Categories
Physician Retirement Planning

Strategies For Asset Allocation In Your Retirement Accounts

In the past, I mainly advised new physicians in our department about retirement investment options at our university. More recently, my children have asked advice about their retirement planning. After you have made the decision about how much money you can invest in your retirement accounts, how do you go about deciding on what kind of investments to direct that money into? A few years ago, one of the wisest physicians at our university had recently retired and lamented to me that every year he had dutifully contributed the maximum he was allowed to his 403b plan but that he had allocated all of it to a very low interest money market fund and consequently, the value of his 403b was not enough to cover his expenses in retirement. Successful retirement planning means getting the right investment allocation in your retirement accounts and that allocation will vary depending on the type of account and your age.

The 4 Types of Retirement Accounts

There are many different types of retirement plans and all of the various plan numbers and names can be overwhelming at times. The plans you have access to will depend on your employer. For example, if you work for a for-profit company, you may have access to a 401k. For a non-profit company, it may be a 403b. And for a government agency, it may be a 457. Your employer may or may not provide a pension plan. However, all of the retirement investments can be divided up into four general categories:

  1. Roth accounts (including the Roth IRA, Roth 401k, and Roth 403b). These are investment accounts that you purchase after paying income taxes. They grow tax-free and when you take money out of them in retirement, you do not have to pay tax on the withdrawals.
  2. Deferred compensation accounts (including the traditional IRA, SEP IRA, 401k, 403b, and 457). These are investments that you direct pre-tax income into. The investments grow tax-free but when you take the money out in retirement, you pay regular income taxes on the withdrawals, based on whatever your income tax bracket is the year you withdraw the money.
  3. Post-tax accounts. These are investments that you purchase with money that you have already paid income tax on and are not subject to withdrawal rules in retirement. These can be broken down into financial investments (such as savings accounts or shares of stocks) and non-financial investments (such as artwork or real estate properties). For the purposes of this post, I am only going to consider the financial investments. The tax you pay on these investments depends on the type of investment: interest is taxed as regular income, dividends are usually taxed as capital gains but some types of dividends are taxed as regular income, and investment appreciation is taxed as capital gains.
  4. Defined benefit plans. These include pensions and social security. They generally give you a fixed income every month for as long as you live and you pay regular income tax on the monthly payments. Nearly every American has some form of a defined benefit plan since most Americans are eligible for Social Security. However the amount that each person gets from their defined benefit plans can vary widely – Social Security will pay out a relatively small amount where as a pension may pay out a very large amount each year. An annuity works similarly, with a portion of the fixed monthly payments being subject to regular income tax. The specific investments in most defined benefit pension plans and annuities are chosen by the company or institution that administers the pension or annuity so the individual investor does not have a choice of how the funds in the pension or annuity are invested.

Roth Account Allocations

Not all Roth accounts are the same. For example, the Roth IRA is not subject to required minimum distributions at age 72 (the IRS requires you to take a certain amount out of a regular IRA, 401k, 403b, or 457 each year after age 72). However, the Roth 401k and Roth 403b do have required minimum distributions after age 72. You can get around this by rolling your Roth 401k or Roth 403b over into a Roth IRA. Because the Roth IRA is not subject to required minimum distributions, many people will not start taking withdrawals from their Roth IRAs until well after age 72. For this reason, the investment horizon for your Roth IRA should be further in the future than the investment horizon for your deferred compensation accounts. The result is that your investment allocation will be different for your Roth IRA than for your other accounts. Strategies for your Roth IRA include:

  • A higher percentage of equities. Because your investment horizon is longer for the Roth account, you can and should invest in more higher risk stocks rather than lower risk bonds compared to the investment mix in your other retirement accounts.
  • No tax-free investments. Certain types of investments grow tax free, mainly municipal bonds. These generally pay lower interest rates than other bonds but the interest is not taxed. Since you do not have to pay income tax on Roth account withdrawals anyway, there is no advantage to investing in tax-free bonds, only the disadvantage of getting lower interest rates.
  • No cash investments. Cash investments include money in your checking account, savings account, or money market account. Although not exactly cash, I would also lump short-term certificates of deposit into this category. The main cash investment that most people will have access to in a Roth account is a money market fund. Because money market funds pay very low interest rates, you really lose the tax advantages of the Roth account by putting Roth money into a money market.
  • Use your Roth account to re-balance. Periodically, you should re-balance your retirement investments to be sure that you are maintaining a desired percentage of stock and bonds. You do not incur capital gains tax when you sell shares of mutual funds within your Roth account in order to exchange those shares for a different mutual fund. However, when re-balancing, remember that your Roth account should be more heavily weighted to stocks than your deferred compensation accounts. Also, be aware that you may be charged administrative fees every time you sell or exchange shares of mutual funds so do not get carried away and be exchanging shares too frequently.

Deferred Compensation Account Allocations

For many people, the majority of their retirement investments will be in a deferred compensation fund: 401k, 403b, 457, or traditional IRA. You do not pay any tax on these accounts until you withdraw money in retirement. Then, you pay regular income tax on the withdrawals. At age 72, the required minimum distribution rules come into play, meaning that the IRS requires you to withdraw a certain percentage from your deferred compensation accounts every year.

  • Get the right mix of stock and bonds. The first issue to be addressed is what ratio of stocks to bonds should you have. There is not a one-size-fits all answer to that question and the ratio will depend on your age, how long you plan to work, and how much in defined benefits you can expect. As a starting point, the percentage of stocks in your account should be 120 minus your age. Next adjust that percentage upward if you plan on a later retirement age or downward if you plan to retire early. Then adjust the percentage upward if you have relatively more defined benefit income in retirement, for example, a large pension. I am 62 years old, so using the equation, I should have 58% of my retirement investments in stocks; however, I will have a pension from our State Teacher’s Retirement System so I have adjusted that percentage upward to 66% in my deferred compensation accounts.
  • Be more conservative than you are in your Roth account. Because of the required minimum distributions starting at age 72, most people will start to withdraw from their defined benefit account several years before withdrawing from their Roth account. By spending down your deferred compensation amount, you can avoid being pushed into a higher tax bracket at age 72 when you may be required to take more out of your deferred compensation account than you actually need to meet your annual expenses.  Because of this shorter withdrawal horizon, you should have a lower percentage of stocks in your deferred compensation account than you do in your Roth account.
  • No tax-free investments. Similar to a Roth account, you should avoid tax-free municipal bonds in your deferred compensation plan since you will not realize any tax advance from the interest in a deferred compensation account and you will get a lower return on your investment.
  • No cash investments. Similar to a Roth account, you should avoid cash investments such as money markets in your deferred compensation accounts, at least until you reach retirement.
  • Use your deferred compensation account to re-balance. Similar to a Roth account, you will not pay capital gains tax every time you exchange one mutual fund for another within your deferred compensation account. But again, be aware of administrative fees charged when you sell or exchange shares of mutual funds within your deferred compensation account.
  • Chose funds with low expense ratios. Small differences in the expense ratio for different mutual funds can translate to big differences in total costs. Let’s take a mutual fund with an expense ratio of 0.75% – it seems like such a small number on the surface – less that one percent. But if you have $500,000 in your deferred compensation fund, you will pay $3,750 each year in expense fees. On the other hand, the same amount of money in a mutual fund with an expense ratio of 0.05% will result in only $250 annual expenses. In other words, you would be spending $3,500 more each year to be invested in the mutual fund with the higher expense ratio. As a general rule, index funds will have lower expense ratios than actively managed funds.
  • Are balanced mutual funds right for you? The default investment in many deferred compensation accounts will be an age-adjusted balanced fund such as a “Retire in 2035” fund. These will have a mix of stock and bonds, both domestic and foreign, with the mix pre-determined by the investment company based on one’s age. As you get older, the investment company automatically re-balances the components with thin these funds based on what is appropriate for your age. For investment novices, these are a great choice (which is why they are often the default investment) but they tend to be 2-3 times more expensive than their component index funds if you were to select the individual index funds yourself. Also, the balance of stocks and bonds in these funds may not be optimal for you if you have additional retirement investments in Roth accounts and post-tax accounts. And if you have a sizable pension, the balanced funds may be inappropriately conservative for your overall portfolio.

Post-Tax Account Allocations

The amount that you can save each year in a 401k, 403b, or 457 plan is limited. For most people, and especially for physicians with relatively high incomes, those deferred compensation accounts will not be enough to fund retirement. Anyone can supplement these by contributing to a post-tax traditional IRA (and then promptly converting it to a Roth IRA) and some people can contribute to both a 403b and a 457 each year (for example, employees of state-supported universities). However, when you maximize your annual contributions to these investments, you will probably still need to add more money into your retirement investments. This usually comes from the income that you have already paid regular income tax on, which I will call post-tax accounts. These accounts are not subject to the same IRS regulations that deferred compensation accounts and Roth accounts are but they have very different tax implications that can affect your asset allocations within them.

  • Here is where you should keep your cash investments. The whole purpose of having cash in your retirement portfolio is to be able to weather downturns in the stock market. In addition, you need to have 3-6 months of cash in an emergency fund in case you lose your job. In both situations, you want to have immediate access to money without withdrawal penalties. This is the where you should have your money market account.
  • This is the place for tax-free investments. Tax-free municipal bonds are not for everyone. The interest is considerably lower than for non-tax-free bonds and the tax advantages are primarily for the very wealthy. But for some people, having a portion of their retirement investments in tax-free bonds can be an important part of a balanced investment portfolio that will allow the retiree to strategically withdraw money from different funds in order to optimize their tax bracket. If you do chose to invest in tax-free bonds, they should be in your post-tax accounts where you can take advantage of the tax-free interest benefits.
  • Minimize re-balancing. Whenever you sell a stock, bond, or mutual fund, you will have to pay capital gains tax on the appreciated value of that investment. If you purchase $1,000 worth of a mutual fund and then sell it a year later for $1,120, then you have to pay capital gains tax on the $120 of appreciated value. The capital gains tax rate varies, depending on your annual taxable income. For married couples filing jointly, their capital gains tax rate is: 0% if making < $78,750; 15% if making $78,751 – $488,850; or 20% if making > $488,850/year. Therefore, if your joint taxable income is < $78,750, you do not pay any capital gains tax so you can sell or exchange your mutual funds all you want and you do not have to pay tax on the appreciated value. On the other hand, if your joint taxable income if > $488,850, then you will be paying the higher capital gains tax rate of 20% and you are better off holding on that investment until you are in retirement and may have a lower taxable income. One caveat to this is during periods when the stock market declines, such as the 2009 recession or the March 2020 COVID-19 market crash, re-balancing post-tax accounts will incur less capital gains tax since there will be relatively little appreciated value of the funds at that time.

My personal philosophy is that everyone should have retirement investments in each of these 4 types of accounts in order to reap the rewards of a fully diversified investment portfolio. Because each of these accounts has different tax implications, the ideal mix of investments in each type of account is going to be different. Begin planning those allocations as soon as you start to save for retirement.

October 12, 2020

Categories
Intensive Care Unit

How Many ICU Beds Does A Hospital Need?

When a new hospital is built or an existing hospital plans to expand, a key question is “How many ICU beds will we need?“. There is not a one-size-fits-all answer to that question but there are some general principles that guide the number of ICU beds that a hospital requires.

Data from the American Hospital Association’s 2020 publication on U.S. hospital resources reveals that there are 6,146 hospitals in the U.S. Excluding the psychiatric hospitals and federal hospitals, there are 5,198 community hospitals in the United States, of which, 51.4% have intensive care units. Overall, there are 792,417 community hospital beds in the U.S., of which 13.5% are ICU beds. The overall make-up of U.S. community hospital beds is:

  • 792,417 total hospital beds
  • 55,663 medical/surgical ICU beds
  • 15,160 cardiac care unit beds
  • 7,419 other ICU beds
  • 22,721 neonatal ICU beds
  • 5,115 pediatric ICU beds
  • 25,157 step down unit beds

Location, Location, Location

Intensive care units are not uniformly distributed in the United States. Many smaller hospitals lack ICUs and consequently, more than 50% of U.S. counties do not have any ICU beds. Most ICU beds are found in metropolitan areas (defined as > 50,000 population) or micro metropolitan areas (defined as 10,000 – 49,999 population:

  • 94% of ICU beds are in metropolitan areas
  • 5% of ICU beds are in micro metropolitan areas
  • 1% of ICU beds are in rural areas

There are a number of reasons for the paucity of ICU beds in rural areas but perhaps the most important reason is that an ICU is more than just a bed and a ventilator, an ICU requires critical care-trained nurses, advanced pharmacy support, 24-hour respiratory therapy, and physicians with critical care skills. Smaller hospitals in rural areas generally cannot support all of these specialized personnel to provide care for a relatively small number of ICU beds.

Although the overall average percentage of hospital beds in the U.S. that are ICU beds is 13.5%, because many rural hospitals lack ICUs, the percentage of ICU beds in metropolitan hospitals is necessarily higher than 13.5%. This is particularly true for academic medical centers and pediatric hospitals that function as tertiary care facilities with the result that these hospitals admit more complex patients who more often require ICU services. So, for example, in Columbus, Ohio, between the 3 major hospital systems plus the children’s hospital, there are 3,873 hospital beds. Of these, 572 (15%) are ICU beds.

Another way of analyzing ICU bed use is by expressing the number of ICU beds per 10,000 population. This can be misleading, however, because many rural areas will send most of their ICU-level patients to nearby metropolitan areas with the result that the larger metropolitan areas will have more ICU beds per capita. Nevertheless, in an analysis by the Washington Post, the major metropolitan areas in Ohio varied significantly in ICU beds per 10,000 population:

  • 6.3 Toledo
  • 5.3 Cleveland
  • 5.0 Cincinnati
  • 5.0 Dayton
  • 4.7 Akron
  • 4.4 Canton
  • 3.6 Columbus

What About Utilization?

The Society of Critical Care Medicine recently analyzed ICU occupancy. Overall in the United States, the ICU occupancy rate is 66.6% for adult ICUs, 61.6% for pediatric ICUs, and 67.7% for neonatal ICUs. One of reasons that these percentages seem low is that there can be wide swings in occupancy and a hospital needs to have sufficient resources to accommodate high-census times. Furthermore, ICU occupancy is generally based on the midnight census in a hospital, that is, the number of patients in a bed at midnight. Because patients usually do not get transferred out of ICUs until early afternoon (after the physicians make morning rounds) but patients get transferred into ICUs continuously throughout the day, the 66.6% occupancy rate at midnight for adult ICUs underestimates the peak occupancy for ICUs at noon which is considerably higher.

When a hospital’s ICU occupancy rate is low, the ICU tends to harbor less acute patients. Conversely, when a hospital’s ICU occupancy rate is high, higher acuity patients often get admitted to non-ICU locations such as step-down units. Consequently, a patient with a COPD exacerbation requiring non-invasive ventilation with BiPAP but not requiring intubation with mechanical ventilation would be admitted to an ICU bed when there is adequate ICU capacity but might be admitted to a step-down bed when there is insufficient ICU capacity.

So, how many ICU beds does a hospital need?

If we start with the U.S. average, then a hospital needs 13.5% of its beds to be ICU beds. Hospitals in larger cities need a higher percentage whereas hospitals in small towns need a lower percentage. Within larger cities there will also be variation: tertiary care hospitals and children’s hospitals will require a higher percentage than other hospitals in metropolitan areas.

In deciding whether to expand ICUs, a hospital should also look at its ICU occupancy rate. If the average occupancy rate is < 66% then the hospital likely does not need additional ICU beds. However, if the occupancy rate is > 66%, then ICU bed expansion may be warranted.

Lastly, the hospital should examine the acuity of patients in the ICU when determining whether ICU beds should be increased. A 2013 study of ICU occupancy and ventilator use in the U.S. found that the mean percentage of ICU patients on a ventilator at any given time was 40%. If a hospital’s ICU ventilated patient percentage averages less than this, then it may not need additional ICU beds. However, if the percentage of ICU patients on a ventilator is > 40%, then more ICU beds may be needed.

A hospital needs to have the correct number of intensive care unit beds to support its operating rooms and general nursing units. There also needs to be sufficient ICU beds regionally to support the community’s need to care for the sickest patients. ICUs are expensive and the specialized staff it takes to care for patients in ICUs are even more expensive. However, the DRG reimbursement for these patients is high and so ICUs can be financially lucrative for a hospital. When hospitals plan bed expansion, it must be done with the right balance of ICU to non-ICU beds in mind.

October 10, 2020

Categories
Life In The Hospital

Why COVID-19 Has Made Me More Efficient

A funny thing happened last month… I realized that I’ve been feeling a lot more rested in the past 6 months. So I asked myself the 5 “whys” to sequentially drill down on the question:

  • Why #1? Because I was getting to bed earlier
  • Why #2? Because I wasn’t doing as much work at home in the evening
  • Why #3? Because I was getting all of my work done at the hospital.
  • Why #4? Because I had more free time during the workday
  • Why #5? Because COVID-19 created free time

How did this happen? COVID-19 has eliminated a lot of non-productive workday time, has shortened the duration of a lot of activities, and has allowed us to multi-task.

Eliminating non-productive time

I spend a lot of time in meetings. Before COVID-19, I was on 30 hospital committees. The coronavirus outbreak has added 6 more regular workgroups and lots of ad hoc meetings. In the past, each of these meetings cost me about 5 minutes each way to get from my office to the meeting room if the meeting is in my hospital and about 25 minutes each way to drive, park, and walk to a meeting room if the meeting is on the campus of OSU. That adds up to many hours every month. COVID-19 has given me all of that time back. Now, getting to and from a meeting involves just the click of the mouse and I am instantly transported via computer to wherever my next meeting is. No elevator rides, no stairwells, no car rides.

Making meetings more efficient

When you go to a meeting in a conference room, there seems to be tacit agreement by all attendees that they are obligated to fill the entire allotted time for the meeting. And so, a meeting scheduled for 1-hour almost always lasts for a full 60 minutes. There are meeting presenters who inevitably use 50 words for a 5 word statement. There is usually minutes taken to get the AV presentations started or download PowerPoint files. And then there are the attendees who feel that the are obligated to ask questions or interject their thoughts and keep doing so until the meeting is out of time.

With virtual meetings, most of that goes away. Meeting attendees are less inclined to drone on with marginally relevant comments (often because they are only half paying attention to the meeting while doing other things on their computer). Presenters tend to be more succinct on video. Many attendees will pose their questions to typed in “chat” boxes on the virtual meeting programs rather than ask them verbally. And all it takes to pull up a PowerPoint file is a single click of the “share screen” button on the program. For these reasons, a lot of meetings that were previously 60 minutes are all of a sudden only lasting 25 minutes.

Multi-tasking during meetings

In the past, it was considered rude to be checking your email or doing paperwork during a meeting held in a conference room. But with virtual meetings, the other attendees can’t tell if your email account is pulled up on your computer or whether you are working on your electronic medical record inbasket during the meeting. In most meetings, there are presentations that are relevant to you and there are presentations that are irrelevant. Now, rather than daydreaming about what you want to have for dinner during the presentation on proposed changes to the color of surgical scrubs used in the OR, you can get on-line and order dinner for pick-up. Overall, 20-30% of meeting time can now be devoted to catching up on email and paperwork.

Telemedicine is quicker

In general, it takes me less time to do an outpatient visit by telemedicine than it does by an in-person office visit. There is no physical examination required. It is easier to type your progress note while you are simultaneously on the computer with the patient. And patients seem to want to talk less on a video chat than in an exam room. As a consequence, I don’t get behind on my clinic schedule nearly as much as I did in the pre-COVID era.

More working lunches

Being particularly paranoid about opportunities for viral transmission, I now avoid cafeterias, break rooms, and lounges. Indeed, we have found that hospital staff are more likely to acquire COVID-19 in these locations than from direct care of COvID-19 patients. Instead, I pack a lunch and eat it in the safety of my own office, generally while on the computer doing work.

COVID-19 has brought economic hardships but it has also brought a paradigm-shift in business practices that have resulted in improved operational efficiencies in the workplace, especially for physicians. I now have about 2 hours a day of extra time during my workday that I previously did not have before COVID-19. As a consequence, I’m getting more sleep than anytime in the past 40 years.

October 2, 2020

Categories
Epidemiology

(Age + BMI) x Hemoglobin A1C = COVID Mortality Risk

OK, not really. This title is not a scientifically-proven equation and so don’t quote me on it. But it does underscore the observations that there are both powerful modifiable risk factors and non-modifiable risk factors for death due to COVID-19. We started anecdotally noticing this in our ICU in the spring as the COVID-19 outbreak unfolded in Ohio. Patients who ended up in the ICU and who died were older and/or had co-morbid diseases. And since then, several studies have confirmed these observations.

Age is the strongest risk factor for death from COVID-19. In a previous post, I noted that in a report of COVID-19 infections in California, for people under age 18, death from COVID-19 infection is exceedingly rare. But for every decade older, the risk of dying if a person becomes infected increases, culminating with a 25% mortality rate in those over age 80. This striking of an age effect on mortality is not seen with other respiratory viruses, such as influenza, which causes death in both the very young and the very old. This was especially true of the influenza pandemic of 1918 and the H1N1 pandemic of 2009 when younger persons who became infected had a higher mortality than older persons.

Obesity is also a predictor of death from COVID-19 infection. In a study of 17 million people in England, morbid obesity (BMI > 40) was associated with a 2-fold risk of dying from COVID-19. This may be why the United States has been so disproportionately affected by COVID-19 compared to other countries. According to the Organisation for Economic Co-operation and Development (OECD), the United States has the highest prevalence of obesity of all developed nations with 40% of Americans having a BMI > 30. In contrast, the average prevalence of obesity in OECD countries is only 24%.

Obesity goes hand-in-hand with diabetes and so not surprisingly, uncontrolled diabetes is also a risk factor for death due to COVID-19 infection. The same study from England found that uncontrolled diabetes (defined as a hemoglobin A1C > 7.5%) conferred a 2-fold increase in likelihood of dying from COVID-19 compared to a normal hemoglobin A1C. Once again, the United States has a higher prevalence of diabetes than the world as a whole with 10.8% of Americans being diabetic and 8.8% of the world being diabetic according to data from the world bank. The U.S. leads all other large developed nations with regards to diabetes prevalence. Like obesity, uncontrolled diabetes is a modifiable risk factor. Obese persons are more likely to become diabetic and diabetics with reduced access to healthcare are more likely to have uncontrolled diabetes. Despite spending more money per capita on healthcare than any other country in the world, Americans see a physician fewer times per year (4) than inhabitants of other OECD nations (6.6) suggesting that the access to healthcare in the United States is actually quite low compared to other countries.

Whether or not a risk factor is considered modifiable or non-modifiable depends on the event horizon of the disease in question. A disease like coronary artery disease results in a fatal myocardial infarction years or decades after coronary artery disease first begins. This gives people ample time to modify their risks for coronary disease. With COVID-19, the event horizon is short and measured in weeks and months, not years. Thus, the “modifiable” risk factors needed to be modified years ago in order to reduce the chance of dying of COVID-19 next today. It is not possible to significantly lower one’s BMI or hemoglobin A1C fast enough to make much of a difference of surviving the current pandemic.

But there are lessons to be learned. If you are 18 years old with a BMI of 22 and a hemoglobin A1C of 4%, then you have higher chance of dying in a motor vehicle accident than from COVID-19. But if you are 70 years old with a BMI of 40 and a hemoglobin A1C of 9%, you would be advised to find an abandoned missile silo, close the door, and leave it locked for the next 12 months.

August 29, 2020

Categories
Medical Education

Making The Most Of Your Virtual Residency Interview

Fourth year medical students are facing challenges that no previous group of medical students have faced. The COVID-19 outbreak resulted in a loss of approximately 1/3 of their clinical rotation time during their third year of medical school as students were removed from our teaching hospitals in order to protect their own health. The re-direction from in-person to telemedicine outpatient visits was largely engineered to ensure continuity of patient care and physician income preservation – medical student education was left out of telemedicine. Students wanting to explore different hospitals or specialties not available at their own medical institution have seen clinical  “away rotations” eliminated due to travel restrictions. And now, the long-standing tradition of the residency interview has been radically changed with the replacement of on-site interviews with virtual interviews performed over the internet.

Residency Interviews are Expensive

In some ways, the virtual interview process brings benefits. Travel costs for medical students average $250 – $500 per interview and with students ranking an average of 12.5 residency programs in last year’s National Resident Matching Program, the typical medical student incurs about $5,000 in interview costs in order to apply to residency programs. There is a time cost as well, with one study finding that the average medical student spends 26 days traveling to interviews. Travel time and costs are the major factors that limit the number of programs a student can interview with.  The probability of matching to a residency program is dependent on both the number of programs a student ranks on their match list as well as the type of specialty that they have chosen. For example, 90% of U.S. medical students applying to pediatric residencies matched in their top 3 rank selections whereas 90% of internal medicine residency applicants  matched in their top 4 selections. Orthopedic surgery is considerably more competitive with 90% of applicants matching in their top 11 selections.

The Coalition for Physician Accountability has recommended that all residency programs commit to virtual residency interviews as opposed to in-person interviews for 2020. One implication of this is that medical students can interview at far more residency programs than ever before. There are no travel costs and a student can potentially interview with a residency program in California in the morning and a different program in New York in the afternoon. However, unlike medical students, residency programs are limited in the number of applicants that they can virtually interview since the faculty from those programs have only so many hours in the week that they can free-up from their regular duties to interview applicants.

One potential danger is that those applicants who appear the strongest on paper (based on grades and board examination scores) could take up most of the interview spots if they choose to interview at 30 or 40 programs. This could result in other applicants being closed out of interviews. As a result, many specialties are calling for a limit to the maximum number of residency programs that each medical student can interview with.

Preparation, Preparation, Preparation

In the past, when traveling to in-person interviews, students would use time in airports and hotel rooms doing background research on the hospital and city that they were heading to. This knowledge is the foundation for a successful interview. With virtual interviews, this down time evaporates so students need to find time in their regular lives to do that background investigation. Knowing about the physician faculty and the institutional areas of clinical expertise allows you to speak from a position of familiarity that in turn indicates your interest in that particular program.

Have a back-up plan in case your computer fails or in case of a technology failure at the institution you are interviewing with fails. That could be as simple as having a cell phone that could be used in a pinch. Also, be sure to log-on to the program 15 or 20 minutes before the time of your interview if possible – this will give you sufficient time to download an app or a software update needed for that particular interview. Make sure that your cell phone is turned to vibrate, your land line phone is off the hook, and your doorbell is turned off before you start your interview. Any programs or apps on your computer that can cause sound alerts should be closed.

Use the Right Equipment

If you are a medical student preparing for virtual residency interviews, you can only appear as good as your audiovisual equipment lets you appear. That means you will need to have a good camera and microphone. That 8-year old laptop that you got as a high school graduation present is not going to do the job. If you do not have a recent generation, high definition camera on your computer, then borrow or buy one. Since you are saving thousands of dollars in travel costs this year, it behooves you to spend a little money on a good webcam. In a previous post, I wrote about microphone selection for optimal audio presentations. To be sure that your camera and microphone are optimized, have a friend do a mock video interview with you with him or her using the equipment that you intend to use for the real interviews so that you can see what the interviewers are going to see. Make sure that you have plenty of bandwidth on your internet connection and since your interview may involve several different interviewers over several hours, be sure that your equipment is plugged in rather than running off of a battery.

Set the Stage to Your Advantage

In a virtual interview, it is not only how you look that is important, but also how your background surroundings look and sound. In a previous post, I wrote about how to improve your camera appearance for video conferencing and these points are equally applicable to the virtual interview. In particular, room lighting needs to be optimized. You should be in a quiet area, free noise created by cars driving on the street or created by your neighbor who practices his tuba in the apartment next to you. The stuff on the wall behind you will tell as much about you as the personal statement in your residency application so be sure that everything the interviewer sees in the camera field reflects the best in you. Be sure that you are in a location where you will not be interrupted – your child pounding on the door, your dog jumping in your lap, or your roommate walking around behind you in his underwear can derail your whole interview.

Dress for Success

It can be tempting to dress for your interview the same way that you normally dress in your apartment – casually. Instead, dress the same way you would if you are going to an in-person interview. If you are a guy, that means a tie and jacket. And don’t forget your pants – if you have to get up for any reason during the interview, you don’t want to be caught wearing your gym shorts. Make sure that the clothes that you wear contrast well with your background – wearing a white blouse in front of a white wall will cause you to fade away. Choose neutral colors – a medical student at the Ohio State University is better off not wearing a scarlet and gray necktie when doing a virtual interview at the University of Michigan.

Making a Good Impression on Camera

One of the criteria residency applicants are judged on during in-person interviews is eye contact. Poor eye contact can sink an applicant’s score on the residency program’s rank list. As humans, we rely on non-verbal communication with our eyes and facial expressions to augment our verbal communication. Video interviewing can disrupt this non-verbal communication. It can be tempting to look at the eyes of the person on the computer screen rather than the camera lens. The interviewers then perceive you as not making eye contact with them. Particularly when you are talking, look at the camera, instead of the computer screen. Shrink the video screen window and move it as close to your computer’s camera as you can. Head nods, smiles, and hand gestures can embellish your interview.

Practice for Success

2020 represents a paradigm shift in residency program interviews. The skills necessary for a successful in-person interview in the past will not always translate to a successful virtual interview this year. The disadvantage that this year’s senior medical students face is that no class of students has ever done this before so there is no precedent for today’s students to draw from. But students can also use this to their advantage. Those students who prepare can improve their interview performance and preparation means practice. Try out different video equipment and different locations. Do mock video interviews with other students and if possible, with faculty from your medical school to get feedback. Record mock interviews so you can see how you appear to the interviewer and then adjust your background, lighting, camera position, and clothes accordingly. This is an opportunity like no other before that allows students to leverage technology skills to set themselves apart from others in the residency selection process.

When it comes to 2020 residency program interviews, “…It’s showtime!”

August 15, 2020

Categories
Outpatient Practice

Telemedicine Across State Lines?

Healthcare providers and patients have embraced telemedicine during the COVID-19 outbreak as a way to ensure on-going medical care while minimizing potential exposure to the virus. But many of my patients live outside of Ohio, so can I use telemedicine to care for them? Unfortunately, the answer is probably not.

“The practice of medicine is deemed to occur in the state in which the patient is located.”

 

Physician medical licenses are state-specific. Therefore, a physician must have a medical license issued by the state medical board in each state that physician practices in. But if the physician is in one state and the patient is in another state during a telemedicine encounter, which state is the medical practice location? The State Medical Board of Ohio, like most other states, defines the location of the practice of medicine to be where the patient is physically located, not where the doctor is physically located.

So, if a patient from West Virginia comes to see me for a face-to-face visit in my office in Columbus, Ohio, the practice of medicine occurred in Ohio. But if I did a telemedicine visit with that patient while the patient was in their home in West Virginia, the practice of medicine occurred in West Virginia. And since I only have an Ohio medical license, I would technically be practicing medicine without a license.

Each state has different laws about medical licensure

 

In Ohio, the laws pertaining to telemedicine are derived from section 4731-11-09 of the Ohio Administrative Code that applies to the prescription of medication. This law states that a physician cannot prescribe any controlled or non-controlled medication to a patient unless that physician has conducted a physical examination of that patient. However, an exception exists if the following criteria are met:

  • The physician establishes the patient’s identity and location
  • The patient provides informed consent for treatment
  • The physician completes a medical evaluation
  • The physician establishes a diagnosis and treatment plan
  • The physician provides appropriate follow-up recommendations
  • The physician documents the encounter in the medical record
  • The physician uses appropriate technology sufficient to conduct the encounter

The State Medical Board has stricter rules regarding the prescription of controlled substances, such as opioids. If a physician has never conducted a physical examination on a patient, the physician cannot prescribe controlled substances except in a few situations, such as the physician is cross-covering for another physician who has examined the patient or if the patient is in hospice.

Physicians outside of Ohio who want to provide telemedicine care for patients who live in Ohio must obtain an Ohio telemedicine certificate (at a cost of $350) and are held to the same standard of care as a physician having a regular Ohio medical license.

The COVID-19 emergency has changed state telemedicine regulations

 

Each state has responded differently to telemedicine regulation changes brought on by the COVID-19 outbreak and each state’s requirements are summarized on the Federation of State Medical Boards’ website. For the State Medical Board of Ohio, there were 2 concessions made for physicians outside of Ohio for the duration of the COVID emergency:

  1. They are able to provide telemedicine services to their established patients who were visiting Ohio and now unable to return to their home states due to COVID-19.
  2. If they are in a contiguous state to Ohio and have established patients who live in Ohio they can also provide telemedicine service to those patients.

In addition, the State Medical Board of Ohio has suspended the requirement that a physician must have performed a physical examination in order to prescribe medications and suspended the requirement for in-person visits to occur for the prescription of controlled drugs, such as opioids.


But the regulations are often very confusing. For example, during the COVID-19 emergency, West Virginia permits a physician licensed in any other state to provide telemedicine to patients located in West Virginia. However, Ohio has not made similar concessions permitting an Ohio-licensed physician to perform telemedicine visits with a patient located out of state. So, the question remains, can a physician licensed in Ohio perform telemedicine to a patient in West Virginia? The State Medical Board of Ohio says no whereas the State Medical Board of West Virginia says yes. This has important implications for malpractice insurance coverage in that if a physician’s medical license does not cover their telemedicine encounter in another state, their malpractice coverage may not cover that telemedicine encounter, either.

So what is a physician supposed to do?

 

The safest bet is to obtain a medical license in all of the states that your patients live in. This would also include states that your patients vacation in if you want to provide care for them by telemedicine if they get bronchitis while visiting relatives out of state. During the COVID-19 emergency, check with the State Medical Board of both the state that the physician is in as well as the state that the patient is in to be sure that both states permit out-of-state telemedicine.

For my own practice, I encourage my patients in Ohio to use one of our telemedicine options. For my patients in other states, I tell them they have to have travel to Columbus and have an in-person visit in my office.

July 25, 2020

Categories
Epidemiology

Mask Myths

One of the most effective ways of controlling the spread of respiratory viruses, such as the COVID-19 virus, is by wearing face masks. Last weekend at the Ohio Statehouse, a group of anti-maskers protested the wearing of face masks, complete with an escort of camo-wearing, body armor-clad, AR-15-wielding gun enthusiasts, presumably there to protect the protesters from throngs of violent mask-wearers. The protesters offered a multitude of reasons why people should not wear masks and so I thought this would be an opportune time to examine some common mask myths.

  1. You can get carbon dioxide poisoning. This theory espoused by anti-maskers proposes that carbon dioxide builds up inside of masks and then when one inhales, they inspire toxic quantities of carbon dioxide leading to disease and death. Carbon dioxide is a gas and cannot build up in a cloth or fiber mask. If it did, we would have to pay surgeons and OR nurses hazard pay since they have worn masks daily for decades. It appears that the protestors confused wearing a cloth mask with tying a plastic trash bag over one’s head.
  2. Masks cover up the image of God. This is the reason that state representative Nino Vitale from Urbana, Ohio used when he refused to wear a mask over his face inside the Ohio Statehouse. Mr. Vitale has quite a celestial opinion of himself and it is suspected that he refuses to wear pants in public for the same reason.
  3. Only N-95 masks protect you. N-95 masks are only necessary when performing aerosol-generating procedures and not when performing routing patient care or when out among the public. As long as you are not performing an upper endoscopy or colonoscopy inside of a McDonalds restaurant, you don’t need an N-95 mask.
  4. Masks only need to cover the mouth and not the nose. This one is partially true… as long as you are holding your nose, it won’t matter if your mask covers it. However, if there is air coming out of your nose, then it needs to be covered.
  5. If you’re not sick, you don’t need to wear a mask. Unfortunately, only about two-thirds of people infected with the COVID-19 virus have symptoms. In other words, one-third of those infected are asymptomatic. The guy sitting on the bar stool next to you who is yelling, laughing, sneezing, or coughing could quite easily be passing the virus on to you whether or not he has a fever.
  6. You only need to wear masks indoors. The idea is that sunlight kills the virus. Although it is true that most of the virus on surfaces is killed after about 20 minutes in direct midday sun, being in the sun will not kill viruses being passed through the air when someone coughs toward you, unless you can hold your breath for 20 minutes.
  7. Wearing a mask shuts down your immune system. Cloth masks are made of cloth, just like clothing is made of cloth. As long as your shirt is not causing you to get leukemia, your mask won’t either.
  8. Masks should be soaked in Clorox bleach before being worn. The idea behind this one is that since bleach kills viruses, any virus in the air that you breathe in will be dead-on-arrival when it gets into your lungs. Pulmonologists, such as myself, wish that this was true because if so, we would have lifetime job security from all of the asthma and lung damage caused by people inhaling bleach vapors.
  9. Wearing masks hurts the economy. Increasing numbers of viral infections hurts the economy. The economy will recover when it is safe to go to the store/theater/stadium/restaurant. Personally, I won’t walk into a public building if I seen other people not wearing masks. Wearing masks is the fastest way to rejuvenate the economy. Countries that enacted mask requirements early have recovering economies and are about to eat the United States’ lunch.
  10. Masks go against the American spirit of freedom. American freedom does not mean you have the right to infect other people with the virus. If a person is asymptomatically infected with the COVID-19 virus that person can infect others who are in contact with him/her. And if 4 of those others who get infected are over age 80, then statistically 1 of them will die. As a physician, I do not have the freedom to deny treatment to a mask-slacker who develops COVID-19 respiratory failure.

Anti-maskers join the legion of anti-vaxxers, anti-hand washers, anti-tooth brushers, and anti-bathroom users. Until we have an effective vaccine, the fastest way to get back to life as normal is to wear a mask.

July 22, 2020

 

Categories
Epidemiology

You Are Safer From COVID-19 In The ICU Than In The Grocery Store

This summer, COVID-19 numbers keep going up. Five months ago, we thought COVID-19 would behave like other respiratory viruses: have peak incidence in the winter and then drop off in the summer. But that has not happened. Across the United States, there is a second surge in new infections and southern states that seemed to be spared from the initial outbreak now have rapidly escalating numbers of new cases. As our hospitals admit record-breaking number of these patients, all of us in healthcare jobs wonder “Are we safe in our workplace?“. It looks like the answer is… we probably are.

In intensive care units full of COVID-19 patients, we are hyper vigilant about using personal protective equipment. Face masks, eye protection and hand sanitizer are mandatory. For patients undergoing aerosol-generating procedures, disposable gowns, gloves, and N-95 masks are added. It turns out that the coronavirus has a hard time penetrating all of that PPE to get to our mouths, noses, and eyes. Infection control procedures work surprisingly well.

The home is a dangerous place

On the other hand, in our homes, grocery store, bars, churches and restaurants, we let our guard down. The masks come off, we don’t use hand sanitizer every 5 minutes, and there are no plastic face shields to protect our eyes. Even worse are those around us who refuse to take any precautions, either because they believe that they are invincible, they are trying to make a political statement, or they are just plain ignorant. During the influenza pandemic of 1918, these people were called “mask-slackers”. Not only were there individuals who refused to adhere to infection control practices, there were entire cities that refused to adhere to these practices. St. Louis was an early adopter of closing schools and businesses whereas Philadelphia did not close businesses and instead held a public parade – the peak death rate in Philadelphia was 257/100,000 whereas the peak death rate in St. Louis was only 58/100,000.

A recent study from JAMA looked at 3,056 healthcare workers at a hospital in Belgium who underwent antibody testing to identify those who had become infected with the COVID-19 virus. All of them additionally completed a survey about exposures. 197 staff were identified as having been infected. But there was no correlation between taking care of COVID-19 patients and becoming infected oneself. Even working in the hospital was not associated with becoming infected. The only correlation was when a healthcare worker had a family member who was infected. The study indicated that healthcare workers who got infected did not get infected from hospital exposures but instead got infected from family members at home. U.S. hospitals are finding the same thing – when healthcare workers are identified as being infected, it is home exposures that are the cause and not patient exposures.

There are steps our hospitals can take

All of us in hospitals feel the risk. Many healthcare workers have decided to just retire or seek other jobs. Others have gone on disability purely due to perceived risk of becoming infected. But we know that strict use of personal protective equipment and hospital visitor limitation works. So what can we do to ensure our staff safety as elective procedures resume and visitors return? Fortunately, there are some specific things that we can do:

  1. Universal masking. Every person in the hospital should be wearing a mask unless they are alone in a room. This means not only doctors and nurses but also visitors and administrative staff. A mask for every person, all the time.
  2. Eye protection during patient care. In addition to face masks, goggles or face shields should be worn whenever a staff member is in a room with a patient.
  3. Hand hygiene every time. Alcohol hand sanitizer needs to be available throughout the hospital and must be used before and after every patient encounter.
  4. Beware of the break room. In hospitals, we often assume it is the patients who could be infected and are thus dangerous to us. However, we are more likely to get infected from a co-worker in the cafeteria, the conference room, or the office suite when we let our guard down by taking off our masks and not using hand sanitizer. It is probably more dangerous to eat in the doctor’s lounge than it is to intubate a COVID-19 patient while wearing PPE. When it comes to who hospital workers get their COVID-19 infection from, in the immortal words of Pogo: “We have met the enemy and they is us“.
  5. Limit visitors. Statistically, the more people that are in the hospital building, the more likely one of them is infected with COVID-19. Some studies indicate that as many as one-third of infected persons have no symptoms so simply screening visitors by symptoms or body temperature will not catch all of those people who can potentially spread the virus.
  6. PCR test all patients. Not only can visitors have asymptomatic infections but so can patients. So the patient coming in with appendicitis, a heart attack, or a bleeding ulcer can also have subclinical COVID-19. Every patient should be treated as if they have the infection until proven otherwise.
  7. Work from home. Healthcare workers can also have asymptomatic infection and so the fewer healthcare workers are in the building, the less likely one of them is going to inadvertently infect someone else. If you can do your job equally well from home, you should not be in the hospital.
  8. Encourage smart behavior outside of the hospital. We cannot control what our healthcare workers do when they leave the hospital but we can at least encourage them to do the right things. Avoid indoor gatherings. Always wear a mask in public. Avoid places where other people do not wear masks. Practice hand hygiene.

The COVID-19 virus is all around us. But it just may be that the safest place to be right now is working in the COVID-19 ICU.

July 19, 2020

Categories
Epidemiology

The Effect Of Age On COVID-19 Mortality Rates

Last week, I was asked if it would be OK if 20 family members visited one of my patients who is in his 80’s over the holiday weekend. My reflexive response was “Don’t come!” but it raised the question of what is the probability of dying should this patient get infected by COVID-19 and how does age effect mortality rates? Although we all know that age is a risk factor for death from COVID-19 infection, it turns out that specific probability statistics are hard to come by.

The U.S. Centers for Disease Control regularly posts information about the COVID-19 hospitalization rate by age and we know that older persons are more likely to be hospitalized than younger persons. For example, the hospitalization rate for people age 18-29 years old is 34.7 per 100,000 whereas the hospitalization rate for people over the age of 85 is 573.1 per 100,000. That means that an elderly person at 85 years old is sixteen times more likely to be hospitalized with COVID-19 than a young adult who is 25 years old. But this data does not tell us about the probability of death for different age groups.

The Ohio Department of Health regularly posts information about the number of Ohioans who have died from COVID-19 by age. This graph shows the COVID-19 deaths in Ohio as of July 1, 2020. It is striking that 1,516 deaths (53% of the total) occurred in people over the age of 80 whereas only 2 deaths have occurred Ohioans under the age of 20. However, the Ohio ODH does not post the total number of cases by age and so we still cannot determine the probability of death for different age groups. For that information, we have to turn to California.

The California Department of Public Health regularly posts both the number of infections AND the number of deaths for different age groups. This is the data from California as of July 1, 2020. By dividing the number of deaths by the number of cases for each age group, we can calculate the probability of death if a person in that age group becomes infected with COVID-19. The numbers are astounding: 25% or one out of every four people over age 80 who get infected with COVID-19 will die of the infection. On the other hand, a young adult between age 18-34 years old who gets infected with COVID-19 has a 0.084% chance of dying (or 1 death for every 1,196 infected persons). That means that an 85 year old person is 300 times more likely to die if infected with COVID-19 than a 25 year old infected with COVID-19. One a more personal front, if one of my children and I both get infected with COVID-19, I am statistically 38 times more likely to die than my child.

So, why is age such a striking risk for death by COVID-19? Although it is true that older people are more likely to have debilitating diseases such as heart failure and COPD that could make death more likely, I do not believe that this fully explains the association of age with COIVD-19 mortality. Furthermore, children almost never die of COVID-19; in Ohio, there have only been 2 deaths in those under age 20 and in California, there have been no deaths in those under age 18. One possible explanation that has been proposed is age-related changes in the level of the cell membrane receptor ACE2, a protein that the COVID-19 virus binds to in order to get inside of cells.

Virology research will eventually give us an answer to the question of why COVID-19 preferentially kills older people. But for now, I’ll stick to my original answer to my 83-year old patient’s family members question about having a family reunion at his house over the holiday weekend… don’t do it.

July 3, 2020

Categories
Epidemiology

Good News For The 2020-2021 Influenza Season?

I have a confession… I am a flu nerd. Every winter, I check the Center for Disease Control’s FluView website every Friday for epidemiology updates and I track the number of cases of influenza in our own hospital weekly. Most years, what happens in Australia in August and September predicts what will happen in the United States in February and March. And this year, there may be some good news from down under.

When it is summer in the United States, it is winter in Australia and so Australia’s flu season is the opposite months of the year as the United State’s. Last year, the Australian flu season was unusual: it started earlier in the year and there was a much higher percentage of influenza B than normal. Sure enough, last winter in the U.S., our influenza season also started earlier than normal and was characterized by mostly influenza B in the beginning of the winter and then mostly influenza A later in the winter. This graph shows the number of influenza cases by week of the year for 7 recent flu seasons (week 1 is in January). The red line is the 2019-2020 flu season (the gray line was the H1N2 pandemic of 2009).

Some studies of COVID-19 infections that occurred last winter indicated a high rate of co-infection with other viruses, particularly in children. The most common co-infecting virus was influenza. A fear of epidemiologists is that when the U.S. has its next influenza season in the winter of 2020-2021, co-infection of influenza and COVID-19 could result in an accelerated spread of COVID–19.

But it turns out that the same public health measures that help control the spread of COVID-19 also help control the spread of other respiratory viruses. Many physicians have wondered why there have been fewer emergency department visits for respiratory illnesses and fewer patients with asthma exacerbations in the past few months. The reason is likely because social distancing, wearing face masks, and frequent hand washing reduces the spread of all respiratory viruses, not just COVID-19.

The epidemiologic data coming from the Australian Department of Health Influenza Report indicates that this is going to be an influenza season like no other in modern history. What is so remarkable is that there is hardly any influenza this year. This graph shows the number of influenza cases over the past 6 seasons in Australia with the current influenza season in red and last year’s season in dotted green. Up until late March, the 2020 Australian influenza season appeared to be almost identical to last season. But then the number of influenza cases plummeted and there has been very few cases of influenza in April, May, and June.

It is still early to be sure since the peak of influenza in Australia normally occurs in August and September. But the early indication is that this is going to be one of the lightest influenza seasons on record in Australia and if so, then history tells us that the U.S. could have a light influenza season, also.

However, for this to happen, the U.S. will need to keep up social distancing and hand hygiene. As schools re-open in the fall and as workers return to their jobs, it may be very difficult for us to maintain our public health momentum next winter. So, this year Australian influenza epidemiology may not predict U.S. influenza epidemiology. Nevertheless, the information indicates that influenza can be controlled the same way that COVID-19 is controlled: staying home when you’re sick, washing your hands regularly, and avoiding those people who are sick.

But all Americans still need to get a flu shot this fall.

June 24, 2020