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

Emergency Department Outpatient Practice

Over The Counter Oral Contraceptives: An Opportunity For Hospitals

Last week, the U.S. FDA approved Opill, the first over-the-counter birth control pill. It contains 0.075 mg progesterone and must be taken every day, at the same time of day. Opill now gives hospitals a new opportunity to reduce unwanted pregnancies by counseling women in the emergency departments, inpatient settings, and outpatient clinics.

How effective is Opill?

Most currently available prescription oral contraceptives are combination estrogen/progestin pills. The estrogen component poses risks of deep venous thrombosis, pulmonary embolism, hypertension, myocardial infarction, and stroke. For this reason, it is likely that combination estrogen/progestin oral contraceptives will remain only available by prescription in the future. Since progestin-only pills lack estrogen, they are generally safer than combination birth control pills. Opill contains norgestrel, a form of progestin. The amount of progestin in Opill (0.075 mg) is much lower than the amount of progestin in most combination pills (typically about 1.0 mg) and less than currently available progestin-only prescription birth control pills (0.35 mg). Because it only contains progestin and only in a very low dose, it is sometimes called a birth control “mini-pill”. 

Opill (norgestrel) works by thickening cervical mucus, creating a barrier to prevent sperm from entering the cervix and uterus. In addition, norgestrel slows the passage of ova through the fallopian tubes and alters the endometrium to impede ova attachment. In about half of women, norgestrel also prevents ovulation. Norgestrel blood levels peak approximately 2 hours after ingestion and the drug is completely eliminated from the body by 24 hours. These pharmacokinetics are why rigid adherence to the dosing schedule at the same time every day is required.

The effectiveness of any form of contraception is often measured by the “Pearl index”, named after biologist, Raymond Pearl. This index is the number of pregnancies per 100 women using that form of contraception for one year. In a 2022 review of the literature in the journal Contraception, the average Pearl index for progestin-only oral contraceptives is about 2. This means that if 100 women use progestin-only pills for a year, 2 of them will become pregnant. However, in real life, the Pearl index is almost never as high as it is in clinical trials where researchers make every effort to ensure that women do not miss doses. It is just too easy to take a dose more than 3 hours late in the day or to forget to take a daily dose altogether. For this reason, it is likely that in regular clinical use, the Pearl index for Opill will likely be closer to the Pearl index of combination estrogen-progestin birth control pills, or around 7 pregnancies per 100 women per year. This puts Opill in an intermediately effective form of contraception: better than condoms but not as effective as IUDs or implants.

However, even with a Pearl index of 4 – 7 pregnancies per 100 women per year, Opill will now be the most effective over-the-counter contraception method available and far more effective than condoms.

Advantages and disadvantages of Opill


  • No physician visit required for a prescription. The wait for a routine return appointment at my own PCP is 4 months. This is too long for most people to wait to get access to contraception.
  • Good option for women/girls who do not want their healthcare provider to know about their sexual activity. This is particularly useful for minors who do not want their parents to know that they are sexually active.
  • Useful for women who frequently travel or occasionally lose medications. It can be difficult to get an emergency refill of a prescription oral contraceptive, particularly when out of state or on weekends. Women can get a refill of their Opill anytime at any pharmacy in the country.
  • Fewer side effects than prescription combination estrogen/progestin birth control pills.
  • Unlike condoms and diaphragms, it is not necessary to interrupt sex to use Opill.


  • No physician visit required for a prescription. This can be a missed opportunity to counsel women/girls about all of the various contraception options.
  • Does not prevent sexually transmitted diseases.
  • Should not be used in women with a history of breast cancer, women with undiagnosed vaginal bleeding, and women with liver disease.
  • Can result in irregular vaginal bleeding.
  • Other common side effects may include nausea, breast tenderness, and headaches.
  • Must be taken every day and within 3 hours of the regular hour of the day that it is normally taken. If a dose is missed, delayed, or there is vomiting after taking a dose, alternative contraception must be used for at least 48 hours.
  • Even with perfect use, 1 out of every 50 women will get pregnant every year.
  • Possibly less effective in obese women/girls.
  • Drug interactions with phenytoin, carbamazepine, barbiturates, rifampin, efavirenz, bosentan and St. John’s Wort. These drugs can render Opill ineffective.
  • Not tested in girls younger than 15 years old.

An opportunity to counsel ER patients

One of the more common diagnoses we make in women in U.S. emergency departments is pregnancy. A 1994 study found that 6.3% of women of childbearing potential presenting to the ER had unsuspected pregnancies. The incidence of pregnancy in women presenting with abdominal pain is even higher at 13%. When women suspect that they may be pregnant, many will present to the emergency department for pregnancy testing rather than their primary care provider. This has become particularly true in states that have time restrictions on abortions. Because women often do not realize that they are pregnant until they miss a menstrual period, they are often 4 – 5 weeks pregnant when they begin to suspect pregnancy. In states where abortion is illegal after 6 weeks gestation, a delay in pregnancy testing of even a few days while waiting to see a primary care provider can result in exceeding the legal gestational time for an abortion. A trip to the ER is often the fastest way for a women to find out whether or not she is pregnant.

As a rule, emergency medicine physicians do not prescribe maintenance medications, including birth control pills. Consequently, until now, all that an ER provider could recommend to women who had came to the emergency department for pregnancy testing and had a negative test was to see their primary care provider for contraception counseling and prescriptions. Unfortunately, many women do not have a  regular primary care provider. Furthermore, many adolescents do not want to speak to their pediatricians about contraception for fear that their parents will find out. Many unmarried adult women do not want to admit to their primary care provider that they are sexually active or do not want that information to be recorded in an electronic medical record that any healthcare worker might get access to.

But now, our ER providers have the ability to recommend reasonably effective non-prescription contraception to any woman. But how should the information be provided and which women should get that information? It is ineffective to simply ask women if they are sexually active in the ER because they are frequently not forthcoming about their sexual history. Indeed, a 1989 study found that 7% of women ER patients who stated that there was no chance that they were pregnant were, in fact, pregnant. Sometimes it is because there is a relative or friend in the ER room with them and they don’t want that individual to know about their sexual history. Sometimes, they don’t want to risk their sexual history being recorded in the electronic medical record. Sometimes they don’t even want the ER provider to know that they are sexually active because it would acknowledge violation of cultural or religious doctrines. The most effective strategy is to provide information about contraception to all women of childbearing potential. But what is the best way to provide that information?

Unfortunately, there are insurmountable barriers to printing up information about Opill on the ER after visit summary for every female patient between the ages of 11 and 50. Twelve-year-olds can and do get pregnant but handing out information about contraception to every 12-year-old who comes to the ER with a sprained ankle will infuriate many parents who in turn will write scathing reviews of the hospital on Yelp that will then infuriate hospital administrators and board members. Although the FDA does not expressly state the youngest age that Opill is indicated for, in clinical trials, it was not used in girls younger than age 15 so hospitals could potentially face legal liability if it is perceived that they were recommending Opill for girls younger than 15. In addition, some women and girls may be offended if this information is printed on their after visit summary. This could include women with previous tubal ligation or hysterectomy, widows, lesbians, Catholics, and the celibate. One compromise would be to just include information about Opill on the after visit summary for female patients between ages 18 and 50 or between ages 15 and 50. This option is less likely to offend parents but can still offend other girls and women. Another compromise would be to only include after visit summary information for patients who had a pregnancy test or a test for sexually transmitted disease in the ER. This would target those women and girls who are presumably at a higher risk of becoming pregnant but because most ER visits do not result in pregnancy or STD testing, most women and girls will not receive any information. Alternatively, information about Opill could be posted in public areas such as posters in examination rooms, posters in waiting rooms, or screen displays on public video/TV monitors. This is the least intrusive and least likely to offend anyone. However, it may be less impactful since there is no printed information for girls and women to take with them. Information does not need to be excessively detailed. For example, a wall poster or after visit summary could simply say something like “Over the counter birth control pills are now available; to learn more, go to this website…”.

Opill and Catholic hospitals

These informational tactics will only be applicable for the nation’s non-Catholic hospitals. Currently, 16% of all U.S. hospitals are affiliated with the Catholic Church. In many communities, a Catholic hospital is the only available healthcare facility. Because of the church’s doctrine prohibiting contraception, these hospitals would face opposition to providing information about Opill from the church. This is particularly unfortunate since a primary mission of many Catholic hospitals is to provide care to the underserved, a population of women who are less likely to have regular primary care providers and thus have less access to prescription contraception. Although 99.0% of Catholic women have used some form of contraception at some time of their lives (despite church doctrine), this is less than women with no religious affiliation (99.6%), mainline Protestants (99.4%), and evangelical Protestants (99.3%). This barrier to contraception access for Catholic women is reflected in the religious demographics of American women undergoing abortion – Catholic women are more likely to have an abortion than women belonging to other religions in the United States. Data from the Guttmacher Institute indicates that 24% of American women undergoing abortion identify as Catholic but only 22% of the American population as a whole is Catholic.

On the other hand, Opill provides a new opportunity for physicians employed by Catholic hospitals – including primary care providers at hospital-owned outpatient clinics. Many such hospitals and clinics prohibit their physicians from prescribing contraception, inserting IUDs, or even performing tubal ligation or vasectomy for the purpose of contraception. Many physicians at these hospitals are not even willing to include documentation of discussions about contraception in the electronic medical record for fear of being identified by hospital officials as providing forbidden services during medical record audits. Now, however, physicians and other providers at Catholic hospitals, emergency departments, and clinics can verbally recommend over-the-counter Opill to their patients interested in contraception without creating an incriminating documentation trail in the electronic medical record that could result in job termination.

Reducing unwanted pregnancies

Abortion legislation is currently one of the most controversial socio-political issues in the U.S. The most effective way to reduce abortion is not by making abortion illegal but instead by preventing unwanted pregnancies in the first place. As Americans, we waste way too much emotional energy arguing about abortion laws while often ignoring tactics to reduce unwanted pregnancies. The availability of Opill now gives us a new opportunity to reduce these unwanted pregnancies by increasing the availability of reasonably effective contraception to women who otherwise have barriers to obtaining prescription contraception. 

We do not yet know how Opill will be priced. Most prescription oral contraceptives currently cost $10 – $50 per month without insurance and presumably, Opill will be in this general price range. Health insurance policies typically only cover prescription medications and generally do not cover over the counter medications. It is unclear if health insurance companies and Medicaid will cover Opill. The cost of Opill for a year is far, far less than the cost of a pregnancy. The Kaiser Family Foundation estimates that the total cost of pregnancy, child birth, and postpartum care is $18,865. In addition, the average healthcare costs per child is $2,966 per year which adds up to $53,388 from birth to age 18. This means that the total healthcare cost of an unintended pregnancy is $72,253. In addition, the average cost of $4 per child per day for SNAP (Supplemental Nutrition Assistance Program, aka food stamps) adds another $26,280 charged to taxpayers over 18 years for every unwanted pregnancy to a low-income woman. Even at a cost of $50 per month, insurance companies and Medicaid programs would be financially foolish to not cover Opill. Indeed, by preventing unwanted pregnancies, Opill could reduce health insurance premiums and reduce taxpayer costs of Medicaid and SNAP.

Not perfect, but…

Opill is not the most effective form of contraception, nor is it for all women and girls. But it is a well-needed addition to the current contraception options and holds the promise of reducing unwanted pregnancies and abortions. Hospitals, and especially emergency departments, can play an important role in educating women and girls about Opill. Each hospital should decide for itself what the best method of patient education is in its own facilities.

July 17, 2023

Emergency Department Epidemiology

July Is The Peak Of Mass Shooting Season In The United States

What do you call a 4th of July when there are five mass shootings? …Yesterday …and just another July day in America. If it seems like there are a lot of mass shootings in July, that’s because there are. There is a seasonality to mass shootings in the U.S. and summer is the busiest season of the year. A mass shooting is defined as four or more persons shot in one incident, at one location, at roughly the same time.

America loves guns. We have a higher ownership of guns than any other country in the world. There are 120 firearms for every 100 American citizens; the next closest country is Yemen with 53 guns per 100 citizens. One out of three American adults own a gun and 42% of households have a gun. Interestingly, the percentage of Americans who own guns has been falling over the past several decades, even as the total number of guns has increased dramatically. This has been attributed to a rising number of “super owners” who posses 10 or more guns. We have 4% of the world’s population but U.S. civilians own 40% of the world’s firearms. Thus, it is not surprising that guns are our method of choice for both homicides and suicides. However, despite the fall in the percentage of Americans who own guns, the annual number of mass shootings continues to increase.

The Gun Violence Archive keeps a list of all mass shootings in the past 3 years and by analyzing their data, we can determine when mass shootings are most likely to occur and where they are most likely to occur. For the past 3 years, July has been the peak month for mass shootings with a total of 264. December had the lowest number of mass shootings at 95.

The number of people injured during mass shootings follows a similar trend. Over the three year period, there were 1,169 mass shooting injuries in July and only 349 injuries in December.

July was not the peak month for mass shooting deaths, however. That honor went to May with 228 deaths; July came in second with 215 deaths. However, the unusually high number of deaths in May is due to the large number of fatalities from shootings in Buffalo, NY (May 14, 2022; 10 deaths) and Uvalde, TX (May 24, 2022; 21 deaths). 

Certain states are more dangerous than others when it comes to mass shootings. Over the past three years, Illinois has led the country with 199 mass shootings, followed by Texas with 152, California with 139, Pennsylvania with 108, and Florida with 100. Several states had no mass shootings in the past three years including Montana, Wyoming, Vermont, and North Dakota,

Mass Shootings by State July 2020 – July 2023

Mass shootings get a lot of public attention and are the focal point for calls for gun control. However, mass shootings are actually a relatively uncommon way to die from a gun. In 2022, there were a total of 44,357 deaths in the U.S. caused by guns. Of those, 24,090 (54%) were suicides and 20,267 (46%) were homicides. Only 1.5% of gun deaths were from mass shootings or mass murder. Indeed, there were more than twice as many unintentional shootings (accidental shootings) than mass shooting deaths.

CDC data from 2021 shows that the states with the most gun deaths from all causes are Texas (4,613), California (3,576), Florida (3,142), Georgia (2,200), and Illinois (1,195). On the other hand, three states had fewer than 100 gun deaths in 2021: Rhode Island (64), Hawaii (71), and Vermont (83). But total numbers alone can be misleading since states with larger populations would be expected to have more deaths from any cause, including guns. So, the rate of gun deaths per 100,000 population is more meaningful and is shown in the map below.

Firearm Death Rates by State 2021

States with the highest rates of gun deaths per 100,000 are Mississippi (33.9), Louisiana (29.1), New Mexico (27.8), Alabama (26.4), and Wyoming (26.1). At the other end of the spectrum, states with the lowest rates of gun deaths in 2021 were Massachusetts (3.4), Hawaii (4.6), New Jersey (5.2), New York (5.4), and Rhode Island (5.6).

What should hospitals do to prepare?

For our country’s emergency departments and trauma surgeons, gunshot injuries and deaths are all too routine. But large numbers of gun casualties from mass shootings are infrequent. Nevertheless, they can occur anywhere at anytime. Mass shootings have been steadily increasing over the past 50 years and so it is incumbent on our hospitals to be prepared to manage mass casualties from gun violence.

Rockefeller Institute of Government

Hospitals are required to do two disaster drills every year. Each disaster drill encompasses different scenarios, such as a bus crash, an infection outbreak, or a tornado. Several years ago, our community also did a mass shooting disaster drill. This was incredibly helpful to make us think about how we get enough units of blood, how we would triage a large number of patients with penetrating trauma, emergent expansion of the operating rooms, and which physicians can supplement the emergency medicine physicians and trauma surgeons. Every hospital should include a mass shooting drill every 4-5 years. Considerations should include:

  • How quickly can off-duty emergency room doctors be brought in and how will you contact them? This requires having a list of phone numbers of all ER physicians in a readily accessible location.
  • How can you increase the number of nurses in the ER on short notice? This may require calling in off-duty nurses and re-deploying nurses from other hospital locations.
  • How many trauma surgeons and general surgeons can you mobilize? This requires having a plan in place for calling in off-duty surgeons. In an emergency, other surgeons may be able to operate on trauma patients or at least assist, including plastic surgeons, orthopedic surgeons, vascular surgeons, and surgical residents.
  • How will you clear out the operating rooms to accommodate a large number of emergency trauma cases? Elective cases may need to be canceled or delayed.
  • How will you mobilize additional anesthesiologists and OR nurses? Tactics can include calling off-duty staff in from home, using anesthesia residents, and CRNAs.
  • How can you re-deploy other physicians to supplement the emergency room physicians on short notice? Hospitalists can often be used to care for the non-trauma patients in the ER.
  • How quickly can your blood bank acquire additional units of blood? In the 2017 Las Vegas shooting, more than 500 units of blood were used.
  • How will you track patients? Victims may not have identification or be alert enough to provide identifying information.
  • How will your medical records department manage a large number of unidentified patients? This requires a system to provide multiple temporary patient medical record numbers until patient identification can be confirmed.
  • How will your hospital disaster command center operate and who will fill each command center role? It is best to rotate who will fill each role during different disaster drills because when a disaster actually happens, not every hospital leader will be in town or otherwise available.
  • How will you manage press communication, family reunification, and morgue demands? All of these can contribute to the chaos attendant to a true disaster. By having plans in place, chaos can be minimized.
  • How will you transport patients to other hospitals once you reach trauma capacity? A disaster, such as a mass shooting, requires a community-wide response. All regional hospitals need to coordinate in order to take optimal advantage of each hospital’s available resources.
  • How can the community be better prepared to provide pre-hospital care? The Stop The Bleed program is a great resource for community education and can result in a higher percentage of casualties arriving in the emergency department alive.

Situational awareness and preparation

The keys to surviving a mass shooting are situational awareness and preparation. It is up to every American to maintain situational awareness and to teach it to our children. Sometimes, there are warning signs before mass shootings take place: someone carrying a gun where a gun is not necessary; someone making verbal or physical threats; drug deals; or the presence of rival gang members. It is unfortunate but necessary that we always know where exits are and be willing to leave an area when warning signs occur.

For the average citizen, being prepared means familiarity with the Run, Hide, Fight strategy recommended by the Federal Bureau of Investigation. For hospitals, being prepared means rehearsing how a large number of shooting victims would be managed in an emergent situation. Once rare, mass shootings are now a way of everyday life in the United States. Our hospitals can do their part to minimize the number of fatalities when mass shootings do occur.

July 5, 2023

Medical Education

Physicians, Race Disparities, And The Supreme Court Ruling On Affirmative Action

In striking down affirmative action last week, Chief Justice Roberts stated of race-based college admission practices: “Those policies fly in the face of our colorblind Constitution.” This decision will also affect medical school admissions and thus the demographics of the U.S. physician workforce in the future. Affirmative action was created to overcome disparities caused by racial discrimination but the Supreme Court has determined that affirmative action itself is discriminatory.

Summary Points:

  • There are significant racial disparities in the U.S. physician workforce resulting from racial discrimination in the U.S. decades ago and from the racial demographics of our foreign medical graduates
  • To overcome those disparities, U.S. medical schools have relied on affirmative action
  • The Supreme Court has recently ruled that affirmative action is itself discriminatory
  • Simultaneously, the U.S. Senate is proposing to increase the number of Medicare-funded residency positions by 14,000
  • These new residency positions will largely be filled by foreign medical graduates
  • The combination of residency position expansion and affirmative action elimination will likely worsen racial disparities in the U.S. physician workforce


For years, medicine has embraced efforts to improve diversity. Our medical schools strive to increase the percentage of underrepresented minorities in admissions. Our deans take pride in publicly stating that “This class is the most diverse that we have ever had.” Our hospital leadership search committees are directed to include increasing diversity as a criteria when identifying job candidates. We champion implicit bias training in our medical centers. Even the NFL has the “Rooney Rule” that requires that league teams to interview minority candidates for head coaching positions. However, under the sociopolitical threat of being accused of practicing critical race theory or wokeness, it is now becoming increasingly dangerous to embrace diversity. The Supreme Court decision was made specifically in regard to undergraduate college admissions but has the potential to be extrapolated to medical school admissions, hospital leadership search committees, and yes, even the NFL’s Rooney Rule.

The racial composition of the U.S. physician workforce 

It has long been recognized that some racial minority groups are under-represented in the physician workforce. As physicians, we are disproportionately White and Asian.  The figure below shows the percentages of the U.S. population (left) and practicing U.S. physicians (right) by race from the 2022 report by the Association of American Medical Colleges.

The U.S. population is 59% White but 64% of U.S. physicians are White. There is an even greater discrepancy for Asians who constitute 6% of the population but 21% of U.S. physicians. On the other hand, although 19% of the population is Hispanic, only 7% of physicians are Hispanic; 14% of the population is Black but only 6% of physicians are black. 1.6% of the population is Native American/Native Hawaiian/Pacific Islander but this group comprises only 0.4% of physicians.

The reasons for these racial disparities are complex and I’ve written in the past about my own thoughts on why there are so many Asian physicians in the U.S. The hard truth is that Black, Hispanic, and Native Americans are far less likely to become physicians than White or Asian Americans.

Race and medical student demographics

When we look at the most recent medical school admissions data from the AAMC, we see that there are notable changes in the racial demographics of our future doctors (who are currently first year medical students) compared to our current practicing doctors.

Notably, fewer of our medical students identify as being White (45%) compared to either currently practicing physicians (64%) or the U.S. population in general (59%). The percentage of medical students who identify as Hispanic (7%), Black (8%), or Asian (24%) are reasonably similar to the percentages of currently practicing physicians. However, the percentage of medical students who report being of mixed race is much higher (11%) than either that of practicing physicians (< 1%) or the U.S. population (1%). It is possible that this reflects a greater willingness of the younger generation of medical school applicants to identify as mixed race either because of greater comfort in professing to be of mixed race than previous generations or because of a perceived advantage in being mixed race when affirmative action was used as a criteria for deciding medical school admissions.

We are facing a physician shortage

Twenty five years ago, many medical economists projected that we would face a surplus of physicians in the future and recommended reducing the number of medical school admissions. Those projections have made a 180 degree turn. The AAMC now projects that by 2034, our country will face a shortage of somewhere between 37,800 and 124,000 physicians. Because completion of residency is required for medical licensure, the rate limiting factor in the number of practicing U.S. physicians is the number of residency positions in this country. Most residency positions are paid for by Medicare graduate medical education (GME) funds and consequently, Medicare determines the number of doctors entering the U.S. workforce. For many years, Congress did not increase Medicare funding for GME until 3 years ago, when Congress expanded the number of Medicare-funded residency positions by 1,200. A new bi-partisan bill proposed by Senators Bob Menendez, John Boozmen, Chuck Schumer, and Susan Collins would further increase the number of Medicare resident positions by 2,000 per year for seven years (14,000 in total). Because most residencies are 3 – 5 years in length, the net effect would be to increase the number of new practicing physicians by approximately 4,000 per year.

But where will those 4,000 new physicians come from? Unless we increase the number of U.S. medical students, these new physicians will be foreign medical graduates. Last year, U.S medical and osteopathic schools graduated 25,051 MD students and 7,303 DO students for a total of 32,354 new graduates. The majority of these new graduates then enter the National Resident Matching Program to be assigned to residency positions. Those medical school graduates who do not do residencies instead go into industry, research, or some other profession. Some medical school senior students apply to the few residency programs that do not participate in the Match. However, last year, 19,748 MD senior students and 7,436 DO senior students did apply for residency in the Match. In other words, there were a total of 27,184 US graduates of MD and DO schools applying for the 40,375 residency positions offered in the Match. Although not all U.S. medical and osteopathic school senior will match to a residency during the formal Match, most of those who do not get a residency position in the Match will get a position during the Supplemental Offer and Acceptance Program (SOAP) when unfilled residency programs seek out unmatched U.S. senior students. The bottom line is just about every U.S. MD or DO graduate who wants a residency position can get one (although it may not be their top choice).

The United States has long depended on international medical graduates to fill our physician workforce. Currently, 25% of licensed U.S. doctors attended a medical school outside of the U.S. Because there are more residency positions than U.S. medical and osteopathic school graduates, we depend on foreign medical graduates to fill our residency positions. Last year, 5,032 non-U.S. citizen foreign medical graduates matched to first year residency positions. In addition, 3,356 U.S. citizens attending international medical schools matched to residency positions. Since there is currently no surplus of U.S. MD and DO graduates to fill the 14,000 residency positions that the Senate proposes to increase, these positions will by necessity have to be filled by international medical school graduates.

So, where will all of these new foreign medical graduates come from? The most recent data indicates that 23% of foreign medical graduates in the United States come from India, 18% from the Caribbean, 6% from Pakistan, 6% from the Philippines, and 5% from Mexico. The remainder (52%) come from a wide variety of countries. Because Asian countries have the largest number of medical schools, we can expect that in the future, a disproportionately large percentage of foreign medical graduates entering U.S. residencies will continue to be Asian and a disproportionately small percentage will be Black or Hispanic. For example, India has 304 medical schools, China has 147, and Pakistan 86. On the other hand, there are only 143 medical schools on the entire continent of Africa (54 countries).

The implication is that in the future, as the number of residency positions increases, unless we increase the number of graduates from U.S. medical and osteopathic schools, we will likely see even wider racial disparities in the U.S. physician workforce due to the racial demographics of foreign medical graduates who apply to U.S. residency positions. It is incredibly expensive to build new medical schools – most are constructed using state government funding and few states are currently able (or willing) to pay for them. It is not just the cost of the physical buildings but also the cost of the faculty salaries for years 1 & 2 and the challenge in finding enough clinical preceptors for years 3 & 4. Consequently, it is unlikely that the proposed increase in Medicare-funded GME positions will be accompanied by a proportionate increase in the number of U.S. medical students, at least in the near future.

To improve physician racial disparities, start in kindergarten

Stating that college (and medical school) admissions should be colorblind turns a blind eye on racial disparities that exist during the 13 years of education before a high school senior applies to college. With public education supported by property taxes, poorer communities have less money for schools. This is amplified when state governments re-direct money for public education to pay for private schools and charter schools. Add in crime, gang violence, poverty, teenage pregnancy, and insecure housing in many communities with high percentages of Black, Hispanic, and Native Americans, and it is not surprising that high school seniors from these communities are at a competitive disadvantage when applying to college and medical school compared to those from more affluent communities.

To level the playing field for those coming from those communities, we must level the educational playing field starting in elementary school. That means ensuring that all American children have access to high quality education in our public schools. It means that a college degree needs to be affordable to all qualified applicants and not just those whose parents can afford the cost of tuition. It means increasing scholarships for low income high school seniors applying to college. It means improving financial literacy for students seeking educational loans and financial aid. It means that any American child should be able to have the audacity to dream of becoming a physician if they are smart enough and willing to work hard enough, regardless of their race or the neighborhood they grow up in.

Ask a room full of doctors how they came to choose a speciality and the majority will tell you that they were influenced by an admired mentor who served as a role model. Doctors live in affluent neighborhoods and serve as career role models for the children that live in those neighborhoods. Those doctors attend the neighborhood churches/synagogues/mosques/temples and the children of those doctors attend the neighborhood schools. One of our challenges in the United States is that Black, Hispanic, and Native American children often do not live in affluent neighborhoods and often lack physician role models. I don’t pretend to know how to fix this but it is a major barrier to overcoming the racial demographic disparities among practicing U.S. physicians.

In an ideal world, I would agree with Chief Justice Roberts that college and medical school admissions should be colorblind. The problem is that the U.S. educational system before getting to college and medical school is not colorblind. Eliminating affirmative action does nothing to address the root cause of racial disparities in the U.S. physician workforce. Indeed, it may make these disparities worse.

Discrimination versus disparity

Although similar, there are important differences between the terms discrimination and disparity. Discrimination is the unjust or prejudicial treatment of different categories of people, particularly on the grounds of race, ethnicity, age, sex, or disabilityDisparity is a lack of similarity or equality, particularly with respect to race, ethnicity, age, sex, or disability. Discrimination usually results in immediate disparity but disparity does not always result from discrimination and when it does, it can be from historical discrimination decades or even generations previously.

Disparities in U.S. medical student demographics is the result of historical racial discrimination in our country. However, disparities in our foreign medical graduate demographics is not a result of racial discrimination in our country but rather a result of where the world’s non-U.S. medical schools are located. These two disparities combine to cause the current racial disparities in the U.S. physician workforce.

Now that the Supreme Court has determined that affirmative action is itself discriminatory, we will have to find other ways to overcome the glaring racial disparities within the medical profession.

July 3, 2023