All posts by mannd

About mannd

I am a retired cardiac electrophysiologist who has worked both in private practice in Louisville, Kentucky and as a Professor of Medicine at the University of Colorado in Denver. I am interested not only in medicine, but also in computer programming, music, science fiction, fantasy, 30s pulp literature, and a whole lot more.

The Smartphone is an Essential Medical Instrument

The storage capacity of the human mind is amazing. One estimate of the size of the brain’s “RAM” is as high as  2.5 petabytes (a million gigabytes). The number is based on the total number of neurons in the brain and the total number of possible connections per neuron. I suspect it is an overestimate, given the vagaries and innate inefficiency of biological systems. Nevertheless the true figure is undoubtedly impressive. But not infinite.

There are well-documented feats of human memory and calculating prowess. Ancient Greeks could memorize and recite the epic poems of Homer. Indeed this was how the Iliad and the Odyssey were passed down for generations before the Greeks acquired writing. Savants can quickly perform cube roots of long integers or have memorized pi to over 20,000 decimal places. Musical prodigies like Mozart or geniuses like Einstein impress us with the capabilities of their brains. Yet for the average person who has trouble memorizing a shopping list, these stellar examples of mental fortitude provide little solace. The old myth that we are only using 10% of our brain capacity has been debunked . So unless you’re willing to believe the combination kelp-Ginkgo-biloba-blueberry supplement you heard about on the radio is really going to work, you are pretty well stuck with the brain and memory capacity you have right now. At least until things get worse as you get older.

While the brain’s capacity may increase due to evolutionary forces over the next few thousands years (or not, see the movie Idiocracy), the amount of information that it is required to hold is not constrained by such a slow process. According to one source , there are now over 50 million scientific publications, with about 2.5 million new articles published each year. There is a 4-5% increase in the number of publishing scientists per year. No one can absorb all this. The days of the “Renaissance Man” who could quote Bulwer-Lytton while relating the latest experimental data from Maxwell and then play a Bach fugue while giving a dissertation on Baroque counterpoint are long gone. So what’s a 21st century scientist (or physician) to do?

One thing we should not do is to attempt to memorize everything. It is important to off-load as much information from our brains as possible. Our brains need to be more like an index than a database. We need to know what information we are looking for and where to find it. Information that we use all the time is automatically memorized and we don’t have to look it up. But a lot of information that we don’t use frequently is better off external to our brains. As long as it is easily retrievable, it will be available. Better to look something up that we are unsure about, such as a drug dose, than hazard a guess and be wrong.

Fortunately we live in an era when we can implement this strategy very easily. We carry smartphones that are constantly connected to the Internet. All the data we need is at our fingertips and incredibly easy to look up. Similarly we can store data on these devices for later retrieval. This constant availability of information makes life easier for doctors and undoubtedly makes for better patient care because of decreased mistakes due to memory errors.

There are those who would argue that relying on these devices is a crutch, and any good doctor wouldn’t need them. What would happen if a doctor’s plane crash landed on some remote island, where there were no charging ports? How could that doctor function?

I think it’s time to put aside such nay-saying and embrace our digital assistants. These devices are our tools, as essential to modern medicine as ultrasounds, blood tests, and MRI scanners. Take away any of these tools, and doctors will be limited in what they can do. We should be proud of the impressive technology that allows us to carry powerful computers in our pockets, and we shouldn’t be ashamed to use them.

Notwithstanding the above, medical board certification is still old-school, rooted in that outmoded 19th century Renaissance Man philosophy that doctors should hold everything in their heads. Certainly some medical board questions are practical and test things all doctors should know. But thrown into the mix are a lot of obscure questions about obscure facts that may be difficult to regurgitate during a testing session, but would be easy to look up online in a few seconds in a real-world setting. So, do these tests actually test one’s abilities as a real-world practicing doctor armed with modern information technology or are they just a particularly arcane version of Trivial Pursuit?

I’ll leave the answer to this question as an exercise for the reader.

Trying Out Vim Using Emacs Evil Mode

After using the text editor Emacs for over 20 years, and after listening to debates on the merits of Emacs vs Vi/Vim  (henceforth in this post referred to as simply “Vim”) for at least as many years, I decided that I wanted to give Vim a try. To be fair, I had used Vim before, but, also to be fair, I had never tried to master it or given it a real chance. I knew enough Vim keybindings (the “hjkl” keys and “ZZ” to save and quit) to get by when editing a file via a remote terminal. But I had never taken the time to really learn Vim to the point that it would be an efficient text editor for me. And I certainly didn’t want to abandon Emacs, mostly because of Org mode  the best organizational tool there is, and Magit , the best Git interface there is. Nevertheless the constant key-chording of Emacs, which uses control key combinations for most editing tasks, continued to be awkward despite many years of practice. The question kept coming up: was using Vim a better way to edit text?

My initial resistance to Vim was not just because I liked Emacs. Vim is a modal text editor, so-called because entering text and editing text require changing modes. Moreover, the “Normal” mode in Vim is the text editing mode. To actually enter text, you use a keyboard command to switch to “Insert” mode. To return to Normal mode, you use the Escape key. So you use the Escape key a lot. On my Mac keyboard, the Escape key is located at the top corner of the keyboard, a tiny sliver of a key that is several inches away from my left pinky. New MacBooks don’t even have a dedicated Escape key anymore.

The modal concept caused problems in my prior limited use of Vim. I would constantly forget what mode I was in and start typing in the wrong mode, causing havoc to my text. But still, lots of people used Vim and liked it a lot.

So I started reading more about it. I bought Drew Neil’s book,  Practical Vim, and skimmed through it. Something he said in chapter 2 of the book I found attractive. To paraphrase him, text is to the writer as a painting is to a painter. A painter spends time studying his subject, mixing paints, selecting brushes, and so forth. Only a fraction of time is used to actually apply paint. Likewise a writer, or programmer, spends a lot of time thinking and editing rather than just putting text down on the screen.

While I suspect the analogy appeals more to my vanity, comparing writing to art, than is true (because I think both writers and painters probably spend most of their time applying words or paint to canvas), I think the theory is at least worth trying to put into practice. Editing is what turns mediocre writing into good writing, and what bit of writing wouldn’t benefit from more editing?

Beyond the theoretical, Drew’s book is chock full of examples in which Vim shines as a way to edit text rapidly with a minimum of keystrokes. I had used Emacs’ macros on occasion to do repetitive tasks, but it looked like Vim had the potential to really rev up my editing speed.

Enter Evil mode  for Emacs. Evil mode is an Emacs major mode that transforms Emacs into a Vim clone. You can edit text using Vim keybindings, and still have all other Emacs functionality available. In other words, the best of both worlds. I have been using it for about a week now, and I think it’s great.

It works fine out of the box, but some tweaking always helps. First off, I remapped my Caps Lock key to be the Escape key in my System Preferences. It’s right next door to the “A” key and makes changing modes (referred to as “States” in the Evil manual, since the word “mode” has its own meaning in Emacs) a snap.

Then I added some fixes so that cursor movement with the “hjkl” keys would respect visual lines instead of physical lines, since a lot of my writing uses Emacs word wrap mode. Here is what I inserted into my .emacs file:

;; play with evil mode
(use-package evil
:ensure t
:config
;; make it default, gulp!
(evil-mode 1)
;; Make movement keys work respect visual lines
(define-key evil-normal-state-map (kbd "<remap> <evil-next-line>") 'evil-next-visual-line)
(define-key evil-normal-state-map (kbd "<remap> <evil-previous-line>") 'evil-previous-visual-line)
(define-key evil-motion-state-map (kbd "<remap> <evil-next-line>") 'evil-next-visual-line)
(define-key evil-motion-state-map (kbd "<remap> <evil-previous-line>") 'evil-previous-visual-line)
;; Make horizontal movement cross lines
(setq-default evil-cross-lines t))

Finally, there are some unexpected niceties of Evil mode that makes it perfect for someone wanting to transition to Vim. First of all, it is pretty easy to tell what mode/state you are in because the cursor changes shape and the mode line has a little indicator like so: <N> that indicates the state.

Second, you can easily go back to Emacs keybindings at any time by pressing C-z. The state indicator indicates for Emacs mode. Press C-z again to return to Vim keybindings.

Third, while in Vim Insert mode, a lot of Emacs keybindings work! You can move around with C-f, C-b, M-f, M-b, etc.! So no need to constantly change modes if you don’t want to. I expect I will use this less as I get more used to “The Vim Way,” but it sure is helpful for learning.

Finally, many other Emacs keybindings work too. C-l centers the cursor in the page. I can use C-x C-s to save the file, as opposed to :w in Vim. Of course M-x commands all still work too. And C-g, the Emacs get of jail key, works as well.

So if you want to have the best of both worlds, and bring the editor wars to a peaceful settlement, Evil mode is the answer.

Here is a good talk on YouTube that also contributed to my decision to try Evil mode.

EHR Copy and Paste Considered Harmful

DRY principle – Don’t Repeat Yourself

How bad are Electronic Health Record (EHR) programs? Let me count the ways. Rather, let me not, as I and many other folks have already done so. Even non-tech savvy doctors (of which there are fewer and fewer) realize something is wrong when they compare their experience using an EHR with virtually every other computer program they come across, such as the apps on their phones. As the click counts required to do simple tasks mount up and repetitive stress injury of the hand sets in, even the most sanguine of medical personnel will eventually realize that something is not quite right. And as EHR companies forbid sharing of screenshots of their user interfaces, you’ll just have to take my word for it these UIs are, let us say, quaint. Hey EHRs, the 90s called and want their user interfaces back.

In this post I’ll point out just one of the many problems with EHRs: EHRs violate the DRY principle.  The acronym DRY is familiar to computer programmers, but not to most medical people. DRY stands for “Don’t Repeat Yourself.” In computer programming it means don’t write the same code in two or more different places. Code duplication is what some programmers refer to as a code “smell.” There is no reason to duplicate code in a computer program. A single block of code can be called from multiple procedures.  There is no reason for each procedure to have its own copy of this code block.   Code duplication leads to code bloat and code rot, where two procedures supposed to do the same thing get out of sync with each other because of changes in one copy of the duplicated code and not in the other.

Applying the DRY principle to a database requires that every item of data has a single location in the database. Multiple copies of the same data increase the size of the database and invariably cause confusion. Which copy is the original? Which copy is the true copy when copies disagree?

An EHR program is at root a gigantic database. Ideally Patient Smith’s X-ray report from 1/1/2017 is filed away properly in the database and easily retrieved. Same with his blood work, MRI results, etc., etc.

Enter Copy and Paste.

Copy and Paste is evil. Unlike Cut and Paste, Copy and Paste’s close cousin that moves data around without duplication, Copy and Paste is bad, lazy, and sloppy.  Copy and Paste needlessly duplicates data. Copy and Paste violates DRY.

EHR notes are rife with Copy and Paste. X-ray reports are copied and pasted. Blood work too. Even whole notes can by copied and pasted. It is easy to copy and paste a prior progress note and then make a few changes to make it look like it wasn’t copied and pasted. Everyone does it.

Many EHR progress notes fall just side short of novel length. Whole cath reports, MRI results, other doctor’s notes, kitchen sinks, and other potpourri are thrown in for good measure. Usually with a bit of skillful detective work one can determine the minor fraction of the note that is original. Usually it is last line. Something like: “Continue current plans.” These could be the only words actually typed on the keyboard. Everything else is just copied and pasted.

So you get all the downsides of DRY: bloated notes, duplication of data, possible inaccuracies and synchronization problems. The X-ray report may be revised by the radiologist after it is copied and pasted into the note. Nevertheless the unrevised report persists forever sitting as a big blob of text in the middle of a now inaccurate note. Of course there is some consolation that no one will ever read the whole note anyway, with the possible exception of a malpractice lawyer.

Why is Copy and Paste so prevalent in EHR notes? It isn’t just laziness. Like the pulp fiction writers of the 30s, doctors are effectively paid by the word, so that the longer the note the better. Longer notes reflect higher levels of care, more intricate thought processes, more — wait a minute! No they don’t. Longer notes reflect mastery of Copy and Paste, something that’s not too difficult to master. Even non-tech docs seem to have no trouble with it. Long notes are a way to justify billing for a higher level of care, i.e. more dollars. Since the Powers That Be Who Control All of Medicine (i.e. not doctors) decided that billing would not be based on what doctors do, but on what doctors write in the chart, it doesn’t take a crystal ball to predict that note bloat, electronically enhanced, would be the inevitable outcome of such a stupid policy.

What are the alternatives to Copy and Paste? The best is the use of hyperlinks, something that you might be familiar with if you ever use something called the World Wide Web. If I want to put a YouTube video on my blog, I don’t copy the video and paste it here, I just provide a link. Similarly, if you want to refer to an X-ray report in a progress note it should be possible to just provide a link to it. Something short and sweet.

Of course the example note I referred to above would be reduced in length to just a number of links and the sentence “Continue current plans.” This will hardly satisfy the coders and billing agents and whoever else is snooping around the EHR trying to find ways not to pay anyone (i.e. insurance companies). Nevertheless these shorter notes would be much easier to digest and might even encourage a doctor to elaborate a bit more in his or her own words on the history, physical, diagnosis, and plans. Unlinking billing and documentation would go a long way towards making EHR notes more manageable and informative. No one seems to keen on doing this however. Documentation as a proxy for care  is just one of many broken pillars of the Byzantine edifice known as the American Health Care System.

[note: the title refers to a famous (in computer circles) 1968 letter by Edsger Dijkstra entitled “Goto Statement Considered Harmful.” It has inspired tons of computer articles with similar titles, including this one.]

The Art of the Compromise

The Book

I haven’t read “The Art of the Deal,” but I suspect that part of it has to do with the give and take that is necessary in order to achieve a deal. My understanding of the word “deal” implies that I get some things I want, and you get some things you want. I don’t get everything I want, and you don’t get everything you want. But presumably each gets enough to be satisified. In other words, a compromise.

Compromise is a lost art nowadays in our political discourse. There is no middle ground, only absolutes. There are no deals. Either I get everything and you get nothing, or vice-versa. Take the issue of gun control for example (brought to mind by the shooting yesterday at the Republican congressional baseball practice). Certainly there are some on the left who would want to ban all weapons more powerful than a cap gun and there are some on the right who see nothing wrong with tactical nuclear weapons in the hands of the mentally ill. But I suspect most people are somewhere in the middle. They don’t want to ban guns outright, but wouldn’t mind at least a smidge of regulation in their sales. However there is never any compromise on this issue in Congress. The NRA raises the “slippery slope” argument, namely that any regulation at all only leads to more and more regulation, until guns are outlawed completely, and only outlaws have guns. The slippery slope argument can be applied to any position one takes and immediately shuts down any attempts to compromise.

Why is compromise a dirty word today?  The word “compromise” as a verb as oppose the the noun has always had negative conotations. A person who has been compromised is open to criticism or even blackmail. Compromise, like the word “sanction”, is a bit of a contronym, that is, a word with meanings that are at odds with each other. How much of the conflation of the good and bad meanings of compromise is the result of politics and how much the result of imprecision of language is difficult to gauge. Whatever the reason, compromise is a bad word in Washington, and possibly in the minds of many people. The constant demonization of the other side, fueled by talk radio and biased news sources, makes any attempt at compromise a “deal with the devil.” Moreover, many people approach debatable topics from an immutable position and with religious fervor, which is understandable because their position is based on religion. Religion and compromise are not words that belong in the same sentence. Religious positions, such as views on abortion and contraception, are simply not open to debate. Thus attempts to limit abortion indirectly by increasing availability of contraceptives and sex education, though logical, fall on deaf ears to the religiously indoctrinated. The increased influence of the religious right in the Republican party has certainly contributed to squelching the spirit of compromise that once existed in Congress.

The left is guilty as well. They demonize any who criticize the tenants of Islam (tenants that are anti-gay, anti-woman’s rights, that include death for apostasy and blasphemy, and so on) as “Islamophobes” and racists. While there is, no doubt, some vicious anti-Muslim sentiment on the right, the attitude that any criticism whatsoever of a religion is forbidden only serves to shut down debate and increasingly polarizes people. It is impossible to advance the debate under these circumstances, and thus we are all paralyzed into inaction while terror attack after terror attack occurs. The mandatory “thoughts and prayers” don’t seem to be cutting it in preventing these attacks.  We need a rational debate on the ideologies that lead to terror attacks, but this isn’t happening.

Returning to the baseball shooting, it was depressing to read the social media posts on Twitter afterwards. References to Kathy Griffin’s decapitated Trump stunt and the Julius Caesar play with Trump as Caesar as instigating factors were common. I do think it is likely that such anti-Trump, anti-Republican imagery and similar violent talk on the left played into the attacker’s rationale for taking matters into his own hand. After all, the attacker was an angry man who supported Bernie Sanders. On other hand there has been no dearth of similar violent talk from the right, and if anything, attacks inspired by the right, such as the knife attack in Oregon on three men defending two Muslim teens, seem to be more common. The point that both sides must now realize is that extreme, violent rhetoric can inspire a nut from either end of the political spectrum, with tragic results.

Let’s face it. In a more and more polarized country, no one is going to get his way, at least for long. Sure one party can come into power and effect its agenda. But then the pendulum will swing, as the other other side gets angry and comes out to vote. Then the other side will come into power and undo everything. This is an incredible waste of resources and a failure of leadership. The only sane course is that of compromise, taking a middle course, and realizing that neither side has all the answers. Of course that only works if the people themselves can move towards the center, away from their protective bubbles on the right and left. I’m not sure this can happen, due to the constant propaganda from non-objective media outlets and the coarsening of discourse via social media.

In an alternative universe there may be a Donald J. Trump who authored “The Art of the Deal” and came to Washington to actually make deals across party lines. Someone who forced Republicans and Democrats to find common ground and to work out legislation that would appeal to both sides. Each side would get some things they liked and some things they didn’t like. Each side could think that perhaps next election the balance of power would shift and they could get a few more things they liked into law. No side would ever be completely happy, but neither they would be completely unhappy either. But each would be respectful of the other side, would use courteous language, and would not accuse each other of being unpatriotic or un-American.

What am I thinking? I sound like a typical libtard snowflake.

CenturyLink Sucks, Part 57

Blogging at Panera’s

I don’t usually work at a coffee shop, but here I am, at Panera’s dealing with their bad (also CenturyLink) internet service, because my internet service is down at home. Yes we are going into DAY NUMBER 4 of the great CenturyLink Internet Service Outage of Parker, Colorado. This started inauspiciously, perhaps coincidentally, during a mild thunderstorm on Friday before the Memorial Day Weekend. Internet could not be reached, internet light on router out, though DSL was on. After the obligatory multiple router reboots, no change. Call to CenturyLink. Outage in our area, should be fixed in 12 to 24 hours. About 30 people affected. This being the start of Memorial Day Weekend, I was not optimistic.

As the weekend has dragged on, my worst fears have been confirmed. That is why I am sitting here, nursing a cup of coffee at Panera’s, writing this. After multiple calls to CenturyLink, the story has not changed, other than the expected duration of outage, from 12-24 hours, to 24-48 hours, and, most recent estimate, from 48-72 hours. When I accused the customer service person that their technicians were goofing off over the holiday, I was answered with an agrieved “Our technicians work 24/7” and “the technician is there now trying to fix it.” Sure.

A little background may be in order. I live within 20 miles of Denver, supposedly a telecommunications hub. I can walk to the top of the hill in my neighborhood and see the buildings of downtown Denver. Despite this, the only option for internet service in my neighborhood is CenturyLink, via the phone lines. And, up until a year or so ago, the only speed we could get was 1.5 Mbps. After writing to the FCC and complaining multiple times, our service has been upgraded to a whopping 3 Mbps. This is in the era of Gigabit internet service. As you may know, the federal government granted billions of dollars of incentives to the ISPs in order to improve the internet backbone with a goal of providing broadband service to “rural” America.  Broadband internet is now defined as a minimum of 25 Mbps.  3 Mbps doesn’t cut it. Sadly, the US is way behind the rest of the world in this regard. It is clear that the ISPs took the federal money and used it to pad their executive salaries. No wonder the most hated company in the US is an ISP, though I bet with the next go-around the airlines will give them a run for their money.

Given the context of baseline sucky internet service and no alternative ISP in our neighborhood, I have very little patience with a 3 day and counting outage. CenturyLink, Shame! (Ding).

EP Studios App Updates

Here’s what’s going on with the EP Studios apps:

EP Calipers

Most of the new stuff is in EP Calipers. Probably the most useful new feature is available on the Mac and Windows versions: a transparent floating caliper window. Use it to overlay calipers over any open window on the desktop. Check figures of journal articles. Use it during slide shows. Use it on webpages or on your EHR. No longer are you limited to just image files you have downloaded onto your computer. Unfortunately due to the nature of mobile device platforms, there is no way to implement similar functionality on a phone or tablet (that I know of).

Using the floating transparent window to check measurements in a published academic paper. It appears the pacing CL is actually 240, not 250 msec.

Several users suggested the capability to color each caliper differently. This is now implemented. Others wanted a way to fine tune caliper position besides just dragging with your finger or trackpad/mouse. This is also implemented, via keyboard arrow keys or buttons that “micromove” or “tweak” caliper positioning.

Finally, in case you missed it, angle calipers are available. They can be useful in Brugada syndrome, in which the so-called beta angle may have predictive value. In addition, the work of Dr. Adrian Baranchuk from Queen’s University in Kingston, Ontario indicates that there is prognostic value to measuring the base of the triangle formed by the angle 5 mm inferior to the beta angle triangle’s apex. EP Calipers now supports this. Provided amplitude has been calibrated in mm, the triangle base is automatically drawn showing this measurement. This technique has been dubbed by Dr. Baranchuk as a “Brugadometer.”  More information on these Brugada Syndrome ECG measurements can be found here.

Using the Brugadometer to measure the beta angle and the triangle base 5 mm below the apex.

EP Coding

EP Coding also received a major update earlier this year. After a few years of relative stasis, the AMA decided to shake up the coding of EP procedures once again by unbundling the sedation component from the procedure codes. The result is a relatively complex coding system for sedation, depending on factors of patient age, who does the sedation, and the sedation duration. EP Coding now allows you to calculate the sedation codes automatically using a sedation coding calculator.

Sedation coding calculator

 

EP Mobile

EP Mobile has been relatively static. It is already chock full of calculators, drug information, risk scores, pictures of ECGs, etc. It is our best selling app, so we must be doing something right. I am always happy to add features; just email me at mannd@epstudiossoftware.com with your requests.

Final thoughts

This is a bit off-topic, but probably not worth a separate blog post either. My old Motorola Droid Maxx Android phone is getting a bit long in the tooth, and way past upgrade time. I was an early adapter of Android, and though I use other Apple products (a Macbook Pro and an iPad Mini 2), I have never owned an iPhone. This may change. In many ways I think Android is a more innovative operating system than Apple’s iOS. Nevertheless we live in an insecure world, and I can’t get timely updates to Android via my phone and Verizon. My phone is stuck on Android 4.4.4 (I even forget what candy that is), whereas the most recent Android version is Android 7 Nougat.  Apple doesn’t have this problem.  Having an outdated, obsolete OS in the current world of bad guy hackers is untenable. I think the problem is (as usual) with the providers, who could care less about updating an older phone when they could be pushing the latest phones on customers. The 2 year cycle of upgrading phones is ridiculously wasteful. But that’s what is driving the industry, with the carriers all too eager to get you in and sign another rip-off contract. So, it might be goodbye to Android soon.

Do No Harm

Cardiac neuroses are often iatrogenic in origin. A well-meaning but careless comment by a physician can change a person’s sense of well-being in an instant. The effect can be permanent and devastating. Many clinicians who complain about overly anxious patients don’t appreciate their own role in the genesis of this problem. Our words matter. They can reverse the good we do with our medications and procedures.

If you are a heart rhythm doctor, the scenario is familiar. Your patient (we’ll assume a male for the sake of pronoun economy) has premature ventricular complexes (PVCs). Not a lot of them, but he feels every one. They are intolerable. There is no underlying structural heart disease. These are benign PVCs. The treatment options are not good. Drugs have side-effects that range from annoying to life-threatening pro-arrhythmia. Catheter ablation offers the possibility of “cure,” but is not a sure thing and has its own set of risks. The PVCs aren’t very frequent and perhaps will disappear with sedation during the procedure. Even if they don’t and they can be mapped, how far should they be pursued? What if they are epicardial in origin? Should we really consider placing a catheter directly into the pericardial sac and ablate near a coronary artery to treat benign PVCs?

Reassurance is the best treatment. You tell the patient that these PVCs are benign. You say that many people have PVCs, even more frequent than the patient has, and that most people aren’t even aware they have them. You tell your patient that there is no underlying heart disease, that these PVCs will not shorten his life, and that the treatments are likely to have side-effects or unwarranted risks. But it doesn’t matter to the patient. His palpitations are incapacitating. He can’t do his job when they come on. He has read a lot about PVCs and has seen several doctors before coming to you, the arrhythmia expert. He wants something done.

You stall. You ask the patient to try a different beta-blocker than the ones he has tried already that haven’t worked. You say you need to get some of his medical records from his other doctors. You want to review his Holter monitors. You need to make sure there is only one PVC focus if ablation is being considered as a treatment option. Mostly you are uncomfortable recommending an aggressive approach and want to put off making a decision.

Six weeks later the patient is back in your office. The new beta-blocker didn’t work. Surprise, surprise. He has read the information you gave him about ablation and wants to try it. He is desperate. He is willing to take the risk.

You look at the patient. He is in his mid 30s. He is an executive, type-A personality. You have seen his type before. But you are curious about something.

“When was the first time you found out about your PVCs?” you ask.

The story comes out. It was about 5 years ago. One of his friends at work had gone and gotten an “executive physical” that was being offered by one of the cardiology groups in town. It was a nice deal. There was a physical exam, they checked your cholesterol, and you ran on a treadmill for a few minutes. Afterwards there was orange juice and bagels. So he signed up for it.

During the treadmill the technician seemed a little nervous. Before he got too far into it, the technician stopped the test. You have an irregular heart beat, he was informed.

This was news to your patient, who had always assumed his heart was just fine. But the technician told him that he should refrain from any strenuous activity and needed to see one of their specialists about the irregular heart beat. In the meantime, a 24 hour Holter monitor was put on and he was sent home.

The monitor was turned in the next day, and he waited nervously for the result. That night, he was awakened from sleep by a phone call. The doctor on-call had gotten a call from the monitoring service. The Holter monitor had shown a critical result. During sleep, your patient had had 3 PVCs in a row. The monitoring service deemed this ventricular tachycardia and dutifully informed the on-call doctor of this “critical” result. The doctor was obliged to call the patient, whom he didn’t know. Not knowing if this was a patient with end-stage cardiomyopathy and ejection fraction of 10% or someone with a perfectly normal heart, the doctor on-call felt it was the better part of valor to assume the worst.

“You are having runs of ventricular tachycardia on your monitor,” he told your patient. “This is a life-threatening emergency. Your heart could stop and you could have cardiac arrest. You need to call 911 and get to the hospital ASAP.”

After hanging up, the on-call doctor rolled over in his bed and went back to bed, knowing he done his job, making sure a patient with a potentially life-threatening problem would take it seriously and get to the emergency room. But for your patient, life had changed forever. Even after a full workup that showed no structural heart disease, he couldn’t get it out of his head that his heart rhythm was unsteady. His heart was unreliable. He could die at any time. He had never paid attention to his heart beat before, but now he could feel the irregularity, the strong beats that told him he was having more PVCs. They were driving him crazy. Crazy to the point he would consider having a doctor insert a catheter into his heart and burn away some of his heart muscle to get rid of them.

This story is not an exaggeration. I have seen something like this happen many times, with patients who have generally benign conditions like PVCs or supraventricular tachycardia, or somewhat more serious problems like atrial fibrillation. Patients with heart conditions are worried that what they have will kill them. They know about heart attacks and cardiac arrest, but they are not as well-informed about lesser cardiac conditions that are not life-threatening. Apparently some doctors are equally poorly informed, or just think they are doing their duty by scaring the hell out of patients in order to get them to do their bidding, whether it is to go to the emergency room or take some medicine or do some procedure. The problem is magnified by the disappearance of long-term patient-physician relationships. Patients are at the mercy of the on-call schedule, and rarely get good advice when they are called with the result of some lab test in the middle of the night by a doctor who doesn’t know them.

What to do? Be careful what you say to patients, especially those you don’t know well. Think about how your would react if you were told the same thing. Don’t use your authority as a physician to bully a patient to do what you thing is “the right thing.”

Choose your words carefully.

Thoughts on Mark Josephson

I’m sure there will be plenty of tributes to Dr. Josephson in the next few days from his colleagues who knew him well and those who didn’t know him personally but learned so much from his books and articles. I fall somewhere in the middle. I wasn’t one of his students at Penn who learned from him directly. I did meet him several times. I did work for years at the University of Colorado with Alden Harken, the surgeon with whom Dr. Josephson developed the “Pennsylvania Peel” — endocardial resection, the first surgical treatment for ventricular tachycardia. Oh, and I did live in the same apartment Mark used to live in during my cardiology fellowship in Philadelphia in the 1970s. More on that later.

Mark Josephson may represent somewhat of a dying breed in academia. In the great academic triad of clinical care, research, and teaching, the last element, teaching, which makes the least money for institutions, is emphasized less and less. Dr. Josephson excelled as a teacher. A lucky few were able to experience his teaching skills first-hand. A far greater number learned from his writing, in particular, from his opus magnum Clinical Cardiac Electrophysiology. Originally a relatively small but densely written book in a red binding, subsequent editions were more massive, filled with page after page of painstakingly labeled intracardiac recordings and clear-cut explanations of obscure electrophysiologic phenomena. I cut my teeth on this book, reading the original through when I was an EP fellow in Houston, and then reading the 2nd edition straight through when preparing for my first EP boards.

The book was important because it set a standard for analysis of intracardiac recordings that inspired subsequent researchers and students of the field. Back in the 70s and 80s, the mechanisms for most major arrhythmias (with the exception perhaps of atrial fibrillation) were worked out solely by analysis of intracardiac recordings and a few pacing techniques. Mark Josephson was instrumental in this process. Back then, working on arrhythmia mechanisms was the important thing. Therapies for ventricular tachycardia were drugs like quinidine or procainamide, and EP-guided drug therapy was, in retrospective, a pseudoscience. Yet working out the mechanisms of WPW syndrome, supraventricular tachycardia, and ventricular tachycardia eventually led to effective ablation and device therapy in the 1990s and beyond.

Dr. Josephson, who along with a cadre of first-generation EP superstars trained by Dr. Anthony Damato (the “godfather” of EP) at the Staten Island Public Health Hospital, set a standard for teaching in the field of electrophysiology that was often emulated, but never matched. Moreover he wrote a number of incisive editorials over the years in an attempt to keep the field rooted in its scientific basis, rather than be swept away by the insidious influence of industry or the idea that it wasn’t necessary to understand the pathophysiology of an arrhythmia if you were just going to burn it away.

As mentioned above, I was lucky enough to meet him on a few occasions and to round with him. By coincidence we discovered that the apartment on Henry Avenue in Philadelphia where I lived when I was a fellow was the exact same apartment he had lived in several years before. He remembered well the old guy who lived one floor above us, a fellow by the name of Sullivan, nicknamed “Sully.” I was just a plain cardiology fellow when I lived there, only subsequently deciding to go into EP and move to Houston for training. I always wondered if I picked up some kind of EP karma from living there. Who knows?

The advances in diagnosis and treatment of arrhythmias that have occurred since the 1970s are extraordinary, and uncounted numbers of people have benefited from these advances.  It seems a shame that most lay people, saddened at the loss of actors, musicians, sports heroes, and other celebrities, have no knowledge whatsoever of the passing of people who have actually had much more impact on their lives, like Dr. Josephson.  So it’s up to us, his colleagues, to remember Mark Josephson and give thanks for his incredible contributions to medicine and the world.

A Tale of Two Histories

Compare the following two versions of the same medical history:

Version 1

CC: chest pain
Mr. Smith is a 57 y/o white man who comes into the office today for the first time with a complaint of chest pain. He states he has been in generally good health in the past, though he has smoked about 40 pack-years and admits to not exercising much, other than occasional games of golf. He has trouble keeping his weight down. He has been a middle-level manager for many years, but about a month ago changed jobs and took a pay cut. He says this has been quite stressful. He has changed jobs before, but states “I’m getting too old to keep doing this.” About 2 weeks ago he started noting some mild heaviness in his chest, lasting up to 5 or 10 minutes. He attributed this at first to eating heavy meals at dinner, but now thinks it occurred after climbing stairs following meals. He took some Tums, but was not sure if the pain eased from this or just from resting. These episodes of discomfort were localized to his anterior chest, without radiation or other associated symptoms at first. Over the last 2 weeks he thought that they were getting a little more frequent, occurring up to twice a day. Two days before this visit, he had an episode of more intense pain that woke him up from sleep at night. This episode lasted about 15 minutes and was associated with diaphoresis. “My pillow was soaking wet.” He woke up his wife who wanted to call 911, but he refused, though he agreed to make this appointment somewhat reluctantly. He has had no further episodes of chest pain, and feels that he is here just to satisfy his wife at this point. He generally doesn’t like to come to the doctor. He doesn’t know his recent lipid levels, though he says a doctor once told him to watch his cholesterol. His BP has been high occasionally in the past, but he attributes it to white coat syndrome: His BP is always normal when he uses an automatic cuff at the store, he claims. He is on no BP or lipid-lowering meds.  He takes a baby aspirin “most days.”  His parents are deceased: his mother had cancer, but his father died suddenly when his 40s, probably from a heart attack, he thinks.

Version 2
  • Mr. Smith
  • CC: chest pain
  • Age: 57 y/o Sex: M Race: Caucasian
  • Onset: 1 month
  • Frequency: > daily [X] weekly [ ] monthly [ ]
  • Location: Anterior chest [X] Left precordium [ ] Left arm [ ] Other [ ]
  • Radiation: Jaw [ ] Neck [ ] Back [ ] Left arm [ ] Right arm [ ] Other [ ]
  • Pattern: Stable [ ] Unstable [X] Crescendo [X] Rest [X] With exertion [X]
  • Duration: < 15 min [X] 15 min or more [X]
  • Risk factors: Tobacco [X] Family history CAD [X] HTN [?] DM [ ] Hyperlipidemia [?]
  • Relief: Rest [?] Medications [?] Other [ ]
  • Associated symptoms:  N, V [ ] Diaphoresis [X] Dizziness [ ] Other [ ]
Which is better?

Version 1 is an old-fashioned narrative medical history, the only kind of medical history that existed before the onset of Electronic Health Record (EHR) systems.  This particular one is perhaps chattier than average.  It is certainly not great literature or particularly riveting, but it gets the job done.  Version 2 is the kind of history that is available on EHR systems, though usually entry of a Version 1 type history is still possible albeit discouraged.  With an EHR, entering a long narrative history requires either a fast, skilled physician typist, or a transcriptionist — either human (frowned upon due to cost) or artificial, such as Dragon Dictation software.  This latter beast requires careful training and is frustratingly error-fraught, at least in my experience.  The Version 2 example is not completely realistic.  In practice there are more check boxes, more pull-down lists and other data entry fields than can be shown here.  But you get the idea.

Version 2 seems to have a higher signal to noise ratio than Version 1.  It’s just Version 1 boiled down to its bare essentials, stripped of unnecessary verbs, conjunctions, prepositions, and other useless syntax.  It contains everything a medical coder, a medical administrator, or a computer algorithm needs to do his, her, or its job.  It has taken the medical history, the patient’s story, and put it into database form.

But Version 1 is not just Version 2 embellished with a bunch of fluff.  Certainly Version 1 is more memorable than Version 2.  There is a chance the physician who wrote Version 1 will remember Mr. Smith when he comes back to the office for a follow-up visit: Mr. Smith, that middle-aged fellow who was stressed out when he took a pay cut while starting a new job and started getting chest pain.  Another physician meeting Mr. Smith for the first time might after reading this history modify his tactics in dealing with Mr. Smith.  One gets the impression that Mr. Smith is skeptical of doctors and a bit of a denier.  Maybe it will be necessary to spend more time with him than average to explain the need for a procedure.  Maybe it would be good to tell his long-suffering wife that she did the right thing insisting that he come in to the doctor.  All this subtlety is lost in Version 2.

There are some cases where Version 2 might be preferable.  In an Emergency Department, where rapidity of diagnosis and treatment is the top priority, a series of check boxes saves time and may be all that is needed to expedite a patient evaluation.  But for doctors who follow patients longitudinally, Version 1 is more useful.  A patient’s history is his story: it is dynamic, organic, personal, individual.  No two patient histories are identical or interchangeable.  Each history has a one-to-one correspondence with a unique person.  A good narrative history is an important mnemonic aid to a physician.   A computer screen full of check boxes is no substitute.

While the Version 2 history was designed for administrators, coders, billers, regulators, insurance agents, and the government, the Version 1 history was designed by doctors for doctors.  We should be wary of abandoning it, despite the technical challenge of its implementation in EHR systems.

 

Massive Heart Attacks

Google Ngram of the phrase “massive heart attack”

Carrie Fisher’s sad, premature death is an occasion to reflect upon the poor job the news media does in reporting medical news. The initial report from TMZ had the headline “Carrie Fisher Massive Heart Attack on Plane.” If one equates “heart attack” to the more precise medical term “myocardial infarction,” as is usually done, then this is certainly diagnostic overreach on the part of TMZ. From their report it appears that Fisher suffered a cardiac arrest; indeed that term is used in the body of the article. So why not use that term in their headline? Perhaps massive heart attack sounds more dramatic. The word “massive” seems to go naturally with “heart attack.” Try to think of other phrases in which massive fits so well. Massive hack? Massive debt, perhaps? Few phrases roll off the tongue as well as “massive heart attack.” But most of the time when used by the media this phrase is not at all accurate.  Rather it is a catch-all term to indicate something serious related to the heart has occurred.

Of course we don’t know exactly what happened to Carrie Fisher, nor is it any of our business, but none of the information available indicates that she had a large myocardial infarction as opposed to a primary arrhythmic event like ventricular fibrillation or ventricular tachycardia. As a cardiologist having seen this sort of event a depressingly large number of times it is possible to speculate on what happened.  She likely suffered a cardiac arrest related to an abnormal heart rhythm starting suddenly in the heart’s ventricles.  Lay persons and the media often refer to this as the heart “stopping.”  While the pumping of the heart stops or is reduced, in actuality the heart is beating very fast or in a disorganized fashion to the point where it can’t effectively pump blood.   Without rapid correction using an electrical defibrillator this leads to sudden death.

In Carrie Fisher’s case CPR was administered while the plane was still in flight. It is unclear how much time elapsed between the onset of the cardiac arrest and administration of CPR.  It is difficult to tell from the reports if an AED was used on the plane or if defibrillation was attempted only after the plane landed.   We know she never regained consciousness and most likely suffered brain death due to prolonged interrupted circulation.

Carrie Fisher was a cigarette smoker and used cocaine, at least during her Star Wars days.  Could heart disease caused by smoking and drug use have contributed to her sudden death? Could more recent use of drugs like cocaine have been a factor? We don’t know, but if the family deems it fitting that the circumstances of her death be made public, it might help educate the public and the news media on some of the nuances of heart disease and the difference between a “massive heart attack” and a cardiac arrest.

Finally it is interesting to examine some of this lay cardiac terminology using Google Ngrams. The Google Ngram site is a search engine that can be used to look up the frequency of words or phrases in thousands of books published over many years. It can help establish when certain phrases like “heart attack” or “cardiac arrest” were first used and when they became popular. The Ngram at the top of this post of the phrase “massive heart attack” shows the rise in popularity of this phrase over the last 50 years. The Ngram below compares the terms “heart attack”, “myocardial infarction”, “sudden death”, and “cardiac arrest.” It is interesting that “sudden death” is a term that has been used without much change in frequency since the year 1800. “Myocardial infarction” and “cardiac arrest” both entered the literature around 1930-1940. “Heart attack” dates back to around 1920, but has become more and more popular, while the medical term, “myocardial infarction” seems to be less used recently. Curiously although the phrase “heart attack” has been around since the 1920s, it is only since 1960 that the phrase “massive heart attack” has become popular.  One wonders why.  These kinds of results are open to all kinds of interpretation: I’ll leave that to the reader as an exercise. But I encourage you to try Ngrams out yourself, on any subject that interests you. The results are often fascinating.

Google Ngram of other heart attack related phrases