Why “Should You Get A COVID Booster?” Is The Wrong Question

Two weeks ago, the new COVID booster vaccines were released and the internet is full of articles titled “Should you get a COVID booster?“. This is the wrong question – the real question is “When should you get a COVID booster?”. We so want the COVID pandemic to be over and gone. Americans are returning to theaters and restaurants, houses of worship are full again, sporting events are sold out, and mask-wearers are a tiny minority at the grocery stores. But COVID is not going away.

For the past 3 years, there have been two peaks of case numbers every year – a large peak in January and a smaller peak in the summer. Data from the CDC this week indicates that the current 2023 summer peak is cresting and cases should begin to fall over the next few weeks (reported case numbers are unreliable but COVID hospitalizations, COVID deaths, and the percent of ER visits due to COVID are accurate measures). If history repeats itself, then we should have a break in cases for the next couple of months until they begin to rise again in the winter.

COVID is a moderately lethal infection – less lethal than Ebola but more lethal than influenza. Immunity is very effective in protecting you from dying of COVID but less effective from protecting you from catching a non-fatal COVID infection. There are two ways to get immunity – either by having a previous COVID infection or by getting a COVID vaccine (or both). On the whole, immunity from past infection is probably more effective than immunity from a vaccine. However, to get immunity from a past infection, you have to first survive the infection. There are a number of advantages to getting immunity from a vaccination compared to getting immunity from an actual COVID infection:

So far, 1,144,539 Americans have died from COVID and most of these were people who had no immunity to the virus and died from their first infection. To understand how our immune system fights COVID, let’s first take a look at the basics of the immune response to viruses.

How the immune system works

Viruses cannot reproduce on their own – they have to get inside of our cells and then hijack those cells’ RNA to produce new viruses. Our defense against viruses takes two forms: the innate immune system and the adaptive immune system. Innate immunity uses parts of the immune system that we are born with to fight any new infection. The innate immune system consists of interferons, natural killer lymphocytes, and macrophages. When a cell gets infected with a virus, that cell releases interferons that then signal natural killer cells to kill any other infected cell before it can produce more viruses. In addition to stopping the infection by killing infected cells, the innate immune system has macrophages that can eat and kill extracellular viruses before those viruses can infect other cells in the body. The innate immune system works whether or not a person has been previously infected with the same virus or has received a vaccine against that virus. Think of the innate immune system working on instinct. The adaptive immune system, on the other hand, can be thought of as working by learning. Of the two, the adaptive immune system is the more powerful.

The adaptive immune system learns from previous infection or vaccination so that when a person is exposed to a future infection, the adaptive immune system can be immediately activated against that virus. The adaptive immune system consists of T-lymphocytes, B-lymphocytes, and antibodies. When a person is first infected with a virus, T-lymphocytes become activated and then in turn activate B-lymphocytes to produce antibodies that are specifically directed against that particular virus. These antibodies are our immune system’s most important weapon against viruses and can defeat viral infections in four ways. First, antibodies can bind to the virus so that the virus cannot get into cells and thus prevent the virus from infecting cells. Second, when antibodies bind to a virus, it signals macrophages to eat and kill that virus. Third, when antibodies bind to an infected cell, they mark that cell for natural killer lymphocytes to kill that infected cell, thus preventing further viral replication. Fourth, when antibodies bind to infected cells, they activate the complement system to punch holes in that cell, thus killing it and preventing further viral replication. Antibodies last for about a month in the bloodstream and after an infection is resolved, the adaptive immune system cuts way back on new antibody production.

The innate immune system works immediately after an infection but it takes the adaptive immune system 1 – 3 weeks to ramp up antibody production after a new infection. However, the second time a person is infected with the same virus, that adaptive immune system can ramp up antibody production much faster, in a matter of days rather than weeks. This is because of memory T-lymphocytes and memory B-lymphocytes that have learned how to make antibodies against that particular virus. These memory cells cause antibodies to be produced much faster than during the first, initial infection with a virus.

Antibodies and COVID

Many people who are now getting infected with COVID are on their second or third infection. For most people, the second infection is not as severe as the first and the third infection is not as severe as the second. This is because the memory T-lymphocytes and memory B-lymphocytes allow the immune system to respond faster and more effectively against repeat infections. Multiple doses of vaccines do the same thing – with each vaccine dose, your body makes new antibodies against COVID variants covered by that vaccine booster and also trains your memory lymphocytes to ramp-up antibody production quickly if you are exposed to the virus in the future.

Because antibodies only have a lifespan of about a month, antibody levels fall after either an infection or a vaccination as the B-lymphocytes start to slow down antibody production. As a result, after vaccination, COVID antibody levels begin to fall after about 3 months. So, you are best protected against a future infection in the first 3 months after a COVID vaccine as well as in the first 3 months after a COVID infection. But what most people do not realize is that it is not just the antibody levels in the blood that protect against COVID infection but it is also the training of the memory T-lymphocytes and memory B-lymphocytes that protect against infection Those memory cells last many years and can sometimes last for a lifetime. We have blood tests that can measure antibody levels but we do not have blood tests that measure memory lymphocyte levels and consequently, this important effect of vaccination is often overlooked.

When you get a COVID mRNA vaccine, you produce antibodies against one small part of the COVID virus. On the other hand, when you get a COVID infection, you produce antibodies against many different parts of the COVID virus. For that reason, a COVID infection will stimulate stronger immunity against another future infection than vaccination does. But because the memory T-lymphocytes and memory B-lymphocytes learn from each exposure to a virus or to a vaccination, the more you stimulate those memory cells, the better they become at fighting infection. Also, because antibody levels eventually fall after a COVID infection, those antibody levels can be replenished if a person gets vaccinated several months after that infection. For these reasons, a COVID vaccination gives you good immunity, a COVID infection gives you better immunity, and a COVID infection plus a vaccination gives you the best immunity.

So, when should you get a COVID vaccine?

Early in the pandemic, the answer to this question was easy – everyone should get a COVID vaccine as soon as possible. However, now that most Americans have at least some degree of immunity from either previous vaccination, previous COVID infection, or both, the answer to the question is a bit more complicated. In order to get the maximum benefit from vaccination, the timing has to be individualized. And the key to individualization is the fact that antibody levels persist for about 3 months after infection or vaccination before those levels begin to drop off. So, here are my recommendations:

  • No previous vaccination or infection. These are people who are most likely to become severely ill or die if they get a COVID infection. They should get vaccinated immediately. Even if COVID case numbers in their community are low, it is not worth gambling with one’s life that they won’t be exposed to an asymptomatic person at the grocery store, at church, or at work.
  • Received an older COVID vaccine within the past 3 months. These people should wait until at least 3 months after their last vaccination. Their antibody levels are already high and it is better to wait until their antibody levels begin to fall before re-stimulating their adaptive immune system. However, given the anticipated January surge in COVID numbers, they should not wait long after that 3-month period.
  • Had a COVID infection in the past 3 months. These people should similarly wait until at least 3 months after their COVID infection. However, they should also get vaccinated before the anticipated winter surge in cases.
  • Previous vaccination more than 3 months ago and no previous infection. These people should time their vaccine to when they are most likely to be exposed to COVID. For the last 3 years, the winter peak of COVID cases has been in the first week of January. Assuming this year is similar, then get a new COVID vaccine now and by mid-November at the latest.
  • Previous vaccination more than 3 months ago and had a previous infection. Congratulations – these people already have the strongest immunity. But their immunity will be even stronger with a new COVID vaccine now or by mid-November at the latest.
  • Moderately or severely immunocompromised. Here is where things get a bit complicated. These people need more vaccine doses in order to be protected. If they have never been vaccinated, they should receive 3 doses of either the new Pfizer or the new Moderna COVID vaccine. If they have previously received 1 dose of either Pfizer or Moderna, then they should receive 2 doses of either of the new COVID vaccines. And if they have received 2 or more Pfizer or Moderna vaccinations in the past, they should receive 1 dose of either of the new COVID vaccines. If you are uncertain, it is better to err on the side of too many rather than too few doses for immunocompromised people.
  • Planning travel or large family get togethers over Thanksgiving or Christmas. Get a COVID vaccine now (or by the end of October at the latest) in order to ensure that you have protective antibody levels over the holidays. First, because it will protect you from getting infected while traveling and second, because you don’t want to get an infection just before your travel date and have to cancel your trip.

There are three COVID vaccines currently on the market. The Novovax protein subunit vaccine is based on the original strain of COVID and is only approved for primary vaccination in people who have never received any COVID vaccines; it is not available as a booster. Anyone who received the Novovax (or the no-longer available J&J vaccine) still needs to get one of the new mRNA vaccines since neither Novovax nor J&J covers the newly circulating COVID variant. The new Moderna and Pfizer mRNA vaccines are available for anyone for either primary vaccination or as a booster. The new Pfizer and Moderna vaccines are interchangeable so if you have previously received a Moderna vaccine, you can get either a Moderna or Pfizer booster and vice-versa.

The bottom line is that everyone should get a new COVID vaccination

Your body’s immune system is like your muscles – the more you train it the stronger it becomes. Vaccinations both keep your antibody levels high and train your immune system to make new antibodies rapidly and in large quantities. There are really no good reasons to not get vaccinated. Everyone should get vaccinated in the next 6 weeks to optimally protect themselves during the upcoming holidays and the anticipated upcoming winter surge in COVID numbers. The Moderna vaccine or the Pfizer vaccine – either one is fine, no matter what brand of vaccine you have received in the past.

And, oh by the way… get your other protective vaccinations, too. I got my influenza and pneumococcal vaccines together on September 1st and my RSV and new COVID vaccines together on September 18th. This was my 6th dose of a COVID vaccine since December 15, 2020. My immune system will be ready for whatever gets thrown at it this winter.

October 2, 2023

Outpatient Practice

Pelvic Floor Dysfunction Is The Epidemic You Didn’t Know Existed

One out of every two women will develop a pelvic floor disorder at some point in their life. These disorders usually require physical therapy and often require surgery. So, why don’t we hear more about pelvic floor dysfunction?

The pelvic floor is a hammock-like group of muscles and ligaments that drape across the pelvis and support all of the pelvic organs. If these muscles and ligaments become damaged, then they cannot hold organs in the pelvis (resulting in prolapse) and cannot maintain sphincter control (resulting in incontinence). The most common cause of dysfunction of these muscles and ligaments is pregnancy and childbirth. During pregnancy, the weight of the gravid uterus plus changes in intra-abdominal pressure can stretch the components of the pelvic floor. During delivery, the levator ani muscle, pubococcygeus muscle, and pudendal nerve are all susceptible to stretch injury. In addition, more than half of vaginal deliveries result in vaginal lacerations which can involve the pelvic floor muscles and sphincters.

The frequency of these disorders is shockingly common. At one year after vaginal delivery, 41% of women experience stress urinary incontinence, 32% experience nocturia, 23% experience flatus incontinence, and 9% have some degree of prolapse. Age also affects the pelvic floor with loss of muscle and ligament integrity, particularly after menopause. The Women’s Health Initiative study found that 41% of older women with a uterus have some degree of prolapse.

So, why don’t we hear about it?

Pelvic floor dysfunction is a silent epidemic because all too often, women do not bring it up when seeing their doctor and their doctor does not ask the right questions.

Assumption of normal. Many women just assume that symptomatic pelvic floor dysfunction is just a normal and expected consequence of “everything getting stretched out” during labor and delivery. Because of this assumption of normal, women frequently do not discuss postpartum urinary incontinence, anal incontinence, or vaginal bulges with their doctor.

Patient embarrassment. Many women have a hard time bringing up issues regarding their urination or bowel movements, even with their physician. Some women don’t know enough about normal female pelvic anatomy to tell when their pelvic structures are not quite right.

Doctors do not ask the right questions. Obstetricians are generally good at asking about pelvic floor dysfunction symptoms but primary care physicians and other non-obstetricians frequently are not. Sometimes it is because the primary care physician just assumes that the obstetrician will take care of any problems resulting from pregnancy and sometimes it is because of lack of familiarity with the clinical manifestations of pelvic floor dysfunction. When asking women about pelvic floor dysfunction, we should remember the 3 “B’s”: Bladder, Bowel, and Bulge.

Pelvic floor dysfunction symptoms

The most common serious consequences of pelvic floor dysfunction are incontinence and prolapse. Types of urinary incontinence include stress urinary incontinence, urgency urinary incontinence, and mixed urinary incontinence. Bowel control issues include fecal incontinence, flatus incontinence, and fecal urgency.

Prolapse occurs when a pelvic organ herniates. A cystocele is when the bladder herniates into the anterior vaginal wall. A rectocele is when the rectum herniates into the posterior vaginal wall. And a uterovaginal prolapse is when the cervix and uterus descends into the lower vagina. Prolapse can result in urinary incontinence, constipation, pelvic discomfort, and pain during sexual intercourse.

What can be done about it?

Pelvic floor physical therapy. Fortunately, there are effective treatments that can significantly improve the quality of a woman’s life. This generally starts with pelvic floor physical therapy. This is performed by a specially-trained physical therapist who can teach women exercises to strengthen the pelvic muscles and help restore normal pelvic function. Most notably are Kegel exercises when the pelvic muscles are contracted and then relaxed.

A bit of history about Kegel exercises. If I was to then ask you who invented Kegel exercises, you might say American gynecologist Arnold Henry Kegel who published an article about exercises to strengthen the pelvic floor in the Annals of Western Medicine and Surgery in 1948. But that wouldn’t be exactly right. Instead, we have to go back 12 years earlier when a book was published by a professional dancer named Margaret Morris. She was born in 1891 and began her career as a child actress and ballet dancer. By age 19, she was an internationally known choreographer and theater producer. In her 30’s she opened a dance school and became interested in how movement and posture affected health. So, in 1925, she went to London’s St. Thomas Hospital to study physiotherapy. She further developed her ideas about exercises and health that culminated in her 1936 book titled “Maternity and Post-Operative Exercises”. In her book, she outlined 21 exercises for women to perform that could improve urinary incontinence and other consequences of childbirth. Her book was reviewed in JAMA in 1937 where the reviewer stated that he was: “..satisfied with the soundness of Miss Morris’s scheme and believe that their application will yield most beneficial results.” Dr. Kegel then wrote about her exercises more than a decade later and he now gets all of the credit for Margaret Morris’s pelvic floor exercises.

Other non-surgical treatments. When symptoms persist despite pelvic floor physical therapy, there are other treatment options. Diet and lifestyle measures to reduce urinary incontinence include weight loss, avoidance of excessively large fluid ingestions, and avoiding drinking fluids shortly before bedtime. Pessaries and over-the-counter vaginal inserts can also be useful. Measures to reduce fecal incontinence include dietary soluble fiber (but avoid insoluble fiber), ritualization of bowel movements, and over-the-counter loperamide. Avoidance of caffeine and avoidance of vigorous exercising after meals can also reduce fecal incontinence.

Surgical options. When these measures are ineffective, there are a variety of surgical options. There have been many recent developments in surgical procedures for pelvic floor dysfunction. For example, in the past, uterine prolapse was primarily treated with hysterectomy; however, now there are many uterine-sparing procedures that can be performed. Other new techniques include sacroneuromodulation for fecal incontinence and onobotulinum toxin for urinary urgency incontinence. This is where a urogynecologist can be an invaluable resource. Many larger medical centers have comprehensive subspecialty peripartum pelvic floor disorder clinics overseen by a urogynecologist. Physicians at smaller hospitals that cannot support a full subspecialty clinic should be familiar with regional pelvic floor disorder clinics for referral.

The bottom line: talk with your patients

Given the frequency of pelvic floor dysfunction, it is incumbent on every primary care physician to be familiar with the symptoms and to be willing to speak openly about them with patients. If your hospital has a labor and delivery unit, then it needs a pelvic floor physical therapist. As an emeritus faculty, I’ve been doing some pro bono teaching at the Ohio State University and recently guest-moderated an OSU MedNet webcast on pelvic floor disorders by Dr. Lisa Hickman. This webcast is a great resource for physicians, nurse practitioners, nurse midwives, and physician assistants who need to brush up on the diagnosis and management of pelvic floor dysfunction. You can view the webcast by clicking on this link.

September 20, 2023

Operating Room

How To (really) Live To Be 100

I just watched the Netflix series Blue Zones that examined habits of societies of people who were most likely to live more than a century. While I agree with most of the conclusions, there is much left out. The problem with such observational studies is that they are subject to population shift bias, observer bias, and selection bias. Over the last 40 years, I’ve seen hundreds of people die. It is inevitable if you are a critical care physician and even more inevitable if you are also a pulmonary physician specializing in idiopathic pulmonary fibrosis, a terminal disease. So, I have my own thoughts on what it takes to live to be a hundred years old (and what it takes to not die in our ICU). But first, let’s take a look at the three forms of bias.

Population shift bias. On the surface, it would seem to be easy to estimate the life expectancy of a group of people. Just look at all of the death certificates and calculate the average age of death. However, human populations are dynamic, with people constantly moving in and out of a given area. Let’s use an example of a hypothetical group of people living on an island in the Mediterranean. You go to the public records department and pull all of the death certificates for the past 10 years and find that the average age of death is 88 years old. You might then assume that the life expectancy is 88 years. But what if there had been no good-paying jobs on that island for the past 10 years and most of the people under age 65 moved to the mainland to find work? In that case, people born on the island who died before age 65 died somewhere else and this makes the average age of people dying on the island look falsely high. Also, the percentage of people living on the island who are older than 100 (per capita rate of centenarians) will be falsely high.

Population shift bias can also occur if there is a change in the birth rate. Let’s say you are measuring longevity by the average age of people on the same island. Three generations ago, families had an average of 6 children but now, families only have an average of 2 children. As a result, the average age of people on the island at any given time is now higher because there are fewer children. But that doesn’t mean that people are really living long.

Observer bias is a problem with any observational study. Let’s say you find that Seventh Day Adventists have a high percentage of people who live past 100. So, you look at the habits of those people to try to determine why they lived as long as they do. There may be hundreds of variables that make them different than everyone else in the world but if you are trying to prove that it is because of diet, then you will have blinders on and only focus on the observation that Seventh Day Adventists eat a plant-based diet. So, you might conclude that the vegetarianism caused then to live so long while overlooking the fact that Seventh Day Adventists also don’t smoke cigarettes.

Selection bias occurs when you look at a small group of people who have a particularly good or bad outcome and then assume that the group of people is representative of the population as a whole. An example of a selection bias error that is frequently made is nursing homes. It is often said that as soon as a person enters a nursing home, it cuts 3 years off of their life. One might then assume that being admitted to a nursing home causes a shortened life expectancy. However, a 70-year-old who need nursing home care is by definition sick and debilitated. A healthy and active 70-year-old would not be admitted to a nursing home. Entering a nursing home doesn’t make you live shorter, being chronically ill and debilitated makes you live shorter. The same can be said of doctor visits – people who visit doctors ten times a year are more likely to die than people who only visit a doctor once a year. If you fall into the trap of selection bias, then you would assume that seeing a doctor causes you to have a shortened life expectancy whereas the truth is that people who see a doctor more frequently have more serious and complicated diseases than those who see a doctor rarely.

The scientist in me would say that the only sure way to know if a habit will make you live longer is to do a randomized controlled trial, preferably placebo-controlled. But this type of study is impossible when looking at people’s life-long habits. So, everything we hear about the habits of people who live beyond 100 years is affected by these forms of bias. And I freely admit that these biases affect my own thoughts on living to be 100. You’ll see that my list is a lot different than the Blue Zone’s list. But I think you’ll find that my list will give you a better chance of becoming a centenarian.  So, here goes:

  • Be a non-smoker. It is almost unbelievable that it was less than 50 years since the U.S. Surgeon General first reported that smoking was bad for your health. A study in the New England Journal of Medicine in 2013 found that women who smoke a pack of cigarettes a day live 11 years less than women who do not smoke. For men, smoking reduces life expectancy by 12 years. If you do the math, that works out to 14 minutes of life lost on average for every cigarette smoked.
  • Get rid of your gun. Most of the people who die of firearm injuries did so from their own gun or the gun belonging to someone else in the family. The CDC reports that in 2022, 48,117 Americans died from a gunshot – 58% of those were suicides. In other words, a good guy with a gun is more likely to kill himself than to kill a bad guy with a gun.
  • Wear a seatbelt. In America, we kill almost as many people with cars as we do with guns. The National Highway Traffic Safety Administration reports that in 2022, 42,795 Americans died in a motor vehicle accident. More than half of the drivers and passengers who died in a car accident were not wearing a seatbelt. In 1984, New York became the first state to legally require people to wear seatbelts – the law was met with outrage by anti-belters who said that it was an encroachment on their personal freedom. Unfortunately, that argument does not fly with widows and orphans.
  • Maintain a normal BMI. We define obesity as a body mass index (BMI) greater than 30. Overweight is a BMI between 25 – 30. The National Health and Nutrition Examination Survey (NHANES) found that the prevalence of obesity in the U.S. is now 42%. As Americans have become more obese, a cultural taboo on criticizing obesity has emerged with the result that those who say anything bad about obesity can be accused of “fat-shaming”. But the reality is that obesity is not healthy. It increases the risk for hypertension, diabetes, and sleep apnea all of which can shorten life expectancy. It can cause arthritis that reduces physical activity and increases the risk of falls. A 2014 study found that people with a BMI > 40 have a life expectancy 14 years less than those who with a normal BMI between 18.5 and 25. A 2019 study found that even those with a BMI between 30 – 40 had a reduced life expectancy of 5.5 to 7.5 years compared to normal weight individuals.
  • Don’t use drugs. In 2022, 105,452 Americans died from a drug overdose. That’s one out of every 3,000 people and more than died by both guns and motor vehicle accidents combined. The drug that causes the most overdose deaths is fentanyl. Most drug users do not call their local drug dealer asking for fentanyl. Instead, it is mixed with other drugs to potentiate their effects at a low cost. However, street drugs are not mixed by compound pharmacies and instead are mixed in unpredictable amounts by dealers with the result that a drug user does not really know what he or she is getting in a dose from one day to the next. Consequently, dying from a drug overdose is now easier than ever before.
  • Get vaccinated. In 2019, 2,854,838 Americans died; of those, 49,783 (2%) died of influenza and pneumonia. In 2021, 3,464,231 Americans died; of those, 416,893 (12%) died of COVID. Last week, for my 65th birthday, I got a flu shot and a pneumonia shot. When they become available later this month, I’ll get this season’s COVID booster. These are some of the best investments you can make in your health. Infections cause inflammation and prolonged inflammation is harmful to the body. Vaccinations also cause inflammation (its how they work) but in contrast, vaccination inflammation is mild and brief – vaccinations stimulate rather than stress the immune system. If you live on a remote island with few visitors, it is easy to avoid respiratory infections since those infections have to be brought to the island by someone who is already infected. But for the rest of us, exposure to infections that have the potential to kill us is unavoidable so our best defense is vaccination.
  • Choose your parents carefully. Okay, I know that no one can choose their parents but it is true that the genes that we inherit from them have a big impact on our life expectancy. Evolution has genetically engineered us to be able to live long enough to have children and then raise them until they can be self-sufficient. The current average age of menopause is 51 but in ancient times, it was much earlier, around age 40. Allowing for 15-20 years to fully raise and protect a child, our genes needed to ideally get us to about age 55 or 60. There was no natural selection advantage to having genes that let a person live older than that because those genes did not give a greater survival advantage to one’s offspring.  Genes that resulted in high cholesterol or breast cancer didn’t really matter 200,000 years ago because people did not live long enough to get the diseases they cause. Consequently, many families carry genes that that result in fatal diseases that occur in the family members’ 60’s or 70’s.
  • Exercise your body. Many studies have shown that people who exercise regularly live longer. There are a lot of reasons for this: lower risk of obesity; lower risk of dying of cardiovascular disease; lower risk of osteoporosis; and better strength and balance that can reduce the chance of falling. However, the most effective physical exercise is a life-long exercise lifestyle rather than a New Years resolution gym membership. Walking can be great exercise but we have unfortunately engineered our communities to encourage sitting in a car rather than walking to workplaces, stores, restaurants, and places of worship. Rather than retiring and moving to a gated community on the outskirts of town, consider moving to a walkable neighborhood – preferably one with a lot of hills.
  • Exercise your mind. What allowed humans to become the apex predators on Earth? Some people would say it is the capacity of speech. Others would say the ability to make tools. Yet others would say the dexterity that resulted from opposable thumbs. The reality is that it is verbal communication, tool-making, and complex dexterity were all facilitated by the homo sapiens brain. Every successive branch of hominid evolution has been associated with a larger and larger brain, from homo habilis (640 cc) to homo erectus (1,029 cc) to homo sapiens (1,350 cc). Our brains are like any other organ in our body – they work best when we use them regularly. Ideally, we should be exercising all areas of our brains. Exercise the brain’s motor centers by activities requiring balance and dexterity, for example, tennis or dancing. Exercise the brain’s left cortical areas with reading, creative writing, and conversation. Exercise the brain’s right cortical areas with music and art.
  • Be engaged with other people. About 400,000 years ago, human ancestors firs started using spears. Ever since then, humans who lived in communities had an enormous advantage over those who lived solitary lives. The more organized the community, the better it’s chance of survival. Communities have propelled humans to the top of the food chain. We need communities as much as communities need us. Social isolation is associated with a higher risk of depression, suicide, dementia, and early death. Keeping connected with other people helps keep us connected with life. There are endless ways to do it: volunteer, be active in your place of worship, speak with family and friends regularly, even use Facebook.
  • Avoid excessive calorie-dense foods. Everyone has an opinion about the best diet for longevity. Vegetarian, vegan, low-carb, herbal supplemented, more olive oil, less nitrates – the list is endless. The reality is that humans are built to be omnivorous and consequently, there are a lot of ways to have a healthy diet, as long as they are nutritionally balanced. The antithesis of nutritionally balanced diets are those that are dominated by calorically dense foods. These include excessively sweetened foods, fast foods, and high fat “junk” foods. MacDonalds french fries, like heroin and Fox News, have been specifically engineered to be addictive after just one bite and make you want more. Daily calorie needs are determined by age and physical activity but 2,000 for women and 2,500 for men is a good average.  Why waste so much of that on a Wendy’s Frosty (393 calories), Burger King large fries (448 calories), and a Chic-fil-A wrap (660 calories)? The advantage of diets that are high in vegetables, beans, and whole grains is that you can eat a lot, feel full, and have balanced nutrition – all without breaking the calorie bank.
  • Drink in moderation (or not at all). For some people, there is no “safe” amount of alcohol – they are wired for addiction. But one or two glasses of wine a day is OK for most people and may or may not actually be beneficial. However, drinking excessively can unquestionably kill you. Excessive alcohol is involved in one-third of gun-related homicides, one-half of gun-related suicides, and one-third of motor vehicle deaths. In addition, chronic excessive alcohol use can cause cirrhosis, pneumonia, various cancers, and dementia. Overall, alcohol is responsible for 140,000 deaths per year in the U.S.
  • Avoid poverty. You don’t need to be extremely rich to live a long life but it is really hard to live a long life if you are extremely poor. Poverty is associated with higher rates of smoking, obesity, drug use, and higher death rates for all of the 14 leading causes of death. Poverty results in inability to afford healthcare, living in crowded and unhealthy conditions, and over-reliance on calorically dense foods. Owning a Tesla won’t make you live longer but having to do all your grocery shopping at the Dollar General and being unable to afford a pneumonia vaccine can make you live shorter. Also, it is a lot more expensive to live to age 100 than to live to age 70, simply because you have to pay for more years of living expenses. So, even a middle-income working couple needs to make careful financial planning to avoid poverty in retirement.
  • See your doctor regularly. A good primary care provider is worth his/her weight in gold when it comes to staying healthy and living longer. Even if you walk 5 miles a day, eat a nutritionally balanced diet, and never smoke, there are still things that can happen that are outside of your control. We can’t always prevent high blood pressure, colon cancer, or high cholesterol, no matter how good our lifestyle is. Five hundred years ago, people rarely died of heart attacks, colon cancer, and dementia for the simple reason that they didn’t live long enough to get them. But these are conditions that early diagnosis by your PCP can result in effective treatment. See your doctor once a year for a routine visit and follow all of the recommendations for health screening and preventive care.

Blue Zones is worth a watch on Netflix. But its conclusions are susceptible to being affected by population shift bias, observer bias, and selection bias. My own personal conclusions about longevity are also affected by these same biases. So, take my recommendations with a grain of salt – just don’t overdue it with too much sodium.

September 8, 2023

Emergency Department Inpatient Practice Outpatient Practice

Does NP + AI = MD?

Artificial intelligence (AI) is causing a paradigm shift in the education, business, and legal professions. But AI is also poised to irreversibly change the way medicine is practiced. Jobs that traditionally relied on extensive training by memorization may be able to be performed as well (or better) by AI than by humans. Jobs that have relied on image analysis or sound pattern analysis are also at risk of being displaced by AI.

Let me give you an example from my hobby of birdwatching. In the past, bird species identification relied on comparing a bird that you saw in a tree to a drawing or photograph in a bird identification book. To become an expert birder, you needed thousands of hours of birding to identify birds by their calls and by their seasonal plumage. But now, we have the Merlin app. When birding, I can turn on my phone’s microphone and Merlin will identify bird species by bird calls. I can take a photograph of a bird, upload it to the app, and Merlin will tell me what bird I saw. With Merlin, even a novice birder like me can identify birds like a seasoned expert.

So, what if we have the Merlin app equivalent to identify heart sounds by auscultation? Or diagnose a rash by a photograph? Or interpret CT scan images? Or read cytology specimens on microscopic slides? Like it or not, artificial intelligence is coming to medicine and it will make many skills traditionally requiring hundreds of hours of training, obsolete.

Artificial intelligence and advance practice providers

To become a primary care physician (general internist, general pediatrician, or family physician) requires 11 years of education and training after high school. To become a nurse practitioner (NP) or physician assistant (PA) only requires 6 years of training after high school. As a result, it is far less expensive to become an NP or PA than to become a primary care physician but the trade-off is that NPs and PAs generally have a  lower annual income than physicians. However, if the salary of an NP and a primary care physician was the same, most hospitals would prefer to hire the physician under the presumption that additional 5 years of training to be a primary care physician would translate to greater skill and knowledge than the NP or PA. On the other hand, if the skillset and knowledge of an NP or PA was the same as that of a primary care physician, most hospitals would prefer to hire the NP or PA because they are cheaper.

Artificial intelligence now offers the possibility of eliminating the need to acquire many of the skills and much of the knowledge currently required to become a physician. This offers a future where an NP armed with a few AI apps may be able to perform many of the tasks currently relegated to physicians.

Need to diagnose a child with a fever and a rash? There’s going to be an app for that. Need to decide the best blood pressure medication to prescribe for a patient with newly diagnosed hypertension? There’s going to be an app for that. Need to recommend follow-up of a pulmonary nodule given a patient’s age and smoking history? There’s going to be an app for that.

The FDA and medical devices

At first glance, it would seem logical to embed artificial intelligence into electronic medical record (EMR) software programs. After all, the EMR is the database of all information about a patient – their blood pressure, their family history, their medication list, etc. However, a barrier to incorporating AI into the electronic medical record is that the U.S. Food and Drug Administration considers AI to be a medical device whereas the electronic medical record is just considered a documentation tool. Medical devices are regulated differently than documentation tools. Medical devices require extensive clinical trials and then FDA approval; documentation tools do not. Clinical trials and FDA regulation are very expensive and can pose a barrier to regular EMR software upgrades. For these reasons, the major electronic medical record companies have been reluctant to incorporate artificial intelligence algorithms into their EMR programs.

For the most part, this makes sense. You don’t want to have an artificial intelligence program to recommend a chemotherapy regimen for advanced lung cancer unless it has been shown in clinical trials to be accurate and has been approved by the FDA. The fear of the electronic medical record companies is that if their EMRs become classified as medical devices, then they will have to get FDA approval every time they want to change the font size in their blood chemistry test results in the EMR. So, at least for now, the electronic medical record and artificial intelligence programs will need to be separated, and that means that there will have to be a human to do a history and physical examination and then to interface between the EMR and the AI. But in many situations, that human can be an NP or a PA, rather than a physician.

Artificial intelligence and primary care

Much of primary care is based on clinical practice guidelines. The U.S. Preventative Services Taskforce has guidelines for everything from colon cancer screening to pre-exposure prophylaxis to prevent HIV. The American College of Cardiology has a hypertension diagnosis and management guideline. The Advisory Committee on Immunization Practices has guidelines for childhood and adult vaccination schedules. And the American Diabetes Association has a guideline for the prevention, diagnosis, and treatment of diabetes. If you roll all of these clinical practice guidelines into one artificial intelligence program, then you have the majority of primary care medicine routine visits covered.

As a medical student, I spent hours memorizing vaccination schedules, hypertension treatment algorithms, diabetes medication drug interactions, and the staging systems for various cancers. And guess what? An artificial intelligence program can do all of these things better than my memory allows me to do. In other words, AI eliminates the need for much of the education and training that we currently require in medical school and residency. Artificial intelligence will allow a practitioner with lesser training (such as an NP or PA) to be just as good as a physician when it comes to preventative care medicine and algorithm-based management of most common medical conditions.

However, artificial intelligence is not infallible

Artificial intelligence is actually not new in medicine. I’ve been using simple forms of AI for decades. Every EKG and pulmonary function test that I have ordered in the past 30 years that comes with a computer interpretation has incorporated rudimentary AI into those interpretations. These interpretations programs are fairly good at identifying normal but invariably come up with an incorrect diagnosis in a substantial percentage of those tests that are abnormal. So, before I am willing to allow an AI program to diagnosis breast cancer from a histopathology slide and before I am willing to allow an AI program to diagnose idiopathic pulmonary fibrosis from a chest CT scan, these programs are going to have to get very, very good. Until then, the use of artificial intelligence for more complex pathologic and radiologic diagnoses will supplement rather than replace a physician.

And then there is legal liability…

If a radiologist misses a lung cancer on a chest X-ray, the radiologist is named in a medical malpractice lawsuit. If a patient dies of sepsis when a hospitalist made an incorrect antibiotic choice for the patient’s pneumonia, the hospitalist is named in the malpractice suit. But if an artificial intelligence program misses the lung cancer or selects the wrong antibiotic, who gets named in the malpractice case? The company that created the AI program? The hospital that purchased the AI program? The FDA that approved the program? The physician who entered the patient’s clinical data into the program? All four of them?

Currently, a physician in primary care practice will pay about $12,000 per year in malpractice insurance premiums whereas a primary care nurse practitioner pays about $1,200. The reason for the 10-fold difference is that in most situations, a nurse practitioner is understood to be working under the supervision of a physician and that physician is ultimately responsible or at least shares responsibility for the management of patients seen by the nurse practitioner.  Artificial intelligence is likely to be similar – if it is considered to be a medical device then that device will need to be used by a licensed medical practitioner who will have the greater burden of malpractice liability. Clearly, laws will need to be written to clarify liability before artificial intelligence can be autonomously implemented in clinical practice.

Who will AI benefit the most – nurse practitioners or physicians?

A recent study from MIT researchers found that artificial intelligence has the greatest impact on the least skilled workers. Workers who were new or had low skills were helped more by AI than highly skilled workers. In other words, AI allows those with less training to be “upskilled” much more than those with advanced training.

Extrapolating from this study, it is likely that nurse practitioners and physician assistants will derive greater benefit from artificial intelligence than physicians. Artificial intelligence can make up for the fewer years of training that it takes to become an NP or PA.

Which physicians are most vulnerable to being displaced by artificial intelligence?

Although artificial intelligence has received a lot of press about its potential in radiology, I would argue that primary care physicians are most vulnerable to being displaced by artificial intelligence. Notice that I used the word “displaced” rather than “replaced”. That is because artificial intelligence is likely to be used to supplement a practitioner rather than become a practitioner, at least in the foreseeable future. In this regard, an NP or PA using an artificial intelligence program can replicate much of the skillset of a primary care practitioner. Thus the combination of an NP or PA plus an artificial intelligence program will together displace the primary care physician.

Physicians who are the least vulnerable are those who perform procedures such as surgeons and interventional cardiologists. Although this could change in the future, for now, no AI program or nurse practitioner is capable of independently performing a hip replacement surgery or a coronary artery stent placement. In primary care practice, the office procedures are far less complex – cerumen removal, IUD placement, and laceration suturing can be performed by an NP or PA and do not require a physician.

Also less vulnerable are physicians who are highly specialized. For example, an artificial intelligence program for brain MRI imaging will need to be used under the supervision of a practitioner who can confirm or contradict the AI’s findings. This will require a practitioner who is already an expert in brain MRI image interpretation, in other words, a physician specializing in neuroradiology. Artificial intelligence can still benefit the neuroradiologist, however, by serving in a capacity similar to that of a radiology resident who performs a preliminary read of the MRI that is then over-read and confirmed by the attending neuroradiogist.

“I’m a medical student, should artificial intelligence affect my career choice?”

The answer is… maybe. Fully implemented artificial intelligence in medicine is still a long way off. There will have to be significant improvements in software, significant legal liability questions resolved, and supervision requirements defined. However, if AI can replace certain medical specialists at a lower cost, then economic theory indicates that it eventually will. General internists, general pediatricians, and family physicians may be more vulnerable to displacement than other specialties, especially if the field of medical artificial intelligence matures coincident with an increase in the number of nurse practitioners and physician assistants. However, when it comes to cajoling a cardiologist to add in a patient with chest pain to their already full Friday afternoon schedule, an AI program simply cannot replace a persuasive family physician. The primary care physician may become more of a manager: coordinating care and overseeing a group of nurse practitioners who each have access to the artificial intelligence program.

Things are about to get interesting…

Change in medicine is inevitable but initial resistance to change is also inevitable. When electronic medical records were initially implemented, physicians universally hated them and many refused to use them. Now, no physician in his or her right mind would want to return to an era of paper records kept in manila folders. Ten years ago, the idea of driverless vehicles was met with skepticism but today, you can order a driverless Waymo taxi in San Francisco and you can buy a driverless John Deere tractor to plow your farm.

Artificial intelligence is coming in medicine and its widespread implementation is unavoidable. The question is whether it will augment physicians or displace physicians. I believe that it will do both, depending on the specialty.  From my vantage point, primary care physicians may be the most vulnerable to displacement. And employment opportunities for NPs and PAs are looking bright.

August 30, 2023

Emergency Department Inpatient Practice Medical Education Outpatient Practice

The New DEA Opioid Education Requirements For Physicians

In March 2023, the U.S. Drug Enforcement Agency (DEA) announced new education requirements for all physicians applying for new or renewal DEA licenses. This was the result of provisions in the Consolidated Appropriations Act of 2023 that enacted a one-time requirement of 8 hours of continuing medical education (CME) on the treatment and management of patients with opioid or other substance use disorders. The requirement went into effect on June 27, 2023. Because DEA licenses are renewed on a rolling 3-year basis, all physicians with DEA licenses must meet this requirement sometime in the next 3 years.

Another provision of the Consolidated Appropriations Act of 2023 was to eliminate the DATA-Waiver (X-Waiver) Program that was previously required for physicians to prescribe buprenorphine. In the past, hospitalists, emergency medicine physicians, and other practitioners needed to obtain an X-Waiver to initiate buprenorphine when patients with opioid use disorder were admitted to the hospital or seen in the emergency department. Because only a small number of physicians took the time and effort to obtain an X-Waiver, the requirement was seen as a barrier to getting patients started on treatment. Now, any practitioner with a current Drug Enforcement Administration (DEA) registration may prescribe buprenorphine for opioid use disorder (if permitted by state law). The trade-off for elimination of the X-Waiver was the requirement that all practitioners with a DEA license be trained in the treatment of opioid use disorder, including the use of buprenorphine.

Who does this affect?

Any practitioner with a DEA registration must meet this requirement. This includes physicians, dentists, nurse practitioners, and physician assistants. However, only practitioners who prescribe controlled substances need to register with the DEA and obtain a DEA number. Although the majority of U.S. physicians have DEA numbers, some physicians do not, either by nature of their practice (for example, pathologists and researchers) or by choice (for example, general practitioners who do not want the hassle of prescribing opioids and other controlled substances).

To obtain a DEA number, a physician must apply to the DEA and pay an $888 fee. DEA numbers are valid for 3 years at which time the physician must re-apply. The DEA waives the fee for certain physicians including those who work in the military, for U.S. government hospitals or institutions, and for state government hospitals or institutions. As an employee of the Ohio State University (a state government institution), my DEA fees were waived. However, even if the fee is waived, the practitioner must still apply for and obtain a DEA number and the practitioner must still meet the new education requirements.

Certain practitioners are exempt from the new educational requirement including veterinarians, physicians board-certified in addiction medicine, and practitioners who have graduated from their professional school within the past 5 years. The latter means that most residents in training are exempt.

What are the specifics of the requirement?

When applying for a new or renewal DEA number, physicians (and other practitioners) must check a box attesting to having completed 8 hours of training on treatment and management of patients with opioid or other substance use disorders. This is a fairly broad topic area and it is up to physicians to maintain their own documentation of completion of education in the event of an audit. In addition, if the physician faces legal action (such as a medical malpractice lawsuit), documentation of completion may be necessary to establish physician competency. The details of the requirement are as follows:

  • The 8 hours of education do not need to occur in one session and (for example) can be 8 individual 1-hour CME events.
  • This is a one-time requirement and will not need to be repeated every three years when re-applying for a DEA number.
  • Education can take the form of grand rounds, classroom sessions, on-line materials, or professional society meetings.
  • Education hours obtained prior to the new requirement also count. For example, attending a grand rounds on buprenorphine in past years can count; just be sure that you have documentation of participation or attendance. Physicians with an X-Waiver can count the training hours from their original X-Waiver application.
  • The education can come from any organization accredited to provide CME credits by the Accreditation Council for Continuing Medical Education.

What do hospitals need to do?

Although the DEA requirement is left to the responsibility of the individual practitioner applying for a DEA number, hospitals do have an obligation to facilitate education. First, if practitioners fail to get the required 8 hours of training and are unable to obtain a DEA number, the hospital’s ability to dispense controlled substances or manage patients requiring controlled substances will be compromised. Second, in the event of a medical malpractice lawsuit involving a practitioner on the medical staff who lacks documentation of completion of the educational requirements, the hospital could be accused of being complicit by not confirming that their practitioners were appropriately trained. Specific steps that hospitals should take now include:

  • Make sure that all members of the medical staff are aware of the new DEA requirements.
  • Inventory practitioners’ DEA license expiration dates and remind practitioners at least 6 months in advance of that date that they must fulfill the educational requirements prior to the renewing their DEA number.
  • Require practitioners with DEA numbers to submit documentation of completion of the educational requirements and then maintain that documentation in each practitioner’s employment record.
  • Require any new practitioners to include documentation of completion of substance abuse treatment CME as part of their application to the medical staff. Those lacking documentation should be required to complete training during their provisional/probational appointment period.
  • Schedule grand rounds or other CME events covering treating and managing patients with opioid or other substance use disorders.
  • Provide practitioners with links to on-line CME resources. For nearly a quarter of a century, I moderated the CME webcast, OSU MedNet-21. We produced many CME webcasts on substance abuse disorders and these webcasts are available to anyone. A recent example is:
  • Many professional societies have included sessions on substance abuse disorders as part of their annual meetings or have prepared on-line CME sessions to help fulfill the requirements. Examples of on-line education programs include:
  • The Centers for Disease Control offers a free on-line 1-hour CME activity about substance abuse disorders
  • Journal subscription materials can count. Practitioners with subscriptions to resources such as UpToDate, JAMA, and the New England Journal of Medicine can obtain CME credit by reading relevant articles and then applying for CME hours.

Why has Congress required this?

The primary impetus for the new requirement is a directive of the U.S. Congress to address the opioid epidemic. Eliminating the X-Waiver program was seen as a way of improving access to treatment for patients with opioid use disorder. But to justify elimination of the X-Waivers, Congress needed a mechanism to ensure that all practitioners were knowledgable in initiating treatment for opioid use disorder.

In 2021, a total of 106,699 Americans died of a drug overdose. Although street-purchased fentanyl was the most common drug implicated, prescription opioids accounted for 16,706 of the overdose deaths in 2021. In fact, the number of deaths from prescription opioids exceeded the number of deaths from heroin (9,173).

Drug overdose deaths are particularly high in Appalachian states. West Virginia has the highest overdose death rate at 90.9 per 100,000 population, followed by Kentucky and Tennessee (each 56.6 per 100,000 population) and Louisiana (55.9 per 100,000 population). My state of Ohio ranks 7th highest at 48.1 per 100,000 population. Nebraska comes in lowest at 11.4 per 100,000 population.

To put these numbers in perspective, last year, the U.S. COVID death rate was 61.3 per 100,000 population. Opioids are abused by more than 10 million Americans each year (3.8% of Americans) and 2.7 million Americans have an opioid use disorder. About half of those who become addicted to opioids first use opioids in the form of prescription pain medications. An estimated 3% – 19% of people who take prescription opioid pain medications will become addicted to opioids. Addiction can occur with only 3-5 days of prescription opioid use.

The good news is that there are effective treatments for opioid use disorder including buprenorphine (often combined with naloxone), methadone, and naltrexone. In addition, the FDA has now approved naloxone to be sold over-the-counter to treat opioid overdose. The goal of the DEA education requirements is that any practitioner in the U.S. who is licensed to prescribe opioids is also trained in identifying and treating opioid abuse.

A quarter of a century of change

In the 25 years since the American Pain Society advocated that physicians adopt “pain as the 5th vital sign” and since Purdue Pharmaceuticals falsely promoted OxyContin as a non-addictive opioid, physicians have become much more aware of the role that we have played in catalyzing the current opioid epidemic. The new DEA education requirements were created as one step in remedying the epidemic. By helping our physicians meet these new requirements, hospitals can help reduce the number of Americans who become addicted and help increase the number of Americans who get their addiction treated.

August 28, 2023

Physician Retirement Planning

Understanding Bonds – And Is It Time To Invest In Bonds?

Most people understand stock investment but investing in bonds is… well, confusing. Part of the confusion comes from the interplay of the interest that the bond pays versus the price of the bond. But another aspect of confusion comes from the words used in bond investment that can seem like a totally different language that requires a translator for the average investor.

Summary Points:

  • When bond prices or bond mutual fund share prices fall, their yields increase
  • Bond prices tend to fall during inflation and when the Federal Reserve increases the Federal funds rate
  • This year, stock prices have risen substantially whereas bond prices have been flat resulting in most retirement portfolios now being overweighted in stocks
  • Because bond prices are currently low and bond yields are high, bonds are now becoming an attractive investment
  • Now is a good time to rebalance retirement portfolios by buying bonds or shares of bond mutual funds


The foundations of a healthy investment portfolio for retirement are diversification and balance. Diversification means owning stocks or bonds in a lot of different companies. The simplest way to achieve diversification is to invest in a broad sector index mutual fund, for example, an S&P 500 index fund for stocks. Balance means maintaining a desired percentage of stocks versus bonds in your portfolio. A simple way to achieve balance is to own a target retirement mutual fund that frequently buys and sells stocks and bonds in order to keep a fixed percentage of stocks and bonds; the fund then adjusts that percentage each year as you get closer to retirement. If you are the kind of person who does not want to put a lot of time into investing, then a target retirement mutual fund that is composed of index stock funds and index bond funds is for you – no investment expertise is required and the annual expenses are low.

But if you invest in individual stocks or stock mutual funds, then it is up to you to ensure that your portfolio is diversified and balanced. This is particularly the case if you are invested in a 401(k), 403(b), or 457 plan that does not offer target retirement mutual funds as an investment option. This then raises the question of when is the best time to re-balance your portfolio by buying or selling bonds? To answer that question, one must first understand the basics of bond investing.

Bond investing 101


When you purchase a corporate bond, you are loaning a company money for a specific amount of time and in return, that company will pay you interest every year until the loan is paid off. A government bond is similar – you are loaning the government money for a specified amount of time and in return, the government pays you interest every year until they repay the loan. So, if you purchase a 30-year bond at 3% interest, then the company or government will pay you 3% of the value of the bond every year for 30 years and at the end of the 30 years, you redeem that bond and get back the amount of money that you originally paid for the bond. This is exactly what happens if you purchase a bond, hold it for the entire duration of the bond, and then redeem it at the end of that period of time. However, most people do not purchase a bond and then hold it for the entire duration, instead, most people resell and buy bonds in a secondary market. And this is where the terminology gets complicated. Let’s take a look at some of the words used in the language of bonds. To illustrate these terms, let’s take an example of a bond that is initially sold for $1,000, pays 6.0% annual interest, and has a duration of 10-years before it will be redeemed. Two years after the initial purchase, the bond is then re=sold on a secondary market for $900.

  • Maturity. This is the amount of time until the bond is redeemed. Think of this as the duration of a loan. In the example above, the maturity is 10 years when the bond was initially purchased but 8 years when it was re-sold on the secondary market.
  • Par. This is the original face value of the bond when it is first issued. It has absolutely nothing to do with golf. In the example above, the par value is $1,000. This is also the amount that the buyer of the bond is paid by the bond issuer at the end of the maturity period ($1,000).
  • Coupon. This is the dollar amount of annual interest that is paid by bond. The amount of interest is set at the time that the bond is first issued and is then fixed for the entire duration of the bond. In the example above, the coupon is $60 ($1,000 x 6.0%).
  • Coupon rate. This is the amount of annual interest (coupon) paid each year expressed as a percentage of the initial purchase price (par value) of the bond. In the example above, the coupon rate is 6.0%. In simplest terms, the coupon rate is the interest rate.
  • Price. When a bond is re-sold on a secondary market, this is the amount that that bond sells for. Bond prices fluctuate and so the price is usually not the same as the par value. In the example above, the price of the bond was $900 when it was re-sold. When the price is lower than the par value, it is said to be sold “at a discount”. When the price is the same as the par value, it is said to be sold “at par”. When the price is higher than the par value, it is said to be sold “at a premium”. Importantly, regardless of the price paid for a bond in a secondary market, the redemption amount of that bond will still be the bond’s original par value. So, in the example above, the person who bought the bond at $900 would be paid $1,000 when they cash it in at the end of 8 years in addition to being paid $60 in interest in each of those 8 years. To take into account both the change value of a bond when it is eventually redeemed as well as the value of the annual interest payments until it is redeemed, we need another measurement and this is where “yield” and “yield-to-maturity” come into play.
  • Current yield. Here is where bond terminology gets even more complicated. In simplest terms, the current yield is the coupon divided by the current price. Think of it as a way of adjusting the effective interest rate when the price of a bond varies. In the example above, the yield of the bond when it was resold was 6.7% ($30 ÷  $900). The current yield will fluctuate as the bond price fluctuates on the secondary market. A key point to understand about bonds is that there is an inverse relationship between a bond’s price and its yield. When the price goes down, the yield goes up and vice-versa.
  • Yield-to-maturity. This is expected annual rate of return earned on a bond under the assumption that the bond is held until maturity and all annual interest is re-invested at the same interest rate. Think of it as the effective interest rate when the current price paid on the secondary market for a bond is different than the original par value of that bond. The calculation is illustrated in the equation below and shows that in our example, the yield-to-maturity is 7.6% when the bond is re-sold at $900 with 8 years of maturity left. For simplicity, you can also use an on-line calculator to determine the yield to maturity of a bond. The good news is that bond mutual funds will normally calculate the average yield-to-maturity of all of the component bonds that it holds and the mutual fund will update the fund’s yield-to-maturity number on-line regularly.

Types of bonds

The term “bond” is fairly generic and is often used to describe a lot of different forms of loans that investors can make to corporations and governments. A more accurate, all-encompassing term is “securities”. Here is a list of some of the more common types of securities:

  • Treasury bills. These have a maturity of less than 1 year. Currently, the U.S. Treasury offers bills of 4-week, 8-week, 13-week, 17-week, 26-week, and 52-week maturities.
  • Treasury notes. These have maturities between 1 year and 10 years. Currently, the U.S. Treasury offers notes of 2-year, 5-year, 7-year, and 10-year maturities. The 10-year Treasury note (10-year T-note) is often monitored by investors as representative of the overall U.S. government bond market.
  • Treasury bonds. These have maturities between 10 years and 30 years. Currently, the U.S. Treasury offers bonds of 20-year and 30-year maturities.
  • Treasury inflation-protected securities (TIPS). These have variable interest rates that fluctuate based on the current inflation rate. The U.S. Treasury currently offers TIPS of 5-year, 10-year, and 30-year maturities.
  • Floating rate notes (FRNs). These have a coupon (interest rate) that moves up or down based on the most recent coupons of Treasury bills sold at public auction. The U.S. Treasury currently offers FRNs with a 2-year maturity.
  • Government National Mortgage Association (GNMA) securities. These are bonds sold by the GNMA (an agency of the U.S. Department of Housing and Urban Development) to provide money to buy mortgages from banks and other mortgage lenders. These are mortgages that are insured by the Federal Housing Administration (FHA), which typically insures mortgages to first-time home buyers and and low-income borrowers. Think of a GNMA security as a bundle of a lot of different mortgages.
  • Municipal bonds. These are bonds sold by state and local governments and are tax-free for federal income tax and state income tax from the state that the bond was issued from. Because the interest is tax-free, municipal bonds pay lower interest rates than other government bonds.
  • Corporate bonds. These are sold by private corporations. Because companies can go out of business before the bond maturity date, they are considered riskier than government bonds and consequently pay higher interest rates than Treasury bonds. The interest rate is affected by the company’s credit rating. “Junk bonds” are issued by companies with a low credit rating and pay higher interest rates than other corporate bonds because of the higher risk that the company will go out of business.
  • International bonds. These are bonds issued by non-U.S. corporations and governments.

The individual investor can either purchase bonds directly or purchase shares of a bond mutual fund. The U.S. Treasury regularly auctions off bills, notes, bonds, TIPS, and FRNs through the TreasuryDirect website. Individual investors can create a TreasuryDirect account through which they can bid on and pay for these auctioned bills, notes, and bonds. They can also be purchased through a bank, broker, or dealer if you do not want to bid through a TreasuryDirect account. Once you own one of these securities, you can sell them on the secondary market if you wish.

Most people prefer to purchase shares of bond mutual funds rather than buy and sell individual bonds. This adds another layer of bond complexity because a given mutual fund will contain many different bonds with different coupon rates and different maturity dates. This is where the yield-to-maturity value can be helpful because it allows the mutual fund to express the overall average yield-to-maturity of all of the component bonds when the fund is composed of bonds of varying coupon rates, prices, and maturities. Bond mutual funds are categorized based on the average maturity dates of the component bonds and are typically classified as short-term (average maturity about 2-3 years), intermediate-term (average maturity about 6-8 years), and long-term (average maturity about 22-23 years). Bond mutual funds may be composed of corporate bonds, government bonds, or a mix of both so it is important to look at the composition of each bond mutual fund.

The 2 major risks with bonds

Inflation and a future rise in interest rates are the two main risks of bonds. If the inflation rate of the U.S. economy is higher than the coupon rate of a bond, then over time, the owner of the bond actually loses buying power. Inflation is perhaps best measured by the consumer price index (CPI) which is the average amount that consumers pay for common goods and services. The U.S. Bureau of Labor Statistics website reports the CPI. Since 1958, the CPI has averaged 3.7% but as shown in the graph below, it has varied from a low of 1.0% in 2010 to a high of 12.4% in 1980. The Federal Reserve strives to keep inflation at 2% by using its monetary policy, which includes adjusting the Federal funds rate (the interest rate charged for banks to lend each other money overnight to maintain liquidity). For 25 years (from 1995 – 2020), the Federal Reserve’s monetary policy worked quite well and kept inflation at an annual average of 2.1%. The COVID pandemic was highly disruptive economically, however. As a result, during 2022, the CPI increased 6.2%, giving 2022 the highest annual inflation rate in 40 years.

Rising interest rates is the second major risk of bonds. Let’s say you have a bond with a par value (i.e., initial purchase price) of $1,000 that has a coupon rate (interest rate) of 3.0% with a 30-year maturity. Plugging those numbers into the yield-to-maturity formula above, the YTM on the day that you first purchased the bond was 3.0% (the same as the coupon rate). Now let’s say that 5 years later, the coupon rate (interest rate) for new bonds being issued has increased to 5%. If you want to sell that bond that you bought 5 years earlier, no one is going to pay you $1,000 for it because it would still have a yield-to-maturity of 3.0% whereas a newly issued 30-year bond would have a yield-to-maturity of 5.0%. Therefore, to find a buyer for that older bond, you would have to drop the price below the par value (initial purchase price) of $1,000. If you do the math, you would have to drop the price of the bond to $700 in order to give it the same yield-to-maturity as a newly issued bond. In other words, over the 5 years that you owned the bond, you would have made $150 in annual interest but you would have lost $300 when you sold the bond. This illustrates why it is not advisable to buy bonds just before interest rates are hiked up.

The corollary of this is that it is a good time to buy bonds if (1) inflation remains lower than the coupon rate of the bond and (2) interest rates are about to fall. In other words, when you buy a bond, you are betting that the bond’s yield is higher than the future inflation rate. You are also betting that the bond’s current yield is higher than coupon rate for bonds sold in the future.

How bond interest rates are determined

In a pure free market setting, interest rates would be governed by supply and demand. When demand for bonds is low, corporations and governments have to pay higher interest rates to entice people to buy their bonds. Conversely, when demand is high, corporations and governments can drop interest rates and still sell plenty of bonds. However, there are a number of non-free market forces that have a profound effect on bond interest rates (coupon rates). One of the most important is the Federal Reserve lending rate (funds rate). This is the rate that the Federal Reserve sets for banks to charge other banks to lend money, usually for overnight loans to maintain liquidity.

The Federal funds rate has a profound effect on short-term bond yields but has less effect on long-term bond yields. In the graph below, the Federal funds rate set by the Federal Reserve is in blue and the market yield for the 6-month Treasury bill is in purple. The two lines match almost exactly, illustrating the close relationship between the Federal funds rate and short-term bond yields. The market yields for 5-year Treasury notes (a form of intermediate-term bond) is in red. The graph shows that intermediate-term bonds are also affected by the Federal funds rate but the relationship is not as tight as with short-term bonds. The market yield of 30-year Treasury bonds (a long-term bond) is in green and this shows even less correlation with fluctuations in the Federal funds rate. The reason for these relationships is that short-term bond yields reflect current interest rates and inflation whereas long-term bond yields reflect what investors think will be future interest rates and inflation.

The current yields on U.S. Treasury bills, notes, and bonds are shown in the table below based on Federal Reserve data from August 16, 2023:

In addition to the Federal funds rate, there are several other variables that affect bond interest rates (and thus bond yields):

  • Anticipation of future inflation. When investors believe that inflation will go up in the future, they are less willing to buy bonds unless the yields on those bonds rises, either because issuers of new bonds pay higher coupon rates (interest rates) or sellers of older bonds on the secondary market are willing to reduce the selling price of those bonds to below the initial par value (initial purchase price).
  • Anticipation of future increases in market interest rates. Similarly, if investors believe that the coupon rates (interest rates) on newly issued bonds is likely to rise in the future, then they will be unwilling to buy old bonds with lower coupon rates on the secondary market unless the sellers of those old bonds drop the price below the par value (i.e., initial purchase price) of the bond.
  • Anticipation of future fall in the stock market. If investors believe that stocks are about to lose value in the future, then they will often move money from stocks into bonds since bond prices are not as volatile as stock prices. This can increase demand for bonds and so unless there is a flood of new bonds being issued on the bond market, the price of bonds on the secondary market will rise, resulting in a drop in the yields of those bonds.
  • Governments or corporations increase borrowing. This can happen if governments increase spending or decrease taxes. When corporations anticipate an increase in demand for their goods, they will also borrow more money in order to build factories, buy new equipment, or hire new workers. This happens during periods of economic growth. When a lot of new bonds are being sold, the supply of bonds can exceed the demand by investors resulting in corporations or governments having to pay higher coupon rates (interest rates) in order to entice investors into buying their bonds.
  • Governments or corporations decrease borrowing. The opposite happens when companies and governments stop selling bonds resulting in a reduced supply of new bonds on the market. In this situation, investors may be willing to accept lower coupon rates (interest rates) to purchase new bonds. On the secondary market, bond prices then rise with a concurrent fall in yields.
  • Wars and international political instability. The U.S. government is currently perceived as being among the most stable and reliable in the world. It is seen as one of the least likely to default on its debts (bonds) and therefore has a very high credit rating. When wars break out or there is the threat of political or economic instability, investors flock to U.S. Treasury securities given their perceived safety relative to other countries’ bonds. This can increase demand for Treasury bonds and thus reduce the coupon rates (interest rates) of new bonds sold at public auctions. A danger of U.S. legislative debt stand-offs and government shut-downs is that they can erode the U.S. credit rating, thus pushing up the interest rates that the Treasury must pay when issuing new bonds.

Nevertheless, U.S. Treasuries are currently considered to be the lowest risk bonds in the world and sell at lower yields than other bonds. In the graph below, 10-year U.S. Treasury note yields (green) are consistently lower than Aaa corporate bonds (red) and Baa corporate bonds (blue). This illustrates the maxim that credit ratings determine interest rates.

Is now a good time to buy bonds?

The current state of bonds

Currently, the yield-to-maturity of the Bloomberg U.S. Long Treasury Index is 4.1%; the intermediate Treasury index is 4.2%; and the short Treasury index is 4.7%. The corporate bond yield-to-maturity for companies with a high credit rating is running about 1% higher than U.S. Treasuries. The Bloomberg U.S. Aggregate Float Adjusted Index (a gauge of the total U.S. bond market, including both corporate and government bonds) has a current yield-to-maturity of 4.9%, midway between the Treasury and corporate values. Most total U.S. bond market index mutual funds should have a similar yield-to-maturity value – around 4.8% – 4.9%.

The inflation rate has been cooling off for the past several months. The consumer price index has increased 4.7% from July 2022 to July 2023. But for the past 3 months, it has only increased by a total of 0.8% and if that trend continues for the next year, then that would result in an annual inflation rate of 3.2%. Although not back to the Federal Reserve’s target inflation rate of 2.0%, it appears that the worst of inflation is behind us.

The Federal Reserve’s Federal Open Market Committee holds eight meetings each year. During those meetings, decisions are made about whether to change the Federal funds rate. Most analysts predict that the Committee will raise the Federal funds rate one more time this year and this would put it at about 5.6%. If inflation appears to be under control, this may be the peak in the Federal funds rate before the Committee eventually starts to lower the rate in another year or two. This implies that current coupon rates (interest rates) on newly issued bonds are likely also at or near their  peak values. Because new bond coupon rates correlate with bond yields when bonds are re-sold on secondary markets, this means that bond yields-to-maturity are also likely at or near their peak. Because bond yields are inversely correlated with bond prices, this additionally means that bond prices (and bond mutual fund share prices) are at or near the lowest point that they will be for the next few years.

Rebalancing your investment portfolio

I have covered investment portfolio balancing in a recent previous post. But in general, the stock-to-bond ratio (“balance”) in a retirement portfolio depends on two factors: the number of years to retirement (in other words, your age) and your tolerance for investment risk. An example of how these two factors affect your desired stock-to-bond ratio is shown in the graph below:

Since January 2023, the S&P 500 index is up 20% but the total U.S. bond market is only up 2%. As a result, investors who last rebalanced their retirement portfolios in January are now significantly out of balance with higher percentages of stock holdings than bond holdings. What this all of this means for the average investor is that now is a good time to buy bonds, whether that means buying newly issued U.S. Treasury securities or buying shares of bond mutual funds. I am normally not a fan of “market-timing”, that is, making investment decisions based on when you think the market is at a high or low. However, the bond market is undeniably attractive right now.

Perhaps the safest strategy is to do a checkup of your portfolio now to determine your current actual stock-to-bond ratio and compare that to your desired stock-to-bond ratio. Next, calculate the amount of money that you would need to re-allocate to bonds in order to re-balance your portfolio to your desired stock-to-bond ratio. Then spread out those bond purchases over the next 4-6 months, using a “dollar-cost averaging” tactic. As an example, say that your desired stock-to-bond ratio is 70%/30%. Because of the recent strong stock market and weak bond market so far this year, you now find that your actual stock-to-bond ratio is 75%/25%. To re-balance, you would then convert 1% of your stock holdings into bond holdings each month for the next 5 months. By spreading those conversions over 5 months, you avoid the potential pitfall of trying to time the stock-to-bond conversion to when you think the Federal Reserve will do its final Federal funds rate hike.

So, is now a good time to buy bonds? More than likely, the answer is… yes!

August 18, 2023

Medical Education

The COVID Generation Of Doctors

This summer, newly trained physicians completing residencies will be entering the medical profession workforce as attending physicians. These are the first group of physicians who did their residency training entirely during the COVID pandemic. Their education and view of medicine has been uniquely affected by their experiences. So, what can we expect from them?

Emergency medicine, internal medicine, pediatrics, and family medicine residencies are 3 years long. Other specialties are longer. U.S. hospitals were first affected by the COVID pandemic in March 2020. The physicians who started 3-year residencies in July 2020 have now completed residency and are either going out into practice or are continuing training in subspecialty fellowships. Residency is the most important experience that molds physicians and residency experience influences physicians’ practice for the rest of their lives. COVID has had an out-sized affect on these newly-trained physicians.

How did resident training change during COVID?

Almost overnight in the spring of 2020, education in the United States changed and residency education was no exception. What did these residents experience that previous generations of residents did not?

  • Lost training time. In March 2020, outpatient clinics shut down, elective hospital admissions were canceled, and medicine, except for COVID, came to a standstill. Early on, there was a prevailing attitude from residency program leaders that as trainees, residents should not be required to care for patients with COVID infection. Across the country, residents were sent home. As a result, the effective duration of residency was shortened by weeks or months for many residents. Attending physicians had to prioritize caring for COVID patients rather than preparing lectures for residents and engaging in bedside teaching. For those residents who remained in the hospitals, procedural experiences were often limited. For example, in the months of the pandemic, I performed intubations and bronchoscopies on suspected COVID patients by myself, without residents or fellows in the room, in order to reduce the number of people exposed to aerosolized virus. Family medicine residents had virtually no sports medicine experiences in the first year of the pandemic since high school and college sports were cancelled.
  • They didn’t attend national medical conferences. In 2020, national medical society annual meetings, such as the American College of Physicians, were canceled. In 2021 and 2022, attendance at medical conferences was down and many people attended virtually, rather than in person. This resulted in a loss of an important networking opportunity for residents during these years in addition to a loss of cutting edge knowledge about new developments in medicine.
  • Remote learning. Prior to 2020, classroom space in most hospitals was premium real estate. Rooms had to be reserved for conferences and lectures months in advance and sometimes, there was simply no convenient place to hold these lectures. Furthermore, residents who either were off-duty due to working night shifts or were doing rotations off-site from the main hospital were unable to attend lectures. With the onset of COVID, lectures were all changed to remote learning by WebEx, Zoom, and Teams video conferencing. Although many educators lamented the loss of the in-person lecture, video conferencing allowed residents to attend more educational conferences than in the past, thus enriching their didactic training. Today, primary and secondary education has largely returned to in-person classroom instruction but residents still mostly attend lectures by video conferencing because it is more efficient. A few months ago, I gave a talk to our fellows – there were dozens of attendees on-line but I was the only person in the lecture hall.
  • Telemedicine. When the pandemic hit and outpatient appointments were converted to telemedicine appointments, many older physicians had a difficult time adapting to new workflows, effective use of video, and the lack of physical exams. But for new residency graduates, telemedicine is normal medicine. Many of them performed telemedicine patient visits during residency before they performed in-office visits. These physicians are not only more comfortable using telemedicine but they will demand that Medicare and commercial health insurance companies continue to reimburse for it.
  • A hostile segment of the population. Early in the pandemic, healthcare workers were revered heroes in the United States. But soon, anti-maskers, anti-vaxxers, and COVID-deniers became increasingly vocal skeptics of the medical community. Across the country, health department medical directors were threatened, public health officials were fired, and even Anthony Fauci was vilified. As a result, these newly trained physicians have felt hostility from a loud group of Americans and have developed a jaded view of public health.
  • Compassion fatigue. The COVID pandemic desensitized many residents to grief. When patients are dying all around you, emotions become hardened. Early in the pandemic, it was the sheer numbers of the dead. Later in the pandemic, most of those hospitalized with COVID or dying of COVID were the unvaccinated and as a result, all too often, we ended up blaming the patients for their illness.
  • More burnout. The pandemic stressed residents in training but also stressed the attending physicians who were their mentors. When the doctors that you are trying to emulate become cynical or want to leave the practice of medicine, the flames of burnout can spread to trainees. COVID brought out both the best and the worst in us. When it brought out the worst in an attending physician or a group of physicians, their trainees were impacted. This year’s group of residency graduates have experienced more burnout than previous groups – both personally and in their colleagues.
  • An unbalanced clinical experience. I am a physician member of the AIDS generation. As a resident, I spent 2 months on the inpatient AIDS service. During my first year of pulmonary and critical care fellowship, I performed 350 bronchoscopies, more than half of which were performed to diagnose opportunistic pneumonia in patients with HIV infection. AIDS dominated my clinical experience. For this year’s group of graduating residents, it is COVID that has by necessity dominated many of their clinical experiences. This has made them very good at managing COVID infections but has often reduced the number of patients that they have seen with non-COVID medical conditions. Many have treated more patients with COVID than patients with heart failure. ICU rotations have been particularly unbalanced with disproportionately more COVID respiratory failure than other critical illnesses such as ketoacidosis and septic shock.
  • Better attention to infection control. Before the pandemic, hospitals had to continually remind physicians to wash their hands after examining patients. Doctors frequently came to work despite having a cold or the flu. That all changed in the spring of 2020 when not wearing a mask or washing your hands could cost you your life. This year’s residency graduates are more attentive to nosocomial transmission of infections and this could make our hospitals and medical offices safer in the future.

What hospitals can do

In the United States, the majority of physicians are now employed by a  hospital or health system. Newly trained physicians are even more likely to be hospital-employed. Our hospital leaders need to be aware that these new internists, pediatricians, ER physicians, and family practitioners are different than previous physicians – not better or worse, just different. In order to maximize the potential of these physicians, there are steps we can make today to ensure that they are happy, productive, and practice high-quality medicine.

  •  Optimize telemedicine capabilty. These doctors have learned to do telemedicine very effectively so give them the tools to do it. This means updating patient teleconferencing hardware, ensuring telemedicine seamlessly integrates into the electronic medical record, and the ensuring that the revenue cycle department is fully up to date on telemedicine billing. Dedicated telemedicine IT support is essential. Outpatient workflows and scheduling need to be re-engineered with telemedicine efficiency in mind.
  • Enhance educational videoconferencing capability. Winding down the pandemic should not mean winding down videoconferencing. Teaching conferences, grand rounds, and departmental meetings should always have video options available.
  • Promote career mentor relationships. Navigating the post-pandemic world could prove challenging for physicians who have only known the pandemic during their training. Ensure that every new physician has an assigned senior physician mentor from the first day of their employment. Over time, physicians usually identify their own career mentors but having an designated experienced physician who a young residency graduate can go to for career advice from day one is ideal.
  • Smother the embers of smoldering burnout. Many of these newly trained physicians are already experiencing burnout and others are teetering of the edge of burnout. There are several practical measures that hospital leaders can take to fireproof their doctors against burnout. Making workplace wellness a priority is essential to bring out the best in the COVID generation of doctors.
  • Step-up your CME program. By attending fewer (or no) national medical meetings during residency, newly trained physicians were dependent on their hospitals’ own attending physicians and on-line sources for their education. They often lacked exposure to opposing or innovative viewpoints on disease diagnosis and management. More than any other generation of physicians, they will benefit by continuing medical education in their first years in practice. Include CME expense allowances in their employment contracts to encourage them to attend regional and national meetings. At the risk of shameless self-promotion, consider a hospital subscription to the medical education webcast, OSU MedNet, that I moderated for 25 years.
  • Keep momentum on infection control. This generation of physicians is more attuned to hand-washing and prevention of nosocomial infections than any other generation of physicians. It is much easier to maintain a culture of attention to infection control than to change a culture of inattention to infection control. Normalize healthcare workers staying home when they are sick and maintain adherence to hand-washing.
  • Encourage proctoring. Because of an imbalance in clinical experiences during training and fewer opportunities to perform procedures during training, some recent residency graduates may not have adequate experience performing office procedures, performing hospital bedside procedures, and interpreting bedside tests. A proctoring program can ensure that they competent to perform these procedures. For example, a hospital could require a new internal medicine hospitalist to have 2 or 3 central venous catheter placements proctored before full central line privileges are granted. Or 2 or 3 IUD placements for a family medicine physician. Or 2 or 3 intubations for an emergency medicine physician.
  • Re-kindle compassion. Compassion is not created by a CME lecture or by reading words in a book. Compassion is created when there is a culture of compassion among one’s peers. It is fostered by the example that is set by senior physicians and medical directors. That means being inspirational, showing empathy, and being considerate to not only patients but other healthcare workers.

The newly graduated residents represent the future of medicine. But they are different from previous generations of physicians with different strengths and weaknesses. It is up to us as medical leaders to ensure that they are able to grow to their full potential.

August 15, 2023


COVID Cases Are Surging… Again

Since the beginning of the COVID pandemic, there have been two surges in COVID cases and deaths every year, one in the winter and one in the summer. Because of this, it was predicted that the U.S. would seen a new surge this summer and epidemiology data indicates that it is now starting. The graph below shows the COVID death winter surges in red and summer surges in black.

However, the peaks in COVID deaths lag about 3 weeks behind the peaks in cases. The typical timeline for a person who dies of COVID is to develop initial symptoms one week before hospitalization and then have a 2-week hospitalization before death. COVID hospitalizations in the United States are now beginning to rise. In the graph below, the weekly new hospital admission number has been increasing for the past two weeks and currently number weekly hospitalizations are 8,035, up 12% from the week before.

An even earlier indicator of COVID surges is the COVID test percent positivity. The percentage of COVID tests that are positive starts to rise before the number of hospitalizations and even before the total number of cases. The graph below shows The test percent positivity in yellow and the deaths in blue.

In the graph above, we can see that the test percent positivity began to increase in early July 2023, suggesting that a COVID surge is eminent. But the COVID percent positivity data can be inaccurate because it is dependent on COVID tests that are reported to health departments. Since many people do home tests that are not reported to health departments, many positive (and negative) tests will be missed.

Another harbinger of COVID surges is the percentage of emergency department visits that are due to COVID infections. Because initial symptoms precede hospitalizations by a week or two, people infected with COVID will often present to the ER before getting sick enough to require admission to the hospital. The graph below shows that surges in the percentage of ED visits that are due to COVID (yellow) precede surges in COVID deaths (blue) by several weeks. Once again, we see that the percentage of ED visits due to COVID began to rise in early July.

Another predictor of COVID surges is COVID sewage wastewater sampling. People infected with COVID will shed virus into household wastewater very soon after becoming infected – often before developing symptoms or getting tested. By testing municipal wastewater for COVID viruses, we can detect surges in COVID early. The graph below shows changes in virus levels from more than 1,200 wastewater testing sites throughout the U.S. The red shade indicates the percentage of samples that show a greater than 100% increase in virus levels and is now the highest it has been since January 2023.

So, what should physicians be doing now?

In the past 3 years, the summer COVID surges have been smaller than the winter surges so if history is any indicator, then the current COVID surge should not overwhelm our hospitals. However, medically vulnerable people are at risk of severe infection or death, including those who are older, obese, or have chronic medical conditions. In addition, with schools opening this month, there is the potential for rapid spread of COVID among children. Here are some practical steps physicians should be taking now:

  • Step up vaccinations. Fewer than 50% of Americans have received an updated bivalent COVID vaccine. Physicians should especially target at-risk individuals for vaccination counseling. This includes pregnant women, the obese, diabetics, the immunocompromised, and those over age 65. The CDC recommends that all people older than 6 months get 1 dose of a bivalent vaccine and those over age 65 or immunocompromised get a second dose of a bivalent vaccine.  New monovalent vaccines directed against the XBB.1.5 variant are expected in October but patients should be told to not wait until then to get vaccinated with a current bivalent vaccine.
  • Have a low threshold for testing. Your patient’s sinusitis or common cold is now more likely to be a COVID infection than it was a couple of months ago. Encourage any patient with possible COVID symptoms to be tested. Even if a person’s COVID infection is too mild to warrant treatment, all infected persons need to be in isolation to prevent transmission to more vulnerable people.
  • Be familiar with isolation guidelines. The CDC recommends that all people who test positive be isolated for 5 days and after at least 24 hours have passed since a fever. After the isolation period, infected persons should wear a face mask for an additional 5 days when in public. People with more severe infection should remain in isolation for 10 days, rather than 5 days.
  • Review current treatment recommendations. The COVID treatment guidelines by the National Institutes of Health are regularly updated. For outpatients, be familiar with the indications for Paxlovid. For inpatients, be familiar with the indications for remdesivir, dexamethasone, heparin, baricitinib, and tocilizumab.
  • Advise patients about COVID trends in your community. Our patients are constantly subjected to conflicting and often misleading information about COVID from the media and from on-line sources. Physicians are often the most trusted source of reliable information for patients. Educate patients when they come into the office and harness group messaging through the electronic medical record system.
  • Normalize masking in high risk settings. High population density indoor settings pose the greatest risk of COVID transmission. This includes churches, airports, aircraft, trains, buses, and stores during busy times of the day. Encourage patients to carry masks with them and then wear them if crowded indoor settings cannot be avoided.

COVID will be with us for the long-term. Inevitably, there will be periodic surges in cases and it appear that one of these surges is underway this month.

August 8, 2023

Medical Education

Is It Time To Do Away With MOC?

MOC, or maintenance of certification, is the requirement used by medical specialty boards for physicians to maintain board certification. But do we really need board certification MOC?

The American Board of Medical Specialties is a non-profit organization consisting of 24 member board organizations. These include the American Board of Internal Medicine (ABIM), American Board of Pediatrics, American Board of Surgery, American Board of Family Medicine, among others. Each board determines the requirements for board certification in its specialty, which is generally completion of an appropriate residency or fellowship followed by successfully passing a board examination in that speciality.

After a physician successfully completes a residency or fellowship, they are then “board-eligible” in that specialty. To become board-certified, the physician must take and pass a board examination in that specialty. These board examinations consist of a 1-day written test and some specialty boards additionally require an oral examination. In the 1970’s becoming board-certified was considered optional and most hospitals did not require a physician to take a board examination in order to practice in that particular specialty. By the 1980’s, many hospitals began to require new physicians to be board-certified in order to have hospital privileges in any given specialty but older, non-certified physicians were generally grandfathered in for hospital privileging. Until 1990, physicians only had to take and pass a specialty board examination once and then they had lifetime board certification. However, after 1990, the specialty board organizations moved to a time-limited board certification and required physicians to re-take the specialty board examination every 10 years in order to maintain their certification.

Although taking and passing the board examination periodically initially sounded like a good idea, it became immediately apparent that this created a problem for many physicians. For example, an internal medicine hospitalist had to take the general internal medicine recertification exam that largely focused on outpatient medicine topics which were irrelevant to inpatient hospitalist practice. Or the oncologist who sub-specialized in prostate cancer treatment would have to take the general oncology recertification examination that tested about breast cancer, colon cancer, and lung cancer treatment, all of which were irrelevant to the prostate cancer subspecialist’s practice. The recertification tests were hard and many physicians had to take a week-long board review and preparation course in order to pass the tests.

In an attempt to maintain relevancy, specialty boards have added maintenance of certification modules in addition to or instead of the every 10-year recertification exam. These MOC modules are generally a series of annual open-book examinations that physicians could take at home, on their own time. The argument for open-book exams is that by making the physician research questions using medical references, the physician would learn about the topic in order to answer the question correctly. However, with the widespread availability of artificial intelligence resources, such as ChatGPT, a person would not even need to have a high school diploma to pass an open-book specialty board MOC module. Each module is worth a certain number of MOC points; as an example, the American Board of Internal Medicine requires a physician to have 100 points every 5 years to maintain certification.

MOC points can also be awarded for other activities, such as attending CME (continuing medical education) events. Thus, MOC points can be awarded for going to a medical conference, attending grand rounds, or viewing on-line medical education webcasts. MOC points can even be awarded for viewing on-line medical reference resources, such as UpToDate.

Physicians already have other educational requirements

Maintenance of certification by specialty boards is not the only on-going educational requirement that physicians face. Here are a few of those that I was required to do in order to practice at our hospital:

  1. Continuing medical education. The Ohio State Medical Board requires all physicians to have 50 hours of CME credits every 2 years to maintain licensure. CME credits are commonly acquired by attending hospital grand rounds or annual specialty medical conferences.
  2. Advanced cardiac life support. In our hospital, critical care medicine privileges and sedation privileges require ACLS certification. Re-certification is necessary every 2 years and consists of a four-hour course in-person course that includes a written examination. Prior to attending the re-certification course, attendees must first read and study the 202-page ACLS manual. Over my career, I took the ACLS course 19 times.
  3. Collaborative Institutional Training Initiative. The CITI course is required for any physician who is involved with clinical research and takes approximately 4 hours. This must be repeated every three years.
  4. Electronic medical record training. Initially, this takes about 10-20 hours. However, once you are facile with it, you just need to get trained on the periodic software updates – about 1 hour per year.
  5. Compliance training. At our hospital, we have a mandatory 2 hours per year for billing/coding compliance training to ensure that we are documenting our services and billing correctly. In addition, there is a 1-hour annual HIPAA compliance module requirement.
  6. Hospital training. These annual modules consist of on-line content with a post-test that requires a passing score of > 80%. They cover everything from what to do in a fire, to how to read a hazardous materials label, to the hospital’s sexual harassment policy. They vary in number from year to year but typically total about 10 hours per year.

The argument for MOC

Advances in medicine happen rapidly resulting in significant changes in medical practice every few years. For example, the way that we manage a patient with a myocardial infarction today is totally different than the way we did 20 years ago. The main argument for MOC is that it is a way to ensure that physicians keep up with the changes in their specialties.

The arguments against MOC

A petition to end the American Board of Internal Medicine’s MOC requirement started 2 weeks ago already has 10,500 signatures. The authors of the petition stated that signers “firmly believe that the MOC program has become burdensome, costly, and lacks evidence to support its effectiveness in improving patient care or physician competence.” So, what are the objections?

  • Cost. The cost of the American Board of Internal Medicine initial specialty examination is $1,430 and subspecialty examinations are $2,325.  The ABIM’s MOC program costs $220 per year to maintain board certification. Each additional subspecialty costs $120 per year. In my case, as an internist who subspecializes in pulmonary medicine and critical care medicine, the initial cost would be $6,080 and then $440 per year after that. Many physicians have expressed concern that the MOC programs are used by the subspecialty boards to increase their revenues and have pointed to the ABIM president’s annual salary of $1,031,924 for his 32-hour work week (more than four times the average salary of an internist).
  • Redundancy. State medical boards already require 25 hours or more of continuing medical education per year in order to maintain a medical license. Most CME activities are also eligible for MOC points so many physicians say that they are paying the boards to keep track of education that they are already doing for their state medical boards.
  • Irrelevancy. As physicians become more sub-specialized, MOC tests that cover diseases that the physicians do not treat in their regular medical practices are irrelevant. Because a physician does not normally manage a particular group of diseases, it takes much more time to prepare for unfamiliar subjects. An analogy would be to require a professor of 20th century American literature to pass an annual test covering 10th century Chinese literature. In my situation, I do not and have never practiced sleep medicine yet 10% of the pulmonary board recertification exam consists of sleep medicine questions. I can remember driving from Columbus to Cincinnati to take my 10-year pulmonary recertification exam and calling one of my colleagues from the car to tell me everything I needed to know about interpreting a sleep study.
  • Unproven benefit. To date, there is no evidence that passing MOC tests and modules makes a specialist a better doctor. In an era where evidence-based medicine is championed, there is no evidence that MOC is effective in determining physician competency.
  • Discriminatory. In the past, once a physician passed the board examination, the physician was board-certified for life and there was no requirement for MOC or re-certification. For hospitals that require board certification for credentialing, older physicians who are board certified for life do not need to do MOC but younger physicians whose board certifications are time-limited to 10 years do need to do MOC.
  • Physician burnout. There is not a single physician in the U.S. who looks forward to taking a recertification examination. Many choose to take board exam review and prep courses (the course offered by the American College of Physicians to prepare for the ABIM exam costs $1,095). This requires time off work and creates anxiety about a tedious process that does not make them better doctors. Many physicians time their retirement to coincide with when their 10-year recertification expires just so they do not have to go through it another time.

So, what is the solution?

Board certification was initially created to document successful completion of a specialty residency or subspecialty fellowship. It was similar to the final exam for a college course. You completed a 3-year residency and then at the end, took the ABIM exam to certify that you learned what you needed to know to be an internist. The board exam should go back to being the final exam of a residency or fellowship. I believe that the specialty boards should not be involved with any form of recertification after that initial test. The practicing physician specializing in breast cancer oncology does not need to be held to the same knowledge level about colon cancer as a physician who just completed a general oncology fellowship.

Specialty board organizations need to be down-sized. Re-certification is big business. The ABIM alone has annual revenues exceeding $71 million. The increased income from recertification has resulted in bloated salaries for senior executives and expansion in the number of employees. These boards were created to serve the medical profession but now, the medical profession is increasingly serving the board organizations. They have become feudal lords over fiefdoms of medical specialists.

Health insurance companies should abandon recertification requirements for physicians. Currently, one of the main reasons that physicians spend so much time and money on board recertification is because it is a requirement to be paid by many health insurance companies. The insurance companies have no way to know whether or not a physician is competent so they have adopted board re-certification as a surrogate marker for competency. The problem is that it is not.

“Open book” MOC tests are no longer valid in an era of on-line artificial intelligence programs. All a physician has to do is copy and paste the question into an AI program and the program will tell you the correct answer. These take-home tests are now meaningless.

We should replace the concept of “maintenance of certification” with “maintenance of competency”. Competency determination should be left to the state medical boards and hospital credentials committees. There is no evidence that completing MOC modules ensures that a physician is competent in their area of practice. State medical boards should dictate the number of annual continuing medical education hours required for maintenance of licensure and continue to sanction or revoke licenses of physicians determined to not meet the standards of medical practice. Hospitals should use their credentials committee to confirm that specialists on the medical staff are practicing medicine and surgery competently. As a hospital medical director, I believe that the people who can best judge the competency of a physician are the other physicians who practice in the same hospital. Over the years, I have seen plenty of physicians who always passed their board re-certification exam but were kicked off of our hospital’s medical staff because they were incompetent.

So, is it time to do away with MOC?


August 7, 2023


Predictions For The 2023-2024 Influenza Season: Lessons From Australia

After two and a half years of the COVID pandemic, influenza has become an after thought for many Americans. But influenza can still kill vulnerable people and even in otherwise healthy individuals, it can cause unpleasant illness, require time off of work, and cause school absences. One of the best predictors of the next U.S. influenza season is the current Australia winter influenza season that occurs during the U.S. summer.

When will the U.S. influenza season start?

The Australian Government Department of Health and Aged Care publishes an influenza epidemiology report every 2 weeks. The most recent report is from July 23, 2023.


The current influenza data is depicted in the red line in the graph above. Last year’s influenza data is in the taller orange line and the 5-year average is in the black line. In this graph, week 1 corresponds to the week of January 1, 2023. Cases of influenza began to be reported early in Australia this year and most closely matched the 2019 influenza season. Cases started to increase in number in week 8 (late February), had an initial plateau from weeks 13 – 17 (late March to late April), then rose to a peak in week 26 (last week of June).

The Centers for Disease Control publishes a weekly influenza report on the FluView website. The United States influenza season is about 6 months later than the Australian influenza season, owing to the seasonal difference between the northern and southern hemispheres. The graph below shows U.S. influenza data for the last several years with the 2022-2023 data in red. Similar to last year in Australia, influenza was seen earlier and peaked earlier in the U.S. last year.

United States

Based on the current year data from Australia, cases of influenza would be expected to begin to rise in late August or early September in the U.S. and then peak in approximately late December or early January. This would be a much earlier influenza season than is typical in the U.S. and would resemble last year’s influenza season.

What influenza subtypes are likely?

Influenza A and influenza B are the most common varieties of influenza in humans. Each of these can be further divided into common subtypes. The most common subtypes of influenza A are H1N1 and H3N2. The most common subtypes of influenza B are the Victoria lineage and the Yamagata lineage. Each of these subtypes can be further divided into clades and each clade can be divided into subclades. Because influenza can and does mutate regularly, the dominant subclades causing human infection change from year to year. Additionally, the relative percentage of influenza cases caused by influenza A & B varies each year and the relative percentage of each influenza subtype also varies each year. The graph below shows the strains of influenza in the U.S. last year. Most cases were influenza A and most of the influenza A was H3N2 (71%, red bars); H1N1 was much less frequent (29%, orange bars). Influenza B cases were relatively uncommon and mostly seen late in the season (green bars). Notably, all of the influenza B cases were caused by the Victoria lineage (100%) and none were caused by the Yamagata lineage.

United States

This year in Australia, influenza A (63%) was more common than influenza B (35%). The vast majority of influenza A was caused by the H3N2 subtype (82%; dark green bars) as opposed to the H1N1 subtype (18%; purple bars). For influenza B, 100% were caused by the Victoria lineage and none were caused by the Yamagata lineage.


Influenza A H3N2 clades and subclades.  The two clades of H3N2 which are currently in circulation are clade 1 (limited to China) and clade 2 (the dominant clade in the U.S.). In the figure below, clade 1 is shown in purple and clade 2 is shown in green. Each clade is divided into subclades based on mutations in the influenza hemagglutinin gene. The hemagglutinin protein is located on the surface of influenza and helps the virus bind to human cells. Hemagglutinin is also the target for influenza vaccines.

Influenza A H1N1 clades and subclades.  The two clades of H1N1 which are currently in circulation are 5a.1 and 5a.2. The H1N1 5a.1 influenza clade mostly made up of the subclade A/Hawaii/70/2019. This subclade is decreasing in frequency and is rarely seen in the United States.

Most H1N1 influenza in the United States is from clade 5a.2. H1N1 5a.2 subclades A/Victoria/4897/2022 and A/Wisconsin/67/2022 are dominant in the U.S. whereas H1N1 5a.2 subclade A/Sydney/5/2021is dominant in Australia.

Influenza B subtypes. Of the two influenza B lineages, only the Victoria lineage is currently circulating on Earth and the Yamagata lineage has not been detected in the U.S. or Australia in the past year. As with influenza A, mutations in the hemagglutinin gene creates clade diversity in influenza B. Currently, the 1A.3a.2 strain accounts for 99% of influenza B worldwide.

The 2023 – 2024 influenza vaccine

Every year, the FDA’s Vaccines and Related Biological Products Advisory Committee (VRBPAC) meets in the spring to project which influenza clades and subclades are likely to circulate during the next influenza season and then selects representative virus strains to use to manufacture the next seasonal influenza vaccines. Because the committee meets in early March, data from the Australia influenza season are not yet available when the U.S. selects influenza strains for vaccines. This year, the strains selected for the quadrivalent vaccines are similar to last year’s vaccine with the exception of the influenza A H1N1 strains; the Victoria/4897/2022 strain replaces last year’s Victoria/2570/2019 and the Wisconsin/67/2022 strain replaces last year’s Wisconsin/588/2019 strain:

The 2023-2024 trivalent influenza vaccines will be similar to the 2023 – 2024 quadrivalent cell-based and egg-based vaccines except that they will not include the Phuket/3073/2013 influenza B strain against the Yamagata lineage. Because there have been no Yamagata lineage influenza B infections in the U.S. last year or in Australia this year, it is likely that the trivalent vaccine will be equally effective as the quadrivalent vaccine this year since coverage for the influenza B Yamagata lineage is unnecessary.


When to get vaccinated. Because the Australia influenza season started early, it is likely that the U.S. influenza season will also start early. Physicians should start vaccinating patients in mid-August and aim to get all patients vaccinated by late October.

Quadrivalent versus trivalent. Because there has not been any recent influenza B Yamagata lineage virus circulating recently, the trivalent vaccine should be just as effective as the quadrivalent vaccine. Therefore, patients can get either vaccine and they can be used interchangeably.

When will hospitalizations peak? This year in Australia, hospitalizations peaked between weeks 19 and 28. This would correspond with early November through early January in the United States. This is normally a busy time for elective inpatient surgeries (such as knee and hip replacements) so hospitals should be prepared accordingly.

The holiday travel effect. Because influenza may be peaking during the U.S. Thanksgiving and Christmas holidays, there is the potential that travel for these holidays could fuel a surge in influenza cases.

Universal flu vaccines in the future?

Because the influenza hemagglutinin gene mutates so readily, the antigen targets on the hemagglutinin surface protein change. This requires new vaccines to be made to generate antibodies against these altered hemagglutinin antigens. The mRNA vaccines that were so successful against COVID offer the hope that mRNA technology could be applied to other anti-viral vaccines, including influenza. A study published November 2022 in the journal Science found that an mRNA vaccine that covered 20 strains of influenza was effective in mice and ferrets. However, recent human trials with mRNA influenza vaccines by Sanofi and Moderna were unsuccessful, mainly due to inadequate immune protection against influenza B strains. Another influenza mRNA vaccine created by Pfizer is currently undergoing phase III clinical trials.

In all likelihood, it will be several years before a universal influenza vaccine is commercially available. Until then, we will have to continue our current process of tracking the dominant circulating influenza clades and subclades in order to produce annual influenza vaccines. Based in Australia’s current influenza season, I recommend getting this year’s flu shots as soon as they are available.

August 2, 2023