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USMLE Step 1 During COVID-19: A Fog of Uncertainty

Marcus Wiggins
Puneet Kaur
Pranav Puri

By PRANAV PURI, PUNEET KAUR, and MARCUS WIGGINS, MBA

As current medical students, the ongoing COVID-19 pandemic represents the most significant healthcare crisis of our lifetimes. COVID-19 has upended nearly every element of healthcare in the United States, including medical education. The pandemic has exposed shortcomings in healthcare delivery ranging from the care of nursing home residents to the lack of interoperable health data. However, the pandemic has also exposed shortcomings in the residency match process.

Consider the United States Medical Licensing Examination (USMLE) Step 1. A 2018 survey of residency program directors cited USMLE Step 1 scores as the most important factor in selecting candidates to interview. Moreover, program directors frequently apply numerical Step 1 score cutoffs to screen applicants for interviews. As such, there are marked variations in mean Step 1 scores across clinical specialties. For example, in 2018, US medical graduates who matched into neurosurgery had a mean Step 1 scores of 245, while those matching into neurology had a mean Step 1 score of 231.

One would assume that, at a minimum, Step 1 scores are a standardized, objective measure to statistically distinguish applicants. Unfortunately, this does not hold true. In its score interpretation guidelines, the National Board of Medical Examiners (NBME) provides Step 1’s standard error of difference (SED) as an index to determine whether the difference between two scores is statistically meaningful.  The NBME reports a SED of 8 for Step 1. Assuming Step 1 scores are normally distributed, the 95% confidence interval of a Step 1 score can thus be estimated as the score plus or minus 1.96 times the standard error (Figure 1). For example, consider Student A who is interested in pursuing neurosurgery and scores 231. The 95% confidence interval of this score would span from 215 to 247. Now consider Student B who is also interested in neurosurgery and scores 245. The 95% interval of this score would span from 229 to 261. The confidence intervals of these two scores clearly overlap, and therefore, there is no statistically significant difference between Student A and Student B’s exam performance. If these exam scores represented the results of a clinical trial, we would describe the results as null and dismiss the difference in scores as mere chance.

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Managing Surgical Wait Times in the Intra-COVID-19 World

Finding the Right Prioritization Model

By JUSTIN SPECTOR

Restrictions on elective surgical volume in hospitals across the United States are causing a dilemma heretofore unseen in the American healthcare system. Surgeons across services have large and growing backlogs of elective surgeries in an environment where operating room (OR) capacity is restricted due to availability of inpatient beds, personal protective equipment (PPE), staffing, and many other constraints. Fortunately, the U.S. is not the first country to experience and deal with this situation; for many countries, this is the normal state of medicine.

By combining the accumulated experience of health systems around the world with cutting-edge technologies, it is possible to make this crisis manageable for perioperative leadership and, potentially, to improve upon the preexisting models for managing OR time.

The first step in creating an equitable system that can garner widespread buy-in is to agree upon a method for categorizing cases into priority levels. Choosing a system with strong academic backing will help to reduce the influence of intra-hospital politics from derailing the process before it can begin.

Why Cases Should Be Prioritized

If your hospital has a mix of surgeons who perform highly time-sensitive cases — cases where patient quality of life is substantially impacted — as well as cases with minor health or quality of life outcomes, it is important to make sure there will be enough capacity to get the higher urgency cases done within a reasonable amount of time. This allows cases in the backlog to be balanced against new cases that are yet to be scheduled and will help to optimize the flow of patients through the OR.

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Contact Tracing: 10 Unique Challenges of COVID-19

Deven McGraw
Eric Perakslis
Vince Kuraitis

By VINCE KURAITIS, ERIC PERAKSLIS, and DEVEN McGRAW

This piece is part of the series “The Health Data Goldilocks Dilemma: Sharing? Privacy? Both?” which explores whether it’s possible to advance interoperability while maintaining privacy. Check out other pieces in the series here.

A worldwide dialog about COVID-19 contact tracing is underway. Even under the best of circumstances, the contact tracing process can be difficult, time-consuming, labor-intensive, and invasive — requiring rigorous, methodical execution and follow-up.

COVID-19 throws curve balls at the already difficult process of contact tracing. In this post we will provide some basic background on contact tracing and will list and describe 10 challenges that make contact tracing of COVID-19 exceptionally difficult. The 10 unique challenges are:

1) COVID-19 is Highly Contagious and Deadly

2) Contact Tracing is Becoming Politicized

3) We Lack Scientific Understanding of COVID-19

4) Presymptomatic Patients Can Spread COVID-19

5) Asymptomatic Patients Can Spread COVID-19

6) Contact Tracing is Dependent on Availability of Testing

7) Contact Tracing is Dependent on New, Extensive Funding

8) Contact Tracing is Dependent on an “Army of Tracers” and Massive Support for Patients

9 ) The Role of Technology is Unclear — Is it Critical Support or a Distraction?

10) The U.S. Response Has Been Fragmented and Inconsistent

The thrust of this post is about traditional boots-on-the-ground contact tracing conducted by public health agencies. We will touch on a few aspects of digital contact tracing (e.g., smartphone apps), but we’ll go into much more depth on digital contact tracing in future posts.

How does contact tracing relate to the theme of this series — The Health Data Goldilocks Dilemma? It’s about obtaining the right amount and types of information — not too much, not too little. Not too much data so that privacy rights or civil liberties are infringed, or that contact tracers are overwhelmed with useless data; not too little data so that public health agencies aren’t handcuffed in protecting our safety in tracing COVID-19 cases.

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Escaping COVID-19

By RAGHAV GUPTA, MD

“In seeking absolute truth, we aim at the unattainable and must be content with broken portions.”

William Osler

A colleague shared an experience with me about testing one of his patients for the novel coronavirus and it left me a bit puzzled.  An elderly gentleman with past medical history of severe COPD (chronic obstructive pulmonary disease) and heart failure came to the ER with shortness of breath, edema and fatigue.  Chest x-day suggested pulmonary edema.  He wanted to test him for SARS-CoV2 but hesitated.  Eventually he was able to order it after discussions with various staff administrators.  Dialogue included sentences like “why do we need testing? He has Congestive Heart Failure (CHF), not COVID-19” and “it could create panic amongst staff taking care of him”. I applauded his persistence as eventually the test was done.  To not test is counter-intuitive and more like an escape from diagnosing the virus rather than escaping the virus itself. 

One – the mere fact that we might hesitate before testing for a virus which is a cause of a (ongoing) pandemic should ring all the bells of concern about lack of an optimal strategy.  Inadequate testing has remained the Achilles heel of our stand against COVID-19 because to have a lasting stand, we must know where to take the stand.  

Two – the concern of CHF raised above is clinical and valid, but it is of grave importance to understand that CHF and COVID-19 are not mutually exclusive.  We now know that even the infamous flu and COVID-19 are not mutually exclusive.  Common protocols from a few months ago to test for flu in sick outpatients and not test for COVID-19 if flu was positive was like the prey closing its eyes and hoping the predator does not see it.  It did defer the use of an already scarce resource at the time, testing.  SARS-CoV2 is a virus and the disease caused by it is called COVID-19.  Virus can be ubiquitous; disease does not have to be.  A patient with CHF exacerbation can be an asymptomatic carrier of SARS-CoV2 but may not phenotypically express the disease manifestations of COVID-19.  Or may be his COPD or CHF exacerbation has happened due to a milder COVID-19 inflammatory response?  What we know about COVID-19 is that we don’t know enough about it and therefore we cannot rule out its presence.  Especially while we are in the middle of a growing pandemic.  

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The Lack of Persuasion as a Failure Against COVID-19

By RAFAEL FONSECA, MD

Reopening safely out of the current pandemic ought to be done via persuasion, not coercion.

It has been more than five months since the world first learned about COVID-19. Models predicted a sharp increase in the number of cases, and a seemingly high likelihood the pandemic would overwhelm our hospitals. These models were often inaccurate, and we have all come to learn about the imprecision of epidemiological prediction.  Nevertheless, the infection is far worse than anyone initially accepted – becoming a staple of our generation. Fearing uncountable deaths and the possible need to prioritize resources for those affected, initial government measures were put in place to curtail the spread of the virus. Images of the Lombardic tragedy compelled all to stay in place and wait for the storm to pass, and with few exceptions most complied. Realizing the gravity of the situation, governments gradually implemented measures to prevent infections.  With some vacillation, we evolved from travel restrictions, to social distancing, shelter in place and universal mask use.

As the pandemic ensued, we watched the horror stories taking place in New York City and Boston. Even while we are in the midst of the so-called first wave, with thousands of deaths per day, many have started to wonder how long society will remain isolated and locked. Politicians look to experts for recommendations regarding policies that might save lives, and for the most part they have complied. However, as the weeks ensue, we see growing jobless claims, lines for food banks, and impatience.

This brewing impatience is a response to an unknown future dictated by the vagaries of nature and the lack of a coherent strategy to resume a life with a resemblance to normal. The public searches for guidance from federal agencies, state governments, and health authorities. A lack of clear direction from these institutions has heightened this anxious impatience. Additionally, the conversation is now ideological, with an almost Manichaean division between those wanting to save lives more so than the economy, and vice versa, creating cartoons of opposing perspectives.  Even for those recognized as  accomplished, dissenting from orthodoxy is punished severely. In the background, the public’s patience is running thinner.

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Even Covid-19 May Not Be Causing Your Doctor To Wash His Hands

By MICHAEL MILLENSON

If you think the grim coronavirus death toll is causing health care workers everywhere to always wash their hands, think again.

A recent research letter published in The Journal of Hospital Infection examined whether it’s “possible to achieve 100 percent hand hygiene compliance during the Covid-19 pandemic.” The medical center involved in the research, Queen Mary Hospital in Hong Kong, had reached a pre-Covid-19 hand hygiene rate of over 75 percent.

Yet the hospital’s goal of complete compliance proved surprisingly elusive. In one pediatric ward devoted to suspected or confirmed Covid-19 patients, doctors and nurses followed hand hygiene rules 100 percent of the time, but in another ward with similar patients and staff, compliance was 83 percent, or about one-fifth less.

Given Covid-19’s risk to providers as well as patients, this was “unexpected,” the researchers admitted. 

The Queen Mary study supports what infection control experts have long maintained: awareness isn’t enough. Doctors and nurses, particularly during a pandemic, understand that hand hygiene is “the most important intervention” to reduce the staggering death toll from infections, as the American Journal of Infection Control put it.

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Primary Care Practices Need Help to Survive the COVID-19 Pandemic

Ken Terry
Paul Grundy

By PAUL GRUNDY, MD and KEN TERRY

Date: June 20, 2022.

The Smithsonian National Museum of Natural History has reported its biggest number of visitors in more than 2 ½ years. There’s a string of new Broadway musicals that are well-attended every night. It’s safe to shop in malls, eat out in restaurants and go to movie theaters again.

Of course, this has all been made possible by an effective vaccine against COVID-19 that was widely administered in the fall of 2021. Vaccinated citizens of the world are now confident that it’s safe to go out in public, albeit with appropriate precautions.

However, U.S. residents who have health problems are facing a new challenge. Five years ago, in 2017, the median wait time of new patients for doctor appointments was six days. In 2022, the wait time is six months or more.

The reason for this is no mystery. While life has started to return to what we think of as the new normal, the U.S. healthcare system has taken an enormous financial hit, and primary care practices have been especially affected. Many primary care physicians have closed their practices and have retired or gone on to other careers. Consequently, the shortage of primary care has been exacerbated, and access to doctors has plummeted. Urgent care centers, retail clinics and telehealth have not filled this gap.

Because of the long waiting times for primary care appointments, many more people now seek care in emergency departments (EDs). The waiting rooms of these EDs are overcrowded with people who have all types of complaints, including chronic and routine problems as well as emergencies. And this is not just a common sight in inner-city areas, as it once was; it’s now the same pretty much everywhere.

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What’s a diagnosis about? COVID-19 and beyond

By MICHEL ACCAD

Last month marked the 400th anniversary of the birth of John Graunt, commonly regarded as the father of epidemiology.  His major published work, Natural and Political Observations Made upon the Bills of Mortality, called attention to the death statistics published weekly in London beginning in the late 16th century.  Graunt was skeptical of how causes of death were ascribed, especially in times of plagues.  Evidently, 400 years of scientific advances have done little to lessen his doubts! 

A few days ago, Fox News reported that Colorado governor Jared Polis had “pushed back against recent coronavirus death counts, including those conducted by the Centers for Disease Control and Prevention.”  The Centennial State had previously reported a COVID death count of 1,150 but then revised that number down to 878.  That is but one of many reports raising questions about what counts as a COVID case or a COVID death.  Beyond the raw numbers, many controversies also rage about derivative statistics such as “case fatality rates” and “infection fatality rates,” not just among the general public but between academics as well.  

Of course, a large part of the wrangling is due not only to our unfamiliarity with this new disease but also to profound disagreements about how epidemics should be confronted.  I don’t want to get into the weeds of those disputes here.  Instead, I’d like to call attention to another problem, namely, the somewhat confused way in which we think about medical diagnosis in general, not just COVID diagnoses.

The way I see it, there are two concepts at play in how physicians view diagnoses and think about them in relation to medical practice.  These two concepts—one more in line with the traditional role of the physician, the other adapted to modern healthcare demands—are at odds with one another even though they both shape the cognitive framework of doctors.  

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The 2020 COVID Election

By KIM BELLARD

Many believe that the 2020 Presidential election will be a referendum on how President Trump has handled the coronavirus pandemic.  Some believe that is why the President is pushing so hard to reopen the economy, so that he can reclaim it as the focal point instead.  I fear that the pandemic will, indeed, play a major role in the election, but not quite in the way we’re openly talking about.  

It’s about there being fewer Democrats.

Now, let me say right from the start that I am not a conspiracy believer.  I don’t believe that COVID-19 came from a Chinese lab, or that China deliberately wanted it to spread.  I don’t even believe that the Administration’s various delays and bungles in dealing with the pandemic are strategic or even deliberate.  

I do believe, though, that people in the Administration and in the Republican party more generally may be seeing how the pandemic is playing out, and feel less incentive to combat it to the fullest extent of their powers.  Let’s start with who is dying, where.

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How to Practice High-Quality Telemedicine in the Era of COVID-19

By ANISH MEHTA, MD

My practice received its first question about coronavirus from a patient on January 28, 2020. Though there were over 200 deaths reported in China by that time, no one could have imagined how drastically this would come to disrupt our lives at home.

Thankfully, I had a head start.

As a doctor at an integrated telemedicine and primary care practice in New York City, nearly two out of every three of my medical encounters that month was already virtual.

I spent much of January caring for patients who had contracted seasonal viruses, like influenza or norovirus (i.e. the stomach flu). My patients reached out nearly every day with bouts of fevers, fatigue, diarrhea, and vomiting. Our team did all we could to encourage each of these patients to stay home and avoid spreading their highly contagious virus throughout the community (sound familiar?).

We are now guiding our patients through the COVID-19 outbreak using the same tools we use to guide them through any healthcare need – real-time monitoring, proactive outreach, and team-based care.

After our first COVID-19 question, our team started compiling information about every patient who reached out with symptoms that even slightly resembled COVID-19. This soon turned into a comprehensive patient registry containing the epidemiologic risk factors, clinical risk factors, symptoms, and a follow-up plan for each patient. Based on their total risk level, we follow up with these patients every 24 to 120 hours.

Every day, one provider on the team texts or schedules a video visit with each follow-up patient, reassesses their symptoms, and re-stratifies their risk. Most patients respond with a text message letting us know that their symptoms are the same or slowly improving. But for patients at higher risk, we want more information. We help these patients acquire a thermometer or pulse oximeter to follow up on their respiratory vitals. With this data, our team can provide patients and their families with thresholds on when to seek out a higher level of care.

Our job for these patients is clear: provide treatment at home and only recommend the hospital if there is no other option. By centralizing data and establishing clear triggers for a new plan of care, a single provider can follow up with over 30 COVID-19 patients in a single day.

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