By Dr. Wes

Cardiovascular predictions for next year are always fun to contemplate this time of year.  So much is happening to the practice of medicine as we’ve known it that it can be helpful to highlight some of those changes, both good and bad, as our medical world continues to evolve.  While these predictions contain pure guesses, they also contain one doctor’s observations of our new evolving medical world.  Many of these changes will profoundly shape how doctors interact with their patients.

So grab some coffee and strap in.  Here are my 2013 predictions of life as a cardiologist in 2013.  (Please feel free to add your own predictions in the comments section.)

Valvular Heart Disease

• TAVR for critical aortic stenosis will be applied to progressively younger and healthier patients.
• As smaller delivery systems for percutaneous heart valves gain widespread acceptance, government payers will look for new and inventive techniques to restrict patient access to these devices.  No heart valve will remain untouched as creative uses of the approved devices are attempted in non-surgical patients.
• Innovations valve design will improve the safety and effectiveness of this therapy.

Continue reading “My Grand, Sweeping Cardiovascular Predictions for 2013″

By Clifton Meador, MD

A few months ago, a young cardiologist told me that he rarely listens to hearts anymore. In a strange way, I was not surprised.

He went on to tell me that he gets all the information he needs from echocardiograms, EKGs, MRIs, and catherizations. In the ICU, he can even measure cardiac output within seconds. He told me that these devices tell him vastly more than listening to out-of-date sounds via a long rubber tube attached to his ear.

There was even an element of disdain. He said, “There is absolutely nothing that listening to hearts can tell me that I don’t already know from technology. I have no need to listen. So I don’t do it much anymore.”

I began to wonder. I called my longtime friend and colleague, also a cardiologist. I knew him to be one of the best heart listeners. I asked him if he still listens to hearts. He answered, “Of course I do. I could not practice medicine if I didn’t. But you know every week, several patients tell me when I listen to their hearts that I am the first doctor ever to do that. Can you imagine that?”

Playing the devil’s advocate, I challenged my friend to tell me what he learned from listening to hearts.

He answered, “How could anyone not want to hear those murmurs, sometimes ever so soft, like whispers? Murmurs from the heart, even very faint ones, are trying to tell us significant things. Some sounds are very localized, even hidden or obscured by layers of air. And then there is the rhythm and the beat and the cadence that you cannot hear on the paper strip of the EKG. Also, careful listening is the only way to appreciate the rubs of friction if there are any. The devices are important, but the heart has its own spoken and unspoken language if you know how to listen.

Continue reading “The Unheard Heart: A Metaphor For Medicine In the Digital Age”

By Dr. Wes

Recently I was asked to serve as a consultant on a medical matter.  Interestingly, they requested my hourly price for my services.  I thought about this and wondered, “What am I worth in per hour in the open market?”

It is an interesting question to ponder.

I have decided to ask the blog-o-sphere.  Call it a bit of “free market economics.”  For the record, 100% of my hourly wage for my services will be sent to our cardiovascular research fund at our hospital to avoid any conflict of interest.  I will not see ANY of the money the blog-o-sphere decides personally, but I really want to know what people think.

So where to begin?

Should I compare my hourly wage to MGMA standards for the annual physician salary of a physician of my subspecialty?  If so, do I pick the 50% percentile, 25th percentile, 75th percentile, or 95th percentile?  On what basis do I have to assure this is a fair price?  Who sets this price?  Are these data accurate or based on earlier years’ hospital data and physician surveys?  Can I verify that their hourly price is justified?  If so, how?  Or are their data proprietary?

Continue reading “What Am I Worth?”

By SANJAY BASU, MD

By MERRILL GOOZNER

The number of Americans with serious heart disease in need of hospital treatment is on the decline. A new study in today’s Journal of the American Medical Association shows the overall rate of coronary revascularizations — ranging from the coronary artery bypass graft (CABG) surgeries to in-and-out catheter-based procedures like angioplasties and stent insertions — fell from just under 1,500 per million adults a quarter in 2001 to less than 1,250 per million adults a quarter in 2008, a 15 percent decline.

The most intriguing finding in the data was that virtually all of the decline was in the most serious cases — those requiring CABG, which fell by about a third. The rate of percutaneous coronary interventions (where they snake a catheter through the thigh into the blood vessels feeding the heart, propping them open with either drug-eluting or bare metal stents) remained virtually unchanged.

The study authors, who hailed from the Philadelphia Veterans Affairs Medical Center, suspect the decline in CABG was driven by “a sizable shift in cardiovascular clinical practice patterns away from surgical treatment toward percutaneous coronary interventions” using catheters (so-called PCI). In other words, in recent years people with serious heart disease are more likely to be treated with the less invasive procedure. Continue reading “CABG in Decline”

By KIMBERLY MANNING, MD

“I can’t sleep, doc.”

“Really?”

“Yeah. And it ain’t like I ain’t sleepy, either. I just be sitting there. Just up and bored.”

“Tell me about your evenings.”

“I get in bed at like eleven. I turn on my television and just watch some TV. You know, Leno and the news.”

“Okay.”

“My old lady falls asleep and then I just sit there. Wide awake.  After while, I shut off my television and just lay there.”

“Hmmm.”

“I know . . . .  I ain’t supposed to watch TV in bed, but I’m telling you, doc, it ain’t that.”

“That television can be harder on you than you think. Has it always been hard for you to sleep?”

“No, ma’am. I used to sleep fine. And as for that TV? Naw, it ain’t that. I been sleeping with my TV for years.” Continue reading “Perspective”

By DAVID WILLIAMS

An Archives of Internal Medicine article (Conflicts of Interest in Cardiovascular Clinical Practice Guidelines) is getting a lot of notice this month. In essence, many of the physicians who develop guideline that influence practice patterns and payment decisions have conflicts. The authors recommend only allowing those without conflicts to write the guidelines.

This isn’t a new issue. In 2006 I wrote a piece (Another dirty little secret is out in the open) and am reposting it below because it’s timely:

A year ago in Time to deal with medicine’s dirty little secrets?, I wrote about a variety of practices that are relatively well-known in the health care field but would be shocking to outsiders. Industry often takes the blame for “aggressive marketing tactics,” and no doubt some of that is deserved. But physicians are also culpable.

The open secrets include the ghostwriting of journal articles by industry sponsors, physicians and academic medical centers holding ownership stakes in companies whose products they are researching, the clinical role sometimes played by orthopedic sales reps, and perhaps the most egregious example: physicians who set guidelines having financial relationships with the companies that benefit from how those guidelines are set.

Now we have a new example, which is even more serious than usual. A recent New England Journal of Medicine article blames Eli Lilly for overzealous promotion of Xigris. According to the Boston Globe:

Eli Lilly and Co. funded medical guidelines created for the treatment of [sepsis] in an effort to boost sales of a drug with questionable benefits. The allegation was made by senior scientists at the National Institutes of Health. [They] said Lilly tried to shape the guidelines for use of the drug Xigris by sponsoring a three-pronged marketing campaign

The first two phases are by now almost standard practice in the industry:

1. Lilly paid a task force to spread the word that hospitals were rationing Xigris because of its cost, which forced docs “to decide who would live and who would die”
2. Lilly “orchestrated” the development of practice guidelines to treat sepsis that called for early use of Xigris (an example of the phenomenon I have described before)

But then Lilly allegedly took a third step, which was a little shocking even to me:

Now, Lilly is sponsoring lobbying efforts to turn the guidelines into quality standards. Hospitals that follow such quality measures receive higher payment from insurers.

What’s happening here? Basically, an influential group of doctors is being lazy and greedy, and Lilly is enabling their behavior. The doctors put their fingers in the cookie jar and Lilly keeps restocking it. The public is paying for the cookies –in the form of higher product sales and sub-optimal health care– and should get fed up!

I have no problem with companies using legal means to promote their products, even if their tactics are “aggressive.” They owe it to their shareholders to maximize return on investment. But it isn’t in their long-term interest to push things as far as the medical profession often lets them.

Industry leans on the reputations of individual physicians (aka “key opinion leaders”), medical societies (aka guideline writers), and journals to legitimize their marketing messages. It’s up to the medical profession to scrutinize industry claims and issue independent guidelines and quality standards. Sometimes these claims hold up and deserve to be propagated. Sometimes they don’t. If the docs and journals don’t do their jobs they deserve to lose credibility.

It’s hard to know the extent to which medical guidelines are already corrupted. The situation is a bit like the incident when the Chinese President’s plane was refitted. In the process of fixing up the plane someone inserted a bunch of listening devices (presumably at no extra charge). When the Chinese checked out the plane and realized it was bugged they had to rip the whole thing up. That’s something like what is going on within the major payers. They’ve stopped treating journal articles and guidelines as objective and have started doing their own analyses. But do we really want to leave health care decisions just to them?

Here’s some free advice to the different players in health care:

• Industry: Feel free to market your products and services aggressively, but don’t take things too far. If you do you’ll end up killing the goose that lays the golden eggs. No one will trust doctors, guidelines or journals anymore
• Physicians: Remember that pharma and device companies are not stupid. If they spend money supporting your research or sending you to conferences or sponsoring continuing medical education it’s because they expect to get a return on their investment. It’s awfully hard to remain objective in such instances. Your job is to adopt the best medical practices and put the patient first –sometimes that requires expensive new treatments and sometimes old, cheap standbys are better
• Payers: Go ahead and challenge the objectivity of journal articles and guidelines. On the other hand, don’t pretend that low cost is always synonymous with best treatment. Expect physicians to keep you in line on that.
• Patients: You need to look out for yourself. Find a good, honest physician. Take a look at who’s sponsoring the educational materials you receive. Ask your physician about alternative treatments and do some research yourself