The Covid-19 6%

 

August 31, 2020

The #Covididiots are out in force on this one, and I am frustrated and angry.  Our nation has gone from willful ignorance to malicious ignorance because people have such a poor understanding of science and medicine mixed with radical political polarization.  Part of me just wants to lash out in anger, part of me just wants to give up, and a part of me wants to educate people, but many just don’t want to be educated. I'm not going to link to these people as I don't want to give them anymore oxygen to spew their conspiracy theories.

From the Centers for Disease Control and Prevention (CDC) website: Weekly Updates by Select Demographic and Geographic Characteristics: Comorbid Conditions (Accessed August 31, 2020)

“Table 3 shows the types of health conditions and contributing causes mentioned in conjunction with deaths involving coronavirus disease 2019 (COVID-19). For 6% of the deaths, COVID-19 was the only cause mentioned. For deaths with conditions or causes in addition to COVID-19, on average, there were 2.6 additional conditions or causes per death.“

For what it is worth, it won’t change any minds, but it may …

"Here's the story of a lovely lady

Who was bringing up three very lovely girls

All of them had hair of gold, like their mother,

The youngest one in curls

Here's the story, of a man named Brady,

Who was busy with three boys of his own,

They were four men, living all together,

Yet they were all alone.

'Til the one day when the lady met this fellow

And they knew that it was much more than a hunch

That this group must somehow form a family

That's the way we all became the Brady bunch"

You know the rest.... 

Now one day, in 2020, they had a family reunion. Their dog, Tiger the 3rd, had escaped again. They all piled into the minivan to go look for him. Cousin Oliver, an alcoholic due to his parents abandoning him when he was a kid, happened to have been drinking all day.  As soon as he got the text about Tiger the 3rd missing, he jumped in the car and rushed over. He was impaired and driving so fast, he hit the minivan head on as it was coming out of the driveway. The accident killed him instantly due to blunt force trauma.

In the minivan:

Mike: 70s, heart condition, on blood thinners, head hits windshield causing intracranial hemorrhage and dies within 24 hours.

Carol: late 60s, metastatic breast cancer, compromised immune system due to chemotherapy, multiple injuries requiring multiple surgeries. She dies after three weeks due to sepsis.

Marcia: 40s, Rheumatoid arthritis, on immune suppressant medications, lung is punctured in the accident. Is on a ventilator, she dies after two weeks due to pneumonia.

Jan: 30s, Obese and poorly controlled diabetic. Dies of sepsis in the hospital within the week

Cindy: 20s, survives with broken arm.

Greg: 40s, Hypertension, Heart disease, Smoker with COPD, Obese, multiple fractures, dies due to massive pulmonary embolism from blood clot in the leg.

Peter: 30s, otherwise healthy, bleeds out due to multiple penetrating injuries.

Bobby: 20s, Gets thrown out of the minivan and dies when his neck is snapped due to blunt force trauma.

In summary, dead within a month of the accident: Mike, Carol, Marcia, Jan, Greg, Peter, Bobby, and Oliver. Alive: Cindy.

For all of those who went to Faux News University, went to The Facebook School of Medicine,  and did residency at Google Medical Center, who died from the car accident?

If it was NOT for the car accident, who would have lived to see 2021?

People don't OF the flu, they die BECAUSE OF the flu.

Looked at it another way, 6% of people didn't have underlying comorbid conditions.  They were the young healthy ones who died because COVID19 is a killer.  This is not the same thing as the urban myth of the guy getting killed in a car accident who just happens to have COVID19 and then the death is coded as COVID19.  Doctors are not that stupid.

#WearADamnMask

PS: A better, more scientific, less confrontational explanation: Your Local Epidemiologist on FB

#EndofCall & Frontline Healthcare Workers who died fighting CoVID-19

When a peace officer or other first responder dies in the line of duty, there is a very solemn End of Watch ritual at the memorial where the dispatcher calls out the call sign and then signs off, sometime with the phrase "End of Watch."  Listen to the recordings, it will bring tears to you eyes.

In my own way, for the past several years, I have been honoring physicians who have died.  I have lost several friends who are physicians and done my bit to remember them.  Physicians are known worldwide to be "On Call" for our patients, and as such, I have memorialized those close to me on social media with the hashtag #EndofCall.

There is a grim project undertaken by a very kind soul, Jim Duehr, in light of the COVID-19 outbreak.  He is compiling a list of frontline workers, many of whom are physicians, who have given their lives fighting the disease.  His pinned tweet on twitter feed is here.  

The document is available at:

Frontline Healthcare Workers who died fighting CoVID-19

We are going to lose a lot more physicians in the next coming weeks and months.  We will also lose nurses, techs, and other frontline healthcare workers.  While I can't speak to the rituals for other health care workers, I urge you to memorialize the fallen Physicians with the hashtag #EndOfCall.

Our small bit, to remember those who sacrificed their lives for humanity.

As of 03/13/2020

Roberto Stella

Vahid Monsef    

Zhongming Mei 

Sisi Xia  

Yinhua Peng

Zhiming Liu         

Wenliang Li

Wudong Liang

 #EndOfCall & Rest in peace my colleagues.

Robbing Peter to pay Paul in Academic Medicine

"To robbe Petyr & geve it Poule, it were non almesse but gret synne.”

("To rob Peter and give it Paul, it were not alms but great sin.")

Jacob's well: an English treatise on the cleansing of man's conscience, circa 1450

Measuring Clinical Effort

An increasing trend in American medicine is that clinicians (specifically Physicians) are expected to take EMR work home and take care of patient issues after hours on a daily basis.  This is rarely the case for the majority of other professions.  As the recent New York Times editorial points out, the system is taking advantage of our professionalism and altruism. (https://www.nytimes.com/2019/06/08/opinion/sunday/hospitals-doctors-nurses-burnout.html). Not surprisingly, in an academic enterprise, calculation of clinical effort is more complex than in a non-academic enterprise.  Clinical effort, in my opinion, is defined as including all patient care activities, including EMR charting and responding to homework issues (EPIC inbasket).

We should develop systems to allow all clinical documentation to be done by the end of business, daily.  Clinicians taking work home and spending time away from family and other life obligations to document in the EMR are at high risk for burnout and decreased productivity. Pajama time and weekend charting are a major source of burnout and clinician dissatisfaction. 

From various sources, enlightened non-academic enterprises include EMR documentation time into their work days and allow time for clinicians to address EMR and homework issues.  They also employ clinician extenders to triage homework so only the relevant issues are presented for their review.  In enlightened practices, a clinician that is 100% clinical (5 full days of direct patient care per week) actually has half day to a full day built into their templates to address homework issues.  I will explore this topic further in another post, but before I get there, let’s discuss the crux of the issue for academic physicians.

Robbing Peter to pay Paul

In the academic arena, all too frequently, homework spills into the other half of our mission, the “academic time” which is comprised of all activities that are not direct patient care related (non patient care education / research / administrative service).  What complicates the equation is the education component, which can fall into both buckets. Clinicians that spend four days a week in clinic spend the bulk of their academic day responding to homework issues, thus negating their ability to be productive on their academic time.

Academic centers also “rob Peter to pay Paul” when it comes to allocating conference and academic travel.  Clinicians that are out for conferences are forced to make up clinics on administrative days to prevent a fall in RVUs.  As such, the academic mission suffers further. Conversely, in the private practice world, clinicians work 5 days a week (without a significant administrative component) simply accept time lost to conference and CME as the cost of doing business, and as such, lower revenue and RVU targets.  Loss of revenue is mitigated by income and business tax deductions for the conference.
Additionally, those in private practice that have administrative duties in the practice or local hospital are compensated as such.  For many in academic medicine, administrative service is simply part of the expectation of service.  Many of us enter academic medicine precisely to serve in a variety of roles.  The conflicts start to arise when one component spills into the other.

In the majority of academic institutions, conference and CME time, is taken away from academic time.  The clinician is not on campus to take care of their education / research / administrative duties, and is actually “working” full time at the conference.

For the typical work week in the academic setting, a month has 20 business days.

A clinician at 80% clinical is defined as working 80% of their time in a clinical role, so 16 days a month of direct patient care.

If a clinician is 80% clinical and goes for a four day conference, then they are expected to make up those 4 days, so the following month of 20 business days, they are swapping their four academic days to make up for their missed clinics, so they end up being 100% clinical for that month.  The average for the two months then becomes: 16 days direct patient care + 20 days direct patient care = 36 direct patient care days / 40 business days = 90% clinical effort.

As you can see, we have robbed Peter (Academic) to pay Paul (Clinical Care) and the clinician is now no longer at 80% clinical, but 90% (the great sin!)

Therefore, it is imperative that we consider CME/Conference time as a subtraction from the denominator of available business days.

My attempt at a solution:

I have had the following schema in place since 2015 as Section Chief of the Consultative Medicine service:

We have three major buckets, on any given business day, you are either in a

1. Clinical Role: Direct patient Care +/- Patient Care education duties
2. Non Clinical Role: Academic / Administrative / Non Patient care education duties
3. Away: Not at work in the hospital or your office, vacation, Family Medical Leave (special case), conference, jury duty, etc.

For the typical work week in the academic setting, a month has 20 business days.  We actually break out each day into 2 sessions and have half day administrative and half day clinical care roles and do the math based on 40 business sessions a month.  For the purposes of this thought piece, I am simplifying.

A clinician at 80% clinical is defined as working 80% of their time in a clinical role, so 16 days a month of direct patient care:

Clinical Care Days / Business Days = Numerator / Denominator = 16 days / 20 days = 80%

A clinician at 60% clinical is defines as working 60% of their time in a clinical role, so 12 days a month of direct patient care:

Clinical Care Days / Business Days = Numerator / Denominator = 12 days / 20 days = 60%

My calculations:

Numerator = Number of business days per month in clinical role.

Denominator = Number of AVAILABLE Business days in a month.  (Business days – Away days)

It’s crucial to remember that clinical effort is the same if a clinician is away from the institution for vacation time.

If the clinician has 5 days of vacation, the number of available business days drops to 15 days in that month.  The 80% clinician is responsible for 80% of AVAILABLE business days: 15 x 0.80 = 12 business days of direct patient care.

The same applies for conferences and CME:

In the above example: 3 days of conference + 2 days of vacation = 5 days AWAY

Numerator = # of business days in a clinical role.

Denominator = Number of business days in a month MINUS number days away

So 12 / (20-5) = 80%

In my current practice model, no one is 60%/80%/90% each month on the dot, there are variances month to month, but the goal is to make it as close to goal as possible on a rolling quarterly basis.  In other words, at the end of each quarter, you should be close to goal, and I make manual adjustments to the next quarter to make it work out.  Any clinician that is within 5% of goal at the end of the fiscal year is considered to be on target.

Systemic and transparent use of the calculation allows us to maintain the integrity of academic enterprise.  All too often, clinicians in an academic environment are asked to sacrifice teaching / research / administrative work in pursuit of the RVU benchmark.  As a result, academic RVU benchmarks, in my opinion are over estimated.  The clinician who is forced to add on extra clinics to make up for academic conference time or vacation is actually “squeezing” more RVUs into the 80% bucket and as such inflated numbers are being reported to bench-marking organizations such as AAMC and MGMA.

At this point, health care administrators and physician leaders reading this are about to storm the barricades and make various arguments about the need for increased clinical throughput, not less.  My point is that we should be increasing clinical throughput (efficiency) for providers while they are in their clinical roles, not relying on them to make up for missed clinics by sacrificing the academic component.

Thoughts appreciated!

There's some good in this world...

Authors note: Originally published on 11/9/2016.  I took this post down in January 2017 because I was informed that it was detrimental to my career. After this weekend's events in Charlottesville, VA.  I will be leaving it up. Career consequences pale in comparison to to the death of Heather Heyer and those who were physically beaten by American Nazis while our President stood by doing nothing.

I have been trying to wrap my mind around what happened in the last 24 hours. A highly qualified woman lost to a racist, misogynistic, bombastic, hateful man with no credentials. All the lessons that my wife and I try to teach our children are clearly for naught for large swath of America (CNN's Van Jones said it best).

For my white friends:

You will never be looked upon with suspicion by Federal agents or the Police. I saw my 9 year old daughter humiliated by the TSA for Flying While Brown and I could not do anything about it without being arrested. (She saw a father that failed to protect her in a scary situation).

You will never experience the fear of being a 8 year old beat up in a bathroom in 1979 by kids calling you a "camel jockey" and the school authorities blowing it off as "boys will be boys" (locker room talk?).

In the last 24 hours two Muslim woman students have been assaulted by punks yelling "Trump"

My daughter is brown skinned and she is scared. My son is brown skin and he is scared.

Donald Trump has normalized public hate against minorities and people of color, and the thin veil of public decorum has been ripped away. The change that people on my side of the skin tone barrier I see is that it now acceptable to voice and act on your deepest darkest thoughts and it will be excusable because the President of the United States enables it.

Can you please explain to me why this is okay? Day 1 in Trump's America

I thought of turning to scripture or faith for solace, but that somehow rings hollow when 80% of Evangelicals voted for DJT. Somehow, the Hindu/Buddhist concept of detachment just does not apply fully.

Then I remembered the words of one very wise Hobbit, Samwise Gamgee:

Frodo: I can't do this, Sam.

Sam: I know. It's all wrong. By rights we shouldn't even be here. But we are. It's like in the great stories, Mr. Frodo. The ones that really mattered. Full of darkness and danger they were. And sometimes you didn't want to know the end. Because how could the end be happy?

Sam: How could the world go back to the way it was when so much bad had happened? But in the end, it's only a passing thing, this shadow. Even darkness must pass. A new day will come. And when the sun shines it will shine out the clearer.

Sam: Those were the stories that stayed with you. That meant something. Even if you were too small to understand why. But I think, Mr. Frodo, I do understand. I know now. Folk in those stories had lots of chances of turning back only they didn't. They kept going. Because they were holding on to something.

Frodo: What are we holding on to, Sam? 

Sam: That there's some good in this world, Mr. Frodo. And it's worth fighting for.

Lord of the Rings, The Two Towers, Director: Peter Jackson

My Tweet went viral, now for the Mea culpa

On the afternoon of Tuesday, 11 November 2014, a small part of the twitterverse exploded.  Dr. Oz of America's Doctor fame asked for questions via Twitter using the hashtag #OzsInBox.  The adage of be careful what you wish for came true, and numerous physicians whom I follow tore into him, quickly making it a trending topic.  Mixed in with 95% tweets meant to tweak his nose and make fun of him where about 5% serious questions.  The majority of tweets were quite hilarious.

Seeing all the fun they were having, I decided to give it a try, and asked a semi serious question after midnight:

I have always wondered why Dr. Oz has not been censured or disciplined for his lack of scientific and medical morality on his TV show by his colleagues at the medical school where he holds the position of Vice Chair of Surgery.  I would like to think that if my institution had a MD that was spouting nonsense about miracle cures and melting fat away, they would be soundly denounced by their colleagues, privately and publicly.  Even if his speech is protected by the Columbia University Faculty Free Speech policy, he has an obligation, as a physician, not to mislead his viewers.

I forgot about it on Wednesday morning and went about my normal duties, occasionally checking twitter to see if someone had posted something funny.

On Thursday morning, my twitter inbox was getting busy.  Several people questioned my professionalism.  They stated that Twitter was not the appropriate platform for calling for a a fellow physician's firing;  especially since I had linked to the Columbia Department of Surgery's twitter account.  Being a relative twitter neophyte, I started answering some of the questions and tweets personally, not realizing that I was being baited by twitter trolls and others. 

Later that morning, my twitter inbox exploded.  The apparent cause was a USA Today article that featured my tweet.  My tweet was later picked up by Salon.com also

My tweet has become the subject of several mini debates about professionalism, and I have decided not to take any further part in them, and hoping it will die a natural death. As of this writing, I am the 4th top ranked mention in regards to this topic.

My Mea Culpa...

 

In hindsight, my tweet probably should have never went out.  In the twitterverse, I have been accused of being mean, unprofessional, greedy, and not being a gentleman etc...

Gentleman

Gentleman is defined by Merriam Webster as: c (1) :  a man who combines gentle birth or rank with chivalrous qualities (2) :  a man whose conduct conforms to a high standard of propriety or correct behavior. 

While I have never met the man personally, I cannot make a judgement of his personal conduct.  A such, I should not have accused him of conduct unbecoming a gentleman.  I was trying to make a humorous play on the phrase "conduct unbecoming of an officer and gentleman."  I certainly think his public conduct leaves much to be desired, but in a polite and civil society, it was low blow, and for that I am sorry.   Like others, I should have mocked the behavior, not the man.

@ColumbiaSurgery

Tagging the Columbia Med Department Surgery's twitter account also was a mistake. I should have used the hashtag #ColumbiaMed or #ColumbiaSurgery or something similar, not their actual twitter handle.  With all the retweets and mentions, I probably inundated their twitter feed and made their social media team have a heart attack.  The @ColumbiaSurgery twitter tag is designed to present the best of what they have to offer, not a platform for ridicule.  In an attempt to make things right, I did post the following apologies earlier on Thursday AM:

For the record, I do apologize to the professionals at Columbia Department of Surgery for involving them.

Unprofessional

This accusation actually bothers me the most. I have always tried to be a professional and collegial with my colleagues.  I am still struggling with the issues raised about physicians criticizing other physicians, privately and publicly.  Many medical blogs refer to not publicly criticizing another physician because it undermines the confidence of our patients.  I certainly don't do that in person, so why would I do it on twitter? My approach in person is to talk to them one on one, and it is usually about a mistake, or something missed that caused an error.  Universally, all physicians take that kind of critique at heart, and vow to do better next time. I certainly do.  One of my favorite phrases is that when it comes to patient safety, I have no ego.  I have called out MDs who I think are gaming the system, but do so in a much more professional way.

Twitter has opened up a new paradigm in terms of professional interaction on all sorts of levels.  It's great during medical conferences to discuss breaking news and controversial studies.  But again, this is using twitter to critique the topic, not the person.  Instead of using my "professional and official" twitter account which is @drsunilksahai, perhaps I should have used my personal private citizen account @sunilkumarsahai to post the tweet.  That way, it would have been me, as a private citizen commenting.  I know I am the same guy, but one account is meant for more medical news and professional interactions, than the other.  That way I can use my personal account to tweet about my cable company, airline snafus, and humorous memes that don't have a natural fit on the professional side.  I'm pretty sure my medical followers don't want to hear about my latest interaction with @att.

However, I am not sure the same can be applied in Dr. Oz's case.  He is not making medical mistakes on patients he treats and has a physician-patient relationship with.  He is promoting pseudoscience to his viewers who have put their trust into him.  I think the two are very different matters.  As of this writing, I don't have a good answer to that.  Other physicians and bloggers do a much better job at criticizing Dr. Oz than I did, so I will leave it to them from now on.

The Tweet I Should Have Tweeted: (updated 11/14 AM)