How The Implantable Defibrillator Became An Abomination

DrRich | January 28th, 2011 - 10:52 am


When DrRich decided to become an electrophysiologist over 30 years ago, it was because he wanted to help figure out how to prevent sudden death.  Sudden death from cardiac arrhythmias is estimated to kill over 300,000 Americans each year, and at the time, some of the more recent victims of sudden death had been DrRich’s friends or loved ones. Because cardiac arrhythmias – even the lethal ones – can virtually always be stopped if appropriate interventions are available, these deaths can be prevented, at least in theory. DrRich wanted to help turn the theory into reality.

In 1982, by virtue of being in the right place at the right time rather than by virtue of his own qualities or qualifications, DrRich’s electrophysiology shop at the University of Pittsburgh became the third institution in the world (after Johns Hopkins and Stanford) to gain access to the highly experimental implantable defibrillator. The gradual development of the implantable cardioverter defibrillator (ICD) from a primitive and often dangerous device that was suitable only for the very highest-risk patients, to the finely-tuned life-saving instrument it is today, is an amazing story in itself. Perhaps some day DrRich (who was in the thick of it for two and a half decades) will try to tell it.

But the bottom line is that today we know how to prevent sudden death. And if the evolution of ICDs were permitted to follow the path which is followed by most modern technologies, these devices could, relatively quickly, become small enough, simple enough, safe enough, effective enough, and cheap enough for the kind of widespread usage which would be necessary to actually produce a large reduction in those 300,000 deaths per year. The ICD companies all know how this could be accomplished, and for that matter, so does DrRich.

But alas, this is not going to happen. ICDs will remain extraordinarily complex and expensive devices, which can only be wrestled to ground by highly-trained electrophysiologists (EPs), and which therefore will only be available to a very tiny proportion of the people who could benefit from them. And rather than being celebrated as the typical American success story of harnessing vision, persistence, and innovation to solve a very difficult problem, ICDs instead are widely castigated (by the press, the public, the insurers, the government, and even most doctors) as a symbol of excess, as the poster child for expensive and wasteful medical technology. (And so, when the DOJ goes after ICD companies and the doctors who implant them, the press and the people cheer them on.)

While most EPs and all of the ICD companies refuse to see it, ICDs – a remarkable technology which prevents an all-too-common tragedy – have become an abomination in the eyes of our society.

There are many reasons for this. DrRich will list just three of them, in ascending order of importance.

The third most important reason ICDs are an abomination is: The Toxic Symbiosis Between ICD Companies and Electrophysiologists.

EPs were important during the initial years the ICD was being developed, since expertise regarding complex cardiac arrhythmias had to be translated into engineering language, and then packed into the ICDs, in order for these devices to work the right way. But at some point in the 1990s, ICD companies should have realized that EPs had made their contribution, and were now leading them out on a limb.

Once the fundamental problems in building ICDs were solved, the companies should have been working to make their devices simpler to use, more reliable, and cheaper, so that they could be used by more doctors in more patients. Instead, following MBA Dictum Number One, they “listened to their customers,” the EPs. And the EPs (for whom, like most medical specialists, turf protection is very high up on their priority list), unfailingly counseled the ICD companies to make these devices more and more complex, so that only EPs can understand how to use them. And so, this is what the ICD companies did.

As a result, today’s typical ICD has extra leads (wires) which add appreciably to the difficulty and the risk of implanting these devices, without adding much practical value for most patients; and they have incorporated literally tens of thousands of programming options, ostensibly so that device function can be carefully “tailored” for the individual patient, but which are seldom actually used profitably, and whose chief effect is scaring off non-EPs.

By “listening to their customers,” ICD companies have been led away from simplicity and into unnecessary complexity, and today’s typical ICD is burdened with layers of grotesque tailfins, running lights, oversized tires, and massive engines. In building their vehicles, the ICD companies should have solicited the needs of the typical commuter; instead, they consulted only with monster truck enthusiasts, and so they are producing vehicles that are not suitable for highway use.

The second most important reason ICDs are an abomination is: Government Price Controls (As Usual) Are Keeping Prices High.

The price of ICDs, fundamentally, is determined by Medicare. Way back when ICDs were first approved for use, Medicare determined that a fair price was somewhere in the range of $15,000 – $25,000. This high price was justifiable back in the 1980s, since it cost nearly that much at the time to make one of these things. But the way government price controls seem to operate, ICDs will probably remain in this price range forever.

Now, to be sure, the government does not directly determine what companies get paid for ICDs. Rather, they indirectly determine the price by deciding what hospitals and physicians will be reimbursed for implanting ICDs – and the ICD companies subsequently are paid by the hospital. Those Medicare reimbursement rates apparently vary substantially from region to region and hospital to hospital (who knows how the government determines these things?), and the various rates are not publicly available to DrRich’s knowledge. But ICD manufacturers, at worst, can impute the reimbursement rates by figuring out the top price which specific hospitals are willing to pay them for ICDs (hence the range in prices).

Having determined the top price they can possibly get paid for ICDs, the only logical strategy for manufacturers is to figure out how they can always get paid that top price for every device they sell. They do this by making ICDs specifically aimed at keeping the decision makers happy. And the decision makers, as we have seen, are the EPs.

EPs, having (so far) successfully protected their turf, most often decide which patients get ICDs, and they decide which company’s ICDs to implant. So, to be competitive among their customers, ICD companies must cater to the wants and needs of EPs, and so must produce a steady stream of new, improved ICDs whose novel features are requested by these very high-end, high-maintenance physicians (who again, are dedicated to turf protection through complexity).

Since their product therefore grows more complex with each succeeding generation, in response to the “needs” of their customers, ICD companies have been able to successfully argue to Medicare that ICD reimbursement should be maintained at high levels (and in some cases they have been successful in getting reimbursements to increase even further).

All the ICD manufacturer needs (and wants) to know is: what new geegaws do I need to add to my next generation of ICDs in order to make them even more stupefyingly complex, so as to maintain the loyalty of my EP customers, and to justify high reimbursement rates?

And this is why, despite the fact that ICD technology has been fully mature (says DrRich) for at least a decade now, which in a functional market would cause the price to plummet, the cost of ICDs remains so high. Whatever has developed in the complex interplay between ICD manufacturers, EPs, hospitals and the government, it’s not a functional market.

In fact, there are no market forces at all in play here. Furthermore, there is no evil-doing. The “players” in this scenario – CMS personnel, ICD manufacturers, and EPs – are all simply behaving logically, and are all responding as anyone would to the incentives that have been established within a system which employs government price controlls to keep costs down.

As a result, ICDs remain extraordinarly and unnecessarily expensive.

And the number one reason ICDs are an abomination is: Sudden Death Is Good Public Policy.

A well-known and often-repeated assertion is that 75% (or some similar high proportion) of all healthcare expenditures are consumed during the last six months (or some similar brief interval) of life. Whenever this assertion is made, the clear implication is that some means ought to be found to stop wasting all those healthcare resources, once that six-month clock is found to have started. The debates as to how to go about doing this (since the initiation of the six-month clock can really only be determined retrospectively) often become very nasty, very quickly.

In this light, consider sudden death. Sudden death has the virtue of being completely unexpected – and therefore very cheap. Victims of sudden death will not have spent the last six months of their lives selfishly consuming all our healthcare resources. Likely, they will have spent that time earning money, consuming goods, and paying taxes. These patriots are doing what every healthcare policy expert agrees we should all do – to go directly from being productive citizens to six feet under. For sudden death is free, and if everyone did this we wouldn’t have a healthcare crisis at all.

Furthermore, consider the kind of patient who receives ICDs. Some of these, of course (probably less than 10%) are young individuals with some sort of genetic propensity for sudden, lethal arrhythmias. But by far, most people who get ICDs are older folks, generally in their 60s, who have underlying cardiac disease. These are people who, if their sudden deaths are prevented, will go on consuming large amounts of Medicare dollars for the maintenance of their sundry significant medical conditions, who will go on collecting monthly Social Security payments, and who, when the end finally does come (possibly a decade or more into their ICD-extended life) will do so in the classic American manner – in an ICU, supported by incredibly expensive machines, drugs, and medical professionals. And thus, thanks to their ICDs, 75% of their lifetime healthcare expenditures will also be gobbled up during their last days.

Consider also that there is no constituency for “sudden death.” There is a constituency for breast cancer; a constituency for HIV-AIDS, a constituency for muscular dystrophy; a constituency for autism; and even a constituency for flatulence. But there is no constituency for sudden death. People who die suddenly (all 300,000 of them per year) generally have no idea that they are likely to become victims of arrhythmic death, and don’t care one way or the other if the means are available to prevent this unfortunate event. Until, perhaps, the last five seconds of their life, they are entirely unaware that sudden death is even a remote possibility.

So the path is open to demonize ICDs and those who build or implant them, and to hound them into curtailing – if not stopping entirely – their counterproductive activities.

While ICDs are indeed too expensive and too complex, the chief reason they are an abomination is that they prevent the very kind of death that every health policy expert understands is the ideal. And they convert that ideal death into a years-long orgy of entitlement-consumption, capped off by a typically American, very non-ideal, very expensive kind of death. Small wonder that ICDs are being specifically targeted by the Feds.

Because of what they do, and not because of their cost, the use of ICDs must be curtailed. ICDs would be targeted even if they were as simple, cheap and reliable as DrRich thinks they could and should be.

ICDs would be targeted even if they were FREE.

Heck, the very concept of an ICD is an abomination.

What Should Electrophysiologists Make Of The DOJ Investigation?

DrRich | January 24th, 2011 - 11:32 am


Two weeks ago DrRich wrote about the abuse of implantable defibrillator guidelines, as illustrated by a recent JAMA article claiming that over 22% of ICD (implantable cardioverter defibrillator) implantations are “non-evidence based.” The abuse of the guidelines, DrRich showed, was perpetrated less by ICD implanters, and more by the authors of that article. That fact being interesting but irrelevant, DrRich went on to speculate that perhaps the Feds would rouse themselves to take this issue to the next level.

It certainly did not take long. Indeed, just a days after DrRich’s post (which ought to completely absolve him of having any direct impact on the Feds’ action), it was revealed that the Department of Justice had already launched an investigation of ICD implants, as related to “proper guidelines for clinical decision making.”

This revelation was made on the website of the Heart Rhythm Society, the professional organization of electrophysiologists (EPs). HRS went on to say that it (HRS itself) had “agreed” to assist the DOJ in an advisory role in its investigation. Furthermore: “Because this is an ongoing investigation, HRS Staff or Leadership is not available for further comment. HRS will communicate additional information to its membership when permitted to do so by the DOJ.” (Emphasis DrRich’s.)

So here’s what we know:

1) The DOJ is actively investigating ICD implantations.
2) Their investigation has to do with the “proper use of guidelines” in selecting patients for ICDs.
3) HRS, the professional organization to which EPs pay huge dues each year in order that it might represent their interests, most especially their interests in Washington, has been preemptively co-opted by the Feds, and indeed has been gagged, so that any further communication to its own membership regarding the investigation is forbidden until further notice.

What will HRS tell the DOJ? It hardly matters, since the important thing has already been accomplished, i.e., effectively silencing the sole organization which represents the interests of EPs in Washington. But, while the HRS statement indicates that the organization is “assisting” the DOJ with “information that does not include either identifiable patient or facility level data,” and while DrRich has no doubt that this is the sincere intent of HRS, DrRich also believes it to be a sure thing that, at the end of the day, HRS (if it wishes immunity from any liability it might find itself subject to, regarding the advice, statements, educational materials, &c., it might have produced over the years, relating to clinical guidelines, or to any other matter of interest that might surface during the DOJ’s open-ended investigation), will tell the DOJ Anything It Wants To Know.

DrRich’s fellow bloggers who are also electrophysiolgists, Wes Fisher and John Mandrola, quickly noted the HRS statement on their respective blogs, and each expressed a certain amount of concern as to the implications of the DOJ’s investigation. But Larry Husten, who writes the excellent Cardiobrief blog, offers a calming voice: “I doubt that the DOJ is gearing up to tackle the vast majority of “reasonable” off-guideline implants. I think they will be going for the real outliers, and when and if they reveal the details of their case there will be little sympathy for their targets.”

Some of DrRich’s readers, who not inappropriately consider him to be a bit paranoid about the Central Authority, may find it surprising that, fundamentally, he agrees with Larry on this matter. He does not think the DOJ will round up large numbers (or even moderate numbers) of EPs who have been practicing basically sound electrophysiology, and who likely have reasonable explanations for any off-guideline ICD implantations they may have committed. DrRich agrees that the DOJ instead will go after a few outliers, figures who – very specifically – will garner little sympathy amongst the public, and indeed, who can be held out, with good effect, for public castigation. Preferably, these figures will be individuals about whom the marketing departments of one ICD manufacturer or another will have generated a few embarrassingly glowing e-mails, celebrating the sheer number of sales these doctors have produced, and discussing strategies – offering speaking engagements in exotic locations, putting on pig roasts, &c. – to keep the ball rolling.

In other words, it is likely at the end of the day the DOJ will produce a few doctors who are truly abusing the system, and harming patients to boot, and who will actually deserve what they will get.

There is no guarantee about this, of course. DrRich has written about how he himself, in his pristine innocence, was once the target of a federal investigation of ICD implants. And while he had on his side the virtues of good medical practice, truth, justice, the American Way, ethics, and even the law, and while he eventually was extricated from his situation with an entirely clean record, it was a close thing, and his escape was based more on luck than on being right. More recently, when DrRich had the “opportunity” to testify under oath in a DOJ investigation on another matter (which he is not yet at liberty to discuss, but regarding which, happily, he was only a witness this time, and not a target), DrRich was required by the DOJ to answer several questions about this very blog and its content, which (as far as DrRich could tell) had nothing whatsoever to do with the matter at hand. By this means DrRich was led to know that the Feds are either among his very great fans (Hi, Fellas!) – or something else.

DrRich’s paranoia, you see, is hard-won, not to mention evidence-based.

So it is indeed possible for innocents to get drawn into such matters – collateral damage is always unavoidable when one is at war – but odds are it won’t be You, or You, or You, so like Larry says, not to worry. They are looking for true evil-doers.

DrRich also agrees with Larry that this DOJ investigation is not a direct response to the JAMA article. The JAMA article appeared a mere week or two before HRS made its announcement – and its announcement obviously was so carefully lawyered-up that it must have taken weeks if not months to negotiate just that one detail with the DOJ. This has all been in the works for a while.  But DrRich does not believe for a moment that the DOJ was unaware that the JAMA article was coming out, or that its content, and the subsequent media attention it would create regarding the widespread ICD abuses being perpetrated by EPs, would dovetail nicely with the subsequent revelation by HRS of the DOJ investigation.

ICDs, and their implanters, have long been a target of the payers – both government payers and insurers – and this new enterprise is merely the latest battle in a long war.

As it happens, DrRich spoke at a certain investigators’ meeting just this past weekend, which was attended by a score or so of prominent electrophysiologists. He can report that the JAMA article (which defined off-guideline ICD usage as bad medicine and harmful to patients), followed by the intense publicity in the media this article generated (also emphasizing bad medicine and harm to patients), followed by the DOJ investigation related to the “proper use of guidelines” in ICD implantation, followed by the co-opting and the gagging of the EPs’ own professional organization, is having a delightfully chilling effect on the profession. DrRich thinks it is unlikely that very many off-guideline ICD implants will be performed for the foreseeable future, no matter how much individual patients might benefit from them, at least while this investigation continues. In fact, while the investigation is ongoing, DrRich suspects that even referrals to EPs for ICD implants will drop off. Because, until then, it will remain an open question just how rigorously one must stick to the letter of the guidelines in order for the DOJ to give one a pass, and to not be considered as guilty of crimes against humanity. The profession is duly intimidated.

Whatever the final outcome of this investigation, it has has already had its intended effect.  DrRich respectfully suggests that the DOJ might just as well take its time with it, and let the effect percolate to perfection.


Note: Further evidence came this afternoon (January 24) that the effect the Central Authority had in mind is being realized, when Wells Fargo Securities downgraded St. Jude Medical from Outperform to Market Perform. The downgrade was based on WFS’ assessment that ICD implants will be reduced by 10% in 2011, thanks to the DOJ investigation. That reduction doesn’t quite do it, of course, but it’s a start.

Who Writes Those Clinical Guidelines, Anyway?

DrRich | January 19th, 2011 - 8:50 am


While DrRich is a conservative American, and has made plain the difficulties he has with the Progressive program in general and with Progressive healthcare reform in particular, at times he is forced to admit that, on occasion, the Progressive way of looking at the world has certain merits. And as DrRich contemplates a question that has been bothering him lately, a question that no doubt plagues many American physicians who (unlike DrRich) are still toiling away in the trenches, he finds that this is one such occasion.

That question is: Just who are the people writing all those clinical guidelines – the  “guidelines” physicians are now expected to follow in every particular in every case, on pain of massive fines, loss of career, and/or incarceration?

DrRich is quick to say that the act of creating clinical guidelines is not inherently evil, and indeed, back in the day when guidelines were merely guidelines (instead of edicts or directives that must be obeyed to the last letter), creating clinical guidelines was a rather noble thing to do.

But today, we have physicians clamoring to become GOD panelists (Government Operatives Deliberating). These aristocrats of medicine will render the rules by which their more inferior fellow physicians, the ones who have actual contact with patients, will live or die. Clearly positions of such authority will be very desirable, and so, as one might predict, they are being vigorously pursued. And we are seeing candidates audition for these panels with efforts ranging from amateurish to ruthless. It puts one in mind of the early-season contestants on “American Idol.”

We see them vociferously extolling, in every public venue they can find, the idea of “fly by wire” medicine, whereby every decision physicians make will be determined not at the bedside but by the best and the brightest experts, acting at a distance. The experts will distribute rules of action based on only the best scientific evidence (“best” being determined by those selfsame experts). The directives they hand down will be models of actionable simplicity,spelled out so unambiguously that even doctors born, raised, and trained in the Midwest or the South will be able to follow them.  (And if the doctors refuse to cooperate sufficiently, non-physician medical professionals will be able to do the job.) We see them writing scientific papers that spin the evidence in such a way as to generate conclusions which will be soothing to the Central Authority. We see them editing medical journals in order to make certain that the correct conclusions are published, and the incorrect ones are not. We see them taking control of professional organizations, and using their positions to promulgate changes in medical ethics that advance the Borg-ification of medicine, and to formally endorse Obamacare on behalf of American physicians who, for the most part, were against doing so.

These people have gained great prominence within our healthcare system, and practicing physicians will be dealing with them and the consequences of their actions for many years to come. While the natural impulse of us typical American doctors may be to simply marvel at the wonder of it all, shake our heads resignedly, and go about our increasingly distressing business, it may behoove us to take a closer look at these individuals, to attempt to understand them a little better. After all, their activities in the near future promise to greatly impact our lives, our fortunes, and our sacred honor.

So – who are they, anyway?

This, dear reader, is where the Progressive mode of thought comes in handy. DrRich refers, of course, to the Progressive doctrine of Diversity.

Diversity, for those who pretend not to know, is perhaps the chief mechanism by which Progressives attempt to control the behavior of the population.

Recall that the Progressive program is to create the perfect society. The Progressive elite know just how to do this, of course, but individuals within every population throughout human history have insisted upon acting in their own self-interest, which is counterproductive to the collective goal. In past efforts to perfect human societies, such individual recalcitrance has been dealt with by means of concentration camps and pogroms and the like. “Diversity,” we all should admit, is a much kinder and gentler approach to curing the problem of individualism.

Specifically, the doctrine of Diversity defines the range of permissible behaviors and thoughts for a given group of people within a society. The numerous celebrations of Diversity we see all around us invariably turn out to be strategies to reinforce those allowable ranges of thought and behavior. In this way, members of a particular group who begin behaving and thinking outside the allowable range can be quickly identified and dealt with, either through correction (which brings them back into the group), or through vilification (which marginalizes them). It is easy to become confused about this, since classically “diversity” means something other than “conformity.”  (As a general rule, if you want to know what Progressives are really up to, listen to what they say and then look to see if their deeds are actually working toward the opposite thing.  DrRich thinks that much of the time you will find that they are.)

In any case, while in general DrRich does not approve of Diversity as it is being practiced today, he finds that the concept might be useful in attempting to answer the question at hand.

Specifically, DrRich refers to his theory that physicians (like any humans) tend to end up in careers that best suit their underlying personalities and proclivities, and so physicians in a given specialty will tend to think and behave like other physicians within that specialty, and unlike physicians in other specialties. If this theory has any merit (and let us call it the Diversity Theory of Physicians), it will allow us to make some generalizations about the characteristics of individuals who have chosen specific kinds of medical careers. DrRich stresses that he is aiming to make generalizations only, and while those generalizations might help enlighten us to a modest degree regarding, say, what sort of physician will end up on the GOD panels, they can tell us nothing about particular individuals.

With that annoying disclaimer out of the way, let us examine some ways in which the DTP reveals Truth. An obvious example is the specialty of psychiatry, which tends to attract doctors who are, perhaps subliminally, concerned that they are just a little crazy themselves. As it happens, it often turns out they are correct. In DrRich’s experience, and in the experience of just about anyone who has encountered more than a handful of shrinks, these fine physicians, on average, display an astonishing degree of off-the-wall psychopathology. (Not that there’s anything wrong with that.)

Emergency room doctors have short attention spans and are afraid of commitment.

Endocrinologists get their jollies by sitting alone in cramped offices, parsing tremendous volumes of laboratory data from blood tests, which they claim reflect moment-to-moment variations in hormone levels, and from this arcane evidence are able to parse out (so they say) subtle glandular difficulties. If endocrinologists were not physicians they would be accountants; the more aggressive endocrinologists (who are identifiable by the dirty glance they give you if you happen to interrupt their lonely cogitations) might be forensic accountants. (How anybody could specialize in any organ that just sits there, perhaps secreting various invisible substances, but otherwise not doing anything whatsoever,  DrRich will never understand.)

Orthopedic surgeons are former jocks, or wish they were, and the ones who end up replacing hips in old ladies instead of patrolling the sidelines at college football games are often very frustrated individuals.

Party animals who manage to gain entrance to medical school often end up as anesthesiologists.

Cardiologists like to envision themselves (and would like others to envision them) as living on the edge. After all, they put catheters into damaged coronary arteries in patients on the brink of heart attacks, and, through their skillful manipulations, open those arteries and save lives. They are the extreme sportsmen of medicine, so they believe. But really, their jobs are ones of relative security, predictability and instant gratification. What they do in the cath lab actually is pretty rote, and it provides them with immediate, concrete results. They can even show the “before” and “after” pictures to the person they just saved, who will then heap praise and shed tears of gratitude upon them. But any time fixing a particular artery looks a little too risky, they call a cardiac surgeon right away. This pattern of behavior suggests to DrRich that their aggressive personnas and glory-seeking activities are actually masking an underlying insecurity.

It would not be fair of DrRich to psychoanalyze all these other specialists – who have done nothing to provoke him – without also doing the same for electrophysiologists. All electrophysiologists started out as cardiologists, of course, so they have that going for them. But to really understand electrophysiologists, one must invoke the principle of sublimation. To sublimate is to channel an underlying negative tendency to some activity that partially gratifies that tendency, but that is considered worthwhile by society. So, for instance, people with a tendency toward pyromania may become volunteer firefighters. People with sadistic tendencies may become prison guards. Foot fetishists can become shoe salesmen. Compulsive liars can become novelists.

Who, then, become electrophysiologists?

Back in the 1980s and 1990s, when DrRich was practicing, what electrophysiologists mainly did was to try to prevent sudden death in patients who had a high risk of dying suddenly from cardiac arrhythmias. And in order to find the optimal therapy for these patients, it was necessary to induce, intentionally and repeatedly, cardiac arrests under controlled conditions. This was done in an effort to find an antiarrhythmic drug that would prevent the induction of cardiac arrest. This behavior we euphemistically called “serial drug testing.”  Fortunately, this procedure is no longer necessary, since the implantable defibrillator has been perfected and is now widely available for high-risk patients (if you can get it paid for).

While it has been widely remarked that those early-day electrophysiologists were a very strange group indeed, most of us who did this serial drug testing ended up successfully absorbed into normal society, and today (as far as DrRich can tell) we are for the most part generally pretty harmless. But DrRich sometimes finds himself wondering what might have become of some of us (some in particular more than others) if we had not had this remarkable opportunity to sublimate what one might speculate to be some rather unpleasant tendencies. And what is to become of that young person today who has whatever those unfortunate tendencies might be, and who, 30 years ago, might have found release as an electrophysiologist? One must not think too deeply about this.

Let us now turn our attention to those would-be GOD panelists, and see if we can decipher what kind of people these might be. Admitting that what follows – and, for that matter, what has just been said – amounts only to an educated guess, DrRich submits that the GOD panelists are people you already know well, if you have worked within the American healthcare system.

These are the kids you knew in college who studied all the time and got straight A’s in all the hardest courses, buttered up their teachers, then aced their MCATs. For them the hardest part about applying to medical school was in deciding which of the many schools that accepted them they should attend. Likely, they chose one of the Ivy League ones. Their first two years of medical school – the didactic years – were much like their college experiences. They studied hard, aced all the exams, and were generally acknowledged by both faculty and peers to be at the very top of their class.

Then they reached their clinical years, and things changed. They still knew more information than anyone else, and in fact their information base continued to expand. They read all the journals, and could always quote new research findings chapter and verse. They could conjugate the Krebs cycle on demand (or whatever it is you do with the Krebs cycle), and could recite precisely which enzyme that new drug inhibited, and could say why doing so made it OK to eat pizza again.

But what they could not do was be a good doctor. They had no instinct for it; no ability to get the patients to tell them the important information; no ability to read a patient’s facial expression, or phraseology, or body language, those signs that reveal the real truth. They had no ability to discern useful information from the flood of partial and contradictory clinical evidence that is always pouring in from several sources. When time was of the essence, they had no capacity to figure out what was going on or what they should do about it. They could not adjust to changing clinical situations on the fly. In an emergency they were paralyzed, trying to match the quickly evolving situation in front of them with the static words on the printed page. And often they were klutzes.

They were perfectly cut out to learn medicine, but lousy at actually doing it. What was worse, some of their colleagues who were mediocre in the book-learning department suddenly blossomed into highly competent clinicians on the wards, and quickly became recognized as rising stars by attending physicians, while they themselves were repeatedly chastised, or ignored.

And it just wasn’t right. It just wasn’t fair. They had worked harder than everyone else, had twice the brains as those others, and had learned the material three times as well. But the way God set it up, they just weren’t good doctors.

Many of these unfortunate souls quickly left clinical medicine, and branched off into research, academics, or administration. Most of them did quite well for themselves, because they really are very smart. But they never really got over their frustration and anger over their unjust  failures on the clinical wards, a place where their obvious inferiors lorded it over them. They have now spent years engaging in cognitive dissonance, convincing themselves that their apparent failure was an illusion, merely a sign of having been subjected to the anti-intellectual, shoot-from-the-hip, do-it-quickly-and-make-more-money environment that is American healthcare. After all, how could they be sub-optimal physicians when they are clearly far more intelligent and knowledgeable than the supposed “stars?” If the healthcare system had been arranged differently, in such a way as to make the cowboys behave the right way, they would have proven themselves to be the best clinicians in the land.  It is a bitter, bitter pill.

These are the guys, DrRich thinks, who are chomping at the bit for the opportunity to sit on the GOD panels. They would dearly love the chance to utilize their superior intellectual firepower, to distill the clinical research data, to digest it painstakingly and thoroughly (not haphazardly and on the fly like those others), to put down on paper the RIGHT way of practicing clinical medicine -  and to have the authority to do it in such a way (backed up by the full force of the Central Authority) that those lesser doctors will HAVE to do it their way, at long last.

The point of all this psychoanalytic guesswork is to suggest that the GOD panelists, even the GOD panelists who are physicians, will have no sympathy for the idea that the practice of medicine should be individualized to any degree whatsoever. The idea of individualizing medical care, rather than practicing by formula from a book, is what caused these people the most uncomfortable moments in their professional lives. Far from being sympathetic to the idea, they will probably be more hostile to it than the non-physicians on the GOD panels. When somebody on the panel suggests that, perhaps, we should give the doctor a little more leeway on this particular issue, these physicians will speak up and say, “Listen. I’ve been there and you haven’t. These doctors don’t need any more rope, unless it’s to bind them even tighter.” They were themselves shown no quarter, in the tough arena of clinical medicine where outcomes (and not process or book knowledge) is the only mark of success, and they will offer none in their turn.

DrRich cannot prove any of this, of course. He is just theorizing, based on his own personal observations and prejudices, having observed many of these whiz-kids in his 25 years of teaching medical trainees, and watching where they wound up. He could, of course, be wrong.

In any case, for allowing him to carry on in this manner DrRich owes one more expression of gratitude to his Progressive friends, whose doctrine of Diversity supplies the necessary substrate, and the ethical “cover,” for mercilessly stereotyping selected groups of what otherwise might turn out to be individuals.

The Abuse of Implantable Defibrillator Guidelines

DrRich | January 13th, 2011 - 10:36 am


Last week the newswires hummed with reports that doctors from all over America are grossly over-utilizing implantable cardioverter-defibrillators (ICDs), much to the detriment of patients themselves (whose persons are being physically violated by avaricious and/or ignorant physicians), and to the hard-pressed Medicare budget (ICDs being so incredibly expensive).

These reports were based on a study appearing in the Journal of the American Medical Association, which analyzed data from the National Cardiovascular Data Registry (NCDR) in an attempt to determine the proportion of ICD implants in the US which constitute deviations from government guidelines. CNN put it like this: “Of more than 100,000 people who received ICDs, almost 23% did not need them according to evidence-based guidelines.” As the lead investigator of the JAMA study told CNN, “It’s a lot of people who are getting defibrillators who may not need them.”

Specifically the new study shows that a full 22.5% of patients receiving ICDs in the US from 2006 to 2009 received them outside of guidelines sanctioned by CMS. Furthermore, patients receiving “non-evidence-based” ICDs had a significantly higher rate of in-hospital mortality (0.57% vs 0.18%, p<.001), and of post-procedure complications ((3.23% vs 2.41%; p<0.001). Notably, ICDs implanted by non-electrophysiologists were significantly more likely to be non-evidence-based than ICDs implanted by electrophysiologists (24.8% vs. 20.8%).

The lead author stressed this latter point to “Electrophysiologists — who do these procedures day in and day out and are more likely to be more familiar with the guidelines and the evidence that supports ICD use — were significantly less likely to use these non-evidence-based devices.” And an accompanying editorial in JAMA, also written by a couple of electrophysiologists, says that the results of this study indicate that the “intensive training” which electrophysiologists undergo “may improve both the preoperative evaluation of patients as well as the operative and immediate postoperative care of patients undergoing ICD implantation.”

So this study purports to tell us several things: A) Doctors who implant ICDs are surprisingly poor at following clear-cut, evidence-based guidelines; B) As a result, patients are receiving unnecessary medical devices, and suffering unnecessary harm; and C) At least one mitigation for this problem would be to make sure all ICD implantations are conducted by electrophysiologists. Further, ominously implied in some of the news stories regarding this study is the notion that, perhaps, so clear-cut an abuse ought to be looked into by federal prosecutors, similar to cases we have heard of lately involving the abuse of coronary artery stenting.

To all this, DrRich has a few observations:

1) Guidelines are No Longer Guidelines. “Guidelines” implies, literally, a guide, a signpost, a general set of factors that one ought to take into account when making specific decisions regarding specific individual patients. Guidelines are a strong set of recommendations which (all other things being equal) one ought to follow in the majority of cases, and when one chooses not to follow them, one ought to have a good reason for making that choice.

When the use of clinical guidelines is considered in view of this now-quaint notion, one does not expect 100% compliance. After all, patients being patients, they bring to the table lots and lots of special considerations one ought to take into account when deciding how to apply guidelines. Depending on the level of evidence upon which a certain set of guidelines were established, and considering the array of variations on the mean which patients still insist on bringing to a doctor’s notice, the optimal applicability of a given set of guidelines to a given population of patients ought to look something like a bell-shaped-curve. It is not immediately obvious, for instance, that a rate of compliance with a set of guidelines of 77.5% is simply too low. Indeed, a rate of compliance with your typical clinical guidelines well north of that number might imply, when one fully considers the matter, an abrogation of the physician’s duty to make informed clinical decisions based on ALL available evidence, including those introduced by an individual patient’s specific circumstances.

As a matter of fact, the very guidelines regarding ICDs which doctors are now accused of abusing admit that “the ultimate judgment regarding care of a particular patient must be made by the physician and the patient in light of all of the circumstances presented by that patient.”

In this light, a very striking feature of this new report is its baseline assertion that the strict following of guidelines is “evidence-based” practice, while any deviation is “non-evidence-based;” that is, by implication at least, it is good medicine vs. bad medicine. And so, “only” 77.5% of ICD implanters are practicing good medicine, and that is clearly a major concern – one for which urgent solutions should be sought.

It is one thing for the government to insist that doctors follow their guidelines to the letter, or face fines or worse; it is another for physicians themselves to internalize the same paradigm. Where does that leave patients who are relying on their doctors to use their clinical judgment for their own, individual benefit?

Anyway, guidelines are no longer guidelines; they are directives. Even the doctors agree with this.

2) Most of the Patients Who Received “Non-Evidence-Based ICDs” In This Study Actually Were Indicated For ICDs. News reports of this study, and public pronouncements from the authors themselves, imply that patients in this study who received ICDs outside of the guidelines were getting devices that were unnecessary; that their ICDs, which are deemed “non-evidence-based ICDs,” should never have been implanted. This is a misapprehension.

In the large majority of cases, the deviation from the guidelines was simply in the timing of ICD implantation. Patients received their indicated ICDs earlier than the guidelines specify. CMS guidelines say that patients who are indicated for ICDs should not receive them for 40 days after a heart attack, or three months after the diagnosis of heart failure. Most deviations occurred when patients who were supposed to get ICDs got them during the 40-day (or three-month) window.

So the doctors who violated the guidelines were deciding that, for one reason or another, their patients who needed ICDs would be better off receiving their potentially life-saving devices now rather than two or three months from now.

DrRich will leave aside for now the relatively weak evidence upon which CMS based its recommendation to delay ICD implantation following a heart attack or heart failure diagnosis, and simply assert that it is probably the least evidence-based portion of the ICD guidelines, and in fact, the language in the guideline’s supporting documentation, provided by CMS itself, admits to a certain amount of aribitrariness here. (Perhaps DrRich will discuss in detail in a future post the very “interesting” process CMS followed in establishing these ICD guidelines in the first place.)

But even if you buy the notion that the delay prescribed by the guidelines is fully legitimate, there are still many good reasons one might choose not to wait. Perhaps the patient also needs a pacemaker, and implanting a pacemaker now, and subsequently removing it and replacing it with an ICD (which also functions as a pacemaker) in less than 40 days makes little sense. Perhaps the patient will soon be losing her health insurance (not an uncommon situation these days). Perhaps there are features suggesting that the heart failure is particularly unlikely to improve during the next 3 months. Perhaps there are features that imply that a patient has a particularly high risk of sudden death in the near term.

Whatever. The point is that this study does not show that 22.5% of ICD implants are unnecessary. It shows that sometimes ICDs which everybody agrees are indicated are being implanted a few weeks earlier than the Central Authority would like. The NCDR database the authors used to determine guideline compliance did not allow them to assess the legitimacy of the doctors’ decisions to implant them earlier than CMS prescribes.

Back in the 1990s, when the enlightened idea of “medicine by guidelines” was first being promulgated, it was taken as a basic tenet that, after sufficient training and education had been accomplished regarding a set of guidelines, if deviations from the guidelines still exceeded expectations, then it is necessary to consider that there may be something amiss about the guidelines themselves, and the rationale behind the guidelines ought to be formally revisited. But that was back when guidelines were still guidelines, and not directives.

3) The Important Outcome Is Conspicuously Absent In This Study. One can surmise that the main reason doctors implanted ICDs earlier than the guidelines recommend, 22.5% of the time, is that they thought their patient might experience sudden death during the waiting period. That is, they wanted to protect their patient from sudden death now, instead of two or three months from now. Maybe they were just being obstinate, or stupid, but that was their rationale.

This being the case, the critical information we would want to know is whether the early implantation of ICDs might have led to an overall difference in survival. But alas, that critical information is also not available in the NCDR database. So we know (because the authors were quick to point out) that patients who received “non-evidence-based” ICDs had a worse in-hospital mortality (a difference of roughly 0.4%), and a worse post-procedure complication rate. But what was the difference in survival at, say, one year? Did the early implantation of ICDs increase overall mortality (which is the impression the authors and the newswires leave us with), or did it reduce overall mortality by offering extended protection from sudden death? An overall reduction in mortality was, after all, what the physicians intended when they selected a subset of patients they thought would benefit from not waiting for their ICDs. And it is entirely possible that their decisions did just that.

It seems to DrRich that we might want to know this information, before we castigate too severely (or submit for prosecution) the physicians who judged that “early” ICD implantation would be the best approach in a certain proportion of their ICD-indicated patients.

4) Electrophysiologists Can Be As Self-serving As Anyone Else. This last observation saddens DrRich, himself an exceedingly humble and self-effacing electrophysiologist, as his many thousands of great admirers will attest.

The authors of this study – and the editorialists who wrote in the same issue of JAMA – are all among DrRich’s brethren electrophysiologists. All of them seem to conclude from their analysis that ICDs ought to be implanted by electrophysiologists pretty much exclusively, since we EPs are demonstrated to be (thanks to this study) more likely to follow the guidelines, presumably because we are more “familiar with the guidelines and the evidence that supports ICD use,” by virtue of our “extensive training,” our vast experience, &c.

But once again, the majority of guideline “deviations” which were seen in this study were in the timing of ICD implantation, and not in the fact of ICD implantation. In effect, therefore, the authors are arguing that electrophysiologists are simply better at counting to 40 than those other kinds of doctors. DrRich does not find this a compelling argument for instigating an amendment to the guidelines aimed primarily at protecting the electrophysiologists’ turf.

Furthermore, DrRich suspects that the better compliance with the guidelines evidenced by electrophysiologists has less to do with their superior guideline-following prowess, and more with the fact that there tends to be a built-in delay when EPs implant ICDs. Patients with fresh heart attacks and recent heart failure diagnoses are under the care of non-electrophysiologists (many of whom can implant ICDs themselves, whenever they think they ought to), while patients seen by electrophysiologists generally have to first be referred – a process that introduces a fortuitous delay, and thus, of better guideline “compliance.”

Indeed, when one considers this built-in advantage enjoyed by EPs, one must wonder at the fact that, even for patients implanted by electrophysiologists, nearly 21% still received “non-evidence-based” (i.e., “early”) ICDs. This value, statistically-speaking, may indeed be significantly less than the overall value of 22.5%. But practically speaking it is pretty much the same rate of non-compliance. Which leaves one wondering: Why are electrophysiologists – who suggest that they alone ought to be doing these procedures – themselves so lousy at following the central directives?

Perhaps they, too, need remedial counting lessons. Or perhaps they, with their superior intellect and experience and so forth, actually agree with their non-EP colleagues that delaying ICD implantation in all patients with recent heart attacks and heart failure diagnoses may sometimes (roughly a fifth of the time) be counterproductive.

But no matter. Guidelines are guidelines, which is to say, they’re directives. Following them to the letter is good. “Interpreting” them is bad. It is now apparent that even sophisticated physicians, who should know better, have completely bought in to this new paradigm on guidelines favored by our Central Authorities, and appear less concerned about the implications of this paradigm on their patients and on the practice of medicine, than about how to turn it to their own, narrow advantage.


DrRich hates to be so darned prescient.  On January 19, it was revealed that the Department of Justice has launched an investigation regarding ICD implants, as related to “proper guidelines for clinical decision making.”  DrRich tells electrophysiologists, and other ICD implanters, what to make of this rather scary prospect, here.

The Constitutionality Briar Patch

DrRich | January 7th, 2011 - 7:17 am


“Drown me! Roast me! Skin me alive! Do whatever you please!” cried Br’er Rabbit. “Only please, Br’er Fox, please – whatever you do, just don’t throw me into that briar patch!”
- Joel Chandler Harris

Quite a lot has happened on the healthcare front over the holidays, even in addition to the Telltale Pacemaker story, and DrRich suspects that more than a few of his readers – busily eating, drinking and being merry – may have missed some of it. But fear not. DrRich is committed to catching you all up.

One story even the most dedicated of you revelers might have heard something about is that a U.S. District Judge, Henry E. Hudson, has declared the Obamacare individual mandate to be unconstitutional.

This ruling has no immediate practical result, since the individual mandate is not scheduled to go into effect until 2014. But Hudson’s ruling has given a great boost to Tea Partiers, certain Republicans, constitutional fundamentalists, and other recalcitrants who keep trying to disrupt the modern Progressive program by invoking the Constitution, and other old-timey scripture, written by slave-holding, wig-wearing, pompous old white men who didn’t even like each other very much, let alone Diversity, and who had never even heard of Twitter or Facebook or 4G networks, and whose scribblings therefore cannot possibly have anything important to say to modern-day people like us. In any case, Hudson’s ruling is not dispositive, and the matter of the constitutionality of the individual mandate will finally be decided in the U.S. Supreme Court.

In a related matter, also over the holidays, President Obama phoned the president of the Philadelphia Eagles to praise him for giving Michael Vick a second chance.

Some readers will not immediately see how President Obama’s phone call to the Eagles is relevant to Hudson’s ruling on the individual mandate, but that’s what DrRich is here for. You see, Dear Readers, Mr. Obama is a very brilliant and subtle man, whose actions and words can never be taken at face value, but which (like, as it happens, the actions and words of Christ) must be interpreted in the context of the entirety of his life’s work. Accordingly, his phone call to the Eagles can only be properly interpreted if one understands (as the President undoubtedly does) that Judge Hudson is the selfsame judge who sentenced Mr. Vick to the federal penitentiary for engaging in unsavory sporting activities involving dogs.

It should be clear then that President Obama’s real message, for those few of us who are perceptive enough to understand it, is: “Judge Hudson has a history of making rulings whose ultimate result is the precise opposite of what one might originally think. His Vick ruling was seen by everybody as an action that would ruin Mr. Vick’s career forever. But, as a result of that action, Mr. Vick dedicated himself as never before to becoming a great quarterback, and has already achieved heights he might never have reached if Hudson had been more lenient. So when Hudson says the individual mandate is unconstitutional, take heart! The final effect of his ruling will be – as in the case of Michael Vick – the opposite of what everybody thinks.”

The loud protests you hear from Mr. Obama’s side regarding the challenge to the constitutionality of the individual mandate, for the most part, are genuine. Most Progressives, lacking Obama’s subtlety, are outraged that something as important and as groundbreaking as Obamacare is threatened by mere scratchings made by old men in ancient days on a piece of cracked parchment. The official defense of the individual mandate made shortly after Hudson’s ruling, by none other than Kathleen Sebelius and Eric Holder, stresses this point. These eminences (one of whom is the Attorney General of the United States for goodness sake!) were utterly unable to come up with a legal or constitutional justification for the individual mandate, and based their defense entirely on the proposition that Obamacare is really, really important, and that the individual mandate is vital to Obamacare. The notion that if something is important enough the Constitution must be pushed aside (or, more accurately, “re-interpreted” in light of modern-day exigencies) is a given for Progressives, and they just don’t understand how any reasonable person could think otherwise.

Mr. Obama, DrRich believes, looks at it differently. Let us review some basic facts:

1) President Obama favors, and is working toward, a single-payer healthcare system. He has said so publicly many times. (Here’s one example.)
2) Obamacare places us on the road to a single-payer system – either a direct single-payer system run entirely by the government, or a single-payer system which is administered by minutely-regulated “health insurance utilities.”
3) The health insurance industry is currently running out the string on its fundamentally broken business model, and desperately needs Obamacare as a pathway to a graceful exit strategy.
4) The sole reason for the individual mandate was to get the health insurance companies on board with Obamacare, that is, the individual mandate buys the insurance industry a few more years of life – one last windfall – in return for which they will become heavily regulated utilities,  and likely avoid the ignominious and catastrophic failure their current trajectory suggests.
5) On the other hand, if we instead went to single-payer healthcare like the President and his Progressive friends want – such as Medicare for all – then the constitutionality of the individual mandate would immediately become moot.

If these facts – particularly the ones about the state of the health insurance industry – are correct (and DrRich believes he has amply demonstrated that they are), then declaring the individual mandate to be unconstitutional will actually play into Mr. Obama’s hands quite nicely.

If the individual mandate is declared unconstitutional and Obamacare becomes entirely defunct, the insurance industry will remain on their path to imminent disaster. They will be forced to price nearly everyone out of the insurance market, and themselves out of business, and we Americans will be left with no obvious choice but single-payer, Medicare-for-all healthcare by default, as the only obvious constitutional option. (There are, of course, other options – such as the one DrRich has proposed – but these likely will continue to be ignored.)

Mr. Obama will go on TV and say:

“We tried! Nobody can say we didn’t. We presented our nation with a healthcare plan that would cover almost everybody, and which would save the private insurance industry. But now, the actions of the Republican naysayers have destroyed the only mechanism that would have allowed the insurance industry to continue to function.  And now the insurance companies are falling like dominoes, and uninsured Americans will soon number over 100 million.  You and your loved ones and your neighbors face imminent death or disability from Republican neglect.  We must act, and we must act now.

“I and my Democratic colleagues did not want it this way. We fought hard for our centrist, market-based plan.  But our Republican opponents and their allies in the reactionary Court leave us no choice.  My fellow Americans, as a matter of national security, and of national survival, we must pass into law, within the next 30 days, my new program to expand Medicare to cover all Americans. All other paths have been closed to us. And if you don’t like it, as I myself do not, you know who to hold responsible at the polls.”

On the other hand, of course, the individual mandate may be declared constitutional by the Supreme Court. (DrRich does not understand how this could happen under the Constitution as written, and neither, apparently, does Mr. Holder. But given the “living document” proclivities of many justices these days, one must admit it is reasonably likely to happen.) And if the individual mandate is declared constitutional, then the federal government will have been granted the authority to dictate any behavior it wishes upon individual Americans, as long as those behaviors are deemed to be important enough by the government to the collective interest.

Either outcome to the constitutional challenge to the individual mandate, therefore, will be more than convenient to the ends of President Obama. He understands this very well as he stands there, entirely serene and above the fray, watching Sebelius and Holder, and his other minions, caterwauling over the constitutional challenge to the individual mandate.

“Please, Br’er Elephant,  whatever you do, please don’t throw my individual mandate into that briar patch!”

Fugitive Busted By His Pacemaker (And His Doctor)

DrRich | January 3rd, 2011 - 6:35 am


In Durango, Florida the week before Christmas, the FBI arrested fugitives Roger Gamlin, 62, and his wife Peggy, 54, at Mercy Regional Medical Center after a doctor determined their real identities through Roger’s pacemaker.

Wanted by the feds for 2 1/2 years on suspicion of embezzling millions of dollars from their south Florida title company, Roger and Peggy had been living quiet and unassuming lives as Ron and Nancy Jenner in Durango.

Then Peggy brought Roger to Mercy Medical Center after he developed a nose bleed that would not stop. The hospital (in accordance with the sage advice of its attorneys) is not saying exactly what happened next. But we know that Roger’s true identity was determined through his pacemaker, and the FBI quickly showed up to arrest him and his wife. Roger and Peggy waived their rights to an identification and detention hearing, were placed into custody, and will be transported to south Florida to face embezzlement charges.

The reason this story made the newswires, of course, is because the fugitives were identified through a pacemaker. Pacemakers can be electronically scanned to reveal information about the patient’s cardiac condition. Every implanted pacemaker also stores information that identifies the patient. That’s apparently what did Roger and Peggy in.

The “angle” that has made this a news story is the pacemaker angle. And yes, it’s true that when you receive a pacemaker or an implantable defibrillator, it’s like receiving a subcutaneous electronic identity chip, like the one you have in your dog. Anyone with the right scanner can find out who you are. So if you plan to become a fugitive from the law, it is best not to have one of these. (Alternately, get your pacemaker AFTER you change your identity, so that it matches with your alias.)

But really, you don’t need to have an implanted medical device in order for a hospital to learn your true identity. A medical facility could find out who you are any time they wanted, by surreptitiously obtaining DNA samples, for instance, or – for extremely rapid identification – dusting your drinking cup for fingerprints and doing a computer match. DrRich doubts whether such things are occurring today. His point is that it could happen whenever somebody wanted it to happen, whether you have a pacemaker or not.

To DrRich, the interesting part of the storyline only peripherally involves the pacemaker. The real story is this:

  • A patient goes to a hospital for medical help.
  • A medical procedure is done which generates certain data for the medical record.
  • The data in the medical record is immediately cross-referenced with data from a federal database that lists persons of interest.
  • The FBI shows up at the bedside in less time than it takes to raise a nurse with a bedpan.

Now, that’s actually a pretty interesting story.

(And people wonder why the Central Authority is so hot to have electronic medical records.)

But even that is not the most interesting angle. What DrRich wants to know – the angle he would explore if he were writing this up for the Sunday Times – is: What was the doctor thinking?

You’re an ER doc. A guy comes in with a bad nosebleed. You stabilize the bleeding, but the guy looks pretty pasty and you’re worried about his heart, so you interrogate his pacemaker. (Here’s the first red flag. For an ER doc, interrogating a pacemaker – not a routine procedure in most emergency rooms, and one which yields only sparse information about the status of a patient’s heart – is generally pretty far down the list of things to do. Could it be that Roger is acting suspiciously, and you want to find out whether he is who he says he is? If so, you are no longer acting as a doctor, but as an agent of the government.) In any case, whether intentionally or not, you learn that the patient has checked in under an alias.

So now what do you do?

There are some things you need to consider as you decide what to do. First, you have established a doctor-patient relationship with Roger, which binds you to confidentiality – unless you believe Roger is an imminent threat to himself or others. But simply using an alias does not constitute an imminent threat to anyone. Besides, using an alias is not necessarily illegal. Samuel Clements used one, and so do most people who work in Hollywood. And how many times has Barack Obama changed the name he answers to?

Second, you yourself might get into trouble if you look into the matter. For instance, if Roger were an illegal alien and you took it upon yourself to escalate the matter of false identity, you could get into serious trouble. After all, the U.S. Attorney General has determined that an Arizona law is unconstitutional which would permit police officers to investigate the actual identities of suspected illegals who are detained for other offenses. And you are not even a police officer, and Roger is not being detained for an offense, but has come in to seek medical assistance. Furthermore you are well aware that if a suspected illegal alien shows up in your ER, you are supposed to treat him/her without asking any questions about identity or legal status.

But you determine that Roger does not look Hispanic (or Arabic) – a determination that by any reasonable definition would constitute racial profiling – and so is not likely to be a member of a protected group.

DrRich thinks you are thinking like this: “This man is obviously using an alias – so what is my obligation here? In the old days my obligation would be to honor the confidentiality of my patient, who, for possibly very legitimate reasons, has altered his identity. But it’s not the old days. Now, I’m obligated to do what’s best for the collective, and only secondarily what’s best for this patient. I suspect the collective would like to know about this guy, to check him out. It’s a little risky – what if he turns out to be an illegal from, say, Argentina? A lot of people from Argentina look European. But that risk seems small, and if he is some kind of fugitive from the law I would be doing a great service to my overlords.”

So you rat him out.

We indeed have come a long way. Not only have our doctors apparently lost their scruples, but we also appear to have already arrived at a place where medical records can relatively seamlessly interface with other federal databases. Once medical records become fully electronic, patients needing medical aid will have a lot to consider. Are you an embezzler on the lam? Are you behind in paying your income taxes? Are you a parking ticket scofflaw? Do you have erectile dysfunction, or venereal disease? (These latter conditions cannot get you arrested – as of yet – but we know that all databases controlled by the government, no matter how “confidential,” also interface seamlessly with WikiLeaks, and so the publication of lists of patients with embarrassing medical conditions always remains a possibility.)

Once again, DrRich marvels at the fact that, soon, the only safe way to get your healthcare will be through the black market.