contrast, the low performers activated their frontal lobes when things did go as expected, said Bhatt. “In other words, they succumbed to ‘confirmation bias,’ ignoring failures and learning only from the successful cases. Each success confirmed what the low performers falsely thought they already knew about which treatment was better.” The researchers termed this counterproductive learning pattern “success-chasing.”

“The problem with remembering successes and ignoring failures is that it doesn’t leave us any way to abandon our faulty ideas. Instead, the ideas gain strength from each chance success, until they evolve into something like a superstition,” said Downar.

The fMRI showed that a portion of the brain called the nucleus accumbens “showed significant anticipatory activation well before the outcome of the trial was revealed, and this anticipatory activation was significantly greater prior to successful outcomes,” Montague said. “Based on the outcome of the training phase, we were actually able to predict results in the testing phase for each low-performing subject’s final set of spurious treatment rules.”

The authors state in the article that the formation of spurious beliefs is universal, such as an athlete’s belief in a lucky hat. “But the good news is that physicians can probably be trained to think more like the high performers,” said Downar. “I tell my students to remember three things: First, when you’re trying to work out a diagnosis, remember to also ask the questions that would prove your hunches wrong. Second, when you think you have the answer, think again and go through the possible alternatives. Third, if the treatment isn’t going as expected, don’t just brush it off — ask yourself what you could have missed.”

“These findings underscore the dangers of disregarding past failures when making high-stakes decisions,” said Montague. “‘Success-chasing’ not only can lead doctors to make flawed decisions in diagnosing and treating patients, but it can also distort the thinking of other high-stakes decision-makers, such as military and political strategists, stock market investors, and venture capitalists.”

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The above story is reprinted from materials provided by Virginia Tech, via AlphaGalileo.

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Journal Reference:

  1. Jonathan Downar, Meghana Bhatt, P. Read Montague. Neural Correlates of Effective Learning in Experienced Medical Decision-Makers. PLoS ONE, 2011; 6 (11): e27768 DOI: 10.1371/journal.pone.0027768

Note: If no author is given, the source is cited instead.

Disclaimer: This article is not intended to provide medical advice, diagnosis or treatment. Views expressed here do not necessarily reflect those of ScienceDaily or its staff.

Selecting the right treatment is a tricky business and this paper reveals some interesting results on physicians’ decision-making processes
>>>Clinicians who pay attention to failures as well as successes become more adept at selecting the correct treatment.

These findings underscore the dangers of disregarding past failures when making high-stakes decisions,” said Montague. “‘Success-chasing’ not only can lead doctors to make flawed decisions in diagnosing and treating patients, but it can also distort the thinking of other high-stakes decision-makers, such as military and political strategists, stock market investors, and venture capitalists

So when looking for a physicians maybe looking for the more experienced one if not the main characteristic to focus on.

Interesting ideas and helpful in understanding the clinical decision making process

Teen smoking

Posted in Uncategorized by drnic on March 12, 2012
I what appears to be a reversal of the downward trend in smoking teenagers appear to be taking up smoking in increasing numbers prompting the surgeon general to declare teen smoking to be an epidemic. Over half a million middle school children and over three million high school students smoke.

It is not clear why but there is a clear problem with tobacco promotion in young adults and teenagers and w need to address this quickly.

D.C. Week: Teen Smoking Called Epidemic

Doctors engaging in Social Media

Posted in Uncategorized by drnic on March 12, 2012
Helpful piece covering the increasing number of clinicians who are jumping into the world of social media incorporating it into their practice and engaging patients in new, interesting and valuable ways.

SocialMed: Docs Worth Following