Paul J. Hauptman, MD

Herb Fred does it again. In a prior blog, I mentioned the great teacher’s wonderful and informative column in the Texas Heart Institute Journal. Recently, he described what life was like in medicine and cardiology when he was starting out in the late 1940s and early 1950s (Tex. Heart Inst. J. 2013:40:508-09). It made me think about the 1980s when I was in medical school and in training (I am likely two generations removed from Dr. Fred).

When I mention some of these to our young house staff, they look at me as if I were from the Stone Age:

• For a while, the cause of AIDS was not known to be a virus and various odd explanations were posited.

• The big debate in acute myocardial infarction care was whether tissue plasminogen activator was better than streptokinase.

• We gave the first dose of a new prescription of an ACE inhibitor (captopril) to outpatients with hypertension in the waiting room to gauge whether they would get hypotensive.

• We admitted patients the night before a cardiac catheterization and kept them overnight after the procedure.

• Heart transplantation was novel, and we really did not know a whole lot about what we were doing.

• The first implantable cardioverter defibrillators were implanted by thoracotomy and the generators were huge in size.

• Beta-blockers for heart failure were discussed sparingly until the early 1990s (when I recall Bill Colucci telling me that "this is going to work!").

• A night float meant that we were going out late to get a milk shake or related dessert.

• We were on duty every third night (and sometimes every other in the units).

• As in Dr. Fred’s early era, there was a small lab for the house staff to perform Gram stains and spin hematocrits, but as house officers, we surely did not perform liver biopsies, pleural biopsies, or sternal bone marrow aspirations!

Dr. Fred’s last two entries certainly applied to my generation as well (and these are direct quotes):

• "Trainees, faculty members, and practitioners considered it a privilege to be a doctor."

• "Everyone understood and firmly believed that medicine is a calling, not a business, and that the patient comes first, always."

Back in the 1980s, when disco was dying, we had our naysayers who told us that the best days of medicine were behind us. While it’s tempting, I do not want to sound the same alarm. As a consequence, I am holding on to the belief that we will still see the commitment to medicine that I saw in my elders and among many of my contemporaries. I’ve even made a few house calls in my time. May our trainees take note.

Dr. Hauptman is professor of internal medicine and assistant dean of clinical-translational research at Saint Louis University and director of heart failure at Saint Louis University Hospital. He is an associate editor for Circulation: Heart Failure and blogs while staring out his office window at the Arch.

Herb Fred does it again. In a prior blog, I mentioned the great teacher’s wonderful and informative column in the Texas Heart Institute Journal. Recently, he described what life was like in medicine and cardiology when he was starting out in the late 1940s and early 1950s (Tex. Heart Inst. J. 2013:40:508-09). It made me think about the 1980s when I was in medical school and in training (I am likely two generations removed from Dr. Fred).

When I mention some of these to our young house staff, they look at me as if I were from the Stone Age:

• For a while, the cause of AIDS was not known to be a virus and various odd explanations were posited.

• The big debate in acute myocardial infarction care was whether tissue plasminogen activator was better than streptokinase.

• We gave the first dose of a new prescription of an ACE inhibitor (captopril) to outpatients with hypertension in the waiting room to gauge whether they would get hypotensive.

• We admitted patients the night before a cardiac catheterization and kept them overnight after the procedure.

• Heart transplantation was novel, and we really did not know a whole lot about what we were doing.

• The first implantable cardioverter defibrillators were implanted by thoracotomy and the generators were huge in size.

• Beta-blockers for heart failure were discussed sparingly until the early 1990s (when I recall Bill Colucci telling me that "this is going to work!").

• A night float meant that we were going out late to get a milk shake or related dessert.

• We were on duty every third night (and sometimes every other in the units).

• As in Dr. Fred’s early era, there was a small lab for the house staff to perform Gram stains and spin hematocrits, but as house officers, we surely did not perform liver biopsies, pleural biopsies, or sternal bone marrow aspirations!

Dr. Fred’s last two entries certainly applied to my generation as well (and these are direct quotes):

• "Trainees, faculty members, and practitioners considered it a privilege to be a doctor."

• "Everyone understood and firmly believed that medicine is a calling, not a business, and that the patient comes first, always."

Back in the 1980s, when disco was dying, we had our naysayers who told us that the best days of medicine were behind us. While it’s tempting, I do not want to sound the same alarm. As a consequence, I am holding on to the belief that we will still see the commitment to medicine that I saw in my elders and among many of my contemporaries. I’ve even made a few house calls in my time. May our trainees take note.

Dr. Hauptman is professor of internal medicine and assistant dean of clinical-translational research at Saint Louis University and director of heart failure at Saint Louis University Hospital. He is an associate editor for Circulation: Heart Failure and blogs while staring out his office window at the Arch.

Herb Fred does it again. In a prior blog, I mentioned the great teacher’s wonderful and informative column in the Texas Heart Institute Journal. Recently, he described what life was like in medicine and cardiology when he was starting out in the late 1940s and early 1950s (Tex. Heart Inst. J. 2013:40:508-09). It made me think about the 1980s when I was in medical school and in training (I am likely two generations removed from Dr. Fred).

When I mention some of these to our young house staff, they look at me as if I were from the Stone Age:

• For a while, the cause of AIDS was not known to be a virus and various odd explanations were posited.

• The big debate in acute myocardial infarction care was whether tissue plasminogen activator was better than streptokinase.

• We gave the first dose of a new prescription of an ACE inhibitor (captopril) to outpatients with hypertension in the waiting room to gauge whether they would get hypotensive.

• We admitted patients the night before a cardiac catheterization and kept them overnight after the procedure.

• Heart transplantation was novel, and we really did not know a whole lot about what we were doing.

• The first implantable cardioverter defibrillators were implanted by thoracotomy and the generators were huge in size.

• Beta-blockers for heart failure were discussed sparingly until the early 1990s (when I recall Bill Colucci telling me that "this is going to work!").

• A night float meant that we were going out late to get a milk shake or related dessert.

• We were on duty every third night (and sometimes every other in the units).

• As in Dr. Fred’s early era, there was a small lab for the house staff to perform Gram stains and spin hematocrits, but as house officers, we surely did not perform liver biopsies, pleural biopsies, or sternal bone marrow aspirations!

Dr. Fred’s last two entries certainly applied to my generation as well (and these are direct quotes):

• "Trainees, faculty members, and practitioners considered it a privilege to be a doctor."

• "Everyone understood and firmly believed that medicine is a calling, not a business, and that the patient comes first, always."

Back in the 1980s, when disco was dying, we had our naysayers who told us that the best days of medicine were behind us. While it’s tempting, I do not want to sound the same alarm. As a consequence, I am holding on to the belief that we will still see the commitment to medicine that I saw in my elders and among many of my contemporaries. I’ve even made a few house calls in my time. May our trainees take note.

Dr. Hauptman is professor of internal medicine and assistant dean of clinical-translational research at Saint Louis University and director of heart failure at Saint Louis University Hospital. He is an associate editor for Circulation: Heart Failure and blogs while staring out his office window at the Arch.

Having recently recertified for the second time, I find myself among the legions of physicians who consider the process to be highly disruptive, expensive, time consuming, and an unwarranted threat to our professional identities and well-being. But that would be an acceptable state if I felt that I could convince myself that the recertification process is a good measure of knowledge and practice. Sadly, it is not.

The questions are, at times, superficial and vague. Conventional study won’t help you here. The Program Improvement Module is a time sink and nothing more. While I do not intend to invite a challenge by the American Board of Internal Medicine, suffice it to say that it seems unlikely that your score reflects the quality of care you deliver, your knowledge of guidelines, your bedside manner, or your clinical diagnostic capabilities.

To top it off, the ABIM now wants the Maintenance of Certification process to be re-initiated within 2 years of passing your recertification.

If the Board has empiric evidence that this process improves physician behavior and performance, I’ll rename this blog "Recertification: We have a winner!" In the meantime, all I can say is recertification, reschmertification. It’s just another example of how ideas that sound good on paper often fail us in practice. Heart failure quality metrics, anyone?

Dr. Hauptman is professor of internal medicine, assistant dean of clinical-translational research at Saint Louis University, and director of heart failure at Saint Louis University Hospital. He is an associate editor for Circulation: Heart Failure, and blogs while staring out his office window at the Arch. Write to Dr. Hauptman at cardnews@frontlinemedcom.com.

Having recently recertified for the second time, I find myself among the legions of physicians who consider the process to be highly disruptive, expensive, time consuming, and an unwarranted threat to our professional identities and well-being. But that would be an acceptable state if I felt that I could convince myself that the recertification process is a good measure of knowledge and practice. Sadly, it is not.

The questions are, at times, superficial and vague. Conventional study won’t help you here. The Program Improvement Module is a time sink and nothing more. While I do not intend to invite a challenge by the American Board of Internal Medicine, suffice it to say that it seems unlikely that your score reflects the quality of care you deliver, your knowledge of guidelines, your bedside manner, or your clinical diagnostic capabilities.

To top it off, the ABIM now wants the Maintenance of Certification process to be re-initiated within 2 years of passing your recertification.

If the Board has empiric evidence that this process improves physician behavior and performance, I’ll rename this blog "Recertification: We have a winner!" In the meantime, all I can say is recertification, reschmertification. It’s just another example of how ideas that sound good on paper often fail us in practice. Heart failure quality metrics, anyone?

Dr. Hauptman is professor of internal medicine, assistant dean of clinical-translational research at Saint Louis University, and director of heart failure at Saint Louis University Hospital. He is an associate editor for Circulation: Heart Failure, and blogs while staring out his office window at the Arch. Write to Dr. Hauptman at cardnews@frontlinemedcom.com.

Having recently recertified for the second time, I find myself among the legions of physicians who consider the process to be highly disruptive, expensive, time consuming, and an unwarranted threat to our professional identities and well-being. But that would be an acceptable state if I felt that I could convince myself that the recertification process is a good measure of knowledge and practice. Sadly, it is not.

The questions are, at times, superficial and vague. Conventional study won’t help you here. The Program Improvement Module is a time sink and nothing more. While I do not intend to invite a challenge by the American Board of Internal Medicine, suffice it to say that it seems unlikely that your score reflects the quality of care you deliver, your knowledge of guidelines, your bedside manner, or your clinical diagnostic capabilities.

To top it off, the ABIM now wants the Maintenance of Certification process to be re-initiated within 2 years of passing your recertification.

If the Board has empiric evidence that this process improves physician behavior and performance, I’ll rename this blog "Recertification: We have a winner!" In the meantime, all I can say is recertification, reschmertification. It’s just another example of how ideas that sound good on paper often fail us in practice. Heart failure quality metrics, anyone?

Dr. Hauptman is professor of internal medicine, assistant dean of clinical-translational research at Saint Louis University, and director of heart failure at Saint Louis University Hospital. He is an associate editor for Circulation: Heart Failure, and blogs while staring out his office window at the Arch. Write to Dr. Hauptman at cardnews@frontlinemedcom.com.

Another trial in HFpEF, another surprise? To the contrary, the TOPCAT data on heart failure with preserved ejection fraction were in line with prior trials in the diastolic heart failure space. At long last, heart failure hospitalizations, if not mortality, were decreased. Of course, that finding may not be reproducible in the real world. If spironolactone becomes widely used in patients with preserved LV function, does anyone think that hyperkalemia won’t be a problem? It was after the Randomized Aldactone Evaluation Study (RALES) was published (N. Engl. J. Med. 1999;341:709-17; N. Engl. J. Med. 2004;351:543-51).

TOPCAT (Treatment of Preserved Cardiac Function Heart Failure With an Aldosterone Antagonist) also had the usual array of strange subgroups based on site: Eastern European sites were outliers this time with an unexpectedly low event rate in the placebo arm. (I’ll have more on this issue – the negative aspects of international randomized clinical trials – in some future column.) But the bottom line remains the same. There is little reason to think that our approach to HFpEF patients will significantly change. Indeed, if a pharmaceutical company had a new drug for HFpEF, I would advise them to think very carefully about whether it was worth the financial risk of conducting a large outcomes trial. Even if the trial name had no embedded CAT, odds are the trial would still be a dog.

Dr. Hauptman is professor of internal medicine and assistant dean of clinical-translational research at Saint Louis University and director of heart failure at Saint Louis University Hospital. He is an associate editor for Circulation: Heart Failure and blogs while staring out his office window at the Arch. Write to Dr. Hauptman at cardnews@frontlinemedcom.com.

Another trial in HFpEF, another surprise? To the contrary, the TOPCAT data on heart failure with preserved ejection fraction were in line with prior trials in the diastolic heart failure space. At long last, heart failure hospitalizations, if not mortality, were decreased. Of course, that finding may not be reproducible in the real world. If spironolactone becomes widely used in patients with preserved LV function, does anyone think that hyperkalemia won’t be a problem? It was after the Randomized Aldactone Evaluation Study (RALES) was published (N. Engl. J. Med. 1999;341:709-17; N. Engl. J. Med. 2004;351:543-51).

TOPCAT (Treatment of Preserved Cardiac Function Heart Failure With an Aldosterone Antagonist) also had the usual array of strange subgroups based on site: Eastern European sites were outliers this time with an unexpectedly low event rate in the placebo arm. (I’ll have more on this issue – the negative aspects of international randomized clinical trials – in some future column.) But the bottom line remains the same. There is little reason to think that our approach to HFpEF patients will significantly change. Indeed, if a pharmaceutical company had a new drug for HFpEF, I would advise them to think very carefully about whether it was worth the financial risk of conducting a large outcomes trial. Even if the trial name had no embedded CAT, odds are the trial would still be a dog.

Dr. Hauptman is professor of internal medicine and assistant dean of clinical-translational research at Saint Louis University and director of heart failure at Saint Louis University Hospital. He is an associate editor for Circulation: Heart Failure and blogs while staring out his office window at the Arch. Write to Dr. Hauptman at cardnews@frontlinemedcom.com.

Another trial in HFpEF, another surprise? To the contrary, the TOPCAT data on heart failure with preserved ejection fraction were in line with prior trials in the diastolic heart failure space. At long last, heart failure hospitalizations, if not mortality, were decreased. Of course, that finding may not be reproducible in the real world. If spironolactone becomes widely used in patients with preserved LV function, does anyone think that hyperkalemia won’t be a problem? It was after the Randomized Aldactone Evaluation Study (RALES) was published (N. Engl. J. Med. 1999;341:709-17; N. Engl. J. Med. 2004;351:543-51).

TOPCAT (Treatment of Preserved Cardiac Function Heart Failure With an Aldosterone Antagonist) also had the usual array of strange subgroups based on site: Eastern European sites were outliers this time with an unexpectedly low event rate in the placebo arm. (I’ll have more on this issue – the negative aspects of international randomized clinical trials – in some future column.) But the bottom line remains the same. There is little reason to think that our approach to HFpEF patients will significantly change. Indeed, if a pharmaceutical company had a new drug for HFpEF, I would advise them to think very carefully about whether it was worth the financial risk of conducting a large outcomes trial. Even if the trial name had no embedded CAT, odds are the trial would still be a dog.

Dr. Hauptman is professor of internal medicine and assistant dean of clinical-translational research at Saint Louis University and director of heart failure at Saint Louis University Hospital. He is an associate editor for Circulation: Heart Failure and blogs while staring out his office window at the Arch. Write to Dr. Hauptman at cardnews@frontlinemedcom.com.

Since writing a blog about the 30s ("The magic of 30 and 35"), I have thought about artificial time lines in general but also the skewing of incentives.

The penalties meted out by the Centers for Medicare and Medicaid Services for hospitals that exceed specific 30-day readmission rates for heart failure are based on two very faulty premises. First, that sociodemographics don’t matter, since patient zip code and related factors do not enter the calculation. Second, that there is something meaningfully different about a patient readmitted on day 29 vs. day 31. Does anyone really think that there is a physiological, structural, or other difference? The 30-day construct is artificial, though as I write this sentence I can hear the response from the regulators: "Well, we had to make a cut somewhere!"

Maybe so, but how should we judge a health care system in which a hospital spends significant resources to prevent a 30-day readmission but then may not pay much heed to the initiative once a financial penalty is no longer a risk. In other words, a system in which the penalty for day 31 is lower (zero) than for 29?

©kyoshino/thinkstockphotos.com

It’s also interesting that we talk about length of stay for heart failure, but not quite as much as we used to. Indeed, lengthening the length of stay might reduce readmissions, if we can take a lesson from our European colleagues.

Expounding a bit more on the topic of artificial metrics, why does the Food and Drug Administration want 180 days of safety information for a study in which in-hospital patients are randomized to active study drug versus placebo for acute decompensated heart failure? How about 145.6 days instead? Is the patient with a left-ventricular ejection fraction of 36% safe, while one at 34% is a "must do" defibrillator implant? Does the patient with dyspnea and a b-type natriuretic peptide of 101 pg/mL have heart failure but at 99 pg/mL they are safe? I won’t name names here, but such conversations have been duly noted by your blogger/columnist, which prompts me to discuss receiver operator curves. Unfortunately, I don’t seem to get very far.

Frankly, a small dose of nihilism and a bit more understanding of statistics are needed in our profession. It’s also time to reestablish some common sense. The number 31 is not lower than 29 even if regulations make us (and hospital administrators) think it is.

Dr. Hauptman is professor of internal medicine and assistant dean of clinical-translational research at Saint Louis University and director of heart failure at Saint Louis University Hospital. He is an associate editor for Circulation: Heart Failure and blogs while staring out his office window at the Arch.

Since writing a blog about the 30s ("The magic of 30 and 35"), I have thought about artificial time lines in general but also the skewing of incentives.

The penalties meted out by the Centers for Medicare and Medicaid Services for hospitals that exceed specific 30-day readmission rates for heart failure are based on two very faulty premises. First, that sociodemographics don’t matter, since patient zip code and related factors do not enter the calculation. Second, that there is something meaningfully different about a patient readmitted on day 29 vs. day 31. Does anyone really think that there is a physiological, structural, or other difference? The 30-day construct is artificial, though as I write this sentence I can hear the response from the regulators: "Well, we had to make a cut somewhere!"

Maybe so, but how should we judge a health care system in which a hospital spends significant resources to prevent a 30-day readmission but then may not pay much heed to the initiative once a financial penalty is no longer a risk. In other words, a system in which the penalty for day 31 is lower (zero) than for 29?

©kyoshino/thinkstockphotos.com

It’s also interesting that we talk about length of stay for heart failure, but not quite as much as we used to. Indeed, lengthening the length of stay might reduce readmissions, if we can take a lesson from our European colleagues.

Expounding a bit more on the topic of artificial metrics, why does the Food and Drug Administration want 180 days of safety information for a study in which in-hospital patients are randomized to active study drug versus placebo for acute decompensated heart failure? How about 145.6 days instead? Is the patient with a left-ventricular ejection fraction of 36% safe, while one at 34% is a "must do" defibrillator implant? Does the patient with dyspnea and a b-type natriuretic peptide of 101 pg/mL have heart failure but at 99 pg/mL they are safe? I won’t name names here, but such conversations have been duly noted by your blogger/columnist, which prompts me to discuss receiver operator curves. Unfortunately, I don’t seem to get very far.

Frankly, a small dose of nihilism and a bit more understanding of statistics are needed in our profession. It’s also time to reestablish some common sense. The number 31 is not lower than 29 even if regulations make us (and hospital administrators) think it is.

Dr. Hauptman is professor of internal medicine and assistant dean of clinical-translational research at Saint Louis University and director of heart failure at Saint Louis University Hospital. He is an associate editor for Circulation: Heart Failure and blogs while staring out his office window at the Arch.

Since writing a blog about the 30s ("The magic of 30 and 35"), I have thought about artificial time lines in general but also the skewing of incentives.

The penalties meted out by the Centers for Medicare and Medicaid Services for hospitals that exceed specific 30-day readmission rates for heart failure are based on two very faulty premises. First, that sociodemographics don’t matter, since patient zip code and related factors do not enter the calculation. Second, that there is something meaningfully different about a patient readmitted on day 29 vs. day 31. Does anyone really think that there is a physiological, structural, or other difference? The 30-day construct is artificial, though as I write this sentence I can hear the response from the regulators: "Well, we had to make a cut somewhere!"

Maybe so, but how should we judge a health care system in which a hospital spends significant resources to prevent a 30-day readmission but then may not pay much heed to the initiative once a financial penalty is no longer a risk. In other words, a system in which the penalty for day 31 is lower (zero) than for 29?

©kyoshino/thinkstockphotos.com

It’s also interesting that we talk about length of stay for heart failure, but not quite as much as we used to. Indeed, lengthening the length of stay might reduce readmissions, if we can take a lesson from our European colleagues.

Expounding a bit more on the topic of artificial metrics, why does the Food and Drug Administration want 180 days of safety information for a study in which in-hospital patients are randomized to active study drug versus placebo for acute decompensated heart failure? How about 145.6 days instead? Is the patient with a left-ventricular ejection fraction of 36% safe, while one at 34% is a "must do" defibrillator implant? Does the patient with dyspnea and a b-type natriuretic peptide of 101 pg/mL have heart failure but at 99 pg/mL they are safe? I won’t name names here, but such conversations have been duly noted by your blogger/columnist, which prompts me to discuss receiver operator curves. Unfortunately, I don’t seem to get very far.

Frankly, a small dose of nihilism and a bit more understanding of statistics are needed in our profession. It’s also time to reestablish some common sense. The number 31 is not lower than 29 even if regulations make us (and hospital administrators) think it is.

Dr. Hauptman is professor of internal medicine and assistant dean of clinical-translational research at Saint Louis University and director of heart failure at Saint Louis University Hospital. He is an associate editor for Circulation: Heart Failure and blogs while staring out his office window at the Arch.

I attended a grand rounds recently on a nonacademic topic: improving work flows with electronic medical records (EMR). It was standing room only, a unique phenomenon. Clinicians of all shapes and sizes were in attendance to listen to one of their colleagues provide "useful suggestions" about navigating a somewhat cumbersome and nonintuitive EMR system.

In this "How To" session, we learned about segregating physician notes from other encounters; methods to transpose a comprehensive review of systems from one note to the next; how to filter cardiac test results from all other test data; and more.

©sergojpg/Fotolia.com

The speaker was selected because of his recognized facility with and apparent mastery over the EMR; he knew the shortcuts and every aspect of the system’s functionality.

Herein lies a new definition of the "triple threat": a good clinician, teacher, and EMR navigator.

But is this last skill truly a preferred one? Should we start to select medical students and residents on the basis of computer skills rather than GPA, MCAT, personal history, board scores, or personality? Maybe we should add an EMR challenge to the interview process? After all, successful navigation of EMR seems to be a new metric. Every time I log in, I am provided inane scores on a 0 to 100 scale based on promptness of completing notes, adding new diagnoses, etc. I suspect that the grand rounds speaker scores 100. I do not but take some solace in the fact that I’m nicely and consistently situated near 85. Adequate and acceptable, I hope, until my pay is somehow tied to my EMR "performance."

What does any of this mean to the patient? Is our grand round speaker able to appreciate jugular venous distention, an S3, a precordial knock? Is he listening to the patient? Is he empathic?

All I know is that the next time I click on the imaging tab and see results for a foot x-ray instead of a cardiac echo, it will be clear that I missed something vital during the presentation. Time to deduct some of my Continuing Nonmedical Education credits!

Dr. Hauptman is professor of internal medicine and assistant dean of clinical-translational research at Saint Louis University and director of heart failure at Saint Louis University Hospital. He is an associate editor for Circulation: Heart Failure and blogs while staring out his office window at the Arch.

I attended a grand rounds recently on a nonacademic topic: improving work flows with electronic medical records (EMR). It was standing room only, a unique phenomenon. Clinicians of all shapes and sizes were in attendance to listen to one of their colleagues provide "useful suggestions" about navigating a somewhat cumbersome and nonintuitive EMR system.

In this "How To" session, we learned about segregating physician notes from other encounters; methods to transpose a comprehensive review of systems from one note to the next; how to filter cardiac test results from all other test data; and more.

©sergojpg/Fotolia.com

The speaker was selected because of his recognized facility with and apparent mastery over the EMR; he knew the shortcuts and every aspect of the system’s functionality.

Herein lies a new definition of the "triple threat": a good clinician, teacher, and EMR navigator.

But is this last skill truly a preferred one? Should we start to select medical students and residents on the basis of computer skills rather than GPA, MCAT, personal history, board scores, or personality? Maybe we should add an EMR challenge to the interview process? After all, successful navigation of EMR seems to be a new metric. Every time I log in, I am provided inane scores on a 0 to 100 scale based on promptness of completing notes, adding new diagnoses, etc. I suspect that the grand rounds speaker scores 100. I do not but take some solace in the fact that I’m nicely and consistently situated near 85. Adequate and acceptable, I hope, until my pay is somehow tied to my EMR "performance."

What does any of this mean to the patient? Is our grand round speaker able to appreciate jugular venous distention, an S3, a precordial knock? Is he listening to the patient? Is he empathic?

All I know is that the next time I click on the imaging tab and see results for a foot x-ray instead of a cardiac echo, it will be clear that I missed something vital during the presentation. Time to deduct some of my Continuing Nonmedical Education credits!

Dr. Hauptman is professor of internal medicine and assistant dean of clinical-translational research at Saint Louis University and director of heart failure at Saint Louis University Hospital. He is an associate editor for Circulation: Heart Failure and blogs while staring out his office window at the Arch.

I attended a grand rounds recently on a nonacademic topic: improving work flows with electronic medical records (EMR). It was standing room only, a unique phenomenon. Clinicians of all shapes and sizes were in attendance to listen to one of their colleagues provide "useful suggestions" about navigating a somewhat cumbersome and nonintuitive EMR system.

In this "How To" session, we learned about segregating physician notes from other encounters; methods to transpose a comprehensive review of systems from one note to the next; how to filter cardiac test results from all other test data; and more.

©sergojpg/Fotolia.com

The speaker was selected because of his recognized facility with and apparent mastery over the EMR; he knew the shortcuts and every aspect of the system’s functionality.

Herein lies a new definition of the "triple threat": a good clinician, teacher, and EMR navigator.

But is this last skill truly a preferred one? Should we start to select medical students and residents on the basis of computer skills rather than GPA, MCAT, personal history, board scores, or personality? Maybe we should add an EMR challenge to the interview process? After all, successful navigation of EMR seems to be a new metric. Every time I log in, I am provided inane scores on a 0 to 100 scale based on promptness of completing notes, adding new diagnoses, etc. I suspect that the grand rounds speaker scores 100. I do not but take some solace in the fact that I’m nicely and consistently situated near 85. Adequate and acceptable, I hope, until my pay is somehow tied to my EMR "performance."

What does any of this mean to the patient? Is our grand round speaker able to appreciate jugular venous distention, an S3, a precordial knock? Is he listening to the patient? Is he empathic?

All I know is that the next time I click on the imaging tab and see results for a foot x-ray instead of a cardiac echo, it will be clear that I missed something vital during the presentation. Time to deduct some of my Continuing Nonmedical Education credits!

Dr. Hauptman is professor of internal medicine and assistant dean of clinical-translational research at Saint Louis University and director of heart failure at Saint Louis University Hospital. He is an associate editor for Circulation: Heart Failure and blogs while staring out his office window at the Arch.

There was quite a lot of discussion around patient-centered outcomes at the recent annual meeting of the American College of Cardiology. A fine development! Colleagues of mine have been in the wilderness for years on this topic but maybe, in a post-COURAGE world, with more limited resources, we are finally starting to get it.

What are patient-centered outcomes? It’s actually a complicated concept, and there are numerous related terms, like "patient focused" and "patient related." In general terms, they are outcomes that are reported directly by patients themselves and not interpreted by an observer, and may include patient assessments of health status, quality-of-life, or satisfaction with care or symptoms.

In heart failure, we know that dyspnea is the most common presenting symptom during acute decompensation (Eur. Heart J. 2003;24:442-63) and that relief of dyspnea is important to patients (J. Am. Coll. Cardiol. 2008;52:1702-8). On the other hand, while dyspnea is a therapeutic target for drugs and devices, it is not at all clear that the Food and Drug Administration would agree to approve a safe intervention that relieves only this one symptom. In addition, a strong argument can be made that we don’t even really know how to measure dyspnea in a way that is valid, reproducible, and clinically meaningful. For example, if an intervention changes the average dyspnea score on a 7-point Likert scale from 1 ("slightly improved") to 2 ("moderately improved") when measured at 48 hours following an admission for heart failure, is that enough to warrant approval?

Clearly, to deliver patient-centered care, we have to measure the correct outcomes. But beyond that, we have to find a way to align the interests of disparate parties looking in at the doctor-physician interaction: the funding agencies (National Institutes of Health, Patient-Centered Outcomes Research Institute, Agency for Healthcare Research and Quality, and others), the regulatory bodies (Food and Drug Administration, Centers for Medicare and Medicaid Services) and third-party payers.

Patient-centeredness: Great concept, uncertain delivery.

There was quite a lot of discussion around patient-centered outcomes at the recent annual meeting of the American College of Cardiology. A fine development! Colleagues of mine have been in the wilderness for years on this topic but maybe, in a post-COURAGE world, with more limited resources, we are finally starting to get it.

What are patient-centered outcomes? It’s actually a complicated concept, and there are numerous related terms, like "patient focused" and "patient related." In general terms, they are outcomes that are reported directly by patients themselves and not interpreted by an observer, and may include patient assessments of health status, quality-of-life, or satisfaction with care or symptoms.

In heart failure, we know that dyspnea is the most common presenting symptom during acute decompensation (Eur. Heart J. 2003;24:442-63) and that relief of dyspnea is important to patients (J. Am. Coll. Cardiol. 2008;52:1702-8). On the other hand, while dyspnea is a therapeutic target for drugs and devices, it is not at all clear that the Food and Drug Administration would agree to approve a safe intervention that relieves only this one symptom. In addition, a strong argument can be made that we don’t even really know how to measure dyspnea in a way that is valid, reproducible, and clinically meaningful. For example, if an intervention changes the average dyspnea score on a 7-point Likert scale from 1 ("slightly improved") to 2 ("moderately improved") when measured at 48 hours following an admission for heart failure, is that enough to warrant approval?

Clearly, to deliver patient-centered care, we have to measure the correct outcomes. But beyond that, we have to find a way to align the interests of disparate parties looking in at the doctor-physician interaction: the funding agencies (National Institutes of Health, Patient-Centered Outcomes Research Institute, Agency for Healthcare Research and Quality, and others), the regulatory bodies (Food and Drug Administration, Centers for Medicare and Medicaid Services) and third-party payers.

Patient-centeredness: Great concept, uncertain delivery.

There was quite a lot of discussion around patient-centered outcomes at the recent annual meeting of the American College of Cardiology. A fine development! Colleagues of mine have been in the wilderness for years on this topic but maybe, in a post-COURAGE world, with more limited resources, we are finally starting to get it.

What are patient-centered outcomes? It’s actually a complicated concept, and there are numerous related terms, like "patient focused" and "patient related." In general terms, they are outcomes that are reported directly by patients themselves and not interpreted by an observer, and may include patient assessments of health status, quality-of-life, or satisfaction with care or symptoms.

In heart failure, we know that dyspnea is the most common presenting symptom during acute decompensation (Eur. Heart J. 2003;24:442-63) and that relief of dyspnea is important to patients (J. Am. Coll. Cardiol. 2008;52:1702-8). On the other hand, while dyspnea is a therapeutic target for drugs and devices, it is not at all clear that the Food and Drug Administration would agree to approve a safe intervention that relieves only this one symptom. In addition, a strong argument can be made that we don’t even really know how to measure dyspnea in a way that is valid, reproducible, and clinically meaningful. For example, if an intervention changes the average dyspnea score on a 7-point Likert scale from 1 ("slightly improved") to 2 ("moderately improved") when measured at 48 hours following an admission for heart failure, is that enough to warrant approval?

Clearly, to deliver patient-centered care, we have to measure the correct outcomes. But beyond that, we have to find a way to align the interests of disparate parties looking in at the doctor-physician interaction: the funding agencies (National Institutes of Health, Patient-Centered Outcomes Research Institute, Agency for Healthcare Research and Quality, and others), the regulatory bodies (Food and Drug Administration, Centers for Medicare and Medicaid Services) and third-party payers.

Patient-centeredness: Great concept, uncertain delivery.

It’s the title of a great song from 1930, with Duke Ellington’s version a true classic. Three little words seem to apply to overused and now nearly meaningless vocabulary in medicine and probably the wider world: "robust," "transparency," and "paradigm shift." Admittedly, those are four words, but I’m not alone in miscounting to make a point. Vice President Joe Biden famously once said that "the No. 1 job facing the middle class and it happens to be ... a three-letter word: jobs, J-O-B-S, jobs."

How many times have you seen those words in the cardiology literature or heard them at grand rounds?

Findings in a study are "robust." A new therapy represents a potential "paradigm shift." Justification for an increase in the number of rules and oversight is based on a goal to increase "transparency."

The problem now is that the meanings behind those words have been cheapened and, ironically, we frequently observe that findings labeled as robust (as in a phase II study) often do not pan out. Paradigm shifts are few and far between (our advances are usually gradual and incremental), and transparency is often an excuse used by bureaucrats and political agenda artists to justify more regulation.

I’ll stick with the 1930s original Three Little Words. Look them up and repeat them to someone important in your life. They will have far more resonance than "paradigm shift."

Dr. Paul Hauptman is Professor of Internal Medicine and Assistant Dean of Clinical-Translational Research at Saint Louis University and Director of Heart Failure at Saint Louis University Hospital. He currently serves as an Associate Editor for Circulation: Heart Failure and blogs while staring out his office window at the Arch.

It’s the title of a great song from 1930, with Duke Ellington’s version a true classic. Three little words seem to apply to overused and now nearly meaningless vocabulary in medicine and probably the wider world: "robust," "transparency," and "paradigm shift." Admittedly, those are four words, but I’m not alone in miscounting to make a point. Vice President Joe Biden famously once said that "the No. 1 job facing the middle class and it happens to be ... a three-letter word: jobs, J-O-B-S, jobs."

How many times have you seen those words in the cardiology literature or heard them at grand rounds?

Findings in a study are "robust." A new therapy represents a potential "paradigm shift." Justification for an increase in the number of rules and oversight is based on a goal to increase "transparency."

The problem now is that the meanings behind those words have been cheapened and, ironically, we frequently observe that findings labeled as robust (as in a phase II study) often do not pan out. Paradigm shifts are few and far between (our advances are usually gradual and incremental), and transparency is often an excuse used by bureaucrats and political agenda artists to justify more regulation.

I’ll stick with the 1930s original Three Little Words. Look them up and repeat them to someone important in your life. They will have far more resonance than "paradigm shift."

Dr. Paul Hauptman is Professor of Internal Medicine and Assistant Dean of Clinical-Translational Research at Saint Louis University and Director of Heart Failure at Saint Louis University Hospital. He currently serves as an Associate Editor for Circulation: Heart Failure and blogs while staring out his office window at the Arch.

It’s the title of a great song from 1930, with Duke Ellington’s version a true classic. Three little words seem to apply to overused and now nearly meaningless vocabulary in medicine and probably the wider world: "robust," "transparency," and "paradigm shift." Admittedly, those are four words, but I’m not alone in miscounting to make a point. Vice President Joe Biden famously once said that "the No. 1 job facing the middle class and it happens to be ... a three-letter word: jobs, J-O-B-S, jobs."

How many times have you seen those words in the cardiology literature or heard them at grand rounds?

Findings in a study are "robust." A new therapy represents a potential "paradigm shift." Justification for an increase in the number of rules and oversight is based on a goal to increase "transparency."

The problem now is that the meanings behind those words have been cheapened and, ironically, we frequently observe that findings labeled as robust (as in a phase II study) often do not pan out. Paradigm shifts are few and far between (our advances are usually gradual and incremental), and transparency is often an excuse used by bureaucrats and political agenda artists to justify more regulation.

I’ll stick with the 1930s original Three Little Words. Look them up and repeat them to someone important in your life. They will have far more resonance than "paradigm shift."

Dr. Paul Hauptman is Professor of Internal Medicine and Assistant Dean of Clinical-Translational Research at Saint Louis University and Director of Heart Failure at Saint Louis University Hospital. He currently serves as an Associate Editor for Circulation: Heart Failure and blogs while staring out his office window at the Arch.

The acronyms for clinical trials are an endless source of fascination to me. Yes, the famous TIMI family is in its 50s (by volume) and we have multiple EVERESTs, but there is something about heart failure trials that brings out the most optimistic streak in us. Take for example: RADIANCE, VICTOR, SURVIVE, BEST, and RELAX.

We have a drug to SAVE and a drug that SOLVDs. Ironically, at the same time, we thought we had a drug to REVIVE, a drug to PROTECT and a drug to IMPRESS. But we were wrong. A name only goes so far. The drug or intervention has to work.

©Elena Moiseeva/fotolia.com

So is the name of the trial important? I guess you could ask the same about a car. Few would go out and buy a car named "Clunker," even if it were the best and most reliable car ever made. In that context, I doubt we will ever see a heart failure trial by the name of LIMIT or FAIL.

My own favorite and the winner at pivotal times of the day? MOCHA!

The acronyms for clinical trials are an endless source of fascination to me. Yes, the famous TIMI family is in its 50s (by volume) and we have multiple EVERESTs, but there is something about heart failure trials that brings out the most optimistic streak in us. Take for example: RADIANCE, VICTOR, SURVIVE, BEST, and RELAX.

We have a drug to SAVE and a drug that SOLVDs. Ironically, at the same time, we thought we had a drug to REVIVE, a drug to PROTECT and a drug to IMPRESS. But we were wrong. A name only goes so far. The drug or intervention has to work.

©Elena Moiseeva/fotolia.com

So is the name of the trial important? I guess you could ask the same about a car. Few would go out and buy a car named "Clunker," even if it were the best and most reliable car ever made. In that context, I doubt we will ever see a heart failure trial by the name of LIMIT or FAIL.

My own favorite and the winner at pivotal times of the day? MOCHA!

The acronyms for clinical trials are an endless source of fascination to me. Yes, the famous TIMI family is in its 50s (by volume) and we have multiple EVERESTs, but there is something about heart failure trials that brings out the most optimistic streak in us. Take for example: RADIANCE, VICTOR, SURVIVE, BEST, and RELAX.

We have a drug to SAVE and a drug that SOLVDs. Ironically, at the same time, we thought we had a drug to REVIVE, a drug to PROTECT and a drug to IMPRESS. But we were wrong. A name only goes so far. The drug or intervention has to work.

©Elena Moiseeva/fotolia.com

So is the name of the trial important? I guess you could ask the same about a car. Few would go out and buy a car named "Clunker," even if it were the best and most reliable car ever made. In that context, I doubt we will ever see a heart failure trial by the name of LIMIT or FAIL.

My own favorite and the winner at pivotal times of the day? MOCHA!

Is this really important? Yes, it is. Hospitals are now seeing their precious profit margins decimated by penalties up to 1%, soon to be 2% and then 3%. The Centers for Medicare and Medicaid services, in its wisdom, has decided that heart failure readmissions are largely preventable and that all a hospital has to do is institute some form of improved discharge planning, telemanagement, visiting nursing, disease management, home weight scales, iPhone or iPad or email or other electronic communication, and – poof! – the problem dissipates.

I wish it were so simple.

Multiple intervention trials, including a high-visibility effort at telemanagement (N. Engl. J. Med. 2010;363:2301-9), have failed, perhaps because patients are readmitted for a variety of causes. Surely some are directly preventable. Back in 1990, Vinson and associates (J. Am. Geriatr. Soc. 1990;38:1290-5), listed the top causes of readmission (which included noncompliance with medications, 15%; noncompliance with diet, 18%; inadequate follow-up, 20%; and lack of social support, 21%).

From personal experience, the noncompliance part seems to have magnified. Take a look at a study by Dr. Ruben Amarasingham and colleagues (Med. Care 2010;48:981-8). His group found that important predictors included the number of home address changes, a history of cocaine use, depression or anxiety, and a history of a missed clinic visit. Noteworthy in the analysis is the absence of all those physiological parameters we seem to discuss at national meetings. No surprise there. The biomarkers, echo parameters, and hemodynamics all count, but the devastating effect of dietary and medication nonadherence seems to trump all.

©anakondasp/fotolia.com

Recently, at the annual meeting of the Heart Failure Society of America, Narendra Bhalodkar of Bronx-Lebanon Medical Center, New York, described the efforts at his hospital (in, of all places, the South Bronx) to decrease readmissions in a talk entitled "Can Horse Drink the Water Please?" It was a remarkable presentation of the tribulations that his program has experienced in its futile attempt to act not just as a provider of heart failure care but as social worker, psychologist, nurse, dietician, and community organizer ... all for naught.

I plan to discuss this more in later columns, but let me add just a few interesting tidbits.

First, in Europe, lengths of stay for heart failure are longer but readmission rates are lower.

Second, an admission with heart failure is not an admission for heart failure. Maybe we should be less aggressive in our coding!

Third, the readmission debate has not included frank discussions about patient responsibility.

Finally, expect some form of regression to the mean. Programs spared in the first round will undoubtedly find themselves dinged in the second.

Mark my words, this will happen. In the meantime, a lot of money and a lot of effort will be expended in pursuit of an ill-defined goal line.

Good luck to all of us.

Is this really important? Yes, it is. Hospitals are now seeing their precious profit margins decimated by penalties up to 1%, soon to be 2% and then 3%. The Centers for Medicare and Medicaid services, in its wisdom, has decided that heart failure readmissions are largely preventable and that all a hospital has to do is institute some form of improved discharge planning, telemanagement, visiting nursing, disease management, home weight scales, iPhone or iPad or email or other electronic communication, and – poof! – the problem dissipates.

I wish it were so simple.

Multiple intervention trials, including a high-visibility effort at telemanagement (N. Engl. J. Med. 2010;363:2301-9), have failed, perhaps because patients are readmitted for a variety of causes. Surely some are directly preventable. Back in 1990, Vinson and associates (J. Am. Geriatr. Soc. 1990;38:1290-5), listed the top causes of readmission (which included noncompliance with medications, 15%; noncompliance with diet, 18%; inadequate follow-up, 20%; and lack of social support, 21%).

From personal experience, the noncompliance part seems to have magnified. Take a look at a study by Dr. Ruben Amarasingham and colleagues (Med. Care 2010;48:981-8). His group found that important predictors included the number of home address changes, a history of cocaine use, depression or anxiety, and a history of a missed clinic visit. Noteworthy in the analysis is the absence of all those physiological parameters we seem to discuss at national meetings. No surprise there. The biomarkers, echo parameters, and hemodynamics all count, but the devastating effect of dietary and medication nonadherence seems to trump all.

©anakondasp/fotolia.com

Recently, at the annual meeting of the Heart Failure Society of America, Narendra Bhalodkar of Bronx-Lebanon Medical Center, New York, described the efforts at his hospital (in, of all places, the South Bronx) to decrease readmissions in a talk entitled "Can Horse Drink the Water Please?" It was a remarkable presentation of the tribulations that his program has experienced in its futile attempt to act not just as a provider of heart failure care but as social worker, psychologist, nurse, dietician, and community organizer ... all for naught.

I plan to discuss this more in later columns, but let me add just a few interesting tidbits.

First, in Europe, lengths of stay for heart failure are longer but readmission rates are lower.

Second, an admission with heart failure is not an admission for heart failure. Maybe we should be less aggressive in our coding!

Third, the readmission debate has not included frank discussions about patient responsibility.

Finally, expect some form of regression to the mean. Programs spared in the first round will undoubtedly find themselves dinged in the second.

Mark my words, this will happen. In the meantime, a lot of money and a lot of effort will be expended in pursuit of an ill-defined goal line.

Good luck to all of us.

Is this really important? Yes, it is. Hospitals are now seeing their precious profit margins decimated by penalties up to 1%, soon to be 2% and then 3%. The Centers for Medicare and Medicaid services, in its wisdom, has decided that heart failure readmissions are largely preventable and that all a hospital has to do is institute some form of improved discharge planning, telemanagement, visiting nursing, disease management, home weight scales, iPhone or iPad or email or other electronic communication, and – poof! – the problem dissipates.

I wish it were so simple.

Multiple intervention trials, including a high-visibility effort at telemanagement (N. Engl. J. Med. 2010;363:2301-9), have failed, perhaps because patients are readmitted for a variety of causes. Surely some are directly preventable. Back in 1990, Vinson and associates (J. Am. Geriatr. Soc. 1990;38:1290-5), listed the top causes of readmission (which included noncompliance with medications, 15%; noncompliance with diet, 18%; inadequate follow-up, 20%; and lack of social support, 21%).

From personal experience, the noncompliance part seems to have magnified. Take a look at a study by Dr. Ruben Amarasingham and colleagues (Med. Care 2010;48:981-8). His group found that important predictors included the number of home address changes, a history of cocaine use, depression or anxiety, and a history of a missed clinic visit. Noteworthy in the analysis is the absence of all those physiological parameters we seem to discuss at national meetings. No surprise there. The biomarkers, echo parameters, and hemodynamics all count, but the devastating effect of dietary and medication nonadherence seems to trump all.

©anakondasp/fotolia.com

Recently, at the annual meeting of the Heart Failure Society of America, Narendra Bhalodkar of Bronx-Lebanon Medical Center, New York, described the efforts at his hospital (in, of all places, the South Bronx) to decrease readmissions in a talk entitled "Can Horse Drink the Water Please?" It was a remarkable presentation of the tribulations that his program has experienced in its futile attempt to act not just as a provider of heart failure care but as social worker, psychologist, nurse, dietician, and community organizer ... all for naught.

I plan to discuss this more in later columns, but let me add just a few interesting tidbits.

First, in Europe, lengths of stay for heart failure are longer but readmission rates are lower.

Second, an admission with heart failure is not an admission for heart failure. Maybe we should be less aggressive in our coding!

Third, the readmission debate has not included frank discussions about patient responsibility.

Finally, expect some form of regression to the mean. Programs spared in the first round will undoubtedly find themselves dinged in the second.

Mark my words, this will happen. In the meantime, a lot of money and a lot of effort will be expended in pursuit of an ill-defined goal line.

Good luck to all of us.

"Please accept my resignation. I don’t want to belong to any club that will accept people like me as a member."        –Groucho Marx

I caught up recently with a colleague, a cardiac surgeon, about 5 years after we last saw each other. What a delight, and a reminder that we really do participate in a unique profession. Indeed, one of the great pleasures of attending national meetings has been and will always be the opportunity to see colleagues from one’s past: from medical school, residency, fellowship, or just prior collaborations. In these difficult times for medicine, it’s a positive that we can have warm personal relationships built on professional ones.

Wikimedia/Ralph Stitt/CC License

Even without a secret handshake or password, there is something special, something unifying about our training, about the long hours (at least before the so-called reforms), about our mutual dedication to the welfare of patients, and to the profession. Though it is a cliché, we share the fact that we’ve been involved with critical "life and death" decisions and real life dramas. We’ve witnessed both the touching and the absurd.

I am not anticipating another 5-year wait to see my friend again. I suspect he feels likewise because over dinner we made plans, albeit tentative, to finally write "the paper" we’ve been talking about for over a decade. Even if we never get around to doing it, we have an excuse for more meetings and for keeping it on our mutual "to do" lists.

As for Groucho Marx (and with apologies to Mr. Boothroyd, my seventh grade grammar teacher), this is one club I still want to belong to.

"Please accept my resignation. I don’t want to belong to any club that will accept people like me as a member."        –Groucho Marx

I caught up recently with a colleague, a cardiac surgeon, about 5 years after we last saw each other. What a delight, and a reminder that we really do participate in a unique profession. Indeed, one of the great pleasures of attending national meetings has been and will always be the opportunity to see colleagues from one’s past: from medical school, residency, fellowship, or just prior collaborations. In these difficult times for medicine, it’s a positive that we can have warm personal relationships built on professional ones.

Wikimedia/Ralph Stitt/CC License

Even without a secret handshake or password, there is something special, something unifying about our training, about the long hours (at least before the so-called reforms), about our mutual dedication to the welfare of patients, and to the profession. Though it is a cliché, we share the fact that we’ve been involved with critical "life and death" decisions and real life dramas. We’ve witnessed both the touching and the absurd.

I am not anticipating another 5-year wait to see my friend again. I suspect he feels likewise because over dinner we made plans, albeit tentative, to finally write "the paper" we’ve been talking about for over a decade. Even if we never get around to doing it, we have an excuse for more meetings and for keeping it on our mutual "to do" lists.

As for Groucho Marx (and with apologies to Mr. Boothroyd, my seventh grade grammar teacher), this is one club I still want to belong to.

"Please accept my resignation. I don’t want to belong to any club that will accept people like me as a member."        –Groucho Marx

I caught up recently with a colleague, a cardiac surgeon, about 5 years after we last saw each other. What a delight, and a reminder that we really do participate in a unique profession. Indeed, one of the great pleasures of attending national meetings has been and will always be the opportunity to see colleagues from one’s past: from medical school, residency, fellowship, or just prior collaborations. In these difficult times for medicine, it’s a positive that we can have warm personal relationships built on professional ones.

Wikimedia/Ralph Stitt/CC License

Even without a secret handshake or password, there is something special, something unifying about our training, about the long hours (at least before the so-called reforms), about our mutual dedication to the welfare of patients, and to the profession. Though it is a cliché, we share the fact that we’ve been involved with critical "life and death" decisions and real life dramas. We’ve witnessed both the touching and the absurd.

I am not anticipating another 5-year wait to see my friend again. I suspect he feels likewise because over dinner we made plans, albeit tentative, to finally write "the paper" we’ve been talking about for over a decade. Even if we never get around to doing it, we have an excuse for more meetings and for keeping it on our mutual "to do" lists.

As for Groucho Marx (and with apologies to Mr. Boothroyd, my seventh grade grammar teacher), this is one club I still want to belong to.