Categories
Inpatient Practice

Changing To A Different Hospitalist Group

Hospitalists have gone from rarities to dominating inpatient care in the past 25 years. Currently, there are approximately 50,000 hospitalists in the United States. The term “hospitalist” was first coined by Dr. Robert Wachter and Dr. Lee Goldman in their 1996 article in the New England Journal of Medicine. The young specialty was quick to show financial benefits to hospitals with studies showing improved hospital length of stay and lower costs per admission in patients cared for by hospitalists. Currently there are 3 common hospitalist practice models:

  1. Hospital-employed physicians
  2. Physicians who are part of local primary care or multi-specialty group practices
  3. Physicians employed by regional or national hospitalist companies that contract with numerous hospitals

There are advantages and disadvantages for each of these 3 models and the optimal model will be different for different hospitals. Periodically, hospitals will choose to change to a different hospitalist model or change to a different physician group within a given model. Managing this transition can pose unique challenges to the hospital.

Timing the decision

The decision to change hospitalist models or change to a different hospitalist group requires long-term planning, and should ideally be made 12-18 months before the intended transition date; the larger the hospital, the more time you will need. A small hospital that only needs a few hospitalists can change groups fairly quickly. But if the hospital is looking at changing coverage of a large number of inpatient beds, then the sheer number of new doctors that have to be recruited and hired takes a lot of advanced preparation. For example, to cover 100 beds, the hospital will need somewhere between 20-30 hospitalists, depending on patient acuity and other factors. Because of the high-demand for hospitalists, it can take many months to recruit this large of a number of doctors – there are not many unemployed hospitalists reading the help-wanted classified ads in the newspaper each morning.

Many new hospitalists will be recruited from internal medicine residency programs. Residency programs run on a July through June cycle so residency graduates will be available in July/August each year. These physicians generally start interviewing for hospitalist jobs about 1 year in advance and most residents from the better programs will have signed contracts by October or November of their senior year of residency. If a hospital waits until December to recruit and interview new graduates, there will be very few uncommitted residents left.

When do you let the doctors know?

The initial planning for a hospitalist transition is usually done privately with only a small number of hospital leaders aware of the plan to change to a different hospitalist group or model. This is necessary because as soon as the current hospitalists know that their employment contracts are going to be terminated, they will start looking for a new job. When to make the upcoming transition public depends on the employment contracts that the doctors have. Most physicians will have a 60, 90, or 120 “without cause” termination clause in their contracts. This means that they have to give 60, 90, or 120 days notice if they intend to leave. The day that you tell the doctors that their employment contracts are going to be terminated is the day that they will begin looking for another job.

You want all of your doctors to stay at the hospital until the date of the upcoming hospitalist transition. If you tell them about the transition 180 days before the date and the doctors have a 90 day without cause termination clause in their employment contracts, then you are going to find yourself with no hospitalists in the final weeks or months before the transition. However, you do want to be fair to the physicians who have been providing care to the patients at your hospital – you might want to hire them again in the future plus it is just the right thing to do. It generally takes at least a month for a hospitalist to find and sign a contract for a new job so a good rule of thumb is to let the current doctors know 30 days more than whatever their without cause termination period is in their contracts. So, if they have a  90 day without cause termination clause, let them know that their contracts will be terminated 120 days in advance.

Have a contingency staffing plan

As soon as the contract termination becomes public knowledge, it will be nearly impossible for the existing hospitalist group to hire new physicians – doctors looking for permanent employment do not want to sign up to work for two or three months. Inevitably, there will be some hospitalists in the current group that were planning on leaving, get sick, get called up for military reserve duty, or go on maternity/paternity leave in the months before the transition. So you have to have a reserve of short-term physicians who can fill in the vacancies until the new hospitalist group starts.

The easiest solution is to hire locum tenens physicians. These can sometimes be local physicians that the hospital can contract with individually to provide short-term hospitalist coverage but more often, these physicians come through a locum tenens company that maintains a pool of doctors who are available for short-term employment. It is important to plan early with the locum tenens physicians so that you can get them through your hospital’s credentialing process well in advance of when you will need them. If the hospital’s credentials office takes 3 months to complete credentials for new physicians, then you need to identify and get started on credentialing those locum tenens physicians shortly after announcing the hospitalist transition decision. Even if you have to pay a retainer to the locum tenens company, it can be worth it so that you do not find yourself with patients but no doctors to take care of them just before the transition date.

Create a transition workgroup

Key leaders from the hospital, the existing hospitalist group, and the new hospitalist group need to meet regularly. Because there can be animosity between the two hospitalist groups, it may be necessary for the hospital leaders to do most meetings with the hospitalist groups individually. Initially, the workgroup should meet monthly and then in the final 2 months of the hospitalist contract, the meetings should be weekly. These meetings may only take 10 – 15 minutes but it is important to put them on everyone’s calendar to ensure a safe and efficient transition. Specific issues to cover include:

  • How will test results that come back after the transition be handled? This will usually require some way of routing electronic medical record “inbaskets” to the new hospitalists.
  • Who will sign verbal orders after the transition date? Verbal orders have a  habit of showing up in the electronic medical record a day or two after the physician actually gave the verbal order. There needs to be a process in place for getting those orders signed. The same goes for signing discharge summaries, H&Ps, and operative notes.
  • How will death certificates be managed? If a patient dies a couple of days before the transition date, the funeral home will likely send the death certificate over to the hospital after the transition date. A mechanism for signing these in a timely fashion must be agreed upon.
  • How long will the current hospitalists have access to the electronic medical record? The doctors may only need to have access for a couple of weeks to sign verbal orders. However, their billing office may need access for several months to manage late bills and provide documentation of services to insurance companies.
  • Managing patient hand-offs. Ideally, the transition hour should be at the end of a day shift rather than the end of a night shift. The hospitalists who have been managing the patients during the daytime are generally in the best position to answer questions about their care than the night coverage hospitalists. This can result in a smoother transition.
  • What about trainee evaluations? If the current hospitalists have medical students or residents, then work with the appropriate education office to ensure that there is a mechanism for end-of-the-rotation evaluations to be completed after the current hospitalists have left. Trainees are notorious for completing their notes late so there needs to be a mechanism for co-signing these notes after the transition date.
  • Get an equipment inventory. After a period of time, is can be easy to forget whether the hospitalist group or the hospital purchased computers, furniture, phones, journal subscriptions, printers, and fax machines. Make sure everyone knows what stuff stays and what stuff goes.

Meet with the nurses and other physicians

Change can be alarming for doctors and nurses who have been accustomed to one group of hospitalists and one pattern of practice. There must be a mechanism for the hospital to clearly articulate the reasons for the change and reassure the staff that there will not be a reduction in the level of medical care provided by the new hospitalist group. Surgeons who have relied on the hospitalists for inpatient consultative co-management need to be engaged. The emergency department physicians need to be aware of any change in the admitting process with the new hospitalist group. Consultants need to be confident that the new hospitalist group will not reduce the number of consults that they order.

The things you didn’t think about

Different hospitalist groups practice medicine differently and one cannot be simply substituted for another. Consideration need to be made about:

  • Who manages cardiopulmonary arrests? Stroke alerts?  RRTs (rapid response team alerts)? Not all hospitalists have experience managing these situations and may require additional training prior to starting coverage.
  • Who manages bedside procedures such as central venous catheters, lumbar punctures, and intubations? Increasingly, internal medicine residents are not being routinely trained in these procedures. Endotracheal intubation is a particular problem – fewer and fewer hospitalists perform them and so you will need to decide if anesthesiologists, emergency medicine physicians, or respiratory therapists will become responsible for airway management if the old hospitalists performed these but the new hospitalists do not.
  • How will physicians be contacted? Maybe the existing hospitalists prefer to use pagers but the new hospitalists use their cell phones or an app in the electronic medical record. Be sure that it is clear how nurses and other physicians contact the specific hospitalist managing any given patient.
  • Clean up the electronic medical record. Don’t leave an option for a consult or admission to be placed to the old hospitalist group once the new hospitalist group takes over. That order for a consult will not go anywhere and patient care could suffer.

Your quality metrics will take a hit

During the last month of the old hospitalist group, the doctors will be less motivated to help the hospital with things that matter to the hospital. Anticipate that the inpatient length of stay will go up, hour of discharge will be later in the day, patient satisfaction will go down, and quality events will increase. This will be particularly true if the hospital has to rely on a lot of locum tenens hospitalists in the last weeks before the transition. It is very similar to college students getting “senioritis” in the months just before graduation. You can partly preserve performance on these various quality metrics by developing a bonus plan to pay the physicians for their performance in the last couple of months of their contract.

Be collegial

When a hospital changes to a different hospitalist group or model, the current hospitalists are going to feel betrayed and devalued. The end of their employment at the hospital means the end of friendships with nurses, other physicians, and hospital staff. It may mean that they have to sell their houses and move to a new community. It may mean that they will be out of work for a few months while seeking a new job. It likely means an end to a job that they really liked and were passionate about.

These physicians need to be treated as the professionals that they are. Meet with them regularly. Volunteer to provide job references. Provide them access to continuing medical education such as hospital grand rounds for a few months. And most importantly, explain to them that it was a business decision and not because they are bad doctors. Who knows, you might want to hire that physician or hospitalist group again in the future.

There will often be non-compete clauses in their employment contracts so the hospital or new hospitalist group may not be able to hire them. For those hospitalists who are superstars, it may be worth trying to negotiate a buy-out for the non-compete contracts. It costs a surprisingly large sum of money to hire a new hospitalist when you consider paying for a search firm as well as interviewing, credentialing, and orienting the new hospitalist. You may have to pay moving expenses or medical school loan repayments. When all of these are considered, it may be cheaper to pay a $25,000 or $50,000 buy-out for a current hospitalist than to hire a new hospitalist.

Managing change is one of the main things that hospital leaders do and it can be time-intensive as well as emotionally draining. But by planning in advance and giving attention to detail, changing from one hospitalist model or group to another can happen smoothly and offer new opportunities for the hospital.

November 7, 2020

Categories
Epidemiology

Anti-Maskers And The Company They Keep

Anti-maskers are flourishing in the era of COVID-19 but they are not new. During the 1918 influenza epidemic, the wearing of masks was mandated in many U.S. cities and “mask slackers” rebelled with one Portland, Oregon city council member arguing “Mask requirements are autocratic and unconstitutional; under no circumstances will I be muzzled like a hydrophobic dog.” The anti-maskers never went away during the past century, they’ve been quietly meeting in secret, just waiting for a new pandemic to happen so that they can once again profess the dangers of wearing masks. So, who are these anti-maskers? Most are members of a fraternity of organizations whose mission is ostensibly to protect personal liberties. Here are some of these other organizations in the fraternity of the anti-maskers:

The Anti-Hand Washing League. This secret society was created in 1848 to combat the hand washing hysteria being propagated by Dr. Ignaz Semmelweis, the physician on the lunatic fringe of medicine who had the audacity to recommend that doctors wash their hands after performing autopsies. The League’s mission is to globally eliminate hand washing in order to preserve the natural body oils of the hands. Says League president Max Saponify, “Requiring me to wash my hands after using the toilet is an infringement of my constitutional rights!

The Federation Dedicated to a Deodorant-Free World. This group has a goal of global elimination of antiperspirants and deodorants. “These chemicals are a well-known cause of armpit cancer” says Federation chairman Axilla LaPue. The Federation’s motto is that “A man should smell like a man… and a bear,… and a boar,… and a Tasmanian Devil”. Many members are also affiliated with the Anti-Bathing Guild whose motto is “Satan made soap”.

The Stogies in School Society. Formed after municipal laws against smoking in public were enacted in the early 2000’s, the Society’s mission is to preserve the rights of middle school students to smoke cigars in class. A side project of the Society is the “Spittoons in Church” project to promote legislation requiring all churches to provide spittoons in the pews for parishioners who chew tobacco during services.

The Pull My Finger Association. This organization is committed to the promotion of public flatus. The annual meeting is held in Boston every December and culminates with the group’s baked bean dinner followed by the flatus a cappella contest. Last year’s winner was the Central City Cheese Cutters with their rendition of Bob Dylan’s “Blowing in the Wind”. Afterward, the attendees went caroling in downtown Boston with their unique wordless Christmas carols.

The Anti-Vaxxers. This mainstream group opposes vaccines of all kinds. Said one anti-vaxxer: “They say vaccines prevented smallpox and polio. I don’t know anyone who ever had polio or smallpox. I think drug companies just made up those diseases so they could scare people into buying their vaccines.” Group members have determined that vaccines cause disease. “You get a flu shot and your bowels will be irregular for months… not for me!” wrote another member in a letter to the editor of the Cowtown Gazette. The group points to the Will Smith movie I Am Legend as evidence that vaccines turn normal people into flesh-eating zombies.

The Free the Snot Foundation. Dedicated to liberating oppressed nose mucus from confinement in Kleenex and handkerchiefs, the FSF is considered by some to be a terrorist group, spewing unsuspecting passersby with nasal secretions. Among the group’s more mainstream activities is the annual “Shoot the Snot” contest to see which contestant can propel sinus secretions the farthest. The current world record is held by Charlie “Booger” Snout with his 2015 performance of 15 feet, 3 inches. But a darker side of the Foundation is the rumored rite of passage for admittance that allegedly requires initiates to clandestinely launch snot over the rail of the Empire State Building creating the so-called “rhinitis rain” that the City of New York is widely known for.

The Anti-Trouser Alliance. This male-only organization seeks to overturn local ordinances requiring men to wear pants. “If God wanted us to wear them, we’d be born with pants” said the Alliance’s spokesman I. M. Stark. The Alliance’s annual project this year is the “Butts on Buses” initiative to promote the freedom to sit on public bus seats pants-free. The initiative was conceived after the enormous success of the “Butts on Banisters” project last year.

The MPH Liberation Club. This group hopes to eliminate speed limits in school zones. “Those roads were built with my tax dollars. If I want to drive 60 miles an hour in front of St. Mildred’s Elementary School, then it should be my right!” said member Phlatt N. Quash. The group also seeks to eliminate stop signs, traffic lights, and center lane lines on public roads.

The Sidewalk Turd Confederation. The Confederation’s mission is to eliminate public bathrooms. It is composed of individual groups including libertarians that want to eliminate highway rest areas in order to reduce government costs, the gas station worker’s union that objects to requiring employees to mop restroom floors, and environmentalists seeking to save trees by abolishing toilet paper. Said the Confederation’s Secretary General, P. N. Yard, “Squirrels do it, birds do it, dogs and cats do it. Don’t we have the same rights as the animals?”

The Yell “Fire” In Movie Theater Consortium. This organization’s goal is to preserve the First Amendment right to free speech. Members are encouraged to walk through maternity wards and randomly tell new parents that they have an ugly baby, to tell their mother-in-laws that her cooking is terrible, and to  shout “Shark!” at public beaches.

Anti-mask = Anti-business

The reality is that masks work. The COVID-19 virus is spread through the respiratory tract – when you cough, sneeze, or talk loudly, you exhale viruses. If you want to stop a respiratory virus from spreading, you have people wear masks to catch viruses contained in exhaled breath. Wearing masks is the fastest way to re-open stores, stadiums, bars, churches and restaurants. Anti-maskers have the confused notion that masks infringe on their human rights; the reality is that the more people wear masks, the sooner the economy recovers and jobs return. Don’t be a member of one of these fraternal organizations, wear a mask!

November 1, 2020

 

Categories
Academic Medicine Medical Economics

Why Are There So Many Asian Physicians In The U.S.?

People of Asian descent comprise 5.6% of the American population but Asian Americans comprise 19.8% of all U.S. physicians. Two things happened this week that led me to think about this statistic and why Asian Americans are so disproportionately represented in American medicine. First, I listened to the America’s Test Kitchen podcast, Proof, about why there are so many Chinese restaurants in the U.S. (quite fascinating and worth a listen). Second, I listened to this week’s MedNet webcast on Racism and Racial Bias in Medicine that included an exploration of why African Americans are under-represented in U.S. medicine. Part of my interest is because of my own Chinese heritage (albeit only 1/8th).

Several years ago, there was a lawsuit against Harvard University by a group of Asian students who were denied college admission and claimed that the University discriminated against Asian applicants who had superior admission test scores and grades than applicants of other races. The allegation was that Harvard made it harder for Asian applicants in order to keep the percentage of Harvard students who were Asian from becoming too high. The press surmised that Asian American students have a culturally-driven higher study ethic than students of other races. But I think that the reason for the high percentage of Asian students at elite U.S. universities and the high percentage of U.S. physicians who are Asian American has a deeper and darker cause that has its roots in immigration laws that paradoxically were created to keep Asians out of America. As the law of unintended consequences dictates, those laws ultimately resulted in Asian Americans being more academically successful and more overly-represented in American professions such as medicine.

The Naturalization Act of 1790

One of the first laws of the new U.S. government was the Naturalization Act of 1790 that limited naturalization to “free white person[s] … of good character“, thus excluding Asians (as well as anyone else who was not from Europe). This law essentially banned Chinese from immigrating to the United States but this was in many ways a moot point since travel by ship to the Eastern seaboard of the country from China via the Atlantic Ocean was very difficult and expensive. Not until the country’s westward expansion opened California to development did travel from China to the U.S. via the Pacific Ocean become feasible.

The next major event that affected immigration and naturalization of Asians was occurred in 1868. That year, the first section of the 14th amendment to the U.S. Constitution stated: “All persons born or naturalized in the United States, and subject to the jurisdiction thereof, are citizens of the United States and of the State wherein they reside.” The implication was that even if a non-white immigrant to the U.S. could not obtain citizenship himself or herself, their children could become citizens if born in U.S.

The Chinese Exclusion Act of 1882

The California gold rush attracted many Chinese to the west coast of the U.S. where they worked in mines and then when the mines played out, they worked in railroad construction. But soon, these laborers were competing with American citizens for labor jobs and often accepting much lower wages thus making it harder for white Americans to find work. This created a lot of hostility by many Americans toward Chinese immigrants. Notably, 140 years later, that same hostility would be directed against Latin American immigrants who are perceived as “stealing” jobs from other Americans.

The Chinese Exclusion Act of 1882 was enacted to appease this hostility. The act barred Chinese laborers from immigrating to the U.S. and also made Chinese immigrants ineligible for citizenship. The only exceptions were for Chinese merchants and teachers. At the time, Chinese were subject to racial discrimination equal in many situations to Blacks. In fact, in in 1896 Supreme Court case, Plessy v. Ferguson,  Justice John Marshall Harlan wrote in his dissent: “…the Chinese race is a race so different from our own that we do not permit those belonging to it to become citizens of the United States.”.

Because the Chinese Exclusion Act limited immigration to merchants and teachers, the act essentially barred Chinese women from immigration since at the time, the vast majority of merchants and teachers were men. Indeed, by the end of the 19th century, Chinese men in the U.S. outnumbered Chinese women 27 to 1. Many of these Chinese store owners and teachers married white women since there were so few Chinese women in the country. One of those men was my great-grandfather, who came to the United States from China in 1873, opened a Chinese laundry, married a white woman (my great-grandmother), and ultimately became the president of the Chinese Merchant’s Association of America (but that is another story).

The unintended consequence of the Chinese Exclusion Act was that it selected out only educated Chinese men from immigrating to the U.S. And when these men married and had families, they instilled the importance of education into their children. The unwritten message was that if you were Chinese in America, you had to have an education to economically survive. Racism against Chinese created a more educated and middle class Chinese population in the U.S. In contrast, racism against Blacks in the U.S. resulted in Africans being brought to America as slaves and education of their children was suppressed in order to maintain a population of unskilled enslaved laborers.

Many of these Chinese merchants opened restaurants. Chinese restaurants proliferated because their owners had to sell better food at a lower cost than other American restaurants since they had no other employment options than to be a merchant, even if it meant making a lower income by selling inexpensive food.

The Immigration and Nationality Act of 1965

After World War II, the Chinese Exclusion Act was repealed, in part because China had been a U.S. ally during the war. However, immigration from China was limited to only 105 Chinese immigrants per year. The Immigration and Nationality Act of 1965 eliminated national origin, race, and ancestry as basis for immigration. Importantly, it created a “special immigrant” category that was not subject to quotas – included in this category were foreign medical graduates. The implication was that if you wanted to immigrate to the United States, you had to go to medical school first.

Currently, 25% of U.S. physicians are foreign medical graduates. The more medical schools a given country has, the more physician immigrants that country can send to the U.S. There are 348 medical schools in India offering an MBBS degree. There are 154 medical schools in China that offer an MBBS degree and 50 of these teach in English. In contrast, there are only 160 medical schools in the total of the 48 countries in Sub-Saharan Africa; consequently, India and China are capable of producing more medical graduates that can then immigrate to the United States than other countries can.

One of the best predictors of whether or not a person will become a doctor is whether their mother or father was a physician. In the United States, 20% of doctors have a parent who was also a doctor. I’m a perfect example, a third-generation doctor, with my physician-father a descendent of one of the Chinese immigrants affected by the Chinese Exclusion Act. Medicine is the family business.

The counter productivity of Chinese racism

For a century after the inception of the United States of America, Chinese were usually disdained and immigration from China prohibited. For the second century of our country, some Chinese were tolerated, but only those who were well-educated and entrepreneurial. As a result of policies and laws to keep Asians out of the U.S., we now have a disproportionately high percentage of Chinese and other Asians occupying the ranks of physicians. And given the propensity for children of doctors to become doctors, the percentage of doctors who are Asian American will likely grow in future decades.

Racism is always morally wrong. And racism is always bad policy. There can be unanticipated consequences of racism that result in exactly the opposite of what racism intended… your doctor is likely going to be someone like me, a son of a son of a daughter of a Chinese immigrant.

October 30, 2020

Categories
Operating Room

Operating Room Block Scheduling Versus Open Scheduling

There are some healthcare services that hospitals lose money on and some services that hospitals make money on. Hospitals tend to lose money on medical admissions and uninsured/Medicaid patients but make money on surgeries. Specialty hospitals, such as orthopedic surgical hospitals, take advantage of this and consequently can be quite profitable. However, for community hospitals to meet their obligation to align the healthcare resources of the hospital with the healthcare needs of the community, those community hospitals must maintain an adequate ratio of surgical to non-surgical services. But it also means that the hospital’s operating rooms must consistently function at maximum efficiency. And that is where OR scheduling can make or break a hospital’s financial bottom line.

In simplistic form, there are basically two ways to schedule surgeries: block scheduling and open scheduling. In block scheduling, a block of time is assigned to a specific surgeon or surgical group and no other surgeon can schedule cases in that particular operating room during that particular time and day. In open scheduling, surgical cases are booked in an operating room based on first-come, first-served and many surgeons may book cases in any given room in the OR area on any given day. As an analogy, block time is like a restaurant reservation – you reserve a table days in advance and you know when you walk in the restaurant that you are going to have a table at that particular time and day without having to wait. There are certain guiding principles to block time:

1. Block time belongs to the hospital

2. Block time is an extremely valuable asset

3. The hospital must designate a guardian of the block time

Block scheduling has certain advantages. It allows for specific operating rooms to be dedicated to specialized equipment (laparoscopic equipment, robotic equipment, fluoroscopy, etc.). It is allows the surgeon to make the most efficient use of his/her time by clustering cases at one time so that the surgeon does not need to be constantly racing between the office and the operating room. The surgeon can then schedule other times during the week to be seeing outpatients, thus making that surgeon’s office practice more efficient. It can allow the hospital to make most efficient use of a given operating room since the same surgeon will be physically present and ready to go as soon as the next patient is brought into the OR.

Similarly, open scheduling can have certain advantages. It allows accommodation of urgent or emergent cases. It can result in more consistent use of the operating room, nursing staff, and anesthesiology staff during regular work hours. It can result in less use of staff overtime. There is no need for a block time release policy or monitoring of block time utilization.

What really constitutes a block?

In order to maintain optimal utilization of the operating room, it is best to avoid half-day blocks and instead grant full-day blocks, whenever possible. It takes time to set up an operating room for a spine surgery case if that OR has been used for ENT surgeries all morning and therefore there is less down-time when reconfiguring a room for a second half-day block. Furthermore, no surgeon can predict with perfect accuracy how long it will take to do a particular surgery – there are inevitably unexpected delays or complications that can make a surgery go longer and there are inevitably last minute cancelations that can make the schedule shorter. If either of these happen during a morning half-day block, then it can result in either the OR going unused at the end of the morning or the surgeon with the afternoon half-day block having to wait to start her/his surgeries. It may be operationally most efficient to have some blocks end at 3:00 PM rather than at 5:00 PM.

Some surgeons may not need a full-day block each week. In these situations, scheduling an every-other-week block for that surgeon can make sense and be preferable to scheduling a weekly half-day block. Usually, you can find a second surgeon who also needs an every-other-week block to counter balance scheduling.

Surgeons frequently define their value by block time

When a hospital recruits a new surgeon, one of the first things that surgeon will ask for is block time. From the surgeon’s perspective, it is an indication of how much the hospital values her/him and the surgeon with block time will have a perception of having a greater chance of success. Indeed, to recruit the best surgeons, a hospital must be willing to offer block time. And if that surgeon can reliably fill their block time, then it is a win-win financially for both the surgeon and the hospital. However, the philosophical question will always remain: “Is block scheduling a right or a privilege?”. The bottom line is that a surgeon’s pride is often enhanced by having block time but the hospital’s financial viability is enhanced by the surgeon consistently filling that block time.

Some surgical specialties are better suited for block time

Surgeries that can be planned weeks in advance are the most efficient users of block time. For example, orthopedic joint replacements, spinal operations, and hernia repairs are elective surgeries and can be scheduled far in advance – these are best suited for block time scheduling. On the other hand, cholecystectomies, fracture repairs, and dilation & curettage procedures are often scheduled with only 24 – 48 hours notice – these are best suited for open scheduling. Sometimes, it is necessary to have a dedicated block that is not scheduled weeks in advance, for example, a trauma block. Although some trauma cases need to go to the OR emergently, most trauma cases can wait until the next morning. Having a dedicated block in the mornings for hip fracture repairs may be necessary for a hospital that is a designated trauma center.

Block vs. open scheduling is not an either/or proposition

A high-functioning hospital must use both block scheduling and open scheduling. The challenge is getting the right ratio of block to open scheduling in order to perform the maximum number of surgeries each week with the most efficient use of the surgeons’ time. To do this, there has to be rules for which surgeons get block time, how block time is released when the surgeon does not have cases to fill his/her block time, the amount of open scheduling necessary to meet the demands of urgent surgeries, and the amount of utilization that a surgeon must maintain in order to keep her/his block time. All of this means that the hospital must have good data including data on utilization, data on how accurately individual surgeons estimate it will take to do a given surgical procedure, and how often the operating room runs overtime. In order for the surgeons to believe the data, it has to be accurate, timely, and transparent.

So, what is the ideal ratio of block:open scheduling? As with most things in hospital management, it depends. For a hospital that does a lot of joint replacements and spine surgeries, a block ratio of 80% block time may be appropriate. For a hospital that depends on emergency department admissions to fill their operating rooms with trauma cases and appendectomies, then a ratio of 60% block time may be appropriate. For most hospitals, the maximum percentage of block time should not exceed 75-85%.

Not only is it necessary to have an optimal overall monthly block ratio, but it is necessary to have an optimal daily block time ratio. There are certain days of the week that are more desirable for surgeons to operate on than others. Surgeons who do inpatient surgeries tend to prefer Mondays, Tuesdays, and Wednesdays so that their patients can be discharged by Friday and so they do not have to round on the weekend. But Monday is also a day that typically has a high utilization of open schedule cases for all of the patients admitted over the weekends with fractures and acute cholecystitis. For the hospital to function at peak efficiency, it has to maintain a constant census throughout the week and so some surgeons will necessarily have to be assigned the less desirable Thursday and Friday blocks. This is often newer surgeons which allows the hospital to reward those surgeons with the highest block time utilization with the most desirable block times.

The importance of a block release policy

Sometimes, a surgeon does not need their block time. Maybe they have a planned vacation or will be attending a medical conference. Maybe they may just not have enough cases to do that week. In order to avoid the operating room being unused on those occasions, there must be a robust mechanism for releasing that surgeon’s block time so that other surgeons can schedule cases into that time. Vacation and time off for conferences needs to be communicated to the OR scheduling desk as soon as the surgeon knows she/he will be taking time off. If this is two or three months in advance, it allows another surgeon to pick up an extra day of block time that week. However, if this is only two or three days in advance, then no other surgeon will have enough notice to schedule a full block of elective cases and that OR will need to be filled by open scheduling.

Because individual operating rooms may have specialized equipment (robot, imaging capability, etc.), it may be preferable to have a staged block release policy in order to most efficiently use that operating room. So, for example, the orthopedic joint replacement surgeon’s block time gets first released to other orthopedic surgeons and then later gets released to all of the other surgeons if none of the orthopedic surgeons want that time.

Be prepared for concerns by your surgeons

  1. If I release my block months in advance of a conference I’ll be attending, will that be held against me?
  2. If a patient is unexpectedly sick or cancels an elective surgery at the last minute, will that be held against me?
  3. Am I going to be penalized if I operate faster than other surgeons and finish my block earlier in the day?
  4. Am I going to be penalized if the OR staff take excessively long to turn the room over between my surgeries so that I finish late?
  5. If I don’t have block time am I going to be stuck doing all of my elective cases at 4:00 in the afternoon?

Block time management requires resources

Perhaps nowhere else in the hospital does the adage “You have to spend money to make money” apply better than the OR scheduling desk. Optimized block time management requires the hospital to invest in a robust OR scheduling program, ideally one that is embedded in or communicates with the hospital’s electronic medical record. But the hospital cannot rely on a computer program alone – there has to be a human being who is overseeing the OR scheduling process. Block time optimization is a data-driven process and so there has to be a mechanism to have reliable information about individual surgeon first case start times, case duration times, block finish times, case cancelation rates, percent of blocks released, and room turnover times. There also has to be physician leadership intimately involved in block time management and data review. This will ideally involve a dedicated medical director of preoperative services but also a committee of involved surgeons in order to provide self-monitoring of block utilization. Ideally, block utilization data should be posted regularly (weekly or monthly) in a location that all of the surgeons can see.

Ideally, a given block should be utilized 80% of the time. If it is less than that, then the OR is likely to be frequently sitting idle in the afternoon. If it is more than that, then the OR is likely frequently running overtime into the evening and the surgeon may be developing a back-log of cases.

Block time management is complicated and can be costly. Within the hospital, it can be politically charged. But when done right, it can make the surgeons happy and the hospital profitable.

October 25, 2020

Categories
Physician Retirement Planning

Strategies For Asset Allocation In Your Retirement Accounts

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

The 4 Types of Retirement Accounts

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

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

Roth Account Allocations

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

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

Deferred Compensation Account Allocations

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

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

Post-Tax Account Allocations

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

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

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

October 12, 2020

Categories
Intensive Care Unit

How Many ICU Beds Does A Hospital Need?

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

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

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

Location, Location, Location

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

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

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

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

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

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

What About Utilization?

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

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

So, how many ICU beds does a hospital need?

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

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

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

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

October 10, 2020

Categories
Life In The Hospital

Why COVID-19 Has Made Me More Efficient

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

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

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

Eliminating non-productive time

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

Making meetings more efficient

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

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

Multi-tasking during meetings

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

Telemedicine is quicker

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

More working lunches

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

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

October 2, 2020

Categories
Epidemiology

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

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

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

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

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

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

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

August 29, 2020

Categories
Medical Education

Making The Most Of Your Virtual Residency Interview

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

Residency Interviews are Expensive

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

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

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

Preparation, Preparation, Preparation

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

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

Use the Right Equipment

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

Set the Stage to Your Advantage

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

Dress for Success

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

Making a Good Impression on Camera

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

Practice for Success

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

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

August 15, 2020

Categories
Outpatient Practice

Telemedicine Across State Lines?

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

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

 

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

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

Each state has different laws about medical licensure

 

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

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

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

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

The COVID-19 emergency has changed state telemedicine regulations

 

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

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

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


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

So what is a physician supposed to do?

 

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

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

July 25, 2020