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

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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.

 

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

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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.

New Study Suggests Gender, Race, And Age Gap In Responsible Use Of OTC Medications

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Millions of Americans use over-the-counter medicines; in fact, about 35% of Americans use OTC medications on a regular basis. A recent national survey of 2,038 U.S. adults suggests that many Americans are not in touch with the risks associated with OTC medications, and don’t feel compelled to review OTC drug facts labels carefully. As I have discussed on this blog previously, excessive medication use (regardless of whether they are prescription or OTC) can be dangerous.

Some of the survey’s key findings include:

  • 2 in 5 respondents believe that OTC dosing instructions are suggestions, not directions
  • While all age groups find it important to read the label on OTCs they are taking for the first time, significantly more millennials say it is still important to read the label on OTCs they have taken before (82%), whereas only 54% of older Americans over age 70 agree
    • 75% of those over age 50 believe that it’s not possible to overdose on an OTC medication
    • 25% of respondents feel it’s ok to not read the drug facts label if they’ve taken the medicine before

On the brighter side, some consumers are doing a little better than others at taking OTC medicines as directed and these differences are very apparent if we look at age, gender, and ethnicity.

For instance, the survey revealed that more women believe it’s important to read an OTC label than men (81% compared to 62%), and that African Americans and Hispanics are more likely to know active ingredients (72% and 66% respectively) than Caucasian (58%) consumers. Perhaps most surprising: younger generations (ages 18-49) seem to be more aware of the risks of OTC overdosing than older generations, while ethnic minorities are more likely to read an OTC label a second time than Caucasians.

The results of this survey are driving a new “Every Label, Every Time” campaign by Johnson & Johnson Consumer Healthcare, McNeil Consumer Healthcare Division in an attempt to raise awareness of OTC appropriate use. I applaud them for continuing to educate on the appropriate use of OTC medicines, and I sincerely hope that we can shift our culture from casual to conscientious when it comes to drug consumption as a whole.

To that end I hope you’ll join me in encouraging everyone to be careful with their medicines and read every label, every time.

Disclosure: Dr. Val Jones is a paid consultant for McNeil Consumer Healthcare Division.

How Are Medical Personnel Involved In Search And Rescue Missions?

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This is another post derived from a presentation given at the 2011 Annual Summer Meeting of the Wilderness Medical Society. Aaron Billin delivered an excellent lecture on search and rescue.

Search and rescue has been defined a few different ways. Two definitions are: “the use of available resources to assist persons or property in potential or actual distress” and “an operation to retrieve persons in distress, provide for their initial medical or other needs, and deliver them to a place of safety.” Search and rescue types are mountain rescue, combat search and rescue, air-sea rescue, urban search and rescue, and ground search and rescue.

Organized search and rescue is the responsibility of national arks, state parks, county sheriffs, state conservation officers, or state police. Most search and rescue missions are carried out by volunteer groups. Ninety percent of all rescues involve Read more »

This post, How Are Medical Personnel Involved In Search And Rescue Missions?, was originally published on
Healthine.com by Paul Auerbach, M.D..

Virtual World Hopes To Find Path To Real Participatory Healthcare

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One of the best initiatives in social media and healthcare I’ve recently seen is definitely the Radboud REshape Academy.

Finding for our path to migrate into real participatory healthcare we come across a lot of interesting people, information, innovations and most of all questions.

Right from the beginning we started to share, with our network. We have been doing this with our conferences, our research, our lectures and through field trips made to our Radboud REshape & Innovation Centre for HC institutions, insurers, government and other people interested in changing healthcare. And of course our Innovation Centre.

In setting up The Radboud REshape Academy (@REshapeAcademy on twitter) we would like to create Read more »

*This blog post was originally published at ScienceRoll*

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