Physician Finances

Why Doctors Should Be Really, Really Afraid Of Inflation

We have been living in an era of incredibly low inflation rates. In fact, for the past decade, the inflation rate has been the lowest in U.S. history since the 1930’s and has averaged only 1.77% per year since 2010. But economic history teaches us that inflation rates will inevitably rise in the future and when they do, that rise will be especially harmful to physicians.

In the year that I started medical school, 1980, the inflation rate was an astounding 13.5%! Along with high inflation came high interest rates – in April 1980, the average 30-year fixed mortgage rate was more than 16%. Inflation means that the cost of goods and services goes up. Inflation is often measured by the consumer price index, which is derived from the cost of 8,018 items weighted for the amount of each of those items purchased by consumers the previous month. Inflation is heterogeneous in that the cost of some items will rise more than other items thus affecting some groups of people differently. For example, if the cost of gasoline preferentially increases, then the independent long-haul trucker will be affected more than the person who works from home and does not drive a car. Alternatively, if the cost of food preferentially increases, then the family with 4 teenagers will be affected more than the empty nesters who live next door.

Overall, when the cost of goods and services increase, the average worker’s wage generally increases in tandem. The group that gets hurt the worst with inflation is people with a fixed income, for example, retirees living off of pensions or Social Security. But because of the the way healthcare financing works in the United States, doctors are also ultimately on a fixed income.

The reason is that about 64% of U.S. healthcare spending comes from governmental sources – mainly Medicare, Medicaid, the Veterans Administration, and CHIP (Children’s Health Insurance Program). Physician payments for most of these governmental sources are tied to the Medicare Conversion Factor which is the amount of money that doctors get paid per RVU (relative value unit). When inflation rises, the Medicare Conversion Factor does not keep up. In the graph, we can see the effect of inflation compared to the change in the Medicare Conversion Factor since 1998. So, for example, in 1998, the conversion factor was $36.69/RVU and remained relatively stagnant for the next 20 years so that by 2019, the conversion factor was $36.04/RVU. On the other hand, goods and services that cost $36.69 in 1998 cost $58.46 in 2019 due to increases in the consumer price index (inflation). In other words, doctors get paid about the same to do a given medical service in 2019 as they did in 1998 but the cost of all of the goods and services that doctors purchase has increased by 62%!

Despite the static conversion factor, doctor’s incomes have increased since 1998 and kept up with inflation. There are three main reasons for this. (1) There has been a shift toward optimizing physician work efficiency by improving office workflows and improving hospital throughput; this has resulted in physicians being able to increase patient volumes. (2) Computerization of medical practice has also improved efficiency and physician work output; this has also resulted in increased patient volumes per workday. (3) There has been a shift from physicians being self-employed to being hospital-employed with hospitals now subsidizing physician salaries.

These three things have allowed physician income to rise but will they be able to keep up with inflation in the future? Most physicians would say that they are currently at the limit of the number of outpatients that they can see in a day. Most hospitalists would say that they are at the limit of the number of patients they can take care of during a hospital shift. Most hospitals have streamlined operating room throughput so that surgeons would say that they cannot do many more surgical operations on a given day. In other words, gains from increased operational efficiency of medical practice cannot be further increased in the future. And that means that in the future, cost of living increases in physician incomes will have to come from greater subsidization rather than greater revenue from clinical care.

Inevitably, with subsidization comes loss of autonomy. And if/when the inflation rate increases, the degree of subsidization will likely increase since there is no reason to expect that the Medicare Conversion Factor is going to increase based on the precedent of the last 20 years. Fortunately, there are a few things physicians can do to protect themselves from inflation:

  1. Invest. Except for the decade of 2000-2009 (the “great recession”), the increased value of stocks has outpaced the rate of inflation every decade for the past century. Although there can be considerable year-to-year fluctuations in stock market returns compared to the consumer price index, over time, the stock market always beats inflation. Given that physicians have relatively high incomes compared to the U.S. average worker, one of the best hedges against inflation for physicians is to invest and invest early in one’s career.
  2. Have a good electronic medical record and use it efficiently. It is said that “A cheap tool is an expensive tool”, essentially meaning that you get what you pay for and electronic medical records (EMRs) are no exception. An inexpensive EMR that does not improve physician efficiency will result in lower net physician income over time compared to an expensive EMR that allows physicians to perform documentation in less time. Moreover, the EMR is evolving from a computerized patient documentation system to a computerized patient management system by incorporating decision-making algorithms and artificial intelligence into the EMR program. Therefore, your EMR should not just make your documentation more efficient, it needs to make your patient management more efficient.
  3. Incorporate industrial engineering principles into office practice. A high-functioning factory is one where there is a minimum of unnecessary motions made by the workers, workers are properly trained to perform their assigned tasks, workers have the right tools they need to perform each task, and each employee works at the top of their skillset. By optimizing office practice efficiency, physicians can reduce overhead expenses, reduce billing costs, improve patient throughput, and reduce patients no-shows & cancelations. Together, these process improvements can reduce the amount of each RVU that goes towards overhead expense and increase the amount that goes toward physician income.
  4. Develop mutually beneficial financial relationships with hospitals. Currently, there are more physicians employed by hospitals than in physician-owned practices. This is even more pronounced for younger physicians – 70% of doctors under age 40 are employed by hospitals and this portends a future where few physicians will be self-employed. Physician-hospital partnerships that result in lower length-of-stay, lower readmission rates, lower pharmacy charges, and higher patient satisfaction will be more mutually financially lucrative in the long run – a hospital with a larger positive financial margin can afford to subsidize its physicians more than a hospital with a lower financial margin.
  5. Advocate for contractionary monetary policy when economically indicated. When consumers have too much money to spend, inflation occurs. A government can reduce spending by enacting contractionary monetary policy that takes cash out of circulation and moves that cash back to the government and banks. There are essentially three tools a government has to do this: (1) Increase interest rates – this is primarily done by interest rate decisions made by the Federal Reserve Board. (2) Increase the reserve requirements which is the amount of money banks are required to maintain on reserve when making loans – this is also determined by the Federal Reserve Board. (3) Reduce money supply by increasing government bond rates and by increasing income tax rates. Most Americans have a visceral distain for higher interest rates and higher income taxes but sometimes these are necessary to rein in out of control inflation.

It has been nearly 30 years since the annual inflation rate exceeded 4% and consequently most physicians have never experienced the effect of high inflation rates. When it comes to inflation in the future, the saying “Hope for the best but prepare for the worst” is good advice for physicians. In the event of unexpectedly high inflation, physicians would likely see a decline in their relative income compared to other professionals.

November 24, 2019

Hospital Finances

The 2020 Medicare Readmission Penalty Program

Each year, Medicare analyzes the readmission rate for every hospital in the United States and then imposes financial penalties on those hospitals determined to have excessively high readmission rates. And every year, most U.S. hospitals get penalized. This year is no exception – 83% of all hospitals face penalties.

The Medicare Hospital Readmission Reduction Program

The hospital readmission reduction program was created as a part of the Affordable Care Act as a way to improve quality of care and reduce overall Medicare costs. Readmissions are defined as a patient being readmitted to any hospital and for any reason within 30 days of discharge from the hospital being analyzed. The program began in 2013 by looking at readmissions for just 3 conditions: myocardial infarction, heart failure, and pneumonia. In 2015, the program expanded to 5 conditions by adding readmissions for chronic obstructive pulmonary disease and knee & hip replacement surgery. In 2017, the program further expanded to 6 conditions by adding coronary artery bypass graft surgery. Each year, Medicare calculates the penalties based on the previous 3 years’ readmission data and then hospitals are penalized up to 3% of their total Medicare payments the following year.

The program has been controversial since inception with concerns that it preferentially penalized hospitals that care for sicker patients as well as for lower-income patients and underinsured patients who often lack the resources to get outpatient medical care that can keep them out of the hospital. Medicare responded by making 2 adjustments to the penalty based on a given hospital’s patient demographics:

  1. The severity of illness of the hospital’s patients (often called the case mix index) with the premise that the sicker a patient is, the more likely that patient is to be readmitted to the hospital.
  2. The rate of “dual eligible” patients, that is , patients who are eligible to receive both Medicare and Medicaid with the premise that lower income (i.e., Medicaid) patients are more likely to be socioeconomically disadvantaged and therefore more likely to be readmitted because of lack of outpatient resources beyond a hospital’s control that can affect readmission.

Adjusting the penalties for socioeconomically disadvantaged patients

Medicare divided all U.S. hospitals into quintiles based on the percentage of dual eligible patients.  Hospitals were only compared to other hospitals within the same quintile for the purposes of penalty calculation; therefore, a hospital with a high percentage of dual eligible patients was held to a different readmission rate expectation than a hospital with a low percentage of dual eligible patients. In fiscal year 2019, the dual eligible adjustment went into effect and the effect of this on the Medicare readmission penalties has now been analyzed in an article in the June 2019 issue of JAMA Internal Medicine. Hospitals that were more likely to be classified in quintile 5 (high percentage of socio-economically disadvantaged patients) were more likely to be:

  1. Teaching hospitals
  2. Larger hospitals
  3. Public hospitals
  4. Rural hospitals
  5. Medicaid expansion state hospitals
  6. Northeastern and Western U.S. hospitals
  7. Hospitals in neighborhoods with high prevalence of disabled persons

As one would expect, on average, hospitals in quintiles 1, 2, and 3 saw an increase in their readmission penalties whereas hospitals in quintiles 4 and 5 saw a decrease in their readmission penalties.

Characteristics of the 2020 readmission penalties

Last month, Medicare released the penalties for next year. These are based on 2015 – 2018 readmission data. 2,142 hospitals were exempt (childrens hospitals, veterans hospitals, Maryland hospitals, critical access hospitals, psychiatric hospitals, and hospitals with too few admissions for statistical significance). Overall, out of 3,129 U.S. hospitals included in the penalty program, 2,583 hospitals (83%)  received penalties totaling $563 million. The average penalty was 0.71% of total Medicare payments. 56 hospitals received the maximum (3%) penalty.

In Ohio, 90% of hospitals were penalized. Our medical center, the OSU Wexner Medical Center, received the lowest possible penalty, 0.01% which amounts to $14,000 for next year (last year, our penalty was 0.06%). In fact, all seven of the hospitals in Central Ohio fared very well for next year’s penalties with all of them coming in at less than half of the average U.S. hospital penalty.

In a previous post, I commented on the unintended consequence of the Medicare hospital readmissions reduction program, specifically that the program is associated with an increase in outpatient mortality. Since hospitals are paid by the DRG (in other words, by the diagnosis), hospitals are financially incentivized to discharge patients as quickly as possible in order to reduce their expenses. The Medicare hospital readmission reduction program was designed to offset that financial incentive by penalizing hospitals that discharge patients prematurely. Overall, the current readmission penalty program appears to be more fair to hospitals that care for socioeconomically disadvantaged patients. However, the danger remains that by creating a barrier for hospitals to readmit patients who truly need to be readmitted, outpatient mortality can increase.

November 17, 2019

Medical Education

Gender Bias In Lecture Acoustics

Last month, I attended the American College of Chest Physicians annual meeting. At one of the sessions, I realized I could hear the men talking but I had a hard time hearing the women despite the fact that they were all standing in front of the same lectern and all speaking in what seemed to be normal conversational speech. I realized that there can be implicit gender bias in lecture acoustics and that women need to be aware of some of these sources of acoustic bias in order to be effective speakers. There are several sources of acoustic gender bias. In this post, at the risk of being a male talking about female gender bias, I’ll explore several of these.

Gender differences in vocal frequency

Male and female voices occupy different sound frequencies. A typical male voice extends from 150 Hz to 6,000 Hz and a typical female voice extends from 350 to 8,000 Hz. However, in normal voiced speech, a male voice is 85 – 180 Hz and a female voice is 165 – 255 Hz. Certain vocal sounds occur at higher frequencies than others. For example, the sound of “J”, “M”, or “Z” occurs at a low frequency whereas the sound of “K”, “F”, or S” occurs at a much higher frequency.

Humans are wired to associate lower frequency voices with authority. In a study of male CEOs, the size of the company that a CEO ran correlated with the frequency of his voice – a lower voice pitch was associated with running a larger company and correlated with a higher salary. Interestingly, the average frequency of adult women’s voices has fallen by 23 Hz since 1960 which may reflect evolving societal differences in women in positions of authority. Because children have higher pitched voices than adults, a high-pitched voice can make a person sound young or inexperienced.

Many sound systems are adjusted to make the (often male) CEO sound great and this can put people with higher frequency voices at an inherent disadvantage unless there is someone tending the sound system who can make everyone sound just as great as the CEO.

We lose high frequency hearing with age

As we get older, our ability to hear high frequencies is diminished. Business owners use this to their advantage when they install a Mosquito alarm outside their buildings. This device emits an annoying 17,400 Hz noise that loitering teenagers can hear but older people are oblivious to. High frequency hearing loss begins at age 30 and increases with each decade of life.

As a result, many older people have a hard time hearing female voices with their higher frequency pitch. This is not an issue if you are lecturing to a group of college students. However, if you are lecturing to an older group of people or giving a presentation at a board meeting full of older board members, then a higher frequency voice is harder to hear. A woman often needs to speak slightly louder to be heard as well as her male colleague.

Equipment bias

There are two pieces of equipment that can affect how women’s voices project as opposed to men’s voices: the microphone and the equalizer. Each microphone will have a frequency rating that reflects how well it picks up different sound frequencies. A microphone that is better at picking up lower frequencies will tend to make a male voice sound louder and a female voice sound softer.

A second way that the microphone can cause discrimination by the “proximity effect”. This occurs because lower frequencies tend to be lost the further away a person is to the microphone. The average American man is 5 foot 9 inches tall where as the average American woman is 5 foot 4 inches tall, a difference of 5 inches. If a lectern microphone is set to position that microphone for the height of a man’s head, then a woman’s head is going to be 5 inches further away from that microphone with the effect of losing her lower frequency elements of speech. Therefore, simply by being closer to the microphone, you can augment the lower, or base frequencies in your voice. An easy way to demonstrate this is to use the “voice memo” app on your phone and record your voice saying the same thing with the phone 2 inches, 12 inches, and 24 inches away from your mouth. At 2 inches, your voice will have more base elements and will sound deeper and richer.

Microphones come in two general categories, directional and omnidirectional. A directional microphone picks up sounds from one specific direction and should be positioned so that it is pointed toward the source of that sound. An omnidirectional microphone picks up sounds from all directions from the microphone. The microphones on lecture room lecterns are usually directional so that the speaker’s voice is picked up but room noise is minimized. However, even with a directional microphone, as you increase the distance from the microphone, room noises will start to creep into the audio if the audio technician is attempting to maintain your voice at a constant volume. To ensure optimal acoustics, be sure that the directional microphone is pointed at your mouth.


Two other effects of the distance to the microphone is on reverberation and “popping noise”. Reverberation, or the echo of one’s voice in a room, becomes more evident when there are non-porous materials in the room (for example, concrete walls) and when one gets further from the microphone that they are speaking into. Those echos can make words harder to hear. If a person gets too close to a microphone, then the microphone can pick up puffs of air that can accompany sounds like the letters “p” or “b” and this can result in a distracting popping sound to one’s speech. Professional musicians overcome this by using a pop-filter composed of a piece of stocking-like material stretched and mounted as a screen between the microphone and the singer’s mouth. Pop-filters are impractical in a typical lecture room. The best distance is usually 6-12 inches between microphone and mouth; this distance is the best compromise between reducing popping sounds at the same time as reducing reverberation and room noise.

In order to account for different frequencies, equalizers are often used by sound engineers. An equalizer allows the engineer to preferentially amplify sounds in different frequency ranges and this can be used to “equalize” voices of different pitches, for example, men versus women. The bass and treble knobs on a radio are the most simple form of an equalizer. An equalizer in a lecture room can have between 5 and 31 sliders with each controlling a range of frequencies. Most lecture rooms don’t come with professional sound engineers, however, and so equalizers in a sound system may be set to a factory default frequency preference or the equalizer may be run by an audio-visual staff member with little idea of acoustic optimization. If you ever go to a small venue concert, the singer will almost always recognize the person running the sound system at the end of the show – how well that person manages the equalizer can make an enormous difference in how the singer sounds. The person running the lecture room sound system is just as important to the effectiveness of the lecturer.

Room bias

The acoustic response of a room if affected by many variables but one of the more important is the degree of absorption of different frequencies. Porous materials in a room, for example, carpet or fabric, can reduce reverberation and echos but will also absorb high frequency sounds. Thus, a person with a high frequency voice may not seem to be as loud as a person with a lower frequency voice. The more porous materials are in a room, the more a woman’s voice can be lost.

The individual’s “voice brand”

There are 5 main features of a person’s individual voice brand: intensity, inflection, rate, frequency, and quality. Adopting different elements of each of these features can significantly impact the effect a voice can have on a listener.

Intensity is the loudness of a voice in decibels. Too soft of a voice can come across as meek and timid but too loud of a voice can come across as if you are shouting or angry.

Inflection is the intonation of voice or the degree to which the pitch varies. An excessively monotone voice has little variation in the frequency of the words spoken and can come across as uninteresting. An excessively up-and-down voice with constant swings in the frequency of words can come across as unintelligent.

Rate is the speed of one’s speech. Too slow comes across as condescending but too fast comes across as being rushed. Varying the rate of speech can be an effective way of emphasizing certain points. A good rate range is 162-175 words per minute.

Frequency is the pitch of the voice, usually measured in hertz (Hz). Too high of a frequency can make one sound young or less intelligent, as discussed above. Too low of a frequency can be authoritative but can also come across as aggressive.

Quality are those characteristics of a voice that can create an “interesting voice”. Two voice qualities to avoid in public speaking are the “glottal fry” and “up-talking”. Glottal fry is when a person takes their voice down to an unnaturally low pitch during part of a phrase resulting in a creaky or graveling timber. A study of voice perception found that people over age 40 believe that speakers using vocal fry sound like they lack authority. Up-taking, or high rising terminal, is when a person increases the frequency of their voice at the end of a sentence. This results in a tone that sounds like a question and can make the speaker come across as unsure of themself or uncomfortable.

So what can women do?

To create an equal acoustic playing field, there are some things that you cannot control. For example, you cannot control the shape of the room, the extent of porous room materials, or the frequency rating of the microphone. However, there are some things that you can control and you can use these to your advantage.

The first thing one can do is to speak louder. As men and women speak in a loud (but not shouting) voice, the differences between the acoustic perception of different frequencies of sound become less apparent. So, if a woman speaks slightly louder than normal, she can eliminate the auditory perception gap that exists between male speech and female speech, particularly in the lower vocal frequencies. This becomes more necessary when a woman is speaking to an audience of mostly older persons.

A second strategy involves speaking with the person running the sound equipment for the lecture room (when such a person exists!). Many times, they will have set the equalizer to a default setting or they will have optimized it for whoever the first speaker is. If that first speaker is a man with a low pitched voice, then the woman who is the second speaker will often be acoustically disadvantaged. Asking the sound technician to be sure to adjust the equalizer when you are giving your presentation will remind that technician that you are aware of the importance of what they do and ensure that he or she optimizes the settings for the unique frequencies of your voice.

A third strategy is to adjust the microphone height. In order to retain the authoritative lower frequency vocal intonations, one has to maintain proximity to the microphone. Sometimes this may mean adjusting the height of a lectern (if it is adjustable) and sometimes this means bending a flexible goose-neck microphone down to an appropriate height. Stand close to the microphone with a goal of your mouth being 6-12 inches away. Be sure that the microphone is pointing directly at your mouth. Lavalier microphones are a great choice because they stay pointed directly at the mouth and they stay a fixed 8 inches from the mouth.

A fourth strategy is to adjust your voice brand. Most of us do not really know how we sound to others. Recording a practice session of your presentation and then listening  to it can help you identify features such as glottal fry and up-talking that may not have much impact on younger audiences but can make you seem less authoritative to older audiences. Ensure that your rate is 162-175 words per minute and that your intonation is neither too monotone nor too up-and-down.

To be successful, it is important to not only be qualified but to also sound qualified.

November 12, 2019

Emergency Department Inpatient Practice Outpatient Practice

Suicide Risk Assessment

Suicide is the master thief. He steals from our family, from our friends, and from those that we admire. These are the faces of some of the lives that he has stolen. Although we have greater fear of his brother homicide, suicide takes more lives each year than homicide. Sometimes, suicide slips into our homes after we’ve feared him, after we thought we locked the doors and closed the windows to keep him out. Sometimes, he catches us off guard and we wake up in the morning and find that he’s stolen a life when we least expected it. He doesn’t discriminate by age or race or gender. He’ll strike the rich and the poor, the famous and the unknown, the strong and the weak. He has preyed on men and women for as long as humans have walked on the earth. Many people turn to him hoping that he can relieve their pain but all together too often, the pain goes on just as intensely in those who are left behind. Sometimes he whispers his intentions in our ears before he comes but all too often, we just don’t hear him or we don’t understand what he is saying to us. As physicians, whether we are primary care providers, emergency room physicians, specialists, or hospitalists, we are often in the best position to hear those whispers and to identify patients who are suicidal early on, when intervention can save lives.

Suicide is an enormous public health problem in the United States. It is the 10th leading cause of death in our country and the 2nd leading cause of death in persons age 10 – 34 years old. One American dies by suicide every 11 minutes. But this is not just a U.S. problem. In fact, the United States has just the 37th highest suicide rate in the world, led by Greenland which has the highest suicide rate at 83 per 100,000 population.

There is a gender paradox to suicide: in the United States, women are 3 times more likely to attempt suicide than men but men are 3.5 times more likely to die by suicide than women. Part of the reason is in the gender differences in method of suicide. Men most commonly use guns and women most commonly use poisoning – firearms are considerably more effective as a means of death than poisoning. Overall, guns account for 50% of all U.S. suicides followed by poisoning at 14%, suffocation at 28%, and miscellaneous other methods at 8%.

There are racial differences in suicide with caucasians having the highest suicide rate at 15.85 per 100,000 population followed by native Americans at 13.42, African Americans at 6.61, and Asian Americans at 6.59 per 100,000. Western states and Alaska have the highest suicide rate. Suicide is increasing – in 2001, the U.S. suicide rate was 10.7 per 100,000 population but by 2017, it was up to 14.0 per 100,000 population – a 30% increase in just a decade and a half.

45% of people who die by suicide saw their primary care physician within a month prior to their death. So what can we do in our office practices and our emergency rooms to identify those patients at risk for suicide and get them the psychiatric care that can save their lives? Fortunately, there are easy assessment tools that we can use that will help identify at-risk patients. There are many suicide screening questionnaires available – two that are commonly used in healthcare settings are the ED-SAFE and the Columbia screening tools.

The ED-SAFE tool (click on the attached images to enlarge) was originated as a National Institutes of Mental Health study performed at 8 emergency departments in the United States to determine the impact of suicide screening in emergency departments. It is available free of charge at the Suicide Prevention Resource Center website. It consists of two parts. The first part is the Patient Safety Screener (PSS-3) which consists of 3 questions and can be administer by nurses doing triage in the emergency department. Patients screening positive on the PSS-3 are then asked questions from the second part which is the ED-SAFE Patient Secondary Screener (ESS-3) which consists of 6 additional questions. The responses to the ESS-3 will stratify patients into (1) negligible risk, (2) low risk, (3) moderate risk, or (4) high risk. The risk categories then provide mitigation and recommended care for patients such as 1:1 observation and use of ligature-resistant rooms.

The Columbia Suicide Severity Rating Scale (click on the attached image to enlarge) was created by Columbia University, the University of Philadelphia, and the University of Pittsburgh with sponsorship by the National Institutes of Mental Health. It is available on-line free of charge at the CSSRS website. It was designed to identify those patients at risk of suicide in general settings and healthcare setting and has been endorsed by the CDC, FDA, NIH, Department of Defense, and other organizations. Based on patients responses to 6 different questions, there are recommendations for either (1) behavioral health referral at discharge, (2) behavioral health consult and consider patient safety precautions, or (3) psychiatric consultation and patient safety precautions.

These screening tools are the first step but frequently, a more detailed suicide assessment is necessary and this may require a more nuanced history from the patient. Major risk factors for completed suicide include:

  1. Prior suicide attempts
  2. Family history of suicidal behavior
  3. Mental illness, especially mood disorders
  4. Alcohol or drug abuse
  5. Access to lethal means of suicide (especially firearms)

There are other risk factors to consider as well:

  1. Caucasian
  2. Male
  3. Divorce or significant loss
  4. Traumatic brain injury
  5. Physicians
  6. Prisoners
  7. History of sexual abuse
  8. Recent psychiatric hospitalization
  9. Attention deficit hyperactivity disorder (ADHD)
  10. Lesbian, gay, bisexual, or transgender
  11. Self-injurious behavior

But in addition to risks, there are also protective factors that can sometimes offset suicide risks for individual patients. These protective factors can often make the difference between a patient being at moderate risk or high risk of suicide:

  1. Family
  2. Pets
  3. The person’s individual morals
  4. Religious faith

Suicide assessment is not just the purview of the psychiatrist. It is up to all of us: emergency medicine physicians, primary care physicians, hospitalists, and specialists. In an era when a hip replacement surgery costs $32,000 and immunotherapy for lung cancer with the drug nivolumab costs $150,000/year, we could save thousands of lives at the cost of just asking a few questions.

November 9, 2019

Life In The Hospital

Controlling The Epidemic Of Outrage

Outrage is one of those human emotions that when used sparingly is useful to separate the most egregious violations of social norms from the constant background of minor social violations. This applies to whether you are working in a hospital or anywhere else. But in excess, outrage can be lethal to workplace culture. We live in an era when outrage surrounds us, whether it be Twitter-tantrums, toxic comments posted to news articles on-line, or angry pundits on TV news commentary shows. We have become saturated with outrage.

Outrage will burn you out

I recently listened to a podcast by a radiologist who had embraced the F.I.R.E. movement (Financial Independence, Retire Early). The radiologist had become burned out less than 10 years into his practice and viewed work purely as a means to retirement; in fact, he did not like his job and wanted to retire as soon as possible, preferably before age 45. After listening to him, I don’t think it was his job that he did not like, I think it was his life that he did not like. He said that he was able to tolerate continuing to work by stopping listening to commentaries on TV and stopping reading news feeds on-line. I think it was the constant barrage of TV and on-line outrage that had been making him unhappy and contributed to him being burned out.

Outrage is contagious

Outrage provokes a response in us when someone fans the fires of our opinions into a conflagration of anger and incredulousness. So what happens when you are told something that sets you into a fit of outrage? You tell it to your buddy sitting next to you in a bar. Or you re-tweet it to your Twitter followers. Or you send a link to a website to your family members. 15 years ago, the contagion of outrage spread slowly since you would have to wait until the next evening when you’d be meeting with your friend at the bar. Today, a pandemic of outrage can occur almost instantaneously via email and Twitter. It is said that 1 person infected with measles will then infect 9 non-immunized people on average. Today, one person infected with outrage can then infect a thousand people within an hour.

Outrage is addictive

We get rewarded for being an outrager. When we post something outrageous on a blog, we get more website visits. When we tweet something outrageous, we get more re-tweets and then other people tweet back equally outrageous tweets and pretty soon we are in a vicious Twitter cycle of  perpetual outrage, a growing vortex of fury burning through the internet. When a commentator says something outrageous on TV, he or she get more viewers. The attention feedback that we get for generating outrage has operantly conditioned us to generate more outrage. If you are listening to a news channel on cable TV, you will likely start daydreaming when the host is talking about a new fruitcake recipe but as soon as they bring on a far-right or far-left news pundit, you will snap back to attention. Outrage makes us feel alive.

Outrage is exhausting

Our emotions need balance, like Yin and Yang. If we spend too much time being outraged, then our emotions become out of balance. It takes a lot of psychological energy to be outraged and if you spend all of that energy being outraged, there’s little left over for all of the good things in life, like your profession or your family. Moreover, if you get all worked up being outraged all day, you can’t fall asleep that night and you end up being chronically sleep-deprived.

Outrage is poisonous

Sometimes, outrage can be unifying, to bring together a group of people for a common goal for the good. For example, when a community comes together after a particularly heinous crime. Or when a football team gets fired up to perform better after a particularly flagrant foul by the other team. But outrage can also be dividing. For example when it comes to politics and religion – both of which can intersect in hospital practice. And when outrage divides us, it can poison team-building efforts and derail interspecialty collaboration.

Outrage is distracting

When we become angry, our minds focus on that which made us angry and we can lose sight of our other tasks. This can foster mistakes and errors in judgment. Working while outraged is like driving while intoxicated.

Professional outragers versus amateur outragers

There are two types of professional outragers. There are those who get paid to be as outraged as possible – the radio political commentators whose voices’ raise as they incredulously mock people of the opposite political party. Then there are those who are paid to enable outrage in others – the TV news commentators who bring people with different opinions about a news item on their show and catalyze them into a shouting match on live TV. These are people whose job it is to be outraged or to create outrage and if they don’t, they lose their job.

Amateur outragers are different – they don’t get paid to be outraged or create outrage, they just do it because they enjoy it. These are the internet trolls who post demeaning comments on blogs and internet chat rooms. The are usually anonymous and for them outrage is a hobby rather than a career.

Fortunately, there are ways to lessen outrage in our hospitals and our workplaces.

  1. No tweeting on the job.
  2. Use work computers for work and not for surfing posted comments on websites.
  3. Keep waiting area and employee lounge televisions on cooking-related channels and home improvement channels; not on news channels
  4. Keep political campaign advertising out of the building
  5. Wait 10 minutes before responding to a “hate email” from someone who is enraged about something
  6. As leaders in the workplace, we need to ration our own outrage so that we set an example for the rest of the employees

I personally do not like being outraged and I have adapted my lifestyle to minimize outrage. I am not on Twitter. I read the local morning newspaper and then do not look at news shows or internet news feeds for the rest of the day. I avoid reading internet articles that encourage viewers to post comments. I flag “hate emails” to come back to later in the day or on the following day, after my emotions (and the email’s author’s emotions) have settled down. I don’t put our hospital’s amateur outragers on hospital committees. I don’t listen to news shows on the radio in the car. And maybe most importantly, I created this blog as a way of cleansing my soul when faced with events that could fester and ferment into outrage if I didn’t reflect on them and analyze them.

Save your outrage for the stuff that really matters and then use your outrage sparingly.

November 3, 2019


Emergency Department

What Does EMTALA Really Mean For The Hospital

The EMTALA law was enacted 33 years ago as an “anti-dumping” law. EMTALA fundamentally has 2 main implications for the hospital: how you manage patients in the emergency room and how you manage hospital transfers. It stands for the Emergency Medical Treatment and Active Labor Act and it placed requirements on hospitals receiving Medicare payments; because almost all hospitals accept Medicare, in practice, it affects nearly all U.S. hospitals.

There are 3 obligations that hospitals have under EMTALA:

  1. The emergency department must provide a medical screening exam to any patient who requests emergency care, regardless of their health insurance status, their ability to pay, or their citizenship.
  2. If the medical screening exam indicates that the patient has an emergency medical condition, then the hospital must provide treatment until the condition resolves or stabilizes and the patient can provide self-care after discharge.
  3. If the hospital does not have the capability to treat the patient’s condition, then it must make an appropriate transfer to another hospital that has the capability of treating the patient’s condition and provide medical records to the accepting hospital. Hospitals with specialized capabilities must accept these transfers and provide treatment.

Why did EMTALA come to be?

In the 1980’s, some hospitals and doctors flat out refused to treat patients in their emergency departments if the patients could not pay. Other hospitals would transfer unstable patients to public hospitals without doing even a basic medical assessment or providing initial treatment to stabilize patients. Physicians at Cook County Hospital in Chicago reported that 87% of patients transferred to their hospital were sent because they lacked health insurance, only 6% of those patients actually gave written consent for transfer, and 24% were transferred in medically unstable condition. Thus emerged the term “patient dumping”. A 1985 exposé on the CBS news show 60 Minutes titled “The Billfold Biopsy” helped raise public awareness of the national scope of the problem.

But if you look a bit closer, EMTALA was, at least in part, designed to protect Medicare patients. Three years earlier, congress had enacted legislation that created DRGs, meaning that hospitals got paid based on the diagnosis rather than being paid based on charges. Legislators were concerned that hospitals would try to game the DRG system by providing substandard care to reduce costs in order to profit by DRG payments by Medicare. EMTALA directly addressed this by requiring hospitals to provide the same emergency care to patients whether they had commercial insurance or Medicare/Medicaid.

What about free-standing emergency rooms?

EMTALA applies to hospital emergency rooms, whether they are physically part of the hospital building or geographically separated from the hospital. In the past 15 years, there has been a nationwide proliferation of free-standing emergency rooms that are located many miles away from its parent hospital, generally in suburban areas. When asked why he robbed banks, Willie Sutton famously said “Because that’s where the money is”. So why do hospitals build satellite emergency departments in the suburbs? Because that is where the money is – lots of commercially insured patients with relatively fewer Medicaid and uninsured patients. These outlying emergency rooms can serve as conduits to direct well-insured patients needing profitable surgeries or inpatient admissions to the host hospital. This type of free-standing emergency room is subject to EMTALA requirements just as if they were physically attached to the host hospital.

There is a second type of free-standing emergency room. These are privately-owned and not associated with a local hospital. Currently, there is uncertainty about whether these facilities fall under the EMTALA requirements and there are state-specific laws and legal precedents about whether or not they must adhere to all of the elements of EMTALA. However, since these emergency rooms are not associated with a hospital, they cannot provide inpatient treatment for emergency medical conditions and so the emergency room physicians can transfer a patient requiring inpatient care to any hospital they choose.

What are the implications for physicians?

The focus of EMTALA was initially on emergency room physicians – that they must do a medical screening exam and provide basic emergent care to all patients. However, when I am on call at night for our intensive care units, EMTALA also applies to my decision making. As a tertiary care medical center, our ICU has the capability of providing a higher level of care than most other ICUs in the region. Many hospitals lack critical care physicians, infectious disease specialists, cardiothoracic surgeons, and other specialists. Because we have residents, nurse practitioners, and fellows in our various ICUs at night to handle most patient care-related calls, the most common calls I get are from other hospitals asking about transferring patients to our medical intensive care units. If we have empty ICU beds, we are usually obligated to take those critically ill patients. However, despite EMTALA being decades old, I am still called by outlying emergency room physicians about transferring uninsured patients purely because the physician considers ours to be a charity hospital since we are a state-supported university. It can often be a fine line to walk: we are obligated to accept in transfer any patient whose medical needs cannot be met at these outlying hospitals but we are not obligated to accept patients simply because they are uninsured. Experienced attending emergency room physicians know about EMTALA requirements but the questionable calls most commonly come from residents in training or junior attending physicians in ERs at hospitals that are part of a larger healthcare system that includes tertiary care hospitals. These less-experienced physicians often do not realize their (and their hospital’s) requirements under EMTALA and as a consequence, “patient dumping” to academic medical centers still occurs.

Overall, EMTALA has improved the care to vulnerable patient populations. But EMTALA is still just as important today as it was 33 years ago and it is incumbent on us to insure that our emergency room physicians, our hospitalists, and our critical care physicians understand EMTALA’s implications for their clinical practices.

October 28, 2019

Outpatient Practice

Making Wound Care Work

Hospital wound care clinics are one of those unheralded parts of healthcare. As our population ages, gets more obese, and has more diabetes, chronic wounds are only going to become more common and having a location within the hospital system that can provide a comprehensive approach to healing wounds is important today but will be even more important tomorrow.

A lot of wound care is general medicine

Many hospital leaders think of wound care as being a part of surgery. And it is true that surgical management is an important part of a comprehensive wound care program. However, healing wound really requires optimizing the patient’s medical conditions:

  1. Controlling diabetes
  2. Smoking cessation
  3. Nutrition optimization
  4. Improving blood flow
  5. Controlling infection

Therefore, physicians, nurse practitioners, and physician assistants who are trained in diabetes management, tobacco treatment counseling, nutrition, and treatment of infections are frequently in the best position to help optimize the patient’s ability to heal wounds. In other words, wound care is a perfect fit for general internists and family physicians.

Wound care does not mean “wound stare”

In order to really heal wounds, it is necessary to debride dead tissue. It is not enough to simply look at a wound every week without doing any intervention – the the patient’s regular primary care physician can already do that. A study in JAMA Dermatology showed that for 321,744 wounds at 525 wound centers in the United States, about 70% of wounds healed and required a median number of 2 debridements per wound. Wounds that were debrided more frequently healed faster and patients who were seen at least weekly in the wound centers had better outcomes.

Hyperbaric oxygen

Hyperbaric oxygen treatment uses a hyperbaric chamber where 100% oxygen is delivered under high pressure. These are body-sized tube-like chambers that the patient can lay in, typically for periods of 60 – 90 minutes at a time. Hyperbaric oxygen can promote wound healing by promoting angiogenesis and fibroblast proliferation. Patients return for repeated hyperbaric treatments as the wound heals. This requires a hyperbaric technician (often a respiratory therapist or EMT) to monitor the patient and manage the hyperbaric “dives”. Hyperbaric oxygen has been demonstrated to be effective in radiation injuries, osteoradionecrosis, osteomyelitis, threatened skin flaps, and diabetic ulcers. Generally 12-15% of would care patients benefit by hyperbaric oxygen treatments.

Wound care nurses

Wound care is more than just the doctors. Having wound care nurses who are trained and experienced in wound care is essential to a high-functioning wound care center. These are truly nurse specialists – it is not sufficient to use general outpatient nurses from medical or surgical clinics. Although a physician/NP may spend 10-15 minutes with each patient, the entirety of that patient’s visit is typically 45-60 minutes when vital signs, positioning, dressing removal, wound cleansing, patient education, and wound photography is factored in.

Sufficient space to practice in

Most primary care offices are set up with 2-3 exam rooms per physician. An effective wound center needs much more, typically 4-6 rooms per practitioner, since a lot of the actual care of the patient is actually done by the wound nurses rather than the physicians. Additionally, there needs to be a room large enough to co-locate 2-3 hyperbaric oxygen chambers so that a single hyperbaric technician can oversee multiple chambers at one time. The rooms need to be large enough to accommodate gurneys since many patients are non-ambulatory. Because wound care requires a lot of supplies, there has to be abundant storage space.

Staying financially viable

Wound centers should be able to at least break-even financially and most should be able to maintain a positive margin. However, to do so, there has to be more than just evaluation and management (E/M) billings. Wound care centers have a higher overhead than a typical primary care or medical specialty clinic given the higher nursing staffing and the higher equipment & supply costs. Therefore, a wound center that relies on E/M billing only will lose money. This is where hyperbaric oxygen treatments and debridements can help maintain sufficient income to offset the loses that would be incurred from E/M visits alone. Therefore financial viability requires a balance between E/M visits and hyperbaric/debridement services. Fortunately, since those hyperbaric treatments and the debridement procedures also improve patient outcomes, it is a win-win, for both the hospital and the patient. And, because hyperbaric treatments and debridements are also financially beneficial for the doctors, it is actually a win-win-win all the way around.

From the physician (or NP/PA) standpoint, there is strong incentive to participate in wound care in terms work RVU generation. The table below lists the common services and procedures performed in wound care (the dollar amounts are the Medicare reimbursable for 2019 in Ohio).

The most common procedure at most wound centers is simple debridement (99597) and skin & subcutaneous tissue debridement (11042). Tobacco cessation is an often-overlooked service in wound care since many patients with chronic wounds are smokers and it is easy to spend at least 3 minutes discussing smoking cessation strategies with the patient, often while doing a debridement.

Hyperbaric oxygen oversight is associated with a relatively large number of work RVUs (2.11) and is billed per treatment. This is different than the facility bill for hyperbaric oxygen which is billed for every 15 minutes of time that the patient is in the hyperbaric oxygen chamber. A patient who is in the chamber for 60 minutes is billed 4 units by the hospital (facility) and 1 unit of 99183 by the physician (or NP/PA). Since hyperbaric treatment oversight generally occurs at the same time that the physician is seeing patients in the wound center, this allows for a surprisingly large number of work RVUs to be generated in a single day of outpatient care.

So, how does wound care compare to regular outpatient practice for a family physician or internist? Assume that the primary care physician is in the office all day seeing level III return visits every 20 minutes. That equates to 23.28 work RVUs or 34.56 total RVUs ($1,217 in Medicare reimbursable dollars). If that physician is working in a wound clinic and doing 1 subcutaneous debridement for every 2 patients plus supervising 4 hyperbaric oxygen treatments, then this adds up to 43.84 work RVUs, 68.16 total RVUs, and $3,163 in Medicare reimbursement! In other words, wound care is one of the most lucrative things a family physician or general internist can do and can be a great way to supplement a traditional primary care practice.

Limb salvage

Inadequately treated foot and ankle wounds often result in osteomyelitis and leg amputations. A major goal of wound care is preventing amputations by “salvaging” the leg. Ideally, this requires a coordinated multidisciplinary approach including primary care physicians (or NPs/PAs), vascular surgeons, infectious disease specialists, and podiatrists. By making the wound center a “one-stop-shop” where the patient with a foot ulcer or wound can see multiple specialists, the care can be optimized and give that wound the best chance to heal without having to resort to amputation.

A natural fit for podiatrists

In most wound centers, diabetic foot ulcers are a major indication for services. This fits perfectly with podiatrists’ scope of practice. In Ohio, one limitation is that podiatrists cannot oversee or bill for hyperbaric oxygen treatments (although nurse practitioners can). An additional advantage that podiatrists have over other practitioners is that they are surgeons who spend a significant amount of their time in the operating room. In other words, the podiatrist has one foot in the ambulatory clinic and one foot in the OR (so to speak) which can facilitate comprehensive care of those foot wounds that require more debridement or surgical care than can be done in the wound center and which require surgical debridement in the operating room.

A multi-disciplinary approach

A high-functioning and effective wound center needs to have easy access to consultation by many types of physicians. Although the main providers responsible for the regular wound care visits may be general internists, family physicians, or nurse practitioners, there are a whole group of specialists whose availability is necessary for comprehensive care of the wound. These specialists may not necessarily practice in the wound center but there needs to be easy access to them, ideally in same facility, such as a hospital outpatient building. These include: plastic surgeons, podiatrists, orthopedic surgeons, vascular surgeons, infectious disease specialists, dermatologists, and endocrinologists. Other healthcare providers needed on-site include physical therapists, orthotists/prostesthetists, nutritionists, radiology services, and occupational therapists.

In summary, a comprehensive approach to wound care is an increasingly necessary part of the overall care provided by hospitals. To be effective, a wound center requires a considerable financial investment and then needs to maintain a coordinated multidisciplinary group of healthcare providers to optimize wound healing rates. Fortunately, under current Medicare reimbursement rates, wound care is financially attractive to physicians, particularly general internists and family physicians.

October 12, 2019

Electronic Medical Records

The Problem With The Problem List: when electronic medical records go rogue

Prior to the 1960’s, medical records were largely illegible, unorganized, and non-uniform. It was difficult for a doctor to keep track of his/her own patient’s histories and nearly impossible for a doctor to tell what was going on with a patient by reading another doctor’s notes. Enter Lawrence Weed, MD, a Professor of Medicine at the University of Vermont who invented the S.O.A.P note and taught generations of medical students to organize their hospital notes into the 4 sections of Subjective, Objective, Assessment, and Plan. He was also the father and champion of the  Problem-Based Medical Record, a way of organizing and filtering the various signs, symptoms, and diagnoses that a patient has in order to coordinate the diagnostic effort and to provide optimal longitudinal care of that patient.

When the Center for Medicare and Medicaid Services (CMS) wanted to encourage the widespread use of electronic medical records, it rolled out the “meaningful use” program as part of the HITECH Act of 2009. Physicians who adopted electronic medical records with several provisions were eligible for incentives of up to $44,000 to help offset the cost of purchasing and implementing an electronic medical record. Those electronic medical records had to:

  • Use computerized order entry for medication orders.
  • Implement drug-drug, drug-allergy checks.
  • Generate and transmit permissible prescriptions electronically.
  • Record demographics.
  • Maintain an up-to-date problem list of current and active diagnoses.
  • Maintain active medication list.
  • Maintain active medication allergy list.
  • Record and chart changes in vital signs.
  • Record smoking status for patients 13 years old or older.
  • Implement one clinical decision support rule.
  • Report ambulatory quality measures to CMS or the States.
  • Provide patients with an electronic copy of their health information upon request.
  • Provide clinical summaries to patients for each office visit.
  • Capability to exchange key clinical information electronically among providers and patient authorized entities.
  • Protect electronic health information (privacy & security)

And so, the problem list because a necessary part of every electronic medical record program in the country. On the surface, this sounds like a great idea – an easy way for multiple physicians using the same patient’s chart to quickly and easily see what is going on with that patient. However, the problem list rapidly morphed into a monstrous of list of often redundant words that became unusable for their originally intended purpose. So what happened to the innocent problem list?

Electronic medical record (EMR) companies designed the EMR so that the problem list was the central repository for all lists used in the chart. Elements of the past medical history fed into the problem list as did billing diagnoses, admitting diagnoses, and discharge diagnoses. Similarly, the problem list could be used to select the billing diagnoses, admitting diagnoses, and discharge diagnoses. Because the problem list was used to assign the billing diagnoses, all 69,000 diagnoses in ICD-10 had to be selectable in the problem list. And thus all of the weird and obscure ICD-10 codes suddenly became available to add to the problem list (such as V91.07XA: Burn due to water skis on fire, initial encounter).

What Is A Problem, Anyway?

Medical diagnoses are clearly problems. But there are other elements that are not so clear. Should the family history be included in the problem list? What about the social history? Should the patient’s list of surgeries be added to the problem list? What about non-specific symptoms – should the patient with I50.23 (Chronic systolic heart failure) also have orthopnea (R06.1), history of cardiomegaly (Z86.09), and pedal edema (R60.0) on the problem list?

Duplicate Problems

Each physician who sees a patient might use a different word to describe the same thing and this led to multiple duplicate symptoms on patient problem lists. For example, if a patient with breathlessness gets admitted to the hospital, the emergency room physician might add add the ICD-10 code “R06.00: Dyspnea“, the hospitalist might use “R06.02: Shortness of breath“, and the cardiologist might use “R06.09: Dyspnea on exertion“. By the end of the day, the patient’s problem list will include all three symptoms: dyspnea, shortness of breath, and dyspnea on exertion.

Multiple Layers Of Specificity

Similar to duplicate problems, many diseases can have many different ICD-10 codes for different degrees of specificity of that particular problem. And so “type 2 diabetes” can have a general code and also have many different subcodes, each of which gets its own place on the problem list. For the patient with diabetes who is seeing a family physician, a nephrologist, a cardiologist, an ophthalmologist, and a vascular surgeon, there can be 15-20 different diabetes-related problems on the problem list.

Immortal Problems

Unless someone actively cleans up the problem list, then signs, symptoms, and diagnoses that have resolved can stay on the problem list, causing further clutter. So, Right arm bruise, initial encounter (S40.021A) from an office visit in 2011 persists in perpetuity with Runny nose (R09.89) from an office visit in 2015. Similarly, the patient who had Hyponatremia (E87.1) during an office visit in June and then had Hypernatremia (E87.0) in July can end up with both hyponatremia and hypernatremia on their problem list. Old diseases don’t go away, they just stay around forever on the problem list.

Whose Problem Is It?

Most would agree that the primary care physician should be permitted to add problems to the problem list. But what about the specialist, the emergency room physician, or the hospitalist? Should advanced practice providers such as nurse practitioners, physician assistants, nurse anesthetists, or midwives be allowed to edit the problem list? What about nurses, pharmacists, psychologists, and dietitians? There is no universal agreement about who the stewards of the problem list should be.

Don’t Touch My Problem

Many physicians are very possessive about their additions to the problem list and can get angry if another physician deletes one of their problems without talking to them. So, the patient who was rude to the office staff at the surgeon’s office might have gotten Negative attitude (F60.2) added to the problem list; when the same patient was a delight to the staff in the endocrinologist’s office, the endocrinologist might have deleted F60.2 from the problem list and then the surgeon later gets mad because he wanted that reminder to the staff that the patient was a handful during the last office visit.

Forcing Review Of The Problem List

For many electronic medical records, an outpatient visit cannot be closed until the physician attests that he/she has reviewed the problem list. Typically, an alert box will pop up when trying to close the encounter reminding the physician to review the problem list. By that time, the patient has left the office and the physician just wants to get done with the day’s charting so the physician will typically scroll down to the bottom of the problem list and click “problem list reviewed”, without actually looking at the problem list. Problem list fatigue is just as much of a challenge as alert fatigue in our offices and hospitals.

More Is Less

In the spirit of Dr. Weed, some physicians will organize their progress note in the electronic medical record by importing the patient’s entire problem list into their daily office note. This can result in progress notes that are the length of a small novel making the note unnavigable to any reader and making it more difficult for other physicians to figure out what the author of the note was actually trying to say.

Too Many Problems

Every physician who sees a patient adds her/his problems to the problem list. When I see a patient whose primary care physician and other specialist physicians use a different EMR than I do, I am the only person adding to the problem list and so that problem list is small, relevant to my practice, and manageable. However, the more physicians using a common EMR a patient sees, the longer the problem list becomes. List of 30, 40, or 50 problems are not uncommon for patients with several chronic medical problems seeing multiple specialists or for patients with several hospitalizations.

Erroneous Problems

Errors in the problem list are rampant. For example, a patient fills out a pre-visit past medical history form and checks the review of systems box for “impotence”. The nurse reviews the form and transcribes the checked boxes into the past medical history and accidentally types the first 4 letters as “impr” rather than “impo”. The first diagnosis that comes up under “impr” is imprisonment and so it gets entered into the past medical history that then feeds into the problem list and now “imprisonment” shows up on the patient’s problem list. There are a myriad number of ways that erroneous problems find their way into the problem list and once they are there, they often stay there indefinitely.

High Maintenance Costs

The currency of work effort in ambulatory medicine is the number of mouse clicks necessary to perform any given task. A typical office visit lasts about 15 minutes and there is a lot of things that have to be done in those 15 minutes. Reviewing and editing the problem list costs time and mouse clicks and usually falls down to the bottom of the priority list of things to accomplish during those 15 minutes. Spending an extra 30 seconds per patient to truly review and update the problem list means that over the course of the day, that doctor will see one less patient than he/she otherwise would have seen. One solution that has been suggested is to partner with the patient so that the patient reviews the problem list to help identify resolved or erroneous problems. However, trying to explain what “suprascapular entrapment neuropathy of left side” means to the patient with a sore shoulder can often add 2 minutes to that office encounter.

“Need for…” Diagnoses

Some tests and vaccinations cannot be ordered unless they are associated with a “need for” diagnosis. For example, if you are going to order a flu shot, you have to use the diagnosis of “Need for influenza vaccine” (Z23). Some insurance companies will not pay for a bone density study unless the order is accompanied by the diagnosis of “At risk for osteoporosis” (Z91.89). If you want to see if a patient could have lead poisoning, you need to include “Need for lead screening” (Z13.88). These diagnosis codes often find their way into the problem list and do not add anything to the long-term management of that patient.

Diagnoses Required For Ordering Tests

Similar to the “need for…” diagnoses, many tests cannot be ordered unless the physician uses a specific ICD-10 code or one of a group of codes. These are so-called “allowable codes”. Many electronic medical records will present an alert box if a non-allowable diagnosis code is associated with an ordered test, such as a glucose level or a cardiac echo. The physician will then either keep adding diagnoses to the diagnosis list until she/he comes up with a diagnosis code that the insurance will accept or they will scroll through the list of allowable diagnoses in the alert box and pick a diagnosis code that is covered, whether or not it perfectly matches the real indication for that test. These diagnoses are necessary for the physician to order the test but may be irrelevant to the longterm management of that patient; nevertheless, the codes often end up on the problem list permanently. Physicians hate the alert boxes – they cost mouse clicks and time. Consequently, physicians, like Pavlov’s dogs, undergo operant conditioning and to avoid those alert boxes, they find a diagnosis that insurance companies accept for any given test and always use that diagnosis whenever they order that test. Thus, there are legions of physicians who always use “Other forms of dyspnea” (R06.09) for every cardiac echo that they order because they know that diagnosis works.

When used right, the problem list is a great tool for patient management. But a number of unintended consequences of electronic medical records have resulted in problem list monstrosities that are often irrelevant or a hinderance to medical care. As physicians, we are the main users of the problem list and it is up to us to truly make “meaningful use” of the problem list. We have met the problem of the problem list and the problem is us.

October 8, 2019

Outpatient Practice

Telomeres And Pulmonary Fibrosis

My stepfather was the quintessential short telomere syndrome patient. His hair turned gray in high school, his father died of idiopathic pulmonary fibrosis, his sister died of idiopathic pulmonary fibrosis, and then he too died of idiopathic pulmonary fibrosis, complicated by bone marrow failure from myelodysplasia. Last month, I attended an international conference on telomeres in lung transplant and the information from that conference has profound implications for treating our patients with these conditions.

Telomeres are repeating sequences of the DNA nucleotides, TTAGGG, that are on the ends of our chromosomes and serve to protect the genes inside those chromosomes from damage, kind of like how the plastic caps on your shoelace protect the shoelace from unraveling and becoming damaged.

We are all born with fairly long telomere segments at the end of our chromosomes but then as we age, our telomeres shorten, presumably making the genes underneath these chromosomes more more fragile and subject to damage. Thus, our telomeres start off about 11 kilobases when we are born but by age 80, they have shortened by two-thirds, to 4 kilobases.

The reason that we lose these repeating TTAGGG sequences is that when our chromosomes divide, about 50-100 base pairs of telomere DNA is lost from the end of one of the two chromosomes because of the way that a chromosome divides and then re-builds new twin strands of DNA to form the 2 new chromosomes.

Our cells can restore these lost telomeres by using a protein complex called “telomerase” that adds TTAGGG nucleotide groups to the ends of our chromosomes. But if there is a genetic abnormality in one of this group of proteins, then telomerase does not work properly and cannot fully restore the telomeres to their previous length. Thus, with each chromosomal division of mitosis, the telomeres get a little shorter. Telomeres are akin to a “molecular clock” in our cells and some people have postulated that if we can maintain normal telomere lengths, that we may be able to avoid the scourge of aging, in other words, create a Fountain of Youth. Although it is not clear if this is possible, it does appear prematurely shortened telomeres due to an abnormal telomerase protein gene results in the opposite, in other words, a “Fountain of Age”.

A patient with one of these abnormal genes will have telomeres that are shorter than normal people of their same age. This results in “short telomere syndromes”. In adults, the main short telomere syndromes are:

  1. Familial idiopathic pulmonary fibrosis
  2. Cirrhosis
  3. Aplastic anemia
  4. Myelodysplasia
  5. Prematurely gray hair

There are two ways to measure telomere length: a polymerase chain reaction (PCR) method and a fluorescent in situ hybridization (flow-FISH) method. The flow-FISH method is considerably more accurate than the PCR method. People can get a take-home telomere PCR test done essentially over-the-counter for about $100 through internet DNA companies. The flow-FISH method is only available at a few university laboratories, requires a physician order, and costs $400-800. I send my patients’ blood to be tested at one of these labs that use the flow-FISH method. The length of telomeres that indicates a short telomere syndrome is unknown but when the length is less than the lowest 1st percentile, I consider it highly likely. Since my clinical practice is primarily patients with interstitial lung diseases (including idiopathic pulmonary fibrosis), I end up seeing a number of these patients. Here is a telomere length test result on one of my patients with familial idiopathic pulmonary fibrosis, cirrhosis, and pancytopenia from a hypocellular bone marrow:

Idiopathic pulmonary fibrosis patients with short telomeres are different

There are some important differences in patients with familial idiopathic pulmonary fibrosis and short telomeres compared to everyone else with idiopathic pulmonary fibrosis. First, they do poorly with immunosuppressives. In the past, we used to use medications that suppressed the immune system to treat idiopathic pulmonary fibrosis, thinking (incorrectly) that inflammation was the genesis of the lung scarring that characterizes the disease. A number of years ago, there was a study sponsored by the National Institutes of Health comparing a treatment with the immunosuppressive medications azathioprine and prednisone with placebo. It turned out that the patients who got azathioprine or prednisone did a lot worse than those getting placebo. Recently, researchers went back and looked at stored blood samples of the patients who were in this study and it turns out that only those patients with short telomeres did poorly with immunosuppressive medications – patients with normal telomeres had the same outcome whether they received immunosuppressive medications or placebo.

Second, these patients do poorly after lung transplant. They are more prone to developing low white blood cell counts, presumably from being more susceptible to side effects of immunosuppressive medications. Also, they are more prone to getting devastating infections with cytomegalovirus (CMV) and aspergillus. Patients with short telomeres who get lung transplants can develop myelodysplasia or cirrhosis after lung transplant and those with liver transplants can develop myelodysplasia or pulmonary fibrosis after liver transplant.

More Questions Than Answers

Our understanding of short telomere syndromes and how to best medically manage these patients is still in its infancy. There is much that we do not yet know. For example:

  1. Which patients with idiopathic pulmonary fibrosis should undergo telomere length testing? Currently, I limit testing to those patients with a family history of idiopathic pulmonary fibrosis who also have a personal or family history of premature graying of the hair, unexplained cirrhosis, myelodysplasia, or unexplained cytopenia. Telomere length testing is not widely available and not always covered by insurance. If it only cost $25 and insurance covered it, I would probably order it on all of my patients with idiopathic pulmonary fibrosis. In addition, there may be other lung diseases associated with short telomeres. For example, pleuropulmonary fibroelastosis appears to be associated with short telomeres.
  2. Which patients with cirrhosis should undergo telomere length testing? NASH (non-alcoholic steato-hepatitis, aka fatty liver) is the most rapidly growing cause of cirrhosis due to the epidemic of obesity and diabetes in the United States. It seems like whenever there is no obvious cause of cirrhosis (such as hepatitis C or alpha-1-antitrypsin deficiency), then patients get labeled as having NASH cirrhosis by default. Many patients who carry a diagnosis of NASH cirrhosis likely have liver disease due to short telomeres.
  3. Should every patient with short telomeres be referred for genetic testing? Genetic testing is usually done in conjunction with genetic counseling by trained genetic counselors. Unfortunately, these counselors are in short supply and are mainly associated with pediatric hospitals and cancer hospitals. Furthermore, genetic testing is not cheap and typically costs around $800; most insurance companies will not cover it or will only cover it after a lot of physician effort doing denial appeals. The results of genetic testing in short telomere syndromes can be difficult to interpret – these syndromes can be associated with abnormal genes such as TERT and TERC but these genetic abnormalities can also be seen in some otherwise normal people.
  4. Should telomere length testing be done in all patients prior to transplant? One of the basic tenets of transplantation is to offer it to those patients who will most benefit by transplant. Since some studies indicate that patients with short telomeres have worse outcomes after transplant, should this affect their transplant eligibility? Could short telomeres be a relative contraindication to transplant?
  5. Should transplant patients with short telomeres get different immunosuppression regimens? Since it appears that patients with short telomeres do poorly with immunosuppressive medications, it may be that they need to have reduced doses of these medications when used to prevent transplant rejection. Or perhaps there are some immunosuppression regimens that are safer than others in patients with short telomeres. Once again, at this time, we just do not know.
  6. Should patients with short telomeres get combined lung and liver transplants? These patients are prone to getting both pulmonary fibrosis and cirrhosis and not infrequently does cirrhosis become apparent only after lung transplant for pulmonary fibrosis and vice versa. At the least, patients with known short telomeres undergoing liver transplant should probably be screened for interstitial lung disease and those undergoing lung transplant should be screened for cirrhosis. Most combined lung/liver transplants in the United States are done in patients with cystic fibrosis. Many centers have found that combined lung/liver transplant in other patients has a high mortality rate. One has to wonder whether a lot of these non-cystic fibrosis patients who have had combined lung/liver transplant actually had undiagnosed short telomere syndromes.
  7. Should patients with short telomeres undergoing transplant get a bone marrow biopsy? This is not part of the normal work-up for patients undergoing either lung or liver transplant. But the development of myelodysplasia or it malignant cousin, acute myelogenous leukemia, can be devastating in the post-transplant period. Clues to subclinical myelodysplasia can include unexplained macrocytosis (increased MCHC), leukopenia, or thrombocytopenia. No transplant physician likes a hematologic surprise after transplant.

One of the simultaneously frustrating and exciting things about medicine is that just when we think that we know everything, we realize that we don’t. Short telomere syndromes epitomize this axiom – clearly, we have much more to learn.

October 2, 2019


Predicting The Next Influenza Season

Last month, in August 2019, we have our first influenza case in our hospital. The patient recently returned from an international gathering so it is likely that he acquired the flu from a Southern Hemisphere resident attending the same gathering. The Southern Hemisphere has its influenza season at the opposite time of year as the Northern Hemisphere. A 2019 article in the journal Scientific Reports indicates that the epidemiology of influenza in Australia in any given season predicts the subsequent epidemiology of influenza in the Northern Hemisphere. So, what does the most recent Australian influenza epidemiology indicate?

The Australian Department of Health maintains a robust website with up to date influenza epidemiology information. The 2019 Australian data indicates that influenza started early this season as is depicted in the red line in the graph below.

Normally, influenza starts showing up in late May in Australia and peaks about the first of September. Australia started the onset of the 2019 influenza season in February, about 3 months earlier than usual, and it peaked about the first of July, about 2 months earlier than usual. So, let’s see how the Australian influenza data compares to information from the U.S. Centers for Disease Control influenza website:

In the above graph, we see the last 5 influenza seasons plus the 2009-10 season (the H1N1 epidemic) and the 2011-12 season. In 2009, the U.S. was caught off guard with the early arrival of H1N1 influenza that started in April and peaked in October. That year, 61,000 Americans got influenza and 12,500 Americans died of it (especially young persons). The 2017-18 influenza season (turquoise line in the graph) had the highest percentage of visits for influenza-like illness in the past 5 years. Comparing that curve to the 2017 Australian influenza season (brown line in the previous graph), there is remarkable similarity.

If the upcoming influenza season in the United States resembles the current influenza season in Australia, then it will start earlier than usual, perhaps in October rather than the normal December onset. The good news is that the most recent influenza season in Australia was not terribly severe with fewer hospitalizations and deaths than normal so hopefully this portends good news for U.S. hospitals and ICUs that may see fewer admissions and deaths from influenza.

What about the specific strains of influenza? Last year in the United States, influenza A H1N1 dominated early in the season in December (brown bars in the graph below). Influenza A H3N2 became the dominant strain by early March (red bars in the graph below). Influenza B was uncommon throughout the 2018-19 season until February and then it increased in prevalence when influenza A was decreasing (green bars in the graph below).



The graph below shows the various strains seen in Australia in the summer of 2019. Once again, influenza A peaked early in the season (red bars in the graph below) whereas influenza B peaked 4 months later (green bars in the graph below). Overall, influenza B accounted for a higher than usual percentage of the overall influenza cases in Australia. Influenza H1N1 all but disappeared shortly after the Australian flu season started and H3N2 was the dominant strain (although most of the Australian influenza A cases went unsubtyped). If the Australian experience predicts the upcoming flu season in the United States, then we should expect to see mostly influenza A H3N2 and also see a higher than normal number of influenza B this winter.

The 2019-20 U.S. standard strength influenza vaccine is quadrivalent and will cover the following 4 strains:

  1. Influenza A/Brisbane/02/2018 (H1N1)pdm09-like virus
  2. Influenza A/Kansas/14/2017 (H3N2)-like virus
  3. Influenza B/Victoria virus
  4. Influenza B/Yamagata virus

The vaccine is available in a standard strength that is indicate for persons over age 6 months and is made by several manufacturer, sold under brand names including Alfuria, Fluzone, Fluarix, and FluLaval. A high strength (Fluzone High Dose) contains about 4 times the amount of antigen and is indicated for persons over age 65. Unlike the quadrivalent standard strength influenza vaccine, the Fluzone High Dose vaccine is trivalent and does not cover the influenza B/Yamagata virus. This could have immunity implications if the U.S. sees an unusually high number of influenza B cases, as was seen in Australia this summer. Also, the Fluzone High Dose vaccine has a higher incidence of side effects such as injection site pain, fever, and myalgia. So the decision of which vaccine to use in persons age > 65 is not clearcut – the CDC does not recommend one vaccine over the other in people over age 65.

The good news for the upcoming influenza season is that we now have a new drug to treat influenza, baloxavir (trade name Xofluza®) that is given as a single one-time dose and will cost about $150. Tamiflu® is now available as generic oseltamivir at a cost of about $50 for a 5-day course.

So, what can physicians in the United States take away from this season’s Australian influenza season? Vaccinate your patients and do it now!

September 28, 2019