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A Minor American Hero

Today is Memorial Day, when Americans remember those who died during military service to defend the liberty, equality, and freedom of being an American. They were heroes. But this post is about another American hero, one who was not even in the military. This is not a post about my usual subjects: hospitals, medical economics, or electronic medical records. But it is about one small step in making the world a better place for us all to live in.

After his internship, my father put his neurology residency on hold and joined the Navy – he was stationed in Japan as a medical officer during the Korean War. His father (my grandfather) dropped out of law school to join the cavalry during World War I – he ended up riding a motorcycle to deliver dispatches to the front lines in France. Both are worthy of hero status but the hero of this story is not my father or grandfather, the hero is my grandmother.

The story begins in 1873 when my greatgrandfather was born in the Canton region of China. His last name was Jung and he adopted the Anglicized first name, Joe, when he arrived in Portsmouth, Virginia at age 12 with his uncle as immigrants to the United States seeking a better life. He eventually moved to Elberton, Georgia where he ran a laundry and became president of the Chinese Merchant’s Association of America. He married Leila Colson, my greatgrandmother and together, they raised their family in Atlanta, Georgia. Their oldest child was Jesse Ruth Jung, my grandmother, born in 1902.

Atlanta in the early 1900’s was a racially segregated community, with whites-only schools. Today, we think of racially segregated schools in terms of “white schools” and “black schools” but back then, there were white schools and non-white schools, the latter meaning anyone who wasn’t caucasian of European descent, and that included the Chinese. And so, my grandmother and her siblings were not permitted to attend Atlanta’s whites-only schools. They learned at home and had a private tutor through elementary school but Joe and Leila wanted their children to have the same kind of education that other children had.

So Joe enlisted the help of the pastor at his church and for two years, they petitioned the Atlanta Board of Education to have his children admitted to the Atlanta school system. Finally, in 1913, he succeeded and my grandmother was allowed to attend 5th grade classes. And so she became the first non-white child to attend Atlanta’s previously whites-only schools. It was not accomplished by public demonstrations, nor by a lawsuit in a Georgia court. It was done by the quiet perseverance of a mother and a father who wanted their children to have an equal education. At the time, there was an article in the Atlanta Constitution newspaper about them (my grandmother is in the center of the photo) and then the Jung’s story faded from memory.

But sometimes heroes pay a terrible price for being heroes. Although my grandmother, her brothers, and her sister were allowed to attend the whites-only school, they were not allowed to be a part of Atlanta whites-only society. It was not easy to be of mixed race in the south at the turn of the century, regardless of the specific race. As Chinese, they considered to be inferiors. They were ostracized and lived apart from the rest of the community. Joe Jung eventually died and then together, my grandmother and her siblings all agreed to change their last name from Jung to Young. They disavowed their Chinese ancestry in order to escape the prejudice and discrimination that they experienced as children and still as young adults. The Chinese heritage of the family was hidden and never again mentioned.

In fact, my father lived his entire life and died at age 55 never knowing that he was of Chinese ancestry. Eventually, all of the Young brothers and sisters died and at my grandfather’s funeral, the last surviving spouse of one of the Young siblings told the secret story that she had sworn to her husband, Ollie (my grandmother’s brother), to never tell. To their generation, their Chinese ancestery was a terrible secret that they were ashamed of. It had only brought them the pain and scorn of being considered second class. But a hundred years later, my family celebrates and takes pride in the fact that we have such a rich racial and cultural heritage.

American heroes come in all ages, both genders, and all races. And today on Memorial Day, I think about the courage of a 12-year-old girl who walked into a 5th grade classroom for her first day in a whites-only school and made a small dent in racial discrimination. It would take another 50 years before the U.S. Supreme Court unanimously ruled that school segregation was unconstitutional in Brown v. Board of Education. And it would be 60 years before another of my (more distant) relatives, President Lyndon Johnson, signed the Civil Rights Act of 1964. Ruth Jung did not want to be a hero, she just wanted to be a regular kid. But the battle that she and her family fought for her to have a normal education is at the core of what liberty, equality, and freedom of being an American really means.

May 27, 2019

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The Internet Is Causing A Shortage Of Independent Medical Examiners

Independent medical examiners are indispensable for unbiased determination of disability, life insurance eligibility, fitness for employment, and civil litigation. But suddenly, the supply of competent independent medical examiners is in peril.

An independent medical examiner is a healthcare practitioner (most often a physician) who is not involved in a person’s medical care who does a 1-time evaluation of the person to determine the person’s medical diagnoses and severity of impairment. Independent medical examiners do not prescribe medications but may do limited testing (for example, x-rays, pulmonary function tests, EKGs, etc.). Primarily, however, independent medical examiners rely on their history and physical exam as well as past medical records. Generally, the patient’s regular attending physician is not used as an independent medical examiner; there is an inevitable human tendency for physicians involved in the care of a patient to want to be their patient’s advocate, making them often biased about the person’s degree of impairment. Furthermore, the person’s regular physician often does not want to lose that person as a patient, also potentially leading to bias.

I have been an independent medical examiner on many occasions and I also review independent medical examiner reports on a regular basis as part of my role as a member of the Medical Review Board of the State Teachers Retirement System of Ohio and also in my role as an expert witness. 10 years ago, it was relatively easy to find experienced specialists to serve as independent medical examiners. After all, it generally pays better than standard Medicare rates for a one-time consult, there is no responsibility of prescribing medications or treatments, and there is no follow-up care involved (including no urgent calls from sick patients and no follow-up paperwork). The best independent medical examiners are physicians who have experience doing independent medical exams and the very best do a lot of these exams. But almost overnight, the pool of independent medical examiners has been shrinking and it is getting harder and harder to find physicians to do independent medical examinations.

The biggest reason is the internet.

If you get on your favorite search engine and type in the name of just about any physician in the United States, you can pull up all sorts of rating systems – these are equivalent to the Yelp or Tripadvisor of healthcare.

These are notoriously inaccurate. As an example, in “Healthgrades.com” and “vitals.com”, I am listed as a neurologist (my father, James N. Allen, Sr. was a neurologist at Ohio State University but died in 1980). As a pulmonologist, I do not practice any neurology.

Anyone can post a star rating on these websites, including persons who have seen a physician for an independent medical examination. If a physician does an independent medical examination for an insurance company regarding a person who is applying for disability and opines that the person is not disabled, that individual is not going to be very happy. This frequently results in vindictive rating posts.

As a consequence, many independent medical examiners who I know personally as outstanding physicians with impeccable medical judgment have some of the poorest star ratings on the internet. Increasingly, patient satisfaction scores are used by hospitals and medical practices that employ physicians as a measure of quality… and frequently as a basis for salary or bonus determination. Prospective patients searching the internet to pick out a doctor use the ratings to decide which doctor to see (just like they use star ratings to pick out a restaurant to go to for dinner). Additionally, health insurance companies use doctor rating systems in their decision making of which doctors will be included on their insurance plan and what fee rates they negotiate with the doctors.

All of a sudden, it has become hazardous to be an independent medical examiner. Too many negative reviews by vindictive disability applicants who did not get their desired disability because of chronic pain, etc. can be both publically humiliating to the independent medical examiners and can hurt them financially. One negative ratings by a person who did not get what they wanted from the independent medical examiner can be diluted out by 40 or 50 positive ratings from real patients who are getting medical care from that examiner. However, if a physician’s practice involves doing a relatively large number of independent medical examinations (for example, an occupational medicine specialist or a forensic psychiatrist), then their star ratings on the internet can suffer. Just like no chef wants to see his or her restaurant with 1 star on Yelp, no physician wants to see himself or herself with 1 star on healthgrades.com.

Last year, I was on Grand Jury duty here in Columbus. Each day, we would review dozens of cases to determine whether the County Prosecutors should proceed with trials for people arrested for crimes. Few citizens would want to be a Grand Jury member if the accused individuals could all post negative comments about their business, restaurant, or medical practice if the accused knew the names of each juror who voted to prosecute them.

So what is the solution? For fair and unbiased opinions by independent medical examiners, they cannot feel pressured, coerced, or extorted to render an opinion one way or another. However, there is virtually no way for independent medical examiners to be anonymous. Perhaps the best way is for more physicians to be independent medical examiners so that no one physician has a disproportionate percentage of posts by unhappy disability applicants who are denied their disability. But this will require us to train residents and fellows in the nuances of doing independent medical examinations, something that is currently not part of routine training in most residencies and fellowships. But for now, some of the best independent medical examiners are those who don’t Google themselves on the internet.

May 24, 2019

 

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Is There A Doctor On Board? In-Flight Medical Emergencies

If ¬†you are ever at an airport and see me standing in line for the plane that you are about to board, just turn around and find another flight… because something bad is probably going to happen. In-flight medical emergencies are reported to occur once every 604 flights but I have not been on anywhere near that number and I’ve been asked to provide assistance at least a half dozen times. Last month, I was flying to the American College of Chest Physicians meeting and had not one but two calls to provide medical assistance.

Somewhere over Tennessee, one of the flight attendants asked over the overhead speaker “If there are any medical personnel, please come to the front of the plane”. So, my wife and I both went up and there was an elderly woman who was unresponsive in her chair. She had a weak and bradycardic pulse and was diaphoretic. Her daughter said that she was diabetic so I handed a nurse who was on board her carry-on bag and asked her to search for a glucometer. There was a guy who was an EMS and I told him to get a blood pressure (it turned out to be normal). After a copy of minutes, she started to wake up. We never did find the glucometer but someone had a lollipop that we gave her just in case.

I moved to the seat across the aisle from her for the rest of the flight and then as we were landing, the flight attendant asked me to come see another unresponsive elderly woman a few rows up. She was traveling alone but had a medical alert bracelet that listed her medical conditions (including partial complex seizures) and medications as well as the phone number for her son. She had a strong pulse and a normal respiratory rate so I just gave her a few minutes and she started to come to but was confused, disoriented and pretty clearly post-ictal. Two sets of EMS units arrived to take the two women off of the plane. Both were OK – the first woman turned out to have a vasovagal reaction and the second patient was, in fact, post-ictal from a partial complex seizure.

Most of the time I’ve been asked to help during an air flight, it has been because of syncope or nausea; fortunately, I’ve never had to do in-flight CPR, deliver a baby, or pronounce anyone dead. So what do you do if you are called to provide medical assistance?

The first thing to realize is that you are never alone. The flight attendants can contact a emergency medicine physician on the ground who can help talk you through whatever medical problem you are faced with so you should not be afraid to help since you are going to have back-up by someone who does this for a living. The second thing to know is that every airplane doing a flight in the U.S. is required to have an emergency medical kit and these have most of the items you need for the most common in-flight medical emergencies. The kit will include:

  1. Automated external defibrillator (AED)
  2. Blood pressure cuff
  3. Stethoscope
  4. Oral airways
  5. Bag-mask ventilation set
  6. IV administration set
  7. Saline
  8. Needles
  9. Syringes
  10. Acetaminophen
  11. Albuterol meter-dose inhaler
  12. Aspirin
  13. Nitroglycerin
  14. Atropine
  15. D50
  16. Diphenhydramine (tablet and IV)
  17. Epinephrine 1:1,000
  18. Epinephrine 1:10,000
  19. Lidocaine
  20. Gloves

If you need something that is not in the kit, often some other passenger may have it in their carry-on bag so you can ask the flight attendant to make an overhead request for the equipment or medication that you think you might need.

Aircraft often fly at 35,000 feet altitude but they are pressurized to 8,000 feet. To put this in perspective, there is about 25% less oxygen per volume of air at this altitude than at sea level. For this reason I will order a high-altitude hypoxia simulation test for my patients with lung disease when they are planning air travel. In this test, the patient will breath 15% oxygen and then then an arterial blood gas or a transcutaneous oxygen saturation measurement is taken to determine if they need oxygen in flight.

But it turns out that the most common reasons for medical emergencies are just otherwise common conditions: Syncope (37%), respiratory problems (12%), nausea/vomiting (9%), cardiac symptoms (8%), seizures (6%), and abdominal pain (4%). Only 1 out of every 300 in-flight medical emergencies progress to death.

As a physician, you are not obligated to respond but most of the time, you are going to be a lot more capable of managing an in-flight emergency than a lay person. But if you don’t want to have to deal with a medical emergency during air travel, just don’t get on the same plane as me… because something bad always seems to happen when I’m aboard.

November 20, 2018