Tag: John Schumann

An Open Letter To Governor Mary Fallin

Nov 1, 2018

By John Schumann, MD

On November 19, the Governor of Oklahoma announced her intention NOT to participate in either a state electronic health insurance exchange or to accept Federal Medicaid dollars to provide coverage to 150,000 Oklahomans out of the 600,000 that currently have no health insurance.

You can read about the decision in brief, with cogent analysis, here.

Below is the text of a letter I faxed to her office:

Dear Governor Fallin:

I am extremely disappointed with the decision declining Oklahoma’s participation in the expansion of Medicaid under ObamaCare.

As a practicing physician and medical educator, I see the impact of ‘uninsurance’ on low income, chronically ill Oklahomans every day. Options for these folks are few. Since they aren’t moneyed, and struggle to get by in every sense, they aren’t well-represented at the ballot box.

The decision not to participate in a broadening of the safety net is morally, financially, and medically wrong.

Zika and Correlation vs. Causation

Feb 8, 2016

BY JOHN SCHUMANN

Last week I told you of my admiration for Dr. Mona Hanna-Attisha, the Michigan pediatrician and epidemiologist whose strong research and advocacy was able to finally bring a shining light to the problem of lead in the water supply of Flint.

Continuing with a theme, I now bring you the story of Dr. Adriana Melo of Campina Grande, Brazil.

Dr. Melo is an OB-GYN who subspecializes in Maternal-Fetal Medicine (MFM), the branch of obstetrics that deals with high-risk pregnancies.

She lives and works in northeast Brazil, which is less populous and more economically challenged than the southern, more well-known parts of the country (including Rio de Janeiro and Sao Paulo).

Dr. Melo noted an uptick in the number of fetuses with small heads on ultrasound — which is the main tool used by MFM doctors to diagnose babies in utero.

How much of an uptick? A rough look at the statistics shows ONE HUNDRED times the ‘normal’ rate of babies born with microcephaly, the medical name for the condition.

Dr. Melo had a suspicion that the mothers giving birth to these babies all had a common trait: they’d all told her that they’d had the characteristic rash associated with the mosquito-borne Zika virus.

Why You Should Care about the New Accreditation Agreement for Osteopaths

Mar 11, 2014• 3

By John Schumann, MD

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.

The Hospice Will See You Now

Dec 31, 2013

By John Schumann, MD

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.

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

Nov 8, 2013• 11

By JOHN SCHUMANN, MD

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.

Diagnosing Concussions and Assessing Balance- On Your iPhone

Aug 19, 2013• 6

By Mike Miesen

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.”

Why Are So Many Younger Doctors Failing Their Boards?

Jul 1, 2013• 23

By John Schumann, MD

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.

Doctors and the Means of Production

May 7, 2013• 15

By John Schumann, MD

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?

ObamaCare effectively bans doctors from owning hospitals in the U.S.
Those already in existence are grandfathered in under the law.
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.

Will Your Health Insurer Pay to Train Your Doctor?

Apr 16, 2013• 8

By John Schumann, MD

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).

How to Write Your Own Obituary

Mar 26, 2013• 9

By John Schumann, MD

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: