Category: Medical Education

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

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

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

You can view my OSU MedNet webcast on PFT interpretation that covers more details here.

Spirometry

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

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

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

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

February 2023 update: the ERS/ATS just issued a revised severity scoring system and recommend using FEV1 z-scores (z-scores are the number of standard deviations below the mean values). The new severity criteria are:

• Mild obstruction: FEV1 z-score -1.65 to -2.5

• Moderate obstruction: FEV1 z-score -2.52 to -4.0

• Severe obstruction: FEV1 z-score <-4.1

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

February 2023 update: the ERS/ATS just issued revised criteria defining reversible obstruction as an increase of at least 10% in the percent predicted value of either the FEV1 or the FVC after a bronchodilator. 

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

Steps in spirometry interpretation:

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

Lung Volumes

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

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

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

Diffusing Capacity

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

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

Flow-Volume Loops

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

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

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

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

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

Putting it all together

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

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

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

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

December 2, 2021

The annual residency match is an event like nothing else in the United States. Each year, 4th year medical students spend the fall and winter applying to and interviewing with residency programs. In February, they submit their ranked list of the programs that they would like to attend next year to the National Resident Matching Program. Simultaneously, all of the residency programs submit their ranked list of the medical students they would like to hire next year. The National Resident Matching Program then pairs the medical students with the residency programs using an algorithm that assigns the students to residency programs by matching the two rank lists. Although it sounds a bit impersonal, it actually is the fairest way to ensure that students get into the residency programs that they want while simultaneously ensuring that the residency programs get the students that they want.

The results of the match were released on Match Day, March 19th, and all across the country, 4th year medical students found out which hospital in which city they will be spending the next 3-5 years at starting in late June. If you drill into the Advance Data Table from this year’s match results, there are some interesting take-away points.

Some specialties are more competitive than others

There are 4 groups of students applying to residency: MD students, DO students, U.S. students attending foreign medical schools, and foreign students attending foreign medical schools. The most competitive specialties are those that fill most of their positions with U.S. medical graduates, and in particular, those graduating with MD degrees.

From this graph, it is apparent that surgical subspecialties are the most competitive residencies. Thoracic surgery, plastic surgery, otolaryngology, and neurosurgery all filled greater than 85% of their available positions with graduates from U.S. medical schools (MD). On the other hand, specialties that filled fewer than 50% of their positions with graduates from U.S. medical schools included radiation oncology, internal medicine, family medicine, and pathology.

The number of osteopathic graduates is growing

The number of applicants from U.S. allopathic (MD) medical schools has been rising slowly over the past 5 years. Combining the number of 4th year medical students applying for residency plus the number of applicants applying who previously graduated from allopathic medical schools, the total number has increased from 18,639 in 2017 to 21,538 in 2021, a 16% increase over 5 years. However, the number of applicants from U.S. osteopathic (DO) schools has increased from 3,590 to 7,710 over the same 5-year period, a 115% increase. Applicants from U.S. medical schools (MD) still have the best chance of getting into a residency with 92.8% of senior MD medical students matching. Seniors from osteopathic (DO) schools were a close second with 89.1% matching. U.S. citizens attending foreign medical schools fair less well with only 59.5% matching into a residency program. Foreign citizens attending foreign medical schools continued to be the least successful in getting a residency with only 54.8% matching. Over the past 5 years, despite the significant increase in numbers of senior students from osteopathic schools applying to residency, osteopathic students have been also been increasingly successful in obtaining residency with their match rate increasing from 85% in 2017 to 89.1% in 2021.

Competitive residencies require lots of ranks

In order to get into a residency program, a 4th year medical student must first apply to that program, then get accepted to interview at that program, then travel to the city where that residency is located to interview, then list that residency program on student’s rank list. In order to increase the chances of getting into a residency somewhere, you need to interview at and then rank several programs. In the past, that meant a lot of expensive travel across the country and a lot of time away from medical school to do those on-site interviews. This year, interviewing became a bit easier and less expensive since COVID-19 resulted in all interviews being done virtually, by video. Overall, the average senior student at an allopathic (MD) medical school ranked 9.4 residency programs. However, that number varied considerably. Not surprisingly, the average number of programs ranked per student correlated with how competitive the specialty is.Vascular surgery led with 20.5 programs ranked per applicant, followed by neurosurgery with 18.2, thoracic surgery with 18.1, and otolaryngology with 15.3. At the other end of the spectrum, students applying to pathology residencies ranked the fewest residency programs per student at 4.4, followed by family medicine at 4.9, and internal medicine at 5.7.

More students go into internal medicine

As in the past, the largest number of positions available is in internal medicine. Medical subspecialties such as cardiology, gastroenterology, pulmonary, and oncology first require an internal medicine residency so many of the students applying to internal medicine have long-term aspirations of subspecializing. Nonetheless, there are twice as many residency positions available for internal medicine (3,523) than are available for the next closest specialty, emergency medicine (1,765). Not included in these numbers are students seeking a preliminary or transitional year of internal medicine which is a pre-requisite before specialties such as neurology, dermatology, and ophthalmology. Of note, ophthalmology is unique in that the ophthalmology match occurs earlier in the year and does not participate in the regular residency match.

Your future doctor is less likely to be an MD

In the past, most U.S. physicians were graduates of U.S. allopathic medical schools and had an “M.D.” after their name. That is changing and with the current trends, this may be the last year that U.S. MD graduates comprise the majority of future physicians.

For the past 5 years, the number of available residency positions in the United States has been increasing. In 2017, there were 27,688 residency positions and this grew to 33,353 in 2021. Although the absolute numbers of applicants from each of the four types of students applying to residency has increased, the numbers of students from osteopathic schools, U.S. students attending foreign medical schools, and foreign students attending foreign medical schools has increased faster than the number of students from U.S. medical schools (MD). As a result, the percentage of students matching to residency from U.S. medical schools has fallen from 65.6% in 2017 to 50.7% in 2021. At this rate, the percentage will likely be < 50% next year. A total of 31% of students who matched this year trained at a foreign medical school, either as a U.S. citizen abroad or as a foreign citizen. That is up from 24% in 2017 and at this rate, in the near future, more U.S. physicians will have trained at a foreign medical school than at a U.S. medical school.

What happens to the students who don’t match?

Unmatched applicants included 1,431 U.S. medical school seniors, 866 U.S. medical school previous graduates, 774 osteopathic seniors, 339, osteopathic previous graduates, 2,143 U.S. citizens attending foreign medical schools, and 3,587 foreign citizens attending foreign medical schools. Combined, this is a total of 9,140 students who did not get into a residency. This is a mixed bag of students. Some will land a residency position in the “scramble” when unmatched students call program directors of residency programs that did not fill in hopes of getting a residency position after the match. Some will take a year or two off to get an MBA or other masters degree. Some will decide not to pursue medicine altogether and switch to another career. Some will take a year off to do research or work in another field and then try again next year.

Those unmatched students who apply to the match a second time face lower chances of obtaining a residency position. Of senior medical students applying to residency for the first time, 92.8% matched; however, of graduates of medical schools applying later, only 48.2% matched. The same trend exists for osteopathic students: 89.1% of senior students applying for the first time matched but only 44.3% of graduates applying later matched.

The results of the National Resident Matching Program tell us a lot about which specialties are hot and which specialties are not. But by looking more closely at the results, we can also forecast who our doctors are going to be in the future.

March 23, 2021

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

Residency Interviews are Expensive

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

Last month, I attended the American College of Chest Physicians annual meeting. At one of the sessions, I realized I could hear the men talking but I had a hard time hearing the women despite the fact that they were all standing in front of the same lectern and all speaking in what seemed to be normal conversational speech. I realized that there can be implicit gender bias in lecture acoustics and that women need to be aware of some of these sources of acoustic bias in order to be effective speakers. There are several sources of acoustic gender bias. In this post, at the risk of being a male talking about female gender bias, I’ll explore several of these.

Gender differences in vocal frequency

Male and female voices occupy different sound frequencies. A typical male voice extends from 150 Hz to 6,000 Hz and a typical female voice extends from 350 to 8,000 Hz. However, in normal voiced speech, a male voice is 85 – 180 Hz and a female voice is 165 – 255 Hz. Certain vocal sounds occur at higher frequencies than others. For example, the sound of “J”, “M”, or “Z” occurs at a low frequency whereas the sound of “K”, “F”, or S” occurs at a much higher frequency.

Humans are wired to associate lower frequency voices with authority. In a study of male CEOs, the size of the company that a CEO ran correlated with the frequency of his voice – a lower voice pitch was associated with running a larger company and correlated with a higher salary. Interestingly, the average frequency of adult women’s voices has fallen by 23 Hz since 1960 which may reflect evolving societal differences in women in positions of authority. Because children have higher pitched voices than adults, a high-pitched voice can make a person sound young or inexperienced.

Many sound systems are adjusted to make the (often male) CEO sound great and this can put people with higher frequency voices at an inherent disadvantage unless there is someone tending the sound system who can make everyone sound just as great as the CEO.

We lose high frequency hearing with age

As we get older, our ability to hear high frequencies is diminished. Business owners use this to their advantage when they install a Mosquito alarm outside their buildings. This device emits an annoying 17,400 Hz noise that loitering teenagers can hear but older people are oblivious to. High frequency hearing loss begins at age 30 and increases with each decade of life.

As a result, many older people have a hard time hearing female voices with their higher frequency pitch. This is not an issue if you are lecturing to a group of college students. However, if you are lecturing to an older group of people or giving a presentation at a board meeting full of older board members, then a higher frequency voice is harder to hear. A woman often needs to speak slightly louder to be heard as well as her male colleague.

Equipment bias

There are two pieces of equipment that can affect how women’s voices project as opposed to men’s voices: the microphone and the equalizer. Each microphone will have a frequency rating that reflects how well it picks up different sound frequencies. A microphone that is better at picking up lower frequencies will tend to make a male voice sound louder and a female voice sound softer.

A second way that the microphone can cause discrimination by the “proximity effect”. This occurs because lower frequencies tend to be lost the further away a person is to the microphone. The average American man is 5 foot 9 inches tall where as the average American woman is 5 foot 4 inches tall, a difference of 5 inches. If a lectern microphone is set to position that microphone for the height of a man’s head, then a woman’s head is going to be 5 inches further away from that microphone with the effect of losing her lower frequency elements of speech. Therefore, simply by being closer to the microphone, you can augment the lower, or base frequencies in your voice. An easy way to demonstrate this is to use the “voice memo” app on your phone and record your voice saying the same thing with the phone 2 inches, 12 inches, and 24 inches away from your mouth. At 2 inches, your voice will have more base elements and will sound deeper and richer.

Microphones come in two general categories, directional and omnidirectional. A directional microphone picks up sounds from one specific direction and should be positioned so that it is pointed toward the source of that sound. An omnidirectional microphone picks up sounds from all directions from the microphone. The microphones on lecture room lecterns are usually directional so that the speaker’s voice is picked up but room noise is minimized. However, even with a directional microphone, as you increase the distance from the microphone, room noises will start to creep into the audio if the audio technician is attempting to maintain your voice at a constant volume. To ensure optimal acoustics, be sure that the directional microphone is pointed at your mouth.

 

Two other effects of the distance to the microphone is on reverberation and “popping noise”. Reverberation, or the echo of one’s voice in a room, becomes more evident when there are non-porous materials in the room (for example, concrete walls) and when one gets further from the microphone that they are speaking into. Those echos can make words harder to hear. If a person gets too close to a microphone, then the microphone can pick up puffs of air that can accompany sounds like the letters “p” or “b” and this can result in a distracting popping sound to one’s speech. Professional musicians overcome this by using a pop-filter composed of a piece of stocking-like material stretched and mounted as a screen between the microphone and the singer’s mouth. Pop-filters are impractical in a typical lecture room. The best distance is usually 6-12 inches between microphone and mouth; this distance is the best compromise between reducing popping sounds at the same time as reducing reverberation and room noise.

In order to account for different frequencies, equalizers are often used by sound engineers. An equalizer allows the engineer to preferentially amplify sounds in different frequency ranges and this can be used to “equalize” voices of different pitches, for example, men versus women. The bass and treble knobs on a radio are the most simple form of an equalizer. An equalizer in a lecture room can have between 5 and 31 sliders with each controlling a range of frequencies. Most lecture rooms don’t come with professional sound engineers, however, and so equalizers in a sound system may be set to a factory default frequency preference or the equalizer may be run by an audio-visual staff member with little idea of acoustic optimization. If you ever go to a small venue concert, the singer will almost always recognize the person running the sound system at the end of the show – how well that person manages the equalizer can make an enormous difference in how the singer sounds. The person running the lecture room sound system is just as important to the effectiveness of the lecturer.

Room bias

The acoustic response of a room if affected by many variables but one of the more important is the degree of absorption of different frequencies. Porous materials in a room, for example, carpet or fabric, can reduce reverberation and echos but will also absorb high frequency sounds. Thus, a person with a high frequency voice may not seem to be as loud as a person with a lower frequency voice. The more porous materials are in a room, the more a woman’s voice can be lost.

The individual’s “voice brand”

There are 5 main features of a person’s individual voice brand: intensity, inflection, rate, frequency, and quality. Adopting different elements of each of these features can significantly impact the effect a voice can have on a listener.

Intensity is the loudness of a voice in decibels. Too soft of a voice can come across as meek and timid but too loud of a voice can come across as if you are shouting or angry.

Inflection is the intonation of voice or the degree to which the pitch varies. An excessively monotone voice has little variation in the frequency of the words spoken and can come across as uninteresting. An excessively up-and-down voice with constant swings in the frequency of words can come across as unintelligent.

Rate is the speed of one’s speech. Too slow comes across as condescending but too fast comes across as being rushed. Varying the rate of speech can be an effective way of emphasizing certain points. A good rate range is 162-175 words per minute.

Frequency is the pitch of the voice, usually measured in hertz (Hz). Too high of a frequency can make one sound young or less intelligent, as discussed above. Too low of a frequency can be authoritative but can also come across as aggressive.

Quality are those characteristics of a voice that can create an “interesting voice”. Two voice qualities to avoid in public speaking are the “glottal fry” and “up-talking”. Glottal fry is when a person takes their voice down to an unnaturally low pitch during part of a phrase resulting in a creaky or graveling timber. A study of voice perception found that people over age 40 believe that speakers using vocal fry sound like they lack authority. Up-taking, or high rising terminal, is when a person increases the frequency of their voice at the end of a sentence. This results in a tone that sounds like a question and can make the speaker come across as unsure of themself or uncomfortable.

So what can women do?

To create an equal acoustic playing field, there are some things that you cannot control. For example, you cannot control the shape of the room, the extent of porous room materials, or the frequency rating of the microphone. However, there are some things that you can control and you can use these to your advantage.

The first thing one can do is to speak louder. As men and women speak in a loud (but not shouting) voice, the differences between the acoustic perception of different frequencies of sound become less apparent. So, if a woman speaks slightly louder than normal, she can eliminate the auditory perception gap that exists between male speech and female speech, particularly in the lower vocal frequencies. This becomes more necessary when a woman is speaking to an audience of mostly older persons.

A second strategy involves speaking with the person running the sound equipment for the lecture room (when such a person exists!). Many times, they will have set the equalizer to a default setting or they will have optimized it for whoever the first speaker is. If that first speaker is a man with a low pitched voice, then the woman who is the second speaker will often be acoustically disadvantaged. Asking the sound technician to be sure to adjust the equalizer when you are giving your presentation will remind that technician that you are aware of the importance of what they do and ensure that he or she optimizes the settings for the unique frequencies of your voice.

A third strategy is to adjust the microphone height. In order to retain the authoritative lower frequency vocal intonations, one has to maintain proximity to the microphone. Sometimes this may mean adjusting the height of a lectern (if it is adjustable) and sometimes this means bending a flexible goose-neck microphone down to an appropriate height. Stand close to the microphone with a goal of your mouth being 6-12 inches away. Be sure that the microphone is pointing directly at your mouth. Lavalier microphones are a great choice because they stay pointed directly at the mouth and they stay a fixed 8 inches from the mouth.

A fourth strategy is to adjust your voice brand. Most of us do not really know how we sound to others. Recording a practice session of your presentation and then listening  to it can help you identify features such as glottal fry and up-talking that may not have much impact on younger audiences but can make you seem less authoritative to older audiences. Ensure that your rate is 162-175 words per minute and that your intonation is neither too monotone nor too up-and-down.

To be successful, it is important to not only be qualified but to also sound qualified.

November 12, 2019

It costs more than $1.1 million to train a doctor in the United States. The societal investment in creating physicians is enormous and has widespread implications for American health care in everything from acceptance of international medical graduates to the future use of non-physician health care providers.

Breaking down the costs

Depending on the specialty, tt takes 11 to 15 years to train a physician when you count college, medical school, residency, and fellowship. At each of these steps there are direct costs and indirect costs. Some of these costs are paid by the physician in training and some of these costs are paid for by society in general (usually through state or federal taxes). Here is a breakdown of the direct and indirect costs at each step along the way:

Undergraduate education. Colleges essentially have 3 sources of income: tuition, endowment, and government funds. For this reason, the total cost to educate an undergraduate is considerably more than what the student actually pays in tuition. It becomes complicated because most colleges not only have to finance the education of students but also have to finance the research activities that professors must perform in order to keep their jobs. Thus, it is hard to separate the costs of education from the costs of research. Public colleges receive state government funds to subsidize their education and research activities and this results in lower tuition for in-state residents than for out-of-state residents. The out-of-state tuition and fees best reflects the cost to teach an undergraduate without the state governmental subsidy. Private colleges and universities generally do not receive state governmental subsidies and have considerably higher tuition costs. For the purpose of this analysis, I used the current cost of attendance for out-of-state freshman at the Ohio State University that includes tuition, fees, books, room, board, and miscellaneous expenses if living on-campus which is $49,556. For four years of college, this would be a total cost of $198,224.

Medical school. Colleges of medicine have the same 3 sources of income as undergraduate colleges so for this analysis, I used the current cost of attendance for an out-of-state medical student at the Ohio State University College of Medicine. Once again, this estimate is for tuition and fees as well as estimated living expenses. Unlike undergraduate college, the cost of medical school varies considerably for each of the four years of training: year one = $80,019, year two = $76,026, year three = $114,442, and year four = $114,542. Totaling all four years, the cost to go to medical school is $385,029.

Residency. There are both direct and indirect costs of resident education. The direct costs are the resident’s salary and benefits. At the Ohio State University Medical Center, these costs are $51,510 for a first year resident (intern) and increases each year so that a fourth year resident cost is $56,636. However, the direct costs are only the tip of the iceberg when it comes to the total cost to train a resident. There is the cost of everything from hospital call rooms, to residency program administrator salaries, to part of the salaries of chairmen and faculty to cover otherwise non-compensated teaching time. Most of these indirect costs are ultimately paid from federal tax dollars- either by Medicare payments to teaching hospitals for graduate medical education or by the higher Medicare payments for clinical services that teaching hospitals get paid (as opposed to non-teaching hospitals). In 2014, the Alliance for Academic Internal Medicine estimated that the total direct and indirect costs to train a resident is $183,416 per year. For the 3 years of residency it takes to become a general internist, pediatrician, family physician, or hospitalist, the cost is $550,248. It takes longer to train other specialists, for example, an obstetrician is 4 years ($733,664), a gastroenterologist is 6 years ($1,100,496), and an interventional cardiologist is 7 years ($1,283,912).

Total costs. Adding all of these together, the total costs to train physicians is astounding. This demonstrates that society has an enormous investment in each physician in the United States.

• $1,133,501 – general internist, family physician, pediatrician
• $1,316,917 – obstetrician, psychiatrist
• $1,500,333 – general surgeon, endocrinologist
• $1,683,749 – gastroenterologist, pulmonary/critical care, general cardiologist
• $1,867,165 – interventional cardiologist, neurosurgeon

Implications for U.S. healthcare

International medical graduates. One of the best ways to reduce the cost of training doctors is to get someone else to pay for it. If you can get another country to cover the costs of college and medical school, then the cost to American society drops. Therefore, the U.S. cost to train a family physician who is an international medical graduate is $583,253 less than a family physician who is a U.S. medical graduate. In other words, the cost to American society of an international medical graduate is about half that of a U.S. medical graduate.

Non-physician providers. Nurse practitioners and physician assistants are far less expensive to train than physicians. The typical NP or PA training consists of 4 years of undergraduate training plus 2 years of NP/PA training. The costs to become an NP or PA is approximately $84,598 after college (tuition and living expenses) and the total cost including college is $282,822. In other words, the cost to train a family practice NP/PA is only one-fourth of the cost of training a family practice physician. Given that NPs and PAs increasingly have a similar scope of practice as physicians, from a societal standpoint, it will be a lot less expensive to train an NP or PA than it is to train a physician to do the same job. The implication is that NPs and PAs will replace many physician jobs in the future.

Repairing broken physicians. In a meeting I was recently attending, a question was asked whether we have different standards for terminating physicians with behavioral problems or substance abuse than we do for terminating other health care workers for the same problems. The reality is that I think we probably do and part of this is because of the enormous societal investment in those physicians. To create an analogy, if you have a broken handle on a screw driver that cost $2, you buy a new screw driver and don’t pay the cost of repairing it. On the other hand, if you have a broken handle on an airplane that costs $1.2 million, you repair the handle rather than throwing out the entire plane. If society invests $1.2 million to create a physician who then develops alcoholism, one can make the argument that hospitals have a societal obligation to first attempt to cure the physician and return him or her to practice when/if safe to do so rather than permanently end that physician’s career. Like it or not, hospitals will often put broken physicians on leave and attempt to rehabilitate them for infractions that would result in an unskilled employee being terminated – it is not necessarily fair but it is an economic reality. On the other hand, if an airplane has a critical mechanical flaw that puts it in continuous danger of crashing, you decommission that airplane – physicians with critical flaws should similarly be decommissioned.

Discussions about the cost of training physicians usually center around the cost to the individual physician and often stop at the average debt of a graduating medical student. But beyond medical student debt, there is a much larger cost that is not paid directly by the doctor but is paid more broadly by the institutions that provide scholarships, by the citizens who pay state and federal taxes, by direct salary costs of residents who cannot bill for their services, and by the indirect costs to hospitals to train residents.

July 11, 2019