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Hardening Of The Categories: Why We Have A Shortage Of Physicians To Treat COVID-19 Patients

January 11th, 2021 by Dr. Val Jones in Health Policy, Opinion
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Because science is advancing our understanding of medicine at an exponential rate, physicians and surgeons have been turning to subspecialization as a means to narrow their required domains of expertise.  “Carving out a niche” makes sense in a profession where new research is being published at a rate of two million articles per year. Just filtering the signal from the noise can be a full time job.

However, the consequences of narrowing one’s expertise is that you lose flexibility. For example, an orthopedist who has subspecialized in the surgical management of the shoulder joint doesn’t keep her skills sharp in knee replacement surgery or other general surgical procedures that she once performed. Neurologists who focus on movement disorders become comfortable with a small subset of diseases such as Parkinson’s, but then close their doors to patients with migraines or strokes.

The continued march towards ultra-subspecialization has been a boon in urban and academic centers, but has left spotty expertise in surrounding areas and small towns. And now, the COVID-19 pandemic has unmasked the biggest downside of niche medicine: a hardening of the categories that prevents many physicians from being able to help in times of crisis. Retina specialists, plastic surgeons, rheumatologists, and radiation oncologists (to name just a few) may want to help emergency medicine physicians (EM), internists (IM), and intensivists (CCM) expand their reach as COVID cases surge and hospitals become overwhelmed. But what are they to do? They are not trained to manage airways, place central lines, or monitor renal function, and legitimately fear legal repercussions should they attempt to do so.

Medicine is fundamentally based upon apprentice-style learning – this is why we undergo years of residency training – to stand shoulder-to-shoulder with more senior experts and learn their craft under close supervision. Upon graduation from medical school, physicians are deemed ineligible to treat patients until they have practical experience under their belts. The old adage: “see one, do one, teach one” is the bedrock of how we train. So now, there needs to be a pathway available for those who have completed residency to re-train to meet the demands of this crisis and others.

Perhaps it’s a radical idea to consider pairing subspecialist physicians with current frontline COVID-19 doctors – but turfing patients to “non physician practitioners” or NPPs when access is limited to an emergency medicine specialist,  internist, or intensivist, seems to be the current plan. I believe that medical school and internship are a solid foundation for COVID management (common to all physicians), and that given a designated EM, IM, or CCM mentor, the willing subspecialists will be able to follow protocols and take on new challenges rapidly and with excellence. I hope that the government will issue more detailed “good Samaritan” type laws to protect mentors and their subspecialty partners from frivolous law suits in times of COVID (those in place are for volunteer positions only), and that the house of medicine, led by the AMA and other sub-specialty organizations, will pave the way for rapid cross-disciplinary instruction and certification.

Going forward, there should be opportunities for post-residency, mid-career physicians to complete fellowship programs outside of their sub-specialty’s usual offerings. An ophthalmologist should have the ability to spend a year studying pulmonary medicine, for example, if they want to moonlight with an ICU physician in the future. In our current system, it is very difficult to obtain a fellowship after significant time has elapsed since one’s residency training. While there are a few “re-entry programs” for physicians who haven’t practiced clinical medicine for years, there is no path established for those who simply wish to switch specialties or assist outside of their specialty in a time of crisis.

I am not arguing that a fellowship should be considered equivalent to a residency program. We may need to create a new type of physician certification that allows fellowship-trained physicians from unrelated residency programs to operate under the license of an agreeable mentor/sponsor already established in the field by virtue of medical school and residency training. This would open up employment opportunities for over-specialized physicians, while not threatening those who are residency-trained in the field. In essence, this would allow physicians to operate in the way that NPPs have been for decades, and get subspecialty physicians off the bench and into the fight against COVID and perhaps into underserved areas more effectively as well.

For those subspecialists who have become disillusioned with their field, but still enjoy medicine or surgery – their talent could be retained if there were a path to re-training. An estimated 20% of physicians would change their specialty if they could. Currently, physicians have few clinical options if they no longer wish to practice in the field in which they completed a residency. I suspect that sweeping physician burnout rates (highest among mid-career physicians) could be improved by providing opportunities for “reimagining” themselves – and course-correcting to rekindle the scientific and clinical passion that led them to apply to medical school in the first place.

This would require some mental and regulatory flexibility – which could be a good side effect of the otherwise dreadful COVID pandemic.

The Paradoxical Under-employment of Rehab Physicians During the COVID-19 Pandemic

January 9th, 2021 by Dr. Val Jones in Uncategorized
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I used to joke that for all the hardships of being a physician, at least we had job security. Little did I know that a viral illness would put some physicians “on the bread line.”

The COVID-19 pandemic has negatively impacted the physician workforce in both anticipated and unanticpated ways. While stay-at-home orders decrease temporary demand for cosmetic and elective surgical procedures by dermatologists and orthopedic surgeons, inpatient rehabilitation facilities are also feeling the squeeze, though the number of patients who need their services are growing exponentially (due to post-COVID syndromes).

In states of emergency, hospitals at (or over) capacity have the right to commandeer beds from other units within their system. So for example, if there is a unit devoted to the rehabilitation of stroke or car accident victims, the hospital might re-allocate those beds to COVID-19 patients. There is also financial incentive to do so because Medicare pays 20% higher rates to hospitals for each COVID patient that requires admission.

So what happens when the rehab unit turns into a COVID unit? A few things. First, the patients who need inpatient rehabilitation with close physician monitoring are turfed to nursing homes. Fragile stroke patients, those with high risk for neurological or cardiac decompensation, and inpatients with complex medical problems (such as internal bleeding, kidney failure, or infectious diseases) are sent to a lower level of care without suficient oversight by physicians. These patients often crash, get readmitted to the hospital, or in the worst case, decline too quickly to be saved.

Second, the physicians who take care of rehab patients (rehabilitation physicians, also known as physiatrists) hand over care of the COVID patients (in the former rehab unit) to hospitalists, reducing their own workloads substantially while the hospitalists are overwhelmed and at risk for burn out.

Third, hospitals are struggling to cut costs due to the suspension of their lucrative elective surgical pipelines during COVID surges – and put a moratorium on hiring additional physicians who would normally be assisting with growth and expansion efforts in neuromuscular, brain and spinal cord injury rehabilitation.

Finally, in some cases rehab units are experiencing low censuses not because their beds were commandeered for COVID patients, but because elective surgeries have diminished and patients are afraid of coming to the hospital. Many of those with symptoms of heart attacks, strokes, brain injuries, etc. are staying home and “gutting it out” while reversible or treatable injuries and disabilities become permanent. The devastating toll will be difficult to quantify until normal medical surveillance and care resumes.

Meanwhile, physiatrists with outpatient practices and pain management clinics are experiencing a dramatic drop in patient throughput, with telemedicine visits largely inaccessible to the poor and disabled populations they serve. Those outpatient physicians seek to augment their income with part-time inpatient work, and unprecidented numbers are seeking employment through locum tenens agencies. Unfortunately, agencies have scant inpatient jobs to offer for the reasons I discussed above, and competition is fierce among agencies and physicians alike. It’s often the case that 7 or more agencies will contact a physician within hours of a new job posting, and that job will be filled before the physician can respond – and at an hourly rate 20-30% lower than pre-COVID days (based on my personal experience).

These are some of the unexpected underemployment consequences of the COVID pandemic for one sub-specialty group: physiatry. I imagine the forces at play may be similar for my peers in oncology, neurology, or preventive medicine, for example.

One thing is for sure: emergency medicine physicians, internists, and critical care specialists are facing a tsunami of patients while others of us are sitting on the bench, wanting to help but not trained to do so, “sheltering in place” as the non-COVID march of disease and disability continues apace.

Patient Access to Medical Services Varies by Individual Physician’s Will to Fight Insurance Companies

July 3rd, 2017 by Dr. Val Jones in Health Policy, Opinion
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American healthcare reform debates are focused on strategies to provide “access” to medical services for all. Lack of insurance (or under-insurance) seems to be the primary focus, as it is falsely assumed that coverage provides access. Unfortunately, the situation is far more complicated.

Once a person has health insurance, there is no guarantee that they will receive the medical services that they need. Not because their plan is insufficiently robust, but because the roadblocks for approval of services (provided in the plans) are so onerous that those providing the service often give up before they receive insurance authorization. In my experience, whether or not the patient gets the service, test or procedure that they require often depends on the individual will and determination of their physician. And that’s something we need to talk about.

Take for example, admission to an inpatient rehabilitation facility. Brain-injured patients aren’t much different than those with broken bones. We all know that bones need to be set (or surgically repaired) right away so that they will heal correctly. The brain is very similar – once injured, it needs to be rehabilitated in an intensive, multi-disciplinary environment at the earliest chance for it to achieve its best healing. Nevertheless, insurance companies regularly deny brain injury rehab to patients in the critical healing time frame. They will approve nursing home care for them, but not the intensive cognitive rehabilitation that they need, unless the rehab physician fights an epic authorization battle that can take 10 days or more to overturn the denial of services!  Imagine if your orthopedist had to beg, lobby, and testify for 10 days to fix your broken hip (while the insurance company simply approved you go to a nursing home)? Would he or she be willing to do this? What would happen to your hip in the mean time?

The “prior authorization” process for imaging studies and non-formulary medications is also designed to wear down the providers and passively deny services to patients, thereby saving costs for the insurers. Patients don’t realize that getting an MRI might mean an hour of automated phone system “hell” for their physician, waiting to speak to an insurance customer service rep with an algorithm that determines whether or not the patient is eligible for the service – unrelated to the physician’s judgment or the particulars of the patient case. In the average American primary care practice, an estimated 20 hours per week is spent by physician and staff, attempting to secure insurance approval for necessary tests and medications.  Will your physician have the endurance to prevail? That might be the difference in diagnosing your cancer early or not.

“Oh,” but the insurance companies say, “we had to put these bumps in the road to prevent over-testing and abuse of the system.” I agree that there are some bad actors who should be identified and stopped. Think of the phony durable medical equipment providers, bilking Medicare and private insurers by prescribing unnecessary and expensive wheelchairs, scooters, and other devices. These bad apples are rare, but because of them – all the “good guys” are being hen-pecked to death just to get a walker for a patient with multiple sclerosis.

Unfortunately, there is no incentive for the private insurers to lift the pre-authorization burdens from the “good guy” physicians. Therefore, this will probably have to be achieved through legislation. With big data, it should be fairly easy to identify extreme provider outliers – and have their practices reviewed. For the rest of us, our pattern of judicious prescription of tests, services, and procedures should win us a break from the daily grind of begging, wheedling, and cajoling payers to allow us to get our individual patients what they need, every single time we order something. Until this freedom to practice medicine is achieved, true access to healthcare will not simply be a matter of having health insurance, it will be whether or not your physician has the will to fight for your needs. A “good doctor” has to be more than an excellent diagnostician these days – she must be a savvy, health insurance regulatory navigator and relentless patient advocate.  Keep that in mind as you choose your next physician!

All Physicians Should Engage In Pharmaceutical Whack-A-Mole: Please Follow Physiatry’s Lead

June 12th, 2017 by Dr. Val Jones in Health Policy, Uncategorized
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Medical school prepares physicians to prescribe medications for prevention and treatment of disease, but little to no time is spent teaching something just as important: de-prescribing. In our current system of auto-refills, e-prescriptions, and mindless “check box” EMR medication reconciliation, patients may continue taking medications years after their original prescriber intended them to stop. There is no doubt that many Americans are over-medicated, and the problem compounds itself as we age. Although “no-no” lists for Seniors (a tip of the hat to the American Geriatrics Society “Beers List”) have been published and promoted, many elderly Americans are prescribed medicines known to be of likely harm to them.

You may be surprised to learn that one medical specialty has taken advanced steps to address this problem. Physiatry (also known as Physical Medicine and Rehabilitation or PM&R) is a national leader in pain management education, and is the author and promoter of  the majority of continued medical education (CME) courses on reducing opioid prescribing in favor of alternative pain management strategies. But did you also know that most patients who are admitted to an inpatient rehabilitation facility (IRF) are tested on their capability to correctly administer their own medications before they are discharged home?

The MedBox test provides a validated cognitive performance assessment of whether or not an individual can correctly distribute multiple prescription medications into weekly pill boxes as directed on the containers. This is a short video of how the test works, demonstrated by some occupational therapists having a good time with it. In one fell swoop, this test checks vision, reading comprehension, pharmaceutical knowledge, manual dexterity, attention, and short term memory.

This test is very helpful in picking up potential misunderstandings in how prescription meds are to be taken, and identifying cognitive deficits that might preclude accurate self-administration of prescription meds at home. One of our main goals in rehab is to make sure that patients have the skills, assistance, and equipment necessary to thrive at home, so that they can remain hospital-free for as long as possible. To that end, we feel strongly that limiting medications to those only truly necessary, as well as making sure that patients can demonstrate safe-use of their medications (or have a caregiver who can do this for them), can reduce hospital readmission rates, falls, unwanted drug side-effects and accidental drug-drug interactions.

In addition to MedBox testing, physiatrists invite hospital pharmacists to join their weekly patient team conferences. While we discuss patient progress in physical, occupational, and speech therapies, we also review nursing assessments of medication self-administration competency, and ask our pharmacist(s) which medications can potentially be stopped or decreased that week. Rehab physicians (familiar with patient health status, goals, and current complaints) and pharmacists together come up with stop dates and taper regimens at these weekly meetings.

Part of the reason why inpatient rehabilitation has been so successful at reducing hospital readmission rates, in my view, is that we are committed to pharmaceutical whack-a-mole. “Test-driving” patient competency at medication self-administration, in the setting of responsible de-prescribing in a monitored clinical environment, is a highly valuable (though sadly under-reported) benefit of rehabilitation medicine. I hope that my medical and surgical peers will join us physiatrists in combating some of the patient harms that are passively occurring in our healthcare system designed to add, but not subtract, diagnoses and treatments.

Words Of Wisdom For Doctors Interested In Trying Locum Tenens Work

June 5th, 2017 by Dr. Val Jones in Health Tips, Opinion
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I receive a significant amount of email in response to my blog posts about locum tenens work. Curious colleagues (from surgeons to internists and emergency medicine physicians) ask for insider insight into this “mysterious business” of being a part-time or traveling physician. I am always happy to respond individually, but suddenly realized that I should probably post these conversations on my blog so that all can benefit.

The most common question I receive is: How do the agencies compare with one another? Followed closely by: Where should I start? There is no online rating system for this industry, and so grade-focused physicians (taught to value performance ratings) feel at a loss as to where to begin. One day I hope we’ll have a locum tenens quality website, but for now  I can offer you my N=1, “case study” experience.

I’ve been doing hospital-based, locum tenens work for 6 years in the field of inpatient rehabilitation medicine. I have accepted 14 assignments through the following agencies:

CompHealth, Weatherby Healthcare, Jackson & Coker, Medical Doctor Associates, LocumTenens.com, and All Star Recruiting

I have had extensive conversations with recruiters at the following agencies, but have not ended up taking an assignment through them:

Staff Care, Delta, Onyx, Barton Associates, and Farr Health

I have summarized my experiences in this table:

*These agencies use VMS systems.

These “data” are highly subjective, of course, but there are a few important points to be gleaned:

1. Bad clients are hard to avoid. When I give a client a “D” rating, that means a hospital or employer that is so bad, you have concerns for your medical license or don’t feel ethically comfortable with what they are asking you to do. These are nightmare assignments and must be carefully avoided. I describe my experience with one of the “D’s” here. Big name agencies (and even I on my own) can be duped into accepting bad apple clients. Since it’s hard to know which ones are truly bad (even after a phone interview), I now only commit to a short (about 2 week) initial assignment and then extend once I feel comfortable with the match.
2. There are good recruiters everywhere. Although the larger agencies pride themselves in outstanding customer service, the truth is that I have had great relationships with most recruiters at most agencies. From a physician perspective, the “customer experience” is fairly uniform.
3. Vendor Management Systems (VMS) don’t create the race to the bottom I expected. The largest agencies are strongly against automated physician-client matching software (which is essentially what VMS does) and argue that they destroy the customer service experience for both hospitals and physicians. Although I am philosophically opposed to being listed on a hospital purchase order along with IV tubing and non-latex gloves, the truth is that such matching has brought me higher-paying assignments at good quality hospitals that do not hire locum tenens physicians outside of a VMS system. I see no reason to exclude agencies who use VMS, though there is a risk of being in a larger competitive pool for each individual assignment. This means that you may waste some time before being placed, but in the end if the pay is $150% of base, then its probably worth it.
4. Boutique is not better in the locum tenens world. Unless you are in a specialty that is so small you require recruiters who can perform highly customized job matches, boutique agencies can be home to some of the most depressing assignments in America. Desperate clients who have not had success in filling positions through the (highly motivated) big agencies will turn to boutique ones, hoping that their sheer force of personality will cover for the flaws that make their hospital’s hiring difficult. I have learned to steer clear of the boutique charm offensive.
5. You can make a higher salary if you find your own job. Agencies provide significant value to physicians. They do the hard work of locating and updating job assignments, assisting with credentialing and licensing paperwork, negotiating salary and overtime, providing professional liability insurance, and handling logistics (travel/lodging booking and re-booking).  That being said, if you’re willing to do all that yourself, you can negotiate a much higher salary if you work directly with hospital HR.
6. Will “gig economics” eventually bypass the current agency model? Online job-matching sites will probably take a big chunk of market share, but won’t “own” the space because they don’t provide the logistical, legal, and credentialing services that physicians enjoy from agencies.  However, given that agency fees add about 40% costs to physician hiring, there is strong motivation to find alternative hiring strategies, and I suspect that Millennial physicians won’t mind doing extra work for higher pay. Websites like Nomad Health are suffering from limited user sign up (both on the client and worker side), but will likely reach a tipping point when a VC firm provides the marketing capital to raise sufficient awareness of the new hiring marketplace that bypasses recruiters and saves hospitals money. Until then, dipping your toes into the healthcare gig economy is easiest to do through an agency – and the big ones (CompHealth and their subsidiary Weatherby Healthcare have about 50% of the market share, followed by Jackson & Coker as the next largest) provide the largest number of options.

The bottom line is that part-time and short term physician assignments can prevent physician burnout and overwork. The pay is generally very good, and agencies can make the experience as painless as possible. Those who desire higher hourly rates can achieve them if they’re willing to take on more responsibility for paperwork and logistics.  Whether this “do it yourself” movement is enhanced by online marketplaces, or good old fashioned cold-calling to find work – physicians hold the cards in this high demand sector. I suspect that more of us will be ready to play our cards in the locum tenens space in the upcoming years, because full time medical work (at the current pace) is, quite ironically, simply not healthy.