Emergency Department Inpatient Practice

What Do You Do When The Hospital Is Full?

The occupancy rate of a hospital is the percentage of available staffed beds that are currently occupied by patients. As the number of COVID cases surges this month, we are about to see our country’s hospitals more fully occupied than ever before.

The need to improve hospital financial efficiency has led many hospitals to try to keep their average occupancy as high as possible, often 90% or higher. But if the occupancy rate is too high, then inefficiencies arise that can be just as detrimental to hospital finances as when occupancy rates are too low. One danger of keeping the average occupancy rate too high is that the hospital cannot accommodate unexpected surges in admissions. This has been a significant problem for hospitals across the U.S. during the various case surges during the COVID-19 pandemic and will be even more so in the next few weeks.

What is occupancy? Most hospitals use the “midnight census” to track their occupancy rate. This is the number of patients in a bed at midnight each day. This metric works well for hotels since there is a defined check-out time in the morning and check-in time in the afternoon each day. However, this number can be misleading for hospitals because hotels, hospital admissions and discharges occur at continuously throughout the day and night with the result that the hospital census at noon is almost always higher than the census at midnight as morning admissions start to pile up while afternoon discharges are still occupying beds. As a consequence, a hospital may have 15% empty beds at midnight but have no empty beds at 2:00 PM. Therefore, the midnight census is useful from a financial standpoint but real-time census is more important from an operational standpoint.

It takes more than just a room with a bed… Not only do you have to have a physical place to put patients, but you have to have the nurses, doctors, pharmacists, and respiratory therapists to take care of them. During the COVID pandemic, at any given time, large numbers of these healthcare workers were unable to work due to having COVID themselves, having to isolate because of a COVID exposure, or having to stay home to take care of  child who was unable to attend school due to COVID. A single nurse can only safely take care of so many patients and if that number of patients is exceeded, then patient care can suffer. Moreover, nursing contracts and nursing units often place a limit on the number of patients a nurse can take care of and a limit on the number of hours per week a nurse can work. When the hospital lacks the personnel to care for patients, it has to “block-out” rooms from use.

Not all hospital beds are equal. Hospitals will try to group similar patients on a single nursing unit. This allows nurses to develop expertise in managing specific types of patients, for example, cardiac, pediatric, psychiatric, post-surgical, and maternity. This also creates better efficiency for the doctors so that, for example, a surgeon does not need to go to 7 different nursing units to round on his/her 7 post-op patients. But as nursing units become more and more specialized, it becomes less desirable to admit one kind patient to a different kind of unit. So, for example, having a lot of open beds in the addiction medicine ward does not really help you if you are trying to find a bed for a post-op neurosurgery patient and all of the surgical nursing units are full. Most hospitals will have a lot of “med-surg” units that can accommodate general medical patients or surgery patients.

What happens when there are no beds?

The need to accommodate the constant flow of admissions has resulted in hospitals putting a lot of resources into capacity management. Smaller hospitals often utilize a “nursing supervisor” who keeps up-to-date information on which patients are projected to be discharged and which patients are awaiting admission. Larger hospitals will utilize a admission control center staffed by multiple nurses whose sole responsibility is directing the flow of hospital admissions and patients being transferred from other hospitals; this is called “bed placement”. In most hospitals, the electronic medical record will facilitate this process by having dashboards that list open beds and beds occupied by patients who will be discharged later that day.

But what happens when all of the beds are full and there are more projected admissions than discharges for the rest of the day? That is when the hospital medical director generally gets involved. Here are the some of the available options:

  1. Expedite discharges. This is usually the first action taken and involves contacting all of the hospitalists and other attending physicians to ask them to hasten discharges. Most of the time, this only results in moving otherwise planned admissions up by a couple of hours but even that can help free up a few beds to help decompress admission bottlenecks. Simply having a discharge order does not ensure that an empty bed will be created, however. Nursing and case management can also expedite discharges by arranging earlier transportation home, by locating nursing homes with available beds, and by using “discharge suites” where discharged patents can wait for their rides.
  2. Focus on long-length-of-stay patients. Every hospital has a group of inpatients that have been admitted for many weeks or months. Often, these are patients who are difficult to get placed in nursing homes because they are uninsured or because they have behavioral problems. By creating  multidisciplinary workgroup to identify and overcome the barriers to discharge of these patients, desperately needed hospital beds can be opened up.
  3. Board admitted patients in the emergency department. There are a lot of reasons why boarder patients are undesirable (see my previous post). But in the short run, this is often the easiest way to accommodate a surge in admissions. If the number of boarders in the ER becomes too high, then the ER becomes congested and unable to provide care for regular emergency patients.
  4. Board post-surgical patients in the post-op recovery unit. Most patients recover in the recovery unit and then go to a regular hospital room to spend the night (for outpatient surgeries that require overnight observation) or spend several nights (for elective inpatient surgeries). Keeping patients in the recovery room longer can allow extra time needed to get other patients discharged and get those rooms cleaned and ready for the post-op patients. However, at some point, the recovery unit becomes full creating a bottleneck in patient flow in the operating rooms. One solution to this is multi-use space that can serve as pre-op beds in the morning and post-op beds in the afternoons. However, if patients remain in the recovery area into the evening or night, then you have to have the nurses to care for those patients and this either means keeping the post-op recovery area nurses overtime or “floating” nurses from other floors to the recovery area.
  5. Stop accepting hospital transfers. This is a tactic that only works for larger referral hospitals that normally have transfers comprise a significant percentage of their admissions. These transfers are usually patients with complex medical or surgical conditions coming from small hospitals that are not equipped to manage them and so these patients still need to be transferred somewhere. If all of the other referral hospitals in the area are also full, this can mean that the patient in a small hospital may need to be transported to a hospital in a far-away city or even another state. During the first surge in COVID cases in January 2021, it was not uncommon for me to get a call about transferring a patient with respiratory failure from a physician in a town such as Defiance, Ohio who had already had his patient turned down for transfer from all of the referral hospitals in Toledo, Dayton, Cincinnati, and Cleveland.
  6. Put the emergency department on divert. When the emergency department goes on divert status, emergency squads are directed to take patients to other emergency departments. This is undesirable from a community standpoint because it can result in delays in caring for critically ill patients by having the squads travel to emergency departments that are further away. There are a lot of reasons why an emergency department might go on divert: too many patients backed up in the waiting areas, a bolus of cardiac arrest or trauma patients that temporarily requires all of the available ER staff to manage, a hospital power failure, too many inpatient boarders in the ER, etc. During the COVID surges, there were days when all of the hospitals in Columbus were at full inpatient capacity and all of the emergency departments went on divert – when this happens, the agency that oversees regional trauma care institutes “city-wide divert”. In this situation, the region’s emergency squads go to hospitals on a rotational basis so that all hospitals share the excess patients equally.
  7. Cancel elective admissions. This mainly affects surgeries – both elective inpatient surgeries (such as spine surgery) and outpatient surgeries that require an overnight stay (such as knee replacement surgery). Hospital leaders hate to do this because these surgeries are very financially lucrative. The result is replacing a surgery patient that the hospital can make money on with a medical patient that the hospital can at best hope to break even on. In addition, by canceling surgeries, the surgeons and anesthesiologists are idle and the hospital usually ends up paying the salaries for these highly-paid physicians since they cannot earn their income in the operating room.
  8. Open up new beds. In a crisis, hospitals can convert many areas of the hospital into emergency-use patient care areas: decommissioned nursing units, the endoscopy suite, the sleep lab, the cardiac cath lab recovery area, etc. There is an inherent inefficiency to using these areas for inpatients as they are not equipped to care for inpatients and the normal nurses for these areas are unaccustomed to regular inpatient care. Also, when these areas are used for inpatients, they cannot be used for their normal purposes and this results in canceling  elective procedures.
  9. Create new space. When the hospital has maximized available space within the building, the next step is often to create temporary hospital space . During the initial surge in COVID cases, we erected a large tent in the parking lot adjacent to the emergency department to do triage and care for low-acuity emergency room patients. The Ohio National Guard helped to convert the Columbus Convention Center into a several hundred bed hospital area for low-acuity inpatients (that we fortunately never needed to utilize). Other hospitals converted parking garages, college dormitories, and hotel rooms into temporary patient care areas.
  10. Ration healthcare. This is usually done only as a last resort. Although often discussed in the U.S. during COVID surges, it was rarely, if ever implemented in our country. But in underdeveloped nations, this is a fact of daily life. If there are only 3 ventilators in a hospital with no others within several hundred miles, then the doctors have to choose which three patients get to use the ventilators. Even in developed countries, such as Italy, the first surge of COVID resulted in rationing of ventilators and ICU beds to only those patients felt to be most likely to survive.

Where do you find more doctors and nurses?

When hospitals start opening up new beds or new space for inpatients, those beds are only useful if there are doctors, nurses, and other staff available to cover them. During January 2021, we staffed new COVID ICU areas with anesthesiologists, hospitalists, trauma surgeons, and emergency medicine physicians rather than critical care internists. Recovery room nurses, addiction medicine nurses, and cardiac cath lab nurses were sent to staff med-surg nursing units and ICUs. We brought in general internists and family physicians who normally worked in outpatient clinics to function as hospitalists. CMS made an emergency allowance that residents and fellows in training could be temporarily credentialed as attending physicians and were allowed to bill for inpatient services. Many hospitals turned to recently retired physicians and nurses. “Traveler” nurses and locum tenens physicians (frequently from out of state) were often brought in to help with inpatient care.

Currently in Ohio, the governor has deployed the National Guard to the most crowded hospitals to assist. The problem with the National Guard is that most of the doctors and nurses in the National Guard are already tied up caring for patients in their own hospitals during the current COVID surge and so the only members of the National Guard available to help are non-healthcare workers who can only assist with support activities in hospitals.

Keeping up morale

When hospitals run out of beds and operate at full capacity (or over full capacity), it puts enormous strain on the mental health of the healthcare workers: Nurses who are caring for patients with conditions that they are not familiar with. Doctors who are taking care of more patients than they normally manage in a day. Everyone exhausted from working extra shifts. Angry patients and families lashing out at healthcare workers. Experiencing mounting numbers of deaths. All of these contribute to burn out. Even if the hospital administrators can open new physical beds, those beds are useless if the healthcare workers call-off work or quit due to burnout. Also, a toxic doctor or nurse may provide a needed warm body in the short run but will poison the workplace for other doctors and nurses in the long run. Fortunately, there are some things that medical directors can do.

  1. Communicate. This is probably the single most important tool that medical directors have to combat staff burnout. Times of crisis create information vacuums and unless hospital leaders communicate regularly, that vacuum will be filled by rumors and conspiracy theories. In-person town hall meetings, virtual Zoom meetings, daily website posts, and emails all have their roles and it is best to use a combination in order to ensure the largest audience possible.
  2. Be a cheerleader. More than any other time, during high capacity periods, medical directors and other hospital leaders need to get out of their offices and get into the patient care areas. It is essential that you are visible to the doctors and nurses and show that you are there to serve them. Look for excuses to give compliments. Show up at code blues, STEMI alerts, and trauma alerts. And don’t forget about the night shift staff.
  3. Recognize burnout. Knowing the signs of burnout can allow you to intervene early when burnout is still reversible. The worst thing you can do is to deny that burnout exists.
  4. Offer help. Counselors and other mental health professionals can help build resilience in the healthcare workers and making them freely available to hospital staff is a must.
  5. Offer accommodations. This could be as simple as allowing staff to do non-standard length shifts so that they can be home to take care of children. It could include reserving a block of hotel rooms for nurses who live out of town to stay in order to avoid long-distance commutes.
  6. Offer perks. Minor services  such as paying the cost of grocery delivery, Uber rides, baby sitting costs, and laundry services are relatively inexpensive for hospitals but can go a long way toward preventing burnout during times of healthcare worker stress from high inpatient capacity. Periodically buying pizza and cookies is a small measure but shows the staff that you are thinking about them.
  7. Pay them. Overtime compensation and bonuses are powerful prevention against disgruntlement. When the hospital is full for prolonged periods of time, it is probably losing money from canceled surgeries, etc. But this is why hospitals maintain a certain number of days cash on hand and the hospital should not be afraid to use those reserves.

U.S. hospitals are about to fill up

As of January 14, 2022, the United States is seeing not only the highest number of daily cases of COVID-19 than at anytime in the pandemic (red line in the graph above) but we are also seeing the highest number of patients hospitalized with COVID (yellow line in the graph above). From experience, we know that hospitalizations do not peak until 2-3 weeks after case numbers peak so our hospitals are only going to become more full before the end of this month. The good news is that the percent test positivity peaks about a week or so before the case numbers peak and the most recent data from the CDC suggests that the percent test positivity is just starting to come down (yellow line in the graph below). If this trend continues, then we should see the case numbers begin to fall within the next week or so.

But COVID does not affect different parts of the country at the same time and many cities and states may not see the peaks in case numbers and hospitalizations for several weeks.

Regardless, we are about to see our nation’s hospitals more full of patients than ever before and each hospital needs to develop plans for how it will get through the next month.

January 16, 2022

Epidemiology Outpatient Practice

COVID And Travel

We are now two years into the COVID-19 pandemic and there is a lot of pent-up demand for travel. Canceled vacations are being rescheduled. Postponed weddings are being booked. Grandparents want to see grandchildren who live in distance cities. People just want to get out. But the pandemic is far from over and travel precautions are as important now as ever. So, how should we advise our patients, families, and co-workers who plan travel?

First… the obvious

There are some travel precautions that can apply to anyone. Travel advice that should be universal includes:

  • Delay traveling until you are vaccinated
  • If you are vaccinated, get a booster before traveling
  • Make sure that your traveling companions are vaccinated
  • If you or your traveling companions have COVID-related symptoms, do not travel

What should you pack?

Since the pandemic began, I’ve made several driving trips to North Carolina, Maryland, and Virginia. I flew to Bar Harbor, Maine for a week of hiking. I flew to northern California for a week at the coast. I flew to San Francisco to visit with a new grandchild for several weeks. Here is my COVID packing list:

  • Rapid COVID tests. You never know whether test kits will be available at your travel destination. You may need one because of symptoms or because it will be prudent to test prior to visiting a relative with risk factors for severe COVID.
  • Extra face masks. Face masks get stuffed into pockets, get left on kitchen counters, and fall off into the mud. The elastic ear loops on surgical masks tend to break. Always carry extras with you.
  • Hand sanitizer. A good idea for travel before COVID and an even better idea during COVID. TSA now allows passengers to carry up to 12 ounces of alcohol hand sanitizers on aircraft. Keep a bottle in your car or in your purse.
  • Clorox wipes. Did a snotty nosed kid grab the door knob to the gas station two minutes before you did? Keeping sanitizing wipes in your car or hotel room can bring piece of mind.
  • Thermometer. Jet lag and sunburn can cause symptoms that can resemble COVID. You keep a thermometer at home in case you get a febrile illness – take it with you on vacation.
  • Oximeter. OK, admittedly I’m biased by being a pulmonologist. But I’ve seen too many “happy hypoxemic” COVID patients in the hospital who had oxygen saturations in the 80’s without any shortness of breath. If you do get COVID, checking your oxygen saturation is just as important as checking your temperature (and maybe more important).
  • Acetaminophen and/or NSAID. If you do get COVID while traveling, you are going to need to isolate yourself. That means not going to the local pharmacy to buy Tylenol so carry some with you.
  • Vaccine card. Here in Ohio, the idea of requiring a vaccine card is about as socially acceptable as laws about gun restriction. However, many communities require documentation of vaccination to go into a restaurant or bar. Even when not required by local ordinances, some restaurants and venues require evidence of documentation because it brings in otherwise wary customers. Take a picture of your card and keep it on your phone.
  • Extra medications. If you take prescription medications, bring enough to get you through a quarantine period in case you or a travel companion have to extend your travel time due to a COVID infection.

Travel within the U.S.

Check the websites first! The CDC’s COVID data website can give you up to date information about the prevalence of COVID at your travel destination and about percent of the county that is vaccinated. In addition, each state’s department of health website can give you even more data. City department of health websites can tell you about local indoor masking and vaccination documentation requirements. Current COVID-related hospital occupancy data can tell you whether or not you will have available healthcare if you fall and break your leg.

Car travel. Keep hand sanitizer, Clorox wipes, and extra masks in your car. Wear masks at all times when indoors at restaurants, rest stops, and gas stations. When driving from Ohio to North Carolina, we no longer stop at restaurants – we pack a lunch and eat it in the safety of our car. If you have to go through toll roads, EZpass allows you to skip the toll both attendants.

Restaurants. Check restaurant websites to find out if they require employees and/or customers to be vaccinated – if nothing else, these restaurants attract customers who take COVID seriously and consequently are less likely to be infected. Eat at off hours – instead of eating dinner at 6:00 PM, consider eating at 4:30 or 9:30 when the building will be less crowded. Consider carry-out – In Bar Harbor, we ate all of our dinners as carry out on the balcony of our hotel room overlooking the ocean – better scenery and no worrying whether the anti-masker at the table next to you is going to cough in your direction while you are eating your sandwich. In cities like New York and San Francisco, you must show your vaccine card to enter.

Minimizing risks during air travel

The airport is often riskier than the plane. Modern aircraft have very advanced air filtration systems. Cabin HEPA filters remove 99.9% of airborne viruses and the volume of air in the cabin is exchanged every 2-3 minutes. Air enters the cabin through the ceiling and exits the cabin through floor vents in the seat rows. In addition, each passenger can adjust their own personal overhead air vent for additional comfort and air flow. So, even though passengers are seated close together, the airflow systems provide a lot more safety than in a building, such as the airport. Furthermore, people tend to be less attentive to masking and social distancing in the terminals than once they get on the plane

In the airport: Avoid traveling on busy travel days – Tuesdays and Wednesdays tend to be the least busy. Use hand sanitizer liberally – as noted above, TSA currently allows you to carry 12 ounces of alcohol hand sanitizer, rather than the 3 ounce limit on other liquids. Maintain social distancing whenever possible – TSA precheck lines are generally less congested than the regular TSA lines; if you have layover, find the least busy gate to sit and wait until your aircraft boarding time. Avoid airport restaurants and bars – eat a meal before you leave home.

In the plane: Turn on your overhead air vent to increase the filtered air that you are breathing. Avoid or minimize eating and drinking during the flight – when the flight attendants pass out beverages and snacks, everyone tends to take their masks off to eat/drink at the same time so wait to eat or drink until after everyone else has finished and re-masked. When eating or drinking on the plane, try not to take your mask off for any longer than you can hold your breath. Wear a mask at all times – the greater the filtration of the mask the better; I am fortunate that I was fit-tested for an N-95 mask (with a beard) and that is the mask I wear.

Travel outside of the U.S.

Check the websites first! COVID travel restrictions are constantly changing and each country is very different. Some countries are not currently permitting non-essential travelers to enter. Check the government websites of any country you plan to visit to find out their specific travel requirements. Next, check the U.S. state department website for travel safety information about the country you will be traveling to. Finally, check the CDC website that stratifies the COVID risk of each country. Don’t go to countries that are classified as level 4 risks and if you can, select from those that are level 1 risks.

You may need COVID travel insurance. Although many commercial health insurance policies will provide at least some coverage for illness-related expenses abroad, most do not cover the cost of medical evacuation or quarantine housing. Many countries now require documentation of a COVID-specific travel insurance policy. These can be purchased on-line and typically run about $500 per person, depending on one’s age and duration of travel.

COVID testing prior to arrival. Most countries currently require travelers to have a negative COVID test prior to entry. Some require a PCR test while others will accept a rapid COVID test. Some require the test to be done within 24 hours prior to arrival, others require it within 48 hours, and others require testing to be done in the immigration area of the airport at the time of arrival. In all cases, some form of documentation of the test is required. For this reason, the self-read home test kits sold at your local pharmacy will not be sufficient. Many pharmacies and U.S. airports will do travel COVID testing with advance scheduling. If the country that you will be traveling to requires testing to be done in their immigration area, they will likely require payment in cash at the time of testing.

Will you need a COVID certificate? Some countries (for example, member of the European Union) require you to have a COVID certificate in order to go just about anywhere in that country. These can be obtained on-line from the each government’s website.

Returning to the U.S.

Check the websites first! The CDC travel website provides up to date information about entry requirements to get into the U.S., including requirement for U.S. citizens returning from travel abroad. These requirements can change so check this website when first planning a trip and again shortly before departing.

You will need a COVID test. The U.S. requires documentation of a negative COVID test (rapid or PCR) within 1 day prior to arrival. This is slightly different than the 24 or 48-hour requirement of most other countries. The test can be done anytime the day before arrival in the U.S. Many hotels and airports in other countries will perform testing and provide documentation for a fee. You can also do an at-home test that has telehealth proctoring. Importantly, most of the commercial test kits sold at pharmacies are self-read and do not have a telehealth component. Because you have to present documentation of a negative COVID test to get into the U.S., these self-read tests will not suffice. Examples of acceptable at-home tests include:

  • Abbott BinaxNOW
  • Ellume-AZOVA
  • Cue
  • Quered

Note that there are two versions of the Abbott BinaxNOW test – one that is sold at retail pharmacies and does not have a telehealth component and a second version that is sold on-line that does have a telehealth component. Only the second version is accepted for entry into the U.S. can can be ordered online at emed or optum. It is a good idea to pack at least one of these tests for each traveler, even if you plan to get your pre-U.S. entry COVID test at a hotel or airport at your travel destination – you just can predict if the hotel will run out of tests or if the airport has staffing issues on the day that you plan to fly back to the U.S.

Weighing the risks of travel

Patients would often ask me “Is it OK for me to travel?” Sometimes, the answer was a flat-out ‘no’ but more often, it was varying degrees of ‘maybe’. There are two considerations: the traveler’s personal risk factors and the risks associated with the travel destination. The good news is that people who have been vaccinated and boosted are at relatively low risk of getting so sick that they require hospitalization or die if they do get COVID while traveling. However, risk factors for severe infection such as advanced age, obesity, diabetes, hypertension, or immunosuppression must be factored in, even for those who are fully vaccinated. The travel destination is at least, if not more important. Locations where there is a culture of masking and vaccination are lower risk than areas dominated by anti-maskers and anti-vaxxers. Destinations where you won’t encounter crowds and where you will mostly be outdoors are lower risk than destinations where there will be crowded indoor areas. A vacation rental home where you will be eating your own meals is less risky than a hotel. Cruises are probably among the highest risk travel options.

Just being a human poses some degree of risk in this COVID pandemic. Traveling incurs some additional risk but the good news is that most people can minimize that risk by careful planning and taking the right precautions.

January 5, 2022

Physician Finances

Choosing A 529 Plan

At the time of writing this post, there are still 3 days to contribute to a 529 plan to take advantage of tax savings this year. So, if you haven’t maximized your annual contribution, now is the time to do so. For most families, life’s five biggest expenses are food, housing, healthcare, taxes, and children’s college education. The 529 plans uniquely allow you to lower your overall costs of two of these: your children’s education and your taxes. I funded all 4 of my children’s college costs through 529 plans and now I am looking at 529 plans for a grandchild.

What is a 529 plan? College is expensive. The average 4-year public college currently costs $102,640 and the average private college costs $215,796. Given the projected annual inflation in college costs, 18 year from now, a public university will cost $265,700 and a private college will cost $559,604. Financial aid and scholarships reduce these costs for most families but physicians generally have a high enough income that exempts them from financial aid and most scholarships. A 529 plan allows a parent (or grandparent or just about anyone) to put money into a 529 investment where it grows tax-free and when distributions are taken out for educational expenses, there is no tax on those distributions. These tax advantages make the 529 plans the absolutely best way to save money for a child’s college education. The account owner is usually a parent or grandparent; the account beneficiary is the child. If the account owner has several children/grandchildren in the 529 accounts that he/she owns, then residual funds in the account of one child can be rolled over into the account of another beneficiary after the first child completes their education. In addition to using 529 plans to pay for college, the money in a 529 plan can also be used to pay for K-12 tuition of up to $10,000 per year – this can be useful for children attending private elementary and secondary schools.

Each state has its own 529 plan. The 529 plans are state-specific and no two states’ plans are exactly alike. Most states will offer a variety of specific mutual funds within the 529 plan that you can choose from. Some states allow you to deduct contributions from your state income tax. Some states provide modest matching contributions. The annual expenses charged to the 529 account vary from state to state. The good news is that you do not need to live in a state to open a 529 plan in that state but the bad news is that tax deductions and matching contributions usually only apply when contributing to a 529 plan when you are a resident of that particular state. In general, the money in the 529 plans can be used for a college anywhere in the country and not just colleges located in the state administering the 529 plan.

Savings plans versus pre-paid tuition plans. Most 529 plans are savings plans that are essentially investment accounts that allow withdrawals for any education-related expenses (tuition, books, and room & board) for any college anywhere in the country. Five states currently also offer pre-paid tuition plans that allow the 529 contributions to purchase tuition for colleges in that state (Florida, Maryland, Michigan, Mississippi, and Nevada). This essentially allows you to lock in tuition purchases at today’s tuition prices and given how rapidly tuition costs have risen each year, there can be an attraction to the pre-paid tuition plans. I personally do not like the pre-paid tuition plans and even when Ohio did have a pre-paid tuition plan in the past, I avoided it. The reason is that if the child elects to go to a college in another state, the tuition credits cannot be used for out-of-state colleges. So, unless you live in one of the five states with pre-paid tuition plans AND your are 100% certain that your child will go to a public college in that state AND you are 100% certain that your child will not get a scholarship to attend that college, it is best to use a 529 savings plan rather than a 529 pre-paid tuition plan.

How to choose a 529 plan

Know whether your 529 plan contributions are tax-deductible. If the state that you live in offers a tax deduction (or a tax credit) from state income tax on contributions, then your state’s 529 plan is the one you should go with. Seven states even allow residents to deduct contributions made to 529 plans in other states (Arizona, Arkansas, Kansas, Minnesota, Missouri, Montana, and Pennsylvania). However, some states do not have state income tax and consequently there is no tax deduction advantage to residents of these states: Alaska, Florida, New Hampshire, Nevada, South Dakota Tennessee, Texas, Washington and Wyoming. Other states do have state income taxes but do not allow you to deduct 529 contributions: California, Delaware, Hawaii, Kentucky, Maine, New Jersey and North Carolina. For the rest of the states, the annual amount that is tax deductible varies from $500 ($1,000 if filing jointly) in Rhode Island to $20,000 ($30,000 if filing jointly) in Colorado. Here in Ohio, the amount that is tax deductible is $4,000 (regardless of whether filing single or jointly) but if you contribute to 529 accounts for multiple children, you can deduct contributions of up to $4,000 for each child from your Ohio state income taxes each year. If you live in a  state where there is no tax deduction, then you should base your 529 choice on the mutual fund options and annual expenses – this may mean investing in a 529 plan from a different state than the state that you live in.

Know what the fees are. There are many different fees that can be associated with each state’s 529 plan. In many cases, the amount of fees charged by the plan may be the deciding factor in selecting one state’s 529 plan over another state’s. Fees can include program management, maintenance, and administrative fees charged by the 529 plan itself. In addition, there will be investment fees charged by the mutual funds within the 529 plan. Many states offer “advisor-sold plans” where there is a company that actively manages the investment selections and charges additional advisor fees. All of these various fees can add up and can erode the value of the account if the fees are excessively high. The good news is that with different 529 plans in all 50 states plus the District of Columbia, competition between the states has helped to keep 529 fees down.

Know what the investment options are. Each 529 plan has multiple different mutual funds that you can select. These may include various stock funds, bond funds, age-based funds, advisor-directed accounts, certificates of deposit, and savings accounts. As a general rule, the younger a child is, the more aggressive option you should choose. As an example, a stock market index fund would be best for a 1-year old and a bond fund or certificate of deposit is preferable for a 17-year old. In 529 plans, I like the age-based funds because you can put money in the fund and then the investment company will automatically adjust the ratio of stocks:bonds each year based on the child’s age. Because of the lower expenses, I also prefer index funds over more costly advisor-directed funds.

Is there a match to contributions? In a few states, there is a small match to initial contributions for residents of that state. These can be an initial incentive to open new accounts. For example, Rhode Island will contribute $100 to 529 plans opened by Rhode Island residents for children before their first birthday. Illinois has a $50 contribution to new 529 plans for Illinois residents. In other states, a portion of initial contributions will be matched for low or middle income families. For example, California will match initial contributions up to $200 for California residents making less than $75,000 per year.

Where to get information. Start by checking with your state’s 529 plan website to learn whether contributions are tax-deductible, what the fees are, and what the investment options are. If you are in a state that does not allow you to deduct contributions from state income taxes, then you should compare different states’ 529 plans and chose one based on other factors, such as annual fees and mutual fund options. There are several good websites that allow you to compare 529 plans from different states, for example, and The 529 plans are constantly changing, so a plan that may be best for you one year may not be the best the next year. Forbes, Investopedia, and Morningstar rate 529 plans each year and these websites can provide useful recommendations.

What about grandparents?

For the past 3 decades, I based my 529  strategy based on the needs of my own children. Now that I am a grandfather, there are a number of other factors to consider when contributing to a 529 plan for a grandchild.

  • A child can be the beneficiary of more than one 529 account. Most typically this will happen if a parent has a 529 plan and one or both sets of grandparents want to open their own 529 account for the child. Or, the parents are divorced and both want to have separate 529 plans for their child.
  • If the 529 plan is in a state that considers contributions as tax-deductible, the grandparent can deduct contributions regardless of whether the 529 plan is owned by grandparent or owned by the parent (as long as the grandparent is a resident of that state).
  • Since the state tax deduction usually only applies when a grandparent contributes to his/her state of residency’s 529 plan, it is best to open a second 529 plan if the child’s parents live in another state and have their own 529 plan in that state.
  • A 529 account from one state can be transferred to a new 529 plan in a different state once per year. This can be an advantage if the 529 owner (parent or grandparent) moves from one state to another and wants to take advantage of state income tax deductions in the new state. It can also be an advantage if a different state’s 529 plan becomes more attractive due to lower expenses or better investment options.
  • The amount of money in a 529 plan that a parent owns will affect a child’s eligibility for financial aid in the FAFSA application. However, the money in a 529 plan that a grandparent owns is not factored into financial aid calculations for FAFSA purposes until that money is withdrawn for the child’s education (at which time, it will be considered as part of the child’s non-taxable income on the FAFSA form). Therefore, the best strategy is to use the parent’s 529 account for the first two years of college (when financial aid applications from FAFSA will be submitted) and then use the grandparent’s 529 account for the child’s last two years (when the FAFSA forms have already been submitted). This strategy optimizes the child’s financial aid and scholarship eligibility.
  • In most states, the ownership of a 529 plan can be transferred (for example, from a grandparent to a parent when the child gets close to college age).
  • Contributions to 529 plans are considered as a gift for federal income tax purposes. Therefore, they are subject to the maximum of $15,000 per person that can be gifted to an individual per year without that person having to pay income tax on the gift. If the grandparents (or parents) are married and file jointly, then each grandparent (or parent) can gift $15,000 for a total of $30,000 from the 2 grandparents (or the 2 parents). A unique feature of 529 funding is that the IRS allows people to do a 5-year front load to the 529 fund without incurring gift taxes. So, a grandparent or parent can contribute $75,000 initially to the 529 plan and then not do any contributions for next 4 years. This can allow more money to grow tax-free with the result of a larger balance in the account when the child reaches college age.
  • In addition to funding a 529 plan, grandparents can also pay tuition directly to the college once the grandchild is enrolled. A provision in the tax code exempts these direct tuition payments from the $15,000 per person per year gift limit ($30,000 if married and filing jointly). This is a strategy that parents often use to help pay for a child’s college expenses without exceeding the annual gift amount limit but it also applies to grandparents. For example, tuition at the University of Notre Dame (one of my children’s alma mater) is currently $58,843 per year. If a grandparent writes a check to a grandchild for that much money, the grandchild would have to pay income taxes for everything over $15,000 (in this case, that would be $43,843 of taxable income). On the other hand, if the grandparent pays the University of Notre Dame the $58,843 directly, then none of it appears as taxable income for the grandchild.

What I did

When 529 plans first came into existence, the Ohio plan was not very good – the mutual funds offered were expensive, the fund’s performance was poor, and the tax breaks were not attractive. So, I initially invested in Iowa’s 529 plan (at the time, I had never stepped foot in Iowa). The reason was that Iowa offered Vanguard index mutual funds with low expenses. When Ohio later changed to offer Vanguard funds and the tax deduction became more attractive, I moved my 529 fund from Iowa’s to Ohio’s. I selected age-based Vanguard index mutual funds for each of my four children and then did monthly direct deposits from my checking account into the Ohio 529 fund. By the time each child was in college, I had enough saved in their 529 accounts to pay for tuition, books, room & board for an in-state public university. When each of my children graduated from college, I rolled over the residual balance in their 529 account into one of my other children’s accounts. I am still using the residual fund balance in my youngest child’s 529 plan to help him out with his medical school costs.

For my new grandchild, I will open a new account in my Ohio 529 plan under my ownership to take advantage of the tax deduction on contributions to the plan. In the unlikely event that there is a residual balance in my son’s 529 account when he finishes medical school, I will roll that balance over to my grandchild’s account. If/when I have additional grandchildren, I will open new Ohio 529 accounts under my ownership for each of them so that if one of them gets a college scholarship or does not go to college, I can roll their fund balance over into one of the other grandchildren’s 529 accounts. I will likely hold off on taking distributions out of their 529 accounts until their junior and senior years of college in order to avoid negatively impacting their financial aid eligibility.

The time to act is now

This year, New Years Day falls on a Saturday so most state offices are closed on December 31st for a state holiday. Therefore, you have until December 30th to make contributions to a 529 plan this year in order to take advantage of a 2021 state tax deduction (if your state allows 529 contributions to be tax-deductible). Education is one of the best gifts that you can give to a child and 529 plans are the best way to invest in that education.

December 28, 2021


The Relationship Between Political Party And Deaths From COVID

Most Americans have had a sense that the COVID-19 pandemic has been politicized. By analyzing publicly available datasets, it is clear that there are striking differences between Republicans and Democrats with respect to COVID deaths, COVID infections, and COVID vaccination rates.

If you have not seen the graph created on the Infection Prevention, Emergency Management, & Safety blog, please click here to view it. This graph shows that there is a dramatic relationship between U.S. counties voting Republican versus Democrat in the 2020 presidential election and the rate of death from COVID infection in those counties. This graph was the inspiration for the following analysis.

Analysis Methods

Data regarding vaccination rates and death rates was obtained from the COVID-19 data sets available on the Centers for Disease Control’s COVID Data Tracker website. Data regarding COVID seroprevalence rates was obtained from the Nationwide Commercial Laboratory Antibody Surveillance Survey website. Results of the 2020 presidential election are available at many sources, including the Federal Elections Commission website. Data from all 50 states plus Washington D.C. were included (Puerto Ricans cannot vote in presidential elections). Statistical analysis was performed using 2-sample t-tests. For death rate analysis, data was obtained from three dates:

  1. January 23, 2020 to present. This represents death rates for the entire pandemic
  2. December 15, 2020 to present. This represents death rates since the date that COVID vaccines were first made available to limited U.S. populations
  3. April 19, 2021 to present. This represents death rates since the date that COVID vaccines became available to all Americans over age 16

Republicans are dying of COVID at a higher rate than Democrats

Because the population size of each state is different, the total number of COVID deaths per state tells us very little. Of greater importance is the number of deaths per 100,000 people in each state. Since April 19, 2021 (when vaccines were available to everyone over age 16), states that voted Republican in the 2020 presidential election have had a higher death rate from COVID than states that voted Democrat (89 per 100,000 versus 53 per 100,000; p < 0.0001).

Analyzing each state separately, there was a direct correlation between the percentage of voters in each state voting Republican and the death rate from COVID since April 19, 2021, regardless of whether the Republican or Democrat party won that particular state. The higher the percentage of Republican voters, the higher the death rate from COVID in individual states. Washington DC had both the lowest COVID death rate (15 per 100,000) and lowest percent of the population voting Republican (5.4%). Wyoming had both the highest COVID death rate (137 per 100,000) and the highest percent of the population voting Republican (69.9%). 

On December 15, 2020, COVID vaccines first became available to restricted populations. In most states, vaccines were initially limited to healthcare workers and high-risk nursing home residents. Assessing deaths since December 15, 2020, Republican states still have had a higher death rate than Democrat states (160 per 100,000 versus 111 per 100,000; P < 0.001)

Once again, there is a direct correlation between the percentage of voters in each state voting Republican and the death rate from COVID since December 15, 2020:

The first cases of COVID-19 in the United States occurred in January 2020. In the first months of the pandemic, there was slow adoption of social distancing and mask-wearing throughout the nation and as a consequence, the largest outbreak of infection initially occurred in New York City (New York voted Democrat in 2020). Despite this, Republican-voting states have had a significantly higher COVID death rate since the pandemic began than Democrat-voting states (252 per 100,000 versus 211 per 100,000; p = 0.019). However, the death rates are not as divergent as they have been since vaccines have been available.

There has been a direct correlation between COVID death rates and the percent of each state voting Republican in 2020 since the beginning of the pandemic on January 23, 2020. However, the slope of the correlation is not as steep as it is since vaccines became available, as shown in the previous scatter graphs.

More Republicans have had COVID-19 infection than Democrats

There are 3 databases that track the number of Americans who have had COVID infection: (1) nasopharyngeal testing reported to the CDC, (2) blood donor surveillance testing, and (3) the Nationwide Commercial Laboratory Antibody Surveillance Survey. In a previous post, the advantages and disadvantages of each of these was discussed but overall, the infection rates determined by the Commercial Laboratory Survey are probably the most accurate.

By comparing the seropositivity data from each state and then comparing states that voted Republican versus states that voted Democrat in 2020, a higher percentage of the population in Republican-voting states have had COVID infection since the pandemic began than in Democrat-voting states (34% of people in Republican states have been infected versus 24% of people in Democrat states; p = 0.0001).

As with the death rate data, there is a direct correlation between the percent of voters voting Republican in each state and the percentage of people in each state that have had a COVID infection since the pandemic began:

Republicans are less likely to be vaccinated than Democrats

Surveys, such as the Kaiser Family Foundation Vaccine Monitor, have indicated that Republicans are less likely to get vaccinated than Democrats. Although one’s political party is not asked about when getting vaccinated, by comparing state voting records with CDC vaccination data, Republicans do appear to be less vaccinated than Democrats. In states that voted Democrat in the 2020 presidential election, 78% of the population has received at least one dose of a COVID vaccine versus 63% of the population in states voting Republican (p < 0.0001).

Similar to the other analyses, there is a direct correlation between the percentage of voters in each state that voted Republican and the likelihood of being vaccinated:

The implications are clear

COVID infection is expensive. At the least, it results in greater employee absences, resulting in significant cost to employers. For many people, infection requires hospitalization, resulting in expensive healthcare costs that are passed on to taxpayers (through Medicare and Medicaid) and American workers (through commercial insurance premiums). Prolongation of the pandemic results in supply chain disruptions that in turn lead to costly increases in inflation. By being less vaccinated and having more COVID infections, Republicans are costing the nation more than Democrats.

The tragedy of COVID is not the financial costs but the cost of human lives. Thus far, more than 800,000 Americans have died from COVID and the projections are for the United States to surpass 1 million deaths before next summer. The above analysis indicates that Republicans are dying at a much faster rate than Democrats. It is my sincere hope that the party leaders get the message that dead people cannot vote and as the pandemic continues, there will be fewer Republicans alive to vote in the 2024 election. With the 2020 presidential election decided by razor-thin margins of votes in Georgia, Arizona, and Wisconsin, it is clear that neither political party can afford to have a disproportionate number of its voters die. However, by politicizing vaccination, mask-wearing, and social distancing, Republican voters are disproportionately dying and the Republican party is thus giving up votes to the Democrats.

As a full disclaimer, I am politically independent and do not affiliate with either party. In the 2020 general elections, I financially supported 2 Democrats and 2 Republicans running for various state and national offices. In this war of the pandemic, the enemy is not Democrats or Republicans, it is the virus… and you cannot win a war unless you know who the enemy really is. It is time for all of us to put our political party preferences aside and fight the true enemy.

December 17, 2021


One Year Of COVID Vaccines

One year ago today, at 7:00 AM on December 15, 2020, I was one of the first people in the United States to receive a Pfizer COVID-19 vaccination. What a wild and weird year it has been since then.

When the vaccines became available, many physicians thought that vaccination would bring an end to the pandemic by the summer of 2021, myself included. In fact, I was so confident that I timed my retirement to May 2021 to coincide with what was anticipated to be a return to normalcy. I could not have been more wrong.

In the first month of vaccine availability, the demand for vaccines greatly exceeded the supply of vaccines and consequently, a nationwide prioritization plan was developed. In Ohio, our governor directed that the first to be vaccinated were front-line healthcare workers and nursing home residents. It was up to individual hospitals to prioritize their healthcare workers. So, our medical center created a committee to determine which healthcare workers would be first to get vaccinated. We started with doctors, nurses, and respiratory therapists in the emergency departments and the intensive care units. As a critical care physician who was intubating and performing bronchoscopy on COVID patients, I was in the first group. I got the first vaccination appointment on the first day of the roll out at 7 AM on December 15th – not because I was the medical director of the hospital, but because I was the fastest to click on the on-line scheduling app when the emails went out to the ED and ICU staff announcing vaccination eligibility.

In the subsequent weeks, there was much controversy about which groups of healthcare workers would be eligible for vaccination next. Should outpatient primary care physicians be prioritized before radiology technicians? When should pharmacists get their vaccinations? What about housekeeping staff? The medical students lobbied to the Dean that they should get vaccinated and then opinion articles in our local newspaper complained that young medical students who were not caring for COVID inpatients were getting vaccinated before senior citizens with health conditions. Every day, those of us on the prioritization committee got emails from impassioned healthcare workers lobbying to be moved up on the vaccination schedule. January 2020 was a month of endless controversy.

As vaccine production ramped up, the Pfizer and Moderna products became more plentiful. The Governor made the vaccines available to Ohio seniors, followed by grocery workers and then first responders. On March 1, 2021, the Johnson & Johnson vaccine was authorized. On April 19, 2021, COVID-19 vaccines became available for all American adults under FDA emergency authorization and then on August 23, 2021, vaccines were fully approved by the FDA for all American adults. On October 29, the Pfizer vaccine was authorized for anyone over age 5 years old. The COVID pandemic should have been over by December 1st. But it wasn’t and it isn’t.

As of today, the CDC reports that 76.6% of Americans over age 5 have received at least one dose of a COVID vaccine and 64.8% are fully vaccinated. As of today, 29.2% of adults have received a booster dose. But there are still too many who are unvaccinated. Fully 15% of American adults have not received a dose of a COVID vaccine. Some have not been vaccinated because they are among the crazies or have gullibly been misinformed by the crazies; most have not been vaccinated because they are cowards.

So, who is left to get infected?

COVID infection can be prevented by either getting vaccinated or having antibodies from past infection. Neither of these will completely eliminate the risk of future COVID infection but they will reduce it and they will nearly eliminate the risk of dying from it. We have great data on the number of Americans who have been vaccinated but it is more difficult to know how many have already been infected. We have 3 databases that tell us how many Americans have been infected, each with its own advantages and disadvantages:

  1. Nasopharyngeal testing data. When a person gets a nasal swab to test for the SARS-CoV-2 virus, the results of that test are reported to the local health department that in turns reports the information to the CDC. Nasopharyngeal testing data indicates that there have been 50,082,008 cases of COVID or 15.0% of the U.S. population. Death certificate data indicates that there have been 796,010 deaths from COVID. Both of these numbers are underestimates. Many people who are infected do not get tested either because they are asymptomatic or because they choose not to be tested. In addition, many retail self-test kits do not require reporting results to the health department so people who do at-home tests can be positive but the CDC cannot track their numbers. The deaths are tracked by death certificate reports and if a physician does not list COVID on the death certificate, the health department will not know if COVID was responsible. Furthermore, many COVID victims are simply found dead at home without having undergone COVID testing and those patients’ primary care physicians simply make their best guess at the cause of death.
  2. Blood donation antibody data. The CDC has a program that anonymously tests samples from blood donations for antibodies against COVID. However, the antibodies tested can be from either previous vaccination or from previous infection. This data indicates that 91.8% of blood donors have either gotten vaccinated or have been infected. A problem with this data is that blood donors are not representative of the U.S. population at large. Blood donors tend to be more socially responsible and are thus more likely to be vaccinated than the average American. In addition, adults with chronic disease and children under age 16 cannot donate blood. The current data can be found here on the CDC website.
  3. Clinical laboratory antibody data. When a person has blood drawn for a clinical laboratory test, left over blood can be used (anonymously) for testing for COVID antibodies through a second CDC seroprevalence program. These can be blood samples drawn because a person was ill or because a healthy person was getting a routine cholesterol screening test. An important difference with this data versus the blood donation data is that the commercial lab testing only tests for antibodies that result from infection and not antibodies that result from vaccination. According to this data, 29.4% of Americans have been infected in the past. This implies that 87,128,000 Americans have had a COVID infection, nearly double the number determined by the nasopharyngeal testing data. Texas has the highest past infection prevalence at 43% of its population. Vermont has the lowest prevalence at 7.7% of its population A limitation of this data is that older people and chronically ill people are more likely to have blood tests than younger people and otherwise healthy people and so the information may not be representative of the American population as a whole. The up to date data can be found here on the CDC website.

In a previous post, I noted that there are demographic groups of the unvaccinated. They are more likely to be younger, male, Republican, rural residents with lower education levels and lower incomes. This has created a uniquely American political dilemma – this is a group that tends to be very vocal but is a group that does not tend to have a lot of money to spend in the economy. As a consequence, our elected officials can score political points and votes by appeasing them even though they do not have much economic clout. The past year has proven that science and public service announcements will not sway this demographic to get vaccinated. Instead, to convince them to get vaccinated will require harnessing that most powerful of all influencers – American advertising. Our corporate advertising agencies have been enormously successful convincing us to buy stuff that we don’t really need and it is in corporate interest to keep us buying stuff instead of dying from COVID. After all, dead people can’t buy cigarettes, tickets to NASCAR races, or country music records… and dead people can’t vote for the candidates from their favorite political party.

Vaccination is the road to a return to normal

This month, I traveled to San Francisco, California and what a difference it was compared to Columbus, Ohio. In San Francisco, everyone wore masks indoors at stores and public buildings; about half of people even wore masks walking outdoors on the sidewalk. The city has an ordinance that requires showing proof vaccination to enter a restaurant, club, bar, or gym. And the stores and restaurants were full – in short, life is almost back to normal. Shoppers feel safe going into a store and diners feel safe eating in a restaurant. More than 95% of all San Francisco residents over age 12 have received a COVID vaccine. As a consequence, despite the fact that the stores and businesses are bustling, the rate of new COVID infections (30 per 100,000 population) and COVID hospitalizations (only 21 in the past 7 days) are among the lowest in the United States.

Meanwhile, back in Columbus, those few restaurants that elected to require customer vaccination get picketed by anti-vaxxer protesters. Only 73.5% of residents over age 12 have gotten a vaccine. The rate of new COVID infections is currently 300 per 100,000 population and there were 351 COVID hospitalizations in Columbus during the past 7 days. In other words, despite being a much more densely populated community, the rate of COVID infection and hospitalization in San Francisco are only 1/10th of the rates in Columbus.

I felt comfortable shopping in San Francisco. It will be a long time before I am willing to eat in a restaurant or enter a store for anything other than essentials in Columbus.

Internationally, countries with more of their population vaccinated are poised to emerge from the pandemic sooner and return to economic prosperity faster. Those countries with fewer of their citizens vaccinated are doomed to pandemic-induced economic stagnation, supply chain disruption, and prolonged inflation. Countries that are leading in the vaccination race are (percent of population vaccinated):

    • United Arab Emirates (100%)
    • Cuba (90.1%)
    • Cayman Islands (89.9%)
    • Chili (89.8%)
    • Portugal (88.1%)
    • Cambodia (88.1%)

The United States is in 28th place overall with 72% of the total population receiving a vaccine. Among the states, there are some clear winners – New Hampshire (with 92% of its population having received a vaccine) leads the rest of the states followed by West Virginia (89%), Massachusetts (88%), Vermont (87%), and Connecticut (86%),  Ohio (with 59% of its population having received a vaccine) ranks 43rd out of all of the states in vaccination rates. Only Alabama (57%), Tennessee (57%), Louisiana (56%), Indiana (56%), Mississippi (54%), Wyoming (54%), and Idaho (51%) have worse vaccination rates. Ohio is in a race to the bottom – our vaccination rate is currently in-between that of India and Venezuela; more closely resembling a third world country than an industrialized nation. As a rule, businesses and tourists do not elect to go to war zones – the U.S. in general (and Ohio in particular) remains a COVID war zone while our competitors are winning their COVID wars.

If we want to get our Ohio businesses to successfully compete with businesses in other states and if we want to get U.S. tourism to successfully compete with tourism in other countries, then we need to get our populations vaccinated. Countries and states with high vaccination rates are poised to become the economic winners; those that do not will become the losers. After a full year of vaccine availability, we really should have done better.

December 15, 2021

Outpatient Practice

Should Doctors Apply To The Interstate Medical Licensure Compact?

Ohio has become the 35th state to join the Interstate Medical Licensure Compact. The Compact permits a physician in one state to easily obtain an expedited medical license in a different state. So, should you apply to the Compact?

What is the Interstate Medical Licensure Compact?

Each state has a state medical board that issues medical licenses but those licenses only allow a physician to practice medicine in that specific state. If a physician wants to practice in more than one state, then that physician must obtain a separate medical license from each of those states. In the past, only a minority of physicians held active licenses in two or more states – mainly physicians who live close to state borders with practice locations on both sides of the border, physicians who recently relocated to a different state, and locum tenens physicians who travel throughout multiple states doing short-term temporary jobs. Telemedicine has created a new need for physicians to hold medical licenses in multiple states.

The emergence of telemedicine in the 1990’s was accelerated in the early 2000’s by the use of electronic medical records. When telemedicine occurs across state lines, medical care is defined as occurring in the state that a patient is in, not the state that the physician is in. Therefore, physicians who practice telemedicine must have a separate medical license for each state that their patients reside in. The requirements for licensure differ from state to state with each state requiring separate applications, background checks, verification of training, and professional references. This process was often expensive and took several months. In 2014, a group of leaders from several state medical boards got together to develop a streamlined process for obtaining a medical license in more than one state and in 2017, the Interstate Medical Licensure Compact became operational.

In the past 4 years, more and more states have joined the Compact. Currently, 36 states are either active in the Compact or have legislation introduced to join the Compact. There are 14 states that are not members of the Compact and have not initiated the process of joining the Compact. These include all of the states shaded in gray below, most notably: New York, Florida, and California.

The Compact is administered by the Interstate Medical Licensure Commission. The Commission in turn is composed of 2 commissioners from the state medical boards of each participating state. As of June 2021, the Compact had processed 14,037 applications and had issued 20,976 medical licenses.

There is an analogous organization for nurses called the Nursing Licensure Compact that was originally developed in 2000, much earlier than the Interstate Medical Licensure Compact. The nursing compact has 38 currently active participating states with pending legislation in 8 more states.

Who is eligible to apply?

The first requirement is that a physician designate a State of Principal License, or SPL. A physician’s SPL must meet at least one of the following requirements:

  1. The physician’s primary residence is in the SPL
  2. At least 25% of the physician’s medical practice occurs in the SPL
  3. The physician is employed to practice medicine by a person, business or organization located in the SPL
  4. The physician uses the SPL as his or her state of residence for U.S. Federal Income Tax purposes

In addition to designating an SPL, there are other requirements for a physician to participate in the Compact. The physician must meet all of the following:

  1. Have graduated from an accredited medical school, or a school listed in the International Medical Education Directory
  2. Have successfully completed ACGME- or AOA-accredited graduate medical education
  3. Passed each component of the USMLE, COMLEX-USA, or equivalent in no more than three attempts for each component
  4. Hold a current specialty certification or time-unlimited certification by an ABMS or AOABOS board

Lastly, there are several exclusions to participating in the Compact. The physician cannot have any of the following:

  1. Any history of disciplinary actions toward their medical license
  2. Any criminal history
  3. Any history of controlled substance actions toward their medical license
  4. Currently be under investigation

Physicians who meet all of these criteria are eligible to apply to participate in the Compact. It is estimated that about 80% of U.S. physicians in participating SPL states are eligible.

What is the application process?

Physicians meeting the eligibility criteria apply to the Compact by paying a $700 application fee and getting a criminal background check (including fingerprints) from their State of Principal Licensure. The application is done on-line at the Compact’s website.

When the physician’s application is approved by the Compact, a Letter of Qualification is issued to that physician. The Letter of Qualification permits the physician to apply for medical licenses in any of the states participating in the Compact and it is good for 1 year. If the physician decides to apply for medical licenses in additional states later during the 1-year period that the Letter of Qualification is valid for, then there is an additional $100 administrative for each additional state the physician applies to. After the 1-year period is over, the physician must re-apply for a new Letter of Qualification if that physician wants to obtain medical licenses in additional states. When it comes time to renew medical licenses in those states that the physician originally obtained a license through the Compact, the renewals are done on-line on the Compact’s website.

In addition to the $700 Compact fee, there is also a fee charged by each state for a medical license. The fees vary from state to state and range from a low of $75 (Alabama) to a high of $790 (Maryland) with most states running around $300-$500. The fees for each state can be found by clicking here.

The average number of licenses that each physician obtains through the Compact is three. The average amount of time it takes to get each license is 19 days with 51% of licenses available within a week.

Should I apply?

If a physician only intends to practice in the state that he/she resides in, then there is no need to apply to the Compact. However, there are 5 groups of physicians who can benefit from obtaining additional state medical licenses through the Compact.

Locus tenens. Physicians who practice at hospitals or medical practices for short-term employment can more easily obtain licenses for the various states that they anticipate working in.

Physicians practicing close to state borders. Many physicians located near state borders may need hospital privileges at hospitals on both sides of the border or may have office practices on both sides of the border.

Physicians seeking new jobs. The standard application process to get a medical license can take a long time – for most states it takes about 3 months but in some states it can take up to 9 months. This can be a problem for residency and fellowship graduates obtaining their first job out of training if it is in a different state than their training program is located. This is also a problem for physicians who are changing jobs to a new practice in a different state. By expediting the licensure process, the Compact can greatly reduce the time required to get a license in a new state.

Medical volunteerism. Physicians often donate their time for providing free care to the underserved. By facilitating licensure, physicians will now be able to more easily provide that care to underserved populations in other states.

Telemedicine. This is perhaps the area of medicine that benefits the most from the Compact. Since telemedicine occurs in the state that the patient is located in, if a physician does not have a license in that particular state, then the physician cannot legally practice medicine via telemedicine with that patient. This was a particular problem for me in my subspecialty interstitial lung disease practice since many of my patients lived in West Virginia, Kentucky, Indiana and other states. Also, many of my patients would winter-over in southern states. If these patients had a medial issue arise while out of Ohio or if they just needed a regularly scheduled visit, they had to travel to within Ohio’s borders for me to legally do a telemedicine visit. During the early part of the COVID pandemic, I did most of my outpatient practice via telemedicine. However, many of my patients living in West Virginia had to either drive to Columbus for an in-person visit or forgo their regular visits since I did not have a West Virginia medical license and could not legally do telemedicine with them in their homes. During COVID, many states waived the telemedicine requirements so that out-of-state patients could legally have telemedicine visits with their doctors (but Ohio was not one of them). Even something as simple as prescribing an antibiotic for a patient with bronchitis or a course of steroids for a patient with an asthma flare is legally risky if that patient calls the office from another state. The Compact permits physicians to practice telemedicine in most states that their patients are located in without requiring those patients to travel the often long distances to get to the physician’s office for an in-person visit.

Don’t forget about malpractice insurance

Just because a physician has a license to practice in a specific state does not mean that their medical malpractice insurance will cover them in that state. This can be a particular problem with telemedicine – there is no guarantee that their policy covers telemedicine when the patient is out of state. Medical malpractice premiums vary considerably from one state to another, depending on a number of factors. Some states have passed malpractice reform legislation that has sharply reduced malpractice lawsuits in those states. In some states, there are limits to the monetary amount of malpractice claims. In other states there is a culture of litigiousness. All of these factors affect the cost of malpractice insurance. As an example, the average internal medicine physician’s malpractice premium is $3,261 in Wisconsin and $15,436 in Florida.

Before obtaining additional state medical licenses for telemedicine purposes, physicians should check with their medical malpractice insurance company to find out if they will be covered to do telemedicine in those states. Many physicians will be required to purchase additional multi-state liability coverage. Large medical centers that are self-insured may not permit their physicians to practice telemedicine in other states, particularly those states that are considered high-risk for malpractice lawsuits.

The future of the Compact

Ideally, all states would join the Interstate Medical Licensure Compact. However, there is a greater need for certain states/territories to participate in the Compact. Alaska, Hawaii, Puerto Rico, and the Virgin Islands could all benefit from participation because of their remoteness – by expediting medical licenses from out-of-state physicians, their citizens would have greater access to specialized care via telemedicine. As an example, there are no lung transplant centers in these states and territories. There is also a greater need for Florida to participate in the Compact given the number of people in the East Coast and Midwest who spend winters in Florida. By facilitating medical licensure for these winter resident’s out of state physicians, better continuity of care can be delivered.

Because participation in the Compact requires endorsement by each individual state’s medical board and requires approval by the legislature of each state, action to get all of the remaining states and territories must start from grass root efforts within each of these states and territories. The medical communities of some of these states could feel threatened by more out-of-state physicians providing medical care by telemedicine that would otherwise have been provided by physicians located in those states. However, the overall cost of medical care could be reduced by facilitating out-of-state telemedicine – it is far less expensive for a patient vacationing in Florida who develops a poison ivy rash to have a telemedicine visit with their primary care physician back in Michigan than to go to an emergency department in Florida.

The medical malpractice insurance barrier must also be addressed. Insurance companies can make it simpler to obtain policies that include multi-state telemedicine coverage. Large medical centers that are self-insured should also make multi-state telemedicine malpractice coverage more easy to obtain – it is in their best interest to enhance telemedicine professional revenue and also to attract more out-of-state patients to telemedicine care who would not otherwise have traveled to their state for in-person medical care.

The group that has perhaps the greatest potential benefit from the Compact are academic medical centers. Most are self-insured and can control the malpractice barrier to out-of-state telemedicine practice. By expanding their telemedicine reach to other states, physicians in academic medical centers can specialize in very specific diseases. For example, there may not be enough Ohioans with Birt-Hogg-Dube syndrome to support a practice specializing in Birt-Hogg-Dube but by marketing a telemedicine practice throughout a multi-state area, an enterprising academic physician could create a specialty clinic to optimize care to large numbers of patients with this rare disease and to develop research protocols for their evaluation and treatment. This is a golden opportunity for academic program development and for promotion & tenure pathways.

Physicians employed by the Veteran’s Administration and by the U.S. military can practice anywhere in the country as long as they are licensed in any one state. It is unlikely that a similar model will be adopted for non-governmental civilian medical licensure in the foreseeable future. However, the Compact is the next best option and our medical communities need to take the initiative to secure participation by all 50 states and all U.S. territories.

December 9, 2021


It’s Time To Put The Pandemic Blame On The Unvaccinated

Today is December 7, 2021 and the 80th year since the attack on Pearl Harbor that brought the United States into World War II. Today, we are in a different war – a war against the coronavirus. In every war there are those who sympathize with the enemy. In today’s war, the sympathizers are the unvaccinated.

On April 19, 2021, COVID-19 vaccines became available for all American adults under FDA emergency authorization and on August 23, 2021, vaccines were fully approved by the FDA for all American adults. Since that time, public health authorities have been careful to avoid placing any blame for the pandemic on the unvaccinated in order to avoid further political polarization. I am not a public health authority so I’m going to say it like it is – the unvaccinated are a primary reason that we are still in a pandemic. It is what doctors and nurses all over the country think but have not wanted to come out and say. The SARS-CoV-2 virus essentially declared war against the human race. Anti-vaxxers and anti-maskers do not stand for freedom – they are sympathizers with the virus in this COVID-19 war.

In the week after the attack on Pearl Harbor, a Gallop poll found that 9% of Americans did not want to fight back against Japan – presumably, these people just wanted the U.S. to roll over and become a Japanese territory. In the American Revolution, 15-20% of Americans were Loyalists (“Tories”) who sympathized with the British and were opposed to American independence – after the war, an estimated 200,000 of them left the new United States for Canada, the Caribbean, and England. Presently, 16.5% of American adults have not received at least one dose of a COVID-19 vaccine, roughly the same percentage of American adults who were Loyalists during the Revolution. Wittingly or unwittingly, they have sided with the virus and against the human race.

Who are the unvaccinated?

The unvaccinated are not the old and wise; instead, they are mostly younger. According to the CDC, >95% of American adults over age 65 have received at least one dose of a COVID-19 vaccine as of December 6, 2021. Based on the CDC graph below, 99.9% of Americans between 65-74 years old have received a COVID vaccine; in other words, only 1 out of 1,000 Americans in that age range has not been vaccinated! American seniors got vaccinated not because they were required to by employment mandates – most of them are already retired. They got vaccinated because they have lived long enough to know that in any war, when the enemy attacks you, your family, and your country, the only way you survive is by defending yourself. In this war, the only defenses that work are vaccination, wearing masks, and social distancing.

So, who are the unvaccinated? They are mostly young. According to data from the CDC, only 68.9% of American adults between 18 and 24 years old have received a vaccine. The likelihood of being vaccinated goes up in direct proportion to one’s age.

The unvaccinated are also more likely to be men. When you look at Americans of all age groups (including young children), 72.6% of women and girls have received a vaccine but only 68.0% of men and boys have received a vaccine.

Vaccination rates by race and ethnicity are much more difficult to determine. According to CDC vaccine administration data, Native Americans are the most vaccinated group followed by Asian Americans, Hispanic Americans, White Americans, and Black Americans. However, the CDC does not have race or ethnicity data for fully 1/3 of people who have been vaccinated. Therefore, statistics from the CDC vaccine administration race and ethnicity data are incomplete. 43 states report race/ethnicity statistics from state health department data. According to these state statistics, Asian Americans are the most vaccinated, followed by White, Hispanic, and then Black Americans. A third way of examining race and ethnicity vaccination differences is by telephone surveys. The National Immunization Survey is a telephone survey involving a sample of the adult population in all states. According to the most recent survey, Asian Americans are the most vaccinated followed by Hispanic, then Black, then White. An inherent problem with telephone surveys is that their accuracy depends on (1) who has a telephone, (2) who is willing to take a survey when the phone rings, and (3) how accurately and honestly a person answers the survey questions. Given the rather dramatic differences in the results of the three methods of assessing the data, the only conclusion that seems certain is that Asian Americans are the most heavily vaccinated group and beyond that, we really do not know how race and ethnicity affect vaccination rates.

There is better data on vaccination rates by community size. The larger the city or town a person lives in, the more likely that person is to be vaccinated. People living in rural communities have the lowest rates based on CDC data. The graph below shows urban versus rural fully vaccinated rates for all ages (not just adults).

Not surprisingly, states with large urban populations are doing better than states with larger rural populations. Coastal states have a greater percentage of their populations vaccinated than southern and midwestern states. My state of Ohio is among the worst performers from a vaccination standpoint. Much has been written about vaccination disparities among racial/ethnic groups but those differences pale when compared to the rural versus urban disparities. When vaccines first became available, the thought was that the low vaccination rates in rural areas were due to less access to the vaccines in those areas; now that vaccines are widely available, it is clear that remaining unvaccinated is a conscious choice that rural people are making.

The unvaccinated are costing all of us

When a person becomes hospitalized because of illness, the cost of that hospitalization is paid for by an insurance company or the federal government (by way of Medicare, Medicaid, VA benefits, or the Federal Employees Health Benefits program). Those costs are then transferred to all Americans by higher health insurance premiums and higher taxes. At this point in the pandemic, the overwhelming majority of Americans hospitalized with COVID-19 are unvaccinated. People who are not vaccinated are 12 times more likely to be hospitalized with COVID-19. Most of the vaccinated patients who are hospitalized are immunocompromised – transplant patients, patients taking chemotherapy, and patients with immunodeficiencies. We are all paying the enormous healthcare costs for the minority of Americans who choose to be unvaccinated.

In addition to occupying our hospital beds, the unvaccinated are far more likely to occupy our hospital morgues. Unvaccinated people are 14 times more likely to die of COVID-19 than the vaccinated. Once again, most of the vaccinated who die of COVID-19 are immunocompromised.

More unvaccinated = more variants

Viruses mutate – that is how they survive. Mutations occur predictably based on the number of individual viruses that exist at any given time. The more people who are unvaccinated, the more viruses are in circulation. Mutations that result in a more contagious variant then quickly become the dominant virus – it is simple survival of the fittest.

The Delta variant originated in India in December 2020. The reason? Vaccines were not yet available and India was undergoing a surge in COVID-19 cases that month. With the massive number of viruses circulating in India, the Delta variant was born.

The Omicron variant originated in South Africa in November 2021. The reason? South Africa had a very low vaccination rate with only 23% of the population fully vaccinated. Omicron causes infection that is far more contagious than the original COVID-19 infections. As an example, there were 120 people who attended a corporate Christmas party in Norway on November 26, 2021. One attendee had just arrived from South Africa and was infected with Omicron. By the end of the party, more than half of the attendees had become infected with Omicron. Fortunately, the attendees were all young (it was a corporate event – they were all of working age) and were all vaccinated so the Omicron illnesses were relatively mild and no one died (at least, not yet). Had it been a nursing home Christmas party rather than a company holiday party, the death toll would have been staggering.

Delta and Omicron will not be the last COVID variants. As long as there are groups of unvaccinated people, new and more contagious variants will emerge.

How do we bring an end to the coronavirus war?

In the beginning of the pandemic, we all owned it – every human being on the planet. Now, it is the unvaccinated who own it. To those who cry “Freedom!” in the name of being unmasked and unvaccinated, I say that if you want life to get back to a pre-pandemic normal, then get vaccinated and wear a mask. You are the ones who are holding us back. Our country prevailed in the American Revolution and in World War II because Americans had a common enemy. The SARS-CoV-2 virus is the human race’s common enemy – black and white, urban and rural, Republican and Democrat. The longer we bicker among ourselves by perpetuating a myth that the pandemic is a political issue, the more casualties the virus will inflict on us. Those who politicize the pandemic are enablers of the pandemic.

If you want to be able to go to a restaurant or a church without having to be 6 feet away from other people, then get vaccinated. If you want your kids to be able to go to school without wearing a mask, then get vaccinated. If you want to prevent your health insurance premiums and Medicare taxes from increasing, then get vaccinated. If you want to see shuttered businesses re-open, then get vaccinated. But if you remain unvaccinated, then this pandemic is on you. The only conceivable reason to be unvaccinated in the United States at this point is cowardice. Wars are won by the patriots. Patriots who fought for independence won the American Revolution 238 years ago. Patriots who supported the U.S. war effort won World War II after Pearl Harbor was attacked 80 years ago today. In the war against the coronavirus, the patriots are the men, women, and children who got vaccinated.

December 7, 2021

Physician Finances Physician Retirement Planning

‘Tis The Season… For Tax Loss Harvesting

Who doesn’t like free money? “Tax loss harvesting” is an investment tactic that does just that – gives you free money. And December is just the time to do it. Careful use of tax loss harvesting can take off up to $3,000 from your taxable income this year, just in time for the Christmas holidays.

What is tax loss harvesting?

In brief, tax loss harvesting allows you to off-set capital gains or regular income with capital losses from investments. Here is how it works. When you have an investment such as a stock or mutual fund that increases in value, the difference between the price that you paid to buy it and the price when you sold it is capital gains. If that difference is a positive value, you pay taxes on those capital gains based on your capital gains tax rate which in turn depends on your income level. There are two types of capital gains: short-term and long-term. Short-term capital gains are those on investments that you have held for less than 1 year and are taxed at your regular income tax rate. Long-term capital gains are on investments you have held for more than 1 year and are taxed at your capital gains tax rate. Most people fall into the 15% capital gains tax rate bracket.

IMPORTANT: capital gains taxes only apply to regular investments and not retirement accounts such as a 401(k), 403(b), 457, or IRA. You will pay regular income tax on all withdrawals from retirement accounts.

One the other hand, if that investment lost value from the time you bought it to the time you sold it, you have a capital loss and this is where tax loss harvesting comes into play. There are two types of tax loss harvesting:

  1. Use a capital loss to offset a capital gain. You get taxed on your net capital gains when you add up all of the investments you sold that you made money on and lost money on. So, if you made $5,000 in long=term capital gains from the sale of one investment but had $5,000 in long-term capital losses from the sale of another investment, the gains and the losses balance out so you do not owe any money in capital gains taxes that year. You have to track and report short-term and long-term capital gains/losses individually and the IRS requires you to first apply short-term losses against short-term gains and apply long-term losses against long-term gains before you can apply short-term losses against long-term gains and vice versa so the IRS reporting on your tax forms can get a bit complicated.
  2. Use a capital loss to offset regular income. What happens if you either do not sell any investments for a capital gain this year or if you sold more investments for a loss than you sold for a gain? You can apply net capital losses up to $3,000 against your regular income. In other words, you can reduce your taxable regular income by $3,000. If your effective income tax rate is 18.00%, that means that you can avoid paying $540 in income tax on that $3,000. In addition, that reduction of $3,000 from your taxable income will drop your effective income tax rate to 17.93% which in turn will drop your income tax by an additional $180 for a total reduction of $720 in income tax.  The net effect: you get $720 in free money!

What are the rules?

First, you have to be able to calculate your cost basis (what you actually paid when you originally purchased an investment). To do that, you have to know the date that you bought an investment and the date that you sold an investment. You also need to know the amount of money that you originally paid for that investment when you bought it and the amount of money you sold it for. This can get a little tricky if you purchased shares of a stock (or mutual fund) on different dates. It can also get tricky if you are automatically re-investing dividends from a stock (or mutual fund) to purchase additional shares of that stock (or mutual fund). Fortunately, most of the large investment companies will track your mutual fund investments for you and will be able to tell you what your short-term and long-term capital gains are at any given time with just a click of your mouse. This allows you to calculate how many shares of a mutual fund you need to sell in order to have a $3,000 capital loss.

Second, you have to avoid a wash sale. The IRS does not allow you to sell an investment to take a loss and then turn around and immediately buy back that investment right away – this is called a wash sale. To avoid wash sale penalties, you have to wait at least 30 days before you purchase shares of the stock (or mutual fund) that you just sold. You can, however, sell a losing stock (or mutual fund) and use the proceeds to buy a different, dissimilar stock (or mutual fund).

Third, you have to fill out IRS form 8949 when you fill out your annual income tax forms. This form summarizes all of the investments that you sold during that tax year. The total amount from form 8949 then has to be reported on schedule D of your 1040 form. Schedule D is where you can deduct up to $3,000 from your taxable income.

What should I sell?

We are living in the longest bull market in U.S. history. Except for the 6 months between February and August 2020 (onset of COVID), the overall stock market has been steadily going up for the past 11 years. As a consequence, most broad market mutual funds and most individual stock have increased in value rather than decreased in value so you may not have any investments to qualify for tax loss harvesting. However, certain specific types of investments have lost money over the past few years. For example, many U.S. and foreign bond mutual funds have lost value over the year and energy sector mutual funds have lost value over the past 10 years. Check all of the specific stocks and mutual funds in your investment portfolio – those that have lost value since you purchased them are eligible for tax loss harvesting.

It is important that you keep sight of your overall investment strategy which should involve maintaining a diversified portfolio of individual investments. Beware of selling off too much of any one type of investment if it puts your overall portfolio out of balance. For example, don’t sell all of your bond funds in order to harvest a tax loss or you will end up with a portfolio comprised exclusively of stocks and thus making you vulnerable to your portfolio losing too much money if/when the stock market falls in the future. If you sell shares of an energy sector stock mutual fund for tax loss harvesting purposes and you feel compelled to have energy stocks for long term investment purposes, just remember that you have to wait more than 30 days before you can buy new shares of that energy fund.

My investment philosophy has always been to “buy and hold”since investment should be for the long term. Stocks and bonds will go up and down in value and the wise investor will ride out the downs in order to take advantage of the inevitable ups. Tax loss harvesting is one exception to this strategy that can reduce your taxes and put more money in your pocket.

December 3, 2021

Medical Education Procedure Areas

How To Interpret Pulmonary Function Tests

Pulmonary function tests (PFTs) can be very intimidating. A PFT report has many different numbers and for the non-pulmonologist, it is often difficult to know which ones are important and what they mean. As a consequence, many non-pulmonologists just look at the computer-generated interpretation and ignore all of the numbers. The bad news is that the computer-generated PFT interpretations are woefully bad – the computer is pretty good at identifying normal but generally terrible at identifying degrees of abnormal. The good news is that PFT interpretation is actually very easy and in this post, I am going to show you everything you need to know to interpret 99% of the PFTs that you order by looking at just 5 numbers. There are fundamentally four components to a complete PFT: spirometry, lung volumes, diffusing capacity, and the flow-volume loop. We will next look at each of these components.


Spirometry is the most common PFT that you will order. It can either be performed by a respiratory therapist in a pulmonary function lab using an expensive PFT machine (> $50,000) or it can be performed by a nurse in an office setting using a portable spirometer (about $1,000). Spirometry is primarily a measurement of air flow and is used to determine whether or not a patient has obstructive lung disease.

You will see a lot of different numbers on a spirometry report but the only ones that are truly important are the forced vital capacity (FVC), the forced expiratory volume in the first second of exhalation (FEV1), and FEV1/FVC which is the ratio of these two numbers. The other numbers are of minimal importance and you can ignore them. The results of the FVC and FEV1 will be listed both as actual values (in liters of air) and as the percent of predicted. In order to determine the percent of predicted, researchers have measured the FEV1 and FVC of thousands of normal people to determine what a normal value is. “Normal” depends on a person’s age, height, gender, and race so it is important that these demographic elements are correctly entered into the PFT machine so that the computer in the machine picks out the correct normal value based on that patient’s age, height, race, and gender. If the patient’s FEV1 or FVC is lower than the 5th percentile of normals (lower limit of normal), then the PFT machine will flag the result – usually with a different color font or an asterisk by the number.

The ratio between these two numbers, the FEV1/FVC, tells you whether or not the patient is obstructed. If the FEV1/FVC is too low, the patient is obstructed and if the FEV1/FVC is either normal or higher than normal, then the patient is not obstructed.  There are 2 definitions of a “normal” FEV1/FVC that are commonly used. The first (and most common) is the definition used by the American Thoracic Society (ATS) – it is based on a patient’s age because the older we get, the lower a normal person’s FEV1/FVC becomes simply as a result of normal aging. The average FEV1/FVC for a 20-year-old is 87% whereas the average FEV1/FVC for an 84-year-old is 71% and the lower limit of normal for an 84-year-old is 59%. The computer in the PFT machine will flag the FEV1/FVC as being too low based on whatever age is entered in the patient demographics. The second definition of normal FEV1/FVC is used by the Global initiative for chronic Obstructive Lung Disease (GOLD) which uses a flat FEV1/FVC ratio of 70% as being normal for everyone and does not make any adjustments based on a person’s age. Almost all PFT machines will use the ATS method when generating a PFT report but Medicare requires the GOLD method when determining eligibility for enrollment in pulmonary rehabilitation.

If the FEV1/FVC ratio is low for the patient’s age, then the next step is to determine how obstructed they are. This is determined by how low the FEV1 is. IMPORTANT: if the FEV1/FVC ratio is normal, then it does not matter how low the FEV1 is since that patient is not obstructed. The severity of obstruction is usually based on the ATS criteria but once again, the GOLD criteria is different.

If a patient is found to have obstruction based on a low FEV1/FVC, then sometimes a bronchodilator study is performed by giving the patient an albuterol treatment and then repeating the spirometry a few minutes later. Reversible obstruction is defined as an increase in either the FEV1 or FVC by 12% after albuterol. In addition, the amount of the increase in FEV1 or FVC must be at least 200 ml to qualify as reversible obstruction. If the initial FEV1/FVC is normal, there is no point in doing a bronchodilator study.

For the spirometry test result to be accurate, three things must occur: (1) the patient’s age, race, height, and gender must be entered correctly, (2) the patient must be coached correctly by the nurse or respiratory therapist administering the test and the patient must give a good effort, and (3) the physician or advance practice provider must correctly interpret the test.

Steps in spirometry interpretation:

  1. Is the patient obstructed? This is determined by whether the FEV1/FVC ratio is low.
  2. If they are obstructed, how obstructed are they? This is determined by how low the FEV1 is below normal.
  3. If they are obstructed, is the obstruction reversible? This is determined by the amount of increase in the FEV1 and/or FVC after albuterol.

Lung Volumes

Lung volumes cannot be measured using an office spirometer and require testing in a pulmonary function laboratory. This is typically done by having a person sit in a plethysmographic box and performing a series of inhalation and exhalation maneuvers. Once again, the PFT machine will generate a whole bunch of numbers but the only one that is really important is the total lung capacity (TLC). If this number is too low, then the patient is restricted and if it is too high, then the patient is hyperinflated. Just as in spirometry, the TLC percent predicted is based on the patient’s age, height, race, and gender.

Of note, some office spirometry machines will give a computer-generated interpretation of restriction based on the FVC alone. You really cannot diagnose restriction using the FVC alone from spirometry, the diagnosis requires measuring the TLC with lung volumes – the FVC can sometimes be low when the TLC is totally normal. The finding of a low FVC on office spirometry should merely be an indication to send that patient to the pulmonary function lab for a complete set of PFTs that includes lung volume measurements.

If the TLC is larger than the upper limit of normal (generally around 120% of predicted), then the patient is hyperinflated. The only other number that is worth knowing about is the residual volume (RV). If the RV is too high (above the upper limit of normal), then the patient has air-trapping. Patients who are obstructed will often also have hyperinflation or air-trapping. In fact, isolated air-trapping alone can indicate early obstruction, even when the FEV1/FVC ratio is normal.

Diffusing Capacity

The DLCO is the “Diffusing capacity of the Lung for carbon monoxide (CO)”. This is measured by having the patient breath a tiny amount of carbon monoxide gas and then comparing the amount of carbon monoxide in the inhaled gas versus the amount in the exhaled gas. The difference indicates how much of the carbon monoxide was taken up by the body (the carbon monoxide binds to hemoglobin in the bloodstream). The more carbon monoxide is taken up, the easier it is for gases to get from the air a person breaths into the bloodstream. If the amount of carbon monoxide taken up is low, then this is a sign that gases cannot move normally from the lungs into the bloodstream.

The DLCO will be low in diseases such as emphysema and interstitial lung disease. However, the DLCO can also be low if the patient has small lung volumes for any reason. Because of this, the PFT machine will often report the DLCO/VA where the VA stands for “alveolar volume” and is more or less the same thing as the total lung capacity. The DLCO/VA is a better measurement of diffusing capacity in situations such as previous partial lung removal or restriction due to muscle weakness. The DLCO can also be low if the patient is anemic. For this reason, the PFT machine will often report the DLCOcor which is the DLCO corrected for the patient’s hemoglobin level. Whether to use the DLCO, the DLCO/VA, or DLCOcor is a matter of debate. Most of the time, you can just go by the DLCO unless the patient is known to have significant anemia or a prior lung resection.

Flow-Volume Loops

Interpreting the flow-volume loop involves looking at the pattern of the graph of airflow during inhalation and exhalation. The PFT machine will not provide an interpretation of the flow-volume loop so the physician or advance practice provider must do their own interpretation. There is a wealth of information in these graphs but too often, people ignore the flow-volume loop and go straight to the PFT numbers. This is a mistake because sometimes the only clue to a disease is found in the shape of the flow-volume loop. Also, the shape of the loop can be an indication that the patient gave poor effort during the test and the results may not be valid. The figure below shows the elements of a normal flow-volume loop with exhalation occurring during the top part of the loop and inhalation occurring during the bottom part. PEF is the peak expiratory flow. The FEF25% and FEF75% are the flow rates between the first 25% of the volume of exhaled air and the last 25% of the exhaled air. But what is important is the shape of the curve.

The shape of the normal loop should have an early expiratory peak with a gradual drop downward until the patient reaches the maximum amount of air that they can exhale (FVC). The inspiratory portion of the loop on the bottom should be more symmetric and look sort of like a half-circle. If the patient does not give a good effort, then the test is invalid and you should not believe the FVC or FEV1 numbers. In this situation, the shape of the loop will be very irregular as shown below:

Coughing during the test will also invalidate spirometry results and can be identified by a sudden drop in expiration causing a crevice or “double hump” to appear in the top portion of the loop:

There are two conditions that can result in flattening of the flow-volume loop. Vocal cord paralysis will cause flattening of the inspiratory limp but the expiratory limb will appear normal. Tracheostenosis will cause flattening of both the inspiratory and expiratory limbs of the flow-volume loop:

Patients with vocal cord dysfunction will clinically mimic asthma with dyspnea and wheezing. The flow-volume loop is often the first clue that a patient has vocal cord dysfunction. The expiratory limb of the flow-volume loop will appear normal but the inspiratory limb will be choppy and irregular. Vocal cord dysfunction can be confirmed by ordering a videolaryngostroboscopy study that will show that the vocal cords come together too much during inspiration, particular in the anterior portion of the vocal cords (anterior is the top portion of the photos below).

Putting it all together

If y0u have a full set of pulmonary function tests, these are the steps to interpreting the results that will be all you need to do in 99% of the PFTs you order:

  1. Is the spirometry test valid? Look at the shape of the flow-volume loop and also confirm that the patient’s demographics were correctly entered.
  2. Is the patient obstructed? Look to see if the FEV1/FVC ratio is low.
  3. If they are obstructed, how obstructed are they? This is determined by how low the FEV1 is below normal.
  4. If they are obstructed, is the obstruction reversible? This is determined by the amount of increase in the FEV1 and/or FVC after albuterol.
  5. Is the patient restricted? Restriction is present if the TLC is below the lower limit of normal.
  6. Is the diffusing capacity reduced? This is defined as a DLCO that is below the lower limit of normal.

Every type of lung disease will give a particular pattern of PFT results. The following table summarizes the most common lung conditions and their PFT patterns. The cells in the table that are shaded yellow are the key findings that point toward each of these 4 conditions:

When it comes to PFT interpretation, less is more. You really only need to know 5 numbers to interpret the overwhelming majority of PFTs. You can ignore the rest of the data and leave that for us pulmonologists who like to get way down in the weeds of the PFT report.

December 2, 2021


Why COVID-19 Will Never Go Away

There are only three kinds of people: those who have been vaccinated for COVID-19, those who will survive COVD-19 infection, and those who will die of COVID-19 infection. Eventual exposure to the SARS-Cov-2 virus is inevitable and the virus will, in all likelihood, be with the human race for generations. The reason is because it is a unique zoonotic virus that infects so many different mammals.

A zoonotic infection is one that can be passed from animals to humans. Some of the most lethal pandemics in human history can be traced to zoonotic infections. The plague (Yersinia pestis) was carried by rats and transmitted to humans through the Oriental rat flee. Ebola is transmitted to humans from fruit bats that carry the virus without becoming sick. Hantavirus is carried by asymptomatic wild mice that can transmit it to humans. The 2009 H1N1 influenza strain (swine flu) came from pigs. Rabies, West Nile virus, Lyme disease… there are more than 250 infections that can be passed from animals to humans. The SARS-CoV-2 virus most likely jumped from horseshoe bats to other wild mammals and then to humans in the Wuhan region of China in late 2019.

Most zoonotic viruses are not easily passed from one human to another – think Zika, rabies, and hantavirus. These viruses can be largely prevented by avoiding contact with the animals that serve as viral reservoirs. Those few viruses that can be easily transmitted from one human to another are really scary – think about Ebola, for example. The reason SARS-CoV-2 is so unique among zoonotic viruses is that it is not only incredibly contagious between humans but it is also incredibly contagious from humans to other mammals that can then serve as a perpetual reservoir where it can then re-infect human populations. There is increasing evidence that these animal reservoirs exist today.

Mink farms. In April 2020, a farm worker in a Dutch mink farm came to work with a COVID-19 infection. Soon, minks at the farm were dying at an abnormally high rate and many of the minks were found to have nasal discharge. The SARS-CoV-2 virus had jumped from human to mink and was soon detected in 200 mink farms in nearby Denmark, most likely from feral cats roaming from farm to farm, stealing mink food and spreading COVID along the way. Not only did the virus spread among the minks like wildfire, but farm workers were soon becoming infected from the minks with a cycle of human to mink and back to human infection. As a consequence, the Danish government euthanized more than 17 million minks in November 2020. To make matters worse, viruses from mink corpses leached into the ground and infected human drinking water. In December 2020, an infected mink from a mink farm in Oregon escaped and soon, the SARS-CoV-2 virus was being detected in wild minks.

Whitetail deer. There are about 30 million whitetail deer in the United States (including this one in my backyard!). The U.S. Department of Agriculture collected samples from 481 deer in Illinois, Michigan, Pennsylvania, and New York between January 2020 and March 2021. In all, 40% of the deer had SARS-CoV-2 antibodies, indicating that they had been infected. A University of Pennsylvania study found that 30% of deer tested in Iowa between April and December 2020 had antibodies – however, a follow-up study found that by the period December 2020 through January 2021, fully 80% of Iowa deer tested had been infected. Genetic studies found that the strains of the virus in deer were the same as the viruses in circulation in Iowa causing human COVID-19 infection at the same time – strong evidence that the deer had become infected from human contact. The USDA Agricultural Research Service then experimentally exposed captive deer to the SARS-CoV-2 virus and found that the infected deer did not experience any overt sign of infection – in other words, the deer had asymptomatic infection. With the 2021 deer hunting season now beginning, it is likely that hunters and butchers will be exposed to infected deer, thus perpetuating the zoonotic cycle. Unfortunately, there is virtually zero chance of passing a law to require proof of COVID vaccination to get a trapping or deer hunting license in Ohio.

Zoos. Compared to wild animals, captive animals in our zoos are relatively easy to study due to the ease in collecting biological samples. The SARS-CoV-2 virus has been found in lions, tigers, gorillas, hyenas, and leopards. At least 4 snow leopards in American zoos have died of COVID-19 infection. In July 2021, Zoetis (a pharmaceutical company that makes medications and vaccines for livestock) donated 11,000 doses of its experimental COVID vaccine to 70 U.S. zoos. The Oakland Zoo was the first to get the vaccine and inoculated its bears, mountain lions, gorillas, chimpanzees, ferrets, and pigs. Fortunately, anti-vaxxers have not taken up protests against vaccine mandates for zoo animals. If animals in the zoo can get infected, then the same kind of animals in the wild are also getting infected.

COVID-19 is not going to go away

Although most data indicates that the SARS-CoV-2 virus originated in horseshoe bats in China, some people have suggested that the virus originated in a Chinese research lab. Whichever origin is correct is irrelevant to controlling the virus in the future. Because the virus has conclusively been shown to infect humans who then infect animals that then infect other humans, there is now a viral reservoir in the wild that can continuously seed the human race in the future. This means that even if we could magically eliminate all human cases of COVID-19 on a Monday, by Friday, some humans would have become infected from animals harboring the virus… and those humans would then infect other humans.

It all comes down to the ACE-2 receptor

The SARS-C0V-2 virus contains an outer glycoprotein called the spike protein. This is the protein that is encoded by the mRNA in the Pfizer and Moderna COVID vaccines. The spike protein on the coronavirus latches onto a receptor on human cells called the angiotensin converting enzyme-2 receptor (ACE-2 receptor). The part of the ACE-2 receptor that the coronavirus spike protein attaches to is called the S-protein binding site. Once attached to the ACE-2 receptor, the virus can then get inside of our cells and take the cells over to make more viruses, similar to the creatures in the movie “Alien” that grew inside the stomachs of the unfortunately infected humans before exploding through their abdominal walls.

All mammals have ACE-2 receptors on their cells. The more similar an animal’s ACE-2 S-protein binding site is to a human’s determines whether that animal is likely to become infected with SARS-CoV-2. For example, the ACE-2 S-protein binding site of mice is very different than that of a human’s and consequently, mice do not develop COVID infection. On the other hand, the ACE-2 S-protein binding site of hamsters is very human-like and indeed, hamsters are quite susceptible to developing COVID infection. Because so many mammals have ACE-2 S-protein binding sites that are similar to humans’, many mammals can develop COVID-19 infection – from domestic animals such as dogs and cats, to wild animals such as bats and deer.

When I was 5 years old, a bat flew into my bedroom and scratched my face while I was sleeping. I ended up getting vaccinated against rabies which at the time consisted of 14 daily intra-abdominal injections of rabies vaccine. I did not come down with a case of rabies but that life experience has shaped my respect for zoonoses. Humans were the vectors that disseminated SARS-CoV-2 to mammals throughout the world. And now, we are going to have to live with the consequences of  that dissemination for years to come. Today, I would have to worry about getting COVID-19 and not just rabies from my bat exposure. Going forward, unless an unvaccinated person lives their entire live in isolation lockdown, then COVID-19 infection is virtually inevitable – if not this year, then next year or the year after or the year after that. We have sown COVID-19 throughout the animal kingdom and we will have to reap its deadly harvest for years to come.

Children will be vectors

Varicella-zoster virus causes chicken pox and shingles. Like COVID-19, chicken pox is usually a relatively mild disease in young children but can cause severe infection in adults. Unlike COVID-19, you can only get chicken pox once and the initial chicken pox infection provides life-time immunity from re-infection. Before the varicella vaccine was first licensed in the United States in 1995, parents would hope that their children got chicken pox early in life, when it cause less severe infection. Some parents would hold “pox parties” to expose their pre-school aged children to an infected child in order to ensure early childhood infection. Attempting to draw from history, some adults have engaged in “COVID parties” in order to become infected and thus develop immunity – these efforts have been disastrous at best but often fatal at worst.

Since no COVID vaccines are currently approved for use in children under age 5, it is likely that the SARS-CoV-2 virus will continue to circulate among young children for the foreseeable future. In other words, children will be another viral reservoir for SARS-CoV-2 until COVID vaccines are approved for all ages. The only good news is that young children are less likely to die when they get infected with COVID than their adult parents are.

Vaccines are the only answer

Yesterday, I flew from Columbus to Las Vegas on a connecting flight while traveling to San Francisco. Behind me, an unmasked and sick 3-year-old coughed and sneezed constantly for the 4 hour flight. Across the aisle, a disruptive passenger tried to wear a mask with quarter-inch holes punched all through it and then when asked by the flight attendant to wear a normal mask, she refused to pull it up over her nose (she was ultimately escorted off the plane by an airport authority on arrival in Las Vegas while having a few loud choice words for the unfortunate flight attendant). This experience illustrates why behavior mandates will not bring an end to the pandemic. Behavior mandates protect the individual that complies but does not protect the human race – some parents will still bring their sick child onto a crowded plane and some anti-authoritarians will continue to refuse to wear masks in public areas. Similarly, travel bans are not the solution. Travel bans that worked in MERS, SARS, and Ebola outbreaks have proven to be ineffective with the initial COVID outbreak and again with the more recent omicron variant outbreak.

Had COVID occurred 30 years earlier in 1989 rather than 2019, then all humans would eventually have become infected and those who survived would have inherited the earth. However, COVID occurred at a unique time in our species’ history when science was able to rapidly invent effective vaccines. And so now, each of us humans have a choice – get vaccinated or get infected. Given the enormity of the mammalian reservoir for the SARS-CoV-2 virus, there really are no other choices. As I walked past rows of slot machines in the Las Vegas airport yesterday, I was struck by how similar COVID is to gambling: living on earth in the era of COVID is like playing Russian roulette with a loaded revolver. Getting vaccinated is like taking the bullet out of the gun.

November 30, 2021