Dr John M

Update on anticoagulation for atrial fibrillation: Encouraging news for rivaroxaban (Xarelto)

2013-05-23T03:29:07Z

It’s time to do an update on the treatment of atrial fibrillation. It’s been a while, and there are worthy things to report from the real world.

Stroke prevention in AF:

Always start with basics: The most important aspect of treating atrial fibrillation is preventing stroke. Although there are some innovative devices and procedures in development, the only proven way to prevent stroke in patients with AF is to use drugs that block coagulation—anticoagulants. (I used to call them blood-thinners, but that’s not accurate; the blood is the same viscosity on or off an anticoagulant.)

In recent years, three novel oral anticoagulants (dabigatran (Pradaxa), rivaroxaban (Xarelto) and apixaban (Eliquis)) have been approved as alternatives to warfarin for patients with AF. The evidence base in support of these new agents is robust. More than 50,000 patients across the world have been enrolled in studies comparing novel anticoagulants head-to-head with warfarin. The results were clear: the new agents were either equivalent or superior in both efficacy (stroke prevention) and safety (bleeding). There was also a consistent trend towards lower mortality with the novel drugs. Other advantages of the new agents include convenience (no INR testing), lack of dietary or drug-drug interaction and rapid anticoagulation after an oral dose (rather than days for warfarin).

But there are headwinds as well. The new drugs are costly, for some, unaffordable. The drugs may be more convenient for patients, but it’s a different story for office staff toiling in the bloated US healthcare system. I know a medical assistant who spends almost every day, all day, just doing pre-authorizations for novel anticoagulants. Five to ten minutes per patient turns into a full-time job with benefits, just for sending information—in triplicate—to insurance companies. Imagine that.

Dabigatran (Pradaxa):

Being first to the marketplace cut both ways. On the one hand, Boerhinger Ingelheim got a head start in a market that had waited nearly 50 years for a warfarin alternative. To say people were excited to have something better than a rodenticide would be a severe understatement. Once approved, dabigatran use soared.

Irrational exuberance usually ends the same way. It turns out there was a steep learning curve with dabigatran. Investigations of early bleeding reports exposed errors in prescribing and clinical judgment. To be fair though, most of the adverse events were simply bleeds that occur when one blocks coagulation, which is the tradeoff when trying to prevent stroke. This notion was born out in subsequent reports of dabigatran-related bleeding events, which failed to reveal a signal of harm. Logic aside, it did not take many adverse event reports to spark the “Bad Drug” ads in mainstream media.

Dabigatran has two other pesky issues: First, in at least 10% (probably closer to 20%), patients experience stomach and esophageal discomfort with the acidic capsule. These are real problems that I have seen range from minor nuisances up to esophageal ulcerations. This is a big issue because patients often feel bad with their AF; it’s not good when their new drugs make them feel worse. Plus, there’s a lot of education to cover with AF; getting bogged down in dealing with stomach pain from an anticoagulant distracts and creates extra work. Finally and not to be dismissed easily: dabigatran must be taken two times per day—a tough ask for many.

Rivaroxaban (Xarelto):

These problems paved the way for rivaroxaban (Xarelto). The once-daily drug is well tolerated and does not often cause stomach pain. The convenience of once-daily dosing is huge. Studies show adherence is better with medicine taken one time per day.

Yet rivaroxaban started slowly. Clinicians were worried the drug wasn’t as effective as dabigatran or warfarin. The Rocket-AF trial showed rivaroxaban to be non-inferior to warfarin, while dabigatran and apixaban could boast superiority from their trials. In fact, debate over Rocket-AF was heated, and the drug had a tough FDA hearing. Then, once approved, it entered a landscape marred by bad-drug ads. Insurance companies make (emphasis on present tense) it tough too; they aren’t paying for a new drug without adding hurdles. (Five to ten minutes of extra paperwork per patient adds up to…)

I was tentative about rivaroxaban for a different reason. As a proceduralist, I was worried that the new anticoagulant had not been tested in AF patients destined for procedures. Unlike dabigatran, which has a solid evidence base as an effective peri-procedural anticoagulant, there was simply no data with rivaroxaban. Could I use it before cardioversion or AF ablation? Would a once-daily non-inferior anticoagulant stand up to the rigors of left atrial ablation? Was it worth switching a patient doing well on rivaroxaban to warfarin before their procedure?

I am happy to report some early information on peri-procedural use of rivaroxaban.

There were 5 studies presented at the Heart Rhythm Society sessions earlier this month. The data were encouraging. For those interested in the medical details, I summed up the abstracts in a short post over at Trials and Fibrillation on theHeart.org.

The presented data mirror my experience. Over the past year, I have yet to see a major adverse event with rivaroxaban, and this experience includes cardioversion and AF ablation. I asked around and my colleagues echo the same sentiment. Although early, and I could be wrong, I don’t think this is fluky. Consider that in the Einstein-PE trial, rivaroxaban, albeit at a higher dose, proved to be an effective strategy to treat pulmonary embolus (blood clot in the lung.) This is significant because PE is a disease that requires potent anticoagulation. That rivaroxaban worked so well speaks to its anticoagulant effects.

Apixaban (Eliquis):

I have not used the newly approved drug enough to render an opinion. Its clinical trial boasts the most impressive data against warfarin, and apixaban is the only one of the new agents that can claim a mortality reduction. As a twice-daily drug, adherence will be an issue. I’ll give you an update when I know more.

Conclusions:

Drugs that block normal coagulation increase the risk of bleeding. That’s how they prevent strokes. It’s a trade-off. The cost of preventing stroke is an increased risk of bleeding. In patients with AF and risk factors for stroke (high blood pressure, diabetes, prior stroke, weak heart muscle, vascular disease, female gender and age > 65), multiple trials have shown a net clinical benefit in favor of anticoagulation. But we must be mindful of two important issues: the risk of stroke in AF is not binary (yes or no); rather it varies depending on associated diseases. (See CHADS-VASC score.) Patients at higher risk of stroke enjoy more risk reduction from anticoagulants than lower risk patients.

Second, and most important, the decision to take an anticoagulant should be a shared one between patient and doctor. The risk of stroke on and off anticoagulants should be presented. Bleeding risk should be considered as well. I never tell my patients they need to take an anticoagulant. I simply try to replace fear and ignorance with the best evidence. Then I am comfortable with what they choose, for it is always their choice.

And to ward off commentary that I am promoting dangerous anticoagulants, let me leave you with the obvious:

It is better not to get AF. If you prevent the disease, then you don’t have to face tough decisions about drugs and procedures. Good movement, good food, good sleep and good attitudes will make it more likely that you will see me on a bike ride than in the clinic.

JMM

Why shouldn’t Cardiology lead the way in shared decsion-making?

2013-05-20T16:38:18Z

Look at this sample question from the American College of Cardiology self-assessment. Tell me whether you see the problem. (It came in a mass advertisement-email, so I don’t think it is a secret.)

Sample Question

A 75-year-old woman is referred to you with a murmur. She has had the murmur for many years and has been followed by her primary care doctor. Recently she has noted increasing symptoms of shortness of breath with exertion, but no angina or presyncope. A stress nuclear study is normal.

She is otherwise healthy except for mild hypertension. Her BP today is normal at 120/20 and she is in normal sinus rhythm. Her only medications are antihypertensive meds. On examination her murmur appears to be that of aortic stenosis. She has no clinical signs of congestive heart failure. You order an echocardiogram that reveals the following:

Echocardiographic report: Calcific aortic stenosis with preserved LV ejection fraction. Left ventricular hypertrophy is present and the LV chamber dimensions are normal. Mild mitral annular calcification is noted. Peak instantaneous aortic valve gradient is estimated at 56 mmHg with mean aortic gradient estimated at 30 mmHg. Aortic valve area by the continuity equation is 0.7 cm2.

You should now consider which of the following?

a. Surgical intervention with surgical valve replacement
b. Percutaneous intervention with a transcutaneous aortic valve
c. Balloon aortic valvuloplasty
d. Continued medical management for now

A hint: Look at the wording of the answers. I kept looking for the choice I would have made–choice ‘e.’ Nowhere in the possible answers was an option to present multiple different paths to the patient and let her choose the one that fits best with her goals.

We will have to foray into valvular heart disease for a minute. This 75 year-old women has a stenotic (partially blocked) aortic valve, which is the valve that lets blood out of the heart to the body. The valve area of 0.7 tells us that the degree of blockage is severe. (Think pinhole.) The three major symptoms of AS are shortness of breath, chest pain and syncope (fainting). And the best evidence suggests that patients with symptomatic AS live longer and feel better with valve replacement surgery. So, given how the question is written, letter ‘a’ correct.

My problem with the wording is that we are not given a choice to discuss different paths and align care with the patient’s goals. In this case, it is true that valve replacement surgery offers the best chance for a longer life and improved breathing. But open-heart surgery is significant. It means cutting the chest and heart open; it means exposing the patient to a 5-day hospital stay, with pain, less of autonomy and possible other complications. I like to tell patients considered for procedures that their disease may limit them today, but they walked in to my office under their own power. They are alive. There is always the risk that surgery or a procedures could render them worse. Risk from intervention may be low, but it is not zero.

The point is that patients vary in their level of risk aversion and goals for treatment. In this valve case, there is another path that the patient can choose: she might prefer to live with the disease and continue to reassess symptoms. Yes, living with the disease exposes the patient to the risk of death, but what if we presented the actual statistics and let the patient decide? Maybe this 75 year-old woman has different views of death than we do? Maybe her symptoms aren’t that bad, or perhaps she fears being in a nursing home more than death?

Don’t misunderstand, I want my patients to live long and well. In this case, if I were seeing the patient I would be clear that the path of surgery offers the best chance for a longer and fuller life, but the tradeoff in getting to that better place means accepting the (low-but-real) risks of surgery. I would also say that no one needs to have her chest cracked open. The path of no treatment is an option.

The practice of medicine, especially in this era of aggressive therapy, will be better when the correct answer to the question above is

‘e’: Aortic valve replacement offers the patient improved survival and better quality of life, but the best practice is to discuss the evidence, present multiple paths and align care with the patient’s goals.

We must get past the paternalism. In the span of my career, Cardiologists have always been leaders. Why shouldn’t we lead the way in shared-decision making and rationale use of our amazing tools?

Vanquishing the word “need” would be a god start.

JMM

Recap of our Social Media Session at HRS 2013

2013-05-15T11:46:28Z

The older I get, the less sure I become of basic cardiac issues. Consider the changing role of ICDs, non-statin cholesterol drugs, vitamins, and fish oil. All of these were once darlings of the field. Now, not so much. And it is not just cardiology, other areas of medicine have their uncertainties: breast and prostate cancer screening and MRIs for uncomplicated orthopedic issues, just to name a few.

But here is one thing I am sure of: Social Media will be a force for good in the healthcare world in the coming years. Sharing, connecting, informing, educating and yes, even empowering, both doctors and patients, will lead us to a better place. Decision quality will improve; it always does with more information.

Bob Coffield, Dr Wes Fisher. me, and Dr Jay Schloss

Major medical societies are seeing it. At last week’s Heart Rhythm Society sessions, I got together with three other giants of the healthcare media world and did a panel on: Social Media for Physicians — The State of the Art.

The recap, with many links, is over at theHeart.org:

Here is a PDF file of my portion of the talk: Twitter Talk at HRS 2013

Enjoy and connect.

JMM

Heart Rhythm Society Meeting 2013 — Hyde Park Lecture

2013-05-10T23:40:16Z

Hi Everyone,

This may be the longest I have ever gone between posts. As all bloggers do, I will tell you the reason.

I was preparing for my invited lecture at HRS 2013. It was a Hyde Park Talk. This means you stand in one of the busiest parts of the convention, and just start talking. You have a mic and the more you talk, the more people gather around. It’s different.

My topic was ICDs, goals of care and end-of-life conversations.

Here is the thing that put me under so much pressure:

The names on that list are the biggest in the field. These talks are usually (and after mine will probably revert back to being) given by distinguished professors. So why would a non-academic like me get a spot on that podium? I’m not sure exactly, but here is what I surmise: Dr. Rich Fogel, the HRS program director, called me up months ago and said he read one of my posts on theHeart.org about ICD decision making. He wanted someone to speak about the state of the quality of the decision to implant an ICD. He knew the evidence base surrounding doctor-patient communication on sudden death prevention and ICD therapy was bleak. I can’t remember his words exactly, but it was something like, “this stuff needs to be said.”

When I agreed, I had no idea how hard it was going to be to understand a topic so well that you can talk, off the cuff, without PowerPoint, and to your peers.. First, you had the mountains of clinical data in support of the ICD that needed to be critically appraised. Then you had the matter of risk stratification–or said another way: the fact more than 80% of the time we implant an ICD, the patient gets no benefit. Next, was the evidence base on the decision making. Surveys of doctors’ and patients’ perceptions paint a bleak picture. I kept looking for one study that said we did a good job; I found none.

I interviewed experts all over the country. Many of the most published doctors on these topics were generous with their time. That was cool. They helped me find areas of improvement. For instance, at the time of ICD replacement surgery, and the decision to use a CRT-Pacemaker rather than a CRT-Defibrillator, and also, a focus on the ethics and legality of ICD deactivation at end-of-life.

The talk went well. A good crowd showed. I liked the fact a prominent thought leader (who will remain nameless) came up after and berated me for giving a slanted view of the data and being totally wrong about the fact that deactivation of devices at end-of–life was NOT physician-assisted suicide. He felt it was–and our discussion was spirited. I liked that. Of course, I was surrounded by folks, who by their attendance at such a talk, supported my view.

Two people mentioned to me that is was telling that such a talk was given in this format–out in the convention hallway, with no CME. That’s a topic for a blog in the future.

I expect a transcript to come up soon over at theHeart.org.

Here is the link: ICDs, goals of care, and end of life: Difficult conversations (Hyde Park talk at HRS 2013)

Today, I will be presenting in a session on Social Media for the Physician with friends Wes Fisher, Jay Schloss and internet lawyer Bob Coffield.

JMM

New post up at theHeart.org — The ethics of ICD decision-making

2013-04-30T01:43:15Z

I’ve got a good one for you.

Who is the better doctor?

Is it the caregiver who–by whatever means–gets her patient on the best treatment, or, is it the doc who communicates the options most clearly?

I ask because the Institute of Medicine has made shared-decision making (or patient-centered care) a major focus of quality healthcare. That sounds good on paper, right? Medical intervention can be burdensome so it’s important to align it with the patient’s goals for care. And, clearly, patient-centric care exemplifies the first tenet of medical ethics–namely autonomy. Though it’s smart to cycle with a helmet or drive with a seat-belt, not everyone shares the same risk aversion.

Enter the second tier of medical ethics, beneficence, which is defined as doing good. There is scientific evidence that certain medical treatments reduce the risk of death. That’s a good thing. Like riding with a helmet or driving with a seatbelt.

As a heart rhythm doctor who implants internal cardiac defibrillators (ICD), the intersection between patient choice and medical benefit comes up often. Clinical trial data tells us that implanting an ICD in “eligible” patients decreases the risk of death. Medical guidelines have set out these benefits. Quality healthcare is that which provides the most benefit. We even have catchy phrases that proclaim such: Get with the guidelines.

Alas, neither the guideline writers, nor the referring doctor, nor the implanting doctor has to have the device implanted in their chest. We don’t have to live with the risk of infection or shocks. This is why I have always felt (even before the Institute of Medicine proclaimed the virtues of patient-centric care) that patients need to understand the trade-offs of an ICD. These shockers come with plenty of trade-offs.

The conflict that comes up in my mind is that presenting the benefits and burdens of an ICD (or any fateful medical treatment) candidly and honestly may lead some eligible patients to decline an evidence-based therapy. In other words, maximizing autonomy–by aligning care with one’s goals–might compromise beneficence. In the case of an ICD, it might mean a patient dies prematurely. That’s huge.

In preparation for my ICD talk at the Heart Rhythm Society meeting I jotted about 1300 words on the matter. The topic was complex enough for me to have asked for help. The essay includes quotes from five thoughtful medical leaders. The quotes are great.

I hope you want to read more. It’s over at theHeart.org. The title and link are:

Autonomy vs beneficence? Shared decision-making in the patient considered for an ICD

JMM

P.S. Worry not afibbers, there is a nugget there for you.

Is it better to burn or freeze atrial fibrillation?

2013-04-22T19:12:31Z

What a trouble it is!

As a disease that associates with wear and tear, aging, obesity, sleep disorders, high blood pressure and inflammation, it’s no wonder the incidence of atrial fibrillation continues to rise.

AF represents a huge health problem. For the individual patient, it can cause life-altering symptoms, increase the risk of stroke or weakened heart muscle and perhaps most troublesome: AF exposes patients to perilous treatments. It brings patients closer to doctors–which is always a risky proposition. For the healthcare system, AF treatment has grown more complex and expensive. There is both under-treatment, which leads to excessive disability from stroke and heart failure, as well as over-treatment, which leads to therapeutic misadventures too numerous to list here. There is a huge knowledge gap on how best to treat this disease.

Over the last decade, catheter ablation has offered patients with AF that won’t go away with medicines or lifestyle changes an opportunity for symptom relief. I’ve written many times about ablating AF. In brief, catheter ablation of AF entails electrically isolating areas of the atria (most often the muscle sleeves surrounding the pulmonary veins). The energy source most often used is radiofrequency energy–a burn. The problem with using RF energy to make electrical lines of block in the atria is that it’s hard to draw a line with dots. An electric fence made with dots tends to have gaps. And these gaps lead to reconnection of the veins and the need for redo ablation procedures.

So investigators, in Europe first, began experimenting with the use of freezing tissue rather than burning. Cryoballoons were developed that could be placed in the orifice of a pulmonary vein. Then, with a single freeze, an entire ring of ablation isolates the vein. Rather than making 20-30 encircling point RF lesions, a single freeze electrically isolates the vein.

Small observational trials and then one big randomized controlled trial (STOP-AF) reveal cryoballoon ablation compares favorably (in safety and efficacy) to RF ablation in patients with intermittent AF. (Though there have been no large trials comparing the technologies head-to-head.) The FDA approved the cryoballoon system and the technique has taken off in the US.

But with any procedure comes risk. Recently, you may have seen Dr Wes’ report on procedural deaths from cryoballoon ablation.

About 6 months ago, after an extensive (and I mean extensive) learning process, I began doing cryoballoon ablation. Why would I change a perfectly well-practiced RF ablation procedure? What are the safety issues? What about efficacy? How does the new generation cryoballoon compare with the first generation? What’s the take home on freezing versus burning?

I hope you want to read more over at theHeart.org. Here is the link:

How safe is cryoballoon ablation of atrial fibrillation?

JMM

Both sorrow and fear about the Boston tragedy

2013-04-19T22:35:54Z

Smarter people have weighed in on the sadness in Boston. I can’t help it. Writing helps me feel better.

I am really sorry for the people who have lost life or limb. As a parent, grandparent, scratch that, as a fellow human, just thinking about bombs and bullets hitting human bodies makes me want to cry. It’s as senseless as the rest of the world’s human-induced tragedies. Is evil any less sad across an ocean? In my blessed cocoon of a life, it’s hard to comprehend this level of evil.

I am fearful too.

Call me naïve, but I harbor little fear of crime and terrorism. Heck, on a statistical level, it is far riskier just driving home from work. (Think texting and driving).

What really frightens me is others’ fear. I dread the response. When people get scared, bad things happen: freedom is diminished; common sense is jettisoned and bad policies become accepted. A colleague today in the doctor’s lounge had it right: he used the word—marionettes.

Our airports are the easy example. Look at how US society has accepted the TSA farce. Illusion.

Never events that occur in the hospital are another example. Most recently, there was a sentinel event alert on hospital monitors. Alas, more policing (monitoring) actually made matters worse; it led caregivers to miss real alarms.

It pains me to write something so obvious, but what makes the US such an amazing place to live is freedom. The phrase, you don’t know what you have till it’s gone, keeps ringing in my head.

Oh, how I fear the loss of freedom that comes from the attempt to prevent rare events. Another word…futility.

Is our society coming apart? I don’t think so. The little history that I have studied suggests we live in a far more peaceful world. You don’t have to go back many years to witness much darker chapters in humanity.

That said, though, don’t you, too, worry about society’s grasp of common sense? For instance, why do we struggle so much with obviousness? Can there be no tolerable level of bad stuff? Perhaps we don’t do a good enough job teaching statistics and basic human nature. It’s just like in Medicine: too much alertness is often worse than too little.

This would be an easy week to be pessimistic about humans.

But one will fight pessimism. It’s bad for the blood vessels and stirs chronic inflammation.

So let’s hope.

I will hope that this great country will grow more tolerant, less insular and less polarized by religion and politics. I will hope that these sorts of failings of humanity teach us that the best way to live together on this planet is kindness and tolerance, not barricades, metal detectors and surveillance.

JMM

Ten simple rules for doctors on Social Media

2013-04-18T05:14:27Z

How should doctors behave online? This is a funny question, isn’t it?

Medical establishment loves rules and hierarchy. Social media does not. Social media levels the playing field of who gets to talk; it gives real caregivers a voice. That’s very cool.

This is just a guess, but I suspect there are many more acts left to play out in the healthcare social media play. Here’s the latest: (h/t to my friend Larry Husten from Forbes.)

The American College of Physicians and the Federation of State Medical Boards have gotten together and published a position paper on how doctors should behave on the “new frontier” of the Internet. At 14 pages and nearly 6000 words, this is one heck of a hefty instruction manual. The authors might have a tough time on Twitter and Facebook. (Insert grin.)

It’s got to be simpler. Of course it is.

Let’s start with a real case:

Years ago, early on in my blogging career, I wrote a post about a patient who presented to the ER with third degree heart block. She was dying before our eyes. As most doctors can attest, emergencies bring out the best in US healthcare. The patient was transferred immediately to the EP lab where I implanted a permanent pacemaker. She went home the next day alive and well. The teamwork that led to a life being saved made me tingle with delight. Adding to the joy was the fact that emergencies mandate jettisoning BS. You have to act first and check boxes later.

That night I sat down at the computer and celebrated the joy of doctoring with words. Mindful of privacy issues, I changed a number of details of the case (time, age and gender, for instance).

Then came “the comment”: My heart sank. Despite changing many of the specifics, a commenter thanked me for saving their family member. Though all were happy with the outcome, my attempt to maintain privacy had failed. This lesson has stuck with me.

With that “learning” case as a backdrop, here are my top-ten nuggets of wisdom on social media for caregivers:

Do not fear social media. It’s an amazing tool for advancing the greater good. The voice of caregivers has never been more vital. I believe the greatest problem with medicine right now is not the lack of available treatments, but rather, a lack of patient education. Patients cannot truly share in decision-making unless they have “the real story.” Both patients and doctors are starved for candid unfiltered information. Social media does real, real well.
Never post anything when angry. Never is a big word but it fits well here. Nothing further needs to be said. Just don’t do it. A corollary: Do not post while neurologically impaired: I’ve said some really dumb things in the haze that encompasses one right after a bike race. (Insert another grin.)
Strive for accuracy: People will read what you post. I’ve written many times that blog posts are not journal articles, but that doesn’t mean you should get lazy with words. Here is the problem: You think electrophysiology is complicated. See what happens when you try being absolutely precise with the English language.
When in doubt, pause. Sleep on it. Re-read. Remember the permanency of digital media. You are a doctor, not a journalist. You have time.
Don’t post anything that can identify a patient. Changing details of the case is not enough. It’s especially important not to post in real-time. Avoid terms like, “this morning,” or “today.” It’s one thing to tell a story about a patient you saw two months ago; it’s yet another to talk about the patients you saw today. Don’t underestimate privacy.
Ask permission: If you want to write about a specific case, get permission from the patient.
Be respectful: Don’t say anything online that you wouldn’t say in person. If you are critical of someone pretend that you are going to run into him or her at a meeting next week. Put yourself in their shoes. Try to understand their position. You think they are conflicted; what about your conflicts? My wife once told that me that all unsolicited advice is self-serving. (Hoosiers are just so sensible.)
Assume beneficence: I’ve been in healthcare for two decades and can testify that truly bad people are a rarity. Most of us aim to do what is right. Some say doctors are too protective of each other; but the thing about medicine is that it’s much easier to practice with a time machine. Social media tempts one to toss stones. Resist that urge.
Be careful “friending” patients online. I say careful because I don’t like rules. Clearly, some patients can also be friends. The lines here are blurry. My attempt at a solution is to have a DrJohnM Facebook page and a regular John page. I try to steer patients to the professional page. I am also a bit old-fashioned with Facebook. I try to avoid posting compromising stuff—even though it would be fantasy to think doctors are any less human than non-doctors.
Educate yourself and ask questions: One of the best references for caregivers interested in learning more about social media is Kevin Pho’s new book: Establishing, Managing, and Protecting Your Online Reputation: A Social Media Guide for Physicians and Medical Practices. Another nifty thing about social media is that many of the experts are approachable. If you email (or direct message) experts like Ves Dimov, Kevin Pho, Wes Fisher, Jay Schloss, Wendy Sue Swanson or Bryan Vartebedian, they are likely to respond with helpful tips. That’s nice. In my limited experience, healthcare social media is populated with nice people.

The bottom line is always the same: Success comes from mastery of the obvious. Common sense, decency, truth and admitting one’s mistakes will rarely steer you wrong.

JMM

P.S. Please feel free to add your own nuggets of wisdom in the comment section. I am 99.9% certain that there are more than just these ten.

Stress is killing our hearts and bodies…But there is hope.

2013-04-16T10:58:08Z

It’s an appropriate day to talk about stress.

If you treat heart rhythm problems, you can’t miss the effects of stress. It matters so much. Both acute and chronic–though mostly chronic–stress wreaks havoc on the heart’s electrical system. And it’s not just the heart rhythm; the chronic inflammation that goes with long-lasting stress negatively impacts many of our vital human processes: cognition, immunity and waste removal, for example.

Over recent decades, technology and science has gifted heart doctors and patients a vast array of mortality-reducing drugs, stents and devices. Taken together, one might think that all this fury would simply melt away heart disease. Humans should be living longer and better lives.

But that hasn’t happened. Heart disease continues to be our number one killer. Atrial fibrillation, a disease that tracks with inflammation and wear and tear is running amok. Diseases of auto-immunity are on the rise. Looking at the big picture, one could be pessimistic about societal health.

Obviously, most agree that our lifestyles have negated the benefits of therapy. We aren’t dying sooner, but we sure aren’t gaining as we should.

As a caretaker of the heart, I strongly believe chronic stress (and the inflammation that goes with it) lies at the center of this problem. Old school thinking, yes, surely, but I believe Mr. Thoreau had it right—though he did seem awfully grumpy.

Follow me for a couple of weeks. I could show you factory workers discombobulated by night work, flocks of unhappy spouses, harried executives, depressed doctors and lawyers and over-scheduled ministry people who tend to everyone but themselves. And if you weren’t yet convinced of the role of stress in disease, I could clinch it with this cohort: the seemingly healthy (thin, fit, with normal blood pressure and cholesterol) but angry patient. These folks often find their way to me. It seems there is a price to pay for chronic anger.

But there is hope. We, as patients, caregivers and society, can better manage stress. For the sake of our health, we must do better.

I would like to share this beautiful presentation on managing stress. I’m a little late to the party as it already has more than 100,000 views on YouTube. Dr. Mike Evans (@docmikeevans), a regular doctor from Canada, with a knack for drawing, guides us through the evidence base surrounding stress and stress therapy.

What is the single best way to manage stress?
What are the characteristics of stress-resistant individuals?
Can stress management skills be learned?
Do you know the 90-10 rule?

I’ve been blogging for more than three years now, and I have tried not to steer you wrong. Trust me, this one is worth the 11 minutes. So good.

JMM

As a novel communication tool, Social Media will improve doctoring.

2013-04-12T10:51:00Z

Wendy Sue Swanson (or @SeattleMamaDoc) is a pediatrician, mother, wife, patient, caregiver and blogger.

In the embedded video below, she speaks about the online revolution and the power of social media to enhance the good that doctors can do. I am a believer.

What if you could read a post/tweet every time your doctor had an idea about a new study, a new medicine? Why shouldn’t [many] patients learn from the whiteboard presentation that just occurred in the exam room with one patient?

Some patients get only 15 minutes per year with their doctor. That’s not much. No wonder 80% of folks go to the Internet for health information.

And it is more than just informational; our presence on social media can transmit empathy and understanding–our humanness. Dr. Swanson uses the example of vaccines. My example might be AF. A patient coming to see my can find out that I had AF–and it sucked.

Yes, this is a special time we live in.

This TEDx talk is worth 9 minutes of your time.

Congrats Doc. Beautiful talk.

JMM

P.S. Another great example of the future: my colleague here in Louisville, Dr Kathy Nieder, a primary care doctor, has an outstanding online presence.