Physician Social Entrepreneurship

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Ordinarily, I work to draw attention away from the crude, bland, anonymizing statistics of public health to the faces they veil, the human stories they obscure.
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But as the coronavirus pandemic becomes an ever more proximal menace, affecting more people we all know and love- I see a need to go the other way, and highlight the use and misuse, the lessons and liabilities of numbers, in and out of context.
I confess the effort is fraught. I am about to tell you- in the midst of this very scary pandemic- that 24/7 news coverage of it; daily and even hourly reporting of its toll; and almost complete lack of any epidemiologic context- is making it seem scarier than it need be. I say this as data support my early impression that many in the population may have had this infection and never known it, with massive implications for the rates of SARS-CoV-2 severe infection and death.
So- with one more bow to the reality that each of these numbers conceals a person, a family, love, tears, anguish, and grief; with one more important acknowledgement that talking in the bland language of epidemiology and statistics can all too easily resemble heartlessness; with one more assertion that my heart goes out to every family subsumed within these numbers- here we go.

Health section of https://www.worldometers.info/ - April 2nd, 2020
 
As of the moment I write this, there have been about 5113 deaths from coronavirus to date in the United States. When you get this number, however, what you don’t tend to be told is this: twice that number die of miscellaneous causes in this country, every day. 
So, yes, 5113 is a large and scary number, especially since we know it will go up from here. But twice that many were dying in America every day of diverse causes before we had a pandemic. We are mortal; we die. Some of us in the fullness of time, all too many- prematurely. But either way, in a population of some 330 million people, roughly 8,000 of us succumb each day.
There have been, to date, just over 48,320 coronavirus deaths around the world. That is a larger, and perhaps scarier number. But around the world each year, there are some 60 million deaths. So far- and again, we are still in the midst of this, and will see these numbers go up- global coronavirus deaths are well below 0.1% of the world’s “routine” mortality toll. 
Moreover, since the coronavirus deaths are heavily concentrated among those most prone to die of other causes- the elderly with prior, major illness- a large portion of the COVID19 fatality toll may be changing the acute cause and exact timing of death, without adding to the annual mortality that would have occurred anyway.
This year, around the world, seasonal flu has claimed over 121,000 lives; roughly three times the toll of coronavirus to date. This year, thus far, in the world, there have been over 420,000 deaths from HIV/AIDS; over 245,000 deaths from malaria; over 338,000 deaths from traffic accidents; and almost 270,000 deaths from suicide. 
Let’s consider just the last of these- suicide- since it is an especially jarring, heart-rending way for a life to end. Imagine if that toll were being reported with the fixation of coronavirus. It is nearly 7 times larger to date, so we would be hearing about new deaths day by day and hour by hour- at 7 times the frequency of COVID19. We would know that for every death by suicide there was a grieving family, harried health professionals, and a larger number of despondent people with a “less severe” version of the same condition, namely a suicide attempt, a gesture, or thoughts but no action.
We would also likely be thinking something like: the sky is falling! Suicides mounting day by day and hour by hour. What is going on?
What is going on would be…just another day in the world. 
You don’t need me to tell you that the coronavirus pandemic is historic, monumental, terrible. You got that memo, I trust. You know how life as we knew it just a few weeks ago is- temporarily, we all hope- over. But maybe you need me to remind you that people were dying before all this, too.
In the United States alone, heart disease kills nearly 650,000 people a year- and nearly all of that is preventable, premature mortality. That is almost 1800 deaths- every day. This is still going on right now- the coronavirus pandemic has not forestalled all the other causes of daily death that were here before. But coronavirus coverage has shrouded all the rest as if the virus were the only thing claiming lives. It is, in fact, very far down the list of leading causes- and will be, even if worst-case scenarios are realized.
Note, of course, that a pandemic is unique in its temporal effects. The harms of it are highly concentrated in time and place, and that of course matters. For everyone who dies of COVID19, a larger number need intensive medical care to recover- and they often seem to need it for an extended period of time- and that is what is overwhelming the medical system and ICUs each place this wave crests, and crashes. We are thus well reminded to do all we can to mitigate spread: social distancing, sheltering in place, wearing a mask when out and about. We must, in particular, do all we can to help protect those most vulnerable to severe infection from exposure.
My early advice about mental health during the pandemic was: look away when you can. I reissue it now. Paying attention, staying informed, and following all the rules about best ways to avoid getting and spreading coronavirus are important. But the anxious preoccupation being fed by relentless coverage of this historical crisis is wiping away context, corrupting understanding, and distorting the toll.
We are all prone to overlook the numbers denied daylight by the vast shadow of coronavirus. Lost in the contagion of clamor is a brutally blunt, fundamentally important reality check about epidemiology, mortality, and context: people were dying before. People die, every day, with or without a pandemic.
Dr. David L. Katz is a board-certified specialist in Preventive Medicine/Public Health, a practicing clinician for nearly 30 years, a clinical research scientist focused on disease prevention, and co-author of multiple editions of a leading textbook on epidemiology. He is almost fully recovered from a suspected case of coronavirus infection.
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If you are following public health alerts, and you are not in an essential industry requiring face to face contact, you should be reading this from home.
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Many of you already have created a side hustle as part of the sick care gig economy or are a 1099-doc. If so, like everyone else, you should make some adjustments to help yourself and your clients make it through the pandemic and lay the groundwork for the inevitable changes that will happen when it ends.
We are all responsible for protecting ourselves, our families, our employees, our clients and our communities from illness, protecting your business and participating in the recovery of our ailing economy.
Prior to the spread of the corona virus, as early as a few short months ago, services were booming. Needless to say, service industries are now suffering the most. Some economists have noted that this is the first recession led by that sector. Consumer spending accounts for 70 percent of American economic growth and many felt a correction was on the horizon even before the spread of the pandemic.
So, if you are a stay-at-home consultant or advisor, what should you do?
1. Be compassionate and cut your clients some slack.
2. When cash is short, think of bartering for services or loaning the accrued costs of your time to your clients, with or without market based interest rates.
3. Communicate frequently on a regular basis using videoconferencing and team building tools to maintain and build on your relationship. Some think that no good deed goes unpunished. Most with an entrepreneurial mindset think that what goes around comes around into your karmic bank account.
4. Prioritize your client portfolio based on meeting the needs of the medical emergency and demand surge.
5. Rethink both your and your client's accounts payable and receivable situation.
6. Double down on creating value during the down time
7. Upgrade the things you put off when times were good. Write more, update your website, redesign or start a newsletter, reboot your strategic marketing plan, expand your internal and external networks, create and participate in virtual internship programs, and explore new strategic partnerships. Here's how to be a compensated connector.
8. Participate in like minded social media groups and share what's working and what's not.
9. Position your brand and product for relaxed rules and regulations (e.g. telemedicine and virtual care, remote sensing, patient reported outcomes, DIY medicine, reimbursement, cross state medical licensing, multi-site data access and interoperability, streamlining and teaching biomedical and clinical innovation and entrepreneurship), new ecosystems and business models and the innovation they will spawn.
10. Expect and pursue the opportunities in public health and emergency medicine, and turning sick care into health care and the public health infrastructure. The results of the Match can be a predictor of future physician workforce supply. The results also can indicate the competitiveness of specialties, as measured by the percentage of positions filled overall and the percentage filled by senior students in U.S. MD medical schools. Specialties with more than 30 positions that filled all available positions were Dermatology, Medicine-Emergency Medicine, Neurological Surgery, Physical Medicine & Rehabilitation (categorical), Integrated Plastic Surgery, and Thoracic Surgery.
Take advantage of virtual teaching opportunities in public health and hospital administration programs
11. If you are retired or interested in re-entering clinical medicine, use the volunteer opportunities available for virtual urgent care triaging to update your knowledge, skills, credentials and EMR competencies for more long term or permanent clinical staff or administrative positions.
12. Use whatever income you generate to avoid having to cash in stocks at rock bottom prices in your retirement funds.
13. Start creating some entrepreneurial habits.
14. Read all those books on your bedside table.
15. Image napping, tea time and cocktail hour every day from now on.
Good luck and don't forget to wash your hands and sanitize your keyboard.
Arlen Meyers, MD, MBA is the President and CEO of the Society of Physician Entrepreneurs on Twitter@ArlenMD and Facebook.
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Patients, sick care workers and organizations in our dysfunctional sick care system of systems were left vulnerable to the pandemic, something many experts predicted, but whose warnings went unheeded.
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But, eventually, the parts of the biomedical industrial and educational complex will either die or recover to some degree and need weeks, if not months, of post-discharge care and rehabilitation to rebuild their immunity as things gradually come back to some semblance of the new normal.
Public policy experts are already planning for how cities should recover.
Here are some places where we need post acute care discharge care pathways now to accelerate healing and recovery and build immunity to prevent post discharge readmission when we see the next wave of disease:

Hospital and non-hospital care facilities, like ERs, urgent care centers, pharmacies, and , yes, pot shops and liquor stores that have been designated essential industries.
Rural health facilities.
Higher ed,graduate schools, health professional graduate schools and residency training programs.
Biopharma , medtech and medical supply chains and innovation.
The clinical trial value chain.
Biomedical and clinical innovation and entrepreneurship clusters.
Nursing homes and long term care facilities.
Federally run care facilities like the VA, the Indian Health Service and the Public Health Service.
Ambulatory surgery and office based surgery centers.
Post graduate health related programs in business schools, schools of public health and health administration programs.

It is likely that the demand for services will dry up for a while and it won't be business as usual after the Coronapocalypse. High school students will reconsider college. Patients will reconsider going to brick and mortar facilities. Medical schools will have to reinvent themselves. Retiring doctors will rewire doing remote, online work and many younger docs will rethink long clinical careers. And, the entire system might finally figure out now to stop wasting close to a trillion dollars in sick care spending every year.
The economy is in the ICU, not just thousands of patients. Long-term morbidity, in the forms of cognitive, physical and psychological impairments, has significant consequences for survivors of critical illness and for their caregivers. ICU patients may develop PTSD anchored to their critical illness experience, with ICU-related PTSD incidence rates of 10%. Using ICU diaries during a critical illness may minimize the occurrence of future ICU-related PTSD. The same could happen to those on the front lines of the pandemic when they come back home.
Like the virus itself, the highest mortality rates in the biomedical industrial and educational complex will be in those with compromised immune systems that can't fight the forces of change to their models and revenue streams. Those that survive, unfortunately, will not develop antibodies to the next wave of illness, that most likely will happen, it they do not fortify their defenses as they recover. The challenge is that, except in a national emergency, corporate immune systems are very effective at snuffing our innovation, not the pervasive systemic and operational effects of the new corona virus.
Arlen Meyers, MD, MBA is the President and CEO of the Society of Physician Entrepreneurs on Twitter@ArlenMD and Facebook.

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I am just back from being tested for COVID19- very efficiently and professionally, I might add- at Griffin Hospital in Derby, CT.
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I can’t commend my Griffin colleagues enough for how beautifully they organized. Below are images of the test facility, and the print guidance I received. That said, I won’t have my test results for 3 to 5 days, which is far too long- not just for me, but for the system that needs those data to understand and best address the pattern of the epidemic.
In the interim, I very much suspect I have coronavirus- today I feel moderately sick- and frankly, hope I do. If I am this sick with something else while still vulnerable to getting coronavirus, too- then I am in real trouble!
If I do have COVID19, it is for the very reasons I have been writing about since before the pandemic reached our shores: lack of advance preparation, lack of risk stratification, and lack of policies predicated on risk differentials. What I mean is this: my most likely exposure is from my adult children sent back to the family home when (A) universities closed down, and (B) businesses closed down and laid people off. I am not saying these things didn’t need to happen- but they needed to happen with some careful consideration of risk tiers.

One of my daughters was working in a now closed restaurant in New York City, now declared the American epicenter of the contagion. She is a very healthy young woman (in fact, ran the 2019 NYC Marathon)- and thus is in a group that appears to be at very, very low risk of severe coronavirus infection. I, however, am a 57-year-old man. I’m not in a high-risk group, but the global data certainly suggest my risk of severe infection to be much higher than my daughter’s.
Fortunately, in my case, my prior health was excellent- that’s my job, after all- health promotion. I practice what I preach. But I am very concerned about my contemporaries around the country- the many hundreds of thousands of late 40-something, 50-something, or early 60-something parents who are not in perfect health, and some far from it, now huddling at home with adult children sent home, infectious status unknown, from the large populations of universities, and in many cases, big cities. I am all the more concerned about those households with yet another generation under that roof, namely the grandparents of those young adults.


We were badly prepared for this pandemic, despite public health experts -me among them- shouting about it for years, begging for preparation- going ignored. If anything, those of us advocating for public health have suffered a blistering assault by the anti-vaccine crowd. I have written about this innumerable times over the years, and of course- no one paid much attention.  
Hence, my worry at the start of this that an approach not focused on risk tiers would spread our very limited resources far too thin to protect anyone reliably. Elderly people, with no clear guidance, were gathering in NYC's Central Park with younger people as of yesterday. They are likely getting exposed to an infection they- the older people- really cannot afford to get. It looks thus far like most of the healthy, young people passing it to them probably can “afford” to get it, because it is overwhelmingly likely to be mild in them- although we need more data to know for sure. Which reminds me: my test result will take too long!
I have been suggesting from the start that- given how ominously ill-prepared we have let ourselves be- that we must think through targeting the resources we do have to those who most need protection. Evidence from other countries with much better data than we have so far shows that to be: the elderly, and those with chronic disease like heart disease and/or diabetes, and those with significant immunocompromise. 
What we can do now is gather and assess data from the US experience, and determine if a pivot to a more risk-based concentration of protections can be carried out. The goal is better protection, not less, for those most in need.  To me, the prospect looks promising.
As for the economy- it simply can't be unbundled from public health; this is what the vitally important “social determinants of health” is all about. It is a major reason, even the major reason, why some people are healthy and others are not. As my colleagues focusing their entire careers on this matter have said: your zip code may say much more about your prospects for health than your genetic code.
Many people in this country are financially marginal, living pay check to pay check. They are now subject to true destitution, desperation, ruin, food insecurity, hunger, and the fallout from that: addiction, domestic violence, suicide. Colleagues and I looking at all that don't know if the deaths from coronavirus will be less, or more, than the deaths resulting from societal collapse. Does anyone want to argue that deaths and misery resulting indirectly from this pandemic are less important than those resulting directly from it? 
Every argument I’ve made is predicated on this simple idea: there is more than one way to lose or ruin a life, devastate a family- and any of them is bad. Preventing any of them is good. Our goal as a society should be to use the best data we can amass, to inform the best policies we can devise, to minimize total harm. Our job is to save the most people, and families, possible from every variant on the theme of calamitous ruin and loss. Some of this can be done with federal financial support; but much of it cannot. 
I am getting emails from vulnerable people with chronic conditions who really don't know what to do now that their young adult children are back home. Can anyone leave the house? How do they handle grocery shopping? We need hotlines to deal with such matters, and we need them now, before all of those most vulnerable to severe infection wind up needing a hospital bed.
Our only immediate option is the best population-wide containment and interdiction we can manage. So to be perfectly clear, we must all now abide by all the rules to the very best of our ability: social distancing, shelter in place as advised. There can be no rush from these policies and practices until there is a fully developed, reliably better next phase ready for implementation.
Accordingly, while social distancing and attempting to interrupt viral transmission, we can gather and analyze data regarding variation in risk. Coronavirus risk differentials, and policies predicated on them, could offer the promise of much better, more dedicated protections of those most in need; less risk of overwhelming the medical systems around the country as a result; a path to more proximal crisis resolution via herd immunity; and more than one way to save a life. 
I also think it would be enormously reassuring to people like my 80-year-old mother, who is somewhat afraid of getting coronavirus and dying, but even more afraid of dying of some other cause over an indefinite period of time in isolation before ever again being able to hug her grandchildren- to know that there is a plan in place. Or, at least, planning for a plan.
I think authorities could align and announce now a commitment to both immediate interdiction efforts that are on-going, and data analysis. That data analysis will inform a major public update "on or by SOME DATE" a week, or two, or three away. It would give people a lot of hope to know there are policies in the works, and a proximal timeline for hearing about them, that address prospects for restoring any semblance of life as we knew it before the pandemic disfigured it all. Actual dates should not be arbitrary, and should be based on progress. But I think there should be announcements now about announcements to come, and work on a phased sequence of policies- including some clear thinking about what will suffice as the "all clear," first for some, and ultimately, for all.
We need to be thinking about more than one way to save lives, because there is more than one way to ruin and lose them. Any of them is bad, preventing any is good. Our objective must always be to use data to inform policy aimed at total harm minimization.
Disagreeing with one another’s ideas is something reasonable people do. Running ideas through a gauntlet of disagreement is, in my view, the best way to ensure that only worthy ideas survive. But we live in a post-truth era our president has effectively institutionalized where every idea is dumbed down, and messed up- before ever getting cautious consideration.
Disagreeing with mangled distortions of one another’s ideas is where all ideas- good and bad- go to die.
It’s not too late for us to think carefully through policy options informed by the best data we can gather, and all we know and learn about the various risks in play. It’s not too late to acknowledge that we want barricades on every route that leads to health and lives lost, health and lives destroyed. It’s not too late for common cause, common ground, common effort, common good, and shared hope. We can practice social distancing- and still, all, be in this together.
 
 
Dr. David L. Katz  is a board-certified specialist in Preventive Medicine/Public Health, a practicing clinician for nearly 30 years, a clinical research scientist focused on disease prevention, and co-author of multiple editions of a leading textbook on epidemiology.

New York Times OpEd by Dr. Katz
New York Times OpEd by Thomas L. Friedman
A draft framework for a risk-based, phased sequence of policy responses to COVID19 for total harm minimization


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The 2019 main residency match was larger than any that preceded it, according to the National Resident Match Program (NRMP). 
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The total record-high 38,376 applicants submitted program choices for 35,185 positions.
According to data on the 2019 Match compiled by the National Resident Matching Program (NRMP), 47% of seniors from U.S. allopathic medical schools got the top choice on their rank-order list—the lowest figure on record—while 72.5% wound up in their top three on Match Day.
The number of available first-year (PGY-1) positions rose to 32,194, an increase of 1,962 (6.5%) over the prior year. That increase in opportunity reflects the growth in the number of osteopathic programs joining the Main Residency Match as a result of the ongoing transition to a single accreditation system for graduate medical education (GME) programs.
The number of U.S. allopathic medical school seniors saw a modest rise of about 100 from the prior year. The 93.9% match rates for such applicants holds with recent trends. Because of the shift in GME, the number of U.S. osteopathic medical school students and graduates who submitted program choices also hit a record high of 6,001, an increase of about 1,400 over last year. Among that group, a record 84.6% matched to PGY-1 positions, up from 81.7% in 2018.
But even that high match rate in 2018 left 1,171 individuals seeking an alternate way to advance their careers. Now everyone is encouraged to use soap. However, some will need to use SOPE-The Supplemental Offer and Acceptance program, while others will pursue non-clinical career opportunities
Here is some advice on what to do if you do not match and are interested in reapplying next year.
The status of more than 4,200 foreign doctors who were chosen to do medical residencies in American teaching hospitals — hospitals that will desperately need their help to cope with Covid-19 — is in doubt because the State Department has temporarily stopped issuing the visas most of them would need to enter the country, according to a group that sponsors international medical graduates.
he status of more than 4,200 foreign doctors who were chosen to do medical residencies in American teaching hospitals — hospitals that will desperately need their help to cope with Covid-19 — is in doubt because the State Department has temporarily stopped issuing the visas most of them would need to enter the country, according to a group that sponsors international medical graduates.
Here is some advice to medical student entrepreneurs who don't match and are thinking of a non-clinical career opportunity:
1. Do an internship with a startup this summer after you graduate. Here are some examples from medical student entrepreneurs. Take advantage of technology, online job searching, interviewing and remote working in the Corona economy.
2. Network as much as you can and find a mentor. A good way to do this is to join The Society of Physician Entrepreneurs and attend virtual (and face to face when they resume) local chapter meetings, connect to other members and get involved with other organizations in your local biomedical and clinical clusters, like biopharma, medtech and digital health organizations and accelerators.
3. Be sure to use social media aggressively to find like minded students around the world and create a ready for prime time profile.
4. Take advantage of free MOOCs being offered in bio-entrepreneurship, medical innovation and digital health. Attain the entrepreneurial knowledge, skills, attitudes and competencies you will need to succeed.
5. Identify others in your class who are interested in biomedical and health innovation and entrepreneurship and start a special interest group or student club and invite members of your local cluster or ecosystem to speak at lunch and learn sessions.
6. Focus on getting education, access to resources, networks and mentors and experiential learning. Find out whether your school offers bio-entrepreneurship workshops, courses or degree programs and rethink getting an MBA. You should also look into iCorps training.
7. Take the requisite tests to get your medical license.
8. Just as there are some states where it is "better to be a doctor", there are locations that have stronger innovation ecosystems with more opportunities. The list will be different depending on whether you are interested in biopharma, medtech, digital health or care delivery innovation and entrepreneurship.
9. If possible, reapply to the match and complete a residency and several years of practice to understand the problems beguiling sick care and possible opportunities to fix them. It's called physician entrepreneur for reason.
10. At this stage of the game, stay fixed on being a problem seeker, not a problem solver. Start by developing your entrepreneurial mindset and practicing entrepreneurial habits. Here are 10 crucial steps to becoming a "pre-entrepreneur".
11. Start to learn about the business of medicine particularly innovation, marketing, the use of health information technologies and business models. There are big opportunities in health IT and data science so consider additional training that does not require enrolling in another expensive, lengthy degree program.
12. If you are not internally motivated to do this for some time, then quit now and save yourself a lot of heartburn.
13. Renegotiate your student loans and debt obligations.
14. Take care of yourself.
15. Out yourself and seek help.
16. Identify were you can add value as the pandemic changes opportunities, the economy and business models.
If you fail to match, it is not the end of the world. There are many non-clinical career opportunities where you can still help patients without spending your career seeing them face to face, or , these days, online. It's your choice whether to use soap, SOAP, SOPE or SOPE. Just because you didn't match, it does not mean you have to wash your hands of medicine. Good luck in the match.
Arlen Meyers, MD, MBA is the President and CEO of the Society of Physician Entrepreneurs on Twitter@SoPEOfficial and Facebook.
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