John Schumann

More than a century of American medical history was turned on its ear last week by the announcement that the groups that accredit medical residencies will unify their standards. Don’t be too hard on yourself if you failed to understand the significance (or notice at all).

But this should be viewed as good news across the land. As someone who trains doctors from both ‘traditions,’ I certainly welcome a more level playing field.

First, a little background:

Osteopathic physicians (those with a D.O., or Doctor of Osteopathy degree) have a history dating back to the 1800s. They comprise slightly more than 10% of practicing doctors in the United States. Currently, there are 35 osteopathic medical schools, compared with 135 ‘allopathic’ institutions, the kind that confer the M.D. (Doctor of Medicine) degree.

Though historically the two educational paths varied in principles and practice, there aren’t many remaining differences. Both disciplines now use biomedical science as their core.

Originally, osteopathy relied on manipulation of bones and joints to diagnose and treat illness.

This tradition, known as Osteopathic Manipulative Treatment (OMT), lives on in the osteopathic curriculum, though it’s now mostly used as an adjunct for treatment of chronic musculoskeletal conditions. Today, most D.O.s leave OMT behind after they finish their training.

Continue reading “Why You Should Care about the New Accreditation Agreement for Osteopaths”

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Doctors are asked to sign things all the time: Prescriptions, home nursing care plans, death certificates, diabetic shoe forms.

Less frequently, hospice verifications.

Why was I asked to sign hospice orders for Mr. Taylor? Sure, he was old. Eighty-seven.

He’d survived decades of high blood pressure, two major surgeries, unintentional weight loss, chronic pain, headaches, even a benign brain tumor. But I had never referred him to hospice.

I wouldn’t have diagnosed him as “terminal,” i.e. expected to live six months or less. As far as I could tell, he’d just keep on truckin’ for another year or three.

So why was I being asked to sign hospice paperwork for him? How did this come about?

“Mr. Taylor, why are you in hospice? Are you dying?”

-Not that he knew of. He’d just been told that he’d get more ‘home services’ that way.

“Who set this up for you?”

-It was one of those “home doctors.” Geriatric care providers that offer house calls to infirm seniors when it’s too hard for them to come to a doctor’s office.

Thing is, he was still plenty able to come to my office. And did so regularly.

Apparently, though, the opportunity to get more home services was too good to pass up.

The agency that was providing him at-home medical services referred him to a for-profit hospice firm–one that could collect the daily Medicare fee for a hospice enrollee.

Is it any wonder, then, that we’ve seen a surge in hospice enrollments in the last few years?

Finally, someone has written something about it. Thank you, Washington Post.

John H. Schumann, MD (@GlassHospital) is a general internist and medical educator at the University of Oklahoma School of Community Medicine in Tulsa, OK . He is also author of the blog, GlassHospital , where this post originally appeared.

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You’re a loyal THCB reader. You have a symptom. You Google it. One of the first three hits will be an entry about the symptom or an associated condition on Wikipedia.

As an informed lay person, you wonder, “How accurate is Wikipedia for medical information?”

You’ve always been a little skeptical of Wikipedia, but over the years you’ve found it more and more reliable for celebrity tidbits (e.g. “How old is Jane Lynch?” or “What was the name of that guy in “Crash?”) and sports trivia (“How many Super Bowls have the Minnesota Vikings lost?”).

In fact, it’s become quite useful for understanding geopolitics, ancient and recent history, and helping explain science topics (Higgs Boson, anyone?).

So why not medicine?

We in academic medicine look down our noses at Wikipedia. “Show us original texts,” we harrumph. “Where does the original data come from?” we ask our residents and students.

Just like high schoolers and college kids are warned NOT to use Wikipedia as a research tool, medical professors hold the site lowly in regard to seriousness of purpose.

Well, it’s time to accept reality.

We all use it, whether we admit it or not. Some of us a lot. The good news is, Wikipedia’s going to get even better in the medical realm.

Continue reading “UCSF’s Wikipedia Experiment: Should Med Students Get Credit For Curating Medical Information Online?”

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The fall sports season is tantalizingly near; players and fans alike are gearing up for the Friday night lights and Sunday afternoon showdowns. But the season comes at a cost; every bone-jarring hit and wince-inducing header carries the risk of sustaining a concussion.

Most media coverage focuses on the National Football League’s professional players, but 65% of traumatic brain injuries are sustained by children. The majority are thought to be undiagnosed, but the Center for Disease Control estimates that 1.6 to 3.8 million sports-related concussions occur each year. This puts athletes at risk of sustaining a second concussion before their brains are fully healed, leading to longer recoveries, permanent neurological damage, and the potentially-fatal Second Impact Syndrome.

A just-released app hopes to change that. Sway Medical, founded by Chase Curtiss in 2011, aims to help health professionals objectively rate the risk of concussion at the source: on the football field or soccer pitch. On-the-spot concussion diagnosis is just the beginning, though; in the near future, the young company plans to enter the hospital space by the end of the year.

The FDA-approved app, called Sway Balance, uses proprietary software and the iPhone’s accelerometer to assess an athlete’s balance over time. In a phone interview, founder and CEO Chase Curtiss said that the app can be used by a health professional to “set up a baseline,” then “compare an athlete over the course of a season to that established norm.” Poor performance compared to baseline is indicative of a possible concussion.

Health care professionals can purchase a yearly subscription to the app for $199 – a fraction of the cost of a typical balance platform – and the patient-facing app is free to download.

Sway Medical has partnered with ImPACT Applications, an organization which Curtiss described as conducting the “gold standard of concussion testing on the market.” ImPACT uses baseline cognitive testing – verbal and visual memory, processing speed, and reaction time – and synchronous testing immediately after a hit to assess if a concussion has occurred.

“But you don’t have an element of physical control of the body,” Curtiss said – which is where Sway Balance comes in. “[ImPACT’s] interest in us is in pairing a balance test with cognitive testing.”

Continue reading “Diagnosing Concussions and Assessing Balance- On Your iPhone”

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An interesting conversation recently took place among residency program directors in my field of Internal Medicine.

At issue was the declining pass rate of first-time test takers of the ABIM Certification Exam.

It’s a mouthful to say, but the ABIM exam is the ultimate accolade for internists; one is only eligible to take the exam after having successfully completed a three-year residency training period (the part that includes “internship,” right after medical school).

An easy analogy is to say that the board exam is for a doctor what the bar exam is for a lawyer. The difference is that a doctor can still practice if s/he does not pass–they might be excluded from certain jobs or hospital staffs; but certification, while important, is a bit of gilding the lily. [Licensure to practice comes from a different set of exams.]

There’s no doubt it’s a hard test. I was tremendously relieved to have passed it on my first try. Over the last few years, the pass rate for first time takers has fallen from ~90% to a low of 84%.

It may not seem significant, but for 7300 annual test takers, the difference in pass rates affects about 365 people–or one additional non-passing doctor for every day of the year.

In any event, we program directors have taken note. And the falling pass rate has raised questions:

  • Has the test increased in difficulty? No, says the ABIM.
  • Are the study habits of millennials not up to the level of Baby Boomers and Gen X’ers? Now you may be on to something.

Continue reading “Why Are So Many Younger Doctors Failing Their Boards?”

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It was bound to happen.

By “it,” I mean that the small group of speciality hospitals (usually orthopedic or cardiology-focused) across that country that are owned by doctors were going to have their “See! We Told ‘ya so!” moment.

Doctor-owned hospitals: How many are there? Two hundred and thirty-eight of them in the whole country (out of more than five thousand)–somewhere between four and five percent of the total in the U.S. (numbers courtesy TA Henry from this excellent piece).

What are the issues?

  1. ObamaCare effectively bans doctors from owning hospitals in the U.S.
  2. Those already in existence are grandfathered in under the law.
  3. We know that doctor-owned hospitals have higher average costs–hence the rationale for banning them under a law with the intent of “bending the cost curve.”

Cue the iron-o-meter:

In the most recent Medicare data (December 2012 report on “value-based purchasing“), doctor-owned hospitals did well in terms of achieving quality milestones.

How well?

Really well. Physician-owned hospitals took nine out of the top ten spots in the country. And in spite of their low relative number, forty-eight out of the top one hundred.

Continue reading “Doctors and the Means of Production”

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Lost in the weeds of President Obama’s budget proposal is a 10-year, $11 billion reduction in Medicare funding for graduate medical education (GME). GME is the “residency” part of medical training, in which medical school graduates (newly minted MDs and DOs) spend 3-7 years learning the ropes of their specialties in teaching hospitals across the country.

Medicare currently spends almost $10 billion annually on GME. One-third of that is for “Direct Medical Education” (DME), which pays teaching hospitals so that they in turn can provide salaries and benefits to residents (current salaries average around $50,000/year, regardless of specialty; there are variances by region). No problem there.

The proposed cuts come from the Medicare portion known as “Indirect Medical Education” (IME) payments. Though IME accounts for two-thirds of the Medicare GME pie, it’s not easy for hospitals to itemize what exactly it is they provide for this significant amount of funding. Instead, hospitals bill Medicare based on a complex algorithm that includes the ‘resident-to-bed’ ratio, among other variables.

A 2009 Rand Corporation study commissioned by Medicare to evaluate aspects of residency training called on the government to tie IME payments directly to improvements in educational and hospital quality, lest the money be perceived to be going down a series of non-specific sinkholes. That idea has caught on, and legislators in both parties now see the healthy IME slice of Medicare education funding as a plum target for cost-cutting, as the direct benefits are difficult to enumerate, let alone quantify.

This has medical educators very worried that we will have to do more with much less (disclosure: I am one).

Continue reading “Will Your Health Insurer Pay to Train Your Doctor?”

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As a proponent of responsible DIY medicine, I love the idea put forth by Alex Beam in a column he wrote exploring the idea of writing your own obituary.

[The cynics chime in: "That's where you'll wind up if you try to "do" medicine yourself."]

Former Surgeon General C. Everett Koop, who died in February, had his obituary in the NY Times initially inked in 1996, more than a decade before he actually died.** Since he was a figure of historic importance, we can’t blame the paper for being well-prepared.

Folks interested in the do-it-yourself approach won’t likely need to go to such lengths to create their own obituaries. Columnist Beam gives a couple of great examples of folks that have made good on such efforts:

Continue reading “How to Write Your Own Obituary”

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Readers know that I am skeptical of medical practices that defy logic, or as we say in the business, evidence. Among the most controversial issues that beguile all of us (patients and docs) is this business about the PSA test.

A loyal reader sent me a doctor-written column with the provocative headline “My Patient, Killed by The New York Times.”

First, keep in mind that the website that posted this, Mediaite, is all about the media covering (really fawning and dishing) itself. The purpose of this story, with its provocative headline, sad outcome, and mea culpa tone, is to generate “buzz.”

Then understand that this is a story of one patient who made an informed decision to forego PSA testing, based on the fact that he was an intelligent person without symptoms who’d read the literature (or at least responsible press coverage of said evidence). He did not want to open the Pandora’s Box (literally: crapshoot) that is PSA screening.

Yes, he wound up with advanced prostate cancer and subsequently died. Had he had his prostate removed or radiation to ablate his cancer, and wound up with horrible side effects (impotence, incontinence) would he value the trade-off?

I offer you the counter-anecdote of Ted, who in a discussion with me, insisted that he get a PSA test because his heroes Joe Torre and Norman Schwarzkopf told him to. When it came back at 4.10 ng/dL (threshold 4.00), he went for biopsy (what else to do?) which showed low grade, gland-confined prostate cancer. Fearful of the “C” word, he couldn’t live with the idea of doing nothing (“watchful waiting”) about his cancer. So he chose external beam radiation, with the hope that it would be less damaging than radical surgery.

Continue reading “Killed by The New York Times?”

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Cause of death on this 1937 death certificate? “Senile gangrene.”

I’ve always had nagging doubts about filling out death certificates.

An excellent article in the trade paper “American Medical News” by Carolyne Krupa explores the “inexactitude” of the custom.

As Krupa points out, doctors are never taught how to fill out the documents. She quotes Randy Hanzlick, MD, chief medical examiner for Fulton County, GA:

“Training is a big problem. There are very few medical schools that teach it,” he said. “For many physicians, the first time they see it is when they are doing their internship or residency and one of their patients dies. The nurse hands them a death certificate and says, ‘Fill this out.’ ”

That’s pretty much how it works. Though sometimes the person that comes calling with the death certificate is a hospital clerk. And she will make you fill out the form carefully, using only ‘allowable’ causes of death.

Of course, everyone dies from the same thing:lack of oxygen to the brain. But you can’t list that. Nor can you list common “jargon-y” favorites like “cardiopulmonary arrest,” “respiratory failure,” “sepsis,” or “multi-system organ failure.” All of which are true, but too inexact to be useful.

It’s intimidating to be the one to “pronounce” someone dead, and be the final arbiter of the cause. Isn’t that why we have medical examiners/pathologists?

We don’t autopsy patients much anymore, a trend that concerns many in the industry but doesn’t seem likely to change. That leaves interns and residents (at teaching hospitals) and community docs (in the real world) in charge of filling out these important statistical and historic documents.

Continue reading “Quantified Death”

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