Medical Education Operating Room

In The Future, Your Nurse Anesthetist Will Be A Doctor

Certified registered nurse anesthetists (CRNAs) are advanced practice nurses who deliver anesthesia. In 2025, the training requirements to become a CRNA will change and require that all new CRNAs have a doctorate degree. In the past, a 4-year bachelors degree followed by a 2-year masters degree in nurse anesthesia was required to become a CNRA. This is similar to other advanced practice providers such physician assistants, nurse midwives, and nurse practitioners. In 2009, the Council on Accreditation of Nurse Anesthesia Educational Programs (COA) voted to require all nurse anesthesia educational programs to transition to 3-year doctoral programs. The deadline for conversion from masters to doctoral programs is 2025. Therefore, after 2025, all newly graduated nurse anesthetists will have doctorate degrees. In order to meet that deadline, beginning this year in 2023, all students enrolling in CRNA programs must enroll in a 3-year doctorate program.

There are six possible doctoral degrees that a nurse can pursue in becoming a CRNA:

  1. DNP (Doctor of Nurse Practice): a degree for a clinical career
  2. DNAP (Doctor of Nurse Anesthesia Practice): a degree for a clinical career
  3. PhD (Doctor of Philosophy): primarily a degree for a career in academics
  4. EdD (Doctor of Education: primarily a degree for a career in education
  5. DNS (Doctor of Nursing Science): primarily a degree for a career in research
  6. DMPNA (Doctor of Management Practice in Nurse Anesthesia): primarily a degree for a career in administration

The vast majority of new CRNAs will have either a DNP or DNAP degree. Both are 3-year programs that require a previous bachelors degree, usually a BSN (Bachelors of Science in Nursing). Both require one year of prior clinical work practice as an RN in a critical care setting but some individual programs may require 2-years of practice as an RN. Both have similar curricula but there are minor differences between the two types of doctorate degrees.

DNP versus DNAP

Doctor of Nurse Practice (DNP). This is a doctoral degree offered at a school of nursing that is accredited by the American Nurses Credentialing Center (ANCC) which is a subsidiary of the American Nurses Association. There are many specialty pathways within the DNP program and a student choosing to become a nurse anesthetist would enroll in the the CRNA pathway. A DNP is considered a “terminal degree”, meaning it is the highest degree that can be obtained in a field. Terminal degrees are usually required for university faculty members seeking tenure.

Doctor of Nurse Anesthesia Practice (DNAP). This is a doctoral degree specially designed for nurse anesthetist students at a training program approved by Nurse Anesthetists Council of Accreditation (NACA). Unlike the DNP, the DNAP is only for nurse anesthetists and not other nurse practitioner specialties. Some, but not all universities consider a DNAP to be a terminal degree; therefore it may not be appropriate for someone who plans to pursue an academic career at a university in order to ensure universal eligibility for faculty jobs.

For the hospital, both the DNP and DNAP programs can be considered equivalent from a training standpoint.

A certification exam is required after training

After graduating from an accredited nurse anesthetist program, individuals must then take the National Certification Exam (NCE) administered by the National Board Certification and Recertification for Nurse Anesthetists (NBCRNA). In 2022, the pass rate for first-time takers of the exam was 83.4%. After passing the certification exam, individuals must then apply for CRNA licensure in their state.

After initial certification, CRNAs are required to be re-certified every four years. Recertification involves having 100 hours of continuing education credits and completion of one core module from each of four core areas: airway management, pharmacology, human physiology & pathophysiology, and anesthesia technology (the core modules provide 60 of the required continuing education credits). CRNA licensure is state-specific and individual states can have additional requirements to practice as a CRNA.

Implications for hospitals

The result of the new requirements is that newly trained CRNAs will have one additional year of training than CRNAs trained in the past. However, because that one year will be nurse anesthetist-specific training, the net result will be a 50% longer training in anesthesia than previously. The additional training should result in greater anesthesia knowledge. The implication is that hospitals may change their utilization of CRNAs:

  • Ability to start cases independently at night. CRNAs are required to work under the supervision of a physician – in Ohio, the “supervising physician” does not have to be an anesthesiologist. The rules on CRNA scope of practice are state-specific but in most states, CRNAs can start surgical cases without a physician anesthesiologist present in the OR area. However, many individual hospitals have rules over and above state regulations and require the presence of an attending anesthesiologist for the CRNA to start a case. This has relevance to cases at night when there can be a delay starting emergency operations while waiting for the anesthesiologist to arrive. Hospitals may find that it is more practical to have in-house CRNAs at night to expedite cases. In this situation, the surgeon would become the CRNA’s supervising physician rather than the anesthesiologist. However, because emergency cases at night are often some of the most physiologically complicated and high-risk, hospitals may still want to have attending anesthesiologists on call from home at night for back-up purposes.
  • Endoscopy sedation. In the past, sedation for colonoscopies and other procedures performed in hospital endoscopy suites was administered by the gastroenterologist or surgeon performing the procedure. In recent years, procedural sedation has increasingly been administered by anesthesiologists. The new requirements may give hospitals more comfort in having CRNAs perform procedural sedation without the physical presence of a physician anesthesiologist in the endoscopy suite area. In this situation, the gastroenterologist or surgeon would become the “supervising physician”.
  • Emergency airway management. In the past, hospitalists were routinely trained in intubation and airway management, such as occurs in the intensive care unit or during cardiopulmonary resuscitation. Because intubation is no longer required during internal medicine or family medicine residency, many hospitalists no longer perform intubation, leaving airway management to critical care physicians, emergency medicine physicians, anesthesiologists, and respiratory therapists. The new training requirements may give hospitals more comfort in designating CRNAs to be responsible for emergency airway management, particularly at night.
  • But, be prepared to pay more. The U.S. Bureau of Labor Statistics reports that CRNAs have a median hourly wage of $97.64 per hour. This equates to an annual income of $203,090 per year. There is considerable variation between different states. For example, the median annual income for CRNAs in California is $246,510 whereas in Oklahoma, the median income is $168,470. Here in Ohio, CRNA income is at about the U.S. average with a median income of $197,630. In contrast, the MGMA reports that the average income for a physician anesthesiologist in academic practice is $407,681 and in private practice is $468,106. In other words, a CRNA costs half as much as an anesthesiologist. However, as the length of CRNA training increases, CNRA incomes are likely to rise in the future.

The trend throughout healthcare has been to increasingly utilize advance practice providers (such as nurse practitioners and physician assistants) to perform services historically performed by physicians. Because these advance practice providers are less expensive than corresponding physicians, they can reduce healthcare costs. The new requirement of a doctoral degree to become a CRNA will likely result in an expansion of the use of CRNAs for anesthesia, sedation, and airway management.

May 3, 2023

Medical Education Physician Finances

Physician Income By Specialty: Does Length Of Residency Determine Compensation?

Physicians earn high incomes but those incomes come at a cost of investing between 7 and 12 years of education and training after undergraduate college. This post will examine the most recent physician compensation report and what it indicates about the relationship between income and the years of training required for each specialty.

Determining average physician incomes by specialty turns out to be a lot more difficult that it would seem. There are many physician compensation surveys and each of them reports compensation a bit differently with the result that it is difficult to accurately know how much the average specialist actually earns per year. Some of the most common surveys include:

  1. AAMC – American Association of Medical Colleges. This annual survey reports physician compensation from 153 U.S. medical schools and > 400 teaching hospitals that serve 124,000 physicians.
  2. MGMA – Medical Group Management Association. This annual reports surveys 3,400 U.S. medical practice administrators that serve 142,000 physicians and advanced practice providers. These group practices are largely mid-sized groups (typically 6 – 50 physicians).
  3. AGMA – American Group Medical Association. This survey represents 380 medical groups from large-sized groups (with > 100 physicians).
  4. Doximity. This survey is of self-reported total compensation from 31,000 full-time U.S. physicians.
  5. Medscape. This survey is of self-reported total compensation from 13,000 U.S. physicians.
  6. Various physician search firms and consultation firms. These are typically of small numbers of physicians and often limited to compensation reports of individual physicians that they have helped with job placement and physician groups that they have consulted with.

I tend to rely mostly on the AAMC and MGMA reports because they sample the largest number of physicians and have stricter methodology regarding what is (and is not) included in total compensation. For academic physicians, the AAMC survey is more comprehensive and generally reports higher incomes for academic physicians than the MGMA survey. For non-academic physicians, the MGMA report provides comprehensive data. For this post, I will use the 2022 MGMA physician compensation report. Total compensation is defined as salary and bonuses as well as physician contributions to retirement plans, health insurance, and life insurance. Notably, the reported compensation does not include employer contributions to retirement plans, health insurance, life insurance, or malpractice insurance.

This is particularly important when comparing academic from non-academic physician compensation since most academic jobs come with lucrative employer contributions. As an example, the Ohio State University contributes about $25,000 per year to their physician faculty member’s State Teacher’s Retirement Plan, life insurance, disability insurance, and health insurance. OSU also pays for medical malpractice insurance – the U.S. national average cost for a critical care physician’s malpractice premium is $20,215 per year. In other words, a typical OSU physician has a total of about $45,000 per year in fringe benefits as an academic physician that they would otherwise likely not have had if they were in a private medical practice. One of the reasons that the MGMA reports that academic physician compensation is much lower than private practice physician compensation is because these employer contributions provided by academic institutions are not included in the total compensation listed in the MGMA reports. If you were to factor in these employer contributions into total compensation, academic physicians’ compensation is closer to that of non-academic physicians.

The MGMA breaks reported compensation into mean, median, 25th percentile, and 75th percentile. For academic physicians, the MGMA additionally breaks down compensation by academic rank: instructor, assistant professor, associate professor, and professor. Other metrics of compensation and productivity are also included such as average total RVUs, average work RVUs, and total compensation per RVU for each specialty. Caution must be exercised when interpreting these data. For example, the mean compensation will include all non-academic physicians in a specialty, regardless of seniority. Physicians in their first years of practice after completion of training are less efficient, less productive, and less highly compensated than physicians in practice for 10, 20, or 30 years. Therefore, a newly-trained physician should not expect to earn the mean or median compensation for a specialty. Conversely, experienced physicians with many years of practice generally earn more than the mean or median. However, for simplicity purposes, this post will focus on the mean total compensation for various specialities for non-academic and academic physicians. The total compensations are summarized in the tables below:

Non-Academic Physician Compensation

This graph illustrates the mean total compensation for non-academic physicians reported by the MGMA in 2022, similar to the table above (to enlarge this graph, click on it to open it in a new window and then click on it again to enlarge). The most highly-compensated specialties were neurosurgery ($947,030), cardiovascular surgery ($829,072), cardiology electrophysiology ($747,947), orthopedic surgery ($715,399), and interventional cardiology ($702,019). At the low end of the compensation spectrum were pediatric specialties: pediatric hospitalist ($237,530), pediatric endocrinology ($239,072), general pediatrics ($252,575), and pediatric infectious disease ($256,364). In fact, of the 9 lowest compensated specialties, all but one (geriatrics) was a pediatric specialty.

Academic Physician Compensation

This graph illustrates the mean total compensation for academic physicians reported by the MGMA in 2022. The most highly-compensated specialties were cardiovascular surgery ($718,802), neurosurgery ($694,605), pediatric surgery ($588,934), thoracic surgery ($581,387), and plastic surgery ($525,215). At the other end of the compensation spectrum were again pediatric specialties: pediatric endocrinology ($184,479), general pediatrics ($189,178), pediatric infectious disease ($201,607), and pediatric hospitalist ($204,661).

In every specialty, academic physician total compensation was lower than non-academic physicians (academic pediatric-internal medicine compensation was not reported). The specialties with the greatest difference between non-academic and academic compensation were cardiology electrophysiology ($293,318), neurosurgery ($252,425), gastroenterology ($244,091), hematology/oncology ($237,720), and orthopedic surgery ($231,973). The large difference between academic and non-academic incomes explains why it has been so difficult for medical schools to keep gastroenterologists and oncologists since they can earn a quarter of a million dollars more per year in private practice. The lure of that much money is just too much for even the most noble of academic teachers and researchers. Specialties with the least difference between non-academic and academic compensation were pediatric hospitalist ($32,869), pediatric nephrology ($44,281), pediatric critical care ($47,283), and pediatric hematology/oncology ($53,152).

Compensation per work RVU

Physician work effort is often measured by the number of RVUs (relative value units) produced. Every physician service and procedure is assigned an RVU value by Medicare and then Medicare pays the physician based on the number of RVUs billed. Currently, Medicare pays $33.89 per RVU. Commercial insurance companies generally pay a higher amount per RVU and Medicaid pays a lower amount per RVU. The RVU is composed of three subunits, the work RVU (wRVU), practice expense RVU, and malpractice RVU. Of these subunits, the wRVU is most commonly used to measure physician productivity. Note that anesthesiology does not use RVUs and anesthesiologist productivity is instead measured by anesthesia units (1 unit = 15 minutes of time).

Physicians who earn a high dollar amount of compensation per wRVU generally require subsidization from hospitals.This is typically done either when the physician performs procedures that are highly lucrative for the hospitals (such as open heart surgery) or when the physician performs a lot of non-compensated work essential to the function of the hospital (such as hospitalists who take night-call). On the other hand, physicians earning a low dollar amount of compensation per wRVU have less (or no) hospital subsidization. These are usually outpatient specialties whose physicians are less often employed by a hospital.

Non-academic physicians with the highest compensation per wRVU are pediatric surgeons ($148/wRVU), pediatric hospitalists ($138/wRVU), pediatric infectious disease ($123/wRVU), neurosurgeons ($113/wRVU), and pediatric hematology/oncology ($112/wRVU). Those specialties with the lowest compensation per wRVU are pediatric/internal medicine ($54/wRVU), endocrinology ($59/wRVU), ophthalmology ($59/wRVU), family medicine ($62/wRVU), and general pediatrics ($62/wRVU).

For academic physicians, the specialties with the highest compensation per wRVU are pediatric hospitalist ($179/wRVU), pediatric surgery ($133/wRVU), internal medicine hospitalist ($123/wRVU), hematology/oncology ($117/wRVU), and infectious disease ($114/wRVU). The high compensation per wRVU for academic infectious disease physicians may reflect the impact of the COVID-19 pandemic when academic infectious disease specialists were called on to perform a great deal of administrative duties (subsidized by hospitals) in addition to their regular clinical duties. Academic physician specialties with the lowest compensation per wRVU are dermatology ($48/wRVU), neonatology ($50/wRVU), pathology ($51/wRVU), radiology ($55/wRVU), and interventional radiology ($55/wRVU). The MGMA survey did not report data for academic pediatric/internal medicine or for pediatric infectious disease.

Compensation per year of residency & fellowship training

Residency and fellowship can be viewed as an investment in a physician’s career. In theory, the longer the period of training, the greater the knowledge and skill of a physician in any given specialty. Residents and fellows do get paid but the average annual income is modest, starting at $61,000 for a first year resident (i.e., an intern) and that amount increases by about $2,500 for each additional year of residency and fellowship. During this time, residents and fellows are also required to start paying back student loans (payments averaging $4,000 per year during residency). As a consequence of residency and fellowship training years, most physicians finally enter the workforce when they are in their 30’s. The total duration of residency varies from the shortest at 3 years (internal medicine, pediatrics, and family medicine) to the longest at 7 years (neurosurgery, pediatric surgery, and interventional radiology). Fellowship training after residency further extends the total duration of training, for example, cardiology electrophysiology requires 8 years of training (3 years internal medicine residency, 3 years cardiology fellowship, and then 2 years cardiac electrophysiology fellowship). Longer residency/fellowship durations also equate to a shorter working career. The general internist with a 3-year residency will typically work 35 years before retiring at age 65 whereas the cardiology electrophysiologist will only work 30 years before retirement at age 65. Thus, the cardiology electrophysiologist sacrifices 5 of their lifetime income-earning years to do fellowship training after their internal medicine residency.

Do more years of residency/fellowship translate to higher incomes? One way to answer that question is to express physician compensation per number of years of training required for that specialty. In a completely free labor market, there would be a direct relationship between income and duration of training: every additional year of training for any given specialty would result in a predictable increase in annual income. In other words, the return on investment in terms of years of training should be constant across all specialties. This turns out to not be the case in reality.

For non-academic physicians, there is a wide variation in compensation per year of training. The specialties with the largest amount of total compensation per year of residency/fellowship are orthopedic surgery ($143,080 per training year), dermatology ($140,439 per training year), cardiovascular surgery ($138,179 per training year), neurosurgery ($135,290 per training year), and emergency medicine ($124,239 per training year). These specialties have a very high return on their investment of training time. At the low end are pediatric endocrinology ($39,845 per training year), pediatric infectious disease ($42,727 per training year), pediatric hematology/oncology ($43,808 per training year), pediatric nephrology ($44,756 per training year), and pediatric hospitalist ($47,506 per training year). These specialties have a low return on investment of training time.

The spread of total compensation per number of years of residency/fellowship training for academic physicians was similar. Specialities with a high compensation per year of training were cardiovascular surgery ($119,800 per training year), emergency medicine ($102,326 per training year), anesthesiology ($101,900 per training year), neurosurgery ($99,229 per training year), and thoracic surgery ($96,898 per training year). Once again, the least compensated per year of training for academic physicians were all pediatric specialties: pediatric endocrinology ($30,747 per training year), pediatric infectious disease ($33,601 per training year), pediatric hematology/oncology ($34,950 per training year), pediatric pulmonary ($35,946 per training year), and pediatric nephrology ($37,376 per training year). The MGMA survey did not report on pediatrics/internal medicine.

Several subspecialties were particularly noteworthy because their total compensation was less than their parent specialties. For example, pediatric hospitalists require 2 additional years of fellowship after completion of a pediatric residency and pediatric endocrinologists require 3 years of fellowship after pediatric residency. However, both non-academic pediatric hospitalists and non-academic pediatric endocrinologists make less money than non-academic general pediatricians who only completed the 3-year pediatric residency. Similarly, to specialize in geriatrics or endocrinology, a physician must first complete a 3-year internal medicine residency followed by a 1-year (geriatrics) or 2-year (endocrinology) fellowship. However, non-academic physicians specializing in geriatrics or endocrinology make less money than non-academic general internists who only completed the 3-year internal medicine residency.

In academic practices, there are even more specialities where subspecialty fellowship results in lower total compensation than the parent specialty. Academic pediatric endocrinologists make less than academic general pediatricians. Academic geriatric, rheumatology, endocrinology, and infectious disease specialists all make less than academic general internists. In these subspecialties, not only does the additional years of fellowship training not result in greater income, but the those physicians are actually financially penalized for their additional years of training by making less money than if they had just stopped after their pediatric or internal medicine residency.

It is noteworthy that there are more factors to consider than just years of training when comparing total compensation between different specialties. Some of the specialties with the highest compensation per year of training are also those with the most grueling on-call schedules, such as cardiovascular surgery, anesthesiology, emergency medicine, and neurosurgery. It is entirely appropriate that the neurosurgeon who has to take trauma call every 4th night for his/her entire life makes a high income. In addition, the cost of medical malpractice insurance premiums varies significantly. The average general internist pays $16,000 per year in malpractice premiums but the average neurosurgeon pays $92,000 per year for malpractice coverage. Once again, it is entirely appropriate that the neurosurgeon has a high income in order to cover the high overhead malpractice insurance expense inherent in that specialty.

What is the solution to these compensation disparities?

In a free labor market, a worker’s income is determined by the supply of workers and the demand for that worker’s services. So, on the surface, it would appear that there is a shortage of heart surgeons and neurosurgeons whereas there is a overabundance of general pediatricians and pediatric endocrinologists. However, American medicine is not a simple free market economy. Hospitals make the most money from procedures and surgeries: the financial margin on a surgery is much greater than the margin on a medical admission. That margin is highest for inpatient surgeries such as cardiovascular surgeries and neurosurgeries. Because of this, hospitals are incentivized to subsidize specialists who perform these high-margin procedures. Furthermore, many of these surgical subspecialists have much more rigorous on-call schedules – a neurosurgeon or interventional cardiologist is much more likely to be called into the hospital in the middle of the night to manage a patient with head trauma or with a myocardial infarction than an endocrinologist or rheumatologist whose practice is largely outpatient and limited to Mondays through Fridays during the daytime. Therefore, in order to provide 24-hour trauma or cardiac care, hospitals must pay these subspecialists substantial on-call pay.

A central problem with physician reimbursement is that it has not kept up with inflation and has, in fact, fallen over the past decades. In 1998, Medicare reimbursement per RVU was $36.69 and 25 years later, in 2023, the reimbursement per RVU had fallen to $33.89. By contrast, if the RVU reimbursement had merely kept up with inflation, then the $36.69 rate in 1998 should be $70.45 today! Physicians have made up for the reduced payments per RVU somewhat by spending less time with each patient in order to see more patients per day but that alone has been insufficient to maintain a constant income. The solution has frequently been for physicians to become employed by hospitals with the hospitals subsidizing their income. This has resulted in physician income becoming untethered from physician work productivity. The effect has been that physician income is increasingly determined by the value of the physician’s specialty to the hospital’s finances more than the physician’s actual patient care work effort.

It has been proposed that the solution would be to pay low-compensation subspecialists more. This would work in a pure free market economy but would not work in our current system of physician reimbursement. Physician services are categorized by CPT codes and then reimbursed by the number of RVUs associated with each of those CPT codes. Non-procedural specialties all use the same CPT codes for the evaluation and management services that they provide. Thus, the endocrinologist or geriatrician bills the exact same CPT codes as the general internist and gets reimbursed the exact same amount per RVU as the general internist. Because of this, the “cognitive” subspecialties of pediatrics and internal medicine (i.e., those without associated procedures) have no chance of generating more RVUs than the general pediatrician or internist. Indeed, the amount of time and effort to see a 10-year old with uncontrolled type 1 diabetes in the pediatric endocrinology office is considerably more than that required to see an otherwise healthy 10-year old with an ear infection in the general pediatrics office, even though the payment is the same for both patients. As a result, for many of these subspecialties, the reward for more years of training is a lower income. Because these pediatric and internal medicine subspecialties do not generate significant margins for hospitals, there is little incentive for hospitals to subsidize them.

It is notable that pediatric subspecialties dominate the low compensation specialties. One of the driving reasons for this is Medicare/Medicaid. Nearly every American over age 65 qualifies for Medicare so older adults are by and large all insured. Children are not eligible for Medicare but are instead covered by CHIP and Medicaid programs (or have no insurance at all!). In most states, Medicaid pays considerably less than Medicare (in Ohio, Medicaid payments for primary care services are only 57% of the Medicare amounts). Consequently, pediatricians of all subspecialties have an inherently worse payer mix than physicians who care for adults. Similarly, pediatric hospitals also have a worse payer mix than hospitals caring for adults.

So, how do we fix this? There are several tactics that can be considered:

  • Increase residency positions in some specialties. This will work only for those highly compensated specialties where there is truly an insufficient supply of physicians for current demands.
  • Re-align RVUs assigned to different procedures and services. The current RVU assignments have been affected by intense lobbying from subspecialty physician organizations and in many cases, the most RVUs have been given to the loudest lobbyists.
  • Increase physician reimbursement for Medicaid and CHIP patients. In an ideal world, a physician would get paid the same for a patient with Medicare, Medicaid, or CHIP. This would help correct the low compensation for pediatric specialties.
  • Increase the RVU conversion factor. The current conversion factor of $33.89 per RVU is too low for the vast majority of physicians to earn a living from professional billings alone with the result that most physicians require hospital subsidization. This has eroded free market effects on physician compensation.
  • Normalize the relation between years of training and income. It is entirely appropriate that the interventional cardiologist who trains for 7 years has a higher income than the general internist who trains for 3 years. But it makes absolutely no sense that the endocrinologist who trains for 5 years makes less than the internist who trains for 3 years.
  • Strategic expansion of advance practice provider utilization. We have to face the reality that income disparities in some specialties will eventually result in fewer physicians entering those specialties. Hospitals should start training nurse practitioners, physician assistants, and pharmacists to perform some of the work done by these specialists. For example, advance practice providers can often effectively replace most of the daily inpatient diabetes management currently done by endocrinologists.
  • Embrace AI. The heart surgeon will not do a coronary artery bypass surgery faster using artificial intelligence but AI may allow the general internist to more efficiently evaluate a patient with chest pain. Similarly, AI may speed up the time required for an infectious disease specialist to come up with a diagnosis based on a patient’s presenting history and lab findings. It can help the endocrinologist select the most effective diabetes treatment based on a patient’s co-morbidities. It can shorten note and order-writing time for patients performing E&M (evaluation and management) services. Artificial intelligence has the greatest potential to improve productivity of physicians in cognitive specialities, which are also the specialties that are the most under-compensated.

The forces that affect physician incomes are complex. But if we do not begin to take corrective action soon, we will find ourselves without endocrinologists, geriatricians, and pediatric endocrinologists in the near future. Because of the structure of American healthcare, we cannot rely on free market forces alone to solve this problem.

April 9, 2023

Medical Education

The 2023 Residency Match

Today, the results of the 2023 National Residency Match Program were released. Every year, the match determines where medical students in their senior year will be doing their residencies starting in July. There are some important take-away lessons from this year’s match.

Summary Points:

  • Surgical subspecialties continue to be highly competitive
  • Primary care specialties continue to be less competitive
  • There is declining interest in emergency medicine
  • Foreign medical graduate applications have increased since the peak of the COVID pandemic

The number of applications increased.

There were 48,156 applicants in this year’s match, up from 47,675 applicants last year. This was driven by an increase in foreign medical graduates (707) and U.S. osteopathic school seniors (153). Notably, the number of U.S. medical school seniors applying to the match dropped by 236 this year. Not all applicants certified a rank order list of residencies but of those who did submit a rank list, 81.1% matched to a first-year residency position. There were 1,239 couples (6% of match applicants) in this year’s match and they had a higher match rate of 93%, which has been constant for the past 35 years.

There were a total of 40,375 residency positions available in this year’s match, 3% more than last year. 93.3% of these positions filled in this year’s match. There were a total of 2,658 unfilled residency spots in this year’s match that will be available to unmatched students in the Supplemental Offer and Acceptance Program. This program is currently actively filling open positions so the results of the SOAP are not yet available.

Foreign medical graduates are back.

Until the COVID pandemic, foreign medical graduate applicants in the match had been steadily increasing. In 2022, there was the first-ever fall in the number of foreign medical graduates, primarily due to COVID travel restrictions and fear of the United States’ high COVID prevalence and high COVID death rate. In 2023, the number of foreign medical graduates increased to the highest number on record. Foreign medical graduates continue to have the lowest match rate with only 59.4% matching into a PGY-1 residency.

U.S. MD applicants once again had the highest match rates.

Seniors at U.S. medical schools had the highest match rate at 93.7%. This is similar to the match rate for these students over the past 40 years. Seniors at U.S. osteopathic schools had the next highest match rate at 91.6% which is the highest match rate ever for these students. U.S. citizens attending foreign medical schools were next with a 67.6% match rate and non-U.S. citizens from foreign medical schools had the lowest match rate at 59.4%.

The most popular specialties.

Categorical internal medicine had the most filled positions (9,345) followed by family medicine (4,511), categorical pediatrics (2,900), emergency medicine (2,456), and psychiatry (2,143). Several specialties have the option of either matching into an integrative PGY-1 position or matching into a PGY-2 position after doing a transitional or preliminary residency year. In the graph below, the specialties include the number of applicants matching into both PGY-1 and PGY-2 positions.

The above graph only includes 25 largest specialties and does not include specialties with small numbers of residency positions such as nuclear medicine.

Specialties with the largest growth in number of residency positions offered compared to last year include categorical internal medicine (+335), family medicine (+172), psychiatry (+117), emergency medicine (+79), anesthesiology (+65), neurology (+49), general surgery (+48), and primary care internal medicine (+24),

The most (and least) competitive specialties.

Competitive specialties are those that have the highest rate of filling either by U.S. medical school (MD) senior applicants or by total applicants. The major specialties with the highest percentage of available positions filled by U.S. medical school (MD) applicants were all surgical specialties: plastic surgery (92.3%), neurosurgery (86.8%), thoracic surgery (83.7%), otolaryngology (83.1%, and vascular surgery (80.6%). Ten specialties filled all available positions (100%) when considering all applicants: plastic surgery, thoracic surgery, dermatology, orthopedic surgery, anesthesiology, interventional radiology, radiation oncology, child neurology, physical medicine, and neurology.

Five major specialties filled fewer than 50% of available positions with U.S. medical school (MD)  applicants: emergency medicine (42.3%), pathology (39.5%), categorical internal medicine (36.9%), family medicine (29.2%), and preliminary surgery (21.7%). When considering all applicants, four specialties matched fewer than 90% of available positions: family medicine (88.7%), transitional year (87.8%), emergency medicine (81.6%), and preliminary surgery (51.4%).

The more competitive a specialty is, the larger the number of programs are ranked by each applicant. The largest average number of residency programs ranked by each U.S. medical school (MD) applicant were vascular surgery (19), neurosurgery (18), thoracic surgery (17), plastic surgery (15), and otolaryngology (14). On the other hand, primary care specialties had fewer average rankings per applicant: family medicine (4), internal medicine (5), emergency medicine (7), and pediatrics (8).

Which specialties are in trouble?

Emergency medicine has seen a fall in the total number of filled positions over the last 3 years. In the past, emergency medicine filled >99% of available positions but this dropped to 93% in 2022 and 82% in 2023. This year, emergency medicine had 554 unfilled positions, second only to family medicine (577 unfilled positions). Because of its past competitiveness, emergency medicine residencies have historically accepted relatively few foreign medical graduates. This year was no exception and foreign medical graduates only accounted for 2% of filled emergency medicine residency positions. The number of residency positions offered in emergency medicine has been increasing each year at a faster pace than other specialties. This, combined with the declining interest in emergency medicine by applicants signals that emergency medicine residencies will need to make adjustments in the future to attract more U.S. medical school graduates and U.S. osteopathic school graduates. In addition, emergency medicine residencies need to be more receptive to foreign medical graduate applicants.

The number of filled internal medicine preliminary year positions has also been steadily declining over the past 5 years. However, this decline has been offset by a steady increase in the number of filled transitional year positions, suggesting that applicants are selecting transitional year programs instead of internal medicine preliminary year programs. These two types of 1-year programs are very similar and often both offered by the same departments at teaching hospitals.

These are your future doctors

In 3 1/2 years, the students who matched today will begin completing residency programs and will begin to enter the attending physician workforce. The results suggest a future worsening of the shortage of primary care physicians and emergency medicine physicians. The results also indicate that foreign medical graduates will comprise an increasing percentage of practicing physicians in the United States in the future.

March 17, 2023

Medical Education

Is ChatGPT Writing Personal Statements On Residency And Fellowship Applications?

ChatGPT is a free artificial intelligence program that can write letters, reports, and research papers using internet information. Recently, it has generated concern by educators that students can use it to write term papers and do homework assignments. I used ChatGPT to write a personal statement for a pulmonary fellowship application that was indistinguishable from the real thing. Our application process now needs to adapt to this new paradigm.

Residency and fellowship application personal statements

Up to now, applying to residency or fellowship programs involved filling out a standard application form that included information such as board examination scores, medical school grades, research publications, and faculty recommendation letters. A central component of these applications has been the personal statement where the applicant tells why he or she has chosen a particular specialty in which to pursue further training. After reviewing these applications, residency and fellowship program directors then select which applicants to invite for a face-to-face interview. Based on the contents of the application, the personal statement, and the interview, program directors then rank all of the applicants to submit to the National Residency Match Program (NRMP). The NRMP then matches the rank list of applicants with the rank list of the residency or fellowship programs to determine where the applicants will do their residency or fellowship training.

Over the past 35 years, I have read thousands of personal statements when grading applications to our internal medicine residency and our pulmonary/critical care fellowship programs. Occasionally, a personal statement would lower my overall grade if it contained misspellings, contained grammar errors, or was just plain weird. Occasionally, a personal statement would stand out as being particularly emotionally moving or show evidence that an applicant had to overcome particularly difficult personal barriers and this could raise my overall grade of their application. Most of the time, however, I viewed the personal statement fairly neutrally and it had relatively little impact on how high I would grade an application. Honestly, most personal statements all sound about the same.

What is ChatGPT?

ChatGPT is an artificial intelligence chatbot that was launched on the internet on November 30, 2022 as a prototype. By January 2023, it had 100 million users, making it the fastest growing consumer application to date. ChatGPT was developed by the company, OpenAI. This was a home run for OpenAI which is now valued at $29 billion.

This morning, I wanted to find out if ChatGPT can be used to write personal statements for residency and fellowship applications. So, I went to the website of OpenAI and opened a ChatGPT account. It is free and took me less than 30 seconds to start my account. I then asked ChatGPT to write a personal statement. I entered the following information: “I am a resident in internal medicine influenced by my intensive care unit attending, write a personal statement for pulmonary fellowship”. That was all the information I included. ChatGPT did not know anything else about me other than my email address, name, and phone number. It took ChatGPT about 15 seconds to write a personal statement and here is what it came up with:

As an Internal Medicine resident, I have had the opportunity to work in various settings, including the intensive care unit (ICU). During my time in the ICU, I have seen firsthand the impact that pulmonary diseases have on patients and their families. I have also witnessed the pivotal role that pulmonologists play in managing these diseases.

My experience in the ICU has solidified my interest in pursuing a fellowship in pulmonary medicine. I am drawn to the complexity of pulmonary diseases and the challenge of managing them effectively. Pulmonary medicine also appeals to me because it is a rapidly evolving field with new treatments and technologies being developed constantly.

I am particularly interested in the intersection of pulmonary medicine and critical care. Through my work in the ICU, I have seen how important it is for pulmonologists to have a deep understanding of critical care principles in order to provide the best possible care for their patients. I am excited about the prospect of gaining advanced training in both pulmonary medicine and critical care through a fellowship program.

During my residency, I have also had the opportunity to participate in research projects related to pulmonary medicine. These experiences have deepened my appreciation for the importance of research in advancing our understanding of pulmonary diseases and improving patient outcomes. I am eager to continue pursuing research opportunities as part of a pulmonary fellowship program.

Ultimately, I am driven by a desire to improve the lives of patients with pulmonary diseases. I believe that pursuing a fellowship in pulmonary medicine will enable me to develop the skills and knowledge necessary to make a meaningful impact in this field. I am excited about the prospect of joining a community of dedicated professionals who share my passion for improving patient care in pulmonary medicine.

I was pretty amazed… this personal statement was darn good and was easily as good as 75% of the fellowship application personal statements that I have read in the past that were written by actual human beings. There were no misspellings and no grammar errors. The personal statement expressed passion about a career in pulmonary medicine and showed no sign that the applicant possesses some underlying psychopathology. In short, it checked all of the boxes. If I had read this personal statement a year ago, I would have passed the application on as perfectly acceptable.

I’m a baby boomer and I’m not supposed to be very knowledgable about new technology and artificial intelligence. Just think what millennials can do with this. Most 4th year medical students submit their residency applications in September/October so ChatGPT has probably not been used for this year’s residency applications. However, I can almost guarantee that every 3rd year medical student who will be filling out residency applications this summer will at least think about using ChatGPT. The same goes for fellowship applications.

As an attending physician, I have also written hundreds of reference letters and letters of recommendation for students applying to residency and for residents applying to fellowship. These letters take a lot of time to write and it would probably cross my mind to use ChatGPT if I got a request from 20 students for residency recommendation letters tomorrow.

What does this mean for the future?

In just the past 3 months, the value of the personal statement has diminished to the point that it is essentially irrelevant. A personal statement that would have taken me 10 hours to write and re-write as a medical student in 1984 would take me less than a minute to generate using ChatGPT. And the personal statement written by ChatGPT would be every bit as good as anything that I would have written. So, should we eliminate the personal statement from residency and fellowship applications altogether?

I think we should.

Personal statements have always been a bit contrived. Most applicants make multiple revisions and have their personal statements critiqued and edited by friends, family members, and colleagues to the point that they are usually excessively washed, polished, and filtered versions of an applicant’s true motivations for choosing a particular specialty. I believe that most of the information contained in the personal statement can be more effectively evaluated during a live interview. Even a virtual interview done over the internet will have greater value than a ChatGPT-derived personal statement.

The world of medicine just turned on its head

But ChatGPT and other artificial intelligence systems have many more applications than just writing personal statements for residency and fellowship applications. In academic medicine, reference letters, grant applications, research manuscripts, and promotion & tenure dossiers can all be created faster and better using ChatGPT. In clinical medicine, letters to referring physicians, consultant reports, history & physicals, and progress notes can be generated in seconds, thus reducing tedious keyboard entry by clinicians.

As a medical student, I memorized mnemonics for hospital admission orders so that I would never forget about including a patient’s allergies or how frequently vital signs should be performed. How to write comprehensive admission orders was a key part of our medical education. The interns and senior residents evaluated students on the completeness of our hand-written admission orders. When computer electronic order entry was created, the computer automatically generated admission order sets that included all of the components in my mnemonic. This made life easier and better but created a void in the usual medical student education.

As an attending physician, I evaluated the proficiency of the internal medicine interns by their written history and physical examinations… did they include a smoking history? Was there a complete review of systems? Did they list the patient’s medications? When electronic medical records were introduced, the interns no longer had to know how to write an H&P, all then needed was a history and physical exam template in the computer software. At first, I lamented the loss of the time-honored skill of a masterfully written history and physical but then quickly realized that the electronic medical record H&P template was the new reality.

It does not matter what any of us think about ChatGPT and other artificial intelligence writing systems. They are the new reality, whether you like them or not. The personal statement has now gone the way of admission order mnemonics and hand-written history & physicals – shadows of a bygone era in medical education. So, how are we going to assess the motivations and passions of our trainee applicants? I think it just comes down to that most human of all methods… we talk with them.

As an aside, I’ve wondered if ChatGPT will be the beginning of the end of blogging. I suspect that ChatGPT could probably write a post far better and faster than I can. But I write posts for my own gratification and enjoyment. So, rest assured, the words that appear on these pages will always be my own.

February 26, 2023

Academic Medicine Medical Education

Results Of The 2022 Internal Medicine And Pediatric Subspecialty Fellowship Match

Yesterday, on November 30, 2022, the results of this year’s fellowship match for internal medicine and pediatric subspecialties was released. This is for fellowship positions that will begin in July 2023. Every specialty has its own fellowship match and the dates of the match results vary from as early as May the year before the start of fellowship (vascular surgery, thoracic surgery, pediatric surgery) to January the year of the start of fellowship (sports medicine, psychiatry). The internal medicine and pediatric match results are released at the end of November.

The results of all of the fellowship match results are made available in a report published by the National Resident Matching Program in March every year. Last year’s match showed that more physicians are subspecializing, fewer foreign medical graduates applied, certain subspecialties were very competitive (surgical and OB/GYN subspecialties) and certain subspecialties were less popular (most internal medicine and pediatric subspecialties).  Although we will not know the complete results of all subspecialty fellowship matches for several months, internal medicine and pediatrics represent the largest number of fellowship positions and so we can draw preliminary conclusions for yesterday’s match results in those subspecialties.

The terminology used in physician specialization can be confusing. As an example, internal medicine is a specialty and cardiology is a subspecialty within internal  medicine. This means that a cardiologist must first complete an internal medicine residency and then do further training in a cardiology fellowship. This post will focus on the recent subspecialty fellowship match results for the specialties of internal medicine and pediatrics.

Internal Medicine

Overall, there were 2,042 different programs participating in this year’s internal medicine subspecialty fellowship match and these programs offered a total of 5,779 fellowship positions. 82.1% of programs filled all of their positions and 89.5% of all positions in the country filled. These results are similar to last year. Of the physicians who did match, 46.8% were U.S. MD graduates, 13.5% were U.S. DO graduates, 12.8% were U.S. citizens who attended foreign medical schools, and 26.7% were foreign medical graduates. This is a slight decrease in the percent filled by U.S. MD graduates and a slight increase in foreign medical graduates compared to last year.

As in the past, certain internal medicine specialties were more competitive than others. Competitive programs are those that had a higher percentage of their total positions filled. The most competitive subspecialties were cardiology and interventional pulmonary that both filled 100% of their positions, followed by gastroenterology (99.8%) and hematology/oncology (99.7%). Three subspecialties filled fewer than 65% of positions: adult congenital heart disease (63.6%), transplant cardiology & heart failure (55.9%), and geriatrics (45.4%).

Two other subspecialties had relatively low fill percentages: infectious disease (74.4%) and nephrology (72.8%). These two subspecialties are concerning because their total number of fellowship positions is considerably higher than other low-performing subspecialties. There were 441 infectious disease fellowships offered and 493 nephrology fellowship positions offered compared to adult congenital heart disease (22 fellowship positions offered) and transplant cardiology & heart failure (127 positions offered). The implication of these results is that our country will face a much larger shortfall in the number of internal medicine infectious disease specialists and nephrologists in the future compared to other subspecialties.

A second way of determining the competitiveness of a subspecialty is by the percentage of positions filled by U.S. medical school graduates (MD). In general, most subspecialty fellowships are affiliated with medical schools offering MD degrees (as opposed to DO, or osteopathic, degrees). Historically, U.S. MD graduates tend to have an advantage over U.S. DO graduates, U.S. citizens graduating from foreign medical schools, or foreign medical school graduates who are not U.S. citizens. Subspecialties with the highest percentage of U.S. MD graduates filling available fellowship positions were adult congenital heart disease, gastroenterology, hematology & oncology, and interventional pulmonary. Pulmonary medicine had a very low filling percentage by U.S. MD graduates but there were only 27 total positions offered in 2022 since most physicians instead choose to do a combined pulmonary & critical care medicine fellowship (748 positions offered).

Graduates of U.S. osteopathic (DO) schools were most likely to fill pulmonary medicine-only fellowships or critical care medicine-only fellowships. But again, these fellowships offer very few available positions since most available positions are in combined pulmonary & critical care medicine fellowships. Geriatrics, infectious disease, and nephrology all had high percentages of U.S. osteopathic graduates.

U.S. citizens attending foreign medical schools account for nearly as many filled subspecialty fellowship positions as U.S. osteopathic graduates and followed a similar trend with a high percentage in pulmonary-only and critical care medicine-only fellowships followed by nephrology, interventional pulmonary, geriatrics, and endocrinology.

The final group of physicians filling positions in the 2022 internal medicine subspecialty fellowship match was non-U.S. citizens who graduated from foreign medicine schools (foreign medical graduates). Subspecialties with the highest percentage of positions filled by foreign medical graduates were endocrinology, pulmonary-only, and nephrology.


Overall, there were 919 different pediatric subspecialty fellowship programs that together offered 1,814 fellowship positions in the 2022 match for fellowships to start in July 2023. 74.9% of the programs filled and 84.7% of all positions were filled. Pediatric subspecialty fellowship positions were most likely to be filled by U.S. MD graduates (61.6%) followed by foreign medical graduates (14.8%), U.S. DO graduates (14.7%), and U.S. citizen graduates of foreign medical schools (8.8%). These percentages were unchanged compared to the previous year’s match. Compared with internal medicine, more pediatric subspecialty fellowship positions fill with U.S. MD graduates.

The most competitive pediatric subspecialty fellowships were gastroenterology, emergency medicine, and cardiology which all filled more than 97% of available fellowship positions. Similar to internal medicine, the least competitive subspecialties were infectious disease (49%) and nephrology (54%), as well as endocrinology (61%).

The pediatric subspecialties most likely to fill with graduates of U.S. medical schools were adolescent medicine, hospital medicine, and infectious disease – all of which filled 73% of positions with U.S. MD graduates. The least likely were transplant hepatology and endocrinology, each of which filled 50% of available positions with U.S. MD graduates.

Subspecialties with the highest percentages of graduates of U.S. osteopathic schools were child abuse (31%), gastroenterology (19%), and hospital medicine (19%). Subspecialties with the lowest percentage of U.S. DO graduates were infectious disease (5%) and rheumatology (4%).

There were only 135 U.S. citizen graduates of foreign medical schools who matched into pediatric subspecialty fellowships with the highest percentages in developmental-behavioral medicine (16%) and endocrinology (14%).

Foreign medical graduates had the highest representation in rheumatology (30%) and transplant hepatology (33%). They had the lowest representation in hospital medicine (1%).

Implications of the match

The overall trends of the 2022 match (for fellowships to begin in July 2023) are similar to the 2021 match. For both internal medicine and pediatrics, two subspecialties continue to be unpopular and had a high percentage of unfilled positions:  nephrology and infectious disease. In both pediatrics and in internal medicine, physicians in these two subspecialties have lower annual incomes than other subspecialties due to the current U.S. physician billing and reimbursement model. For internal medicine, these 2 subspecialties are also those with the highest percentages of foreign medical graduates filling fellowship positions.

The results of the match suggest that the United States will see an increasing shortage of both adult and pediatric nephrologists and infectious disease specialists. Pediatric endocrinology and adult geriatrics will also face physician shortages In order to attract these subspecialists, hospitals will need to subsidize their salaries as they are not able to generate competitive incomes by professional revenues alone. As these shortages become more severe, the clinical services provided by these subspecialists will need to increasingly be provided by primary care physicians and advance practice providers.

December 1, 2022

Medical Economics Medical Education

Are Unionized Doctors Coming To Your Hospital?

Overall, union membership in the United States has been steadily declining over the past 60 years. However, one of the consequences of the COVID-19 pandemic has been a resurgence of interest in doctor’s unions, especially among residents and fellows. In the past two months, residents at the Keck School of Medicine of USC, Stanford Health Care, and University of Vermont voted to unionize. Is a union in your hospital’s future?

Summary Points:

  • Overall, American physicians are less likely to belong to unions than other workers
  • Residents are far more likely to be unionized than attending physicians
  • Physician unions have limited ability to strike
  • Interest in unionization may increase in the future as more physicians become hospital-employed


The Bureau of Labor Statistics recently reported that in 2021, there were 14 million wage and salary workers in the United States who were members of a union. This equates to an overall union membership rate of 10.3%. Overall, union membership has dropped considerably over the past 70 years.

There are tremendous differences in the union membership rates for public sector workers (33.9%) versus private sector workers (6.1%). There are also profound geographic differences in union membership rates ranging from high rates in Hawaii (22.4%) and New York (22.2%) to low rates in South Carolina (1.7%) and North Carolina (2.6%). Physicians are less likely to be unionized than most other professions with approximately 5% of U.S. doctors belonging to a union. Residents and fellows comprise the largest group of physicians who are unionized and their numbers are growing.

The largest union of residents and fellows is the Committee of Interns and Residents (CIR), a part of the Service Employees International Union. In normal years, the CIR reports 1-2 hospitals have union organizing campaigns per year. However, with the COVID pandemic, that number has tripled. Currently, residents at about 60 hospitals nationwide are unionized with an estimated 15% of all U.S. residents belonging to unions.

Fewer attending physicians are unionized. The largest union is the Union of American Physicians and Dentists, an AFL-CIO affiliate. It is estimated that about 10,000 of the 700,000 U.S. attending physicians are unionized, slightly less than 1.5%. Historically, most attending physicians were in private practices, either as solo providers or as part of medical group practices. There was very little reason for these physicians to unionize because they were self-employed. This may change in the future as physicians become increasingly hospital-employed.

The pros and cons of resident unions

The effect of resident unionization has not been well-studied. A 2021 study published in JAMA Network Open of 5,701 U.S. surgery residents found that unionized residents were more likely to have hospital-subsidized housing and more likely to have 4 weeks of vacation per year (as opposed to 2-3 weeks) than non-unionized residents. However, there was no difference in burnout, suicidality, job satisfaction, duty hour violations, mistreatment, salary, or educational environment between residents at unionized and non-unionized programs.

Residents and fellows hold a unique employment status – they are simultaneously trainees and employees of the hospital. They also have time-limited employment, unlike most American union members who can spend their entire employment career as union workers. Because of their unique status, there are advantages and disadvantages to residents unionizing.

The pros of resident unionization

  1. Ability to negotiate salary. Residents earn an average of about $64,000 per year. Typically, salaries increase by about $2,000 for each year of residency. Although the precise salary for residents varies from hospital to hospital, most of the variation is related to geographic cost of living differences. Most of the financial support for resident salaries comes from fixed Medicare payments to hospitals for graduate medical education. Overall, the ability of resident unions to impact base salaries is limited. However, supplemental pay for working during disasters and for in-house moonlighting may be more negotiable.
  2. Ability to negotiate vacation. Unlike salary, hospitals do have more flexibility in the amount of vacation time offered. The JAMA Network Open article found that unionized residents had more vacation time per year than non-unionized residents.
  3. Ability to negotiate fringe benefits. Hospital night call rooms, meals while on-duty, hospital-subsidized housing, and maternity/paternity leave are all on the table when residents are unionized.
  4. Ability to negotiate work conditions. Issues such as availability of personal protective equipment and prioritization of hospital employe vaccination became very important to residents during the COVID pandemic. Most healthcare workers experienced stressful working conditions during the pandemic and residents were no exception. Many residents turned toward unions in hope that unionization would reduce these stressful conditions.

The cons of resident unionization

  1. Union dues. Currently, annual dues for residents who belong to the CIR are 1.6% of their total salary. This can be an important deterrent to joining a union given that residents do not have high salaries to begin with and that residents are often feeling financial pressures due to student loans and young children at home.
  2. Short duration of employment. Internal medicine, pediatrics, and family medicine residencies are 3 years long. Psychiatry residency is 4 years long. Surgery is 5 years long. Many current residents do not want to go through the time and hassle of forming a union since they will personally only experience any benefits of unionization for a short period of time before they become attending physicians.
  3. Barriers to going on strike. The most powerful tool of any union is the strike. Some ethicists have opined that it is unethical for physicians to go on strike as a strike could lead to patient abandonment and resultant patient harm. It has been argued that since residents must be supervised by attending physicians, the attending physicians could cover patient care responsibilities if the residents go on strike. However, residents are integral components of health care teams and if they are not present, then there is a risk of team malfunction. There is also a very different public perception of physicians going on strike as opposed to other workers – if your Starbucks barista goes on strike, it is a minor inconvenience but if your doctor goes on strike, your health is threatened. Striking physicians may find little sympathy from the general public and may garner very negative opinions. That being said, last month, Los Angeles residents threatened to go on strike and the strike was averted at the last minute.
  4. Soured relation with attending physicians. When residents complete their residencies, they either get a job as an attending physician or continue their training as subspecialty fellows. In either case, they rely on the attending physicians that they trained under during their residency for letters of recommendation. If union activities result in an adversarial relation between the residents and those attending physicians, those letters of recommendations may take on a negative tone. Labor laws prohibit retribution against union members for union activities; however, when it comes to these letters, an average recommendation implies that the resident is actually significantly below average. Therefore, a resident whose union activities antagonized his/her attending physician could receive a lukewarm recommendation letter from that attending. Such a letter could not be proven to be retribution from a legal standpoint but would put that resident at a considerable disadvantage when applying to fellowship positions compared to other resident applicants with glowing letters. Moreover, residents who develop reputations for organizing collective actions against their hospitals on the part of their union may be perceived as troublemakers by fellowship programs at other hospitals, placing those residents at a competitive disadvantage when applying for fellowship positions after completion of their residencies.
  5. Lack of credibility. It can be difficult to negotiate for salary and benefits when everyone knows that you are going to have an annual income of hundreds of thousands of dollars in a couple of years.
  6. The ACGME already dictates many work conditions. The Accreditation Council for Graduate Medical Education has fairly strict limits on weekly duty hours, call schedules, educational curriculum, resident responsibility for non-clinical activities (such as patient transportation, blood drawing, etc.), and work environment. As such, the ACGME has functioned in a resident advocacy role similar to the advocacy roles played by unions in other occupations. Failure of hospitals to comply with ACGME requirements can result in loss of hospital accreditation which can be a death sentence to the hospital’s residency program.
  7. The loudest voices do not always represent the majority of the doctors. Often, the residents who are most opinionated and passionate are the ones who become most vocal in union affairs. This can result in issues that are of no importance to the silent majority of residents becoming the forefront of union demands.
  8. Most residents cannot chose to unionize. Senior medical students are assigned the hospital where they will do their residency by the National Residency Match Program. The students create a preference list of the residency programs that they are most interested in and a computer then matches the students with the residency programs based on their degree of mutual interest. Most students will list about 10 programs on their match list but for competitive specialties, such as otolaryngology and ophthalmology, students will typically list 20 or more programs. Unless a residency program is located in a right-to-work state (see below), the students have no say in whether or not they will be in a union. After 3-5 years, all of the residents turn over and those who had originally voted to unionize are replaced by others who may or may not have any interest in belonging to a union.
  9. Loss of autonomy. As a breed, doctors tend to be independent. The surgeon in the operating room, the emergency medicine physician in the ED on trauma call, the cardiologist doing an emergent heart catheterization – all of these physicians have to be self-reliant and generally do not want to be told how to do their job. A hospital with a thousand doctors is a hospital with a thousand people who think of themselves as the CEO. Many physicians are inherently distrustful of any organization that tells them what to do and that includes unions.

Right-To-Work states

American unions became empowered by the 1935 National Labor Relations Act (Wagner Act). This allowed workers to organize into closed shops (where union membership was a prerequisite requirement to employment),  union shops (where non-union workers could be hired with the requirement that they join the union within a specified amount of time), agency shops (where workers were not required to join a union but could still be charged union dues), and open shops (where workers were neither required to join a union nor pay dues). In 1947, the Taft-Hartley Act repealed some elements of the Wagner Act – closed shops became illegal and states were individually allowed to decide whether union shops and agency shops would be allowed.

The result of the Taft-Hartley Act was that some states passed legislation or state constitutional amendments to become “right-to-work” states. In these states, union shops and agency shops were not allowed and unions could only exist act open shops. The phrase “right-to-work” in essence means that workers had the right to work without having to join a union. 27 states have have right-to-work laws (red in the map below) and in addition, Delaware allows individual localities to make their own decisions about right-to-work.

The vast majority of unionized residency programs are in non-right to work states, meaning that once the residency is unionized, future residents do not have a choice about whether or not they want to participate in the union or pay union dues.

A new era of physician unionization?

In the 1950’s, about 75% of U.S. physicians belonged to the American Medical Association. Today, that number is only about 17%. The AMA is not a union but it does play an important role in physician advocacy and lobbying. Today’s physicians have not felt that the AMA provides sufficient benefits to warrant membership and attendant annual dues of $450 per year. As a consequence, the AMA has less political and public health influence today than it had in the past. Some medical leaders have called for a new form of unionization for attending physicians to more strongly advocate for issues of importance to physicians such as gun control and vaccinations against communicable disease. Although a laudable idea, it is probably unrealistic.

However, the recent change in physician employment models resulting in most physicians now being hospital-employed rather than in private practice may change the appetite of some physicians to become unionized. As many specialties have had compensation become untethered to professional practice income, physicians in these specialties depend more on the wording of their hospital employment contracts for their salary and work hours. Anesthesiologists, hospitalists, critical care physicians, and emergency medicine physicians are perhaps most notable. For example, tying hospitalist RVU production too tightly to compensation can work counterproductively to hospital goals of patient length of stay, readmission rates, and patient satisfaction scores. For shift work-based physicians, unionization may become appealing if the physicians perceive that their hospital is not responsive to appeals to improve working conditions or pay competitive salaries and benefits.

Physicians whose incomes are more closely tied to their RVU production (such as surgeons, gastroenterologists, and ophthalmologists) are likely to feel less benefit to unionization as they would want to preserve their ability to tie high incomes to work effort. Also, when there are relatively few physicians in a specialty at a hospital, they already command a great deal of power and may not perceive a benefit to unionization. For example, if there are only 2 orthopedic surgeons at a hospital, just one of them threatening to leave to go to another hospital on the other side of town can be enough for the hospital to acquiesce to their demand to contract with a different joint implant vendor.

For the foreseeable future, there is projected to be physician shortages in most specialties. This results in a state of perpetual imbalance between supply and demand for physicians. A hospitalist who is not happy with their salary or required number of shifts per year at one hospital can easily get a job at another hospital within commuting distance. This imbalance gives attending physicians a great deal of power in negotiating salary, benefits, and working conditions with the hospital. In the future, if the supply of physicians catches up with the demand for physicians, then the benefits of unionization may become more appealing to physicians in some specialties.

For now, unionization is likely to be primarily relegated to residents and fellows. The current increased interest in resident unions will likely be transitory as life in the hospital returns to normal with receding COVID-19 cases.

June 16, 2022

Medical Education

All Hospital Grand Rounds Should Be Online

A hospital’s grand rounds is the way that most physicians receive their continuing medical education (CME). Traditionally, grand rounds was a weekly live event, held in a hospital auditorium. The time has come to offer all grand rounds on-line.

Grand rounds originated with Dr. William Osler at Johns Hopkins in 1889. Initially, it was a patient-centered presentation, where a senior physician would bring out a patient and then discuss that patient’s clinical findings and treatment.

Over the past 50 years, grand rounds has evolved into more of a lecture format to update the medical staff about the latest developments in the medical field. As state medical boards began to require a minimum number hours of CME to maintain medical licensure, hospital grand rounds became accredited for CME and physicians increasingly turned to grand rounds for their CME credits.

But in the past 25 years, attendance at grand rounds has declined and in 2006, an article in the New York Times concluded that “Grand rounds are not so grand anymore.” A primary driver for the decline in attendance is the changing time demands on physicians that frequently place grand rounds at conflict with patient care activities.

There is no best time of the day

Grand rounds are usually held either in the early morning, at noon, or in the late afternoon. Historically, the early morning (typically 7:30 AM) time allowed physicians to round on their inpatients before attending the presentation. Their office hours would then start around 9:00 AM. Several changes to medical practice have made early morning no longer a tenable time for most physicians. With 15-18 inpatients, residents and hospitalists are not able to complete their morning rounds by 7:30. Moreover, they are under pressure to complete the day’s hospital discharges by late morning. The result is that they cannot realistically take time out of their busy mornings to attend grand rounds. Outpatient physicians are under pressure to start their office hours promptly at 8:00 AM in order for the office to run as efficiently as possible – whenever the doctor is not seeing patients during working hours, the office is losing money. For surgeons and anesthesiologists, early morning is prime operating room time and attendance at a hospital grand rounds is impossible. Proceduralists such as gastroenterologists, cardiologists, and radiologists are similarly constrained in the morning hours.

Noon has also become an untenable time for many physicians to attend grand rounds. Although hospitalists are usually able to combine their lunch hour with attending grand rounds, it is difficult for outpatient physicians to attend a noon lecture at the hospital. In the past, outpatient physician offices were located in medical office buildings adjacent to the hospital – a 3-minute walk from the office to the auditorium. But now, healthcare systems are increasingly decentralized with physician offices located far away, many miles from the hospital. As our nation’s hospitals have become larger, parking has become more challenging with parking areas frequently full and located farther from the hospital. The result is that physicians often need 30 minutes each way to travel to the hospital, find a parking place, and then walk to the hospital auditorium. A one hour grand rounds lecture at noon requires two hours for the outpatient physician to attend. Again, pressures to maximize operational efficiency in outpatient practice makes it very difficult for the physician to be away from the office for two hours in the middle of the workday.

Late afternoon is often equally untenable. After the last patient of the afternoon, outpatient physicians still have 1-2 hours of electronic medical record entry, patient phone calls, and paperwork. Outpatient physicians simply cannot get their daily work done in time to attend a 5:00 PM grand rounds. Physicians who perform shift work, such as hospitalists and emergency medicine physicians, are generally unwilling to drive to the hospital to attend grand rounds on their day off.

COVID changed everything

The COVID pandemic drastically changed education worldwide. Grade school and high school classrooms became virtual. College and medical school classes were often recorded for students to view on-demand. National medical conferences were canceled. Hospital grand rounds became on-line lectures. Now that in-person classes have returned, should we abandon our grand rounds Zoom format?

I would argue that hospital grand rounds should continue to be offered virtually. For all of the reasons previously stated, no single time of day is optimal or even possible for all physicians. Years ago, with mounting frustration at declining grand round attendance, our Chairman of the Department of Internal Medicine made in-person attendance mandatory… it didn’t work. It was not because the doctors did not want to attend, it was because they simply could not attend given the demands of modern medical practice.

There are advantages to in-person grand rounds, however. It is easier to pick up on the nuances of non-verbal communication by the lecturer. It is often easier to ask questions. Attendees are less likely to get distracted by emails, the electronic medical record, or the internet while sitting in an auditorium. Perhaps most importantly, it is easier to network with other physicians before or after the lecture. For these reasons, in-person grand rounds should continue.

But grand rounds should also be available online for those physicians who are unable to travel from remote outpatient offices and those shift-based physicians who are off duty. Grand rounds should also be available for on-demand viewing for physicians who are otherwise preoccupied with patient care during the regular “live” grand rounds hour.

The arguments for online grand rounds

About 15 years ago, we started video recording all of our first and second year medical student lectures and gave the students the option of attending in-person or on-line from home. Most students chose to view the lectures online and only about 20% of students now actually come to class. This was disturbing to many of the College of Medicine faculty who wanted to see a large live audience in the classroom. But the goal of medical education is to educate, not to fill the auditorium. And that means putting the needs of those to be educated first and not putting the egos of the educators first.

If you want your hospital’s doctors to be knowledgeable about the latest in medicine, then you need to reach as many of them as possible. Every grand rounds presentation needs to be available in multiple formats: in-person lectures, live online presentations, and video on-demand presentations. This allows the educational event to cross the barriers of geographic distance from the hospital, of conflict with patient care, and of time-of-day conflicts imposed by shift workers.

For hospitals in competitive markets, high quality continuing medical education is one of the best ways of demonstrating the expertise of the hospital’s medical staff, putting faces to the names of consultants, and showcasing the hospital’s services. The physicians in the hospital’s referral area are not going to travel to your hospital for a weekly in-person grand rounds but they will log-on to watch grand rounds online from their office during their lunch hour or in the evening. Online grand rounds should be free and readily available to anyone without requiring an account or log-in password.

At most hospitals, any physician who shows up to attend a grand rounds lecture in-person can get free CME credit hours from the hospital. The same should be true for physicians who watch your hospital’s grand rounds on-line. One hospital that I know offered CME credit to those physicians attending in-person or listening to the grand rounds live but refused to give CME credit to physicians listening to the exact same lecture on-demand later in the day. This is absurd. It is the same educational material regardless of when the physician views it.

Producing grand rounds can be costly. Outside speakers require an honorarium and payment for travel expenses. The technical work to film and maintain online video comes at a price. The good news is that the COVID pandemic has shown all of America that online video education can be produced at minimal cost. If you can’t finance the cost of providing CME free to your viewers through your education department, then go to your marketing department. The expense will be less than the price of producing a 20 second television commercial and the online grand rounds will reach more of the physicians who refer patients for the hospital’s services.

Its not about how you learn, its about how other physicians learn

All too often, decisions about the format of grand rounds are made by the medical staff senior leadership. These are typically older physicians (like me!) who are most comfortable with a traditional in-person lecture format because that is what they grew up with. But this is not how younger physicians learn – they want to get their medical education online. And if they can’t get your hospital’s grand rounds online, they’ll find some other hospital’s grand rounds that they can get online. Grand rounds is not about educating the physicians of yesterday, it is about educating the physicians of today and tomorrow.

June 10, 2022

Emergency Department Intensive Care Unit Medical Education

Clinical Interpretation Of Arterial Blood Gases

In the previous post, the physiology of the acid-base system was discussed. This post will focus on the practical interpretation of arterial blood gases for clinical diagnosis. The arterial blood gas (ABG) is usually the quickest lab test to obtain in a critically ill patient. In the emergency department, in the ICU, in the operating room, and during cardiopulmonary resuscitation, the ABG often leads to a correct diagnosis and directs initial treatment. There are four steps in interpreting the acid-base components of an ABG:

  1. Determine if the primary process is an acidosis or alkalosis
  2. Determine if the primary process is respiratory or metabolic
  3. Determine if the primary process is appropriately compensated
  4. Check the anion gap

This post will focus on the acid-base components of the ABG and will not discuss oxygenation.

Steps 1 &2: Determine the main acid-base disorder

Although normal values for pH, PCO2, and HCO3 are in reality a range, it is much easier to assume a single normal numeric values for each when interpreting an acid-base disturbance. Therefore, assume normal values of:

  • pH = 7.40
  • PCO2 = 40
  • HCO3 = 24

If the ABG shows a pH < 7.40,  then there is an acidosis; if the PCO2 is elevated, then it is a respiratory acidosis and if the HCO3 is reduced, then it is a metabolic acidosis.

On the other hand, if the ABG shows a pH > 7.40, then there is an alkalosis; if the PCO2 is reduced, then it is a respiratory alkalosis and if the HCO3 is elevated, then it is a metabolic alkalosis. Therefore, each of the four primary acid-base disturbances can be defined as follows:

Respiratory Acidoses:

Respiratory acidoses can be divided into those that are acute (duration of minutes to hours) and those that are chronic (duration of days, weeks, or years). The patient’s clinical history will dictate whether the condition is acute or chronic. For example, a newly unconscious patient with a fentanyl ingestion 45 minutes ago will typically have an acute respiratory acidosis whereas a smoker with long-standing, stable COPD will typically have a chronic respiratory acidosis. There are six main causes of respiratory acidosis:

Respiratory Alkalosis:

Respiratory alkaloses can also be divided into those that are acute and those that are chronic. Once again, the patient’s clinical history will dictate whether the condition is acute or chronic. There are eight main causes of a respiratory alkalosis:

Metabolic Acidoses:

There are two subcategories of metabolic acidosis: (1) increased anion gap metabolic acidosis and (2) normal anion gap metabolic acidosis. The anion gap can be calculated using the equation:

Anion Gap = Na – (Cl + HCO3)

The anion gap is normally composed of miscellaneous anionic molecules in the blood such as albumin and phosphate. When the anion gap is increased, then there are abnormal anions in the blood that will result in a lowering of the HCO3 level. The anion gap is often reported from the lab when ordering an electrolyte panel but for general ABG calculation purposes, a normal value of up to 12 mEq/L can be assumed (normal range = 6-12 mEq). However, when the pH is very high (> 7.50), the anion gap will increase to 15-16 by uncovering anionic sites on albumin. Therefore, a slightly elevated anion gap is normal when the pH is very high. The anion gap can be decreased in conditions such as hypoproteinemia, hypophosphatemia, and multiple myeloma (the latter due to an increase in cationic monoclonal IgG levels).

There are five common causes of an increased anion gap metabolic acidosis and two common causes of a normal anion gap metabolic acidosis:

Note that aspirin overdose can cause both a respiratory alkalosis (by direct stimulation of the brain’s respiratory drive center) and a metabolic acidosis (by accumulation of acetylsalicylic acid in the blood).

Increased anion gap metabolic acidoses can be further subdivided into those that cause an increased osmolar gap (> 10 mOsm/L) and those with a normal osmolar gap (< 10 mOsm/L). The osmolar gap is the difference between the measured and the calculated osmolality of the blood and this is normally reported out by the lab when a plasma osmolality test is ordered. The two most common causes of an increased osmolar gap are (1) methanol poisoning and (2) ethylene glycol poisoning. These are critical diagnoses to make because neither ethylene glycol nor methanol blood levels are able to measured quickly and so the arterial blood gas is usually the only way to establish an early diagnosis in order to direct life-saving treatment. All of the other causes of metabolic acidosis result in a normal osmolar gap.

Metabolic Alkaloses:

There are two subcategories of metabolic alkalosis: (1) chloride responsive metabolic alkaloses and (2) chloride unresponsive metabolic alkaloses. Chloride responsiveness is defined by the urine chloride level: if the urine chloride is < 10 mEq/L, the metabolic alkalosis is chloride responsive and if the urine chloride is > 10 mEq/L, the metabolic alkalosis is chloride unresponsive. There are three common causes of a chloride responsive metabolic alkalosis. Although there are also three causes of a chloride unresponsive metabolic alkalosis listed below, the most common is corticosteroid medication.

Step 3: Determine if the main acid-base disturbance is compensated

Very frequently, there will be more than once acid-base disturbance simultaneously. For example, a patient with pneumonia can have both a respiratory acidosis (from respiratory failure) and a metabolic acidosis (from lactic acidosis due to sepsis). To determine if there is more than than one acid-base disturbance, there are compensation rules. If a patient meets the criteria for these rules, then there is a simple acid-base disturbance (i.e., only one acid-base disturbance). Many of these rules are cumbersome and involve using nomograms or complex formulas. The following are the compensation rules that I have used throughout my career that are simple, require minimal calculations, and easy to use:

  • Metabolic acidosis: The last 2 digits of the pH will equal the PCO2
  • Metabolic alkalosis: For every 10 mEq increase in the HCO3, there will be a 6 mm increase in the PCO2
  • Respiratory acidosis:
    • Acute: For every 10 mm increase in the PCO2, there will be a 1 mEq increase in the HCO3
    • Chronic: For every 10 mm increase in the PCO2, there will be a 3.5 mEq increase in the HCO3
  • Respiratory alkalosis:
    • Acute: For every 10 mm decrease in the PCO2, there will be a 2 mEq decrease in the HCO3
    • Chronic: For every 10 mm decrease in the PCO2, there will be a 5 mEq decrease in the HCO3

If the patient fails the simple acid-base disorder compensation rule, then there is more than one acid-base disturbance. The direction of change from the expected compensation in PCO2 (metabolic disorders) or HCO3 (respiratory disorders) will indicate what that second acid-base disorder is.

Although patients can rarely have three or even four different acid-base disorders occurring at the same time, most patients will only have one or have two occurring simultaneously. The table below describes the findings when there are two acid base disturbances:

Step 4: Check the anion gap

Always, always, always calculate the anion gap! If the anion gap is elevated, then there is an increased anion gap metabolic acidosis, even if the pH, PCO2, and HCO3 are all normal.  The combination of a metabolic acidosis plus a metabolic alkalosis can cause the ABG to appear normal and the only clue that the patient has acid base disorders will be the increased anion gap.

The “delta-delta” rule. The Greek letter delta (Δ)is often used in medical shorthand to mean ‘change in’. In a simple, compensated increased anion gap metabolic acidosis, the Δ anion gap should always be equal to the Δ bicarbonate. In other words, the increase in the anion gap in mEq/L from normal should equal the decrease in the HCO3 in mEq/L from normal. Once again, assume that the normal anion gap is 12 mEq/L and the normal HCO3 is 24 mEq/L. If these two values for Δ are not equal, then there is a second acid-base disturbance. For example, if the anion gap is 20 mEq/L (8 mEq/L above normal), then the bicarbonate should be 16 mEq (8 mEq/L below normal). If the change in bicarbonate is larger than the change in the anion gap, then there is a concurrent metabolic acidosis. On the other hand, if the change in bicarbonate is smaller than the change in anion gap, then there is a concurrent metabolic alkalosis.

Questions containing a completely normal ABG with an increased anion gap are a favorite of those who write questions for board examinations, and with good reason. A common scenario where this occurs is the patient with diabetic ketoacidosis (causing an increased anion gap metabolic acidosis) who is vomiting (causing a chloride responsive metabolic alkalosis). In this case, the decrease in the HCO3 from the metabolic acidosis can be offset by the increase in the HCO3 from the metabolic alkalosis – the ABG can look normal but the patient will still be very sick. The Δ bicarbonate will be less than the Δ anion gap. In this situation, the increased anion gap will be the only prompt for the emergency room physician to immediately start the patient on IV fluids and insulin.

There is a wealth of information contained in those four numbers: the pH, PCO2, HCO3, and anion gap. During emergent situations, such as during a cardiopulmonary arrest, there is not time to look up ABG interpretation in a book or on-line reference. By being able to rapidly analyze the acid-base status, the clinician can use that information to direct life-saving treatments. Memorization of the differential diagnosis of each of the four primary acid-base disturbances and memorization of the compensation rules is essential to the practice of emergency medicine, anesthesia, and critical care medicine.

May 9, 2022

Emergency Department Intensive Care Unit Medical Education

Physiology Of Arterial Blood Gases

Part 1 of this post will cover the physiology behind arterial blood gases and part 2 will cover clinical interpretation of arterial blood gases. Arterial blood gases (ABGs) are an essential part of the evaluation of unstable patients. In unconscious patients who are unable to give a history, the blood gas can provide key data that can lead to a diagnosis long before other test results come back. In the intensive care unit and in the operating room, the ABG can provide critical results that can direct life-saving treatment. But optimal use of the arterial blood gas requires the physician to be able to rapidly interpret the results of the ABG. The two main components of the arterial blood gas are (1) oxygenation and (2) acid-base status. This post will focus on the background physiology of the acid-base components of the ABG. If you are primarily interested in the use of ABGs in clinical decision making of acid-base disorders, skip ahead to the next post.

Components of the ABG

Fundamentally, there are 5 main results in an arterial blood gas report: pH, PO2, PCO2, HCO3, and O2%. The pH is measured directly and indicates whether the patient is acidemic (pH < 7.40) or alkalemic (pH > 7.40). The PO2 is the partial pressure of dissolved oxygen in the blood. The PCO2 is the partial pressure of dissolved carbon dioxide in the blood. The HCO3 is the bicarbonate concentration which is very similar to the serum CO2 reported in an electrolyte panel (the serum CO2 is the total of everything that can be converted into CO2 in the blood including bicarbonate, carbonic acid, and dissolved carbon dioxide – it should not be confused with the PCO2 from the arterial blood gas which is a completely different value). The O2% is the oxygen saturation which is the percentage of hemoglobin binding sites that contain bound oxygen molecules. The normal values for each of these results are usually listed as a range of normal but for the purposes of analyzing the acid-base status, consider normal to be single numbers: pH = 7.40, PCO2 = 40 mm Hg, and HCO3 = 24 mEq/L.

Many ABG analyzer machines can also measure other values such as methemoglobin, carboxyhemoglobin, potassium, lactate, hemoglobin, etc. However, these tests usually need to be ordered separately and if only an ABG is ordered, then you will just get the 5 results as described above.

Acid-base regulation

Our bodies try to keep the pH as close to 7.40 as possible. The two ways that we regulate the pH are by (1) increasing or decreasing carbon dioxide excretion by the lungs and (2) increasing or decreasing bicarbonate excretion by the kidneys. When the carbon dioxide level of the blood is too high or too low, the kidneys compensate by increasing or decreasing the bicarbonate level of the blood by altering bicarbonate excretion in the urine. On the other hand, when the bicarbonate level is too high or too low, the lungs compensate by increasing the carbon dioxide level using hypoventilation or by decreasing the carbon dioxide level using hyperventilation.

Our tissues are constantly producing acids (in the form of hydrogen ions) and acid production can increase very rapidly with exercise. Therefore, there has to be an efficient way to get rid of acid as quickly as it is produced. This is done by converting hydrogen ions into carbon dioxide. In the blood, this is done by the enzyme carbonic anhydrase that first converts hydrogen ions into carbonic acid and then converts carbonic acid into carbon dioxide and water. The carbon dioxide is then excreted by the lungs in the form of exhaled carbon dioxide. When more acid (and thus carbon dioxide) is produced, for example, during exercise, the lungs can immediately dispose of that carbon dioxide by hyperventilation. In order to keep the pH at 7.40, we have to maintain a constant ratio of bicarbonate:dissolved carbon dioxide, as dictated by the Henderson-Hassalbach equation.

During conditions resulting in hyperventilation, the lungs get rid of more carbon dioxide and as a consequence, the blood PCO2 can become lower. Conversely, during conditions resulting in hypoventilation, the lungs are not able to get rid of carbon dioxide adequately and the blood PCO2 will rise.

There are other acids that are produced by metabolism that cannot be converted into carbon dioxide. These are called non-volatile acids and must be excreted by the kidneys. The kidneys can also excrete bicarbonate into the urine and can thus respond to a change in the blood carbon dioxide level by either eliminating or retaining bicarbonate. Unlike the lungs which can respond to increased carbon dioxide within seconds, it takes the kidneys 2-3 days to raise or lower bicarbonate levels with the result that the kidney’s full compensatory response to an acid-base disorder takes several days. However, the blood does have the ability to have a small but immediate effect on a changing carbon dioxide level by a chemical buffering mechanism. The result of this is that there are two responses to a high or a low carbon dioxide level: an acute compensation by chemical buffering and a chronic compensation from excretion of bicarbonate by the kidney. The buffering mechanism of the blood is fairly limited and can only result in a mild/limited degree of compensation compared to kidney excretion of bicarbonate.

Base deficit and base excess

In some situations, the ABG report will be resulted as “base deficit” or “base excess”. This is commonly used in the operating room by anesthesiologists. A base deficit refers to the amount that the bicarbonate level is too low and a base excess refers to the amount that the bicarbonate is too high. For practical purposes, base excess can be used synonymously with metabolic alkalosis and base deficit can be used synonymously with metabolic acidosis.

Acid-base disorders

Acid-base disorders can be divided into those that make the pH go up (alkaloses) or make the pH go down (acidosis). Each of these can be dividing into respiratory disorders that affect the carbon dioxide level and metabolic disorders that affect the bicarbonate level. Thus, there are 4 main groups of acid-based disturbances:

In a respiratory acidosis, the primary problem is that the blood carbon dioxide level is too high and the kidneys compensate by retaining bicarbonate. In a respiratory alkalosis, the primary problem is that the blood carbon dioxide level is too low and the kidneys compensate by increasing bicarbonate excretion into the urine. In a metabolic acidosis, the primary problem is that the blood bicarbonate level is too low and the lungs compensate by hyperventilating to reduce the blood carbon dioxide level. In a metabolic alkalosis, the primary problem is that the blood bicarbonate level is too high and the lungs compensate by hypoventilating to increase the blood carbon dioxide level.

As noted previously, the lungs can compensate to a metabolic acidosis or alkalosis within seconds but the kidneys take 2-3 days to fully compensate for a respiratory acidosis or alkalosis. However, there is a partial compensation to a respiratory acidosis or alkalosis by the buffering chemistry within the blood that happens immediately. For this reason, metabolic acidoses and alkaloses can be divided into those that are acute (occurring in minutes to hours) that are partially compensated by buffering and those that are chronic (occurring more than 2-3 days previously) that are more fully compensated by renal bicarbonate excretion.

It is important to note that a person can have more than one acid base disturbance at the same time. For example, a person can have a condition causing a metabolic acidosis and also simultaneously have another condition causing a metabolic alkalosis. Or, a person can have both a metabolic acidosis and simultaneously have a  respiratory acidosis. If there is a single acid-base disturbance, it is called a simple acid base disorder and if there are more than one acid-base disturbances, it is called a complex acid base disorder.

The next post will review the causes of acid-base disturbances and how interpretation of the arterial blood gas can be used to diagnose these disorders.

May 9, 2022

Medical Education

The Last Webcast

After 860 shows, I filmed my last continuing medical education webcast 2 weeks ago and today, it is being released on the internet. In 1998, I took over as moderator and editor of the weekly Ohio Medical Education Network TV series (OMEN-TV) that later became the webcast, OSU MedNet. For 24 years, I have spent every Friday at noon from September through June in a television studio to keep practicing physicians up to date on the newest developments in medicine. Today, I am now officially retired from the Ohio State University.

The third pillar of medical education

MedNet is devoted to continuing medical education (CME). There are three components to medical education: medical student education, graduate medical education, and continuing medical education. Medical student education is based in our nation’s medical schools where medical students receive 4 years of classroom and clinical education in order to receive their MD or DO degrees. Graduate medical education (GME) is based in our nation’s hospitals where graduates of medical schools spend 3-5 years training as residents and then may spend an additional 1-4 years training as subspecialty fellows. Continuing medical education is for physicians who have finished residency and fellowship training and are now out in clinical practice.

CME is the least lauded of these three pillars of medical education. Medical student education is the realm of university professors and deans whose salaries come from tuition, endowments, and state government support. GME is the realm of clinician educators, department chairs, and division directors whose teaching income comes from Medicare education support and clinical revenue. Success in both medical student education and GME can be a foundation for academic physician career development and university promotion. On the other hand, CME often lacks the glamour of medical student and resident education. Success in CME rarely leads to university promotion and most CME educators do it voluntarily, without pay.

Where do doctors get CME?

In order to maintain their medical licenses, doctors are required to have a certain number of continuing medical education hours every year. The specific requirements vary from state to state; here in Ohio, the State Medical Board requires physicians to have 50 hours of CME every two years. In the past, most physicians would get their CME from a combination of hospital grand rounds and medical conferences. Hospital grand rounds are free and the attendees are mostly physicians who practice at that particular hospital. Large hospitals can recruit grand rounds speakers from their own medical staff who present their grand rounds lectures without getting paid; delivering a grand rounds lecture is considered part of one’s normal professional obligations. Smaller hospitals generally have to bring in outside grand rounds speakers who get paid an honorarium fee. Weekly outside speakers can be very expensive for hospitals and for many smaller hospitals, can be cost-prohibitive.

There are two main types of medical conferences: those sponsored by hospitals and those sponsored by national specialty societies. Hospital-sponsored conferences are usually 1-day events that attract local or regional physicians and consist of several lectures on a particular topic, for example diabetes or heart disease. Specialty society-sponsored conferences are held once a year in a convention center and features dozens of lectures over several days that attendees can choose from. Conferences are very expensive to put on and the money to fund conferences comes from a combination of meeting registration fees and educational grants from pharmaceutical and medical devices companies. Like hospital grand rounds speakers, the educators at conferences generally do not get paid for delivering their lectures but sometimes have their meeting registration fees waived in exchange for their presentations.

A different way of doing CME

The Ohio State University was originally established as a land grant college. The land grant concept was created by the Morrill Act signed by Abraham Lincoln in 1862 that allowed the U.S. government to grant some colleges federal land to build on and in exchange, those colleges would focus on science, agriculture, and engineering (in contrast to private colleges that were largely based on liberal arts). Every state in the U.S. has at least one land grant college. One of the provisions of the Morrill Act was that land grant colleges also had to serve as a community resource for agriculture and science. This was the origin of agricultural extension offices that are still in use today.

In 1962, as part of its land grant mission, the Ohio State University created a medical education outreach program that had a lot of similarities to the agricultural extension offices. The program was called OMEN which stood for the Ohio Medical Education Network. It was broadcast at noon from an audio studio set up in Starling Loving Hall on the OSU Medical Center campus. Participating hospitals would be pre-mailed 35 mm Kodachrome slide sets and then OSU medical school faculty would broadcast their lectures over a telephone speaker system with “beeps” indicating when to advance the slides. After each formal presentation, the listeners could call in to get advice from the OSU specialists on the management of their own patients. Initially, most of the participating hospitals were smaller, often rural hospitals in Ohio. Over time, hospitals in other states and many VA hospitals were added. Sixty years ago, this was a revolutionary, state-of-the-art concept in distance education that for the first time, allowed physicians practicing in smaller communities to keep up with breakthroughs in disease diagnosis and treatment.

In 1990, OMEN expanded from the audio program using slide sets into a satellite TV program and was re-named OMEN-TV. The participating hospitals would use a satellite dish to receive the programs and they were filmed in a TV studio in Atwell Hall on the OSU Medical Center campus. The shows were live presentations and satellite time was rented from noon to 1:00 PM every Friday from September through June (mirroring the university’s academic year). The TV program had the advantage that now the audience could see the presenters and we could incorporate video, for example, of a surgical procedure. At the end of each show, viewers could call in and ask questions live on-air. In the early years of OMEN-TV, I was a frequent guest presenter, lecturing on various pulmonary and critical care topics. Then, in 1998, I took over as the moderator and medical editor of OMEN-TV.

Like its audio predecessor, OMEN-TV was a ground-breaking concept for continuing medical education. Initially, there was nothing else like it in the United States. Subscribing hospitals would pay a small annual subscription fee to the OSU College of Medicine and in return, they would get weekly medical education shows that allowed their doctors to get CME credits without having to leave to attend an out-of-town conference. It was also far less costly to the hospitals than bringing in outside grand rounds speakers every week. The downside was that if doctors were in the operating room or attending to sick patients at the time of the broadcast, they would miss the presentation. We did additionally replay the shows on cable TV but it was generally a public access channel and often shown at an inconvenient time of the day or night. The number of subscribing hospitals grew with more VA hospitals and community hospitals throughout the country added every year.

OMEN-TV was costly to produce. The live TV show required 3 cameramen, a sound technician, someone to hold cue cards (and later to run a teleprompter), staff to take viewer phone calls, a film director, computer technicians, a make-up artist, and a full-time producer. The subscription fees only covered a small part of the total production costs so additional financial support came from the OSU Medical Center. But even that was not enough to fully fund the program. So, we would reach out to pharmaceutical companies and educational foundations to get unrestricted educational grants. We would acknowledge these organizations in the credits at the beginning of each show, similar to what you see with PBS broadcasts. The hospital paid 10% of my salary to be the moderator and editor of OMEN-TV. Each show required about 8 hours of my time to recruit presenters, review and edit slides before broadcast, prep the presenters, rehearse, host the live show, and fill out all of the CME paperwork after each show. Each season initially consisted of 28 shows per year and we quickly expanded to 40 per year – every Friday from September through June with weeks off for major holidays. I was the sole host and the only times I could take vacations were July, August, and the weeks of Thanksgiving, Christmas, or New Years Day. Fortunately, I was able to avoid any major illnesses or injuries that would have kept me out of the studio.

But OMEN-TV had its downsides. Since it was a live broadcast, subscribing hospitals were limited to showing the program at noon on Fridays. We did not have a good way to reach physicians who were not on the medical staff of a subscribing hospital. Also, in the early 2000’s, there was mounting pressure from the Accreditation Council for Continuing Medical Education (ACCME) to eliminate educational grants from pharmaceutical companies in order to reduce the risk of conflict of interest affecting presentations. OMEN-TV needed to evolve once again into a leaner, more widely available program.

In 2002, OMEN-TV transformed from a satellite TV show into a webcast. In order to better reflect the internet medium of broadcast, the program was re-named OSU MedNet-21 (medical education for the 21st century). We retained most of the elements of the OMEN-TV production but now subscribing hospitals could show MedNet on any day and time that best fit with the hospitals’ medical staff calendars. Also, by being a video-on-demand product, we could keep the shows available on the internet for 3 years. So, at any given time, we had 120 hours of CME available on the OSU Center for Continuing Medical Education’s website. We made the webcasts available for free for anyone to view – no user account or password needed. The only requirement was that physicians who wanted to get CME credit for viewing the webcasts had to either view them at a subscribing hospital or had to pay a small fee after viewing the webcasts in order to take a 10-question CME post-test. The webcast format allowed us to track viewer numbers – we could not identify individual viewers but we could tell what country they were viewing from. We have had physician viewers from 136 countries watch MedNet webcasts. Soon after converting to a webcast, we moved production to the WOSU-TV studios on the university campus.


As a webcast, we were able to significantly reduce our production costs. In the WOSU-TV studio, we used 3 remotely operated digital cameras, eliminating the need for individual cameramen. We stopped using a make-up artist and since the webcasts were not shown live, we no longer needed people to operate phones. Instead of a massive studio crew, we were able to film each webcast using just 4 people in a separate control room to operate cameras, do audio, operate the teleprompter, and do the computer integration. With with reduction in production costs, we no longer needed grants from pharmaceutical companies and we were able to fully finance the program with subscription fees and support from the OSU Medical Center and the OSU James Cancer Hospital. Each webcast is also available as an audio-only podcast, allowing physicians to get their CME by podcast during their commute to and from work.

Meeting physician educational needs

Today, OSU MedNet goes out to 70 hospitals nationwide, with the largest number of subscribing hospitals here in Ohio. Because most of these hospitals are smaller community hospitals, most of the viewers are primary care physicians: family medicine, general internal medicine, pediatrics, and hospitalists. Each year, we do a needs assessment by soliciting topic recommendations from our viewers. We also ask the OSU department chairs, division directors, deans, and medical directors for topic suggestions. I would go through the last year’s editions of the New England Journal of Medicine, JAMA, and the Morbidity and Mortality Weekly Report from the CDC. From this, we had about 2-300 possible topics. We then use a group of OSU primary care physicians to rank the topics and the highest ranked topics become the next season’s shows. I then identify and recruit physicians from the Ohio State University to present each of those topics. For most of these presenters, it is the largest audience that they will ever have, reaching hundreds of physicians all over the world and impacting thousands of patients’ lives.

As a webcast, MedNet has the flexibility to do additional shows on short notice when new developments in medicine occur. So, for example, we were able to do webcasts on SARS, Ebola, and Zika virus within 2 weeks of the initial cases of these infections. When COVID-19 first developed in January 2020, we were able to put out a COVID-19 MedNet on February 3, 2020, just two weeks after the first reported case in the U.S. and before Ohio had any cases. Since the pandemic began, we have done 9 COVID webcasts as new developments in the diagnosis, treatment, and prevention arose. When case rates began to rise last winter due to the Omicron variant, we were able to get a COVID update on the internet within 5 days of concept inception in order to help physicians manage the surging number of cases in their own communities.

The last webcast

In April 2021, I retired from the Ohio State University and from clinical practice. I was at OSU for 43 years as a research lab assistant, medical student, resident, fellow, and professor. However, after retiring, I agreed to continue as the moderator and host of OSU MedNet until my successor was named. So, for the past year, I’ve continued to host the webcasts every Friday. I’ve done it as a volunteer, without compensation, because I’m very passionate about the program and about the need to continue to provide quality continuing medical education to physicians around the world. Besides, I have a lot of fun hosting the show and it has kept me engaged with the OSU medical community as a way of easing into retirement.

For two years, we recorded MedNet by Zoom from our office computers rather than using the WOSU-TV studios because of the COVID-19 pandemic. In March 2022, the case numbers had fallen low enough to permit us to take off our face masks and return to the studio safely. During the pandemic, construction did not stop on the new WOSU Media Building and last month, we filmed our first webcast in the new WOSU-TV studio. It is a truly state of the art facility with superior cameras, sound, and lighting.

It took nearly a year to solicit applications for the next MedNet moderator and then to select finalists, do auditions, and do the final selection. I am absolutely delighted that Dr. Shengyi (“Jing-Jing”) Mao will be taking over as my successor. She is an OSU primary care physician who is board certified in both internal medicine and pediatrics and has been a regular MedNet presenter in the past few years.

Today, we are releasing my last official webcast as moderator and host of OSU MedNet and next week, Jing-Jing will take over in the studio. I’ll be back occasionally to fill in when needed but for the first time in 24 years, my Fridays will be open and I’ll be free to travel outside of Columbus whenever I want. For my last show, I decided to be both the moderator and the guest and so I hosted my own presentation. I decided to talk about Physician Financial Health. For 15 years, I served as the treasurer and vice chair of the OSU Department of Internal Medicine and part of my responsibilities was to advise new faculty about retirement plan options, personal finances, and saving for children’ college education. That expanded to annual talks to the residents and the fellows about financial planning and has resulted in a number of posts on this blog about physician finances and about retirement planning. So, as a recent retiree, I decided that financial health would be a fitting topic for my last webcast. You can view the webcast by clicking here.

After 810 shows, I’ve learned a lot about areas of medicine that as a pulmonary and critical care physician, I never would have otherwise have learned about. I’ve met fascinating people who were our guests – both doctors and other healthcare professionals. I’ve also learned a lot about TV and webcast production. But most of all, I’ve had fun doing it… a lot of fun. And now, it’s time to become a MedNet viewer, rather than the MedNet moderator.



April 8, 2022