Archive for the ‘Medical Education’ Category

The Hahnemann Disaster

Though the news at first stayed local in Philadelphia and the northeast, it’s gaining traction nationwide. ZDoggMD is on it. Bernie Sanders held a rally.

What happened? The venerable Hahnemann University Hospital, the main teaching hospital for Drexel University College of Medicine in Philadelphia, is bankrupt and will soon close its doors after more than 170 years as a safety-net hospital serving inner city patients.

Why should we care? After all, there are other teaching hospitals in the immediate area with capacity to absorb the patients, and they had several months’ warning to prepare.

We should care for many reasons, but I’ll start with the plight of the 570 residents and fellows who are being displaced from their jobs. Getting a residency position in the first place is a perilous process – there aren’t enough spots for all the graduating medical students who want them. Only 79% of the more than 38,000 applicants in 2019 snagged a first-year or internship position in a residency program.

So the Hahnemann residents – the “Orphans from HUH”, as they’ve started to call themselves – are scrambling on their own to find new jobs at a time when most residents are thankfully settling in to the new academic year. There’s no organized program to help them.

Even for the residents who’ve already found new positions, there are other boulders in the road. To begin with, they haven’t been released yet. They can’t start their new jobs and the Medicare funding for their positions is still tied up in bankruptcy court.

They’re still at work, wandering around a nearly empty Hahnemann with only a handful of patients left. The ER isn’t admitting any new patients and will shut down completely on August 16. The labor-and-delivery ward has closed. The new interns aren’t gaining any real experience and will be lagging behind their peers wherever they go.

“Doctors have been writing notes to update plans of care and people have come in as part of the liquidation to take away their computers,” a third-year internal medicine resident named Tom Sibert, MD, told Medscape reporter Marcia Frelick last week.

Tom Sibert? Any relation? Why yes; he’s my son. You can understand, I’m sure, why I went into full-blown mama lion fury when the Hahnemann situation blew up, and why I was beside myself with worry until he locked in an acceptance to an excellent program where he’ll finish his training.

At risk for deportation

I’m still indignant and angry, though, over the chaos that reigns for the rest of the Hahnemann orphans. According to The Philadelphia Inquirer, 55 of them hold J-1 visas and could be deported if they can’t secure a position in an accredited program within 30 days of the hospital’s closure. Interns are in an especially tough position if they hold a “preliminary” spot in medicine or surgery without a guaranteed residency position to follow. The ACGME, the accrediting organization for residency programs, says it is “acutely aware of the uncertainty and stress”, but “is not directly involved in resident or fellow placement or decisions related to funding.”

Residents and fellows who can’t secure a position near Philadelphia will face moving expenses, penalties for breaking their leases, and possibly the substantial cost of obtaining a license in another state. The Educational Commission for Foreign Medical Graduates (ECGME) is offering some help. But for many residents and fellows – whether international or American graduates – who may be the sole supporters of their families, and often are heavily in debt from student loans, these costs will be devastating.

Residency programs across the country need to pick up the phone and help these residents find new positions. Too many are taking the attitude that their programs are already full and it’s not their problem. The ones that are stepping up – like UCLA and Creighton – deserve our gratitude. The others should realize that the Hahnemann residents are innocent victims who need help. They should realize also that their hospitals aren’t immune from the financial stresses that finally broke Hahnemann – more about that in a moment.

Meanwhile, Drexel University announced that about 40 percent of the 800 physicians and clinical staff will lose their current jobs, including 245 physicians who’ve received severance notices. Tower Health is working with Drexel to try to place employees in affiliated community hospitals, and is planning to increase its residency positions, but does not offer all the accredited programs it would need to accommodate all the Hahnemann personnel.

How did this disaster happen?

You can be sure it didn’t happen overnight. Hahnemann has been on shaky financial footing for decades. Tenet Healthcare Corp. acquired Hahnemann in 1998 following the bankruptcy of Allegheny Health Education and Research Foundation, but couldn’t make a financial go of it either.

In January 2018, Tenet sold the hospital to the private American Academic Health System LLC, an affiliate of Paladin Healthcare. Though new CEO Joel Freedman had prior experience in turning distressed hospitals around, this spring he announced that Hahnemann was losing $3-5 million a month and began layoffs. The official decision to close was announced on June 26.

Hahnemann’s payer mix was always its biggest problem, with more Medicare and Medicaid patients than its competitors. The bulk of admissions came through the emergency department, and it attracted few of the elective surgical cases that provide key revenue for successful hospitals. No rescue offers have come from the state or federal governments, and a bailout seems unlikely.

If you follow healthcare financial trends, the Hahnemann bankruptcy comes as no surprise. Hospitals are going bankrupt by the dozen. The Health Care Services Distress Research Index has experienced “record or near-record highs in each of the past eight quarters”, and is up 305 percent since 2010, which is when the rest of the economy started to turn around after the Great Recession. Since January 1, Becker’s Hospital Review reports that 12 other hospitals in addition to Hahnemann filed for bankruptcy. Dozens of others undoubtedly are in distress due to “reimbursement challenges”, the cost of new electronic health records, and dwindling inpatient volumes.

Just for clarity – no hospital or medical practice can stay afloat on what CMS pays, regardless of what Bernie Sanders thinks. Private insurance payments make up the difference. When private insurance payments shrink, patients can’t pay their high deductibles; and when outpatient centers pick up a growing share of revenue-generating surgical procedures, hospitals are at risk for failure – even teaching hospitals that you might think are too big or too important to fail.

Meanwhile, it’s likely that Hahnemann will be razed and some more profitable enterprise – a hotel, perhaps, or condominiums – will rise where a hospital once stood. The diaspora of its residents and fellows is just beginning.

Once again, it’s Physician Anesthesiologists Week, and it’s a great time to celebrate our specialty’s many successes and accomplishments.

But we’re wasting an opportunity if we don’t also take this week to consider the state of the specialty today, and what it could or should mean to be a physician anesthesiologist 20 or 30 years from now.

There is no question that a seismic shift is underway in healthcare. Look at how many private anesthesiology groups have been bought out by—or lost contracts to—large groups and corporations; look at how many hospitals have gone bankrupt or been absorbed into large integrated health systems. Mergers like CVS with Aetna are likely to redefine care delivery networks. Where does a physician anesthesiologist fit into this new world?

An even better question to ask is this: Is your group or practice running pretty much as it did 20 years ago? If so, then my guess is that you are in for a rude awakening sometime soon. One of two scenarios may be in play:  either your leadership is running out the clock until retirement and in no mood to change, or your leadership hasn’t yet been able to convince your group that it can no longer practice in the same expensive, antiquated model. As one academic chair said ruefully, at a recent meeting, “They’re like frogs being slowly boiled. They just don’t feel what’s happening.”

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Avoiding #metoo in medicine

Let me say first that any woman who has ever been harassed or assaulted should NEVER be made to feel that it is her fault. It is always the perpetrator’s fault. Men can be boors, or worse, and testosterone can be toxic.

I went to Princeton University at a time when the ratio of men to women was 8:1, graduated from medical school in the 1980s, and raised two daughters. I’ve had ample reason and plenty of time to think about strategies to deal with harassment, parry a verbal thrust, and maneuver out of a potentially humiliating or harmful situation.

We’re lucky in medicine that we have intellectual qualifications — board scores, professional degrees — that are our primary entryway into medical school and residency programs. We’re not being judged PRIMARILY on our looks. Yet many social media comments recently have underscored the fact that some women in medicine have endured ridicule, harassment, and even assault in the course of their careers. It makes sense to explore any tactic that can help other women avoid similar painful encounters.

Here are some tips — learned through long experience. My hope is that they might help younger women in medicine feel less like potential victims, and more like strategists in a behavioral chess game.

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The Practical Art of POCUS

The longer you practice a profession, the easier it is not to bother to learn the next new thing. We may think we’re doing just fine without that new drug, or that new piece of expensive equipment. We’ve seen how the new drug sometimes turns out to have more side effects than benefits, and how the equipment may gather dust in the corner because no one really needed it in the first place.

That isn’t going to happen with point-of-care ultrasound, or “POCUS”, I’m willing to bet. As I learned at a weekend conference on POCUS, jointly hosted by the anesthesiology departments at UCLA and Loma Linda University, the practical applications for bedside patient care are multiplying, and the technology is improving all the time. Ultrasound isn’t just for cardiologists and radiologists any more.

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The art of deep extubation

Fair warning — this post is likely to be of interest only to professionals who administer anesthesia or may have to deal with laryngospasm in emergency situations.

There are two schools of thought about how to extubate patients at the conclusion of general anesthesia:

Allow the patient to wake up with the endotracheal tube in place, gagging on the tube and flailing like a fish on a line, while someone behind the patient’s head bleats, “Open your eyes!  Take a deep breath!”

Or:

Remove the endotracheal tube while the patient is still sleeping peacefully, which results in the smooth emergence from anesthesia like waking from a nap.

It will not require much subtlety of perception to guess that I prefer option 2. It is quiet, elegant, and people who’ve seen it done properly often remark that they would prefer to wake from anesthesia that way, given the choice.

There is art and logic to it, which I had the pleasure of learning from British anesthesiologists at the Yale University School of Medicine years ago.

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