Have you ever coerced your doctor into prescribing an antibiotic?

I used to. I stopped. Here’s why.

Like many people I know I also stockpiled antibiotics thinking I knew when to call my physician and get his approval or would infrequently simply start myself on an antibiotic regimen. ZPack for an upper respiratory infection. Augmentin for a sinus infection. Cipro for a prostate discomfort. Doxycycline for Lyme disease.

Here’s the chain of antibiotic abuse and its consequences.

“You’re sick. You’re not sure what it is, but you know you would really love for this achy feeling, stuffed-up head or painful cough to go away. So you go to the doctor and demand drugs.If recent research is any indication, your physician will probably prescribe you an antibiotic, even if he or she knows it won’t make you better any faster.” (A)

“Antibiotic agents don’t work for viral infections and should not be prescribed. However, it is often easier to write a prescription than to explain to a patient why you won’t. I have had patients leave my office very angry and immediately go to another doctor to get the antibiotics that I have declined to give.” (B)

“Antibiotic use promotes development of antibiotic-resistant bacteria. Every time a person takes antibiotics, sensitive bacteria are killed, but resistant germs may be left to grow and multiply. Repeated and improper uses of antibiotics are primary causes of the increase in drug-resistant bacteria. While antibiotics should be used to treat bacterial infections, they are not effective against viral infections like the common cold, most sore throats, and the flu. Widespread use of antibiotics promotes the spread of antibiotic resistance. Smart use of antibiotics is the key to controlling the spread of resistance.” (C)

“Antibiotic resistance is highly problematic because it severely hinders our ability to treat infectious diseases. In addition, surgery is dependent on the administration of antibiotics before and after the operation. Cancer patients and patients who have received organ transplants rely on antibiotics to protect them from bacteria, as the former have compromised immune systems while the latter needs to suppress their immune systems from attacking the transplanted organs.Without effective antibiotics, basic medical procedures and surgical operations could become very high risk because there’s a much higher risk the patient could be infected with an antibiotic microbe and be without appropriate treatment while recovering from the operation.”In addition to causing deaths and preventing basic infectious conditions to be treated, antibiotic and antimicrobial resistance will lead to steeper healthcare costs. Patients will need to spend more time in hospital in order to receive more expensive types of treatment.” (D)

“As drug resistance increases, we will see a number of dangerous and far-reaching consequences. First, common infections like STDs, pneumonia, and “staph” infections will become increasingly difficult to treat, and in extreme cases these infections may require hospitalization or treatment with expensive and toxic second-line therapies…. Health care providers are increasingly encountering highly resistant infections not only in hospitals – where such infections can easily spread between vulnerable patients – but also in outpatient care settings.” (E)

“Any species of bacteria can turn into a superbug. Misusing antibiotics (such as taking them when you don’t need them or not finishing all of your medicine) is the “single leading factor” contributing to this problem, the CDC says. The concern is that eventually doctors will run out of antibiotics to treat them. “What the public should know is that the more antibiotics you’ve taken, the higher your superbug risk …… The more encounters you have with the hospital setting, the higher your superbug risk.” (F)

“For the first time, researchers have found a person in the United States carrying bacteria resistant to antibiotics of last resort, an alarming development that the top U.S. public health official says could mean “the end of the road” for antibiotics.The antibiotic-resistant strain was found last month in the urine of a 49-year-old Pennsylvania woman. Defense Department researchers determined that she carried a strain of E. coli resistant to the antibiotic colistin, according to a study published Thursday in Antimicrobial Agents and Chemotherapy, a publication of the American Society for Microbiology. The authors wrote that the discovery “heralds the emergence of a truly pan-drug resistant bacteria.” (G)

“Taking antibiotics you do not need will not help you feel better, cure your illness, or keep others from catching your infection. But taking them may cause side effects such as: • Nausea. • Diarrhea. • Stomach pain. •An allergic reaction. In rare cases, this reaction can require emergency care.

Antibiotics also can cause Clostridium difficilecolitis (also called C. difficilecolitis), a swelling and irritation of the large intestine, or colon camera.gif. This happens because the antibiotics kill the normal bacteria in your intestine and allow the C. difficile bacteria to grow. This problem can cause diarrhea, fever, and belly cramps. In rare cases, it can cause death. Women may get vaginal yeast infections from taking antibiotics.” (H)

Final Note

“When an antibiotic is prescribed, it is wise to ask what the drug is and whether it is necessary, what side effects to be alert for, whether there are effective alternatives, when to expect the diagnosed condition to resolve, and when to call if something unexpected happens or recovery seems delayed.” (I)

NOTE: This blog shares general information about understanding and navigating the health care system. For specific medical advice about your own problems, issues and options talk to your personal physician.

(A) http://www.cnn.com/2014/05/21/health/antibiotics-virus-bacteria/

(B) https://www.healthtap.com/user_questions/409225-why-would-a-doctor-prescribe-an-antibiotic-for-a-patient-with-viral-pneumonia

(C) http://www.rxlist.com/antibiotic_resistance-page3/drugs-condition.htm

(D) https://www.cbhs.com.au/news/2014/11/24/antibiotic-resistance-causes-and-consequences

(E) http://www.brookings.edu/blogs/up-front/posts/2014/05/22-antibiotic-resistance-fda-phrma-biotech-danielg

(F) http://www.webmd.com/news/20150417/superbugs-what-they-are

(G) https://www.washingtonpost.com/news/to-your-health/wp/2016/05/26/the-superbug-that-doctors-have-been-dreading-just-reached-the-u-s/

(H) http://www.webmd.com/a-to-z-guides/using-antibiotics-wisely-topic-overview

(I) http://well.blogs.nytimes.com/2012/09/10/popular-antibiotics-may-carry-serious-side-effects/?_r=0


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I was flabbergasted when Trump said “We can’t continue to allow China to rape our country.” (A)

There are some words that evoke dramatic imagery and should not be used casually. The recent passing of Elie Wiesel reminds us of the power of the word “holocaust.”

And “rape” is one of those words.

“The use of “rape” in such a casual way misrepresents the gravity of sexual assault. Rape is no laughing matter. In the United States, approximately 16 percent of women and three percent of men have been victims of attempted or completed rape. Fifteen percent of sexual assault victims are under 12. Sexual assault victims are three times more likely to suffer from depression and four times more likely to contemplate suicide than non-victims.” (B)

Rape evokes: sexual abuse on college campuses; Bill Cosby; sex trafficking; out-of-control professional athletes, Comfort Women, Spotlight…..

A new movie makes it very clear.  “The Innocents” begins at the end of World War II in Poland, December 1945. Serene, austere Benedictine nuns sing sweetly in the quiet stillness of morning—until a piercing scream echoes through the stone hallways, sending a chill. Turns out, it’s coming from an extremely pregnant, young nun who’s on the verge of giving birth—and she’s not alone…..As the Reverend Mother (Kulesza) and her right-hand woman Maria (Buzek) matter-of-factly explain it, Soviet soldiers invaded the convent and repeatedly raped the women as the war was ending.” (C)

A college student recently wrote: ” With that said, I urge all of you to stand up. Next time someone makes a joke, tell him or her that it isn’t funny. Next time someone uses rape as a substitute word, tell him or her that it isn’t OK. Stand up because chances are the person those jokes are really hurting is unable to do so—myself included. (D)

Health care providers take this seriously. For example, The Mount Sinai Hospital Sexual Assault and Violence Intervention Program’s mission is:  1. “To meet the needs of rape, sexual assault and domestic violence survivors by offering immediate crisis intervention in hospital emergency rooms. 2. To follow up with psychotherapy, counseling and information both for past and present survivors and their families and friends. 3. To educate the public and professionals regarding services and issues of sexual and domestic violence. (E)

Searching the internet I could not find a single reference that uses “rape” as an (academic) economic term.

Maybe Trump’s children will explain this to him. 

(A)   http://www.cnn.com/2016/05/01/politics/donald-trump-china-rape/

(B)   http://www.huffingtonpost.com/2012/01/09/teen-slang-why-the-word-r_n_1194059.html

(C)   http://www.rogerebert.com/reviews/the-innocents-2016

(D)   http://timesdelphic.com/2011/10/23/misuse-of-the-word-rape-is-a-problem

(E)    http://www.mountsinai.org/patient-care/service-areas/community-medicine/areas-of-care/sexual-assault-and-violence-intervention-program-savi/about-us

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It’s like the Wild, Wild West, the (physician specialty) turf wars…. (A)

My first experience with clinical turf competition was in 1968 as administrator of the Department of Surgery at Wilford Hall U.S.A.F. Medical Center. The Chiefs of general surgery, E.N.T., and Oral Maxillofacial Surgery each needed Head & Neck surgical cases for their residents. Time and time again protocols were agreed upon to rotate the cases but they always broke down when residents in one specialty or another needed the required number of H&N cases before they graduated. Interestingly I never recall that any of the Chiefs thought the patients had a role in the decision-making.


Fast Forward! STENTS

We all know about cardiac stents. Now cardiologists have seamlessly moved on to use stents for treatment of renal artery stenosis (B) and carotid artery disease (C).

But this is just the tip of the iceberg. “Currently, the major interventional specialties are interventional (or vascular) radiology, interventional cardiology, and endovascular surgical (interventional) neuroradiology. All three are perfecting the use of stents and other procedures to keep diseased arteries open, while also evaluating the application these procedures. The rapid new development of imaging technologies, mechanical devices, and types of treatment, while certainly beneficial to the patient, can also lead to ambiguity regarding specific specialty claims on certain techniques and devices.” (D)


Some other clinical areas where specialties overlap or may not be intuitively understood.


Urogynecology. Female Urology.

An urogynecologist is an obstetrician/gynecologist who has completed fellowship training in the evaluation and treatment of pelvic floor disorders. (E)

Urology is a surgical specialty which deals with diseases of the male and female urinary tract and the male reproductive organs……Female Urology (urinary incontinence and pelvic outlet relaxation disorders) (F)


Child Neurology. Pediatric Neurology.

Child neurologists are medical doctors who have completed: Four years of medical school; At least 1 to 2 years of pediatric residency; Three or more years of residency training in adult and child neurology. In addition, most child neurologists have certification from the American Board of Pediatrics and the American Board of Psychiatry and Neurology (with special competency in child neurology). (G)


Sports Medicine

AOSSM members are orthopaedic surgeons and allied health professionals who demonstrate scientific leadership, involvement and dedication in the daily practice of sports medicine. (H)

Sports medicine physicians, who may be allopathic or osteopathic physicians, focus their practice on health care for athletes and physically active individuals. Sports medicine primary care physicians treat anyone who is physically active help them improve performance, enhance overall health, prevent injury and maintain their physical activity throughout their lives. Some work with professional and amateur sports teams. (I)


Pain Medicine

The American Academy of Pain Medicine (AAPM) is the medical specialty society representing physicians practicing in the field of pain medicine. As a medical specialty society, the Academy is involved in education, training, advocacy, and research in the specialty of pain medicine.

The practice of pain medicine is multi-disciplinary in approach, incorporating modalities from various specialties to ensure the comprehensive evaluation and treatment of the pain patient. AAPM represents the diverse scope of the field through membership from a variety of origins, including such specialties as anesthesiology, internal medicine, neurology, neurological surgery, orthopedic surgery, physiatry, and psychiatry. (J)


Board Certified

No matter which type of physician you choose, only go to those who are BOARD CERTIFIED. “Board Certification is a voluntary process, and one that is very different from medical licensure. Obtaining a medical license sets the minimum competency requirements to diagnose and treat patients, it is not specialty specific. Board Certification demonstrates a physician’s exceptional expertise in a particular specialty and/or subspecialty of medical practice.” (K)

Typically, for example a Board Certified surgeons will have F.A.C.S. (Fellow, American College of Surgeons) after their names. John Smith, M.D., F.A.C.S. There is no modesty here, a Board Certified physician will let you know.

There used to be the term “Board Eligible” which meant a physician finished residency training but had not taken and/ or passed the Board exam. Some physicians called themselves Board Eligible for their entire careers. Beware the use of the term Board Eligible unless the physician has just finished training and waiting to take the Board exam the first time it is given.


On the horizon a new clinical specialty? Complex Care Management

“Persons whose conditions require complex continuous care and frequently require services from different practitioners in multiple settings.

Care management of patients with complex care needs Usually patients who are Medicare beneficiaries with multiple chronic conditions, frequent hospitalizations, and limitations on their ability to perform basic daily functions due to physical, mental and psychosocial challenges. Patients with complex health care are patients at the far end of a population-wide spectrum ranging from health individuals to people with serious medical problems and high utilization of heath care services.” (L)


Dentistry is getting confusing too:

We are used to the traditional array of dental residency training programs and Board Certification: Dental Public Health; Endodontics; Oral and Maxillofacial Pathology; Oral and Maxillofacial Radiology; (Pathology and Radiology are news to me) Oral and Maxillofacial Surgery; Orthodontics and Dentofacial Orthopedics; Pediatric Dentistry; Periodontics; Prosthodontics. (M)

Now we see: the elevation of general dentistry (N); cosmetic dentistry (O); sedation dentistry (P); geriatric dentistry (Q); and full mouth reconstruction (have you seen the TV ads for FMR all in one day, financing available!)

As always when faced with difficult and complex clinical options, in this case being certain you are going to see the right specialist, your primary care physician should be your advisor and advocate (and should disclose any “conflicts” he or she has related to the issue at hand).

(A) http://nymag.com/nymetro/health/columns/strongmedicine/n_9311/

(B) http://www.wkhs.com/Heart/Services/Peripheral_Vascular_Disease_Treatments/Renal_Angioplasty_and_Stents.aspx

(C) http://www.texasheart.org/HIC/Topics/Proced/carotidangioplasty.cfm

(D) http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2745361/

(E) https://www.cornellurology.com/clinical-conditions/female-urology-urogynecology/

(F) https://www.auanet.org/about/what-is-urology.cfm

(G) https://healthychildren.org/English/family-life/health-management/pediatric-specialists/Pages/What-is-a-Child-Neurologist.aspx

(H) http://www.sportsmed.org/AOSSMIMIS/Members/About/Members/About_AOSSM.aspx?hkey=170bd237-cc97-4dd0-aa54-3a20f82cf8e3

(I) http://explorehealthcareers.org/en/Career/168/Primary_Care_Sports_Medicine

(J) http://www.painmed.org/

(K) http://www.abms.org/board-certification/

(L) http://www.ncbi.nlm.nih.gov/pubmedhealth/PMH0051448/

(M) http://www.ada.org/en/education-careers/careers-in-dentistry/dental-specialties/specialty-definitions

(N) http://www.agd.org/membership.aspx(O)http://www.aacd.com/american-board-cosmetic-dentistry/

(P) http://www.yourdentistryguide.com/sedation/

(Q) https://www.deepdyve.com/lp/wiley/american-society-for-geriatric-dentistry-GFcIS0a637(R) http://www.yourdentistryguide.com/fmr/

Note: This blog shares general information about understanding and navigating the health care system. For specific medical advice about your own problems, issues and options talk to your personal physician.

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Do you want to be treated by a stranger when you are admitted to the hospital? Every practicing physician should have hospital privileges.

Two recent health care episodes have sharpened my conviction that every practicing physician should be affiliated with a hospital.

In December I was admitted to the hospital for one night for observation. My care was managed by my gastroenterologist and my primary care physician, both of whom I have been with for almost twenty years. There coordination was perfection, I was fully informed, and all worked out well.

While I have been on the faculty of Mount Sinai medical school in New York City for forty+ years, over time, with the exception of my urologist, all my physicians (PCP, GI, orthopedics, ophthalmologist, and dermatologist) now practice near where I live in Hoboken, are on the same hospital medical staff, and know each other well.

Recently I was at physician’s office for a routine periodic screening. A Family Practice resident was shadowing my doctor and when we chatted he said it was not necessarily his plan to be on a hospital medical staff after he finished his training. I was flabbergasted that the GME program had not emphasized that as an “automatic”.

More and more primary care physicians are in full time office practice and hand patients off to hospitalists for inpatient care. Not to be confused with Intensivists: A physician who specializes in the care of critically ill patients, usually in an intensive care unit (ICU). (4)

The American Academy of Family Physicians defines a PRIMARY CARE PHYSICIAN as follows:

A primary care physician is a specialist in Family Medicine, Internal Medicine or Pediatrics who provides definitive care to the undifferentiated patient at the point of first contact, and takes continuing responsibility for providing the patient’s comprehensive care. This care may include chronic, preventive and acute care in both inpatient and outpatient settings. Such a physician must be specifically trained to provide comprehensive primary care services through residency or fellowship training in acute and chronic care settings.”

“All physicians should obtain hospital privileges in accordance with their individual qualifications, i.e., documented training and/or experience, demonstrated abilities, and current competence.” (1)

A Hospitalist is: ”A hospital-based general physician. Hospitalists assume the care of hospitalized patients in the place of patients’ primary care physicians.” (2) *The trend toward full time, salaried hospitalists is driven by “….convenience, efficiency, financial strains on primary care doctors, patient safety, cost-effectiveness for hospitals, and need for more specialized and coordinated care for hospitalized patients.” (3)

Well, I am not convinced!

Why develop a relationship with a PCP only to be treated by a “stranger” team of hospitalists?

Even if you are admitted to the service of a hospitalist or specialist (e.g., neurologist for evaluation for Parkinson’s disease) don’t you want your PCP by your side as well, even if it is not as the primary diagnostician?

If PCPs don’t participate in the care of sick patients don’t their diagnostic skills diminish by what they no longer see and do?

You don’t get to pick you hospitalist. These physicians work in shifts and you are likely to be cared for by multiple hospitalists during a hospital stay.

In my mind the solution is that every practicing physician should be required to have hospital privileges. Every hospital medical staff develops criteria to maintain privileges in the context of accreditation, licensure and other compliance requirements.

The key ones have to do, for example, with attending departmental conferences and serving on clinical committees.

The most important reality is that being on a hospital medical staff subjects each physician to interaction with other physicians on best practices and now many hospitals have physician quality metrics. And it is a safety valve to make sure impaired physicians are identified and helped, and “senior” physicians do not practice outside the scope of their capabilities.

But mostly it is to remember the importance of “continuity of care” (apparently now out of favor) and respect for the patient who must not be handed off to a stranger when serious illness strikes.

1. http://www.aafp.org/about/policies/all/primary-care.html

2. http://www.medicinenet.com/script/main/art.asp?articlekey=8384

3. http://www.medicinenet.com/script/main/art.asp?articlekey=23392

4. http://www.medicinenet.com/script/main/art.asp?articlekey=93946

Note: This blog shares general information about understanding and navigating the health care system. For specific medical advice about your own problems, issues and options talk to your personal physician.


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Stop the name games! University hospitals and regional medical centers should live up to their billing *

Remember when a hospital was just a hospital, and its reputation spoke for itself? Now we have a plethora of self named healthcare institutions such as clinics, community hospitals, institutes, medical centers, national hospitals, specialty hospitals, and teaching hospitals.

My home state of New Jersey, for example, started with one children’s hospital in Newark, followed by a few more designated under state Health Department competitive certificate-of-need guidelines, followed by a few politically designated by the Legislature, followed by a bunch of sound-alikes such as a “children’s medical center” mischievously bypassing the fact that “children’s hospital” is a legislatively restricted name.

For the most part these appellations are used to define the hospital to its community and publicly compare it most positively to other nearby competitors. However, more and more hospitals are now calling themselves regional medical centers and university hospitals. These are very robust terms, sometimes used interchangeably or together, and imply characteristics such as comprehensive critical-care services, cardiac surgery/interventional cardiology, comprehensive stroke care, an academic environment, the latest cutting-edge technology, and a full-time cadre of 24/7 on-site superspecialist physicians, including intensivists.

And the not-so-subliminal message is that when you are very sick or injured you should bypass your local hospital.

The reality is that in New Jersey a hospital can call itself whatever it wants—there is no name regulation or oversight by state authorities. A few years ago Robert Wood Johnson University Hospital challenged and lost, when St. Peter’s Hospital added “University” to its name. Since then a number of other hospitals have added “University” as well, and more will follow. Certainly this phenomenon is not limited to New Jersey.

The Association of American Medical Colleges states: “Teaching hospitals are providers of primary care and routine patient services, as well as centers for experimental, innovative and technically sophisticated services. Many of the advances started in the research laboratories of medical schools are incorporated into patient care through clinical research programs at teaching hospitals.”

I believe a university hospital/regional medical center should have most of the following characteristics typical to “major league” hospitals:

■ First and foremost, it should have a written affiliation agreement with a medical school that includes the rotation of medical students to the hospital for required third year clinical rotations in internal medicine, obstetrics and gynecology, pediatrics, psychiatry and surgery.

■ The hospital should have full-time chairmen in the core clinical departments (e.g., medicine, pediatrics, surgery) selected by a joint hospital-medical school search committee, and not as a reward for seniority or admitting a lot of patients.

■There should be at least three physician residency-training programs under the supervision of the medical school.

■ All physicians teaching students and residents should qualify for faculty appointments at the affiliated medical school.

■ A dean’s committee composed of senior medical and administrative staff from the hospital and school should meet regularly to jointly set strategic priorities and evaluate program efficacy and performance.

■ The hospital’s medical staff bylaws should mandate automatic removal from the staff of any physician who does not achieve board certification after a given period of time, such as five years.

■ The hospital should have at least three state-designated critical-care services such as trauma center, regional perinatal center (high-risk obstetrics), stroke center, children’s hospital or cardiac surgery. There should be full-time intensivists in all ICUs.

■The hospital should be a member of all major statewide multihospital clinical-care quality projects such as the New Jersey Hospital Association’s ICU and pressure-ulcer collaboratives. It should participate in clinical trials that the medical school has undertaken, and be a training site for students in nursing, pharmacy, physical therapy and other health professions.

■It should have a full-time chief medical officer, a senior physician preferably with a master’s degree earned through the American College of Physician Executives (or equivalent) and a chief nursing officer with an appropriate doctoral degree.

■Finally, the hospital’s board, administration and medical staff must have a demonstrable unwavering “safety net” commitment to the medically underserved.

These steps are, of course, easier said than done, so here are some initial steps for the states to consider:

State hospital associations should set up task forces to develop a policy and strategy to make sure hospital names are educational to the public, not exaggerations of capability.

A state could pass a law or the health department could promulgate regulations defining the requirements to be designated a university hospital or regional medical center. These designations should be subject to periodic state review.

Obtaining the appropriate and best hospital care should not be complicated by creative and clever hospital marketing but by easily understandable evidenced-based standards and metrics—and names.

* By Jonathan M. Metsch, Dr.P.H., August 18, 2008 • Modern Healthcare

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Chief Fourth of July Officer

My first experience with hospital administrative titles was in 1967 as a 2nd Lieutenant in the Air Force assigned to Wilford Hall USAF Medical Center in San Antonio. The Hospital Commander was a physician Brigadier General. That was the only title/ rank that mattered.

Returning to NYC in 1972 a typical hospital had a President & CEO, EVP & COO, and an SVP & CFO.

I was taught that President was a title and CEO was a function, nonetheless over time many hospital leaders started referring to their title as CEO, a trend that continues.

On a rapid trajectory we have seen hospitals become regional hospital systems focusing on becoming integrated health care delivery systems, to mega systems focusing on geographic reach, to super-size systems which have started or taken over medical schools, functioning almost like insurance companies and investment banks.

And with that an explosion of C-Level titles.

But I digress.

So now we have, for example (curated from hospital web sites. Really!)….. Chief Medical Officer, Chief Information Officer, Chief Revenue Officer, Chief Affiliation Officer, Chief Learning Officer, Chief Experience Officer, Chief Managed Care and Business Development Officer, Chief Quality Officer, Chief Development Officer, Chief Public Relations Officer, Chief Procurement Officer, Chief Human Resources Officer, Chief Legal Officer, Chief Corporate Compliance Officer, Chief Financial Officer, Chief Operating Officer, Chief Marketing and Communications Officer, Chief Administrative Officer, Chief Nurse Executive, Chief Academic Officer, Chief Strategy Officer, Chief Information Officer, Chief Population Health Officer, Chief Diversity and Inclusion Officer, Chief Risk Officer, Chief Investment Officer, Chief Medical Information Officer, Chief Clinical Integration Network Development Officer, Chief Technology Officer, Chief IT Officer, Chief Sustainability Officer.

“We are living in the age of flattening org structures with the hope of making organizations more fair and efficient, yet employees still want to feel important (like they are progressing up the chain). This is the environment where title wackiness is allowed and encouraged to happen.” (A)

“The snag is that the familiar problems of monetary inflation apply to job-title inflation as well. The benefits of giving people a fancy new title are usually short-lived. The harm is long-lasting. People become cynical about their monikers (particularly when they are given in lieu of pay rises).” (B)

“What began with a C-suite of corporate leaders has morphed into a full-fledged assault on traditional chains of command, with a seemingly endless cascade of increasingly specialized, yet amorphous, positions in an unwieldy hodgepodge of matrixed responsibilities. It’s title inflation at its worst and often counterproductive to effective management.” (C)

C-Level titles have become so pervasive in some mega-systems it is unrealistic that they all report to the CEO or COO. So to reflect the operating TO it is likely a new top-tier-title strata will be necessary to explain who is really in charge and has final authority. Starting with something like Deputy CEO which will later become First Deputy CEO and later Senior First Deputy CEO – then similar clarifiers throughout the C-Suite.

Skipping a level up we already see major hospital systems with numerous Presidents presiding over different types of entities (e.g., hospitals, insurance companies, physician practices, imaging & urgi and surgi centers) and again, at some point differentiators will need to be added.

The key to the future might be the designation of a “Chief Corporate Title Tracking Officer”, unless the rumored so-called “C-Level Title Non- Proliferation Treaty” being advanced by some major academic medical centers becomes a reality.

And of course I am guilty too…using four academic titles…Clinical Professor, Preventive Medicine, Icahn School of Medicine at Mount Sinai; Adjunct Professor, Ziklin School of Business, Baruch College, C.U.N.Y.; Adjunct Professor, Rutgers School of Public Health; & Adjunct Professor, Rutgers School of Public Affairs and Administration.

(A) https://www.linkedin.com/pulse/era-title-inflation-upon-us-edward-kiledjian

(B) http://www.economist.com/node/16423358

(C) http://blogs.wsj.com/experts/2014/03/12/the-proliferation-of-c-suite-titles-is-insane/

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Iatrogenic disorders. Never events. Incidentalomas

“Jon, I recall learning about iatrogenic medicine in grad school; an under-the radar sub-specialty.” (email from Leon Silverberg, a health care MBA student in my  class 45 years ago)

Have you ever coerced your physician to prescribe an antibiotic (think sinus “infection”) or gone to a physician who prescribes antibiotics too automatically? (A) I used to demand and hoard antibiotics. I have stopped and now ask my physicians to explain why they are prescribing an antibiotic.

Overprescribing of antibiotics and other medical care decisions can have adverse consequences often referred to as “iatrogenic.”

“An iatrogenic disorder occurs when the deleterious effects of the therapeutic or diagnostic regimen causes pathology independent of the condition for which the regimen is advised….. Diagnostic procedures (mechanical and radiological), therapeutic regimen (drugs, surgery, other invasive procedures), hospitalization and treating doctor himself can bring about iatrogenic disorders. (B)

Another important term is “Never Events”……”in reference to particularly shocking medical errors (such as wrong-site surgery) that should never occur. Over time, the list has been expanded to signify adverse events that are unambiguous (clearly identifiable and measurable), serious (resulting in death or significant disability), and usually preventable.” (C)

So…. here are some examples of medical care to monitor.


Wrong Site Surgery.

“Of great concern is wrong-site surgery (WSS), which encompasses surgery performed on the wrong side or site of the body, wrong surgical procedure performed, and surgery performed on the wrong patient. This definition also includes “any invasive procedure that exposes patients to more than minimal risk, including procedures performed in settings other than the OR [operating room], such as a special procedures unit, an endoscopy unit, and an interventional radiology suite.”

Solutions: “to improve the accuracy of patient identification by using two patient identifiers and a “time-out” procedure before invasive procedures.” … “to eliminate wrong-site, wrong-patient, and wrong-procedure surgery using a preoperative verification process to confirm documents, and to implement a process to mark the surgical site and involve the patient/family.” (D)


Over Use of Antibiotics.

“’Nightmare bacteria,’ strains of superbugs resistant to even the most powerful antibiotics, have quadrupled in number in the last decade—and have been found lurking in hospitals in 42 states.” “(E)

“Antibiotics are considered the keystone of modern medicine, but their excessive use continues to generate unwanted side effects.

While specialists are making strides to preserve the effectiveness of antibiotics and to slow potential infections through better policy, the overuse of antibiotics continues to have severe health consequences for the U.S. and around the world. (F)


Medication Errors

“… any preventable event that may cause or lead to inappropriate medication use or patient harm, while the medication is in the control of the health care professional, patient, or consumer. Such events may be related to professional practice, health care products, procedures, and systems including: prescribing; order communication; product labeling, packaging and nomenclature; compounding; dispensing; distribution; administration; education; monitoring; and use”.  (G)



….are “incidentally discovered masses or lesions, detected by computed tomography (CT), magnetic resonance imaging (MRI), or other imaging examinations performed for an unrelated reason. (H)

Incidentalomas are increasingly common findings on radiologic studies, causing worry for physicians and patients. Physicians should consider the risk of discovering incidentalomas when contemplating imaging. Patients may assume that incidentalomas are cancer, and may not be aware of the radiation risks associated with repeat imaging. (I)

“Many radiologists and nonradiologic physicians believe we should not report incidentalomas if they appear benign. As pointed out by 2 medical researchers, “Tests that provide information about unrelated conditions leave the physician and patient to contend with information they had not sought but which they find impossible to ignore; patients would be better served if physicians limited their access to unsolicited diagnostic information.”” (H)


 Having said that, your best resource in avoiding an iatrogenic  emergency is a great primary care physician.


(A)          http://www.medscape.com/viewarticle/827888

(B)          http://medind.nic.in/maa/t05/i1/maat05i1p2.pdf

(C)          https://psnet.ahrq.gov/primers/primer/3/never-events

(D)          http://www.ncbi.nlm.nih.gov/books/NBK2678/

(E)           http://www.npr.org/2013/03/08/173821490/nightmare-bacteria-defy-even-last-ditch-drugs

(F)           http://www.healthline.com/health-news/five-unintended-consequences-antibiotic-overuse-031114#1

(G)          http://www.amcp.org/WorkArea/DownloadAsset.aspx?id=9300

(H)          http://www.medscape.com/viewarticle/779377

(I)            http://www.ncbi.nlm.nih.gov/pubmed/25611713

 Note: This blog shares general information about understanding and navigating the health care system. For specific medical advice about your own problems, issues and options talk to your personal physician.


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