David M. Mitchell, MD, PhD

How America’s health care system depends on international doctors

Physician

January 23, 2025

The current U.S. medical education and health care systems undeniably benefit from the immigration of talented international medical graduates (IMGs). Many of my favorite teachers, residents, and colleagues have been IMGs. However, the longstanding U.S. reliance on immigrant physicians raises questions about what policies best support both domestic and international priorities moving forward.

Beyond medicine, the immigration of talented scientists and engineers has also sparked recent public debate. Elon Musk recently …

Creating a subspecialty track for experienced hospitalists

David M. Mitchell, MD, PhD

Physician

August 3, 2024

A formal clinical track should allow experienced hospitalists to function as inpatient subspecialists: a so-called “focused practice in inpatient subspecialty.” This proposal makes sense on multiple levels.

First, there is a shortage of inpatient subspecialists, particularly in small community settings. Hospitalists, qualified and certified as inpatient subspecialists, could fill this gap.

Second, the practice of hospital medicine is an ideal launching pad for a focused practice in an inpatient subspecialty. Hospitalists are …

Health care administrators: a call for equal transparency and accountability

David M. Mitchell, MD, PhD

Physician

June 6, 2024

While physicians are constantly being asked to prove their value with a growing constellation of metrics, health care administrators seem to have escaped a similarly high degree of transparency and accountability about the value of their specific roles. What I mean is that physicians are certainly not equally informed by objective measures of the performance of their administrators. Given the remarkable growth in the health care administrator to physician ratio …

Confronting the damaging hierarchy in graduate medical education

David M. Mitchell, MD, PhD

Education

March 3, 2024

Although I have a deep respect for everyone who contributes to the education of our next generation of physicians, I also feel that the current hierarchy in graduate medical education is damaging U.S. health care. That is, the best students go to the best residency programs and get the best jobs and subsequently teach the best students, and so on, creating highly respected centers of excellence. That’s wonderful, but how …

Is obesity really a disease?

David M. Mitchell, MD, PhD

Conditions

July 17, 2023

Obesity is unquestionably a major risk factor for disease and an increasingly serious societal problem, but is it actually a disease? I would argue that obesity, defined purely by a BMI of >30, is really just a number – an objective finding. In the long-honored tradition of medical science, an objective finding is not a disease, unless it is tied to a pathogenesis. For example, anemia is just a number, …

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Is obesity really a disease?

To admit or not to admit

David M. Mitchell, MD, PhD

Physician

June 25, 2022

Imagine that you hired a teenager to sell hotdogs at the local fair, but the teenager started telling customers that hotdogs were really not very healthy, that the price was ridiculously high, and that they could find healthier, cheaper options just around the corner. Is he wrong? From a business perspective, he’s a nightmare, but from a human perspective, he’s absolutely correct.

Where does your current work setting fall …

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To admit or not to admit

How patient education can save lives

David M. Mitchell, MD, PhD

Conditions

June 4, 2022

A patient undergoing chemotherapy for breast cancer was diagnosed on April 20th with profound secondary adrenal insufficiency (hypophysitis: ACTH undetectable, cortisol 0.2) caused by immunotherapy (pembrolizumab). She was started on corticosteroids and sent home from the hospital on April 24th with a prescription for only five days of prednisone. After completing the five days of prednisone, she predictably began to feel profoundly weak and nauseous. She continued losing weight …

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How patient education can save lives

Did the unvaccinated just save my rural hospital?

David M. Mitchell, MD, PhD

Physician

January 15, 2022

It’s no secret that rural hospitals have been struggling. According to online data from the University of North Carolina, 137 rural hospitals have closed in the U.S. since 2010.

In Appalachia, the rural hospital where I work, which is staffed by a single hospitalist, has been “in the crosshairs” since I arrived in 2016 and has been limping along with subsidies from our regional health system. …

Parallels between Alec Baldwin’s Rust movie set and the unvaccinated

David M. Mitchell, MD, PhD

Physician

December 3, 2021

The recent tragic shooting on the Rust movie set shocked me. A good friend, a prominent cinematographer in Hollywood, texted me his blunt assessment: “Live rounds on a set. Ridiculously unprofessional.”

Humans are naturally shaken when there is a senseless loss of life. Or are they?

As a hospital physician who has personally watched many people die unnecessarily of COVID-19, I found this fatal filming accident to be a powerful metaphor that …

Metric shock: the unintentional consequence of measuring

David M. Mitchell, MD, PhD

Physician

May 6, 2021

Health care in U.S. hospitals is suffering from three under-recognized conditions that I will refer to as “Metris,” “Severe Metris” and “Metric Shock.”

Metris occurs when a health system begins to focus more on achieving certain metrics than on improving actual patient care. Severe metris occurs when pressured providers begin to base their clinical decisions on achieving a metric rather than on their best clinical judgment. And sadly, metric shock occurs …

Food safety and the neglect of the unpeeled potato

David M. Mitchell, MD, PhD

Conditions

September 16, 2020

Judging from the shortage of canning jars and lids in grocery stores recently, the COVID-19 pandemic has spurred fresh interest in home canning (a potentially dangerous practice that has declined since its peak in 1943); and because the public expects doctors to know everything about health, it may be educational for physicians to consider the tragic case of the unpeeled potato.

I recently read a Facebook post in a …

Immunity passports: How to eventually climb out of the COVID-19 pandemic

David M. Mitchell, MD, PhD

Conditions

April 2, 2020

During the influenza epidemic of 1918-1920, my great-grandfather, Ralph Norton Mitchell, was in the military. He helped stack the corpses of those who had died from the infection. I shudder to think about what type of personal protective equipment he used. However, his survival reminds me of a feature of all epidemics–some individuals have or develop immunity, and those who have immunity can “do the work.”

Currently, we are …

Patients: Take back your health information. Here’s how.

David M. Mitchell, MD, PhD

Tech

July 16, 2019

Have you ever wondered why your personal health information essentially belongs to your health care provider or institution? I mean: why do they keep your information under lock and key, and you have to sign a release to get it? After all, it’s your blood that they just pulled out and tested, it’s your body they just shot up with X-rays or operated on — and you paid for these …

6 things wrong with hospital medicine

David M. Mitchell, MD, PhD

Physician

September 10, 2018

In 2002, when I began my first hospitalist job, I was a dyed-in-the-wool hospital medicine convert, convinced that the transfer of inpatient care to true specialists in hospital medicine (hospitalists) would dramatically improve the quality and efficiency of inpatient care, increase patient satisfaction and decrease costs.

By 2008, I had developed serious doubts, which prompted me to publish an editorial in the Journal of Hospital Medicine, entitled “The Expanding or Shrinking …

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6 things wrong with hospital medicine

Here’s what’s wrong with time-based billing in the hospital

David M. Mitchell, MD, PhD

Physician

April 17, 2018

Consider this hypothetical addendum to a hospital discharge summary:

”ADDENDUM @10:56 a.m: In considering the accurate billable discharge time involved in this case (as I have recently been instructed by hospital coders that I must record the exact time required for a patient discharge, rather than simply “greater than 30 minutes” or “less than 30 minutes”), I feel I have stumbled upon a troubling quandary, having failed to note the exact …

It’s time for physicians to demand a national medical license

David M. Mitchell, MD, PhD

Physician

June 30, 2016

The practice of medicine in the United States is almost entirely based on national guidelines and regulations. Minor, inconsequential differences may exist from state to state, but nothing significant enough to justify the current requirement of comprehensive, redundant licensing of physicians in each individual state in which they practice.

Notably, in an uncommon example of federal common sense, physicians can work at any Veterans Administration facility, in any state, with any …

The exotic choice of staying home: Why CME rules have to change

David M. Mitchell, MD, PhD

Physician

December 30, 2015

San Diego, Tucson, Orlando, and Dallas. Those are a few of the modest destinations to which I have traveled, as a hospitalist, to attend CME conferences, using the pre-tax CME benefit from my employer, including paid days off.

As a young professional, my yearly CME trips gave me a mildly magical sense of privilege: “Really? They’re going to pay for all of this?” Browsing through various CME conference options and dreaming …

David M. Mitchell, MD, PhD

David M. Mitchell, MD, PhD

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