Subjective vs Objective Clinical Data: BP Edition

(by whizbang) Feb 06 2015

In medicine, we collect several types of data about patients and their problems. Some is subjective, the stuff the patient tells us - what hurts, where, and why. Then there are the objective findings from our exam and tests.

Guess which type of data we trust most?

Of course, there is another category now of objective data collected by the patient via home monitoring devices. Some of these data are recorded by the device and downloaded into our systems, making patient fabrication or manipulation very difficult. Values written by the patient into a log may not be exactly what the device said.

Before glucose meters had recording capabilities, we all saw patients who never had a reading above 140 but their Hb A1c ran 10% (Hb A1c is a measure of glycated hemoglobin and reflects the average blood sugar reading for the prior 3 months). Now meters have memory; some even have connectivity so they can alert care providers of developing problems.

We need to address these issues for blood pressure measurements.

We have the ability to measure blood pressure around-the-clock, the 24 hour ambulatory blood pressure monitor (ABPM). This provides the gold standard for on-the-hoof blood pressure readings, and we know that our office reading often run high (from white coat hypertension) or may be more normal than the patient (masked hypertension). Readings done at home, work, or school often reflect the patient's true blood pressure better than our office readings, at least under controlled study situation.

But then there are those pesky human issues.

When someone hands me a log book and every reading is 120/80 with no variation, I have a hard time suspending disbelief. Patients want to please their providers most of the time, even though having hypertension can be bad for them. As payors begin to audit our records and reward us for quality of care, we get little notes about things we should respond to: have you considered monitoring complication X? Have you started this drug?

I'm waiting for the one about the hypertensive reading in my office with a patient who has normal outpatient readings. After all, the only blood pressure I can really guarantee was done correctly and recorded accurately is the one in my office.

My own blood pressure cuff sends its reading directly to my smartphone. I can send values to my provider from there, adding a level of objectivity to the process. However, not everyone can afford this cuff and a smartphone. We need an automatic cuff system with the connectivity built in at an affordable price point.

While we're at it, ABPM capabilities would also be sweet. How much trouble could it be to have an option in the app to take blood pressure at intervals for a 24 hour period and then send it to a provider? Even with great monitoring, my patients cannot check their pressure during sleep.

So how about it, health tech firms? In this brave new world of wearables can we have better blood pressure monitoring at a lower price?

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They MOC Us

(by whizbang) Jan 14 2015

Maintenance of Certification (MOC) presents a challenge for me and others trained in my time frame. Before my class, physicians took exams after their post-graduate training and obtained life-long certification in their specialty. My class was the first to be issued time-limited certificates in Pediatrics. What has this meant over time as I have sub specialized and grown older?

A lot of money and pain. MOC has proved so tedious that The New England Journal of Medicine featured articles about the practice in its January 8 issue. One, Boarded to Death, was contributed by Paul S. Teirstein, MD, a physician whose petition to change the process has been signed by 19,000 doctors. 

Since I was in the first wave of time-limited physicians, I have a “historical” perspective on this issue. My initial exams in general pediatrics and pediatric nephrology both occurred in hotel ballrooms. Each cost about $1,000 plus time off of work and travel costs. 

General Pediatrics Recertification (Early 1990s)

In my first job I supervised residents on the inpatient pediatrics service each year. When I had to renew my certification, the process cost about $1,000 (similar to the original exam), but otherwise proved pleasing. The exam came on disks that I ran in my own computer. I had a time limit (in weeks) to complete it once I loaded it, but otherwise I could do as much research as I liked. The questions generally dealt with important clinical topics, and I received immediate feedback about the results. There were several things I learned through this process. Stuff not relevant to my life as a nephrologist had been published, and I had completely missed it! I pulled papers and looked stuff up! I learned a lot, and it was easy to fit into my life as an academic clinician-scientist starting up a lab. 

This format cost money and time, but overall I felt the process was rewarding and useful.  If they had stuck with this, I might still be certified in general pediatrics. Yup, it was that good.

First Pediatric Nephrology Recertification (2003)

By this point, the powers that be had decided that an open-source exam was not appropriate. No, we doctors needed a “high-stakes” exam. I had to find a testing center and take a supervised exam. This meant studying and taking off a day of work; lucky for us, most cities with an academic medical center will have a testing center. A few weeks after the exam, I received my score (passing!) and a summary of the question areas and my score for each category. My weakest area was transplantation; not exactly surprising, since other areas of nephrology have always interested me more.  

This format cost money and time. The proctored exam annoyed me; I could not take my jacket or purse into the exam room. Let’s face it, no doctor knows every fact that they need to know. However, the questions dealt with reasonable topics. Any competent nephrologist should be able to pass this exam.

General Pediatrics Recertification (Late 1990s)

The general exam now required a secure test center. As my new employer no longer required this certification, I opted out. I simply could not justify the cost of the exam, the cost and time off to take a review course (my only hope to pass), and the other annoyance of something not required. 

Next Pediatric Nephrology Recertification (2013)

By this time, recertification has grown into full-blown MOC. Once again, the cost was around $1,000 for a ten-year period. Requirements over that time included:

  • Maintaining valid, unrestricted state medical license (with its own requirements for continuing medical education hours)
  • Educational and quality improvement modules approved by the Board; these could also count for continuing medical education hours, but might conflict or duplicate other activities required elsewhere
  • Another exam at the testing center

 The medical license is pretty easy; if I don’t have that, being board certified is pretty useless. The educational module could be fulfilled by subscribing to a monthly Question and Answer publication sold by the Board (can you say more money). I enjoy this piece of the effort; I learn stuff. The quality improvement modules proved annoying. The ones relevant to my job duplicated efforts my employer had in place (prescription writing, hand washing, weight control). I got through the two required, but the process was generally useless. The cry about this part resulted in the Board agreeing to certify centers (more money) to produce their own modules. Finally, my exam this time included scanning with a metal detector. The questions seemed more esoteric than before, and when I got my letter, it told me I passed. No feedback on areas that might need improvement. Just a score and the cut-off.

The Future of MOC

Compared to Dr. Teirstein, my lot seems light. He is trying to maintain certification in several subspecialties. The time away from my other duties is less problematic for me, and the educational efforts supplement my other academic activities. When we arrange things so institutional quality projects can count for MOC, that part will also be less problematic.

The point many physicians have made regards the secure exam. Physicians simply do not have to remember information the way they once did. I can pull up drug information and other references on my smart phone in the exam room. If I did need to know which interleukin was secreted by a lymphocyte expressing certain markers (an actual question from my last exam; clinically relevant my ass), I can have the answer in about a minute. I am sure the person who wrote that one (a) studies the immune system and (b) considers it relevant, but I still do not know the answer. No one has yet died from this knowledge gap.

In addition to MOC, our institutions have placed further training burdens on physicians. Time here and there, even at no formal cost, adds up. I especially love reviewing fire safety on an annual basis. RACE never changes, you know.

Some form of ongoing education and certification requirements seem reasonable. I have seen some doctors who have not kept up, and it did affect patient care. However, the current system seems as much about income for the Board as it is about quality of care. We have to be able to make it less of a burden, or physicians will just go without it. And then it serves no purpose.

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Meaningless Use

(by whizbang) Jan 12 2015

Unfortunately, I have a prior engagement that prevents my participation in a TEDMED Hangout tomorrow. The topic is important: why do we not discuss socioeconomic and other social factors routinely when we know that these items influence health? As the website states:

We’ve all experienced a doctor visit. The physician measures your blood pressure, pulse, breathing, and temperature. They may ask about personal or family history of specific diseases or even inquire about eating or exercise habits. Rarely, however, do they ask about your income or education, access to healthy foods, the safety of your home, or the stability of your personal life. And yet, we know that 40 percent of one’s health is shaped by socioeconomic factors, and only 20 percent by clinical care.

The site implies that these factors could be another vital sign. I would not put them in that category (just as I would not have made pain a vital sign), but I do agree that we don’t think about these things enough. After all, how can my patients follow my advice when

  • The neighborhood may not be safe for outdoor activity that would help the child with weight control
  • The family can only get to a convenience store; if they pay for transportation to a grocer, they have no food money
  • The parent and patient cannot understand the instructions, even after discussion in clinic and reading the written stuff the electronic medical record prints out (meaningful use can be so meaningless)
  • The parent moves the family frequently because of an abusive ex, making support services difficult to maintain

As physicians, our training allows only the most superficial assessment of these issues. We need specialists in these social issues, people known as social workers! However, in the current reimbursement climate, these services often get cut. 

In a time when economic pressures force us to see patients in less and less time, we need to recognize the need for multidisciplinary more than ever. I hope that events like this one can get the conversation going. I also hope that the role of crushing poverty in bad health gets more attention.

One way or another, we all end up paying for these inequalities. 


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End of Vacation

(by whizbang) Jan 07 2015

Vacation officially ended on January 5, when our son drove back to the tundra and I went back to the office. The patient call backlog did not overwhelm me, and I feel pretty good about the job right now. 

My blogging spirit has not yet caught up with that “put your nose back on the grindstone” mood yet. I have found a couple of nephrology topics that I am reading about for the future. 

For now, I will wish everyone a prosperous new year. 

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Another New Year

(by whizbang) Dec 31 2014

2015 is almost upon us. I am still enjoying time with my son who is home from college. I am also beginning to work with my daughter to plan her upcoming wedding (FINALLY!!!!!).

Hope your New Year is happy and your resolutions attainable! Last year, I set out to finish my book. AND I DID IT!

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Christmas Lyrics That Make Me Giggle

(by whizbang) Dec 24 2014

The Carpenters, a 1970s sibling duo, are the only ones I know that covered this song, Merry Christmas Darling (full lyrics here). The following lines always crack me up:

Logs on the fire
Fill me with desire

Read more: The Carpenters - Merry Christmas Darling Lyrics | MetroLyrics

Yeah, wood can do that...

Here's the story of the song:

Richard Carpenter composed the music for this song in 1966 when he was 19 years old. Frank Pooler wrote the lyrics twenty years earlier, in 1946, when he also was only 19 years old. The song Pooler had written was to be a Christmas gift for his girlriend, whom he was missing while being away from her during a visit with his parents at Christmas time. However, their relationship ended before he could present it to her.

Twenty years later, Pooler was the choir director at California State University in Long Beach, when both Karen and Richard Carpenter were members of the choir. Richard and Karen were performing locally and had tired of playing the usual Christmas fare. Richard asked Pooler, their favorite professor, if he had any ideas for different Christmas songs.

Pooler remembered the Christmas song he had written many years before and mentioned it to Richard, adding that he didn't think much of the melody anymore. Richard said he would try his hand at writing new music for the lyrics. Within about 15 minutes he was finished creating a song, written by two teenagers who were a generation apart, that was destined to become a Christmas classic.

The song was first released as a single (yes, a 45) on November 20,1970, and earned gold record status. This song sparked the idea of a Christmas album by The Carpenters, and on October 13, 1978, "Christmas Portrait" was released with this newly recorded version of the song. Karen re-recorded her vocals for the album version as she felt that she could give the vocals a more mature treatment. This newly recorded version was presented on their TV Christmas special in 1978, as seen here, and became a hit all over again.

And here is Karen Carpenter performing it in their Christmas special:

Happy Holidays to everyone, and as many logs as you desire...

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Coal for Insurance Companies

(by whizbang) Dec 22 2014

Companies providing drug coverage have a perfectly legal way of making patients pay more for drugs. It's all there in the fine print, and I bet you don't even know it.

Your plan likely specifies co-pays for drugs, generics vs brand names, and 30 days vs 90 days. Seems straight-forward, but the fine print actually specifies "up to" a 30 day or 90 day supply. Now, for pills, this language does not matter. For injectable medications, it does. Many shots come in pens and vials with a specific amount of drug in them. The company has probably based each container on a typical dose of some sort, but many patients may need more or less. If that difference is less than a full container, then the insurance company rounds down. Here's the math assuming each container contains 300 units of medication:

Typical Dose = 30 units per day

30 days = 900 units = 3 containers

So what happens if we raise the dose:

Higher Dose = 35 units per day

30 days = 1050 units = 3.5 containers

The company only allows 3 containers to be dispensed (remember, up to 30 days), or a 25 day supply.

What happens if we lower the dose:

Lower Dose = 25 units per day

30 days = 750 units = 2.5 containers

Once again, the insurer rounds down, in this case to 2 containers, a 24 day supply.

Let's assume the monthly co-pay for this drug is $30. The typical patient pays $1 per day out of pocket, while the higher dose patient pays $1.20 per day ($30 per 25 days), and the lower dose patient pays $1.25 per day! Obviously, this calculation does not take into account the annoyance and cost of trekking back to the pharmacy more often. For patients on a tight budget, a 24-25 day refill cycle may leave them reducing or skipping their medication until funds are available. After all, most of us get paid on a monthly or every two week cycle.

Yes, this practice is legal, but I bet Santa knows it's a scam and is updating his naughty list.

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Oops: Repost of Subtle Spirit of the Season

(by whizbang) Dec 19 2014

I accidentally posted this a few days ago in some obscure corner of the Scientopia site. It received little attention, and I'm still looking for movies with a holiday twist that are not in-your-face Christmas movies. To that end, I'm re-posting here.


Sure, there are CHRISTMAS flicks, movies that focus on the holiday. Think Elf, White Christmas, Christmas Vacation...I'm sure you can come up with many more.

I would like to collect less in-your-face holiday films. I will start with some favorites, but I would love to collect more. Sometimes you just need a good movie that fits your mood.

  • An Affair to Remember - You youngsters probably learned about this one from its stalkerish spin-off, Sleepless in Seattle. The original starts with two people otherwise committed falling in love on an ocean cruise, then deciding to figure out how to support themselves before marrying. Tragedy ensues, and they do not find their way to each other again until...Christmas! Have wine, chocolate, and tissues available if you do not know the details.
  • Meet Me In Saint Louis - This musical follows the lives of a family through a year preceding the World's Fair in St. Louis, MO. The climax occurs on Christmas eve with Judy Garland singing Have Yourself a Merry Little Christmas. Everything ends well, of course, at the 1904 Exhibition.
  • Auntie Mame - This one is a year-round favorite, in part because I would like to be "that aunt." Free spirit Mame becomes the guardian of her nephew, despite the general disapproval of her brother and the banker that pays for the boy's upkeep. When Mame loses her money in the crash of 1929, she Needs a Little Christmas Now. Decorations go up in early November (not as early as the stores today) with the song explaining her need for some holiday cheer. Rosalind Russel turns in a wonderful performance, and the scene where she entertains her nephew's fiance and parents will make you wet your pants. If you have never watched this one, stop whatever you are doing and find it.

I will provide one additional bonus film that through chance became part of our holiday traditions. Dogma does not include any Christmas portions, but it came on while my daughter and I were baking Christmas cookies a few years ago. She was aghast that I had never watched it, and I agreed that it was an excellent adventure in religion. She gave me a copy, and it became our cookie-baking flick. It's not for everyone, but keep an open mind. At it's heart, it really has a nice message for the faithful.

What movies do you associate with the season? Comment below!!!

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What's New: #ISpyPhysiology

(by whizbang) Dec 11 2014

The last day or so I have engaged with other members of the American Physiological Society's (APS henceforth) Communication Committee. We kicked around all sorts of ideas for improving outreach to the non-physiologist world, as well as continuing internal communication in an effective manner. Since I had my twitter feed open during the meeting, I tried out one of our hashtag ideas:


The idea of the hashtag is to highlight physiology in everyday life. The link in the tweet takes you to this infographic, Cleveland Clinic's Top Ten Healthcare Transformations for 2015. Let's take a look at the physiology of a couple of these innovations:

  • Mobile stroke units: Strokes, or cerebral vascular accidents in doctor-speak, cause death and disability in lots of people. Basic science study of the brain and its response to loss of blood flow reveals that rapid response to an event can minimize the damage and improve outcomes. These data (many from animal studies) resulted in rapid-response stroke teams in many US hospitals so that patients get their clot-busters ASAP. Taking that one step further is the stroke-mobile, with personnel who can initiate treatment while the patient travels to the hospital. As time = brain, this seems like a winning approach and an excellent result of brain physiology studies.
  • PCSK9 inhibitors for high cholesterol levels: Despite the widespread, near-universal prescribing of statins, many people still have elevated cholesterol levels and high risk of heart disease. This new class of drugs reduces bad LDL cholesterol. Antibodies to proprotein convertase subtilisin/kexin type 9 (yeah, that's why we abbreviate these things) give doctors another weapon for patients who respond inadequately to other measures. Finding this enzyme that controls cholesterol resulted from studies of normal metabolism in cells and animal models. In other words, Physiology!

I am not waiting for approval or permission (I'm a badass that way); I am plowing ahead with #ISpyPhysiology and invite all my physiologist friends to participate. Read your newsfeed, mine your twitter feed, and find examples of physiology affecting everyday life. They are out there waiting!

We just need to spy them!

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No Permission Required

(by whizbang) Dec 09 2014

One of the most valuable things an academic can do requires no permission from your supervisor. While some departments and groups perform the activity formally, many faculty do it on their own. It should not be a solo activity, though. Strength comes from input from others.

I am talking about the CV review.

In The Ivory Tower, your CV is your life and the most important part of your promotion and tenure packet.

Hosting a CV review is pretty simple. I have a guest post up over at Tenure She Wrote detailing how you can make this happen. When you're ready to have your event, you can also download a CV review worksheet from the website for The Promotion Game.


You can also still score a free copy of the book by signing up for the newsletter or following the book on Twitter. 1 in 5 will win!

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