Category: Uncategorized

For decades, physicians have relied on evidence-based guidelines for preventive health measures. The recent changes to the Advisory Committee for Immunization Practices (ACIP) indicates that the CDC vaccination recommendations will now be opinion-based guidelines. The Committee has been completely reconstituted with all-new members who share United States Secretary of Health and Human Services Robert F. Kennedy Jr.’s vaccine skepticism. Initial indications are that the Committee will not be incorporating results of randomized controlled vaccine trials but rather will be starting from a premise that vaccinations are inherently harmful. As a result, future ACIP recommendations and CDC guidelines that then adopt the ACIP recommendations will likely look very different than current recommendations and guidelines with elimination of some recommended vaccines altogether and elimination of certain patient populations to receive other vaccines.

Until now, most physician professional organizations have adopted the ACIP recommendations (and thus the CDC guidelines) for use in clinical practice. Consequently, hospitals and physicians have incorporated the ACIP recommended vaccination schedule into their electronic medical records to trigger alerts and reminders to practitioners about which of their patients are due for various vaccinations. With the impending divergence between the ACIP vaccination recommendations and vaccination guidelines from physician professional organizations, it will be necessary for hospitals and doctors to decide which of these different vaccination guidelines to incorporate into their own clinical practice.

Clinical practice guidelines often use medical jargon and can be confusing for laypeople to understand. Thus, most Americans rely on their own physician’s recommendations when it comes to screening tests, vaccinations, and other preventive health measures. This will be especially true if the public loses trust in the Federal government’s guidelines when those guidelines come under fire from public health authorities and medical professional organizations. When asked “Who do you trust?”, most Americans will say that they primarily trust their own physician.

What are the U.S. physician professional organizations saying?

The good news is that for children, the American Academy of Pediatrics (AAP) publishes its own recommended vaccination schedule and the 2025 AAP vaccination schedule can be found here. Historically, the AAP recommendations mirrored the federal government’s recommendations. However, as of June 24, 2025, the AAP no longer endorses the vaccination schedule published by the CDC. The AAP determined that the newly constituted Advisory Committee for Immunization Practices was aiming to sow distrust in immunizations.

For adults, things are a bit more complicated and thus far, no one professional organization has taken responsibility to develop its own vaccination guideline. Historically, the American College of Physicians has endorsed the ACIP’s vaccination recommendations. Because the American College of Physicians is the largest professional organization of internal medicine physicians, it has been regarded as the adult equivalent of the American Academy of Pediatrics. The American College of Physicians has expressed concern about the membership of the new ACIP and the likelihood of the ACIP eliminating some vaccinations from the federal government’s vaccination guideline. However, to date, the American College of Physician has yet to indicate whether it will develop its own vaccination guideline or endorse some other organization’s guidelines.

The American College of Obstetrics and Gynecology provides recommendations for vaccinations that should be given to pregnant women. One of the first changes to the ACIP’s vaccination schedule was to drop the recommendation that pregnant women should receive a COVID vaccination. The American College of Obstetrics and Gynecology strongly objected to this decision based on published scientific studies that found that pregnant women who developed COVID were more likely to suffer preterm delivery, fetal death, maternal respiratory failure, and maternal death than women who do not develop COVID during pregnancy. Currently, the American College of Obstetrics and Gynecology recommends that pregnant women be vaccinated against influenza, pertussis (Tdap), COVID, and respiratory syncytial virus (RSV). Given the College’s public criticism of the new ACIP, it is likely that its vaccination recommendations will diverge from the ACIP’s vaccination schedule.

The American Academy of Family Physicians represents physicians who practice family medicine. Family medicine practice includes both children and adults. In addition, many family physicians also care for pregnant women. For this reason, the American Academy of Family Physicians is in a unique position to represent the constituency of all of the other three previously mentioned professional organizations. In the past, the American Academy of Family Physicians has endorsed the ACIP’s vaccination schedule. However, the president of the Academy has publicly criticized the vaccine skepticism expressed by Robert F. Kennedy, Jr. and it is likely that the Academy will not endorse the ACIP’s recommendations in the future.

The Infectious Diseases Society of America represents physicians who specialize in infectious disease. This includes both pediatric and adult infectious disease specialists. In the past, the Infectious Diseases Society of America has endorsed the CDC’s vaccination schedule. However, the president of the Society joined the presidents of the other four above mentioned professional organizations to criticize the recent wave of vaccine skepticism expressed by the leadership of the Department of Health and Human Services. To date, the Infectious Diseases Society of America has not stated which vaccination schedule it will endorse.

What about recommendations from outside the United States?

The World Health Organization makes comprehensive vaccination recommendations that are applicable to all countries. By necessity, many individual vaccinations only apply to certain regions of the world where the corresponding infectious diseases occur. For this reasons, the WHO makes recommendations for many vaccinations that are not applicable in the United States. For example, the WHO recommends BCG vaccination in countries where there is a high incidence of either tuberculosis or leprosy (i.e., not the United States). On his first day of presidency, Donald Trump withdrew from the WHO because of his opinion that the WHO mishandled the COVID epidemic. However, the WHO’s vaccination schedule recommendations are likely to be seen as less biased and more scientifically-based than the ACIP’s vaccination recommendations in the future. In other words, even though the U.S. has withdrawn from the WHO, the WHO vaccination recommendations will be more reliable than the U.S. government’s vaccination recommendations.

Because of its geographic proximity, Canada shares a similar infectious disease epidemiology to the United States. The National Advisory Committee on Immunizations makes recommendations to the Public Health Agency of Canada, similar to the ACIP’s relationship with the CDC in the United States. The result is the Canadian government’s vaccination schedule for adults and for children. Historically, Canada’s vaccination schedule has been very similar to the CDC’s vaccination schedule in the United States. As the U.S. vaccination schedule moves away from an evidence-based guideline towards an opinion-based guideline, U.S. physicians may choose to look to our northern neighbor for recommendations about vaccinations that have not been tainted by misinformation.

Other developed countries, such as Australia, the United Kingdom, and France, create their own vaccination schedules. However, specific bacterial and viral infections that are common in these countries are not always common in the U.S. Conversely, infectious diseases common in the U.S. are not always common in other countries. For this reason, there are often very appropriate differences in the recommended vaccination schedules between the U.S. and other developed countries. For example, Japanese Encephalitis is common in Japan but rare in the U.S., resulting in vaccination against Japanese Encephalitis appearing in the recommended vaccination schedule in Japan but not in the United States.

So, what should physicians and hospitals do now?

One thing is certain, if the CDC adopts recommendations from the ACIP that diverge from guidelines from U.S. physician professional organizations, then it will cause confusion and mistrust by the American public. From the layperson’s vantage point, if the CDC’s guideline differ from the American Academy of Pediatrics’ guideline, then one of them has to be right and the other wrong. When in doubt, most patients will turn to their own doctors and their own hospitals for guidance. Therefore, it is incumbent on us to decide whose vaccination schedule we are going to adopt in our clinical practices and incorporate into our electronic medical records.

I used to loathe our hospital’s clinical practice guidelines. We would appoint a group of physicians, pharmacists, nurses, etc. to develop a specific clinical practice guideline for the management of one medical condition. That work group would search the medical literature and spend hours of time that could have been used to take care of patients to instead create a guideline document that usually ended up nearly identical to similar guidelines produced by physician professional organizations. Once loaded onto the hospital’s internet site, the hospital would track the number of views each guideline had every year – frequently fewer than 20 views/year despite having thousand of doctors and nurses on staff. The reason that the hospital’s clinical practice guidelines were not looked at is that most practitioners used on-line resources such as UpToDate to guide them in the management of specific medical conditions – not the hospital’s own clinical practice guidelines. But when it comes to future recommended vaccination schedules, a hospital-created clinical practice guideline may be more important than ever before.

Hospitals should create vaccination schedule work groups now. The best people to have on these work groups are both adult and pediatric infectious disease specialists. For smaller hospitals that do not have pediatric and/or adult infectious disease specialists on staff, possibilities include partnering with referral tertiary care hospitals to adopt their guidelines or incorporating medical staff members from OB-GYN, internal medicine, pediatrics, and family medicine who have expertise in infection prevention to create the hospital’s own vaccination guideline. Alternatively, hospitals may choose to adopt vaccination guidelines from specific physician professional organizations (for example, the vaccination schedule created by the American Academy of Pediatrics). These hospital-created vaccination guidelines should be clearly communicated to the entire medical staff, including the reasons for the guideline and where the guideline can be found on-line. The recommended vaccination schedule should then be incorporated into the hospital’s electronic medical record so that practitioners get alerts for patients needing specific recommended vaccinations.

Physicians in outpatient practices affiliated with hospitals or that use a hospital’s electronic medical record can simply adopt that hospital’s vaccination guideline. Independent physician groups that do not utilize a specific hospital’s electronic medical record will need to decide whether to adopt guidelines from one of their local hospitals, adopt guidelines from physician professional organizations, or create their own vaccination schedule.

But don’t forget the legal risks

One of the important dangers of the ACIP eliminating certain vaccines from the CDC vaccination schedule is the potential for medical malpractice lawsuits if patients receive an unrecommended vaccination and then have an adverse event (whether actually related to the vaccine or not). For example, last week, the ACIP recommended that Americans not receive vaccines that contain thimerosal, a preservative used in multi-dose vials of vaccines. The reason is that some ACIP members believe that thimerosal causes autism. The relationship between autism and thimerosal has been debunked by well-conducted scientific studies but is still held by many ardent vaccine skeptics. The incidence of autism is 3.1% of American children. This means that if 100 pregnant women receive a thimerosal-containing influenza vaccination, 3 of these women will have a child with autism by chance alone (unrelated to thimerosal). These 3 women could believe they have a basis for suing the physician who ordered their flu shot and their plaintiff attorney could use the U.S. government’s position that thimerosal-containing vaccines cause autism as the foundation for a malpractice lawsuit.

This could be particularly risky for physicians who practice in states that have not enacted malpractice legal reforms. These states have considerably higher medical malpractice insurance premiums than other states. For example, the average malpractice premiums for obstetricians in Los Angeles, California (a state with malpractice reform) is $49,804/year. But if that obstetrician moves to Miami, Florida (a state without malpractice reform), his or her premium will increase to $243,988/year. Thus, the obstetrician in Florida is far more likely to get sued when one of his patients gives birth to an autistic child than the obstetrician in California. For this reason, physicians (particularly in non-malpractice reform states) should make their reasons clear for adopting vaccination schedules that differ from ACIP recommendations. This could be done using vaccination consent forms or vaccination handouts to patients.

And lastly, a short story…

Several years ago, we had a hospitalist who was a vaccine skeptic and believe that thimerosal causes autism. She was pregnant during flu season and I recommended that she get an influenza vaccine. She refused and developed influenza when she was in her eighth month of pregnancy. Because of her influenza infection, she delivered prematurely and her baby ended up in the neonatal intensive care unit after sustaining an intracranial hemorrhage. The child spent weeks in the hospital and had permanent brain damage.

The reason thimerosal has been targeted by anti-vaxxers is that it contains about 50% by weight of mercury. Thus, a thimerosal-containing vaccine has about 25 micrograms of mercury. To put this in perspective, that is about the amount of mercury in a half of a 5-ounce can of albacore tuna. Despite the fervor of anti-vaxxer’s beliefs about thimerosal, scientific studies have shown that there is no link between thimerosal-containing vaccines and autism.

Thimerosal is currently only used as a preservative in multi-dose vials of influenza vaccines. Most flu shots in the U.S. are given by single-dose units that do not contain thimerosal. In our hospitalist’s zeal to avoid thimerosal, she ended up with a child with brain damage resulting from influenza infection.

History will not look kindly on the current administration’s approach to vaccinations to prevent infection. At best, it will be viewed as a temporary but tragic period when misinformation reigned. At worst, it will be a laughing stock of future generations. As physicians, we must do what is best for our patients, even if that differs from opinions espoused by U.S. Secretary of Health and Human Services Robert F. Kennedy, Jr.

July 1, 2025

Recently, a relative mentioned that she had heard that doctors were over-diagnosing COVID deaths because doctors get paid $3,000 for every COVID diagnosis listed on a death certificate. Fortunately, she did not believe what she was being told. I personally cared for hundreds of COVID patients in our COVID monoclonal antibody infusion center and in our ICU… and I can promise you that I did not get paid an extra $3,000 for a single one of them. But misinformation abounds when it comes to falsification of COVID diagnoses. The problem is that behind every misinformation lie, there is often a kernel of truth.

 

Do hospitals get paid extra for COVID patients?

It costs a lot to take care of COVID inpatients. They have to be in a private hospital room rather than a less expensive semi-private room. They require nurses and staff to used expensive disposable personal protective equipment. They require expensive medications. And when they end up on a ventilator, they stay in the ICU for a long, long time. Because these costs are considerably higher than for inpatients with other types of respiratory infections, Congress passed the CARES Act (Coronavirus Aid, Relief, and Economic Security Act) that was signed into effect on March 27, 2020 by then-president Trump. The CARES Act created a new ICD-10 diagnosis code for COVID infection (U07.1). The Act also authorized CMS to pay 20% more per DRG for inpatients with COVID infection who are on Medicare.

As a result, hospitals do get paid more for for patients with COVID. However, Medicare specifically requires that patients must have a positive COVID test in order to diagnose COVID – hospitals cannot use diagnosis code U07.1 unless there is a documented positive COVID test within 14 days of admission to the hospital. Using code U07.1 in the absence of a positive COVID test would be considered in violation of Federal fraud laws. In other words, hospitals do not get paid more for COVID unless patients have confirmed COVID infection.

So where did the misinformation come from? In April 2020, Minnesota Republican Senator Scott Jensen stated on Fox News that hospitals get paid more if they list COVID as a diagnosis. Later that month, he wrote:

“Hospital administrators might well want to see COVID-19 attached to a discharge summary or a death certificate. Why? Because if it’s a straightforward, garden-variety pneumonia that a person is admitted to the hospital for – if they’re Medicare – typically, the diagnosis-related group lump sum payment would be $5,000. But if it’s COVID-19 pneumonia, then it’s $13,000, and if that COVID-19 pneumonia patient ends up on a ventilator, it goes up to $39,000.”

Senator Jensen’s and other people’s comments served as the kernel of truth that then morphed into the misinformation that doctors were putting COVID infection on people’s death certificates to get paid more. Additionally, the misinformation was that COVID death numbers were being blown out of proportion because doctors were putting COVID on the death certificates of people who did not really have COVID. So, what is the truth?

Every disease is coded by a unique ICD-10 diagnosis code. However, hospitals get paid by the DRG code (diagnosis related group) and not by the ICD-10 code. A DRG is the code for a number of similar diseases (each disease having its own different ICD-10 code) that are grouped together for hospital billing purposes. Medicare assigns each DRG a payment amount based on the U.S. average length of stay for those diseases and the U.S. average cost to treat those patients (including hospital personnel, supplies, equipment, medications, etc.). No matter how many days an individual patient is actually in the hospital or how much the hospital actually spends to treat that patient, Medicare pays the hospital the same amount – whatever that particular DRG is worth. As an example, DRG #177 (respiratory infection with major co-morbidity) has an average hospital length of stay of 6.9 days and the typical U.S. hospital gets paid $14,263. If a patient has a respiratory infection due to COVID, the hospital gets paid an additional 20%, or $17,116 (nearly $3,000 more). Similarly, DRG #207 (respiratory system diagnoses with ventilator support > 96 hours) has an average hospital length of stay of 14.1 days and the typical U.S. hospital gets paid $45,987. If that patient has COVID, then the hospital gets an additional 20%, or $55,184 (more than $9,000 more).

So, it is true that hospitals do get paid more if a patient is diagnosed with COVID. However, since that payment requires that the patient have a documented positive COVID test within 14 days of hospital admission, it is not possible for hospitals to falsely label non-COVID patients as having COVID for the purposes of getting paid more. Given how much sicker patients with a COVID infection are compared to other viral infections, hospitals needed that extra 20% Medicare payment just to cover their costs.

Do doctors get paid extra for COVID patients?

Unlike hospitals, physicians do not get paid based on a patient’s diagnosis. Instead, doctors are paid by the CPT code. There are 3 CPT codes for the first hospital day, 3 codes for subsequent hospital days, and 2 codes for the discharge day. Each of these CPT codes are based on the patient’s complexity and the amount of time the doctor spent taking care of the patient on that day. A level 1 CPT code is used for patients with the simplest medical problems that require the least amount of a physician’s time. A level 3 CPT code is used for patients with the most complex medical problems that require the greatest amount of a physician’s time. Most inpatients are coded as a level 2 or level 3 CPT code. In addition, there is a separate code for care of critically ill patients (those in intensive care units). It does not matter what the patient’s diagnosis is – doctors get paid exactly the same for a level 3 hospital visit whether the patient has COVID, has a bleeding ulcer, or has a drug overdose.

So, physicians have no incentive to falsely list COVID as a patient’s diagnosis in a hospital chart, on a Medicare bill, or on a death certificate.

That being said, it is true that many critical care physicians did make a lot of money during the COVID pandemic. If you have more patients on ventilators in your intensive care unit, you generate more patient bills. If you generate more patient bills, you get paid more. At the peak of the pandemic, many hospitals had to double or triple the size of their intensive care units due to the massive surge in COVID patients with respiratory failure. All of a sudden, critical care physicians had more business than they could handle and many made a lot of money (but at a cost of becoming overworked and burned out). I personally made a lot of extra income by working at our medical center’s COVID vaccination clinics on the weekends.

So, are the COVID numbers accurate?

Actually, the answer is a resounding “no“, the COVID numbers are not accurate. They are an underestimate of the true number of COVID infections and COVID deaths. Many patients with COVID infection had mild (or no) symptoms and so they did not get tested; without a test, there was no diagnosis reported to the CDC. Once home testing became available, many patients opted to test themselves; the results of those home tests are not reported to the CDC. Many patients with COVID infection died suddenly at home and if they had not been previously tested, then they were often labeled as having “death from natural causes” and the doctors could not list COVID on their death certificates since there was no way to know (or even suspect) that they had COVID.

One way of determining how many people die from a pandemic is the number of excess deaths. We can fairly reliably predict how many Americans will die each year based on how many died in previous years. When there are more deaths than expected, these are called “excess deaths”. The CDC reported that between March 7, 2020 and March 5, 2022, there were 1,105,736 excess deaths in the United States compared to the normal predicted number of deaths. However, there were only 958,864 documented COVID deaths. This means that the excess deaths for that time period were 15% higher than the number of deaths that could be attributed to COVID. It is likely that many (if not most) of these 15% excess deaths were due to undiagnosed COVID infection.

Worldwide, many counties lack the testing and access to healthcare that we have in the U.S. A report from the World Health Organization determined that in 2020 and 2021, there were 14.9 million excess deaths but there were only 5.42 million deaths documented to be due to COVID. The implication is that as many as 9.5 million people worldwide died from undiagnosed COVID.

I experienced the COVID pandemic first hand and saw it through the eyes of a critical care physician and of a hospital medical director. The conspiracy theorists who say that the infection isn’t real or that the case & death numbers have been overstated are just plain wrong. For as long as humans have studied science, there have always been science doubters and science deniers. And history has repeatedly shown that those doubters and deniers were either misinformed or were fools. The COVID era has been no different. It’s like showing a person an ocean but not being able to convince him that it is wet.

September 19, 2022

Today is Memorial Day, when Americans remember those who died during military service to defend the liberty, equality, and freedom of being an American. They were heroes. But this post is about another American hero, one who was not even in the military. This is not a post about my usual subjects: hospitals, medical economics, or electronic medical records. But it is about one small step in making the world a better place for us all to live in.

After his internship, my father put his neurology residency on hold and joined the Navy – he was stationed in Japan as a medical officer during the Korean War. His father (my grandfather) dropped out of law school to join the cavalry during World War I – he ended up riding a motorcycle to deliver dispatches to the front lines in France. Both are worthy of hero status but the hero of this story is not my father or grandfather, the hero is my grandmother.

The story begins in 1873 when my greatgrandfather was born in the Canton region of China. His last name was Jung and he adopted the Anglicized first name, Joe, when he arrived in Portsmouth, Virginia at age 12 with his uncle as immigrants to the United States seeking a better life. He eventually moved to Elberton, Georgia where he ran a laundry and became president of the Chinese Merchant’s Association of America. He married Leila Colson, my greatgrandmother and together, they raised their family in Atlanta, Georgia. Their oldest child was Jesse Ruth Jung, my grandmother, born in 1902.

Atlanta in the early 1900’s was a racially segregated community, with whites-only schools. Today, we think of racially segregated schools in terms of “white schools” and “black schools” but back then, there were white schools and non-white schools, the latter meaning anyone who wasn’t caucasian of European descent, and that included the Chinese. And so, my grandmother and her siblings were not permitted to attend Atlanta’s whites-only schools. They learned at home and had a private tutor through elementary school but Joe and Leila wanted their children to have the same kind of education that other children had.

So Joe enlisted the help of the pastor at his church and for two years, they petitioned the Atlanta Board of Education to have his children admitted to the Atlanta school system. Finally, in 1913, he succeeded and my grandmother was allowed to attend 5th grade classes. And so she became the first non-white child to attend Atlanta’s previously whites-only schools. It was not accomplished by public demonstrations, nor by a lawsuit in a Georgia court. It was done by the quiet perseverance of a mother and a father who wanted their children to have an equal education. At the time, there was an article in the Atlanta Constitution newspaper about them (my grandmother is in the center of the photo) and then the Jung’s story faded from memory.

But sometimes heroes pay a terrible price for being heroes. Although my grandmother, her brothers, and her sister were allowed to attend the whites-only school, they were not allowed to be a part of Atlanta whites-only society. It was not easy to be of mixed race in the south at the turn of the century, regardless of the specific race. As Chinese, they considered to be inferiors. They were ostracized and lived apart from the rest of the community. Joe Jung eventually died and then together, my grandmother and her siblings all agreed to change their last name from Jung to Young. They disavowed their Chinese ancestry in order to escape the prejudice and discrimination that they experienced as children and still as young adults. The Chinese heritage of the family was hidden and never again mentioned.

In fact, my father lived his entire life and died at age 55 never knowing that he was of Chinese ancestry. Eventually, all of the Young brothers and sisters died and at my grandfather’s funeral, the last surviving spouse of one of the Young siblings told the secret story that she had sworn to her husband, Ollie (my grandmother’s brother), to never tell. To their generation, their Chinese ancestery was a terrible secret that they were ashamed of. It had only brought them the pain and scorn of being considered second class. But a hundred years later, my family celebrates and takes pride in the fact that we have such a rich racial and cultural heritage.

American heroes come in all ages, both genders, and all races. And today on Memorial Day, I think about the courage of a 12-year-old girl who walked into a 5th grade classroom for her first day in a whites-only school and made a small dent in racial discrimination. It would take another 50 years before the U.S. Supreme Court unanimously ruled that school segregation was unconstitutional in Brown v. Board of Education. And it would be 60 years before another of my (more distant) relatives, President Lyndon Johnson, signed the Civil Rights Act of 1964. Ruth Jung did not want to be a hero, she just wanted to be a regular kid. But the battle that she and her family fought for her to have a normal education is at the core of what liberty, equality, and freedom of being an American really means.

May 27, 2019

Independent medical examiners are indispensable for unbiased determination of disability, life insurance eligibility, fitness for employment, and civil litigation. But suddenly, the supply of competent independent medical examiners is in peril.

An independent medical examiner is a healthcare practitioner (most often a physician) who is not involved in a person’s medical care who does a 1-time evaluation of the person to determine the person’s medical diagnoses and severity of impairment. Independent medical examiners do not prescribe medications but may do limited testing (for example, x-rays, pulmonary function tests, EKGs, etc.). Primarily, however, independent medical examiners rely on their history and physical exam as well as past medical records. Generally, the patient’s regular attending physician is not used as an independent medical examiner; there is an inevitable human tendency for physicians involved in the care of a patient to want to be their patient’s advocate, making them often biased about the person’s degree of impairment. Furthermore, the person’s regular physician often does not want to lose that person as a patient, also potentially leading to bias.

I have been an independent medical examiner on many occasions and I also review independent medical examiner reports on a regular basis as part of my role as a member of the Medical Review Board of the State Teachers Retirement System of Ohio and also in my role as an expert witness. 10 years ago, it was relatively easy to find experienced specialists to serve as independent medical examiners. After all, it generally pays better than standard Medicare rates for a one-time consult, there is no responsibility of prescribing medications or treatments, and there is no follow-up care involved (including no urgent calls from sick patients and no follow-up paperwork). The best independent medical examiners are physicians who have experience doing independent medical exams and the very best do a lot of these exams. But almost overnight, the pool of independent medical examiners has been shrinking and it is getting harder and harder to find physicians to do independent medical examinations.

The biggest reason is the internet.

If you get on your favorite search engine and type in the name of just about any physician in the United States, you can pull up all sorts of rating systems – these are equivalent to the Yelp or Tripadvisor of healthcare.

These are notoriously inaccurate. As an example, in “Healthgrades.com” and “vitals.com”, I am listed as a neurologist (my father, James N. Allen, Sr. was a neurologist at Ohio State University but died in 1980). As a pulmonologist, I do not practice any neurology.

Anyone can post a star rating on these websites, including persons who have seen a physician for an independent medical examination. If a physician does an independent medical examination for an insurance company regarding a person who is applying for disability and opines that the person is not disabled, that individual is not going to be very happy. This frequently results in vindictive rating posts.

As a consequence, many independent medical examiners who I know personally as outstanding physicians with impeccable medical judgment have some of the poorest star ratings on the internet. Increasingly, patient satisfaction scores are used by hospitals and medical practices that employ physicians as a measure of quality… and frequently as a basis for salary or bonus determination. Prospective patients searching the internet to pick out a doctor use the ratings to decide which doctor to see (just like they use star ratings to pick out a restaurant to go to for dinner). Additionally, health insurance companies use doctor rating systems in their decision making of which doctors will be included on their insurance plan and what fee rates they negotiate with the doctors.

All of a sudden, it has become hazardous to be an independent medical examiner. Too many negative reviews by vindictive disability applicants who did not get their desired disability because of chronic pain, etc. can be both publically humiliating to the independent medical examiners and can hurt them financially. One negative ratings by a person who did not get what they wanted from the independent medical examiner can be diluted out by 40 or 50 positive ratings from real patients who are getting medical care from that examiner. However, if a physician’s practice involves doing a relatively large number of independent medical examinations (for example, an occupational medicine specialist or a forensic psychiatrist), then their star ratings on the internet can suffer. Just like no chef wants to see his or her restaurant with 1 star on Yelp, no physician wants to see himself or herself with 1 star on healthgrades.com.

Last year, I was on Grand Jury duty here in Columbus. Each day, we would review dozens of cases to determine whether the County Prosecutors should proceed with trials for people arrested for crimes. Few citizens would want to be a Grand Jury member if the accused individuals could all post negative comments about their business, restaurant, or medical practice if the accused knew the names of each juror who voted to prosecute them.

So what is the solution? For fair and unbiased opinions by independent medical examiners, they cannot feel pressured, coerced, or extorted to render an opinion one way or another. However, there is virtually no way for independent medical examiners to be anonymous. Perhaps the best way is for more physicians to be independent medical examiners so that no one physician has a disproportionate percentage of posts by unhappy disability applicants who are denied their disability. But this will require us to train residents and fellows in the nuances of doing independent medical examinations, something that is currently not part of routine training in most residencies and fellowships. But for now, some of the best independent medical examiners are those who don’t Google themselves on the internet.

May 24, 2019

 

If  you are ever at an airport and see me standing in line for the plane that you are about to board, just turn around and find another flight… because something bad is probably going to happen. In-flight medical emergencies are reported to occur once every 604 flights but I have not been on anywhere near that number and I’ve been asked to provide assistance at least a half dozen times. Last month, I was flying to the American College of Chest Physicians meeting and had not one but two calls to provide medical assistance.

Somewhere over Tennessee, one of the flight attendants asked over the overhead speaker “If there are any medical personnel, please come to the front of the plane”. So, my wife and I both went up and there was an elderly woman who was unresponsive in her chair. She had a weak and bradycardic pulse and was diaphoretic. Her daughter said that she was diabetic so I handed a nurse who was on board her carry-on bag and asked her to search for a glucometer. There was a guy who was an EMS and I told him to get a blood pressure (it turned out to be normal). After a copy of minutes, she started to wake up. We never did find the glucometer but someone had a lollipop that we gave her just in case.

I moved to the seat across the aisle from her for the rest of the flight and then as we were landing, the flight attendant asked me to come see another unresponsive elderly woman a few rows up. She was traveling alone but had a medical alert bracelet that listed her medical conditions (including partial complex seizures) and medications as well as the phone number for her son. She had a strong pulse and a normal respiratory rate so I just gave her a few minutes and she started to come to but was confused, disoriented and pretty clearly post-ictal. Two sets of EMS units arrived to take the two women off of the plane. Both were OK – the first woman turned out to have a vasovagal reaction and the second patient was, in fact, post-ictal from a partial complex seizure.

Most of the time I’ve been asked to help during an air flight, it has been because of syncope or nausea; fortunately, I’ve never had to do in-flight CPR, deliver a baby, or pronounce anyone dead. So what do you do if you are called to provide medical assistance?

The first thing to realize is that you are never alone. The flight attendants can contact a emergency medicine physician on the ground who can help talk you through whatever medical problem you are faced with so you should not be afraid to help since you are going to have back-up by someone who does this for a living. The second thing to know is that every airplane doing a flight in the U.S. is required to have an emergency medical kit and these have most of the items you need for the most common in-flight medical emergencies. The kit will include:

1. Automated external defibrillator (AED)
2. Blood pressure cuff
3. Stethoscope
4. Oral airways
5. Bag-mask ventilation set
6. IV administration set
7. Saline
8. Needles
9. Syringes
10. Acetaminophen
11. Albuterol meter-dose inhaler
12. Aspirin
13. Nitroglycerin
14. Atropine
15. D50
16. Diphenhydramine (tablet and IV)
17. Epinephrine 1:1,000
18. Epinephrine 1:10,000
19. Lidocaine
20. Gloves

If you need something that is not in the kit, often some other passenger may have it in their carry-on bag so you can ask the flight attendant to make an overhead request for the equipment or medication that you think you might need.

Aircraft often fly at 35,000 feet altitude but they are pressurized to 8,000 feet. To put this in perspective, there is about 25% less oxygen per volume of air at this altitude than at sea level. For this reason I will order a high-altitude hypoxia simulation test for my patients with lung disease when they are planning air travel. In this test, the patient will breath 15% oxygen and then then an arterial blood gas or a transcutaneous oxygen saturation measurement is taken to determine if they need oxygen in flight.

But it turns out that the most common reasons for medical emergencies are just otherwise common conditions: Syncope (37%), respiratory problems (12%), nausea/vomiting (9%), cardiac symptoms (8%), seizures (6%), and abdominal pain (4%). Only 1 out of every 300 in-flight medical emergencies progress to death.

As a physician, you are not obligated to respond but most of the time, you are going to be a lot more capable of managing an in-flight emergency than a lay person. But if you don’t want to have to deal with a medical emergency during air travel, just don’t get on the same plane as me… because something bad always seems to happen when I’m aboard.

November 20, 2018