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

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.

 

 

When All You Have Is A Hammer: The Problem With Outsourcing Primary Care To Non Physicians

Image Credit: Dan Page, Boston Globe

What is the US going to do about our current and future primary care physician shortage? Many believe that the solution is to expand the scope of nursing practice, and license non-physicians (such as naturopaths) to practice medicine. In the face of scarcity, 17 states have licensed naturopaths to provide primary care and nurse-led, in-store pharmacy clinics are gaining popularity.

Studies have shown that nurse practitioners are as capable as physicians at treating common primary care complaints such as strep throat and headache. What studies have NOT shown is that nurse practitioners recognize and diagnose less common diseases with similar symptoms. What if the strep throat were throat cancer? What if the headache were meningitis? Substituting practitioners with half the training and experience of an MD comes at a price. And that price may include missed diagnoses, delay of appropriate treatment, and life threatening consequences.

But the lure of cost savings cannot be ignored. Nurses are paid less to practice primary care, so in theory we could save untold millions each year by having patients see nurses instead of doctors. That sounds good, but now nurse practitioners are lobbying to receive the same salary as MDs for their time. After all, they’re doing the same work, right? Never mind that everyone they treat must be squeezed into a limited set of diagnosis codes – when all you have is a hammer, then everything starts looking like a nail. “Poof” goes the savings, while care quality standards are permanently reduced by forced limitations on differential diagnoses.

A better solution would be to find ways to extend physician reach and expertise with telemedicine platforms, longer patient visit times, and by reducing their non-clinical practice burden. Nurses and ancillary providers are valued members of the clinical team who are dearly loved by patients and doctors alike, but they simply do not have enough training to be ruling out tens of thousands of rare diseases and conditions. This is why we need physicians at the helm of the clinical team – to  make sure that patients are on the right treatment pathway.

Some nurses cry “prejudice” when physicians suggest that MDs provide better primary care. But we all know that knowledge and experience are a critical asset when lives are at stake. As the research results begin to roll in regarding better patient outcomes under the care of physicians versus nurse practitioners, common sense tells us that outsourcing primary care to the less qualified will have undesirable consequences for some. And if you choose to get your primary care from a naturopath or nurse, you’ d better hope that headache isn’t anything serious. Because a little savings now could cost you your life.

50 Percent Of Physicians Disagree With AMA’s Soda Tax Endorsement

The American Medical Association (AMA) voted today to endorse taxation of sugary beverages as a means to raise money for anti-obesity programs. Interestingly, a recent physician survey at Medpage Today suggests that only 50% of physicians think that a soda tax is an effective public health strategy.

I am one of the 50% who feels that this policy will not be effective. In short, this is why:

1. You can become obese by eating and drinking almost anything in excess. Targeting sugary beverages is reductio ad absurdum. Did America become fat simply because of an excess supply of sugary fluids on grocery shelves? What about the super-sizing of our food portions, the change in workforce physical requirements, the advent of cars, escalators, healthy food “deserts” in poor neighborhoods, video games, and cutting gym class from schools?

Holding Coca Cola, et al. responsible  for our own over-consumption of  calories is both unfair and tantamount to spitting into the wind – something bad is going to come back at us. Consumers can easily get around the soda tax by buying sweet alternatives – which may have even more calories than soda. (Caramel latte anyone?) And then what? Are we really going to play public policy, food and beverage whack-a-mole?

Carmelita Jeter's Shopping Cart

2.  You can be thin and fit while eating and drinking almost anything. Obviously nutrition science has shown that a diet rich in fresh fruits and veggies, lean meats, low-fat dairy, whole grains, and healthy fats is the best for our health. However, please consider that the world’s fastest woman, Olympian Carmelita Jeter, eats Hostess cup cakes, Teddy Grahams, Welch’s grape juice, whole milk, and Gatorade. How do I know? Because she posted a photo of her shopping cart on Twitter (see image to the left). I obviously have no idea how much of this she eats – or when she eats it – but if the world’s fastest woman is powered (to some degree) by “Twinkies” then I think we should all think twice about demonizing certain foods/beverages in our anti-obesity fervor.

3. You can’t regulate good behavior. Human behaviors that may lead to obesity are simply too complex to regulate. Who would want to live in a world where government becomes the de facto “Nutrisystem” for its citizens, mailing out pre-packaged, ingredient-controlled meals to 312 million people per day, three times a day, seven days a week?  While that may save the post office from its imminent demise, we can neither afford to do that, nor do we need to.

People who believe that policy should drive behavior point to smoking bans that have cut down on smoking rates. While I agree that small improvements have been made in reducing smoking rates, roughly one in four people still smoke (depending on your source, this number could be as low as one-in-five), and one in every five deaths is still attributed to cigarette smoking. Hardly a resounding victory, alas.

But beyond the fact that policy changes (and the billions we’ve spent enacting and enforcing them) have resulted in a disappointing decrease in smoking rates, is the issue that cigarettes and food ingredients (such as sugar) are not analogous substances. While there is no safe minimum amount of cigarette smoke, our bodies need salt, glucose, and fat to survive. They cannot be cut out of our diet completely – nor should they. And the only way to force people to optimize their intake is to enact Draconian measures.

So instead of starting a food-fight, it’s important to accept the complexities associated with this particular health scourge and promote a broader, more-nuanced approach to wellness incentives. We have to attack this problem from the ground up, because a top-down approach requires our government to become an invasive, food and exercise nanny.

The good news is that one-third of Americans are not overweight or obese, despite our current “toxic” food/inactive lifestyle environment. Perhaps these thinner folks can be ambassadors for the rest of us, and reveal their secrets of healthy living despite our current limitations. Even with our best efforts, we need to understand that (like smokers) we will always have a segment of the population that is overweight or obese.

And as for the Olympians among us – they help to illustrate that obsessing over every morsel of food or cup of soda that we consume is not the way forward. Sorry AMA, I’m with Carmelita on this one.

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Which Doctors Use More Digital Widgets? Hint: The Same Ones Who Play(ed) Video Games

This news flash from the land of no surprises… The Journal of The American Medical Informatics Association recently published a study analyzing physician use of online technology. They hypothesized that certain types of physician specialists (such as dermatologists?) would display higher adoption rates of Internet-based communication technology (including things like social media platforms, podcasts, health apps, and widgets). But instead they discovered that adoption of these technologies was correlated with male gender, younger age, and practicing medicine in an academic hospital setting. In other words, young geeky dudes are the ones who are most likely to use techie medical widgets. Who’d have guessed?

All kidding aside (and in case you hadn’t noticed, I’m a middle-aged, female physician who does not practice medicine in an academic setting. I have a blog, a podcast show, and was recently rated one of the top 10 MDs to follow on Twitter – so I must be a serious, category-blowing geek), this does have implications for healthcare. First of all, according to the US Department of Labor, ~80% of family healthcare decisions are made by women, and we consume a disproportionate amount of healthcare resources too. So in my opinion, healthcare technologies should be built by/for women and marketed to them more aggressively. Because if we’re trying to drive adoption of these things to streamline care, facilitate access, and reduce utilization, then we’ve gotta get the ladies on board too.

This study only confirms to me that we’re not there yet – guys are still more likely to use health apps/widgets, etc. But just as “progress” has been made in the video gaming industry (where only 12% of gamers were girls in 2001, that has grown to 40% in 2009) I think we can make similar gains in healthcare. And it’s for a much better cause than “getting really good at playing Grand Theft Auto.” Health apps have the potential to help people manage their diseases and conditions, avoid unnecessary trips to the doctor, and get them to the right healthcare provider at the right time.

So all you geeky (I say that with the utmost respect as a geek myself of course), male software developers out there – please befriend a few female physicians and work with us to get the tech trends moving in the right female direction. We’re all together in this game of life, right? 😉

Medicare’s Use Of Claims Data: Finding The Outliers

I have opposed Medicare’s use of claims data to evaluate the quality of medical care. Quality medical care is the goal that must be achieved. However, no one has described the measurement of quality medical care adequately.

Physicians recognize when other physicians are not performing quality medical care. Physicians recognize when another physician is just testing and performing procedures to increase revenue.

These over testing physicians are a small minority of physicians in practice.

Quality medical care is not about doing quarterly HbA1c’s on patients with Diabetes Mellitus. Quality medical care is about helping patients control their blood sugars so their HbA1c becomes normalized. It is about the clinical and financial results of treatment.

The clinical and financial results depend on both patients and physicians. Patients must be responsible for Read more »

*This blog post was originally published at Repairing the Healthcare System*

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