Sunday, October 27, 2019

ProPublica Vital Signs

It has been a while since ProPublica came out with a list of physicians who receive money from the pharmaceutical or medical device industry.  They began posting their new list of physicians who get the greatest reimbursement to the outrage of some who saw their Twitter post.  They also posted their updated Vital Signs search engine that allows anyone to search for how much money a physician receives as payments from the pharmaceutical or medical device industry.  I was able to locate my profile (it is not always easy) and it is readable. I do it when they post an update just to make sure there are no errors.  I don't accept money from anybody and also don't attended sponsored free CME courses because that is also listed as a benefit from whoever is sponsoring the course.

Although they are using a practice address I have not had for over 9 years (it is blurred but available on the ProPublica site) - when I was at that site I saw many Medicare and Medicaid patients.  At one point those were the only patients I was treating.  The disclaimers written on this page need clarification.  I am currently working 4 days a week and for me that is at least a 45-50 hour week and seeing full schedules of patients. The reason ProPublica has no information on my medical practice is that I receive no payments from the medical device or pharmaceutical industry, but you don't know that for sure by reading this information and the disclaimers. The introduction to the new database update gives an example of the reporter searching on the names of his primary care MD and the consultants he has seen.  He looks at the report of payments in terms of royalty or licensing fees, promotional speaking, consulting, travel  and lodging reimbursement, and food and beverage reimbursement.  What he does not say is what these figures mean to him.

I have written about this database in the past in terms of what it does and does not mean.  Over the past decade these payments were used as an easy way to discredit physicians, in some cases entire specialties.  Psychiatry and psychiatrists were at the top of the list, despite the fact that according to ProPublica they were ranked well below most other specialties in terms of medical industry payments.  The furor seems to have diminished as physicians are now subject to more rigorous payment reporting than politicians. In modern society - it seems that the illusion of transparency is all that is required to satisfy the moral outrage of the public.  After all - we have politicians who are actively engaged is legislating issues that affect their top campaign contributors.  There could probably not be a more significant conflict of interest and nobody bats an eye.

Despite the unrealistic idea that physicians are easily influenced and are in lock step to treating their patients according to orders from the pharmaceutical and medical device industry - this database serves a symbolic purpose.  That is - personal treatment from your physician will somehow be better now that all of these payments are known. You might make value judgments about physicians on that basis, but it would probably be a mistake. Physicians should be paid for their work and their intellectual property.  As a group they end up giving far too much of it away. And the largest conflict of interest affecting personal medical care is not mentioned in this database.  That is how your insurance company, managed care organization, or pharmaceutical benefit manager rations your care and tells your physician what they must prescribe, what tests to order, and how they can treat you if they want to remain an employee or get reimbursed.  Don't expect to see those numbers anytime soon. And by the way - that rationed care adds at least a trillion dollars to the health care budget - just as a jobs program for administrators and it skims an unknown (but probably large) percentage off the treatment your physician really wants to provide.

In the meantime - remember that this blogger is beholden to no one.

George Dawson, MD, DFAPA

Supplementary 1:

I discussed some critical issues when a Presidential appointee stood to make massive profits while in the Executive Branch.  Although that deal fell through, the President himself has made an estimated $2.3 billion in profits while sitting in the Oval Office.  This is the same President that provided massive tax cuts to businesses and massive rollbacks in environmental regulations on businesses. In the meantime, physicians accepting $10 worth of pharmaceutical or medical device company pizza are reported to the payments database.

Should $10 worth of pizza be a red flag for anything?

Sunday, October 6, 2019

Inappropriate Sinus Tachycardia (IST) In The Psychiatric Clinic

I don’t recall what I was researching the other day but I happened across a brief review paper on a subject I have been following for a while (2). That subject is inappropriate sinus tachycardia (IST). I posted recently about closely following the cardiac status of patients being seen by psychiatry both on the inpatient side and in the outpatient clinic. When that is done a significant portion of those patients will have tachycardia defined as heart rate of greater than 100 bpm. In some cases the heart rate ranges as high as 120 to 130 bpm.  Many of these patients are surprised to learn how high their heart rate is and what constitutes a normal heart rate. Others are very focused on the cardiac status and experience palpitations in periods of rapid accentuated heart rate. I commonly hear “it feels like my heart is coming out of my chest”.

That type of cardiac symptom can certainly occur during panic attacks. The majority of people I see with sinus tachycardia do not have panic attacks or panic disorder. They are generally anxious but the phenomenon I have not seen addressed is how much anxiety is due to the cardiac symptoms? Many have what I describe as cardiac awareness. By that I mean they can sense their heart beating by various mechanisms. Many can feel the pulsation of blood through the body especially in the head and neck area. Others can hear their heartbeat. Many can sense their heart beating against their chest wall. The person has that kind of focus any irregularity like occasional pauses or extra beats leads to heightened anxiety. As that anxiety builds some people will feel chest pain, chest pressure, and shortness of breath or near panic symptoms.

 A significant number of those patients will have anxiety associated with symptomatic IST. There are also groups of patients with frequent panic attacks, nocturnal panic attacks, night terrors, and medical problems associated with tachycardia and other cardiac symptoms.  It has been surprising to me to find that significant sustained sinus tachycardia is often ignored in primary care settings. The reason for that may be the latest review in UpToDate (1). In that review the authors define the syndrome and the evaluation and conclude that the condition generally has a benign course in that tachycardia induced cardiomyopathy is rare. They suggest that diurnal variation of the tachycardia may protect against that.

Since IST is by definition tachycardia with no known medical cause intrinsic heart disease and associated causes of tachycardia need to be ruled out. In psychiatric patients panic attacks and anxiety are typically considered psychiatric causes of tachycardia but they are rare causes of sustained tachycardia. The hyperadrenergic state of panic attacks generally resolves when the panic attack resolves and that is frequently in 20 minutes or less.  It is common to see very anxious people in clinics and when their vital signs are checked they are typically normal. Sustained tachycardia is more common with other comorbidities such as medication side effects, excessive caffeine use, stimulant use, alcohol or sedative hypnotic withdrawal, and in some cases insomnia. Deconditioning can also be a factor one person has been isolated and sedentary for any reason and they suddenly need to walk a distance to get to the clinic. There is a gray zone of overlapping conditions that need to be considered. For example, an acute pulmonary embolism, congestive heart failure, and emphysema or COPD can lead to cardiopulmonary symptoms including tachycardia. They can generally be ruled out by a medical history, review of systems, and brief examination.

Tachycardia secondary to medication side effects often requires tracking several variables.  In the ideal case, an indicated medication can be selected that does not have the side effect - in this case tachycardia. But there re some medications that are unique enough that they may be used in situations where the tachycardia persists because there are no other good alternatives. With clozapine (3) the tachycardia can be secondary to anticholinergic side effects, alpha blockade and hypotension, or intrinsic cardiac side effects like myocarditis. Patient often get tachyphylaxis to the anticholinergic effects but all of these variables need close monitoring. It takes a lot of ruling out to conclude that a patient on clozapine has IST and this is a good example of the importance of the baseline evaluation and reviewing avaiable records and vital signs in the electronic medical record.

A more common scenario is the anxious patient with no clear cardiac or pulmonary disease who has persistent tachycardia and in many cases palpitations. They are often treated with beta-blockers with some success. I have seen people have been unable to tolerate beta-blockers, people who did not respond beta-blockers, and some people with beta-blocker withdrawal who had severe anxiety panic and tachycardia because the beta-blocker was stopped too quickly. In both the review and the up-to-date summary, IST patients are commonly resistant to beta-blockers and need another intervention. The suggested intervention is ivabradine a novel medication described as a blocker of the hyperpolarization-activated cyclic nucleotide-gated (HCN) channel responsible for the cardiac pacemaker If current. That directly affects heart rate at the SA node. It also affects retinal currents leading to phosphenes or transient bright spots in the visual fields. 

The main indication for ivabradine is congestive heart failure. There are cardiac complications including atrial fibrillation. That suggests to me that most psychiatrists should probably not consider prescribing this medication unless there is ample clinical experience and the required monitoring is not intensive - similar to beta-blockers today.

The main message in this post is that close attention does need to be paid to vital signs on every inpatient unit and outpatient psychiatric clinic. It is not enough to say that tachycardia can be dismissed as anxiety. It is also not enough to use a quasi-medical intervention like telling the patient to drink more fluids if they have not been assessed for hypovolemia. A close look for intrinsic cardiac conditions and the list of conditions and the differential diagnosis from the review article below and the UpToDate review should be a minimal requirement for medical psychiatrists. If that cannot be done, the patient should definitely see their primary care physician preferably prior to initiating any treatment with a medication that would obscure the clinical picture. The evaluation and recommendations of the primary care physician should be available in the patients psychiatric chart. For completion, I also get copies of other cardiac testing that has been done including echocardiograms and exercise stress tests.

The advantage of a diagnosis of IST is that it recognizes there is a specific diagnosis to account for inappropriate tachycardia rather than a default psychiatric diagnosis. That is important because it protects the patient and potentially offers more effective care. The treating psychiatrist should still be in the loop for the necessary lifestyle modifications, education about the condition and monitoring and treating any associated anxiety.

George Dawson, MD, DFAPA


1.  Munther K Homoud. Sinus tachycardia: Evaluation and management.  Section Editor: Jonathan Piccini, MD, Deputy Editor:Brian C Downey, MD in UpToDate.  Accessed on October 6, 2019.

2.  Ruzieh M, Moustafa A, Sabbagh E, Karim MM, Karim S. Challenges in Treatment of Inappropriate Sinus Tachycardia. Curr Cardiol Rev. 2018 Mar 14;14(1):42-44. doi: 10.2174/1573403X13666171129183826. Review. PubMed PMID: 29189171; PubMed Central PMCID: PMC5872261

3. Miller DD. Review and management of clozapine side effects. J Clin Psychiatry.2000;61 Suppl 8:14-7; discussion 18-9. Review. PubMed PMID: 10811238.

Saturday, October 5, 2019

Physicians Preservation Act?

I got this idea today while reading the usual Twitter complaints about the electronic health record. A post by physician I knew was particularly poignant. She pointed out that she was getting burnout from the excessive time it takes to do EHR documentation compounded by the fact that nobody ever reads it. This is a complaint I have had for a long time.  I was lucky enough to be on the ground as the EHRs rolled out. There was quite a prelude to the rollout with about a solid 10-year buildup of documentation and billing requirements. Those requirements originated with the federal government specifically HCFA – the precursor to CMS. All of the initial EHRs were designed around these documentation and coding templates. It was strictly a business focus sold as something necessary for medical practice.

I can recall the first people on the medical staff who were designated to sell the system. They came to see me and I pointed out that I have never been a touch typist and the fastest I can type is 12 words a minute with two mistakes. When they realized I wasn’t kidding they tried to soften the blow by saying that we would be slowly transitioned to creating the entire document. During that transition time we would still be able to dictate admission notes and discharge summaries. When I complained that this would still be quite a burden on physicians producing all these documents I was told by an internist (who I had a very high opinion of) “You need to thank our CEO for getting us this state-of-the-art system.” That was one of the more depressing remarks that I’ve heard in my career.

I did try to make the most of it. I got an early version of Dragon and started dictating all my notes and into Word and pasting them into the EHR.  It was not pretty. There were many mistakes and if I missed some of those mistakes it could prove to be an embarrassing document. The nursing staff I worked with helped to edit those documents and point out the mistakes but some mistakes invariably went through. I learned that the nursing staff in my immediate proximity were the only people who ever read those notes. I was generating multiple 500 to 1000 word documents a day and suddenly realized that I had to complete that work between 10 PM and midnight every day. Within a few years the new car smell was off the EHR and things were getting ugly.  I started to see 18 to 20 page progress notes based on import and cut-and-paste features. My speculation is at one point the vendor was desperate to prove they could introduce some physician friendly features. The ability to start a new daily progress note based on yesterday’s note soon became history. Administrators decided that the new note looked too much like the old note even though they were based on same template.

EHR politics is always interesting to observe. There are a cadre of administrators and “super users” who are tasked with selling the product to the frontline physicians. There are also various helpdesks that are run by the vendor. Staff at those helpdesks are supposed to be available for troubleshooting and problem solving. The troubleshooting and problem solving eventually fades away. EHRs are typically implemented in modules. I walked into work one morning and realized that the module that allowed electronic prescribing was completely changed. The change was not announced and since it was an enterprise wide implementation there were hundreds of physicians trying to figure it out for themselves. It added hours to everyone’s day.

With the shift of billing, coding, and documentation to physicians many other jobs were lost due to the EHR. For 15 years I would go to the basement of the hospital every Sunday and make sure all of my records were dictated and signed. I ran into the same staff there every weekend who greeted me and assisted me with completing those records. Suddenly they were gone because now I was doing all of their work in the EHR. When I first started working at my job, I would dictate daily progress notes and they would be pasted into the chart by the secretarial staff the next day. Billing and coding specialists would come to the unit, read those notes, and attach a billing fee. I had no idea about the billing system and didn’t really care. With the EHR all of those staff were replaced. I was not only doing their jobs but now I was legally responsible for any billing errors and the suggested penalties were high. All of this additional work and responsibility was directly transferred to physicians through the EHR.

The only real bright spot from the EHR was the ability to see imaging studies, electrocardiograms, and laboratory results as soon as they were available. It took years to get that implemented to the point it worked effectively.

Are there workarounds to successfully use the EHR without burnout, depression, and excessive work? I think that there are. The last few years I have been seen by ophthalmologists who were retinal specialists and an otolaryngologist or ENT physician. In both cases these positions were using a scribe or a third person in the room who documented the history, exam, findings, and treatment plan as indicated by the physician. In the case of the retinal specialist he was working with an ophthalmology fellow and made corrections to that examination by directions to the scribe. The same thing happened with the ENT physician but in that case the scribe was also an RN who could provide more details about the suggested treatment plan. In both cases the physician walked out of the room at the end of the encounter with no further documentation burden. That led one of my colleagues to point out that the only reasonable workaround for the EHR problem is to use two people - the physician and a scribe or staff person who could also function as a scribe.

That led to my idea about the Physicians Preservation Act at the top of this post. It addresses all the flaws in the system that were brought about by heavy lobbying and Congressional advocacy for a burdensome inefficient electronic documentation system. As I pointed out in a 2015 post, the system has never lived up to claims of efficiency or savings even when physicians started to do the work of four or five people. This entire administrative structure is there to produce excessive documentation that nobody reads. There is also a massive environmental cost since the system must operate through thousands of networked personal computers that in many cases are operating 24/7 along with the associated data storage facilities. 

My suggested solution is a compromise between the likely inertia of the current EHR system and the politics that keep it in place and the massive burden it places on physicians and their families. There are just too many special interests in Congress keeping this system afloat. The question is how long can the country afford to lose doctors because of it.

My guess is not too much longer.

George Dawson, MD, DFAPA