Kurt Munzer

It’s the respiratory failure associated with acute on chronic multi organ failure…I’m an optimist, but I’m consulted daily on octogenarians with O2 dependent COPD, CKD 4-5, CHF with moderate to severe MR/AS, progressive debility, recurrent hospitalizations, etc. I sometimes feel as though I’m consulted only to have a goals of care discussion…

@afinitetimeline We’ve gotten decent of managing chronic illness. That’s my theory. Plus an aging population.

I really lack the words to describe how complicated the pulmonary cases are these days.

Fellow doctors, please don’t have this mindset. We all get this: “I have a bulging disc.” Try: “Oh I’m sorry to hear that.” “What kind of symptoms are you having” “Let’s see if there’s anything I can do for you” And explain the disease

I haven’t looked at the data in a bit, but even with excellent specificity, false positives will occur…I’d imagine testing ‘low risk’ populations will decrease PPV even further-would favor high risk populations initially. Nonetheless, cfDNA tests will continue to improve and transform patient care. Pairing cfDNA testing with LDCT in high risk patients could substantially decrease invasive procedures for benign nodules…

I don’t suppose GRAIL is planning on doing the work up on an “positive” marker lab test or if they were planning to punt that straight to the client’s physician? What are the sensitivity and specificity stats for these markers? I suspect this is one of those things that looks good on paper but smells like bullsh*t the closer to look at it. I can see the new consults now. Reason for consult: “positive lab markers for lung cancer” - leading to unnecessary testing and anxious people. It looks like all profits, no responsibility. All on the backs of the worried well.

When a patient is in the hospital, doctors used to use paper notes to communicate with one another. In the EHR era, the note stopped being a clinical communication tool and became a billing and compliance artifact. The results have been a disaster. One JAMA study found notes got 60.1% longer from 2009 to 2018, while redundancy rose 22%. ONC has explicitly acknowledged that clinicians use templates to stuff notes with unnecessary information into the chart to meet billing requirements, creating note bloat. The clinical note was no longer a method of communication. It was a billing document. So hospitals layered secure chat on top just to communicate the actual plan of care. And even that workaround is not working. A 2024 JAMA study found more secure messaging was associated with more time on the phone, not less. Doctors needed to call to clarify the now constant message stream. Another study found higher messaging volume was associated with higher odds of errors. More messages means a higher cognitive load with most of the information being low-importance. This increased cognitive load leads to more errors. We took what should have been efficiency improving technology, a computerized chart, and so over-regulated it and misaligned incentives that it has led to harmful downstream effects. Now, please don't do this with AI...

@JOSEPHM45075332 @FAHhospitals So true. It’s amazing how much info is collected re referral patterns, clinic utilization, new/estab ratio. Every year, my reimbursement is tied to increasingly specific metrics…

@JOSEPHM45075332 @FAHhospitals I get a monthly email detailing my integrated and non-integrated referrals. EPIC now asks me why I occasionally refer to non-integrated docs (patient preference, clinic location etc)…

There is no issue with physician-led hospitals- the issue is about the conflict of interest when physicians self-refer patients to their own hospitals. The data is clear: POHs tend to treat more commercially insured and healthier patients than full-service hospitals. In rural communities, this can leave rural hospitals with a greater financial burden, further threatening their ability to keep their doors open and keep 24/7 care available in their communities. Read more: fah.org/wp-content/upl…

Oh come on… On self-referral “conflict of interest”: The Stark Law already governs physician self-referral. POH physicians must publicly disclose their ownership interest to every referred patient. Now… what do hospital controlled doctors disclose?? Nothing. They have zero disclosure obligation when they refer patients to the same corporate system that signs their paycheck. They are systematically incentivized to use higher-cost outpatient hospital settings rather than independent facilities. A 2020 Journal of General Internal Medicine analysis of Texas BCBS claims found hospital-owned physician practices generated 5.8% higher annual spending, 13% higher imaging costs, and 21.7% higher outpatient facility costs than independent practices, driven entirely by utilization and site-of-service billing. If the concern is financial conflicts driving utilization, the data points to hospital consolidation, not physician ownership. On the “data is clear” claim about cherry-picking: The data is actually clear in the opposite direction. The 2015 BMJ study examined 219 POHs and 1,967 non-POHs across 95 hospital referral regions and found Medicare patient proportions were statistically identical with 47.1% at POHs versus 47.2% at non-POHs. Medicaid proportions were 14.9% versus 15.4%. Minority patient proportions were similarly equivalent. The 2024 Physicians Advocacy Institute analysis of 20 high-cost DRGs found no evidence of cherry-picking after controlling for patient age, race, and health status. At the same time they found POHs delivered care at 8-15% lower Medicare cost per episode. The 2023 JAMA Network Open study found POHs had 17.5% lower commercial negotiated prices and 46.7% lower cash prices in the same geographic markets. The “cherry-picking” narrative collapses under peer-reviewed scrutiny. On rural hospital harm: The FAH report this argument relies on was commissioned by the Federation of American Hospitals and the American Hospital Association. It is a modeled simulation based on hypothetical scenarios, not observed real-world outcomes. The legislation in question (H.R. 2191) specifically requires a 35-mile separation between a new POH and any existing rural hospital, which is a provision designed precisely to avoid the competitive overlap this model assumes. More importantly, 152 rural hospitals have closed since 2010 (when the POH ban took effect). The ban did not protect rural access. It accelerated consolidation, reduced competition, and drove up costs. Markets with POHs have 16.7% lower concentration scores than markets without them. The real threat to rural hospitals is a Medicare reimbursement structure that already produces -11.8% Medicare margins for sole community hospitals. Fixing that requires payment reform, not protecting incumbent hospital systems from physician-led competition. What’s perhaps not discussed enough is that nearly every procedure performed in hospitals today is subject to utilization review (prior authorization). If someone is looking over the claim to make sure it is indicated and medically necessary, all of these arguments go away anyway. It doesn’t matter if the physician takes the procedures to their own facility, particularly if the physician hospital provides the same or better quality and the same or lower price. The ACA Section 6001 ban on physician ownership was legislative horse-trading, so let’s not pretend to take some high road that this is about protecting patients. Fifteen years later, consolidation has accelerated, patient choices have narrowed, and the organizations lobbying hardest to keep the ban are the ones profiting most from it.

What happened is the “art of medicine” is not taught anymore. I hate that phrase because it is not art, it is doctoring. Clinicians have to balance what is known - history, physical exam, and testing. All imperfect. Against what is not known, we do not have anywhere near a perfect understanding of physiology and pathophysiology. Most docs now do it reverse. Look at the tests first and then decide. Being a great clinician requires a deep understanding of human nature and the individuals we treat. Understanding the problem as best we can and working through tremendous uncertainty with confidence. It is not trainable in 4-6 years. It’s takes a long time and a lot of reps with the guidance of great mentors. Getting a black belt in karate is step one toward real learning. It takes about 4-5 years in many instances, but is individuals in most systems to the person on that journey. Getting a black belt in medicine is 4 years undergrad, 4 years med school, 3-5 years residency. And the the real learning starts as an attending. And it’s only possible to become great at that starting point with great colleagues, mentors, and the time needed for continued learning. Our system is broken and tried to break down patient encounters into relative value units. It’s broken. This is nonsense. To be great at this job, the level of introspection is unfathomable to most people. Doctors work in a space that 99% of people do not have high school level competency - science. And we apply an imperfect science and its principles in treating infinitely complex humans. AI is here. And it will augment the skill of those with skill. It will cripple those without foundations in real clinical medicine. Reminder, we need to take back medicine from the government, insurance, and corporate interests. 💊 @DutchRojas @mass_marion @txsportsdoc @realdocspeaks @BrentAWilliams2 @LighthouseDPC @paulsaladinomd @drcraigwax @BrianSuttererMD @Paul_Wischmeyer @doctorwes @DocLibertarian

have been consulted for this & can confirm that the team is drawn towards a serologic workup like salmon swimming upstream me: this is 2/2 cocaine, the tx is substance use disorder therapy not bronchoscopy team: well... let's see what the extractible nuclear antigen panel shows

In their Wednesday CCC matchup, Klauss and the @LAGalaxy wore black armbands in honor of Ilona Löwen, Edu’s wife who passed away from cancer this week. Klauss explained the importance in postgame comments. An absolute class act by a class friend who was there through so much. #AllForCITY #AllForEdu h/t @GalaxyPodcast for the comments

@brian_rifkin I mean, lasix is not nephrotoxic…, but wowza

Intern: The nephrology consult says to try a higher dose of lasix. Attending: OK, does it say a specific dose or schedule? Intern: 1 gram/24 hours Attending: 🤯🤯🤯 What ⁉️💦💦💦

Never leave your loved one alone in the hospital. Every hour you are allowed to be there, if you are able to, I highly recommend being there. Be perfectly cordial with staff. But watch over everything like a hawk. Trust me on this.

First step for Yale healthcare affordability lab is to give back the $250 million Yale got from CMS for making quality metrics. And then to kill the quality metric program it’s been pushing that drives up the cost of care for everyone. The average hospital has 7 FTE devoted just to quality metrics and the average independent clinic has 1/2FTE per doctor. That’s all to meet your arbitrary metrics. Eliminate it all.

Physician documentation (H&P, progress notes, d/c summary, etc) has regressed significantly over the last several years due to primary focus on meeting outdated CMS requirements and optimizing billing (MDM, DRG, etc). Quality documentation and a thorough med rec would improve patient outcomes…all would likely be improved with a doc friendly EMR

On the contrary, I can’t think of any documentation more essential when admitting a critically ill, highly complex patient to ICU who has been in and out of the hospital on a monthly basis. Reviewing 100s of individual progress notes & piecing tougher a narrative not feasible.

@TheWorthyHouse The number of advanced dementia patients that undergo tracheotomy/PEG tube/LTAC care is continuing to increase…rounding at my local LTAC is heartbreaking. I think we need to have a culture shift re end of life care in the US.

I know a 92-year-old man, who is senile and already had a bypass, who is having an elective aortic arch replacement. This will cost young, productive Americans trying to lead their lives and start families at least $500,000, and him nothing. Atrocious. All extraordinary medical care for anyone over 85 should have to be paid for in full by that person, or not be received. No more parasitical welfare for the old; no more stealing from the young so that old people can eke out a few more months of life. (Boomers who are offended, please unfollow me.)

Here is an odd result from Cologuard: Sample Could Not Be Processed The stool exceeds the allowable weight (300 grams).

LENTZ EQUATION 🔥PEEP = BMI/3🔥 🙅‍♂️Stop under-PEEPing patients with high BMI 🙅‍♂️Stop trying to wean everyone down to a PEEP of 5 Patients with high BMI often need high PEEP as long as they are intubated & can be extubated *directly* off high levels of PEEP 😁

Toronto FC just paid the equivalent of almost 5 Marcel Hartel's for one Josh Sargent. I love Sargent. I grew up training at Soccer Park in Fenton; my dad and I sat there numerous times watching the wonderkid train in his 1 on 1 sessions. But he's not worth (up to) $27m. Plus, it has been widely reported that Sargent only wanted Toronto this time around. It had previously been rumored that #stlcitysc planned to open their wallets for him last winter, but the deal never made progress. Now, instead of dropping an absurd fee on Sargent, #AllForCITY cashed in up to $700k in GAM for their ROFR and can continue building their roster. They need to invest in a DP by the end of the summer window and still have work to do if they want to truly compete this year. If Sargent wasn't the right fit -- and he wasn't, given all the circumstances -- Corey Wray & Co. would have been utterly foolish to rabidly push for him. I know he is a hometown stud. I know he is a great striker. I know he is pushing for a World Cup spot. But STL fans have got to understand that this is the right path forward for St. Louis CITY SC.

@MSharifpourMD Agree. I get multiple ‘clearance’ forms a week as a pulmonary doc. Severe COPD and PHTN-sure, complex patients and optimization is key. Most are for patients with mild asthma, OSA, dyspnea (last seen in my clinic in 2021). It’s ridiculous and serves no real or legal purpose IMO…

Anesthesiologists should be able to clear/not clear patients for surgery. They might ask a cardiologist for risk stratification or medical optimization but they should be able to decide whether a patient is optimized enough to undergo surgery or not

James Van Der Beek passed away today. I’m a healthcare guy and I post about healthcare. Now I want to talk about James. He was special, he was 48 years old, a Father of six, a Husband. He was man who spent his final chapter teaching the ultimate guide to real life. James was part of my growing up. Dawson’s Creek. Varsity Blues. The 90s. He was just there, woven into the background. What he did over the last few years was bigger than any of that. He recorded a video on his last birthday. Cancer had taken everything he used to define himself. He couldn’t be the husband who helped around the house. He couldn’t pick up his kids and carry them to bed. He couldn’t work. He was too weak to prune the trees on his own property. And he sat with that. He asked himself the question most of us spend a lifetime avoiding: If I am none of the things I do, who am I? His answer was simple. Devastating. Beautiful. “I am worthy of God’s love simply because I exist. And if I’m worthy of God’s love, shouldn’t I also be worthy of my own?” That’s it. That’s the whole thing. We spend our careers building identities around what we produce, what we control, and what we can point to. And then life has a way of stripping it all down to the studs. James Van Der Beek faced that moment with the courage. He said cancer was the best thing that ever happened to him because it taught him how to live. He left behind his wife, Kimberly, six children, and a message that every father, husband, and man chasing the next thing needs to sit with. Watch this video. Then call someone you love. Thank you for your contribution. Rest easy…