There was important news recently on statin drugs. As one of the world’s most effective and commonly used medications, statins provide great writing topics. Lots of people have high cholesterol–including cyclists. Lots of people are interested in avoiding our mostly deadly disease.I’d like to tell you about a recently-published landmark study in the Lancet that should quell safety concerns over statin drugs.The punch line after I tell you the study’s ...
John Mandrola, MD
Aggressive care at the end of life continues to grow
There are important medical studies, and then there are landmark studies–the kind of science that disrupts the entire medical community. The most recent game-changer was published recently in the Lancet.Well known surgeon and author, Dr. Atul Gawande and colleagues published this important look-back study on the intensity and variation of surgical care of 1.8 million elderly patients in the US. They put numbers to the well-known and ever-expanding problem of ...
How dabigatran is an atrial fibrillation paradigm shift
My iPhone vibrated with an urgent message that read: "Please call … the INR on your atrial fibrillation patient scheduled for cardioversion is too low. He is on that new blood thinner, Pradaxa. What do you want to do?"I responded, sounding like an expert: "It’s ok. Pradaxa thins the blood adequately, it just doesn’t change the INR."She astutely responded, "How do know the blood is thin? What if ...
Fewer choices for patients with health care consolidation
As a specialist, one of the saddest truisms about practicing medicine in the private world has always been how little one’s clinical skills determines referrals. Unfortunately, as our present healthcare climate pushes "providers" to consolidate along the lines of major hospital networks this injustice will only worsen.A decade-or-so ago when I started private practice it was obvious that referrals came to me because of my association with an established ...
How important is a doctor’s skill in the physical exam of a patient?
How important is a doctor's skill in the physical examination of a patient?To the lay person, a doctor's examination might seem really important. "Of course it is, Dr M ... Come on."But is it so? Or, perhaps, is the examination a charade, a show, a necessity to complete the medical record.It turns out that many in the profession think doctors may be losing the skill of palpating and listening. At ...
Solve the obesity crisis to ensure our country’s financial stability
If I was Surgeon General, I would follow the lead of our country's first Mom.This is serious folks.We, as an American society, need to solve the obesity crisis. Not just for our physical health, but for our country's financial stability.Reducing the spiraling costs of health care is wanted by all. So far, prevention of the diseases which contribute most to our health care costs, (heart disease, cancer and ...
Conflicting stories on alcohol and heart disease
Have you ever had a cold beer after a mountain bike ride?Oh my!But does such indulgence put one at risk for an arrhythmia? Does alcohol exacerbate an existing arrhythmia? How much, if any, alcohol is acceptable?These are questions I am asked frequently. And for those asking, they are very important questions.I wish the answer was straightforward. But it is not.Undoubtedly, excessive alcohol can precipitate an abnormal rhythm. Look no farther ...
Is it the doctor’s fault if an obese patient cannot lose weight?
I need help. In dealing with obesity as a medical problem, that is.I am pretty solid at arrhythmia management, but as an obesity doctor, not so much. If I was the teacher, and my obese patients were the students, I would surely be fired for poor student test performance. At least, if the core measure was the patient's BMI.If a student does poorly on an achievement test, is it the student's ...
Heart health depends on healthy behaviors
Everyone knows that the heart health of Americans is dismal. Obesity, diabetes, and high blood pressure are all on the rise.For now, technological advances in cardiac care continue to maintain, or in some cases, lower the death rate from heart disease. Squishing blockages, ablating abnormal heart tissue, and installing cardiac devices have successfully kept the abysmal lifestyle habits of so many at bay. Despite all the fury of modern technology ...
Stents to treat blocked heart arteries are not an easy fix
Cardiologist Richard Fogoros -- aka DrRich -- has put out an incredibly timely and pertinent piece of advice concerning the common practice of stenting blockages in the coronary arteries.He succinctly summarizes a small retrospective study that showed an increased risk of cardiac events after non-cardiac surgery in patients who have recently undergone either a bare metal or drug-eluting coronary stent.On a website clearly designed to educate patients, DrRich rightly ...
Heart catheterization worries that every cardiologist face
Malpractice and heart catheterization have been in the news recently.A spicy concoction for sure. An epidemiological study published in an online subsidiary of Circulation addresses the role of three major medical issues facing cardiologists today: malpractice, heart catheterization, and medical costs.It is hard to get more controversial.Heart catheterization, the invasive assessment of the coronary artery lumen, has always been a hot-potato topic. The "percent-normal" was the buzz word when I ...
Healthcare needs to be simpler and more like real economics
A middle aged patient whom I have seen in the past for benign palpitations called today because of atypical chest pain. Although I have criticized the overuse of nuclear imaging studies, and probably order the fewest of any cardiologist in the city, there are times when they are appropriate --this was one of those occasions. Symptoms did not rise to the level of an invasive angiogram, but could not be ...
Dying of old age in the era of modern medicine
He is 93 and has numerous medical problems, most of which involved aging blood vessels, as well as multiple orthopedic issues, including compression fractures and diffuse arthritis. The bony issues have resulted in a severely compromised mobility of late.Despite ongoing treatment with both aspirin and clopidogrel, he presents after numerous hours of focal neurologic symptoms. A CT scan shows no evidence of bleeding and the diagnosis is a major stroke ...
Dabigatran is superior to warfarin, but at what cost?
Dysrhythmias like atrial fibrillation (AF), more often than not, require medical therapy.The dreaded blood thinner, warfarin (Coumadin) comes to the fore often. In aggregate, I have likely spent months of my life discussing the risks and benefits of this much maligned drug. Common rat poison is made from the same ingredients as warfarin -- only rats keep eating it and die days later of bleeding, while humans have the blood ...
Peer review helps doctors improve medical care
While typing words, the advertisement for yet another hospital is overheard from the TV. "Ignore it John," I think to myself, but, it is impossible to not look up and see. The head shakes with a smirk, like my grandfather did and without words displeasure was easily conveyed.Do people really think the graphical professionalism of a TV spot is even remotely an accurate metric of quality of medical care?At work, ...
Atrial fibrillation as experienced by an electrophysiologist
Middle age introduces itself in many ways; one is atrial fibrillation. Youth, vigor and a medically-problem free life was seemingly right there in the recent past. A rhythm doctor often hears this suddenness of onset described as "Doc, yesterday, I was fine." As is always the case for a first episode of an arrhythmia, yesterday, you were fine, but today is indeed a new day.It happened during a bike ride. ...
Using CT scans to diagnose chest pain in the ER
During residency, there was always a case of misdiagnosed chest pain to discuss in conference. Incorrectly sending a patient home and missing the diagnosis of cardiac chest pain was an infrequent, but repetitively observed, phenomenon.So as to tread carefully with words, it is sufficient to say that even now, chest pain triage remains a vexing problem.Chest pain diagnosis is like appendicitis; there are always small numbers of unusual cases in ...
Does your cardiologist deserve his salary?
Conflicted am I on reading of the strategy of a group of South Miami cardiologists who have written their patients complaining of the cuts to reimbursement, primarily cuts in imaging procedures. A tension emerges from within upon reading the following quote from a "healthcare expert.""I'm not at all sympathetic with the cardiologists,'' said Robert Berenson, a doctor who was once in charge of Medicare payment policy and now is a ...
How can doctors stop drugs prescribed by other physicians that are no longer effective?
Here are two vignettes illustrating the failure of doctors to master the obvious and maybe a window onto the future struggles to control medical costs.A 90-year old is referred for care due to "end stage dementia." End-stage dementia is medical speak and as such does not really convey the appropriate imagery. It means a skeletal man, in a wheelchair or mostly in bed, with diapers, who has does not know ...
