Emergency Department Outpatient Practice

Over The Counter Oral Contraceptives: An Opportunity For Hospitals

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

How effective is Opill?

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

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

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

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

Advantages and disadvantages of Opill


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


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

An opportunity to counsel ER patients

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

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

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

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

Opill and Catholic hospitals

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

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

Reducing unwanted pregnancies

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

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

Not perfect, but…

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

July 17, 2023

Emergency Department Epidemiology

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

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

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

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

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

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

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

Mass Shootings by State July 2020 – July 2023

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

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

Firearm Death Rates by State 2021

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

What should hospitals do to prepare?

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

Rockefeller Institute of Government

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

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

Situational awareness and preparation

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

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

July 5, 2023

Medical Education

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

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

Summary Points:

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


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

The racial composition of the U.S. physician workforce 

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

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

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

Race and medical student demographics

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

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

We are facing a physician shortage

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

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

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

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

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

To improve physician racial disparities, start in kindergarten

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

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

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

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

Discrimination versus disparity

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

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

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

July 3, 2023


Emergency Department Epidemiology Outpatient Practice

It’s Back! Malaria In The United States

Last week, I was hiking and birdwatching in Fort Macon State Park in North Carolina. I got a few good bird photos but I got a lot of mosquito bites. In North Carolina, they are a nuisance but in Florida or Texas, they can be deadly. Locally transmitted malaria is now present for the first time in 20 years in the U.S. Many physicians are unfamiliar with its presentation and many hospitals are not prepared to perform diagnostic testing.

Worldwide, malaria affects 241 million people each year and and causes over a half a million deaths per year. It is caused by five species of the protozoan parasite Plasmodium (P. falciparum, P. vivax, P. malariae, P. ovale, and P. knowlesi) which are transmitted by the bite of a female Anopheles mosquito. It primarily occurs in equatorial regions, particularly in central African nations.

In the past, it was also endemic in the United States but was largely eradicated by public health efforts at mosquito control. In 2018, there were 1,823 cases of malaria diagnosed in the U.S., all in foreign travelers who became infected elsewhere. Until this year, the last cases of endemic malaria in the U.S. were in Palm Beach, Florida in 2003 when 8 persons were infected with Plasmodium vivax. 

The recent outbreaks occurred in Sarasota County, Florida (4 cases on May 26, 2023) and Cameron County, Texas (1 case on June 23, 2023). In both areas, the species was Plasmodium vivax. Because of rising temperatures from climate change, southern areas of the United States may see more cases of endemic malaria in the future. Because these are locations that many Americans travel to for vacations, physicians in all states need to include malaria not only in the differential diagnosis of patients presenting with fever who have traveled to endemic countries but also in patients traveling to south Texas or south Florida. It has been nearly 3 decades since I last encountered a case of malaria and much has changed in the diagnosis and management since that time. So, this post is to update practitioners and hospitals on what they need to know.

Clinical presentation

After the initial mosquito bite, patients are asymptomatic during the incubation period and symptom onset is generally 1 – 5 weeks after the initial infection. Symptoms are non-specific and most commonly include fever, chills, headache, myalgias, and fatigue. Less commonly, patients can present with GI symptoms such as nausea, vomiting, and diarrhea. If not diagnosed and treated early, patients can become critically ill with mental status changes, seizures, renal failure, acute respiratory distress syndrome, liver failure, and coma. Pregnant women are at particularly high risk for developing severe disease and death. Others at high risk include immunocompromised patients, those with splenectomy, and children less than 5 years of age. Different Plasmodium species cause different severities of infection: P. falciparum and P. knowlesi infections can cause rapidly progressive severe illness or death, whereas P. vivax (the species causing the recent Florida and Texas cases) is less likely to cause severe disease.

Routine laboratory findings are also non-specific and can include anemia, thrombocytopenia, and elevated liver function tests. Patients presenting with thrombocytopenia are more likely to develop severe disease. Because malaria can progress extremely rapidly, it is essential that diagnosis be made immediately. The clinical suspicion of malaria should be considered a medical emergency – this is not a disease that you discharge patients with from the emergency room to follow-up with their PCP the next day.

Diagnosis and treatment

P. vivax on thin blood smear

Malaria should be considered in any patient with fever and recent travel to endemic areas (now including the southern most areas of the United States). The diagnosis is confirmed by thin and thick blood smears for visual identification of the Plasmodium parasite. A new rapid diagnostic test for malaria has also been developed. The BinaxNOW Malaria test is approved by the FDA and has a sensitivity of 94% and specificity of 84%. The BinaxNOW Malaria test can be used to make a quick presumptive diagnosis but because both false positive and false negative results can occur, it should always be followed by thin and thick blood smear evaluation. PCR tests for malaria are very sensitive and are available through the CDC but the time required for specimen transport and test completion makes PCR impractical for clinical decision making.

The treatment of malaria depends on the specific species involved, the geographic location of travel, and the severity of infection. A summary table is available on the CDC’s malaria diagnosis and treatment for U.S. clinicians website. Uncomplicated infections with P. vivax, P. ovale, P. malariae, and P. knowlesi are generally treated with either chloroquine or artemisinin combination therapy. Uncomplicated infection with P. falciparum is generally treated with artemisinin combination therapy. Severe malaria infections are treated with intravenous artesunate. Most hospital pharmacies do not stock arteunate but it can be obtained in an emergency by having the pharmacist call 1-855-526-4827 to identify the closest distributor.

What hospitals should do now

With international travel picking up post-COVID and now that P. vivax malaria has been identified in the United States, hospitals should evaluate their malaria preparation. Specific steps include:

  • Consider stocking the BinaxNOW Malaria rapid diagnostic test.
  • Ensure that laboratory technicians are educated and competent in performing thin and thick blood smears. The CDC has on-line guidelines.
  • Ensure that laboratory technicians and pathologists are educated and competent in the microscopic identification of malaria trophozoites. The CDC has an on-line resource for identification of malaria and other parasites that includes photomicrographs of trophozoites of the various Plasmodium species on both thick and thin blood smears.
  • Educate medical staff about malaria presentation and diagnosis with particular attention to emergency department providers, hospitalists, critical care practitioners, and primary care providers. Patients with suspected or newly diagnosed malaria should either be admitted or kept overnight in observation status.
  • Ensure that the pharmacy has a process in place for obtaining intravenous artesunate in an emergency.
  • Educate primary care providers and travel clinics about current malaria prophylaxis measures for patients traveling to high-risk areas.

Mosquito bites can be more than just an itch

A mosquito is like a flying syringe that goes from animal to animal and person to person. Like a contaminated syringe, mosquitos can transmit a wide variety of blood-borne diseases including malaria, yellow fever, dengue fever, chikungunya, filariasis, West Nile virus, various forms of encephalitis, and Zika virus. The best way to prevent these infections is to prevent mosquito bites in the first place. This is particularly true for people traveling to locations where any of these various infections are endemic. Here are recommendations we can give to all of our patients:

  • Wear loose-fitting long sleeve clothing. As I learned from my recent outing last week, when shirts get soaked with sweat and stick to the skin, they offer no protection from mosquitos.
  • Use effective insect repellant. The most effective is DEET in 25 – 30% concentrations. OLE (oil of lemon eucalyptus) and picaridin are less-effective alternatives to DEET.
  • For those who work outside or spend a lot of time outside, treat clothing with permethrin. Some outdoor gear can be purchased already treated with permethrin but you can also buy permethrin spray and treat clothing yourself. Just be sure to follow clothing washing instructions to prevent the permethrin from being washed away.
  • Skip the citronella candles, sonic repellant devices, and wearable repellant devices. These are nowhere near as effective as DEET.
  • Inspect window screens. Although keeping doors and windows closed is the best way to keep mosquitos from getting into the house, this is not always an option, especially for homes without air conditioning. Be sure that screens fit tightly into window frames and that there are no holes in the screens.
  • Eliminate stagnant water. For property owners, eliminating places where water accumulates can prevent mosquitos from laying eggs and prevent eggs from hatching. These can include bird baths, gutters, old tires, toys, and other open containers.
  • Where stagnant water cannot be drained, encourage community mosquito control spraying programs.
  • When traveling to areas where sleeping outdoors or in unscreened buildings is necessary, mosquito nets can be effective.

It is too early to say whether or not malaria will become regularly transmitted in the United States in the future. But the recent Florida and Texas cases are a reminder that malaria is still with us. International travel makes the world an increasingly small place with endemic areas just a few hours away from every city in the U.S.

June 30, 2023

Medical Economics

Why Conservatives Should Fund Planned Parenthood

I know what you’re thinking about the title of this post: “Didn’t he mean defund Planned Parenthood?” No, you read the title right, I am going to make the argument that social conservatives should donate to and fund Planned Parenthood and similar organizations. The reason why? Because by funding Planned Parenthood, we can decrease the number of U.S. abortions. Now you’re thinking: “That makes absolutely no sense and he is totally crazy“. However, if we apply root cause analysis to U.S. abortions, it turns out to make perfect sense.

Sakichi Toyoda

Root cause analysis is the process that we use in hospitals to figure out why a medical error occurred in order to fix the root cause of that error. The father of root cause analysis was Sakichi Toyoda, a Japanese inventor and entrepreneur who invented the automatic power loom used in textile manufacturing. His company later evolved into the Toyota automobile manufacturing company. Sakichi Toyoda championed the 5 whys: when a manufacturing problem occurs, ask “why” five times to find the true source of the problem in order to correct it. The 5 whys are the basis of the principle of lean manufacturing, a method of improving production efficiency and are a key component of the Six Sigma manufacturing process improvement training program.

A case study using the 5 whys

The best way to understand the 5 whys is by looking at an example of how we use the process in hospital quality control. Let’s take a hypothetical hospital that finds it has a very high rate of post-operative surgical infections. Now, let’s ask the 5 whys and see what the hospital’s solution would be if it stopped before getting to the fifth and last why:

If we only ask 1 why, then the hospital’s solution to the high post-operative wound infection rate would be to close down the operating rooms on Thursdays. This would be terribly unpopular with the surgeons and anesthesiologists who would see a 20% drop in their billable income. The surgery schedule will get backed up with the result that patients become unhappy because they have to wait a long time to get their surgeries. And the hospital’s financial margin would suffer as surgical revenue falls. So, let’s ask a second why:

In this case, Thursday is the day that all of the orthopedic surgeons do their knee replacement surgeries during the Thursday orthopedic surgery OR block time. But if the hospital stops doing knee replacement surgeries, the orthopedic surgeons will be irate because that is one of their primary surgical procedures. Patients will be irate because they will have to go to another hospital to get their knee replacements. And the hospital chief finance officer will be irate because the hospital makes more money on knee replacements than any other surgery. How about the third why:

Drilling down further, it turns out that just one orthopedic surgeon, Dr. Smith, has all of the post-op knee replacement surgical wound infections. If we stop with the third why, then the solution is to take away Dr. Smith’s knee replacement surgery privileges. He will be upset and will have to re-tool his practice to start doing other types of orthopedic surgical procedures, such as hip replacement surgeries. And as we will see, this will not fix the root cause of the problem. So, we now go to the fourth why:

An astute epidemiology nurse discovers that Dr. Smith’s sterile surgical gloves frequently break in the middle of his operations, thus potentially contaminating the surgical field with the bacteria on his skin. Therefore, the medical director of infection control recommends that Dr. Smith double glove so that if the outer glove breaks, there is a back-up inner glove to prevent contamination. But what about if we go all the way to the fifth why:

By asking the final why, we determine that Dr. Smith has unusually large hands and he needs size #9 sterile gloves. But the operating room only stocks size #7 and #8 gloves so Dr. Smith has been using gloves that are too small. The result is that his gloves frequently break, causing his patients to frequently have infections. The root cause of the hospital’s post-op surgical infection rate was that the operating room was not stocking the correct size gloves. The solution was to stock large gloves in the O.R.

If the hospital stopped with the first why, the orthopedic surgeons would just operate on a different day. If the hospital had stopped with the second why, the orthopedic surgeons would just do surgeries other than knee replacements. If the hospital stopped with the third why, Dr. Smith would start doing hip replacements rather than knee replacements. If the hospital stopped with the fourth why, Dr. Smith would have breaks in 2 pairs of gloves instead of just 1 pair of gloves. In all four of these situations, there would have been no effect on the hospital’s post-op surgical infection rate. It is only when the hospital gets to the fifth why that the infection rate actually drops. Now let’s see how we can apply the 5 whys to the problem of abortion.

Abortion and the 5 whys

Just about every American, both conservative and liberal, will agree that we do too many abortions in the U.S. In 2020, there were 930,160 abortions performed in the U.S. To put this number in perspective, there were 350,000 COVID deaths in the U.S. in 2020, the first year of the pandemic. In other words, there were more than two and a half times more abortions than COVID deaths. Overall, 20.6% of all pregnancies ended in abortion and one out of every four American women has had an abortion at some time in her life. So our challenge is to reduce the number of abortions and to do that, we need to do a root cause analysis. So, let’s apply the 5 whys to the problem of abortion in the United States.

If we only ask the most superficial why, we determine that we have a lot of abortions in the U.S. because organizations like Planned Parenthood offer abortion services. When the U.S. was living in the era of Roe v. Wade, this was the approach taken by those opposed to abortion. Conservative states prohibited public funds to be used for abortion and created laws to make it as hard as possible for organizations like Planned Parenthood to perform abortions. But the 930,160 abortions performed in the United States in 2020 indicates pretty clearly that stopping at the first why did not significantly reduce the number of abortions in our country. So, let’s ask a second why:

With the Supreme Court ruling on Dobbs v. Jackson Women’s Health Organization a year ago, those opposed to abortion focused on the second why. The result is that many states have passed or plan to pass laws making it illegal for doctors to perform abortion in most situations. These laws will certainly stop doctors from performing abortions but they will not stop women from pharmacologically inducing abortions on their own and these laws will most certainly not get at the root cause. Now let’s see what happens at the third why:

Here, we find that the doctors were not actively seeking women to convince them to have abortions. Instead, the women were seeking the doctors and requesting abortions. If we stop with this why, then the solution is to make it illegal for a woman to have an abortion. This would not prevent some women from pharmacologically inducing an abortion on their own. For example by buying misoprostol on the street the way people by cocaine on the street or by taking a high dose of FDA-approved drugs like methotrexate or non-steroidal anti-inflammatory drugs. State laws making it illegal for a woman to willingly undergo an abortion will not eliminate abortion any more than laws making marijuana illegal has stopped marijuana use. Such state laws also would not stop women from traveling to another state to get an abortion where it is legal. What about the fourth why:

Now we find that America’s abortion problem is actually an unwanted pregnancy problem. If we stop with the fourth why, then the solution would seem to be to tell women and men that it is illegal or immoral to have sexual intercourse unless they are married and are doing it in an attempt to have children. The Catholic Church has been trying this tactic for nearly 2,000 years and it hasn’t worked yet. I can confidently say with 100% certainty that telling people in their teens and 20’s that they can’t have sex outside of marriage will not work. You can’t stop people from having sex any more than you can stop the sun from rising. So let’s look at the fifth why:

Now we see that abortions are performed because of unwanted pregnancies that in turn resulted because adequate birth control methods were not used and because of a lack of sex education. And where do many women (particularly low income women and teenage girls) go to get birth control? …Planned Parenthood. In addition, organizations such as Planned Parenthood provide free community sex education and this fills an unmet need in those communities that lack effective sex education in their schools – either because of state laws or school board decisions in the case of public schools or religious doctrines in the case of private schools.

The economics of abortion

If we approach abortion from an economic viewpoint, it all comes down to supply and demand. Focusing on laws that penalize doctors from performing abortion or penalize women from having an abortion is supply-side economics. If social conservatives really want to reduce the number of abortions, then it is necessary to focus on demand-side economics. And that means finding ways to reduce unwanted pregnancies and redirecting efforts to address the fifth why. So, what should pragmatic conservatives do to really make a difference in the number of abortions performed in the United States?

  1. Restore effective sex education in schools. Avoiding talking about sex with teenagers in schools and banning books about sex in libraries will only increase unwanted pregnancies. Similarly, teaching that abstinence is the only way to get to heaven in our private schools is out of touch with reality. Sure, it would be nice if every parent had “the talk” with each of their children at age 12 but history has proven that this just does not always happen. Schools are the only realistic venue for universal sex education.
  2. Make effective birth control available. The emphasis here is on the word “effective“. Not all forms of birth control are equally effective. Condoms are frequently ineffective and birth control pills are sometimes ineffective. A law requiring all commercial health insurance policies and all state Medicaid programs to provide IUDs, hormonal implants, vasectomies, and tubal ligations with no co-pays would eliminate far more abortions than defunding Planned Parenthood or making abortion illegal in your state. What are effective birth control methods?
    1. > 13 pregnancies per 100 women per year: withdrawal, condoms, spermicides, diaphragms, calendar methods
    2. 4 – 7 pregnancies per 100 women per year: birth control pills, hormonal patches, cervical rings, hormone injections
    3. < 1 pregnancy per 100 women per year: IUDs, implants, vasectomy, tubal ligation
  3. Donate money to Planned Parenthood for pregnancy prevention programs. Who goes to Planned Parenthood for birth control? It’s women who do not have a primary care provider, women who lack health insurance coverage for effective birth control, and girls who do not want their parents to know that they are sexually active (Sorry to tell you this America, but your kids did not have sex because they went to Planned Parenthood, they went to Planned Parenthood because they were having sex). This is actually a huge part of what Planned Parenthood really does and this is often neglected in public discussion. If you really want to reduce abortions, then pay organizations like Planned Parenthood to reduce unwanted pregnancies.

You can’t stop all unwanted pregnancies

Not every unwanted pregnancy can be avoided. Sometimes, even diligent use of an effective method of birth control does not work. Sometimes people have unplanned consensual sex or unplanned sex when intoxicated. Sometimes pregnancy results from rape. Sometimes complications of pregnancy pose a health risk to the woman. And sometimes there are severe fetal abnormalities even when pregnancy was intentional. So, we cannot totally eliminate the demand for abortion but by focusing on birth control availability and sex education, we can substantially reduce the demand for abortion. By doing so, we can reserve abortion for these other situations where there is perhaps less controversy about whether abortion should be accessible. That would be fare less polarizing and decisive than making abortion illegal except in these situations.

By stopping at the first, second, third, or fourth why of abortion, all we do as a society is engender anger and cause Americans to face off against each other, without actually reducing the demand for abortion. It is just like the analogy with the hospital with a high post-op surgical infection rate. It is only by reaching the fifth why that we can actually make a difference in abortion demand and reduce the number of abortions in our county.

I fear that history will judge us as foolish. Instead of directing our efforts at the underlying root cause of abortion, we as a society have put all of our energy into the downstream effects of that underlying root cause. In this way, we are like the man who kept blasting away every night at the snakes and wrecking his house rather than simply closing the back door so that the snakes could not get into the house in the first place.

June 26, 2023

Outpatient Practice

Prostate Cancer Screening

The prostate cancer screening pendulum just swung… again. One of the most vexing problems in outpatient medicine has been prostate cancer screening: who should be screened and when should they be screened? New developments are finally giving us some clarity. We have a highly effective screening test in the prostate specific antigen test (PSA). This simple blood test is inexpensive and widely available. Finding an elevated PSA can result in detecting prostate cancer at an early, curable stage. But sometimes, the PSA can be too good.

Every year, our hospital holds an annual Community Day where physicians and hospital staff volunteer their time to provide free health information and screening tests to the public. Many of the community members attending are uninsured and low income so Community Day is their only source of screening for chronic diseases and cancers. A few years ago, the hospital agreed to perform free PSA tests and I asked two doctors to staff a prostate cancer screening station. One doctor said “If attendees don’t get PSA tests, I’m not going to participate” and the other doctor said “If attendees do get PSA tests, I’m not going to participate“. So which doctor was right? This is a question that as a 64-year-old man I’ve thought about a lot and it turns out that that both of them were right and both of them were wrong.

The history of PSA screening

Prostate cancer is the most second most common cancer in men (after skin cancer) and the second most common cause of cancer death in men (after lung cancer). It is estimated that 288,300 American men will be diagnosed with prostate cancer and 34,700 American men will die from prostate cancer in 2023. Prostate cancer is most commonly first identified by an elevated PSA level.

The PSA test was first approved in 1986 and became widely used to screen for prostate cancer in the 1990’s. With widespread screening came a dramatic increase in the number of new prostate cancer diagnoses that peaked in 1992 at 225 per 100,000 population, as shown by the light green squares in the graph below.

But despite all of these new cancers being found, there initially was no significant reduction in the prostate cancer death rate, as shown by the dark green triangles in the graph above. The implication was that the PSA test was finding lots of very low-grade, slow-growing cancers that were never going to spread during a man’s life. This raised a concern that we were doing a lot of unnecessary prostatectomies on men who did not need them… and prostatectomies have a significant risk of causing urinary incontinence and impotence. In addition, at the time, an elevated PSA was followed by a transrectal prostate biopsy that carried with it a 2-4% incidence of sepsis and further concern was raised that we were subjecting a lot of men to unnecessary biopsies. The enthusiasm for universal PSA testing began to wane and then in 2009, the PLCO study was published in the New England Journal of Medicine that caused many physicians to stop screening for prostate cancer altogether.

The PLCO (Prostate, Lung, Colorectal, and Ovarian Cancer Screening Trial) examined 76,693 men American men who were randomized to either get annual PSA tests for 6 years or get “usual care”. After 7 to 10 years, there was no difference in prostate cancer mortality between the two groups and it was concluded that annual PSA testing does not lower the death rate from prostate cancer. As a result, in 2012, the United States Preventive Services Task Force (USPSTF) gave the PSA a grade “D” recommendation, meaning that the harm of testing outweighed the benefits of testing. Overnight, prostate cancer screening braked to a halt. A second study in 2009 from Europe looked at 182,000 men randomized to either be screened every 4 years with a PSA or to not be screened. This study did find a 20% reduction in prostate cancer deaths in the group undergoing screening but the USPSTF chose to base its decision on the U.S. study rather than the European study.

But then in 2016, it came to light that in the PLCO, 90% of the men randomly assigned to the “usual care” group actually had a PSA test before or during the PLCO study by their regular physicians. In other words, both groups of men were getting screened using the PSA. It is not surprising, therefore, that there was no difference in the prostate cancer survival between the two groups in the PLCO study. This new revelation was published as a letter to the editor in the New England Journal of Medicine in 2016 and thus did not get as widespread attention as the original PLCO study 7 years earlier. Another important feature of the PLCO study was that only 4% of subjects were African American (who have a higher risk of prostate cancer) whereas in the U.S. as a whole, 12% of men are African American. In 2018, the USPSTF published new prostate cancer screening guidelines upgrading the PSA test to a grade “C” recommendation that stated “The decision to be screened for prostate cancer should be an individual one.” In other words, the USPSTF left it up to each doctor to decide whether or not to screen any given man for prostate cancer using a “shared decision making” approach.

In the past five years, there have been 4 new studies of PSA screening that have all shown that screening reduces prostate cancer death, ranging from 1 death prevented for every 101 men screened to 1 death prevented for every 570 men screened. Taken together, the data to support PSA screening is looking better and better every year.

New developments

Since the peak use of the PSA to screen for prostate cancer in 1992, there have been a number of developments that have changed our approach to the diagnosis and treatment of prostate cancer:

  • The open radical prostatectomy has been largely replaced by the minimally invasive robotic prostatectomy which has lowered the complication rate of surgery.
  • Advances in radiation therapy have led to radiation therapy now being a non-surgical treatment option for many men with prostate cancer.
  • There is greater recognition that certain men are at significantly higher risk of getting prostate cancer and of dying from prostate cancer. These include African Americans, those with a family history of prostate cancer, those with the BRCA gene and those with another genetic condition called Lynch syndrome. In addition, men who develop prostate cancer at a young age are more likely to have aggressive, fatal prostate cancer than those who develop it during older ages.
  • The prostate MRI has emerged as the preferred initial test for men with an elevated PSA and this has reduced the need for subsequent biopsy by 28%.
  • The transrectal prostate biopsy that carried with it a 2 – 4% risk of sepsis has been largely replaced by the less risky transperineal prostate biopsy which has a < 1% risk of sepsis.
  • There are new androgen-deprivation treatments and chemotherapies for patients with metastatic prostate cancer that can significantly prolong survival.

The net result of all of these developments in addition to the use of PSA testing has been a reduction in the mortality rate of prostate cancer from 39.2 per 100,000 men in 1992 to 18.6 per 100,000 men in 2020. That is a 50% reduction in mortality!

So who should we screen in 2023?

It remains true that many men with prostate cancer have slow-growing cancers that will never require any treatment. In these men, if you find a prostate cancer, you probably are not going to treat it and knowledge of the cancer only causes the man anxiety. Screening these men violates the cardinal rule of “Don’t ask a question that you don’t want to know the answer to“. Our challenge is to preferentially screen only those men who are at higher risk of developing a prostate cancer that will actually kill them. The current USPSTF recommendations of “shared decision making” between the primary care provider and the patient is vague and nebulous. It can leave the physician with the sense that the USPSFT is just saying “We really don’t know what to recommend, so you decide“. In order to provide a bit more direction, here are my personal recommendations:

  • PSA testing starting at age 40: African American men, men with a family history of prostate cancer, men with BRCA1 or BRCA2 gene and men with Lynch syndrome.
  • PSA testing starting at age 50: all other men.
  • Don’t do a rectal exam as part of screening (reserve it only for those men with an elevated PSA).
  • Repeat the screening PSA every 1-2 years.
  • Stop PSA testing in most men at age 70 or in men with less than 10 years to live. For exceptionally healthy men, continued screening into their 70’s is prudent.

There are a few other caveats to PSA screening. Do not do a PSA test in a man with a urinary tract infection (false positives). If the PSA is elevated, the next step is usually to just repeat the PSA in 4 – 6 weeks (there are other reasons for false positives). What constitutes an elevated PSA depends on the man’s age: PSA > 2 in their 40’s, PSA > 3 in their 50’s & 60’s, PSA > 4 in their 70’s. Not every elevated PSA is from prostate cancer – chronic prostate inflammation, prostatic hypertrophy, and prostate trauma can also cause a high PSA level.

For a more in-depth update on PSA testing, you can watch a recent OSU MedNet webcast on prostate cancer screening by the Ohio State University’s Dr. Shawn Dason by clicking here.

Getting back to the hospital’s Community Day

Should you offer PSA testing as part of a cancer screening program at a hospital community day or health fair? I think that the answer is “Yes!”. However it should be targeted to men between the ages of 50 – 70 years old. For those men with risk factors (African American, family history, genetic predisposition), an age range of 40 – 70 is preferred. Screening should be accompanied by a discussion with the patient that not every man with an elevated PSA will have prostate cancer and not every prostate cancer has to be treated. That discussion should also include that prostate MRI and transperineal biopsy can now be done instead of the older transrectal biopsy, resulting in fewer complications.

The PSA pendulum has swung from screen all men to screen no men and most recently to screen some men. I believe that the pendulum is now swinging towards screening all men at an appropriate age. Primary care providers should get ahead of the pendulum and implement these screening practices now.

June 23, 2023

Emergency Department Intensive Care Unit

It’s Time To Trade In Your Direct Laryngoscope

Emergency endotracheal intubation is commonly performed in patients with cardiac arrest, loss of consciousness, or severe respiratory failure. A study published this month in the New England Journal of Medicine found that emergency intubation using video laryngoscopes is more successful than intubation using direct laryngoscopes. In the hospital, emergency intubations typically occur in the emergency department, intensive care unit, or in a regular hospital bed and these patients are by definition physiologically unstable. In contrast, elective intubations are performed in the operating room under controlled conditions in surgical patients who are usually physiologically stable. Over the decades, I have performed or supervised hundreds of emergency intubations and there are always two goals: (1) do it fast and (2) do it right the first time. During the emergency intubation procedure, the patient is unable to breath effectively and if too much time is taken or too many attempts are required, the patient can become dangerously hypoxemic.

Direct laryngoscopy

For years, the only way to intubate a patient was by using a direct laryngoscope. There are two main types, the Macintosh laryngoscope and the Miller laryngoscope. Both have a handle that contains batteries and a blade that is inserted into the mouth to pull the tongue out of the way in order to get a view of the vocal cords. In the blade of the direct laryngoscope, there is a small light bulb to help improve the ability to see the vocal cords. Once the laryngoscope is inserted into the mouth, a plastic endotracheal tube is guided through the vocal cords and into the trachea.

The Macintosh laryngoscope has a curved blade and comes in a variety of sizes. My go-to laryngoscope blade for most of my career was a #3 Macintosh. For large patients, I would sometimes use a #4 Macintosh. The Miller blade is straight. I personally found it harder to use for most patients but it was sometimes helpful for obese patients and in situations when I just could not get a good view of the vocal cords with a Macintosh blade. The Miller blade also comes in a variety of sizes. In the past, direct laryngoscopes were reusable after sterilization but most hospitals now use disposable, non-reusable laryngoscopes.

Intubation using a direct laryngoscope requires the operator to be directly behind and above the patient’s face, within a few inches of the mouth. You have to wear a face mask and plastic face shield – it is pretty common to get spattered with sputum, blood, saliva, or vomit. Because you are so close to the patient’s airway, there is also a risk of becoming infected with a contagious microorganism. This was a big danger during the COVID pandemic and we largely abandoned direct laryngoscopy when intubating COVID patients because of this risk.

Video laryngoscopy

About 15 years ago, a new type of laryngoscope emerged on the market that uses a tiny camera at the end of the laryngoscope blade, adjacent to the light bulb. The view from the end of the blade can then be displayed on either a small video monitor attached to the laryngoscope handle or a larger video monitor connected to the laryngoscope by wires. The downside of video laryngoscopes is that they are far more expensive to purchase and maintain than direct laryngoscopes.


The video laryngoscope blades are all curved and have a greater degree of curve than the Macintosh blade. Because of this, they require a special curved rigid metal stylet to be inserted into the endotracheal tube. Once the tip of the endotracheal tube is positioned just above the vocal cords, the endotracheal tube is advanced while simultaneously pulling back on the stylet so that the endotracheal tube can assume a straight path in the trachea, below the vocal cords. This usually requires an assistant to control the stylet or an extremely dexterous operator who can control both the stylet and the endotracheal tube with one hand.

There are three main advantages to the video laryngoscope. First, you can get a better view of the vocal cords than with the direct laryngoscope. This is especially true in patients with “anterior” larynxes that are hard to see with direct visualization through the mouth and in patients with large tongues that obstruct direct visualization. The Mallampati score is often used to classify the airways – those with Mallampati class III or IV airways are better seen with the video laryngoscope. Second, the video laryngoscopes allow the operator’s face to be a couple of feet away from the patient’s nose and mouth, rather than a few inches as with direct laryngoscopes. This can reduce the chances of acquiring a communicable disease. For this reason, video laryngoscopy became our preferred approach to intubating patients with COVID infections. Third, it is easier to teach trainees how to perform endotracheal intubation since the attending physician can point out the anatomy and see if the trainee is inserting the endotracheal tube correctly. In contrast, during direct laryngoscopy, only the person actually performing the intubation can see the vocal cords and watch the tube insertion so it is not possible for the attending physician to know if the trainee is performing the intubation correctly.

Which method of laryngoscopy is better?

Anecdotally, our pulmonary/critical care fellows tell me that they get proficient with endotracheal intubation faster using video laryngoscopy than using direct laryngoscopy. They cite the better view of the vocal cords plus the improved feedback from the supervising attending physician. From my own personal experience, I found that video laryngoscopy was particularly useful in those patients who I could not get a good view of the vocal cords during an initial intubation attempt with a direct laryngoscope. But anecdotes are not as persuasive as randomized, controlled, multi-center trials. So, what does the medical literature show?

A 2021 study in JAMA found that worldwide, 81% of emergency intubations are performed using direct laryngoscopy. There have been a number of studies comparing direct and video laryngoscopy for endotracheal intubation. Some have shown that both techniques are equally successful, others have shown that video laryngoscopy is superior, and others have shown that direct laryngoscopy is superior. But until recently, there have been no large, randomized, multi-center trials comparing the two techniques for emergency intubation. In a 2020 review of tracheal intubation in critically ill patients published in the American Review of Respiratory and Critical Care Medicine, the recommendations stated that video laryngoscopy should be available in every ICU and ER and that the first attempt at emergency intubation should be made using video laryngoscopy. The recent study in the New England Journal of Medicine now provides the most convincing evidence to date that video laryngoscopy is superior to direct laryngoscopy during emergency endotracheal intubations.

What the study found. In this study, 1,417 patients undergoing emergency endotracheal intubation at 11 U.S. hospitals in 2022 were randomized to the use of video laryngoscopy or direct laryngoscopy for the first attempt at intubation. 70% of patients were in emergency departments and 30% were in ICUs. Because all of the hospitals were teaching hospitals, the vast majority of intubations were performed by trainees: 72% were by residents and 24% were by fellows. Notably, these are less experienced physicians who have performed fewer intubations than more senior attending physicians. The findings were statistically significant: 85% of patients were successfully intubated on the first attempt using video laryngoscopy but only 71% of patients were successfully intubated on the first attempt using direct laryngoscopy. It also took the operators less time to perform intubation using video laryngoscopy (38 seconds) than using direct laryngoscopy (46 seconds).

What the study did not find. Because the overwhelming majority of intubations (96%) were performed by trainees, it is uncertain whether video laryngoscopy is also superior to direct laryngoscopy when experienced attending physicians are performing emergency intubation. Anecdotally, I believe that video laryngoscopy is superior, at least from my own personal experience using both types of laryngoscopes. The study only examined emergency intubations and not elective intubations (such as occur regularly in the operating room). Therefore, the results do not necessarily mean that we should abandon direct laryngoscopy for elective surgeries. Finally, there were no differences in procedural complications using the two types of laryngoscopes.

So, what should hospitals do?

For the hospital medical director or the medical director of an emergency department or intensive care unit, there are several practical implications from the most recent study:

  1. Training programs should incorporate video laryngoscopy. All health care providers who perform emergency endotracheal intubation should be taught to use video laryngoscopy during their formal training programs. In the United States, emergency intubations can be performed by a variety of providers including residents, fellows, attending physicians, respiratory therapists, EMTs, CRNAs, nurse practitioners, and physician assistants. Each hospital is different, depending on the staff availability, state laws, and hospital regulations. Moreover, emergency intubations in the ICU and during cardiopulmonary arrests often occur at night or weekends when experienced attending intensivists and anesthesiologists are not immediately available.
  2. Make training available to existing staff. Newly trained ER residents and critical care fellows will already be experienced using video laryngoscopy devices and should not be required to undergo additional training as attending physicians. However, it is necessary to have a process in place to train more senior physicians and other health care providers in the use of the equipment. Because internal medicine residents are no longer required to be trained in intubation, at our hospital, we developed a “Difficult Airway Course” for our hospitalists who covered the ICU at night and who responded to cardiopulmonary arrests in the hospital. This included demonstration of the video laryngoscope equipment and opportunity to use the video laryngoscope to intubate manikins. It took less than an hour and was included as part of orientation for new hospitalists. To make training even more palatable, offer CME credit.
  3. Video laryngoscopes should be available wherever emergency intubations are performed. At a minimum, this should include emergency departments and intensive care units. However, cardiopulmonary arrests can occur anywhere in the hospital so there should be protocols in place in order to deploy video laryngoscopes rapidly to any location in the hospital.
  4. Choose a brand (and stick with it). To date, there are no studies comparing one type or brand of video laryngoscopes to another. The decision about which video laryngoscopes the hospital should purchase should be made based on preference consensus of physicians who perform emergency intubation and on cost. In my own experience using multiple types of video laryngoscopes, I recommend choosing one type and then using that one type throughout the hospital, rather than having different types or brands in different hospital locations. Although they are all relatively similar, even a few extra seconds required to figure out how to use an unfamiliar brand of a video laryngoscope during cardiopulmonary resuscitation can result in patient harm.
  5. Buy enough devices. Medical equipment periodically breaks and has to be sent out for repair or replaced. It is important to always have back-ups in event of breakage. In addition, patients do not schedule their need for emergency intubation and there can be several emergency intubations during any given ER or ICU shift. Have enough video laryngoscopes to accommodate multiple intubations occurring simultaneously and if your video laryngoscope requires cleaning and sterilization, be sure you have enough video laryngoscopes on hand to last until equipment can be cleaned.
  6. Don’t completely abandon direct laryngoscopy. Because direct laryngoscopes are inexpensive and small, hospitals can afford to keep them in every crash cart and airway kit. It is prudent to always have a direct laryngoscope on hand in case the video laryngoscope quits working in the middle of an intubation. Furthermore, the availability of multiple sizes and shapes of the direct laryngoscope blades allows a more tailored selection of equipment for patients with larger or more unusually shaped mouths. When it comes to emergency airway management, it is always important to have a back-up plan and direct laryngoscopy is the key component of the back-up plan for video laryngoscopy. The implication is that we must therefore continue to teach our trainees how to use direct laryngoscopes and not completely abandon them from ER residencies and critical care fellowships.
  7. Recommend but do not require the use of video laryngoscopy. When ultrasound to guide central venous catheter placement first came out in the late 1990’s, many of us thought that ultrasound would soon come to used for all central line procedures. Indeed, almost all residents and fellows adopted ultrasound. But many attending physicians who were very experienced and adept at performing central lines found ultrasound slowed them down and did not improve their already very high success rates. A physician who is highly skilled using direct laryngoscopy may have better outcomes continuing to use the equipment he/she is comfortable and experienced with, rather than being forced to change to new equipment. Many physicians are resistant to change but most physicians find that once they actually use video laryngoscopy, they do not want to go back to direct laryngoscopy.
  8. Avoid special credentialing. Another lesson from vascular ultrasound for central line placement was credentialing. When hospitals first acquired these ultrasound devices, there was concern that the operation of the ultrasound equipment and the interpretation of the ultrasound images required specialized skills. Consequently, hospitals required physicians to have special credentials in order to use ultrasound to facilitate central venous catheter placement. Credentialing required several hours of training and required proctored performance of several ultrasound procedures before the physician was permitted to use vascular ultrasound. This posed a barrier to its implementation because many attending physicians found it easier to continue to do non-ultrasound guided procedures rather than take the time and effort to get credentialed for the use of ultrasound. In hindsight, this was a mistake and should be avoided with video laryngoscopy.

Final thoughts

The two goals of emergency endotracheal intubation are to: (1) get it done fast and (2) get it done right the first time. Video laryngoscopy offers an improvement in both of these goals compared to direct laryngoscopy. It is time to equip our emergency departments, intensive care units, and crash carts with these devices. And it is time to encourage our health care providers to adopt their use.

June 21, 2023

Physician Finances Physician Retirement Planning

When Is The Best Time To Rebalance Your Investment Portfolio?

An essential element of investment portfolio health is periodic rebalancing. This means evaluating your current mix of stocks, bonds, cash, and real estate investments, then selling and buying these various components to ensure that the actual proportions are the same as your desired proportions. For example, let’s say you want a portfolio that is 60% stocks and 40% bonds. If the stock market falls and you find yourself with 55% stocks and 45% bonds then you sell some bonds and buy some stocks to rebalance to the 60/40 mix. But how often should you rebalance and is there a best time of the year to rebalance? By using a little strategy in deciding when to rebalance, you can increase your overall investment returns.

Components of a diversified investment portfolio

The simplest way to think of portfolio diversification is stocks and bonds. As a general rule, when a person’s investment horizon is long, that person should have a higher percentage of stocks compared to bonds in their portfolio. On the other hand, when a person’s investment horizon is short, that person should have a  higher percentage of bonds compared to stocks in their portfolio. Consequently, a 25-year old who is 40 years away from retirement should be primarily invested in stocks. A 65-year old who is ready to retire should have a higher percentage of bonds and a lower percentage of stocks in their investment portfolio.

In addition to one’s investment horizon, one’s willingness to take investment risk also affects the stock:bond ratio in a portfolio. For any given investment horizon, a higher risk portfolio will have a greater percentage of stocks than a lower risk portfolio. Because of this, a higher risk portfolio will have a greater chance of larger long-term returns but also has a greater chance of short-term losses. Investment anxiety is one way of determining investment risk. For example, if you lose sleep every time your 401(k) falls in value, then you should take a lower risk approach to investing. On the other hand, if the ups and downs of the stock market does not bother you, you can adopt a higher risk approach to investing. Life expectancy also affects investment portfolio risk. For example, a person in excellent health who anticipates living to an old age can afford to have a higher risk portfolio since their investment horizon is quite long, even at the age of retirement. Having a pension serves as a buffer in the event of short-term losses, therefore, a person with a sizable pension can afford to have a higher risk portfolio. If a person’s anticipated monthly income from their retirement portfolio is considerably higher than their monthly basic living expenses, then that person can afford to not take money out of retirement investments in years that the market has fallen and thus that person can also afford to have a higher risk investment portfolio.

By combining one’s investment horizon (i.e., age) with one’s willingness to accept investment risk, an individualized stock:bond ratio for their retirement portfolio can be created and might look something like this:

Merely looking at the ratio of stocks to bonds is an over-simplification of investment diversification. A better way to diversify is to subdivide stock and bond investments into U.S. versus foreign and to add a real estate component. This results in 6 categories of investment components:

  1. Cash
  2. U.S. stocks
  3. Foreign stocks
  4. U.S. bonds
  5. Foreign bonds
  6. Real estate

Cash is any account that you can readily access for discretionary or emergency spending. Most people should have a minimum of 3 months and preferably 6 months of living expenses held in cash. Cash accounts include checking, savings, and money market accounts. Some people put certificates of deposit in the cash category but this can be risky. A 12-month CD results in money being tied up for 12 months before you can access it. This is fine for money you are planning to use for a down payment on a house you plan to buy a year from now but is inaccessible if you lose your job and need to buy groceries next month.

Stocks can be divided into those from U.S. companies and those from foreign companies. The difference between them can be confusing. For example, some foreign companies are traded on the New York Stock Exchange and many U.S. companies have a global presence by generating revenue from sales of products in other countries. Most mutual funds will specify whether their component stocks are from U.S. companies or foreign companies. So, for example, an S&P 500 index fund consists of 500 U.S. companies whereas a European index fund will consist of only European companies. However, the terminology can be confusing because a “global”, “international”, or “all-world” index fund may or may not include U.S. companies so it is important to understand the make-up of any given mutual fund.

Bonds can be divided into U.S. versus foreign but can also be divided into government bonds versus corporate bonds. As a general rule, corporate bonds have greater risk but higher potential returns than government bonds. Municipal government bonds are often tax-free whereas returns on U.S. treasury bonds are subject to tax.

Real estate can be an investment property that you personally own but most investors do not buy individual properties. Instead, they purchase REITs (real estate investment trusts) that are sort of like mutual funds for real estate. The REIT will own multiple properties (typically office buildings, hotels, apartment buildings, and shopping centers). The investor then buys shares of that REIT, just like they would buy shares of a stock mutual fund consisting of stocks from multiple companies.

Because the U.S. economy has historically out-performed most other nations’ economies and because the U.S. economy (and government) has also been more stable than most other nations’ economies, it is prudent to have a higher percentage of one’s investments in U.S. companies than in foreign companies. A typical tactic for stocks in a portfolio would be to maintain a ratio of 60% U.S. stocks and 40% foreign stocks. A typical tactic for bonds in a portfolio would be to maintain a ratio of 70% U.S. bonds and 30% foreign bonds. When it comes to risk and potential returns, REITs tend to fall in-between stocks and bonds. Therefore, it would be prudent to maintain a small percentage of one’s investment portfolio in real estate, for example, 5% of the total portfolio.

All of this can be complicated, so many people just purchase an “all-in-one” mutual fund that combines U.S. and foreign stocks and bonds in ratios depending on one’s investment horizon. These will sometimes be labeled as “Target Retirement 2045” for a person anticipating retiring in about the year 2045, for example. The following is the breakdown of Vanguard’s all-in-one mutual funds:

These all-in-one funds are a good choice for the investor who lacks the time, knowledge, or confidence to manage their own investment portfolio. An advantage of these funds is that the investment company does all of the rebalancing in order to maintain the desired ratio of stocks:bonds and then adjusts that desired ratio each year as a person gets older and their investment horizon shortens. However, these funds do not take into account the individual investor’s willingness or ability to assume risk and simply rely on investment horizon. Furthermore, the all-in-one funds generally do not include any real estate holdings, such as an REIT.

How often should you rebalance?

The largest investors on the planet are pension funds that can have billions or even trillions of dollars of invested assets. Although there is a lot of variation, most of pension funds rebalance monthly or quarterly. But for the individual investor, this is probably too frequent. For most of us, rebalancing once or twice a year is sufficient. The danger of rebalancing too frequently is that you can over-respond to short-term fluctuations in the market, resulting in a lot of buying and selling of investments. This can in turn result in a lot of investment transaction fees and a lot of capital gains. Those capital gains get taxed at either short-term or long-term capital gains tax rates. Short-term capital gains are on those investments that you sell less than 12 months after you purchased them; these are taxed at your regular federal income tax rate. Long-term capital gains are on those investments that you held for more than 12 months before selling and are taxed based on annual income levels at either 0% (for very low income investors), 20% (for very high income investors), or 15% (for most of us). As a general rule, your long-term capital gains tax rate will be lower than your short-term capital gains tax rate. The effect of this is that by rebalancing your non-retirement investment portfolio too frequently, you end up paying more in income taxes.

The danger of rebalancing too infrequently is that your investment portfolio can become too conservative (resulting in diminished long-term returns) or too aggressive (resulting in an excessively high-risk portfolio). Therefore, the timing of investment portfolio rebalancing is the intersection of patience and prudence.

I recommend doing a comprehensive rebalancing once a year and then doing an investment check-up every 3 or 6 months. During the check-up, if you find that your portfolio has become unexpectedly and significantly out of balance, then go ahead and rebalance at that time. What constitutes “significantly” out of balance is open for debate but I recommend using a 5% rule: if the percentage of one category of investments is off by more than 5 percentage points from your desired percentage, then it is significantly out of balance.

Take taxes into account

Investments can be grouped into three different categories: (1) regular investments, (2) tax-deferred retirement investments, and (3) Roth retirement investments. Regular investments are those that you purchase with your cash and you will pay capital gains taxes on them when you sell them. In addition, you will pay regular income tax on any interest or ordinary dividends that you earn from those investments each year.  You will pay capital gains tax on any qualified dividends you get from an investment each year. If you own a stock for less than 60 days before the dividend date, then those dividends are considered ordinary and if you own a stock for more than 60 days before the dividend date, then those dividends are considered qualified. Tax-deferred investments include the 401(k), 403(b), 457, and traditional IRA. You pay regular income tax on any withdrawals when you are retired. There is no additional annual tax on interest and dividends earned from those investments but you will pay regular income tax on money generated from interest and dividends when you withdraw that money in retirement. Roth retirement investments include Roth IRAs, Roth 401(k)s, Roth 403(b)s, and Roth 457s. For these investments, you pay regular income tax in the year that you originally earn the money and deposit it in the Roth account; that money then grows tax-free until you take withdrawals in retirement. There is no tax on interest, dividends, or withdrawals.

The investment horizon differs for each of these three categories of investments. In general, Roth accounts have the longest investment horizon because it is prudent to wait until you turn 72 years old to begin withdrawals from Roth accounts. This is because required minimum distributions from tax-deferred retirement accounts (such as a 401k) begin at age 72 so it is usually to one’s advantage to begin to spend down those tax-deferred retirement accounts prior to age 72. Roth accounts are not subject to required minimum distributions. Regular investments typically have the shortest investment horizon because these are often used for non-retirement purchases, such as a house, college education, etc. Because of these differing investment horizons, it is wise to have stocks comprise most or all of one’s Roth accounts, a mix of stocks and bonds in one’s tax-deferred retirement accounts, and a higher percentage of bonds and cash in one’s regular investments.

The differences in how these different investments are taxed has implications for portfolio rebalancing. Most people will have their highest annual taxable income during their middle or late working years (i.e., in their 40’s, 50’s, and 60’s). This equates to having a higher marginal income tax rate during those years. Because you will be taxed at your regular income tax rate for any short-term capital gains, you will end up paying more in income taxes if you rebalance using regular investments during those peak earning years. Instead, it may be wise to rebalance using investments in your tax-deferred retirement account during those working years when you have a high income.

The exception to this is when you can take advantage of tax-loss harvesting. For example, say you find that your stock:bond ratio is 65:35 but your desired ratio is 60% stock and 40% bonds. So, you decide to sell some of your stock investments and buy some more bond investments. If one of your stocks has lost money since you originally purchased it, you can sell it for a loss. Tax-loss harvesting works by off-setting up to $3,000 in taxable capital gains each year with those losses. If your losses from sales of securities are greater than your capital gains from the sale of other securities for the year, then you can also use tax-loss harvesting to reduce your annual taxable income by up to $3,000. As a result, you can reduce your federal income tax in two ways: you have less income subject to tax and because of that your marginal income tax rate falls. But remember that tax-loss harvesting only applies to regular investments and not to the sale of securities within tax-deferred retirements or Roth accounts.

Rebalancing checklist

Taking all of these various factors into consideration, late December is an ideal time for most people to do a comprehensive investment rebalancing. By then, you should have a good idea of what your annual taxable income will be for that year and you can determine whether tax-loss harvesting will be beneficial. Early July is a good time to do a 6-month investment check-up. The following are considerations to take into account when rebalancing:

  • What is the dividend calendar? Some funds pay dividends once a month but others pay dividends once a quarter or even less often. Many funds pay dividends in mid-December. Do not rebalance by selling an investment just before dividends are paid or you could lose out on those dividends.
  • How long have you held an investment? If you rebalance by selling an investment that you have held for less than 12 months, you could end up paying the higher short-term capital gains tax rather than the lower long-term capital gains tax.
  • Is your emergency fund sufficient? Every year, our basic living expenses increase due to inflation. But a new child adds considerably to those monthly expenses as does a new house with a larger mortgage or a new car loan. A marriage may increase or decrease the combined emergency fund needs of the two spouses, depending on individual circumstances. Reassess your current basic expenses to ensure that you have 3 to 6 months worth of those expenses held in cash.
  • Do you have new non-retirement expenses in the future? Maybe you are planning on buying a more expensive new house in a year or two. Or maybe a new car. Or maybe you need a knee replacement surgery. If you need money for these types of expenses in the next 2-3 years, then the money should be in a safe investment such as a certificate of deposit or a money market. If you anticipate needing money for an expense 3-5 years from now, then some of that money could also be in bonds (but not in stocks).
  • Have you lost money on some investment securities? If so, you may be able to take advantage of tax-loss harvesting.
  • Has your investment horizon changed? Did you change your mind about when you or your spouse plan to retire, either earlier or later?
  • Has your life expectancy changed? No one knows exactly how long they will live but in the past year, if you were diagnosed with cancer or developed congestive heart failure, then your life expectancy has likely decreased so you should adopt a lower risk investment strategy. On the other hand, if you successfully quit smoking, lost excess weight, and committed to a regular exercise program, then your life expectancy likely increased so you can adopt a higher risk investment strategy.
  • Did your pension status change? If you change jobs so that you are no longer eligible for a pension, then you should adopt a lower risk investment portfolio. On the other hand, if you just got a job at a Veterans Administration hospital and will now be eligible for a federal pension, then you can adopt a higher risk investment portfolio.
  • Did the total amount of your investments grow significantly? In retirement, the closer your annual income is to your annual basic living expenses, the less risk you can afford to take with your investments. This is because if the market falls, then you will have to deplete your retirement account faster than you anticipated in order to pay your living expenses. On the other hand, if your annual income in retirement is much higher than your basic living expenses, then you can reduce discretionary spending during years that the market falls and avoid depleting your retirement account. Consequently, if your retirement account has grown significantly in the past year, you may be able to adopt a higher risk investment portfolio. This is why the rich get richer – they can afford to.

Rebalancing is security

It is often said that money can’t buy you happiness. Although this is true, it can help you avoid unhappiness, which in not exactly the same thing. Annual or semi-annual investment portfolio rebalancing can increase your long-term investment returns. This can help to ensure that you have the money you need for a new home purchase, a wedding, or the life you dreamed about in retirement. But even more importantly, rebalancing forces you to critically evaluate your investment portfolio and this can give you confidence in your future and can give you a sense of control over your future. The real value of rebalancing is more than just the money.

June 16, 2023

Outpatient Practice

Designing A Long-COVID Clinic

Long-COVID is also known as PASC (post-acute sequela of COVID). A study in this week’s JAMA found that 10% of people infected with COVID had symptoms lasting for more than 6 months. These symptoms negatively affect quality of life and can result in significant impairment. There is a need for hospitals to create specialty clinics for PASC patients.

Long-COVID symptoms

Development of long-COVID symptoms depends on several variables. For example, women are twice as likely to develop long-COVID symptoms after an infection than men. People with repeated COVID infections are more likely to develop long-COVID symptoms than those with a single infection. People infected with the Delta variant are more likely to develop long-COVID symptoms than those infected with the Omicron variant. The severity of the initial infection also affects the likelihood of developing long-COVID: infected persons requiring hospitalization or ICU care are twice as likely to develop long-COVID symptoms compared to those with milder infections treated as outpatients. Other risk factors for developing long-COVID symptoms are being unvaccinated, older age, smoking, pre-existing chronic medical conditions, and obesity.

Long-COVID is a heterogeneous condition and patients can have a wide variety of symptoms. Most of these symptoms are non-specific. Among those who develop long-COVID symptoms, the most common include:

  • Post-exertional malaise (87%)
  • Fatigue (85%)
  • Brain fog (64%)
  • Dizziness (62%)
  • GI symptoms (59%)
  • Palpitations (57%)
  • Hearing difficulties (54%)
  • Joint pain (42%)
  • Weakness (42%)
  • Sexual impairment (42%)
  • Smell/taste impairment (41%)
  • Headache/muscle pain (39%)
  • Shortness of breath (36%)
  • Cough (33%)

Long-COVID clinic structure

Because of the wide variety of symptoms that people with long-COVID can develop, the evaluation of patients should be tailored to the specific presenting symptoms. The key purposes of a long-COVID clinic should be (1) to measure quantifiable impairment, (2) exclude other conditions that mimic long-COVID, (3) prescribe treatments to relieve symptoms, and (4) direct rehabilitation efforts. The long-COVID clinic should in a location that has on-site EKG testing, phlebotomy for lab testing, and radiology for chest x-rays. It should also be in close proximity for schedulable tests such as pulmonary function tests and echocardiograms.

A full set of vital signs (including resting pulse oximetry) should be performed for each visit. The clinic should be able to refer patients for speciality consultation including cardiology, pulmonary, rheumatology, physical medicine, sleep medicine, physical therapy, occupational therapy, and dietary. Ideally, there should also be access to a pulmonary rehabilitation and cardiac rehabilitation program in the area. Because of their protocol-driven nature, long-COVID clinics are an opportunity for advance practice providers (nurse practitioners and physician assistants).

For most patients, symptoms of acute COVID infection can take many days or even several weeks to fully resolve. The majority of these patients do not require evaluation in a specialized long-COVID clinic. It is reasonable to set a threshold of symptoms persisting for more than 6 – 12 weeks as criteria for referral to a long-COVID clinic. The initial evaluation should include a complete history and physical examination with attention to symptoms during the acute phase of the COVID infection, severity of the infection, vaccination status, age, BMI, smoking status, and co-morbid medical conditions.

Special effort should be given to medication reconciliation at the initial visit. Patients who were hospitalized for acute COVID infection are particularly likely to have had previous medications discontinued during hospitalization and/or new medications started. Sometimes these changes were because a chronic medication was not needed during hospitalization. Sometimes a chronic medication was stopped or changed during hospitalization due to a prohibitory drug-drug interaction with a medication necessary to treat the COVID infection. Or sometimes a drug was changed during hospitalization because that drug was not on the inpatient hospital formulary. During medication reconciliation, attention should be directed toward eliminating duplicate medications, discontinuing unnecessary medications, and resuming maintenance medications held during the acute infection.

Symptom-directed diagnostic testing

The history and physical exam may dictate initial testing. For example, the finding of dry crackles on pulmonary auscultation may dictate pulmonary function tests and a high resolution chest CT. On the other hand, pedal edema, an S3, and moist crackles may dictate a BNP test and an echocardiogram. Sudden onset of dyspnea and pleuritic chest pain shortly after resolution of an acute COVID infection may dictate a d-Dimer test and/or a CT pulmonary angiogram. Diagnostic testing in other patients should be ordered based on the specific long-COVID symptoms each patient has:

Fatigue: Laboratory testing should include: CBC, TSH, chemistry panel, and LFTs. An EKG should be performed. Oxygen saturation at rest and during exercise should be measured (for example, using the 6-minute walk test). Because many of the risk factors of long-COVID are also risk factors for obstructive sleep apnea, patients with fatigue should be screened for sleep apnea (for example, using the STOP-BANG questionnaire). Patients who received corticosteroids as part of their acute COVID treatment should be tested for adrenal insufficiency.

      • Mimics include: anemia, chronic kidney disease. chronic liver disease, sleep apnea, adrenal insufficiency, and hypothyroidism

Shortness of breath: Initial testing should include: BNP, CBC, TSH, chemistry panel, LFTs, chest x-ray, 6-minute walk test and EKG. If these tests are unremarkable, then additional testing could include a full set of pulmonary function tests (spirometry, flow-volume loop, lung volumes, diffusing capacity) and an echocardiogram. If these tests are also unremarkable, then a cardiopulmonary exercise test (CPET) should be considered. If post-inflammatory pulmonary fibrosis is suspected based on chest x-ray abnormalities (or crackles on pulmonary auscultation), a high resolution chest CT should be obtained. Patients with resting or exertion hypoxemia in the absence of radiographic abnormalities should be screened for thromboembolic disease with a d-Dimer test or CT pulmonary angiogram.

      • Mimics include anemia, heart failure, hypothyroidism, chronic kidney disease, chronic lung disease (asthma, COPD, interstitial lung disease), pulmonary embolism, and vocal cord dysfunction

Cough: Initial testing should include a chest x-ray and spirometry with flow-volume loop.

      • Mimics include asthma, gastroesophageal reflux, post-nasal drip, use of ACE inhibitor medications, and vocal cord dysfunction

Brain fog: Initial testing should include CBC, chemistry panel, LFTs, TSH, and 6-minute walk test. A screening test for cognitive impairment should be performed; in the past, this was typically the Mini-Mental State Examination (MMSE) but because that test now requires a fee to perform, the free SAGE test may be preferred. Another screening test for cognitive dysfunction is the Montreal Cognitive Assessment (MoCA); however completion of a mandatory 1-hour training program is required to perform this test.

      • Mimics include anemia, hypothyroidism, chronic liver disease, hypoxemia, sleep apnea, and early dementia

Dizziness or palpitations: Initial testing should include CBC, BNP, EKG, orthostatic blood pressure measurement, and 6-minute walk test. If these tests are unremarkable, additional testing could include Holter monitor, echocardiogram, and tilt-test.

      • Mimic include anemia, heart failure, orthostatic hypotension, and cardiac arrhythmias

GI symptoms: Initial testing should include CBC and LFTs. Patients with diarrhea should be tested for C. difficile if they received antibiotics or were hospitalized. Older age is a risk factor for both long-COVID and lactose intolerance.

      • Mimics include C. diff gastroenteritis, lactose intolerance, and irritable bowel syndrome

Weakness or muscle pain: Initial testing should include chemistry panel, CK, TSH, and LFTs.

      • Mimics include electrolyte disorders, drug side effects (statins), and hypothyroidism

Taste and olfactory dysfunction: These are common after COVID infection, particularly with the earlier Delta variants. There is no particular testing required but nutritional assessment may be useful in those losing weight due to altered diet resulting from abnormal taste and smell. Patients with smell dysfunction should be advised to have working smoke detectors in their homes.

      • Mimics include chronic sinusitis

Chest x-ray abnormalities: Patients with pulmonary infiltrates at the time of the initial COVID infection should have a follow-up x-ray. If infiltrates persist beyond 12 weeks, a chest CT should be performed. It should be noted that 50% of patients hospitalized with COVID who have x-ray abnormalities at the time of initial infection will still have x-ray abnormalities 6 months after the infection. However, because older age and cigarette smoking are risk factors for both long-COVID and lung cancer, resolution of chest x-ray abnormalities must be confirmed.

      • Mimics include lung cancer


Patients with severe impairment, particularly those with neuromuscular impairment, may require referral to a physical medicine specialist to direct rehabilitation. Patients with fatigue, mild-moderate exercise limitation, cardiac symptoms, and pulmonary symptoms can usually have rehabilitation efforts overseen from a long-COVID clinic. Prior to recommending a rehabilitation regimen, patients should complete diagnostic testing to exclude other medical conditions mimicking long-COVID and to identify any objective evidence of cardiorespiratory impairment.

Deconditioning is common following COVID infection. Patients are often sedentary for many days and often sustain weight loss and nutritional deficits during the acute COVID infection. In these patients, dietary guidance to restore body mass coupled with a regular exercise program can be very effective. There is not a single “best” exercise for patients with long-COVID symptoms, rather the best exercise is whatever exercise the patient will actually do consistently. In general, patients should be given a target of 150 minutes of weekly aerobic exercise (walking, stationary bike, treadmill, swimming, etc.). Patients with moderate or severe deconditioning may require several weeks to work up to 150 minutes per week. One of the barriers to aerobic exercise is the fear that exercise-induced dyspnea is a warning sign that the body is being harmed from exercise. A pulse oximeter can be very helpful to reassure patients that their oxygen level remains normal despite dyspnea and to help guide the heart rate during exercise. Patients should target keeping their heart rate during exercise at < 60% of their maximum predicted heart rate (maximum predicted heart rate = 220 – age).

Formal cardiac rehabilitation and pulmonary rehabilitation programs can be beneficial but Medicare will only cover these programs if there is objective evidence of cardiac or pulmonary impairment (some commercial insurance companies have less strict criteria for admission into these programs). For patients not eligible for cardiac or pulmonary rehabilitation, referral to a physical therapist can be useful, not only to define physical capabilities but for exercise guidance.

The special case of athletes

Vaccine skeptics often point to vaccine-induced myocarditis as a reason to avoid vaccination. However, a 2022 study found that people are 11-times more likely to get myocarditis from a COVID infection than they are from a COVID vaccination. Moreover, previous vaccination cut the chances of getting myocarditis after a COVID infection by half. Fortunately, most people who develop myocarditis (from either infection or vaccination) go on to have complete recovery. Nevertheless, those who have myocarditis at the time of their initial COVID infection should undergo cardiology consultation prior to resuming athletic activities.

Long-COVID can be devastating for a young athlete. Missing one season of their sport can mean an end to their high school or college athletic career. It is especially important to evaluate young athletes with long-COVID symptoms for exercise-induced bronchospasm and vocal cord dysfunction since these conditions can be readily treated. This should start with spirometry before and (if obstructed) after a bronchodilator to screen for asthma. A flow-volume loop should also be performed and if inspiratory notching is observed, vocal cord dysfunction should be suspected. In athletes with exertional cough and normal spirometry, a bronchoprovocation study should be performed. If available, a eucapneic voluntary hyperventilation study is the preferred test to identify athletes with exercise-induced bronchospasm. If unavailable, then a methacholine challenge test is an alternative.

If there is no evidence of asthma or vocal cord dysfunction in athletes with persistent dyspnea on exertion following COVID infection, a cardiopulmonary exercise test should be considered. This is an under-utilized test that can be extremely helpful in the evaluation of unexplained dyspnea.

Long-COVID disability determination

For some patients, impairment from long-COVID symptoms can be disabling. Most organizations require objective evidence of impairment before granting permanent disability. In general, subjective symptoms such as fatigue and pain must have objective correlates on diagnostic testing to qualify for disability. Patients with cardiac symptoms, such as chest pain, palpitations, dizziness, or dyspnea should undergo appropriate cardiovascular tests to determine if there is objective evidence of impairment. These tests could include echocardiograms, tilt tests, or cardiac stress tests.

Patients with pulmonary symptoms such as cough or dyspnea on exertion should undergo appropriate pulmonary diagnostic tests to determine if there is objective evidence of pulmonary impairment. These tests should include pulmonary function tests (spirometry, lung volumes, diffusing capacity). If these are normal and disability is still being considered, a cardiopulmonary exercise testing (CPET) should be performed.

Patients seeking disability for brain fog should be evaluated for objective evidence of cognitive impairment with neuropsychological testing.

Long-COVID prevention

The best way to prevent long-COVID symptoms is to prevent COVID infection. All persons should be recommended to get a bivalent COVID vaccine. Not only does vaccination reduce the chance of becoming infected in the first place but those who get infected despite being vaccinated are less likely to develop long-COVID symptoms than those who were never vaccinated. Those with risk factors for long-COVID such as being older, obese, or smokers should continue to take precautions against acute COVID infection including wearing masks in crowded indoor settings and avoiding contact with other people with acute infections. It is important to emphasis that recovery from a previous COVID infection is not protective because repeated COVID infection is an independent risk for developing long-COVID symptoms.

Long-COVID is very real and very common. But by listening to our patients and by using a symptom-driven approach to evaluation and rehabilitation, we can improve their lives.

May 26, 2023

Hospital Finances Medical Economics

Working From Home: Short-Term Benefits But Long-Term Costs

During the COVID pandemic, working from home was mandatory for many workers. But now that the pandemic is fading, working from home is becoming optional. In our hospitals, some employees could not work from home, for example: nurses, respiratory therapists, pharmacists, radiology technicians and lab technicians. But other jobs could be done remotely, for example: scheduling, revenue cycle, customer service, and finance. Should these workers now return to work in the hospital?

In many industries, remote working has now become the norm. Historically, the U.S. average office space vacancy rate was 12.5%. In the first quarter of 2023, that rate is now 18.5%. New office construction has plummeted and many downtown office buildings are being converted into apartments. 39% of American workers have “tele-workable” jobs that can be done remotely. During the height of the pandemic, 55% of these workers with tele-workable jobs did work from home. Currently, 35% of these workers continue to work from home. Overall, 22 million Americans work from home all the time and many more have “hybrid” work, meaning that they work from home some days and work in the workplace building other days.

Advantages of working from home

Every job is a little different and some jobs have more benefits from working remotely than other jobs. There are benefits to both the employer and the employee to working from home. For the employer, advantages include:

  • Reduced need for office space and conference rooms
  • Reduced need for parking space
  • Reduced utility expenses
  • Reduced need for security staff and janitorial services
  • Reduced use of sick time by employees who are either on COVID isolation or have other infections with only mild symptoms
  • Reduced use of personal time-off by employees to stay home with a sick child
  • Improved employee satisfaction
  • Ability to draw workers from a larger geographic area

For the employee, there are even greater advantages:

  • Reduced commuting transportation costs
  • Elimination of daily commute time
  • More time with family and pets
  • Reduced expense of commercially-prepared food (lunches, coffee, snacks)
  • Reduced cost of work attire
  • Potential for fewer work-time interruptions by co-workers
  • Greater flexibility of working hours
  • Flexibility of living location
  • Greater flexibility to take care of errands and appointments
  • Reduced exposure to infected co-workers (not only COVID but also influenza and common colds)

Disadvantages of working from home

As the pandemic has been winding down, many employers are requiring their employees to return to the office, at least some days of the week. The reason is that for many employers, there are disadvantages to remote working that out-weigh the advantages. Some of these disadvantages to the employer include:

  • Potential for some employees to not work the expected number of hours per week
  • Potential for worker distraction by children, spouses, pets and other temptations of home
  • Reduced ability to have group “brainstorming”
  • Reduced spontaneous interactions with other employees
  • Potential for communication errors from inability to pick up on non-verbal communication
  • Reduced mentoring of junior employees by more experienced employees

For the worker, there can also be disadvantages, including:

  • Reduced access to mentoring by senior employees
  • Reduced visibility to company leaders for promotion consideration
  • Reduced networking with other employees outside of one’s own department
  • Social isolation and loneliness
  • Elimination of on-site work perks such as office supplies, coffee, company fitness centers
  • No daily change of scenery
  • Expenses such as computers and video equipment

So, who should and who should not work from home?

Every year, the senior leaders of our hospital would get together for an all-day retreat. We would set our goals for the upcoming fiscal year as well as the strategies and tactics we would use to achieve those goals. Part of that process included succession planning for hospital managers and directors. We would identify not only those employees who we thought had potential for promotion in their own department but also those employees who demonstrated skills that predicted success in a different department. The workers who were most typically considered were those who we knew from interpersonal interactions in the hospital or who we had been able to directly observe at work. Working from home can put the employee at a disadvantage when senior leaders do succession planning and consider employees for promotion.

Working from home is a trade-off of advantages and disadvantages. The balance between those advantages and disadvantages will differ between different employers and departments; it can also differ between different employees in the same department. Every employer and every department within the employer needs to determine where that balance lies in order to decide about continued utilization of working from home. For most employers, offering the option of working from home can insure access to highly qualified employees who, because of geographic location or personal preference of remote working, would otherwise not consider working for that employer. For the employee, choosing to work from home may be preferable at a time in their life when their priorities are the flexibility of work hours and time savings from the lack of a commute. However, for employees who need the benefit of workplace visibility and mentoring for promotion and career advancement, working in the workplace is often preferable.

Work from home is not a one-size-fits-all proposition. Most employers (including hospitals) should neither require all employees to come to work in the workplace nor require all employees to work from home. Just because someone can do their job working from home does not mean that they should do their job working from home. The U.S. unemployment rate is currently 3.4%; the last time the rate was lower was in 1953. With the unemployment rate at a historic low, employers experience stiff competition for the best employees. By not offering a work-from-home option, employers restrict the pool of job applicants and risk resignation of some existing employees. But by not offering in-workplace options, employers miss opportunities for professional growth of their employees which in the long-term can stifle innovation and expertise development.

The COVID pandemic has showed us that working remotely is possible for our hospitals. With the worst of the pandemic behind us, we now must decide which jobs can be performed remotely and which employees are best served by working remotely. Hospitals and employees also need to realize that the short-term advantages of working from home can sometimes come at long-term costs.

May 21, 2023