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Educating the Public About SCA and AEDs: Remembering Fred Thompson, Age 19 December 21, 2011

Posted by Joshua M. Cooper, MD, FACC in Education, Sudden Cardiac Arrest.
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I posted the following comment on an internet news column that reported the sad story of the sudden death of a young athlete, named Fred Thompson.  To save young lives (and also middle-aged and older lives), it is *critical* for the public to understand the difference between a “heart attack” and “sudden cardiac arrest,” so that bystanders can use an Automatic External Defibrillator (AED) even before the ambulance arrives.  My posted comment was intended for the lay-public, hoping to reach at least one person who may witness a sudden cardiac arrest event and then have the knowledge and courage to act: (more…)

Transition from EP Fellowship to Practice July 22, 2011

Posted by Joshua M. Cooper, MD, FACC in Education, EP Physicians.
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There are many milestones that physicians reach during their training and career, but perhaps the biggest step is the one where the tables are suddenly turned – the transition from training to practice. All at once, we must decide on the type of career we want, where we wish to live, how to balance our work and personal life, how to manage our finances, how to document and consent and bill and communicate, how to make independent decisions, how to teach, and how to take on the ultimate responsibility for the well-being of our patients. It can be an overwhelming time, with all the choices and the new burdens that we must bear, but it is also the most exciting transition we will ever make. (more…)

Health Care Quality Improvement: How Can It Be Achieved? February 21, 2011

Posted by Joshua M. Cooper, MD, FACC in Health Policy.
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Improvement in the quality of health care delivery will not only improve patient well-being, but it should also result in a major reduction in costs. Imagine the savings that would come from fewer repeated procedures, fewer complications, fewer duplicate imaging studies, better patient evaluation, and better outcomes. But how can health care quality be skillfully evaluated, given the great spectrum of specialties and expanding medical knowledge?  (more…)

Education, Disclosures, and Bias, Oh My! (Part Two of Two) January 24, 2011

Posted by Joshua M. Cooper, MD, FACC in Education, Industry.
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Part 2: Evaluating the Paradigm of Industry Sponsorship of Medical Education

In my previous entry, “Part 1: The Case for In-Person, National Meetings,” I made the argument that medical education programs remain necessary to maximize the quality of health care delivery, and that in-person learning opportunities are likely more effective than computer-based self-study modules or webcasts. In fact, in this era of rapidly-growing medical knowledge and rapidly-shrinking training time for residents and fellows, one could argue that medical education programs are more vital than ever before. (more…)

Education, Disclosures, and Bias, Oh My! (Part One of Two) August 6, 2010

Posted by Joshua M. Cooper, MD, FACC in Education.
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Part 1: The Case for In-Person, National Meetings

In this time of hyper-scrutiny of financial relationships between health care providers and industry, medical education is an arena that requires some reflection, as industry-sponsored programs may be at risk of extinction.

Before reaching the issue of what role industry should have in supporting medical education programs, the fundamental question is whether or not medical education programs should be continued at all. The answer is a resounding “Yes,” in my opinion. The practice of medicine is evolving at such a rapid pace, that only through discourse, teaching, and interaction, can health care providers (especially those with fewer opportunities for daily collaboration) attempt to maximize quality and keep up with the ever-changing standard of care (See my previous post, “Silo Busting“).  (more…)

Silo Busting: Why I Attend HRS Scientific Sessions May 18, 2010

Posted by Joshua M. Cooper, MD, FACC in EP Physicians, Scientific Sessions.
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It is human nature to develop a routine in our life and career. As we care for patients, perform procedures and think critically about medical and scientific issues, we tend to establish fixed patterns of behavior and thought. Our practice is molded by our prior training, personal career experiences and exposure to the experience of others in the form of publications, conferences and conversations. I would argue that the last factor is the most important one – the exchange of ideas and observations with colleagues from other institutions. These are the influences that keep us centered and on track.

When we become insulated from outside influences, we may easily establish a practice pattern that veers off from the mainstream, occasionally to the point of failing to adhere to the standard of medical care. The concept of practicing medicine without sufficient outside influence has been metaphorically likened to a grain silo because of how a silo both stands out from the surrounding scenery and creates a firm barrier between its contents and the outside world.

(more…)

Advisory Advice April 12, 2010

Posted by Joshua M. Cooper, MD, FACC in Education.
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I can summarize my desires for dealing with device “recalls” in one word: transparency. When making medical decisions with patients, the benefits and risks surrounding a treatment choice must be weighed against those of alternate options. Whether discussing new device implantation or possible replacement of an advisory device, health care providers must be able to understand, as fully as possible, what is the frequency and nature of device failure, how might it manifest, and how does the risk change over time? In other words, we must understand the nature and magnitude of the risk in order to have proper discussions with our patients and help them make intelligent decisions.

Fortunately, when advisories have been issued in recent years for a particular pacemaker, ICD, or lead, the failure rate in that model has been in the range of 0.01% up to a few percent (usually less than 1% of devices are affected). And many of these failures can be detected before there are clinical repercussions. With regard to new device implants, which clearly would not include advisory devices, the risk of random component failure or future device recall is far outweighed by the benefits that these devices afford. And so, while the informed consent process should involve a discussion about the small risk for device failure, this risk should almost never sway the decision of whether or not to implant. The decision of whether to replace an advisory device is complex and should be made on a case-by-case basis. A few elegant decision analysis models have been developed that give perspective to this question (including Amin et al, JAMA 2006 and Priori et al, JCE 2009, which demonstrate that device replacement is generally associated with greater risk than simple monitoring for failure (except when the failure rate is high or in pacemaker-dependent patients).

But the purpose of this entry is to articulate my firm stance that health care providers must be provided with prompt, complete, up-to-date information about device advisories so that appropriate conversations and decisions can be made with our patients. When information is released in a guarded, sequential, piecemeal fashion, it can garner skepticism and erode trust. I do appreciate the medico-legal concerns that might impede full disclosure, as well as the desire to avoid giving hasty, incomplete data that later require revision. I am a bit less understanding of the concept of withholding data under the notion of protecting proprietary information. (more…)

Taking Clinical Trials with a Grain of Salt March 30, 2010

Posted by Joshua M. Cooper, MD, FACC in Science & Research.
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I must confess that I am not a big fan of clinical trials, given the many ways that they can provide misleading information. In my opinion, the fatal flaw of clinical trials is the assumption that the enrolled subjects are biologically homogeneous. And a close second is the belief that we understand and have accounted for all the variables that impact the study hypothesis. In virtually every trial, there are patients who benefit from the therapy and those who are harmed. While the aggregate results may point toward benefit or harm, how do we know if the solitary patient sitting in the office will be in the majority? It might be exciting to the statistician to discover how a group of 5,000 heart failure patients would best be treated, but to the clinician, it can remain agonizingly unclear what to do with the individual.

Here are a few examples of how I believe trials may lead us astray.

1) A simple randomized trial of  beta-blocker use in patients with vasovagal syncope may show no statistical difference in the number of syncopal events on or off the drug.  I cringe when I hear someone proclaim that “Beta-blockers do not work for vasovagal syncope!”  How foolhardy. Of course beta-blockers work for vasovagal syncope – but not in everyone. I have treated many patients where daily pindolol or acebutolol has been life-changing. The biologic heterogeneity in the mechanisms of vasovagal syncope and response to pharmacologic intervention can easily account for a negative trial and, regrettably, the inappropriate unconditional rejection of beta-blockers by the naive clinician.

2) A large randomized trial of biventricular pacing in heart failure patients with a wide QRS overwhelmingly shows a benefit in both morbidity and mortality. Practice guidelines declare a solid indication for bi-v pacing in cardiomyopathy/CHF patients with a wide QRS.  And yet, we are learning that not all bundle branch blocks portend a vigorous response to CRT.  The right bundle branch block patient minority (who probably derived much less benefit, if any) might have been carried along with the triumphant left bundle branch block majority (who likely had an even greater response than the mean result would suggest).  And the same goes for those patients who squeaked into the trial with a QRS of 125ms.  The heterogeneous response of trial subjects to CRT is under-appreciated when only the average result is considered, and, consequently, a subset of patients who are now being implanted (supported by guidelines) will derive no benefit and may be harmed by the treatment. (more…)

The Importance of Taking Time to Take a History March 15, 2010

Posted by Joshua M. Cooper, MD, FACC in Education.
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Case: A young woman came for a second opinion for palpitations after seeing a cardiologist and an electrophysiologist. After wearing an event monitor, she was given the diagnosis of inappropriate sinus tachycardia and was given an option of either beta-blockade or sinus node modification with possible pacemaker insertion. A review of the monitor strips  revealed likely sinus tachycardia, given the P wave axis and warm up/warm down pattern. After a detailed history was taken, it was found that the palpitations would always follow a period of feeling jittery and sweaty. These episodes occurred more often when the patient awakened in the morning or skipped a meal, but her symptoms would resolve promptly after she consumed simple carbohydrates (not including vegetables).One of her relatives owned a glucometer, so I recommended that she check her blood glucose level at the time of the symptoms.

At a follow-up visit, the patient reported that her blood sugar was always low (50-70 mg/dL) at the time of the symptoms, so I knew we were dealing with hypoglycemia and appropriate sinus tachycardia. Obviously beta-blockade would be counterproductive by masking hypoglycemic symptoms, and an EP procedure was clearly not indicated.  The young woman is now seeing an endocrinologist. (more…)

How can we Prevent the Erosion of Academic Teaching? March 2, 2010

Posted by Joshua M. Cooper, MD, FACC in Education.
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All residency and fellowship-trained physicians are beneficiaries of post-graduate medical teaching at academic medical centers and teaching hospitals. We can all recall our favorite clinicians and teachers — mentors who perhaps inspired us to train in a particular field, or molded us into the physicians we are today. These mentor physicians specifically chose academic careers because of their devotion to teaching and research. While the latter pursuit can yield budgetary support in the form of research grants, teaching does not typically have a dollar value assigned to it, and is not directly remunerative for the physician, hospital or medical center.

In the current health care environment, where the problem of skyrocketing health care costs looms large, significant reform efforts are being directed toward reducing reimbursement for services. Can anyone think of any other career/business where, in the setting of inflation and innovation, payments are reduced as time moves forward? (more…)

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