Computers & Software Electrophysiology Medicine

The Rent is Too Damn High. Why Does Medical Software Cost So Much?

In an era when Apple gives away its Mavericks OS X operating system for free, when completely free open-source operating systems like Linux and BSD are available, when even Microsoft is considering giving away its Windows operating system for free, one has to ask the question, why is medical software, in particular EHR (Electronic Health Records) systems, so expensive?  The software industry appears to be headed towards a business model of low-cost or free software, with profits generated in other ways.  Linux distributions (“distros”) sell the Linux operating system at no or minimal cost, but generate profits by providing support services.  Apple gives away its software but profits from hardware sales.  Google gives away its software in exchange for advertising revenues.  Of course not all software is free.  Oracle still charges an arm and a leg for its database systems, but viable open-source alternatives such as Postgre, MySql exist.  Many companies have moved to these lower-cost or free alternatives due to this cost.  But even the cost of enterprise software like Oracle pales in comparison to the cost of EHR systems.

Case in point, Epic System’s EPIC EHR.  The costs of this system can only be described as astronomical.  Duke paid $700 million for their system, while UCSF managed a bargain-basement price of $120 million (see this Forbes article).  And what do you get for this price?  As a former user, I am not in the minority in my opinion that EPIC sucks.  The problem is, the other EHR systems suck worse.  EPIC is replete with useless mouse clicking to satisfy bureaucratic ideas of what doctors need to document.  It is the epitome of software written with a total disregard for the end-user.  It is difficult to go into more specifics.  Epic Systems is touchy about their software.  I know from personal experience that EPIC employs full-time staff whose sole responsibility is to scan the Internet for EPIC screenshots and have them removed.  Isn’t it remarkable to spend $700 million and not even get a screenshot to look at?

Medicine is big business, so it attracts the big business types.  I remember a simpler time.  Back in the 1980s, prior to the advent of electrophysiology recording software (like the GE Cardiolab system), I wrote some software (in Turbo Pascal — oh the nostalgia!) that used a graphics tablet to enter measurements such as A1A2 vs A2H2 intervals into an Apple II or IBM PC computer.  The software constructed tables of intervals and graphs, and could calculate such now-a-days neglected functions as the anterograde functional refractory period of an accessory pathway.  Today we don’t measure this value, we destroy it using radiofrequency ablation, but in those days of yore when we were trying to figure out why our patients placed on class I antiarrhythmic drugs for PVCs were dying suddenly, figuring out the effects of these drugs on the electrophysiology of the heart was important.  The software I wrote helped ease the pain of doing these repetitive measurements for the poor EP fellows who were wearing out their calipers otherwise, and they at least were thankful for this early example of medical software.

The American College of Cardiology or the American Heart Association (I don’t remember now which) had an abstract session back then devoted to medical computer software.  I submitted an abstract for the program and it was accepted.   I went to meeting where the ACC or AHA (darn which was it?) provided the hardware and I got to demonstrate my program to the participants milling through the exhibit area.  It was similar to showing a poster, which, if you have not done it, is one of the most fun things you can do at a medical meeting.  People who come by are nice, interested in your work, and ask good questions.  This is diametrically opposed to the nervous tension of presenting an abstract in front of a large group.  So presenting my program at the meeting was a blast.  People came by, both health care workers and from industry, and had a lot of nice things to say.   Of course a few years later the program was obsolete due to the launch of computerized EP systems as mentioned above.  But  I learned a lot from the experience, not the least of which was how to code properly linked lists.

Flash forward to modern times, about 2 years ago.  The Heart Rhythm Society (HRS) at their upcoming meeting planned to showcase medical software relating to electrophysiology.  I had written the mobile app EP Mobile for Android, and somehow HRS had gotten wind of this and invited me to show the app at their meeting.  Distant happy memories of my earlier experience with software and medical meetings came back to me, and so I eagerly replied positively to the HRS email.  Then in a follow-up email came the fine print.  HRS wanted me to pay $3000 to show my app.

A quick email exchange followed.  EP Mobile for Android was a free app.  EP Studios, my little company I set up to try to protect my personal assets from liability, though not technically a non-profit company, was in a very real sense more non-profit than any so-called non-profit company, and I could not afford to contribute $3000 to the Heart Rhythm Society for the honor of displaying my software.  I explained this to the contact at HRS, but he was not able to wrap his head around the concept of free medical software, even in the form of an mobile phone app, so the deal fell through.

Winston Churchill purportedly said:  “You can always count on Americans to do the right thing – after they’ve tried everything else.”  The use of monolithic, proprietary medical software has been foisted on us by our government, at the behest of the multi-billion dollar medical software industry.  Everyone is happy about this except the doctors and their patients.  Is it too late to fix this?  Probably.  However, maybe there is still a way out of the current disastrous situation.  There is little doubt that, if done properly, codifying medical data is good thing.  The problem is the current interfaces are terrible.  There are too few vendors and they don’t care about user feedback.  I would go back to basics.  Medical data is after all just data.  There needs to be a standard data format for medical data.  I know that HL7 exists, but it seems to be pretty messy, and only last year opened itself up as a free standard (it required a license fee before).   If all the energy devoted to making mutually incompatible EHR software systems was instead directed towards defining a good, open, free medical data standard, to be used by all computerized medical hardware, imaging, and so forth, I believe we could break down the medical software oligopoly.  Domain specific languages and APIs (application programming interfaces) could be developed and with these building blocks anyone could create medical software.  It wouldn’t have to free, but it would have to be affordable to sell, unlike the present situation, so costs would go down.   User interface quality should improve.  And Judy Faulkner, billionaire CEO of Epic Systems, might finally have some competition.

Electrophysiology Medicine

Making a MOCkery of Medicine

NotABIMI thought I’d weigh in on the American Board of Internal Medicine (ABIM) recertification process after reading an excellent article on it today. After all, I’ve been through the process several times, most recently enduring it in 2012. I was lucky enough to be “grandfathered” with regard to my Internal Medicine and Cardiology board certifications. Unfortunately no such option exists for my Cardiac Electrophysiology board certification, it having been created in 1992 after the ABIM wised up the fact that life-time certifications were not profitable. Thus there was no option but to renew the certification in 2002 and 2012, which I duly did, much to my distress. I know a few physicians who claim to enjoy taking these tests, even retaking a certification exam that they are grandfathered into. More power to them. There are a few masochists in every crowd. But the ABIM is determined to take away even their fun, by ramping up the Maintenance of Certification (MOC) requirements to the point that even the most committed connoisseur of the painful is bound to cry uncle.

There are two aspects to recertification. First there is the test that one takes for an exorbitant fee every ten years. Note that physicians are already required to take many hours of Continuing Medical Education (CME) courses per year (which is another scam, but I will pass over that for now). All the physicians I know are very interested in keeping as current as possible in their specialty and don’t require external incentives like mandatory CME or board recertification to do so. Even if one is cynical and refuses to believe that physicians do things like this for the sake of delivering the best patient care, one should at least grant that medicine is a business and it is necessary to keep up to stay competitive with other physicians. Nevertheless in addition to mandatory CME the recertification exam pops up every ten years, and one risks being ostracized if it is not taken and passed. Unfortunately I can’t say much about the test itself. Before I took it I signed a form (in blood, I think) that forbad me from revealing anything about the test. I do know something about how the questions are selected. When I was in academics I, like many of my academic colleagues, was asked to submit 4 questions on electrophysiology to the board. These questions and the hundreds of others sent in were reviewed by the ABIM question selection committee (which I believe was also primarily made up of academicians) who then picked out the actual test questions. I remember when I made up my questions I made an effort to come up with something obscure or tricky. Having taken the test before, it seemed that those were the kinds of questions the board liked. Apparently the process hasn’t changed, judging by the types of questions on the most recent test I took in 2012.

I’ve been taking tests my whole life, and, as much as I dislike them, it wasn’t the test so much as the MOC requirements that rankled me. I was told that I should start the MOC a minimum of 1 year prior to the test. Really? (footnote: now the MOC requirements have changed and start within 2 years of the last test. Ugh!) I thought to myself, what could they possibly make me do that would take a whole year? So, when the countdown to recertification reached T – 1 year, I fired up the ABIM website to find out what I had to do.

My first reaction was that I must have pulled up the wrong web page. I was re-certifying in Cardiac Electrophysiology, the subspecialty of cardiology dealing with problems with the rhythm of the heart. The options presented looked like suggestions for a high school science project. Some were so vague as to be meaningless. For example, from the current ABIM website:

Approved Quality Improvement (AQI) Pathway

The Approved Quality Improvement (AQI) pathway offers diplomates the opportunity to earn practice assessment Maintenance of Certification (MOC) points for participating in externally developed quality improvement (QI) activities that have met ABIM’s standards for measuring and improving patient care.

Whatever that means. Some of the more understandable options had to do with collecting data from patients to send to the ABIM. What they wanted this data for or what they would do with it I had no idea. The striking thing though was that NONE of the options had anything to do with the subspecialty I was certifying in, i.e. Cardiac Electrophysiology. No MOC having to do with the heart rhythm. So this was all just a rather large hoop that I had to jump through. I ended up selecting the Hypertension Module because one of my colleagues had done that option before and had managed to complete it.

What the Hypertension Module involved was collecting a huge amount of data on 50 to 100 office patients. Supposedly the patients were to enter this data on their own on the Internet. In Kentucky this just wasn’t going to happen. So as an alternative I ordered 100 questionnaire booklets from the ABIM. I handed these out to the office patients and asked them to answer the questions. There was no IRB consent form or real explanation as to why I wanted this data from them. I told them that the ABIM required me to collect this data from my patients for some unknown reason but participation was voluntary. Most of my patients were nice enough to fill out the forms.

Not having my own staff of dedicated data entry personnel, I had my long-suffering medical assistant enter the data from the forms into the computer. I did pay her for this out of pocket, though not as much as she deserved (Thank you Karen!). Up until this point I really didn’t know what would happen once all the data was in. The ABIM site was very mysterious about where this module was heading. I was still in Step 1, and couldn’t go on to Step 2 until at least 50 sets of patient data were in the computer. So, after several months of data collection (I now saw why it was important to start the process a year ahead of time), the data was in, and the Step 2 button, which had been grayed out and disabled, stood before me in an activated state, ready to be pushed. It reminded me a little of a computer game, in which you try to open a door but it just gives a rattly sound and a text appears that says “you don’t have the key” until you actually find the key. So without further ado I clicked on the button and the computer churned away, analyzing my trove of what was admittedly somewhat sketchy data to begin with. Then after a dramatic pause the ABIM website announced its findings.

I wasn’t sure what it had to do with hypertension (this was the Hypertension Module, wasn’t it?) but the grand analysis revealed that a greater percentage of my patients than was deemed acceptable were failing to meet goals for lowering of serum cholesterol. (Flash forward 2 years: those goals have been thrown out the window anyway in the latest guidelines). Hmm. So my patients referred to me for the most part by other cardiologists for consideration of pacemaker or defibrillator implantation or catheter ablation of arrhythmias were not meeting standards for cholesterol lowering. I thought to myself: whose fault is that? I don’t usually have anything to do with managing lipid levels. I am a subspecialist, which one would think the ABIM would be aware of as they were requiring me to take their subspecialty certification test. As a matter of fact most of the cardiologists who referred patients to me had little to do with managing cholesterol levels either. In Louisville, Kentucky the management of lipid levels is the jealously guarded province of the family practice doctors. But there it was staring me in the face. After several months of effort that completely distracted me from my real job as an electrophysiologist, the answer to the question of Life, the Universe and Everything was a faulty cholesterol level.

So on to Step 3. The ordeal was not over. For the next step in the MOC Holy Quest was to develop a plan to address this dreadful oversight in my clinical practice and implement it. After that there was Step 4, which was to assess the wonderful success of my innovative plan and show how it had revolutionized my clinical practice so that I would be eternally grateful to the ABIM for my enlightenment that was only possibly through the MOC program. And they wanted me to do this assessment by repeating the data collection in another 50 patients after I had put my fool-proof-amazing-cholesterol-lowering plan into effect.

Excuse me, ABIM, but I do have a real job, and is there any way I can get on with it, instead of spending the rest of my life on your science project? Well, reading the proverbial fine print, there was a way. I could, if I so desired and were so lazy (though they would so much prefer the more complete option) only collect the specific data that was identified in the original number crunching and submit that to them. In other words, I could get 50 cholesterol levels (never mind that I virtually never order a cholesterol level in my field of work) and show that they were better than before. Ah, I know an out when I see one.

So I wrote my MASTER PLAN FOR THE LOWERING OF CHOLESTEROL AND THE SALVATION OF THE HUMAN RACE which I think had something to do with asking the patients to exercise more and eat fewer buckets of Kentucky Fried Chicken, and immediately put the plan into effect. Then, after waiting what I thought was a realistic number of months, I resubmitted my data. Wow, the cholesterol levels were much, much better. The plan had worked! I just hope the ABIM is not planning to publish my data. Because… I made it all up!  And I bet I’m not the first to have done so.

As a medical professional and former academic researcher, I never would dream of falsifying data under any normal circumstances, but I was driven to this by the completely unreasonable nature of the MOC requirement. To summarize this unreasonableness:

1) There were no MOC module options that were relevant to my subspecialty.

2) My patients, my staff and I were forced to waste time on a project of no clinical value.

3) There was ZERO educational value to this project.

4) There seemed to be some undisclosed (sinister?) ulterior motive for the ABIM to collect this data from my patients.

5) I was an unpaid data gatherer for the ABIM (No. Worse, I paid them for the privilege).

6) My patients were unwitting participants in a project that was not important to them or me. I’m sure many participated because they trusted me, but by asking them to participate I was violating or abusing that trust.

I’m not sure what else to say. It is unbelievable that physicians have to go through this process. As much as taking a clinically irrelevant test every 10 years irks me, it is still far preferable to the sham that is the MOC. It really has to go.

Computers & Software Electrophysiology Medicine

Fair Use Justification of CPT® Codes in EP Coding

The following is a formal justification for use of a limited number of CPT® codes under the US Copyright law fair use exemption in the soon-to-be-released mobile app EP Coding.

EP Coding icon
EP Coding icon



As CPT® codes are copyrighted by the American Medical Association, it is important to make the case that use of a very small percentage of these codes, with paraphrased descriptions in a mobile app is covered under the Fair Use doctrine of US copyright law. Note that the AMA does acknowledge the possibility of fair use of CPT® codes. Also please note the following:

CPT copyright 2012 American Medical Association. All rights reserved. CPT is a registered trademark of the American Medical Association.

Fair use criteria

Four criteria are used in determining fair use of copyrighted material:

  • The purpose and character of the use, including whether such use is of a commercial nature or is for nonprofit educational purposes.
  • The nature of the copyrighted work.
  • The amount and substantiality of the portion used in relation to the copyrighted work as a whole.
  • The effect of the use upon the potential market for or value of the copyrighted work.

The purpose and character of the use, including whether such use is of a commercial natue or is for nonprofit educational purposes.

EP Coding is intended not for coders, who definitely need the AMA documentation, but for physicians who need to document with codes (in addition to documentation in their procedure notes) the procedures that they do. With the advent of EHR (Electronic Health Records) there is frequently a need to enter codes by the physician directly into the system. This is true of the EPIC EHR that I’ve had experience using. Entering codes is not an easy task. As the CPT® descriptions are obtuse, at least as presented in EPIC, looking up codes by description is difficult if not impossible. For example, a search for “PPM” which is a common abbreviation for pacemaker yields 0 hits in EPIC. Searching for “PACEMAKER” or “PACER” yields a very long list of hits, but they are all hardware codes for individual pacemaker types and not procedure codes. Searching by code, such as the code for dual chamber pacemaker implant, code 33208, yields this:


Hardly intuitive! Similarly searching for “ABLATION” yields over 50 choices, many not related to cardiology, and search for “AFB” yields “AFB stain” used to diagnose tuberculosis. The actual code for AFB ablation, 93656 yields this:


So there is a need for a “cheat sheet,” a list of codes relevant to his or her specialty that the physician carries around to help remember the codes and enter them in the computer. This list of codes may not be enough however. One must remember that one can’t code transseptal puncture or LA pacing and recording with AFB ablation, or that 3D mapping is already included in VT ablation. This sort of information is ideal for encoding into a mobile app.

As the app improves physician coding skills and thus enhances the ability of the physician to code accurately and quickly so he or she can then turn his or her attention to more pressing matters, the app meets the criterion that its purpose is educational and benefits science and the public. There is no benefit from keeping the physician in the dark regarding these codes. The physician is not going to buy or carry the whole AMA CPT® code book around, nor should he or she, given the very limited number of codes that need to be used in his or her line of practice. Certainly an actual written “cheat sheet” that is commonly used is considered fair use. The EP Coding app merely is a more intellegent version of that cheat sheet.

Regarding the commercial nature of the work, the app is priced at a very low cost (99 US cents) both to help defray the costs of development and to discourage downloading by those who don’t need access to these codes. EP Studios does generate some income, but has not generated a profit. Its main purpose is to help my colleagues by developing apps relevant to practicing medicine.

Thus with these points I believe the app qualifies for “fair use” by the first criterion.

The nature of the copyrighted work.

Despite their absolute necessity for the practice of medicine in the United States, the AMA has a copyright on the CPT® codes. This is despite the fact that the CPT® codes are also the level I codes required by Medicare for all providers to use. The AMA code books are expensive and license fees are required to use the codes as well. The amount may be debatable, but there is no doubt the AMA makes a lot of money from their codes. The codes are essentially a database, matching code numbers with descriptions, as well as information of what codes cover and what codes can and cannot be used together. Professional coders definitely need to know all the ins and outs of these codes, however physicians only need to know a subset of the codes. The EP Coding app uses some of the numbers and paraphrases the descriptions of the codes. As such it is not a direct copy, other than of the numbers. Numbers as such may not be subject to copyright. It should also be noted the the CPT® manual is largely a functional and not artistic work, and as such may be more subject to fair use than other less functional works.

The amount and substantiality of the portion used in relation to the copyrighted work as a whole.

A Google search for number of CPT codes gives various sites stating a number from 7800 to 8800. These figures are unsourced, but there is no doubt the number of CPT® codes in in the thousands. As of February 16, 2014 there are 73 codes in EP Coding. Assuming 7800 total codes, that is 73/7800, i.e. 0.9% of the total number of CPT® codes. This is a small percentage of codes. Note that the codes used in EP Coding are only codes for electrophysiology and are limited further to only non-surgical codes (i.e. excludes codes utilizing thoracotomy). In addition codes for office visits, hospital visits, and device checks are not included. The text of the descriptions is not copied from the AMA manuals, but is a paraphrase. Thus the amount of text copied is limited to a small subset of the code numbers. The ideas associated with these numbers are used, but not copied directly. Note that copyright protects literal text, but not the ideas underlying the text. Per the US Copyright Office:

“Copyright does not protect facts, ideas, systems, or methods of operation, although it may protect the way these things are expressed.”

In addition, most if not all of the information in this app is readily available online. For example this article outlines how to code EP procedures.

The effect of the use upon the potential market for or value of the copyrighted work.

EP Coding is intended for physicians, who are not the intended audience of the AMA documentation. That audience is made up of professional coders. EP Coding is more akin to a cheat sheet than a work competing with the AMA code book. Physicians are not likely to purchase the AMA book whether or not they use EP Coding. Coders cannot substitute EP Coding for the AMA book. Thus there is no real competition between the app and the AMA copyrighted works.

In summary, I believe that use of CPT® codes in a limited way in the context of the mobile app EP Coding meets all 4 criteria for fair use under US Copyright law.


Device Reps and Patient Care — An Inconvenient Truth

Device Programmer
Device Programmer

Most people who don’t deal with the Health Care System on the inside are likely unaware of the exact role that industry representatives play in the care of patients. As a cardiologist who implants pacemakers and defibrillators, I have worked with the representatives of the companies that manufacture these devices for many years. I will use the term “device reps” for these people, mostly because that is usually how they are referred to on a day-to-day basis, but in using this term I am referring both to device sales representatives and to device field clinical specialists. In theory the sales reps are more involved with sales, and the field clinical specialists with technical support, but in practice there is a blurring of these roles, with considerable overlap even in the job descriptions and training required, as can be seen here. Generally both jobs require at least a bachelor’s degree and training by the device complany. Although there is no specific requirement for a health care degree, some of these people are former nurses, cath lab technicians, or physicans assistants. On the other hand some, in particular the sales reps, have a background in business and not health care. Despite this, the job description of the sales rep includes providing pacemaker and defibrillator follow-up, technical assistance, programming, troubleshooting, and training.

So what does this translate into in practice? For one thing, these device reps are present in the cath lab or operating room when pacemakers and defibrillators are implanted. They are there to provide the actual devices and run the programmer (essentially a specialized computer for testing and programming devices). In my experience they never scrub in or otherwise assist in the procedure. Using these same programmer machines (note that each company has its own programmer and they are not compatible with other company’s programmers) the reps test and reprogram devices throughout the hospital, at least technically under supervision of a physician, though the physician may not be physically present. They often do the same thing in doctor’s offices, especially for physicians who do not have dedicated staff to follow pacemakers or defibrillators. They provide these services at no cost to the hospital or physician, though presumably the cost is bundled into the rather hefty price tag of pacemakers and defibrillators.

These services are not performed rarely. The reps take call at night and are expected to be available 24 hours 7 days a week. Each device company provides its own group of reps.  Because the implantable device business is very competitive, any company providing less than this level of service would soon lose its business. Hospitals and physicians receive a “free” service that, if it did not exist, would have to be provided by hiring their own technical personnel at considerable cost. The industry argues that only they know their proprietary products well enough to provide adequate technical support, and there is certainly some truth to this argument.  In general, I think most hospitals and physicians see the present system as perhaps a little awkward but beneficial and don’t want to kill the goose that laid the golden eggs.

Nevertheless, the current system is rife for abuse. Let me first say that most of the industry reps I know and have worked with are exceedingly technically knowledgable and good, ethical people whom I would rather have program my pacemaker than some of the doctors whom they work for. But I also should say that there are exceptions, and a small minority are really just interested in sales and are not so technically knowledgable. So this brings us to the most obvious problem with this system:

Why is a sales person assisting in implanting my pacemaker or changing settings on my implantable defibrillator?

This is the first question that would occur to most people. The person adjusting the IV is a trained nurse. The person adjusting the ventilator settings is a trained respiratory technician. Neither one is trying to sell IV equipment or ventilators. Why does a sales person program a pacemaker?

I remember back when I was in training in the early 1980s the TV program 60 Minutes  came to Baylor in Houston purportedly to do a documentary on new pacemaker technology. Our pacemaker specialist, Dr. Jerry Griffin, was interviewed in his office about this subject. The CBS crew then requested to film a pacemaker implantation procedure in the cath lab. Consents were signed and the procedure was filmed. No one realized that the whole thing was a bait and switch. Everything else was edited out and the only thing shown on TV was the bit where Jerry asked for the pacemaker from the sales rep in the room. The show was actually an expose on relations between the pacemaker industry and physicians and the fact that industry sales people were in the cath lab assisting in pacemaker implantation. About the same time, there was a US Senate investigation of the pacemaker industry, and amongst the many criticisms and abuses identified, the role of the sales reps in pacemaker procedures was noted. All this has led to a crackdown on industry reps providing physicians trinkets such as pens, but the role of the reps in device implantation and follow-up seems not to have changed a whit.

The present system is flawed and suffers from a lack of oversight. Despite an attempt by the Heart Rhythm Society to codify the relationship between industry and physicians, there really aren’t any hard and fast rules. This leads to abuse of the reps themselves, and some questionable practices. The reps have been trained never to say “no” to any request by a physician. Courts have ruled that it is not the responsibility of the rep to correct the physician if the physician is doing something wrong. So what is a rep to do if an undertrained physician asks him or her to program a device in a fashion detrimental to a patient? The rep is in a bad spot, risking losing business from that physician if he or she doesn’t just “follow orders.” Although it is well established that other healthcare personnel should speak up and question orders they seem to be in error, there is no expectation that a sales rep should do so. In large part this is a fault of the device industry that has often tried to train physicians in pacemaker implantation who have not undergone formal pacemaker implantation training, in order to increase sales.  This can result in the awkward situation of the rep being more knowledgable than the supervising physician.

Device reps are also often asked to program devices on and off for surgery, when it really is not necessary to do this. Much of the time no programming needs to be done in this situation, or only a pacemaker magnet needs to be applied during the course of the surgery to put the device into a “safe” mode that won’t cause problems when the surgeon uses electrocautery. These unncessary programming interactions are abusive to the device reps, could conceivably result in incorrect programming, are costly to the patient (device programming is billed by the supervising physician), and lead to delays in starting surgery while waiting for the device rep, notified invariably at the last minute, to drive from one hospital to another. Since the whole device rep system is outside the normal hospital chain of command, it is difficult for the devices reps to find a champion who would talk to the anesthesiologists or surgeons and change this policy. I mention this example because I saw it again and again in one hospital in particular in Louisville, Kentucy, where I worked.

Device reps can get in over their heads. In the emergency room in the middle of the night they may be asked to use the device to electrically cardiovert or pace terminate an episode of ventricular tachycardia. They may be the only one in the room who knows what they are doing. The cardiologist is happy he or she doesn’t have to get out of bed to do this. Yet here again this is a person often without a medical degree performing a medical procedure with potentially serious consequences. The device rep may also be asked to turn off a defibrillator or pacemaker in a terminally ill patient. While turning off a defibrillator generally has no immediate effect, turning off a pacemaker in a patient who is dependent on the pacemaker results in death that occurs about as fast as a gunshot to the head. To push that button on the programmer that shuts off the pacemaker is as morally vexing an act as one can conceive of, yet this is something that we ask the device rep to do (“under physician supervision”).

Device follow-up in the office doesn’t have to be done by device reps, yet it often is. In the Heart Rhythm Center at my former work-place all the device follow-up was done by trained nurses and technicians. Many cardiologists though have a rep come to their office periodically to do device follow-up. There is push-back against changing this system, because device follow-up generates income. Yet often the “supervising physician” has no training in pacemaker follow-up and leaves the programming decisions to the rep. This is wrong.

So, what to do about all this? The system is quite well-entrenched and I’m not sure if it can be changed. I think having the rep in the cath lab during device implants, that was so shocking to the 60 Minutes viewers, is probably the most justifiable of these practices. They are equipped with all sorts of leads, adaptors, and devices that really are necessary to have to do the procedure. Their role of assessing pacing thesholds and device function is not particularly troublesome, especially as this is the one situation where the supervising physician is actually guaranteed to be present.

Regarding device follow-up and reprogramming in the hospital and doctor’s offices, I do think it would be better if it were done by specialized personnel who work for the hospital or doctor, and not for the various device companies. This is already done is some doctor’s offices, such as our own. This would require an outlay of cost by the hospitals, as someone would have to be on call all the time for these services. I suspect that most hospitals would prefer to keep the current system, but in the long run having a minimal sales presence in the hospital might lead to lower costs of devices.

I’m curious what other physicians or health care workers think about this. What do the reps think about it? What do people on the receiving end, i.e. patients with implantable devices think about it? It doesn’t seem to be discussed very much. Please feel free to leave any comments you might have.


EP Studios on a Mission

Near EP Studios European Headquarters
Near EP Studios European Headquarters

EP Studios has never had a mission statement — until now.  The only mission up until this point has been to do some computer programming, write sometimes serious but often silly blog posts, and otherwise use up your precious bandwidth with whatever comes into my head to write about.  Now that I have reached the end of my actual doctoring career it has struck me that I need a purpose other than shiftlessly lazing around in Paris, France, eating French food and drinking French wine.  Then again, maybe not.  Well, regardless, I came up with what I think is a way I can still contribute to the medical community while no longer on the front lines, fighting the good fight.  Doctors (and other health care workers) are like the foot soldiers in the war.  They are so preoccupied with just staying alive from day to day that it is difficult to get any perspective on why they are putting themselves through this hell.  The people who actually make the decisions are always safely away from the front lines, nicely ensconced in their safe multi-million dollar homes with their multi-million dollar CEO salaries (to shift the metaphor gradually from armies back to the health care system).  I have worked in both academic medicine and private practice.  I have seen a lot happen and a lot change over the years.  The American health care system, always broken, is always changing, but the changes just tend to break it in new ways.  There are too many financial fingers in the pie to start over and fix the system.   Only more patches can be applied and,  as with very old legacy software, applying a patch at one place tends to break something else in a another place.  So, the Mission of EP Studios is NOT to fix the American Health Care System.  That’s way too hard.  It is more modest.

What I’d like to do is try to help doctors, nurses, and other health care professionals get their job done.  I think I am in in a good position to do this.  Whether through apps that make taking care of patients easier, or just blog posts that try to impart some of the things I have learned over the years, I think I can help.  As a side mission though I will continue to post on non-medical topics — basically anything I feel like writing about.   Come to think of it, maybe not a whole lot will change here after all.

Electrophysiology Medicine

Winding Down

The+Countdown+Five+countdown_5The countdown clock app on my phone reads 73.6 days.  That is the number of days until January 1, 2014.  My retirement day.

It has been a good run.  I graduated from Dartmouth Medical School in 1976, got married, and have practiced medicine ever since.  I went through internship and residency in Rhode Island, thought cardiology was pretty neat, and did a fellowship at the Medical College of Pennsylvania in Philadelphia.  The week before my fellowship started, one of the faculty, Dr. Toby R. Engel, was seriously injured in a car crash on East River Drive.  My first day of fellowship was memorable for two reasons.  My car was stolen, and I had to take care of one of my attendings, Dr. Engel, who was in a coma in the ICU.  It took about a year, but he did fully recover (I never saw my car again, however).   I developed a certain fondness for Dr. Engel, who became my fellowship mentor.  During my second year of fellowship (believe it or not, the average cardiology fellowship was only 2 years back then), I looked to him for career advice.  Dr. Engel was a devotee of the then fledgling field of cardiac electrophysiology.  He thought I had a knack for the electrical end of cardiology and urged me to go into it.  He gave me a list of programs to look into.  I ended up in Houston, Texas at Baylor, with another great mentor, Dr. Christopher Wyndham — Australian and protege of another early EP pioneer, Dr. Ken Rosen.  Chris was/is incredibly smart, but also very mild-mannered in a Crocodile Dundee sort of way and a gentleman with a great sense of humor.  He was a role-model for me, demonstrating that one doesn’t have to be a jerk to be a physician, despite the prevailing wisdom.   With limited success, I have tried to pattern my doctorly personality after his.

I didn’t mean to turn this into a life-story.  I’ll fast-forward through a year of electrophysiology fellowship at Baylor, 3 years working there on faculty, then 18 years of academic medicine at the University of Colorado Health Sciences Center in Denver, culminating in a fully tenured, Professor of Medicine position which I then cast aside to become a private practice cardiologist in Louisville, Kentucky.  Now after 10 years of that I have decided it is time to hang up the skates.  There are only so many atrial fibrillation ablations, biventricular ICD implants, and call nights one can do in a lifetime.  I would rather leave on a relatively high note than linger on to the point where someone has to drag me away for the good of the patients.

I have seen a lot happen in the last 30 plus years in the EP business.  I entered the field not exactly at the dawn of EP  but close to it.  ICDs were just coming out (circa 1980), and the field of electrophysiology was just a few steps away from pseudoscience.  The main thing we did back then was drug testing guided by programmed stimulation, something current electrophysiologists never do, thanks to studies like ESVEM from the 1990s that I participated in.  EP was only an academic field in those days.  There were no EP docs in private practice then, and the entire membership of NASPE (predecessor of HRS) could fit into one medium sized hotel meeting room.  Interventional EP, meaning practical ablation and ICD implantation by non-surgeons, was still years away in the future.   But all the time that we were giving patients false hopes that quinidine would cure their sustained monomorphic ventricular tachycardia, we were also learning a lot about the mechanisms of abnormal heart rhythms, until the right tools (mapping and ablation) were developed that allowed us finally to defeat these noxious arrhythmias and really help our patients.

I have had some accomplishments I have been proud of.  As a fellow I wrote and presented at the AHA the first paper analyzing the use of triple extrastimulation for inducing ventricular tachycardia.  I wrote the first paper that suggested that the characteristics of entrainment changed depending on the relationship between the pacing site and the reentry site, an important concept which led to entrainment mapping, though it took smarter people than I to grasp the full implications of this.  I also first reported giving a shock internally through an electrophysiology catheter to rescue a patient from refractory ventricular fibrillation.

I started this blog, not because I was interested in social media, but because I was interested in computers and needed a justification to run my own web server.  Looking at the blog, the first post is dated August 22, 2006.  This would make EP Studios  one of the earliest medical blogs, except I rarely have blogged much about medicine, especially back in the beginning.   So this blog is a big gemisch of topics: fantasy and science fiction, movies, 1960s TV shows, classical music, computer programming, politics, and, once in while, some medicine thrown in.  With a little more self-promotion, focus, and hard work I might have developed a more high-profile medical blog, but “I am what I am” as both God and Popeye have stated.

I am hoping that once I do retire and am away from the “Stop the World, I Want to Get Off” life I have been leading, I can spend a little more time writing about the things that interest me, including some more of my thoughts about the medical world of yesterday, today, and tomorrow.

Computers & Software Electrophysiology Medicine

The Evils of CPT®

Yours for only $114.95!
Yours for only $114.95!

Current Procedural Terminology (CPT®) codes are 5 digit codes for billing procedures performed by physicians in the United States.  The use of these codes is mandated by all insurers and the whole CPT® coding system forms Level I of the CMS (i.e. Medicare and Medicaid) Healthcare Common Procedure Coding System (HCPCS) code set.  The system is complicated and changes yearly.  This year there have been major changes in the coding of electrophysiology procedures.  In a characteristically inconsistent and confusing fashion some codes have been bundled together and other haven’t.  An example: the ventricular tachycardia ablation code includes 3D mapping, but the atrial fibrillation code doesn’t.  Great!  These changes are well covered here.  Reading this and dealing with these procedures on a daily basis, I toyed with the idea of incorporating an electrophysiology coding module into my mobile app, EP Mobile, or spinning off a separate app (since many who download my app are non-Americans, for whom this information is totally useless).  Certainly since use of these codes is mandated by the federal government, I could just go to the CMS website and download the codes I needed, since they are part of the HCPCS code set.   Wrong!  They aren’t there.  If you go the the relevant CMS website you will read:

Issues related to the application of Level I HCPCS codes (CPT-4) for physicians will be referred to the AMA. See Related Links Outside CMS below.

CPT® codes are copyrighted by the American Medical Association.  They are only available through the AMA.  Worse, the AMA has a licensing policy for use of these codes.  Presumably hospitals, codes, doctor’s offices, insurers, and maybe even our government through CMS pay not only for the yearly updated coding books published by the AMA, but just to use these codes.  What about using the codes in a computer program like my app?  To quote from the AMA website:

I am developing a product that will contain CPT codes. Do I need permission from the AMA?

Yes. The AMA holds copyright in CPT and use or reprinting of CPT in any product or publication requires a license. To use CPT codes in a product that will be sold or distributed to others, please obtain a distribution license.

And how much will this distribution license cost me?

What is the fee for a distribution license?

The royalty for the use for CPT material in an electronic or Internet product is $14 per user per product. Depending on the terms of the License Agreement, royalties are due either quarterly or semi-annually in arrears. Print publication royalty is $14 per distributed copy. No minimums or upfront fees are required. You will, however, need to purchase the CPT data file separately.


Not very practical for an app that is free or costs 99¢ like EP Mobile.  So much for that idea.

The AMA makes money from the CPT® system.  How much money I won’t say.  Last time a quote was made on the Internet about this, the AMA lawyers came calling.  It is outrageous that this coding system that is used throughout the United States — in fact whose use is mandated by CMS — is proprietary and not in the public domain.   Having an inconsistent and constantly changing coding system that is not easily available to either health care provides or patients does not serve the best interests of our health care system.  Nice work, AMA lobbyists!

Books Electrophysiology Medicine

The MOC Program’s Story (With Apologies to Lewis Carroll)


… They had not gone far before they saw the MOC Program in the distance, sitting sad and lonely on a little ledge of rock, and as they came nearer, Alice could hear him sighing as if his heart would break. She pitied him deeply. What is his sorrow? she asked the Gryphon, and the Gryphon answered, It’s all his fancy, that: he’s worried that the doctors aren’t qualified, that testing alone is not good enough, not even every 10 years, and that CME requirements are not adequate.

So they went up to the MOC Program, who looked at them with large eyes full of tears, but said nothing.

This here young lady, said the Gryphon, she wants for to know your history, she do.

I’ll tell it her, said the MOC Program in a deep, hollow tone: sit down, both of you, and don’t speak a word till I’ve finished.

So they sat down, and nobody spoke for some minutes. Alice thought to herself, I don’t see how he can EVEN finish, if he doesn’t begin. But she waited patiently.

Once, said the MOC Program at last, with a deep sigh, I was a real Program.

These words were followed by a very long silence, broken only by an occasional exclamation of Hjckrrh! from the Gryphon, and the constant heavy sobbing of the MOC Program.. Alice was very nearly getting up and saying, Thank you sir, for your interesting stroy, but she could not help thinkg there MUST be more to come, so she sat still and said nothing.

When I was little, the MOC Program went on at last, more calmly, though still sobbing a little now and then, I was a real Testing Program. Doctors would take my test and be certified in their specialty for life.

For life? asked Alice. Isn’t that a long time?

It can be, it can be, sighed the MOC Program.

You ought to be ashamed of yourself for asking such a simple question, added the Gryphon, and then they both sat silent and looked at poor Alice, who felt ready to sink into the earth. At last the Gryphon said to the MOC Program, Drive on, old fellow! Don’t be all day about it! and he went on in these words:

Yes, the certification was lifelong then, though you mayn’t believe it–

I never said I didn’t interrupted Alice.

You did, said the MOC Program.

Hold your tongue! added the Gryphon, before Alice could speak again. The MOC Program went on.

Then we found we could get more money, I mean, we could make sure the doctors really knew their stuff, if we repeated the testing every 10 years.

What a curious plan! exclaimed Alice.

That’s enough about testing, the Gryphon interrupted in a very decided tone: tell her something about Maintenance of Certification now.

Ah, that’s the MOC in my name, said the MOC Program. Maintenance of Certification Program in full. I used to worry so much that testing alone, even every ten years, was not good enough to make sure that I received enough money, I mean that the doctors really, really knew their stuff. So I went from a Testing Program to a MOC Program. The MOC Program sighed again.

I had the doctors do additional review modules, and also do research on their patients for me, said the MOC Program.

Research on their patients? exlaimed Alice. Isn’t patient data confidential, and isn’t it illegal for patients to be forced to participate in studies without their consent? What was this research about?

Oh, for example, we would collect data about patient’s blood pressure and cholesterol levels in an arrhythmia clinic…

But heart rhythm doctors are subspecialists and this kind of research is incidental to what they do, let alone intrusive! Alice couldn’t believe what she was hearing.

The MOC Program sighed deeply, and drew the back of one flipper across his eyes. He looked at Alice and tried to speak, but for a minute or two sobs choked his voice. Same as if he had a bone in his throat, said the Gryphon: and it set to work shaking him and punching him in the back. At last the MOC Program recovered his voice, and, with tears running down his cheeks, he went on again:–

You don’t know what it is like to be a Testing Program. Just giving a test every ten years doesn’t pay the bills! When I became a MOC Program, I thought things would be better, but, no, still not good enough.

What more could you ask of those poor doctors? cried Alice.

Every two years, every two years. The MOC Program shook his heavy head and sobbed.  The doctors will have to earn MOC points every two years, or they won’t be certified.

That’s crazy, said Alice. The doctors will be upset, but I don’t know why you are crying about it.

A tear rolled down the cheek of the MOC Program. It’s not enough, it’s never enough. I won’t be happy until all the doctors are spending every minute of their day working on Maintenance of Certification.

Alice said nothing; she had sat down with her face in her hands, wondering if anything would EVER happen in a natural way again.






The Old Man and The Doctor — A Fable

fablesOnce Upon A Time, there lived an old man and an old doctor, in a far away village. The old man was sick, and so he called for the doctor. The old doctor came to visit, and found the old man had a diseased heart. The doctor knew he was going to die soon. The doctor comforted the old man, and gave him medicine to ease his pain. The old man’s suffering was relieved and he was grateful to the doctor. Feeling more alert, he watched the doctor jot down a few notes on a piece of paper before he packed his bag and made ready to depart.

“Will you return, Doctor?” the old man asked.

“Yes, of course. In a few days,” the doctor replied.

“What were you writing in your notebook just now?” The old man was curious.

“Oh, just a few notes to help remind me about your case,” said the doctor. “You see, I have a lot of patients, and sometimes I need to jog my memory. I too am getting older, as is my memory.”

“I understand completely,” the old man said, and bade the doctor farewell.

The old man, despite his heart malady, began to feel stronger. After a few days he started to wonder when the doctor would return to visit him again. He needed more medicine and was surprised that the doctor had not come back to him. He made some inquiries and was soon saddened to learn that the old doctor himself had succumbed to a sudden heart attack, and was no more.

Being of a practical nature, the old man knew that he needed to find a new doctor. And lo! there was a new doctor, fresh out of Medical School, who had come into town that very day to replace the old doctor who had died. He sent out a request for this new doctor to come and visit him. To his surprise he received an answer that this new doctor did not come to his patients’ houses. Rather, the patients were expected to come to his clinic in the center of town. This was a hardship for the old man, but he quickly understood that this was the way of the world, and there was no use fighting against it.

So the old man got his cane, put on his coat, and made his way down to the new doctor’s clinic.

Here he sat and waited along with many fellow patients until finally a nurse came and brought the man into the inner part of the clinic, where, after another wait, the new doctor finally appeared.

The old man knew that the new doctor did not know his case, so he started telling him his story. The doctor though held up his hand and said,

“Wait a minute.”

The doctor opened up a notebook sitting on a table next to him. He spent a few minutes turning pages until he got to the page he was looking for. He then started writing in the notebook.

After a few minutes, the old man asked, “What are you writing in your notebook just now?”

The doctor was silent. He continued to scribble furiously in the notebook. He did not look up at the old man or ask him any questions. It appeared that there was a certain amount of information that he needed to enter into the notebook, and he only had a limited time to do so. The doctor’s forehead broke out in a sweat as he tried to write things down as fast as he could. Finally, the doctor slammed the notebook shut, and without a word, left the room.

The old man was stunned. Before he could react, however, the nurse came in and told him it was time to leave. The old man asked the nurse about his medicine. The nurse said that the new doctor had a system whereby his medical prescription would automatically be sent by carrier pigeon to the apothecary in town, to be picked up at his convenience. The nurse assured him that everything was taken care of, and she needed to prepare the room for the next patient.

The old man asked the nurse, “Is the doctor a good doctor?”

The nurse seemed taken aback. “Yes, of course.”

“How so?” asked the old man.

The nurse laughed. “What a silly question. The doctor went to the best medical school. He won awards in his internship and residency. But more important than any of that, he has a System.”

“What kind of System?” The old man could tell from the nurse’s tone of voice that the word “system” was capitalized.

“Well, you saw it in action. He is able to generate a complete history, upload the past medical and surgical history, create a full 12 point review of systems, and generate a physical that touches on each major body part in an amazingly short period of time.”

The old man pondered this. Then he said, “But the doctor did not talk to me, did not examine me, did not tell me what was wrong.”

The nurse laughed again. “Of course not. If he did all that, there would be no time for him to create his documentation. He would have to see fewer patients and you would have to wait even longer to see him. You wouldn’t like that, now would you?”

The nurse tried sheparding her patient out of the room. The doctor would be mad at her if she didn’t get the next patient ready quickly enough. But the old man resisted, and she became frustrated.

“What is wrong?” she asked.

“I…I am having pains in my chest. I think I am having a heart attack.” The old man turned pale, and he collapsed to the floor.

The nurse called for the doctor. The young doctor came back in, glanced at the old man clutching his chest on the floor, and went back to the table where his notebook lay. He opened, found the correct page, and started writing again.

The nurse looked at the old man writhing on the floor, and she became concerned. She didn’t want to interrupt the doctor in his important task of documentation, but finally she could hold back no longer.

“Doctor!” she said in an urgent tone of voice. “You are getting behind in your appointments. Can’t you do something?”

The doctor did not look up from his task, but did answer. “It’s this new System. The forms don’t allow entering a second patient visit on the same day without amending the initial visit, which, as you know, is a 10 step process. If I miss one of the steps I have to start over again. So it does not help if you interrupt me, Nurse.” He said the last rather curtly.

The nurse was subdued. “Yes, Doctor. I’m sorry, Doctor.”

Finally with a look of relief, the doctor finished his task and closed the notebook. He smiled and addressed the nurse.

“Sorry I was a bit abrupt with you. But, after all, this was an emergency situation. I had not planned for this episode of critical care in my office. Overall though, despite its quirks, the System worked and I am back on track.”

The nurse smiled. “Don’t mention it. I’m just amazed that the System was able to handle something like this. It certainly has been a boon for Medicine that the technology exists today to create such a System for Documentation.”

“Indeed.” The doctor pulled out his pipe and lit it, taking a few puffs. It was something he did when he became contemplative. He grinned.

“With this Documentation System, I can handle something like this and even have a few moments to think about how things used to be. You know, how the doctors of yore took care of patients.” He tapped some ashes from his pipe.

The nurse, who was older and did remember those days, nodded her head. “Yes, I remember those days. The doctors spent all their time talking to patients, and examining patients, and thinking about what would be the best treatment for their patients. They spent so much time with those tasks that they didn’t have time to fully document in their charts!”

“Yes,” agreed the doctor. “Those docs of old couldn’t nail a 12-point review of systems if they tried. So, all that work, and they could only bill a Level I visit! Ridiculous.” He opened the notebook and pointed to the page with the stem of his pipe. “Here today, on this gentleman, I have documentation to support a Level V office visit, plus 15 minutes of Critical Care Time. There’s is no way the old docs could have done that.” He glanced at his watch. “Oh, if I don’t stop chatting, I really will be getting behind.”

The nurse nodded, and glanced down at the old man, who now lay stiff and still. “What about him?” she asked.

The doctor stepped over the old man to leave the room. “Well, call for an ambulance to take him to the hospital. He needs a doctor.”

The nurse knelt down and felt the old man’s carotid artery. There was no pulse.

“He has died, Doctor,” she stated.

“The morgue then.” The doctor rolled his eyes. “Now I have to do a death summary too. This is not my day.” He went back to his notebook once again, now in a foul mood. “This will never do.”

The nurse hesitated, then finally asked, “Should I cancel Mrs. Thornsberry?”

The doctor continued scribbling furiously, and the nurse knew better than to ask again.



Medicine Society TV

Ask Your Doctor if TV Drug Ads Are Right For You

Separate bathtubs.  Maybe that's the problem.
Separate bathtubs. Maybe that’s the problem.

The only thing more annoying than TV commercials is TV drug commercials. Nowadays the two have become virtually synonymous  Whatever happened to commercials for Tide or the Ginzu knife? Now it’s one mind-numbing Cialis, Pristiq, or Lyrica commercial after another. There’s the commercial with the doctor standing in his white coat out in public next to a giant mirror, not saying a word as people walk up to him. That guy should be arrested. There is the glowing nocturnal butterfly, flying from house to house, presumably flying into the head through your ears while you sleep, to eat your brain. There are sad people who suddenly have drug-induced happiness. There are COPDers, accompanied by elephants. There’s the guy who doesn’t have to make the turn off to the Protime Clinic because he’s on Xarelto, and can go fishing instead. All the commercials have high production values, but many, like the doctor and the mirror, just seem weird. Each commercial follows the same pattern:

Part I: The cheerful narrator sets up the problem and then introduces the drug-based solution. No commercial gets to the point quicker than the Cialis commercial. The awkward, non sequitur intro goes something like this: “It’s the little things she does, you never get tired of. But your erectile dysfunction? That may be a matter of blood flow.” (I tried to google the exact text, but, have you ever tried to search for anything with the word Cialis in it? I warn you, don’t try it.)

Part II: The same narrator reads the list of side-effects, in the same cheerful but somewhat more pressured tone of voice, having only 30 seconds to get them all in (“…stop taking Cialis and seek medical attention if you have an erection lasting more than four hours…” or “…in rare cases Happy Drug X may cause death, suicide, liver failure, kidney failure, and so forth and so on…” or “…if your pregnant wife accidentally mistakes your Axiron for deodorant your baby will be born with two heads…”).

Direct to consumer prescription drug advertising was approved by the FDA in 1997 and is only legal in two countries in the world: the USA and New Zealand. Proponents of these ads argue that they should be permitted by First Amendment free speech and that they are useful to raise public awareness of diseases and their treatment. Opponents argue that this is wasteful spending, adding to the cost of these drugs, and that the ads create pressure on physicians to prescribe drugs they wouldn’t otherwise prescribe. The ads encourage the viewer to self-diagnose conditions like insomnia, restless leg syndrome, or “Low-T”, leading to unnecessary drug treatment of naturally occurring conditions. And, as the commercials warn us in that cheerful, friendly voice, there are some risks associated with these drugs. Even though the $4.8 billion dollars the drug industry spent (in 2008) on direct to consumer advertising is considered trivial compared to the total cost of health care (and is much less than the money spent on direct to physician marketing — which should be another blog post), clearly these ads work for the industry, or they wouldn’t bother spending the money.

I would love to make a policy of not using drugs that are advertised on TV, but the practice is universal, and some of the drugs, like the new anticoagulants are actually useful. I would be cheating my patients if I did that. With Congress being the representative of industry rather than of the people, it is unlikely direct to consumer drug advertising will ever change. Maybe if US physicians united to protest these commercials, then… Whoa! What I am thinking.  Physicians in this country actually uniting to accomplish something? Sadly, I will undoubtedly be reminded of the perils of four hour erections for the rest of my life.