Author Archives: Dr. Russell Kridel

Honoring Women in Medicine

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Women in Medicine Have Elevated Our Profession

As women’s history month comes to a close, I can’t help but reflect on a few of the women in medicine who forged new paths, broke through glass ceilings, and overcame obstacles of every kind to elevate medicine to a higher level.

In 1849 Elizabeth Blackwell, MD became the first woman in the United States to be granted an MD degree. She began her journey after a deathly ill friend insisted she would have received better care from a female doctor.

In 1855, Mary Edwards Walker, was the first female surgeon in the United States and the second female graduate of an American medical school behind only Dr. Elizabeth Blackwell

In 1864, Rebecca Lee Crumpler, became the first African-American to become a doctor of medicine in the United States. She was also one of the first female physician authors in the 19th century.

In 1947, Gerty Theresa Cori was the first U.S. woman to win a Nobel Prize in science.

In 1990, Antonia Novello was appointed Surgeon General of the United States by President George Bush in 1990, she was the first woman—and the first Hispanic—ever to hold that office.

In 1998, Nancy Dickey was the first female president of the American Medical Association.

In 2019, Patrice Harris was the first black woman elected to serve as president of the American Medical Association.

Suzanne Yee, MD, one of the first board certified female facial plastic surgery specialists and the first Asian-American female facial plastic surgery fellow. I am proud to have selected her and to have been her Fellowship Director for a year.

Angela Sturm, MD, my previous fellow and associate is one of the first female facial plastic surgeons to offer body affirming surgeries for transgender patients in the U.S.

As President of the American Academy of Facial Plastic and Reconstructive Surgery (AAFPRS), I initiated the Women in Facial Plastic Surgery Committee to help women address issues in the male dominated specialty and to encourage leadership opportunities for them. And as a result, two women have since become president of AAFPRS, Mary Lynn Moran and Theda Kontis.

And, certainly my mother, Veezie Mazzeo, a first generation American, who had to change her name to get a job because employers did not offer interviews to Italian-Americans.  Her courage, strength and determination as a single mother supporting and bringing up two young sons was an inspiration. She instilled in her children that with hard work and tenacity comes professional reward and with kindness and charity comes even greater personal reward. She encouraged her sons to follow their dreams, because anything is possible.  A dream for one to be a physician, a dream for the other to be a lawyer — both realized.

Shining A Light On Victims Of Domestic Violence

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Domestic Violence Rates Are Alarming

When I first opened my practice as a young surgeon and father of two young children, I often cared for patients in the emergency room at a nearby hospital.  As a board-certified head and neck surgeon, I saw trauma and injuries of every kind, but I was particularly disturbed by the number of women and children I saw in the emergency room with injuries due to domestic violence.

And now, years later, it is alarming to see that domestic violence is still a pandemic within a pandemic. Throughout the COVID-19 pandemic, there has been a significant rise in domestic and intimate partner violence. According to the American Journal of Emergency Medicine, domestic violence cases increased by 25-33% globally in 2020.

Surveys around the world have shown domestic abuse spiking since January of 2020—jumping markedly year over year compared to the same period in 2019.  In the U.S. the situation is equally troubling, with police departments reporting in cities around the country increases of 18% in San Antonio, 22% in Portland, Oregon, and 10% in New York City, according to the American Journal of Emergency Medicine.

As the pandemic has dragged on, so too has the abuse. Just as the virus continues to claim more lives, quarantine-linked domestic violence is claiming more victims and not just women in heterosexual relationships. Intimate partner violence occurs in same-sex couples at rates equal to or even higher than the rates in opposite sex partners. And over half of the victims receive blows and injuries to the head and face.

Communities of color are more affected, with systemic inequities meaning lower income and less access to social and private services. “While one in three white women report having experienced domestic violence [during the pandemic], the rates of abuse increased dramatically to 50% and higher for those marginalized by race, ethnicity, sexual orientation, gender identity, citizenship status, and cognitive physical ability” stated Erika Sussman, executive director of the Center for Survivor Advocacy and Justice (CSAJ).

The scars, both mental and physical, need to be addressed. With my training, I know that I can make a lifelong positive impact on the physical appearance of these victims so that they have less of a reminder when they look in a mirror every day.

In 1995, I founded The Face Foundation to provide an avenue for survivors without the financial means to obtain quality facial plastic and reconstructive surgery, pro bono, to help them regain a sense of inner and outer beauty. Through The Face Foundation, I provide complimentary reconstructive facial surgical services. In addition, some hospitals also donate resources such as operating rooms, nursing staff time and supplies and the services of an anesthesiologist. The total average benefit to each patient is often in excess of $15,000. Surgery on battered women and children participating in The Face Foundation program is done in conjunction with a program sponsored by the National Coalition Against Domestic Violence (NCADV) and the American Academy of Facial Plastic and Reconstructive Surgery (AAFPRS) and its Face To Face program, which won an AMA citation several years ago.

The AMA established policy is that reconstructive surgery to return patients to a pre-injury state should be covered by insurance companies. Unfortunately, many domestic violence victims are not covered by insurance, so programs such as Face to Face, The Face Foundation and others are a critical lifeline to a return to normalcy.

SUMMARY:

As physicians, I believe we can all make an impact in our individual ways to help reduce domestic violence and its effects on victims. Whether it is counseling patients, volunteering at call centers and shelters, or providing direct health care services to victims, every action of support can change a life.

“Sometimes it takes the helping hands of others to wipe away the past and bring a fresh face to life,” Russ Kridel, MD

Valuing DEI Is Fundamental to Achieving Better Lives for Patients and Physicians

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Diversity, Equity and Inclusion (DEI) in our institutions, practices, and our lives is an important issue.  Any form of prejudice, discrimination, or unequal treatment is counter to my values and counter to our AMA core values.

The AMA and all of us, have a growing responsibility to improve diversity, equity, and inclusion (DEI) efforts not only for our colleagues, but also to better serve patients, their families, and our employees. By working to bolster DEI efforts we have an opportunity to improve the lives of those providing and receiving care.

In my leadership positions on the Board, I was involved in numerous actions to help bring DEI to the forefront both to the public and within our own organization. As Board Chair I helped prioritize the agenda of our Center for Health Equity; including the Board approval of a multi-million budget increase for the Center, and funding for the Chicago West End inner-city health endeavor.  We also approved the actions taken by the JAMA Editorial Board to make the journal and its specialty journals more responsive to diversity and anti-racism.  We encouraged the Council on Medical Education, as well as the Association of Medical Colleges to increase minority admissions and retention.  As member and Chair of CSAPH, we developed papers and positions on many health issues; such as, maternal mortality and morbidity and focused on underserved communities with recommendations to address inequities and bias. In my role as Clinical Professor, I have encouraged our educational institution to improve diversity in the University and mentored BIPOC (Black, Indigenous, People of Color) medical students and residents rotating through my practice to pursue specialty training. As Fellowship Director, I selected one of the first female fellows in our specialty, as well as one of the first BIPOC fellows.  As a private practitioner, a core tenet of our hiring practice has always been to have a diverse workforce.

The AMA has made significant efforts to promote DEI and adopted many policies and programs that have produced positive change, including establishing the Center for Health Equity. The Embedding Equity Initiative focuses on making racial justice and health equity a key focus throughout the American Medical Association.

SUMMARY

This touches all of us, regardless of our race or ethnicity.

Commitment to consistent DEI initiatives, especially training is not only important for patient safety, but also for better health outcomes. There is still more to be done. We cannot change our history, but we can continue to expand our efforts to eliminate bias and discrimination. We can’t rest on our laurels.  Eliminating health inequities is an ongoing issue and one that needs to remain in the forefront.

 

 

Health Care Advocacy Early On Can Have A Great Impact

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Getting Involved in Health Care Advocacy Early On Can Have Great Impact

I realized there were significant problems in health care delivery as a medical student at the University of Cincinnati College of Medicine. Socioeconomic determinants of health, compounded by rising health care costs, and inadequate care for the underserved, were not addressed in the curriculum for medical students in most schools. 

So, I jumped at the opportunity when I learned that my medical school had a unique program where students could get involved in taking care of patients in underserved areas of the local community. I also joined the Student American Medical Association (SAMA) because it had established a program called MECO (Medical Education and Community Orientation), where students could do an elective in primary care in non-urban communities away from the super-specialized academic medical center.

My involvement in medical education started while still a medical student. I lobbied for and initiated the first comprehensive course on human sexuality for the medical school, which the OB/GYN and Psychiatry departments embraced. I was beginning to see the role I could play in improving our health care system and medical education.

When I was a junior in medical school, I was named president of SAMA and was asked to do an interview for a national Blue Cross Publication. In the interview, I lamented the low 4.8 percent level of African-Americans in U.S. medical schools and felt the enrollment of all minority students should appropriately reflect the actual population of the country. I talked about the difficulties that minority groups had in getting into medical school, including inadequate support and encouragement in the pre-requisites necessary for admission, an insufficient number of role models, and inadequate support for minority students once admitted to medical school.

Shortly thereafter, I realized that in order to do the job well as National President to represent all of the medical students in the United States, I needed to take a year off from medical school. During my presidency, SAMA’s Minority Group Affairs Committee undertook a national program to improve and prepare minority students from high school onward to prepare for entry into the medical profession. We also worked through our representation on the National Board of Medical Examiners and the Association of American Medical Colleges, to see that the medical college admission test didn’t discriminate against anyone because of the type of questions asked.

At the same time, the then-president of the American Medical Association (AMA) formed an AMA Commission on the Cost of Health Care, recognizing that physicians, as purchasing agents for their patients’ health care needs, knew little about the actual cost of tests, supplies, and hospital charges that patients had to pay. As SAMA president at the national level, I organized grassroots efforts to inform physicians-in-training of their obligations in this area and push hospitals to be transparent in their charges. (And it took recent legislation to make this a law.)

This was the stimulus for a book that I later wrote as a surgical resident, along with another Baylor resident, that the AMA published on Medical Cost Containment. I will never forget the pushback I got after the publication came out as I had given many lectures at local hospitals. One hospital administrator called me directly and asked me to stop talking about fair pricing and transparency. I should have been intimidated but instead told him that we had full support from the then-president of the American Hospital Association to do so. It was then that I learned that when you know you are championing a just cause, you will meet resistance, but action and progress can, and must continue.

SUMMARY:

I was hooked on being involved in health care advocacy, the AMA, and  being a practicing physician. I knew that being involved in organized medicine at the local, state and national level, as well as providing the highest quality patient care as a physician helps bring better health care to all patients.

I applaud all medical students, physicians in training and young physicians in their involvement and strong efforts to improve our healthcare and educational systems and to provide care to all. I encourage others who are not currently involved to get involved. Healthcare advocacy is critical and has such a significant impact for patients.

Physician Burnout At Crisis Levels

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Burnout affects all physicians; from medical students, residents and fellows, to young physicians and those in practice for several years. The Covid-19 pandemic pushed physicians to the max and accelerated burnout.

Physicians have long experienced high levels of stress and burnout, and COVID-19 has only exacerbated the problem. While helping their patients fight for their lives, many physicians and other health care professionals are coping with their own trauma of losing patients and colleagues and fear for their own health and safety. No wonder physician burnout has become an epidemic within an epidemic.

Among recent surveys, nearly three-quarters of physicians age 25-54 and two-thirds of those age 55-73 said burnout has had a negative effect on their lives.  Burnout was described as long-term, unresolved job-related stress leading to exhaustion, cynicism, detachment, and a lack of a sense of personal accomplishment. About 51% of women physicians said they were burned out, compared with 36% of men – a greater disparity than usual, a recent Medscape report noted.

For medical students it can be debt, lack of personal time and flexibility and huge amounts to learn. For residents and fellows it can be the stress of putting knowledge into practice, learning new skills, added responsibility, and finalizing career paths. And for young physicians and for those practicing for years it can be hours of needless documentation, electronic health records (EHR) that are unusable and unfriendly, prior authorization, MIPS requirements and set-up costs, insurance reimbursement and Medicare payroll cuts. 

The highest-ranked specialties for burnout these past couple of years were critical care (with the highest burnout rates), rheumatology, infectious diseases, urology, and pulmonary medicine. However, suicidal thoughts were most common among OB/GYN, orthopedics, otolaryngology, plastic surgery, and diabetes specialists.

One positive step in addressing burnout, is the recent signing by President Biden of the Lorna Breen Health Care Provider Protection Act (HR1667) into law. This bill helps promote mental and behavioral health among those working on the frontlines. It also supports suicide and burnout prevention training programs and increases awareness and education about suicide and mental health concerns among health care professionals. The AMA actively supported passage of HR1667.

Addressing burnout and mental health continues to be a priority for all of us, including the AMA.  The AMA has done research and developed resources that prioritize well-being to help physicians with many practical tools that give health care organizations a way to assess and improve burnout at the system level and developed targeted solutions to support physician well-being. The AMA, through its advocacy divisions, has strongly advocated against administrative burdens that add to your workload and stop you from caring for your patients and has developed practice management modules to help address daily stress points.

SUMMARY:

With so many suffering from physician burnout, it is important for doctors to understand they are not alone in how they are feeling. Even physicians who have achieved the heights of the profession have experienced burnout at some point in their careers.

Post-pandemic, we, the medical community, including the AMA, have an opportunity to rethink how best to support physicians so that we can start to see meaningful reductions in burnout, depression and suicide rates. For example, time is perhaps one of the most valuable commodities for medical residents, fellows and students. Giving a few hours back per week—time which they can have to themselves—may lead to decreased burnout and increased well-being.

There is much, much more we need to do.  But as a start, let’s all feel free to ask, “Are you doing okay? How can I help?”

The Need for a Diverse Workforce in Healthcare

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A DIVERSE WORKFORCE IS NEEDED IN HEALTHCARE

Only 22% of Black patients have a physician or healthcare provider of the same race as opposed to white adults (73.8%) or adults of other races (34.4%). And only 23.1% of Hispanic/Latinx adults shared a racial, ethnic, or language background with their doctor. This is so important because evidence shows that patients have better trust and communication with doctors of the same race or ethnic identity. Without that established relationship, medical care can become delayed causing worse outcomes, especially in populations that already have higher instances of diabetes, hypertension, obesity, and cardiovascular disease. Some minorities have mistrust in the healthcare system because of previous racist practices and so shun seeing a physician or getting necessary tests or vaccinations.

Blacks comprise 12% of the US population but only 5% of all physicians. How do we improve those statistics?  First of all, young blacks in their early formative years need to see black physician role models and teachers to inspire them and let them know that obtaining that degree is a possibility.  Medical schools should proactively see a social responsibility to increase the diversity of their students. But even then, most medical students graduate with debts of over $200,000! Minorities often come from families of little financial means as opposed to others who can get parental support for help through those lean years.  Some medical school debt can be forgiven in return for promising to practice in an underserved area for a few years. Many medical foundations provide minority scholarships, but that aid is often a drop in the bucket. Tuition in medical schools must go down or be at no cost (as in some other countries) for all students as these high costs dissuade many from entering medicine or going into a specialty that pays poorly, which is usually primary care, which we need the most!

SUMMARY:

University of Houston College of Medicine

We are seeing a trend towards having training geared to turn out more primary care physicians and to train more minority students. Here in Houston, we have just started a new medical school focused on training Primary Care physicians. University of Houston College of Medicine whose current first year students are 36% Black and 36% Hispanic, has as part of their mission the training of doctors who look like the communities they serve.

Nationally we are improving. According to the Association of American Medical Colleges (AAMC) our first-year students in medical schools are now 11.3% Black and 12.7% LatinX, but it will take years to catch up and we need to continue to make this a priority.

Patients want and need to have the cultural and ethnic diversity of physicians reflect their own.

 

Mentorship and Graduate Medical Education (GME) Slots

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We can all point to people that changed the course of our lives.  Mentors, many from our graduate medical education, that inspired us in medicine.

After my residency at Baylor College of Medicine, and as I pursued a fellowship in my specialty, I came to study under William K. Wright, MD.  From the first day, Dr. Wright not only readily shared his knowledge, but challenged me to build on his advances; to create and innovate new surgical techniques, to improve the level of patient care. With him the patients always came first and he would strive to do the best he could for each one of them.

The power of professional and personal mentorship inspired me to achieve excellence. I wanted to propel others and pay it forward for the next generation of surgeons in my specialty. As a clinical professor at University of Texas Health Science Center & McGovern Medical School, Department of Otorhinolaryngology, Head and Neck Surgery, residents rotate through my practice and many have been inspired to pursue private practices of their own, while others have thrived in academic settings.  It has been so rewarding to me to have had the opportunity to sit down with these beginning physicians and help and advise them as they plan out their career and life plans.

As a Fellowship Director for the American Academy of Facial Plastic and Reconstructive Surgery, I have trained more than 35 fellows and I know my current fellow will use her training to mentor others as well. Many of my previous fellows have continued to participate in organized medicine at the local, state, or national levels. Many have achieved leadership positions as well.  And one of my previous fellows is now my associate and partner in my own practice in Houston.

Yet, like other specialties, there are not enough Fellowship or Resident slots for the number of highly qualified candidates.  I get over 20 applicants a year for my one fellowship spot.   The AAMC’s annual survey shows that student body growth won’t alleviate the looming physician shortage unless the shortfalls in residencies and clinical training sites are also addressed.

SUMMARY:

Enrollment in the nation’s medical schools continues to grow, but leaders at many of those schools worry that there are not enough residency programs and clinical training sites for students to complete their requirements to become medical doctors, according to a new report from the Association of American Medical Colleges (AAMC).

We must find solutions. There needs to be more federal and state funding for residency training slots. Perhaps there are other funding sources as well for GME like the private or corporate sector as exemplified by performing arts groups.

Paying it forward to a new generation pays it forward to patients too.

Prior Authorization Burdens Effect Quality Of Patient Care

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The burdensome process of prior authorization reduces the time physicians have to take care of their patients.

As an active practicing physician and a past president of the Harris County Medical Society, I know the hassles of prior authorization.

Ninety-four percent of doctors reported care delays while waiting for health insurers to authorize necessary care. Nearly 80 percent of physicians say patients abandon treatment due to authorization struggles with health insurers.

Thirty percent of physicians report the prior authorization process required by health insurers for certain drugs, tests, and treatments has led to a serious adverse event, such as: death, hospitalization, or disability for a patient in their care.

On average, practices complete 40 prior authorizations per physician, per week, which can consume an average of nearly two business days of physician and staff time.

These results from the AMA’s survey conducted at the height of the COVID-19 pandemic in December 2020 highlight the significant negative impact of prior authorization on patients and physicians. The findings illustrate a critical need to streamline or eliminate low-value prior-authorization requirements to minimize delays or disruptions in care delivery.

The AMA has taken a leading role in advocating for prior authorization reforms and convening key industry stakeholders to develop a roadmap for improving the prior authorization process.

The AMA has developed model state legislation and resources to support and drive prior authorization and step therapy reforms. In 2019, there were more than 80 bills in state legislatures addressing utilization management, and in 17 states, medical societies were able to enact prior authorization or step therapy legislation despite facing strong opposition from insurers and their local trade associations. There are numerous bills under consideration this year. Texas was able to convince its legislature to enact a “gold card” for doctors who don’t order unnecessary tests who then get a pass on prior authorization.

For several years, the AMA has conducted a multi-faceted campaign urging health plans to “right-size” prior authorization programs. Due to successful AMA advocacy, CMS is addressing prior authorization burdens through the “Patients Over Paperwork” Initiative.

SUMMARY:

But, we can’t let up.  Prior authorization burdens are a major issue for patients and physicians. As physicians we need to continue to advocate for ourselves and for our patients. Physicians can get involved in the AMA grassroots advocacy campaign — FixPriorAuth.org.   And physicians need to continue to raise their voices through their local, state and national government representatives.

International Medical Graduates Are Vital

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Politics too often play a role in the immigration system and all groups are lumped together without an examination of the vital role that immigrants play in our country. This is also true for International Medical Graduates (IMGs) who have provided a vital role in health care in the US for decades, especially in underserved and rural communities, and for whom we are grateful.

For decades IMG physicians have provided a valuable safety net of care for patients in this country. The commitment of International Medical Graduates not only extends to the patients they serve but the communities in which they live, where IMGs become valuable community leaders and stewards of health. In 2017, nearly a third (31.8 percent) of all physicians specializing in family medicine, internal medicine, and pediatrics—three specialties associated with primary health care—were foreign-trained.

But at the same time IMG’s have had to face almost insurmountable hurdles to get to this country and then practice: special examination requirements, repeating of residencies, acculturation problems, country visa quotas, long administrative and decade long delays and bottlenecks for J-1, H-1B visas, and green cards and unreasonable requirements for spouses (H4-EAD) of H-1B visa holders not to work. Also, IMGs often experience implicit bias not only from their patients but also from their non-IMG medical colleagues.

I have been one of those to have brought those problems back to the Board. Our advocacy and education divisions, and a very active response has helped to improve the situation on many fronts. For example, when I was Board Chair during the Covid-19 pandemic, we successfully urged the State Department to reverse the suspension of visa processing for foreign-born medical professionals, successfully encouraged them to allow the extension of programs for J-1 physicians, and encouraged the U.S. Citizenship and Immigration Services  to temporarily expedite extensions and changes of status for foreign national doctors currently in the U.S. We also joined with medical education and other health care organizations to fight an Immigration and Customs Enforcement proposal that would upset the “duration of status” for foreign trained medical professionals.

During my tenure as Chair, when the Trump administration attempted to scrap the DACA program, the AMA, which has long been opposed to such an immigration action, filed an amicus brief in the Supreme Court in support of the estimated 30,000 DACA recipients who work in healthcare nationwide and persuaded the Supreme Court to allow the DACA program to continue. I also asked Aletha Maybank, MD, SVP and head of the Center for Health Equity to look into expanding her great work and that of the Center into confronting the bias problems IMGs encounter.

Summary:

However, there is certainly more that can be done at the local, state and national level. While, numerous International Medical Graduates have attained leadership roles in State Medical Associations and in the AMA, the numbers are not enough based upon the percentage of physicians IMGs represent in the physician population. As active physicians at the local and state level we can help to increase the participation of IMGs. The AMA should continue to fight for fair requirements and special treatment of IMGs that recognize their training and importance to health care in our country and do away with the delays that impede that progress. And the AMA can also work within the academic spheres to make the transition and educational requirements to providing care in the U.S. after a full residency abroad not so onerous.

No Medicare Pay Bump Recommendation for Physicians Is Harmful

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Recently the Medicare Payment Advisory Commission (MedPAC) made a misguided recommendation to Congress to continue the Medicare physician payment freeze for calendar year 2023, while at the same time recommending increases for hospitals.

In committing this act of health policy malpractice, the Commission has failed to consider the realities today’s practicing physicians face across all modalities of delivery of care — particularly during a time of COVID, massive staff shortages and skyrocketing expenses.

The Need for An Increase in Medicare Payments

There is a plethora of factors demonstrating the urgent, real-life need for an increase in physician payments.  To mention a few:

  • After adjusting for practice costs inflation, physician payments under Medicare DROPPED 20% from 2001 to 2020.
  • The gap between payment and the cost of running a practice has increased consolidation and caused physicians to flee rural and underserved areas, leaving patients who desperately need healthcare with little or no access.
  • There is a 7% increase in the consumer price index. A 0% payment update for physicians is in stark contrast and makes the practice of medicine unsustainable.
  • One in five physicians across all delivery modalities is considering leaving practicing within the next two years, given the burnout, stress, unmanageable workload and fear of COVID-19 infection.
  • There is an expected 1.5 million increase in Medicare enrollees annually through 2029. If physicians reduce their hours or leave practice as reported, there will not be enough physicians available to deliver care.
  • In an environment where inflation is unpredictable and quite high as it is now, it is an issue for physicians in all settings who need to hire and retain staff. Without any boost in payments, staffing will become even more difficult, leading to delays in care.
  • For most physicians, it has gone beyond burnout and, in many cases, escalated to a post-traumatic stress disorder-like situation. Seeing patients die from COVID who would normally survive or patients not receive care or die from other causes because beds are being taken by COVID patients is overwhelming.

Out of the 17 MedPAC members, only 6 have a medical degree and none are actively practicing to my knowledge.  Without being in the day-to-day trenches, MedPAC is missing the actual reality for doctors and the detrimental impact a zero percent increase will have on patient care. Medpac’s decision to make Medicare payments fall behind overhead will only increase the shortages of physicians and harm access to care. Simply put, no Medicare payment bump will harm both physicians and patients.

What can you do?

Write or call your Congressperson.  If you aren’t a member, join the AMA and your local medical society and add your voice to the advocacy team.  Be vocal and talk about the issue to others and use social media to spread the word and keep the issue at the forefront.  Others need to help advocate for physicians when they cannot advocate for themselves.  They just may be saving the life of a loved one.