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

Academic Medicine Medical Education

Lessons From The 2022 Fellowship Match

NOTE: This post is about the various fellowship matches that were held between May 2021 and January 2022 for various fellowships starting in July 2022. For a post about the internal medicine and pediatric subspecialty match released November 2022 for fellowships beginning in July 2023 click here

This month, the National Resident Matching Program (NRMP) released the results of this year’s match for fellowships that will begin in July 2022. Match day for most subspecialty fellowships was in December 2021 although some subspecialties had their match day earlier in the year. The new report summarizes the results of these match days.

The process for physician training begins with medical school graduates entering a residency in a specific specialty such as internal medicine, pediatrics, obstetrics & gynecology, or surgery. After completing residency, physicians can do further subspecialty training in fellowships. For example, cardiology is a subspecialty of the specialty of internal medicine. Therefore, to become a cardiologist, a physician first completes an internal medicine residency and then completes a cardiology subspecialty fellowship. Some subspecialties have their own subspecialties. For example, a physician completing a cardiology subspecialty fellowship can go on to do an even more specialized subspecialty fellowship in cardiac electrophysiology.

In the match, physicians who are either in their final year of residency or have already completed residency apply to fellowship training programs. The physician applicants then rank the training programs in order of their preference and the fellowship training programs also rank the applicants in their order of preference. The NRMP computers then assign each applicant to a specific training program using an algorithm that matches the applicant’s preferences with the training programs’ preferences. Overall, the process works and ensures that the applicants get into their most preferred training program that will accept them.

Every spring, the NRMP releases an annual report of the data from the match and by examining the data, there is a wealth of conclusions about the current state of the various subspecialties.

More physicians are specializing

From 1995 to 2000, the number of fellowship positions as well as the number of physicians applying to fellowships fell. However, since 2000, there has been a steady increase in both the available fellowship positions as well as the number of applicants for those positions. This year, 13,586 physicians applied for 12,571 fellowship positions. The majority of applicants were U.S. MD degree graduates (7,141), followed by non-U.S. citizen graduates of international medical schools (2,619), U.S. DO degree graduates (1,991), and U.S. citizen graduates of international medical schools (1,791).

The number of fellowship positions has been increasing faster than the number of resident positions. Over the past 2 decades, resident positions have increased by 74% from approximately 20,200 in 2000 to 35,194 in 2021. During that same time period, fellowship positions have increased by 558%, from approximately 1,900 in 2000 to 12,571 in 2022. In other words, resident positions have not quite doubled in the past twenty years whereas fellowship positions have increased by 5.5-fold.

Internal medicine subspecialties account for the largest number of fellowship positions. 49% of the 12,571 fellowship positions were in internal medicine subspecialties, followed by pediatrics (14%), surgery (7%), and radiology (7%). The penetration of subspecialty fellowships varies between different specialties. For example, there were 1,137 resident positions offered in radiology in 2021 (the most recent year resident data is available) and 869 fellowship positions offered in radiology in 2022. Therefore, there were 0.76 radiology fellowship positions for every 1 radiology resident positions. If all resident and fellow positions were filled, then this would imply that 76% of radiology residents go on to do radiology subspecialty fellowships. Similarly, this analysis would estimate that 69% of internal medicine residents do fellowships whereas only 13% of physical medicine & rehabilitation residents do fellowships.

The number of foreign medical school graduate applicants fell

In recent years, the number of all types of applicants for subspecialty fellowships have been increasing. For the 2022 year, the number of non-U.S. citizens graduating from international medical schools (foreign medical graduates) decreased for the first time from 2,332 in 2021 to 2,280 in 2022. All other types of fellowship applicants increased in number in 2022. One of the main reasons for the decrease in foreign medical graduates was the COVID pandemic that resulted in immigration and travel restrictions that prevented many foreign applicants from coming to the U.S. for medical training.

Non-U.S. citizens who graduated from international medical schools make up a minority of physicians who match in most subspecialties. However, in subspecialties that are less popular with U.S. MD degree graduates, foreign medical graduates comprise the largest percentage of matched positions. Four subspecialties had more foreign medical graduates than U.S. MD degree graduates filling fellowship positions: adult endocrinology (40.4%), adult nephrology (35.8%), adult pulmonary (26.1%; note that there are relatively few positions available for adult pulmonary-alone fellowships and most positions are for combined pulmonary & critical care medicine), and medical genetics (52.2%).

U.S. DO degree graduates (osteopathic school graduates) have historically comprised the smallest number of subspecialty fellowship applicants but now exceed the number of applicants who are U.S. citizen graduates of foreign medical schools. Because of the traditional emphasis on musculoskeletal elements of disease and rehabilitation, osteopathic graduates tend to gravitate to certain subspecialties. Those with more than 20% of filled positions going to U.S. DO degree graduates include: pain medicine (21.5%), emergency medicine services (27.2%), global emergency medicine (22.7%), hospice & palliative medicine (20.7%), brain injury medicine (27.3%), spinal cord injury medicine (35.3%), and sports medicine (36.6%).

Highly competitive subspecialties

The more applicants (particularly U.S. MD degree graduates) there are per subspecialty fellowship position is a marker of how competitive that subspecialty is. Those subspecialties with more applicants than available fellowship positions are highly competitive whereas the subspecialties with more fellowship positions than applicants are less competitive. The 2022 NRMP fellowship match report reveals that some subspecialties are for more competitive than others. Overall, the average subspecialty fellowship filled with 51% U.S. MD degree graduates. The results listed below are the subspecialty fellowship positions that filled with more than 70% U.S. MD degree graduates:

  • Obstetrics & Gynecology. Overall, the subspecialties of OB-GYN are the most competitive of all major specialties: complex family planning (100%) filled all available positions with U.S. MD degree graduates followed by gynecologic oncology (94%), reproductive endocrinology (90%), maternal-fetal medicine (88%), pelvic & reconstructive surgery (79%), and minimally invasive gynecologic surgery (73%).
  • Surgery. Highly competitive subspecialties include: pediatric surgery (95%), hand surgery (85%), colon & rectal surgery (80%), and thoracic surgery (71%).
  • Pediatrics. Three of the 17 pediatric subspecialties were highly competitive: adolescent medicine (77%), child abuse (70%), and pediatric hospital medicine (70%).
  • Internal Medicine. Only hematology (85%) was highly competitive. However, relatively few physicians do a hematology-only fellowship (14 positions) and the vast majority do a combined hematology/oncology fellowship (663 positions).
  • Emergency Medicine. Medical toxicology (74%).

A second marker of competitiveness is the percentage of available fellowship positions in each subspecialty that fill with any applicant, including U.S. MD degree graduates, U.S. DO degree graduates, U.S. citizens graduating from international medical schools, and foreign medical graduates. Below are the subspecialties that filled more than 90% of their available fellowship positions:

Unpopular subspecialties

As in past years, some subspecialties are less popular. Those that filled with fewer than 40% U.S. MD degree graduates were mostly subspecialties of internal medicine and pediatrics:

  • Internal Medicine. The least competitive subspecialty was pulmonary disease (16%). However, relatively few physicians do a pulmonary-only fellowship (25 positions) and the vast majority do a combined pulmonary & critical care medicine fellowship (721 positions). Other unpopular subspecialties included nephrology (20%), geriatric medicine (20%), heart failure & heart transplant (27%), endocrinology (32%), infectious disease (38%), interventional pulmonary (38%), and oncology (38%). However, like hematology-only fellowships, there are relatively few positions in oncology-only fellowships (8) and most positions are in combined hematology & oncology (663) which was a considerably more popular subspecialty.
  • Pediatrics. The least popular pediatric subspecialty was infectious disease (20%) followed by developmental & behavioral pediatrics (29%), endocrinology (30%), and nephrology (32%).
  • Physical Medicine & Rehabilitation. Spinal cord injury medicine (32%).

Below are the subspecialties that filled fewer than 90% of there available positions with any applicant including U.S. MD degree graduates, U.S. DO degree graduates, U.S. citizens graduating from international medical schools, and foreign medical graduates:

Nephrology, endocrinology, and infectious disease remain unpopular

In both internal medicine and pediatrics, nephrology, endocrinology, and infectious disease are among the least popular subspecialties. One of the reasons that infectious disease and endocrinology remain unpopular is salary. According to the 2021 Medscape Physician Compensation Survey, the average general internal medicine physician had an income of $248,000 last year. However, despite requiring two additional years of subspecialty fellowship training after internal medicine residency, adult endocrinologists and infectious disease physicians made less than general internists at $245,000 for both subspecialties. It is difficult to justify investing two additional years into training in order to make less money than if you had gone straight into clinical practice after completing residency. A second physician salary survey is done by Doximity. Like the Medscape survey, Doximity also found that endocrinologists and infectious disease specialists have incomes less than general internists. In addition, the Doximity survey reports salaries for pediatric subspecialties and like their adult counterparts, pediatric endocrinologists and pediatric infectious disease specialists have a lower income than general pediatricians.

The Medscape survey also asks physicians if they feel they are adequately compensated – infectious disease physicians and endocrinologists are the least satisfied with their compensation at 44% and 50% of survey respondents satisfied respectively. The salary disparity has been particularly acute for infectious disease physicians who over the past two years of the COVID pandemic have been among the most over-worked physicians of any specialty. In other words, the message that internal medicine and pediatric residents hear is to go into infectious disease is to train longer, work harder, and get paid less.

The reasons for nephrology continuing to be unpopular are less clear. Nephrologists have a higher annual income than general internal medicine physicians with an average of $311,000 per year. However, this is less than other procedural internal medicine subspecialties such as pulmonary medicine, critical care medicine, cardiology, and gastroenterology. One of the primary clinical activities of nephrologists is overseeing dialysis. Most patients with end-stage renal disease receive hemodialysis three days per week, either Monday-Wednesday-Friday or Tuesday-Thursday- Saturday. Because of this schedule, nephrologists typically have a 6-day workweek to cover dialysis with a 1-day weekend (Sunday) whereas other subspecialties typically have a 5-day workweek with a 2-day weekend. It is possible that the longer workweek attendant to nephrology could be discouraging physicians from entering the subspecialty.

Geriatrics continues to be an unpopular subspecialty. Unlike many of the other fellowships, a physician can do either an internal medicine or a family medicine residency prior to a geriatric medicine fellowship. Salary is one of the barriers to applicants. Geriatric medicine requires a 1-year fellowship and most geriatricians practice primary care medicine for people over age 65. There is no additional compensation in terms of RVUs for caring for older patients and many of these patients have multiple concurrent medical problems as well as cognitive impairment. As a result, it can take a geriatrician longer for an outpatient visit while getting paid the same amount that a primary care internist or family physician would be paid for an office visit for a younger, less medically complex patient. Thus, the economics of geriatric medicine discourages family physicians and internists from entering the subspecialty.

So, what does all of this mean?

As fewer physicians go into specific subspecialties, there will likely be shortages of those subspecialists in the future. The pediatric subspecialties of endocrinology, infectious disease, and nephrology had a lowest percentage of available fellowship positions fill and will therefore face physician shortages in the near future. However, I believe that the most serious future shortage will be in adult nephrology. Pediatric subspecialists are relatively small in numbers and almost always located in large referral pediatric hospitals. On the other hand, adult nephrologists are needed in most community hospitals and any town large enough to have an outpatient dialysis center.

The number of unfilled subspecialty fellowship positions is even larger for geriatrics. However, general internal medicine physicians and family physicians can more easily fill in for shortages in geriatricians. Therefore, shortages of physicians trained in geriatrics will not be felt as severely by most communities.

For capitalism to work in medicine, supply and demand have to be unconstrained so that when the supply of a subspecialty falls, demand for that subspecialty can bring the supply back up through free market forces that increase the pay for those subspecialists. The U.S. system for paying physicians has led to an uncoupling of supply and demand. Unless health policy changes the way that subspecialists such as endocrinologists, infectious disease specialists, and nephrologists are compensated, we will be facing an increasing shortage of these physicians in the future. In the meantime, if your hospital has one of these subspecialists who is a high-performer, treat him or her well – they are becoming a very rare breed.

March 30, 2022

Medical Education Procedure Areas

How To Interpret Pulmonary Function Tests

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

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


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