Tuesday, October 21, 2014

Reviewing The Regulators

In 1990 the American Board of Medical Specialties (ABMS) and the American Board of Internal Medicine (ABIM) changed their requirements for physician board certification from a voluntary life-long designation and educational process to a time-limited designation lasting 10 years.  This decision to require repeated testing, the public was told, was based on data from a single highly flawed retrospective literature review that suggested physician competence deteriorates over time.  Despite this, over the ensuing years hospitals and insurance companies increasingly require physicians to be board certified for credentialing or billing purposes.  And as a result of changing the life-long designation of board certification to a temporary one, physicians were left with little choice but to pay for and participate in the ABMS/ABIM MOC program to practice their trade.

In 2005, the ABMS modified their re-certification requirements and created a program called "Maintenance of Certification" (MOC).  This program required completion of "Practice Improvement Modules" in addition to the completion of certain knowledge-base testing modules before a physician could sit for their secure re-certifying examination.  This decision to include "Practice Improvement Modules" was a unilateral one by the ABMS and its subsidiaries and was never scientifically challenged or validated by the independent physician community.

This year, the requirements for MOC changed again when all US physicians were now required to pay for and participate in the ABMS/ABIM MOC process every two years, in addition to re-taking their certifying examination every 10 years.  Because of the added cost and time requirements with the most recent change to the ABMS/ABIM  MOC process, physicians began questioning the MOC program's legitimacy as a means of assuring physician quality verses the ABIM's bottom line.  An online petition was signed by over 18,850 physicians asking to "recall the changes to MOC and to institute a simple pathway consisting of a recertification test every ten years."   In his response to this petition and to support the credibility of the MOC process, the President and CEO of the ABIM referred to the research conducted by the ABIM leadership and staff:

"There is a good deal of research demonstrating the value of MOC: from the validity of the examination, to the importance of independent assessments – clinicians are not good at evaluating their own weaknesses. All of this research drives and informs our program requirements and product development."  

Review of the ABIM’s "research" topics showed they cover a wide range of important clinical care issues including trust, teamwork, ethics, obligations of the Hippocratic Oath, characteristics of internal medicine physicians and their practices, teaching, staffing patterns, electronic health records, clinical skills, and the structure of medical homes. But closer inspection of much of this work shows it was not research, but rather opinion and editorial.  Much of the "research" resides behind expensive online paywalls free to the academic community, but expensive for the non-academic physician and public to review.  Given these realities, before casting aspersions on physicians' ability to evaluate their own weaknesses, it appears a review of the ABIM's "research" in regard to its clinical legitimacy is in order.

In 2014, the Center for Medicare and Medicaid Services (CMS) published the entire database of $77 billion dollars of payments made to US health care providers in 2012.  The data are easily reviewed using a website created by the Wall Street Journal.  In an effort to establish the credibility of the ABIM leadership and staff's journal publications as it pertains to the various aspects of medical practice they claim to actively monitor, each author published in the 2014 collection of journal articles published on the ABIM website was cross-referenced with their CMS 2012 Medicare provider payment data.


 The ABIM publishes journal articles authored by ABIM staff and leadership for the years 2000-2014 on its website.  The 31 articles published so far in 2014 were randomly selected for review. Each author of each paper was then compared to their 2012 Medicare payment data.  If the payment data for a particular author were non-zero, then the total number of inpatient and outpatient new and existing patient encounters were totaled to determine the total 2012 annual Medicare patient care encounters seen by the author.  Procedure counts were not added to this total of encounters, since the intent here was to "even the playing field" between "proceduralists" and hospital- or office-based clinicians in terms of the number of patient contact episodes they had each year.  In the event more than one physician author's first and last names were identical, the source article was reviewed to assure the proper physician data was obtained based on their city, state, or academic institution.

Authors designated as employees of ABIM, those with acknowledged conflicts of interest or those with non-academic or policy affiliations were also recorded. The average, median and standard deviation of 2012 Medicare payments and patient encounters were then calculated.

As a point of reference, the author of this blog post received a total of $163,184.55 in Medicare payments representing 529 patient encounters (298+75+13 established outpatient visits, 31 outpatient new visits, 82+14 initial hospital/inpatient care and 16 subsequent hospital care visits) according to the 2012 Medicare database. This number of encounters represented 1.5 days of outpatient clinic visits per week in 2012 (personal data) as well as inpatient patient care encounters payments received from Medicare patients. This encounter volume represented 42% of this author’s total number of clinical encounters billed in 2012 (personal data).


Thirty-one articles published by the ABIM staff and leadership in 2014 (so far) represented work by 150 authors.  Of the 31 articles published on the ABIM's website to date for 2014, ten of them (33%) were published solely by ABIM employees or leadership. Only 80 of the 150 authors held an MD degree.  The authors were a heterogeneous mix of US and non-US physicians, one veterinarian, nurses, students, statisticians, researchers, representatives from National Board of Medical Examiners, Center for Medicare and Medicaid Services, the Urban League, the Foundation for Advancement of International Medical Education and Research, Mathematica Policy Research, Inc., the National Collaborative for Improving Primary Care Through Industrial and Systems Engineering, the VA medical system, staff members of the American Board of Internal Medicine Foundation, and others from Consumer Reports Health.

Clinical Involvement

Of  physicians with an MD degree, the average 2012 Medicare payment amount was $18,196.97 ± $68,220.55 (median $0). Only thirty-seven of the 80 physician authors (46%) had Medicare payments paid to them in 2012.  Three authors had payments exceeding $100,000 in 2012 while the vast majority (30 of the 37) received under $25,000. This average payment amount corresponded to an average of 131 ± 308 patient encounters (median 0) for the entire year 2012.

If all of the authors were included in the analysis, the average 2012 Medicare payment was $9705.05 ± $50,502.95. The median Medicare payment to the authors published in 2014 to date was $0. The average number of patient encounters per year in 2014 was 70 ± 234. The median number of patient encounters in 2012 by the authors published to date was 0.

The entire spreadsheet (pdf) of the 2012 Medicare payment and encounter data by each author that published with ABIM leadership and staff in 2014 can be reviewed here.


This study is the first to cross-reference a portion of ABIM publishing authors to the 2012 Medicare provider payment database. While Medicare payment data might not represent the full workload of today's clinical physicians, it is the most complete database of US physician clinical work performed on patients in the United States published to date.

The ABMS/ABIM's Maintenance of Certification program has been criticized by many working physicians as onerous, expensive, time-consuming and a poor reflection of physician quality. In his response to physician concerns over the MOC process, the President and CEO of the ABIM stated:

"ABIM's mission is to enhance the quality of health care by certifying internists and subspecialists who demonstrate the knowledge, skills and attitudes essential for excellent patient care."

Dramatic changes to the health care landscape have occurred over the past five years.  If the mission of the ABIM is to truly certify internists who with “skills and attitudes essential for excellent patient care," we are left to question the legitimacy of recommendations made by physicians who no longer care for patients in today’s health care arena. The ABIM seems content with making recommendations to physicians while being woefully inxperienced about the challenges that face internists today.   In fact, the data presented in their work confirms that physician quality is are being regulated by an unqualified body.

While some might argue that regimented study and time-consuming non-clinical data acquisitions are required to assure physician quality, it remains quite possible that such a dishonest and lopsided approach will backfire as physicians refuse to participate in this process or retire early from medicine just as more patients are entering our health care system. Burdening clinical physicians with unrealistic and unproven demands for non-clinical tasks detracts from needed patient care.  Recall that only three of the physicians included in the author list of ABIM's 2014 publications received over $100,000 of Medicare payments while 30 of 37 physicians in the published articles in 2014 received less than $25,000.   Might the recommendations and data that the ABIM is making available to hospital groups and insurance organizations be seriously flawed?

Even a cursory review of the background of the authors of several published works of the ABIM staff and leadership reviewed suggests a troubling narrative. For instance, one article included with the ABIM's 2014 list of journal articles is entitled "Internists' attitudes about assessing and maintaining clinical competence" (J General Int Med 2014; 29(4):608-614).  While this title might seem reassuring to the public that the ABIM is serious about their mission, their credibility becomes suspect when closer inspection of the background of the authors revealed only one of the six authors had any clinical encounters in 2012 and another author was a veterinarian. In another article entitled "Time to trust: longitudinal integrated clerkships and entrustable professional activities," (Academic Medicine, 89(2), pp 201-4) none of the authors received payments for patient care in 2012 and the authors acknowledge the ideas presented were provided by two political "think tanks."  Should these be the people we entrust to develop clerkship ideals and "entrustable professional activities" (whatever that is) for our future physicians?

We should note that despite fourteen years of articles on the ABIM's website, none of the ABIM’s "research" has ever evaluated any negative consequence of their MOC program.  Rather, these ABIM papers "drives and informs" additional unsubstantiated "program development" like a public relations firm. Without independent assessment of their practices, it remains completely possible that the MOC process causes more harm than benefit to actual patient care delivery as a result.

The Medicare payment data of ABIM authors also begs the question, how are the ABIM physicians and legislators spending their time?  It is apparent that most physician members of the ABIM are not involved in clinical care.  Given the conflicts of interest mentioned in the various citations, physician quality assurance is not the ABIM's priority.  Perhaps the physician members of the ABIM would have more credibility advising struggling doctor-employees on beefing up their curriculum vitae, earning consulting fees, perfecting public relations skills, and creating multiple income streams since their annual revenue take with their MOC program implementation went from $46,131,129 in 2010 to $55,625,925 in 2012 (Data from the 2011 and 2013 IRS Form 990 published on guidestar.org/).  Given these data, it is appears that the ABIM is more concerned about padding their resume to (1) create and air of legitimacy, (2) serve a political agenda, and (3) to provide a smoke screen for the high salaries of their board members.

Clearly, busy front-line full-time practicing physicians do not have the time for creating publishing mills or for scientifically meaningless survey collection.  Patients want capable practicing physician availability, not survey collectors. Assuring physician quality should not be about creating and funding a political action committee subservient to a political agenda, but rather understanding the challenges physicians face in their workplace and knowledge base and working collaboratively to offer continuous professional improvement.


There are several limitations to this study.  First, because the CMS Medicare payment database does not capture work performed on patients under the age of 65, the database does not accurately reflect the total clinical work load a physician performs each year.  Physicians who do not accept Medicare for payment would not appear on this database.  However, since older patients commonly access our health care system more frequently as they age, it would be expected that internists writing policy for health care delivery would participate in the Medicare government program.  Second, the 2012 Medicare payment data reviewed does not correlate to the year the articles were published in the literature.  However, one would expect that experienced physicians who changed the testing requirements for MOC in 2014 would have recent direct patient care experience to appreciate the many factors that impact physicians today.  Finally, reviewing only one year's literature published on the ABIM's website might have introduced sampling bias.  Still, the sampling of the most recent year offers the advantage of reviewing articles that might affect upcoming policy decisions.


Physicians are not above proving their competence and establishing quality standards, especially if those standards are scientifically sound and transparent.  The legitimacy of the MOC process to assure physician quality should be called into question based on a careful literature review of the many conflicts exposed by this review and the limited recent clinical experience of those that contribute to their evidence base.  Citing numerous publications to legitimize the MOC program creates the illusion that this process of insuring quality care and has been vetted by actual scientific data.  Nothing could be further from the truth.


What Signs Would Bureaucrats and Regulators Hold Up?

Nice to see front-line health care workers finding their voice.

I wonder what signs our health care bureaucrats and regulators would hold up?


Thursday, September 25, 2014

The Last Reprogramming

He had called the other day to update me up on his condition.  He did not sound upset, but resolute.  "They offered me peritoneal dialysis," he said, "but I decided against it and figured I'd just let nature take its course.  The hospice people are so wonderful - I've got things all set here at home, but I have two questions.  What should I do about my warfarin?  You know, I just don't want to have a stroke.   And what I do about my defibrillator?"

We were colleagues once and grew to be friends later when life's circumstances brought us together. He, a revered senior neurologist and me, a relatively new doctor in town. I could remember overhearing his heated discussions about administrative snafus with colleagues in the hall, or watching a horde of residents and medical students following him into a patient's room to teach at the bedside.

"Of course he didn't want a stroke," I thought.

So we decided to keep the coumadin and let him continue his daily INR checks at home and to turn off just the tachyarrhythmia detections on his biventricular defibrillator.

"I'll come over tomorrow and we'll turn it off," I said.

There was a brief silence, perhaps because of momentary disbelief that I'd do such a thing.  Then he proceeded to give me detailed directions and landmarks to watch for on my way over.  "I'm sure I can find it," I said thanking him.

So the next afternoon after most of the day's events had finished, I grabbed the programmer and drove to his home.  It was an unusually beautiful day - mid 70's, sunny - as if Someone had wanted it that way. There in the yard, was his wife, wearing a large-brimmed hat and holding a hose while pretending to water the shrubs.  She came over to greet me: "Thanks so much for coming over," she said, "I know this means so much to him." Then she realized she was still holding the hose. "Oh, I'm so sorry, it's just that someone has to try to keep the place up," she said, voice cracking.

The "place," of course, was beautiful.  A majestic grande dame of a house - one I would later learn they had occupied for the past 44 years and bought when they were "just kids on the block."  It was meticulousy kept, stately.  I entered with his wife and noticed a shadowy figure two rooms away sitting at the edge of a mechanized hospital bed.  The bed was placed in what must have been his study with a large bay window with a couch next to it.  A reading lamp was over the head of the bed and the walls held books from the floor to ceiling with icons and statues, likely from other, more active time.

"Thanks for coming, Wes," he said, looking up.

"How are you feeling?" I asked, somewhat stupidly.

"Pretty good, considering everything.  See?  My legs aren't quite so swollen and my abrasions all have eschars on them," he noted as only a doctor could.

"Is there a plug nearby?" and he proceeded to point me the way so I could plug in the programmer to do my job while he explained the device to his wife.  The process was quick and I interrogated his defibrillator, then turned off the tachyarrhythmia detections, therapies and now needless alarms. "There, that didn't take long.  All done," I said.

There was a moment of silence as I sat with this man whom I known for so long.  Like a wise sage and hospitable host, it was clear he wanted to talk for a bit, so I slowed my exit.

"You know, I've always appreciated your frankness about my condition," he said. "You're a lot like me in many ways, I think.  You never overstepped, let me have control, to manage things like I wanted to, and I've always appreciated that," he said.

Embarassed by his frankness, I wondered what to say.  At a loss for words, I told him how much I enjoyed meeting his family, wife, daughters, and grand-daughters recently in the hospital.  He looked puzzled, forgetting. "You know, that day I brought my daughter in your room with them?"  His eyes brightened and his smile widened as he remembered. 

"Oh, yes! That was wonderful!  How fast times flies, doesn't it?" he said.

"You know, I wrote about that day in my blog," I mentioned, ".. and included some pictures of my daughter from 10 years ago - about what she thought about medicine - can I show you?"

"Of course!"

So I showed him the picture and we shared our thoughts about family.  Then, to make reading from my iPhone easier, I read him the post I'd written about that day.  We talked about family and what they meant to each of us.  And then he shared with me another nugget, that he grew to become a writer, too.

"You know, I spent some time and wrote an autobiography for my kids not too long ago - over a hundred pages - about everything I could remember - from my earliest years as a child, about my immigrant father and  American mother.  My father made it as a successful lawyer - came over from eastern Europe - I even know the ship - I remember the picture of him standing there with his hat..., and I wrote about my family, influential teachers in grade school, fellow professors, and people that I knew throughout the years - everything.  You should do that, too, you know.  I'm so glad I did.  I gave them to my kids and even made some some extra copies - maybe for the grandkids, in case they want it someday..."  He looked away to see his wife leave the room, trying not to be noticed as tears filled her eyes once more.   She didn't want to him to see her this way.

He stared down at the floor beneath his swollen feet, then continued.

"You know, it was therapeutic for me to write that autobiography.  After all, what we do is terribly isolating for the most part.  No one understands that.  Like you do your procedural stuff and I do my diagnosing.  We do most of it all alone, with no one else there.  Just the patient and the doctor.  Wonderful, to be sure, but isolating.  So many memories.  I guess it helped me to put some of those feelings and the thoughts I had about those I loved into words.  It's hard to capture it all..."

He looked up from the floor and stared in my eyes.  "Thank you," he said extending his hand.

I sat motionless for a bit digesting the gravity of his words, lost in them before I saw his hand.  Once I noticed, I lept up to shake it and gave him a long hug to his increasingly skeletal frame.  It was a brief moment to share together once more and one I now realized I had done too infrequently with other patients in a similar circumstance.  Here he was, an incredible man who'd given so much to his family, fellow colleagues and patients, now teaching me once more so much about life as a doctor, about grace, and about real love.  Just the two of us, isolated again, but as friends. 

With great reluctance I packed things up and found his wife on my way out.  "Thank you," she whispered with swollen eyes, "I just don't want him to be in pain." 

"He's going to be fine," I told her, "... perfectly fine, especially now. He's such a wonderful guy." She smiled and opened the door.

As I drove away I realized we probably won't see each other again - his remaining time here will be saved for others now. There were so many thoughts, so much to remember, so much still to learn. Perhaps because I'd been through something like this before I was more prepared - it's never easy - but I still felt okay about it all - not sad - confident that we did the right thing... 

... together.


Tuesday, September 23, 2014

Time Lapse: Pacemaker Implantation Table Setup

Oh, the wonders of Apple's iOS8!  Now there's no excuse for slow room turnovers:

Yeah, I can see all kinds of applications for time lapse photography, especially when it comes to improving my productivity...


Friday, September 19, 2014

Case Study: What They Don't Teach You in EP Fellowship

These days, pacemakers and defibrillators are often interrogated via a home-monitoring system that uploads information contained in the implanted cardiac devices automatically to a central server so it can be accessed by physicians remotely.  This feature was added to most defibrillators after the rash of recalls struck the industry in 2005-6.  Not only can the information be uploaded electively by the patient, it can also be automatically uploaded if a nightly self-check detects a parameter out of range.  In this case, the patient was being monitored by Medtronic's Carelink remote monitoring system.

"Dr. Fisher, I think we have a problem with Mr. Smith's RV lead (not his real name)," my device nurse said as she handed me the Carelink transmission that triggered an superior vena cava (SVC) high voltage coil impedance warning:

Click to enlarge

"What did the last interrogation look like?" I asked.

"Here's the old one was sent just three days before and looked fine," she said. "It's so weird.  We've not had a problem with this patient's device since it was implanted in 2012."

Click to enlarge

Real-time intracardiac electrograms seen on the earlier transmission - Click to enlarge

"Strange.  I'm not sure what to make of this.  Give him a call - we might have to change that RV lead," I said.

"Okay," she said, then returned to the device clinic and I went back to seeing patients.

Some time later, my nurse returned.

"Um, Dr. Fisher, could I speak with you a moment?" she asked.  "I got some more information.  I think you better look at this" and she handed me his most recently transmitted real-time intracardiac electrogram recording that was sent with the latest transmission.

What did it show and why were the RV lead parameters abnormal?


Wednesday, September 17, 2014

Rebuttal: A Bit More on MOC Failure Rates

Recently, David H. Johnson, MD, Chair of the American Board of Internal Medicine (ABIM) Board of Directors and Internal Medicine Chairman at UT Southwestern Medical Center in Dallas, and Rebecca Lipner, PhD, Senior Vice President of Evaluation, Research, and Development at the ABIM published a "guest blog post" over at MedPageToday regarding Maintenance of Certification (MOC) pass rates, entitled "Debunking the MOC Pass Rate Myths." I do not know if they were directing their comments directly to me, but since I was the one who brought the issue of rising MOC failure rates to the public's attention some time ago using the ABIM's own published data of first-time MOC takers, I thought I should respond.

I appreciate Drs. Johnson and Lipner providing more insight into how the MOC examinations are constructed and scored.  The ABIM's arbitrarily-defined "65%" marker based on "expert consensus" and undisclosed "psychometrics" is an interesting one, and at least now we understand how this benchmark was arbitrarily created. They also acknowledge that "significant changes in the practice of the discipline may require that the passing standard be reset."  Unfortunately, they do not disclose what those changes might be, which way their 'standard' might be adjusted, or what internal or external force might mandate such an "reset."

Drs. Johnson and Lipner also confirmed the rising failure rates of board examinations over the past five years.  Oddly, they then seem to imply that this "decline in pass rates" is due to a misunderstanding by "some social media observers" of their testing and scoring process:
"Recently, based on a slow decline in pass rates over the past 5 years for the American Board of Internal Medicine Maintenance of Certification exam, some social media observers have made erroneous assertions about how the exams are constructed and scored.

Without a full understanding of the exam process, they have nevertheless claimed that the exam is being made more difficult, that the standard for passing the exam changes every time an exam is given, or that the exam is 'graded on a curve.' These assertions are all incorrect."
Rather than attack what was said or what wasn't by those unruly social media types, I will merely say this: my assessment of the rising failure just focused on simple math.  Because there are higher numbers of doctors taking this examination year after year due to the American Board of Medical Specialties' recently-imposed MOC requirement, the stable "65%" pass rate means there is necessarily an INCREASE in the number of total physicians who are FAILING the examination.  It goes without saying that a requirement for repeated testing or adding more people to the testing pool handsomely profits the ABIM and similar subspecialty organizations that provide proprietary subspecialty MOC-preparation courses taught by ABIM test question contributors (this relationship is also conflicted, by the way). But the downside of more testing is multi-pronged: it also redirects physicians away from direct patient care to formal classrooms, expensive hotel meeting rooms in cities often outside the physician's hometown, and ultimately to expensive corporate test taking centers.  The ABIM never considers these high costs nor the negative effects absence from one's practice has on patients or a physician's limited family time.

Drs. Johnson and Lipner also remind us that "pass rates are higher among first-time test takers." While there are likely many reasons for this, we must conclude that significant AGE BIAS against older, more experienced physicians exists.  Since this proprietary MOC process was cleverly made a "quality measure" imbedded in our new health care law, the logic of this biased process contradicts common sense.  Are patients not our best teachers? Are we to assume that physician experience after years of direct patient care is of less value than ABIM-selected facts and principles culled from an exponentially-growing body of medical literature regurgitated on a computer screen in an expensive testing center?  Furthermore, how the test is constructed or scored is of little relevance to more procedural based specialties of internal medicine like mine because these skills are never assessed.

Drs. Johnson and Lipner also mention (without supporting data)  that physicians who take their examination three times (at their expense) ultimately achieve a 95% pass rate. As if this is the point. Instead, we should ask what patients and physicians lose each time they must repeat this onerous, time-consuming and unproven process.  Can the personal, financial and professional losses of repeated testing ever be regained? How, exactly, does repeated testing of a flawed process help our patients?  What marginal utility to our health care system does this whole test-taking exercise really provide?  Does this MOC process actually separate the good physician from the bad physician or the good test-taker from the bad one?  Since ABIM never knows a doctor's scope of practice before their assessment, they make some heady assumptions about what they should test.  In reality, the ABIM only tests what THEY think should be tested, rather than what matters to the particular physician's patient population.  Worse still, since the ABIM remains completely unaccountable to doctors or patients in regard to their MOC process, their assessment may have absolutely no relevance to a particular physician's practice.  Shouldn't we be discussing these issues before arguing how the test is constructed and scored?

No physician I know argues with the need for continuing, life-long education in medicine, especially when its performed in a relevant, transparent, informative, collegial and feedback-oriented process without a ulterior financial motive.  If fact, most of us do this every week as part of our state licensure requirements and have plenty of continuing medical education credits to prove it.  Allowing the ABIM to monopolize this process as we have through artificial MOC point acquisition exercises that are often irrelevant to a physician's scope of practice not only circumvents more healthy and sustainable learning environment, but also might cause more harm than good if that physician loses their practice privileges as a result. 

In summary, I believe the ABIM's lucrative MOC process is no more valid than what doctors have already been doing for years before the American Board of Medical Specialties decided to make their MOC program an annual exercise.  The MOC process remains unproven in its ability to improve patient care and (as we've now confirmed) discriminates against more senior physicians. Those of us who have endured this process multiple times have witnessed the growth of "board certification" from a self-imposed professional milestone to a money-making scheme filled with clinically-irrelevant busywork that often detracts, rather than augments, patient care (especially those non-validated "practice improvement modules").

It is time that doctors of all ages insist that these self-appointed non-profits organizations cease their attempt to become expensive continuing education providers and stick to what they do best: assessing a doctor's ability to reach a level of exceptionalism of their practice during their career, rather than pretending that they can assure some arbitrary level of ongoing practice adequacy for the business community.  Until the ABIM comes to grips with their increasingly bipolar agenda, their ability to remain credible and relevant to practicing physicians, the public, and the mysterious "stake holders" they claim to serve will continue to be challenged, both on social media and in the court of law, as "significant consequences from losing certification" occur with increasing frequency to experienced and fully-capable physicians.


Thursday, September 11, 2014

The Big Flail

After you've written on a blog for a long time, you begin to ask yourself why.  Oh sure, there are the great opportunities for a single person to make a point, to act as a tiny tugboat trying to push a corporate mothership in a slightly different direction, but you begin to realize that there are very few times that actually happens. You try to provide a voice to issues that are often unheard, then realize that voice is only occasionally appreciated but more often duly noted, then ignored.  This is the nature of internet and quite frankly, medicine now - it is a world of competing interests.  On one side you have the patients, doing a messy job of getting sick, and corporate health care systems - either government, private, for-profit or non-profit - doing their very best to make sure their illness is neat and tidy, easy to control, perfectly understood, and quantifiable.  To this end, each has their own agendas that must be served, be it another regulation, value-added improvement, or a profit motive to secure the bottom line. 

This idea came to me yesterday in clinic.  Increasingly, every microsecond of my day, my week, my weekend has now been efficiently parsed into tiny computerized scheduling chunks.  It doesn't matter where I work, because like The Cloud, location doesn't matter - schedulers and administrative handlers can reach me, be it by beeper, computer, Outlook email, EPIC email, desk phone or my personal iPhone. There are so many places to check for messages that when I don't respond, the person trying to reach me just moves up the chain of communication options.  Eventually there's no down time, no time to think, there are few places to go where there is quiet any longer. It's become life by a thousand interruptions - a Big Flail.

Increasingly, there's a push to do away with beepers and move telecommunications in medicine to my personal iPhone.  But I an resisting this because I need to set a boundary between work and my personal life - if for nothing else but self preservation.  We are told this is being done in the name of "security" and "non-secure beeper messages" but I think it's because people don't want to wait.  They need their answer now. I really wonder what the evidenced based data on beeper message hacking is in health care and if more patients were helped or hurt by beeper data breeches.  There's a better idea, they say: consolidate.  It's more "efficient."  I know, I'm such a Luddite. But to whom do I respond when that head administrator calls on my iPhone as I'm  examining a patient?  How to I separate a Twitter message from an ER message? Does the act of looking at my phone when I'm with a patient engender trust or an appearance of distraction?

It's hard to argue with "security" when someone creates a new medical policy.  We all want to be secure.  We all want to know that our most private and personal  medical information is protected from prying eyes.  But quite frankly (and this is very politically incorrect to say) real information security in medicine is a joke.  After all, people's lives are perfectly encoded on a computer now and eight different billers, coders, insurance company trolls or hospital marketers can delve into that database of information and find specifics about a patient or group of patients with simply the click of a button.  Phishing schemes make a mockery of our passwords.  Seriously, who are we fooling? Let's be honest: paper charts housed in a known location behind a locked door were MUCH more secure. 

Hurry up.  Click here, click there, "Excuse me," "Can I have a moment of your time?", "There's a the 7 am meeting tomorrow," "What was that Ms. Jones?", "Yes, I'll try to make it," "Did you try it unipolar?", "Yes, I'll check my inbasket,""You left your addendum open,""They're calling for the cardioversion,""Should we add him in?", "I have to take my board review course, can you take call?,"The ER's calling,""Can you check her pacer, too, when you see her?", "Did you sign the EKG?"

Doctors need some quiet, down time, some time to think, to pay attention. We need to create our own boundaries between our personal and professional lives that are respected.  We need to think we can get away, to regroup, have some quiet time for ourselves or with a patient, even for a moment.  And if that means that some of us want to separate work from home by the use of a beeper instead of an iPhone, so be it. 

Otherwise, our personal lives will become a Big Flail, too.


Monday, September 08, 2014

Another MacGyver Moment in Pacemaker Implantation

Installing a permanent pacemaker or defibrillator has become commonplace event in cardiology these days.  These devices implanted in a patient are comprised of two main parts: the lead(s) and the pulse generator.  After installing the leads in the heart and connecting them to the pulse generator, the lead and pulse generator assembly are then placed beneath the skin in a small subcutaneous (or in rarer cases, submuscular) "pocket" that is created surgically.  Considerable care is taken to cauterize bleeding vessels when the pocket is created.  To facilitate visualization of these occasional bleeding vessels deep within the created pocket, I prefer to use a surgical headlamp to direct the light deep within the pocket cavity rather than relying on a conventional overhead surgical light.  I have found that headlamps have helped me limit my incidence of post-operative pocket hematoma development.

So as things have had it, I seem to have a knack for attracting every eighty- or ninety-plus year old who needs an emergency pacemaker on the weekend when I'm on call, and this past weekend was no exception.

So the team was assembled and the pacemaker implantation equipment readied.  They knew I liked a headlamp, so they dug deep into the recesses of their inventory to pull out their only headlamp that appeared to be from a bygone surgical era.  Being pressed for time, I couldn't argue and had to make due, but knew that this headlamp might not be very reliable, especially as I saw how the headlamp's fiberoptic cord was secured to the light source that generated about as much light as a few well-lit candles by a cumbersome spring-loaded Rube Goldberg contraption.  As I placed the headlamp on my head, and tightened the plastic strap that housed the headlamp to my head, I needed a backup plan in case the light failed.

Would I have to use the overhead light and make do, or might there be another way? 

I needed another MacGyver Moment.

That's when my on-call staff team came up with a brilliant, simplified idea:

iPhone to the rescue!


(PS:  This device is experimental and has not been approved by the FDA.  Use this device at your own risk.    If you experience headaches, nausea, difficulty with concentration, or an erection lasting for longer than four hours, discontinue use of this device and contact your doctor immediately.  I have no commercial interest in this device.  Also, since the headlamp still worked this weekend, no workaround was needed for the patient, but something tells me we might be getting a new headlamp soon.)