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People are not units — US healthcare policy obstructs good doctoring
There is a lot of talk about rewarding value in US healthcare. Don’t believe any of it. It’s not happening. Not even close. This is a post about the real world–where I practice medicine. In a comment on yesterday’s post, Lisa wondered how I connected the current model of employing doctors and paying them on productivity to the three trends I wrote about on Medscape Cardiology–fear-mongering, lack of communication, and treating diseases not people. I started to explain in the comments section but then realized the topic was big enough to warrant a new post. To be blunt again: the current model ...
Source: Dr John M - November 2, 2014 Category: Cardiology Authors: Dr John Source Type: blogs

Medical decisions — tradeoffs, emotions, preferences and experts
Maybe you wonder why I, a cardiologist, writes about vaccines and mammography. It is because I have grown intensely interested in the medical decision. As a doctor in a preference-sensitive field, electrophysiology, how do I help patients understand and choose the best path–of which there are many. This seems like a simple task, but with humans, it is not. Especially these days, when we choose from so many tools. Many forces play on the act of deciding on action or inaction. There is how I feel as a doctor about the risks and tradeoffs. That’s important because we influence decisions based on how we present the...
Source: Dr John M - October 24, 2014 Category: Cardiology Authors: Dr John Source Type: blogs

A case that illustrates the good, the bad and the ugly of American medicine
I had a recent conversation with an old friend about her elderly father that encapsulates a lot of what is both great and terribly wrong with health care in America today. Here are the basic facts: the man is in his mid-80s, retired from teaching school, and is active and vigorous, living in the community; he is cognitively intact. He has a history of coronary disease and had an intracoronary stent placed some years back. He is asymptomatic on a typical “cocktail” of meds including aspirin, a statin, and an ACE inhibitor. Over the summer, he had a routine follow-up visit with his cardiologist, who detected a carotid br...
Source: Kevin, M.D. - Medical Weblog - October 23, 2014 Category: Journals (General) Authors: Tags: Physician Geriatrics Heart Surgery Source Type: blogs

Missing the first US Ebola case – A learning opportunity in patient safety and caregiver distraction
It was a mistake to send the Liberian national Thomas Eric Duncan home from a Dallas emergency room after he presented with fever and pain, which were early signs of Ebola infection. It would be a larger mistake to miss an important learning opportunity. This case demonstrates what I believe to be a major threat to patient safety—caregiver distraction. Doctors and nurses are increasingly prevented from giving full attention to the important things in patient care. The degree of value-added nonsense has reached the point where delivering basic care has gown dangerous. This morning, in Canada, news of a case of deadly drug...
Source: Dr John M - October 6, 2014 Category: Cardiology Authors: Dr John Source Type: blogs

You Say You Want Some Revolutions? - Famed Academic Physician Dr Milton Packer's Endless Alternating Turns as Drug Company Spokesperson and FDA Advisor
Last week, we noted  we again discussed the web of conflicts of interest that is draped over medicine and health care, and seems responsible for much of our current health care dysfunction.  We have discussed examples of conflicts of interest affecting clinical research, clinical teaching, clinical care, and health care policy.  Each time I think we must have cataloged all the useful examples, a striking new one appears.Only a few days later, yet another new variant has in fact appeared. A New Kind of Revolving Door A new version of the "revolving door" apparently was first noted by Public Citizen, and then ...
Source: Health Care Renewal - September 16, 2014 Category: Health Management Tags: Avandia Bristol-Myers-Squibb conflicts of interest FDA GlaxoSmithKline Milton Packer Novartis Pfizer revolving doors sacubitril Source Type: blogs

Research and Reviews in the Fastlane 048
This study looked at one institution’s discrepancy rate between EP and radiologist plain film reads over 10 years. They found overall an ~3% discrepancy rate on all plain films. This of course does not mean the radiologist was correct in every discrepancy. But it does show we agree most of the time. Most interestingly, the rate of discrepancies requiring emergent change in management was a mere 0.056%! Recommended by: Zack Repanshek Prehospital/Retrieval Braude D et al. Air Transport of Patients with Pneumothorax: Is Tube Thoracostomy Required Before Flight? Air Med J. 2014 Jul-Aug;33(4):152-6. PMID: 25049185 C...
Source: Life in the Fast Lane - September 15, 2014 Category: Emergency Medicine Authors: Anand Swaminathan Tags: Anaesthetics Cardiology Education Emergency Medicine Pediatrics Pre-hospital / Retrieval Public Health Respiratory Resuscitation Toxicology and Toxinology critical care Intensive Care literature R&R in the FASTLANE recommendati Source Type: blogs

Research and Reviews in the Fastlane 047
In this study, the research team collected pooled urine (read many people used the urinal they collected from) from a popular nightclub area in London and analyzed the specimens for the presence of illicit drug compounds. The goal was to determine whether this method could be used to track patterns and monitor trends in recreational drug use.  Recommended by: Anand Swaminathan Emergency Medicine, Critical Care, Anaesthetics Hindman BJ et al. Intubation Biomechanics: Laryngoscope Force and Cervical Spine Motion during Intubation with Macintosh and Airtraq Laryngoscopes. Anesthesiology. 2014; 121(2):260-71. PMID...
Source: Life in the Fast Lane - September 9, 2014 Category: Emergency Medicine Authors: Anand Swaminathan Tags: Clinical Research Education Emergency Medicine R&R in the FASTLANE critical care Intensive Care literature recommendations Research and Review Source Type: blogs

The desire to spoon-feed medical residents today
As I begin another year teaching EKGs to our new residents, I find I am increasingly asking myself, “Where to teach?” I do not mean to imply a geographic sense to the word “where” (although this is difficult, too, as residents move from hospital to hospital in large health care systems like ours as they change rotations), but rather as more of a “level.” What level do I teach our residents the art of EKG reading? Do I keep it rudimentary or do I teach it at the level of a good cardiology fellow? Are we striving for excellence or striving for adequacy in EKG interpretation? Said another w...
Source: Kevin, M.D. - Medical Weblog - September 2, 2014 Category: Journals (General) Authors: Tags: Education Heart Residency Source Type: blogs

Is this the most important cardiology study of the last decade?
In recent years, progress in the field of cardiology has been painfully incremental. We have enjoyed small gains–a better ablation catheter and mapping system, a couple of new anti-platelet drugs, maybe better stents, and even the highly touted anticoagulant drugs are within 99% in efficacy and safety of warfarin. Major breakthroughs, though, are non-existent. (And please don’t tell me squishing valves in the frail elderly is a major advance.) This absence of game-changing type progress has an explanation. Perhaps the answer will be obvious after I tell you about the most important cardiology medical study of t...
Source: Dr John M - August 27, 2014 Category: Cardiology Authors: Dr John Source Type: blogs

Research and Reviews in the Fastlane 045
Welcome to the 45th edition of Research and Reviews in the Fastlane. R&R in the Fastlane is a free resource that harnesses the power of social media to allow some of the best and brightest emergency medicine and critical care clinicians from all over the world tell us what they think is worth reading from the published literature. This edition contains 10 recommended reads. The R&R Editorial Team includes Jeremy Fried, Nudrat Rashid, Soren Rudolph, Anand Swaminathan and, of course, Chris Nickson. Find more R&R in the Fastlane reviews in the R&R Archive, read more about the R&R project or check out the f...
Source: Life in the Fast Lane - August 25, 2014 Category: Emergency Medicine Authors: Anand Swaminathan Tags: Clinical Research Emergency Medicine Intensive Care R&R in the FASTLANE critical care Education literature recommendations Research and Review Source Type: blogs

Getting the dabigatran (Pradaxa) story right… Correcting four common mistakes.
This purpose of this post is to clarify misstatements made in a recent New York Times article about the anticoagulant drug dabigatran (Pradaxa). The piece had three major inaccuracies, plus one thought-error from a cardiology leader. I write these words because the most valuable tool in the treatment of AF is knowledge. Getting it right is critical. (For readers that persist, I offer a bonus at the end.) The thrust of the Times’ story concerned editorials in the British Medical Journal that questioned the safety of dabigatran. The first non-warfarin anticoagulant has had plenty of controversy, the most recent of whic...
Source: Dr John M - August 21, 2014 Category: Cardiology Authors: Dr John Source Type: blogs

Research and Reviews in the Fastlane 044
This study looks at the agreement between radiologists in reading CTPAs for pulmonary embolism. They found that more than 10% of studies initially read as positive were later read as either negative or indeterminate. Many of the change in read occurred in subsegmental embolisms. This study throws further doubt on starting patients on long term anticoagulation based on the presence of a subsegmental pulmonary embolism. Recommended by: Anand Swaminathan Education Raemer DB. Ignaz semmelweis redux? Simul Healthc. 2014 Jun;9(3):153-5. PMID: 24401925 As a rabid in situ simulationist it is good to be tempered now an then by a...
Source: Life in the Fast Lane - August 18, 2014 Category: Emergency Medicine Authors: Jeremy Fried Tags: Cardiology Education Emergency Medicine Haematology Infectious Disease Intensive Care R&R in the FASTLANE Resuscitation critical care literature recommendations Research and Review Source Type: blogs

Mexico congress recap — Is it selfish for doctors not to be on Social Media?
When Dr Eduardo Hernandez Castillo (@CardioLeaks) asked me to come to Mexico to speak with a group of physicians about the power of social media, I paused. Should I go to Mexico? I have been traveling a lot; it was a long trip; I was just starting to get fit again, and the atrial fibrillation/anticoagulation congress was industry-sponsored. I wrote back to Eduardo about these reservations. He explained that there was a great need for education (of patients and doctors) in Mexico. Yes, it was true; Bristol-Myers Squibb and Pfizer, the makers of apixaban (Eliquis) were sponsors of the E-Summit 2014. But Eduardo said I would ...
Source: Dr John M - August 18, 2014 Category: Cardiology Authors: Dr John Source Type: blogs

Physician Payments Sunshine Act: Over 100 Medical Associations and Societies Urge CMS To Reconsider CME Exemption and Open Payments Timeline
Medial associations and specialty societies have been understandably frustrated with the way the Physician Payments Sunshine Act has rolled out so far. Yesterday, over 100 medical societies including the American Medical Assocation--49 state medical societies and 64 medical specality societies--sent a letter to Marilyn Tavenner, Administrator of the Centers for Medicare and Medicaid Services (CMS) asking for redress over three problematic issues: (1) the expansion of reporting requirements for educational activities, (2) Open Payments’ condensed timeframe for physician registration, and (3) the complicated r...
Source: Policy and Medicine - August 6, 2014 Category: American Health Authors: Thomas Sullivan Source Type: blogs

What is chronic rheumatic carditis?
Rheumatic carditis lasting more than 6 months is considered as chronic rheumatic carditis. Evidence of recent streptococcal infection as an essential criteria for the diagnosis of rheumatic carditis cannot be applied in this situation. Such cases may present with late onset heart failure in rheumatic fever. It is also known as smouldering carditis in rheumatic fever. Teaching personnel working in schools with children having recurrent streptococcal infection are prone to get recurrent streptococcal infection and consequently stand the chance of developing such chronic rheumatic activity without an acute phase and developm...
Source: Cardiophile MD - July 30, 2014 Category: Cardiology Authors: Prof. Dr. Johnson Francis MD, DM, FACC, FRCP Edin, FRCP London Tags: General Cardiology chronic rheumatic carditis indolent carditis mouldering carditis in rheumatic fever primary rheumatic carditis smouldering carditis Source Type: blogs