Advocate to Preserve Residency Funding

bills,budgeting,businesses,cash,cost cutting,currencies,dollars,savingsSo, you have probably heard about the Supercommittee (gang of 12) and the need to brace for massive cuts to control federal spending.  But, do you know that the chief target is RESIDENCY TRAINING!   That is right.   Funding for residency largely comes from Medicare, and the general concern is that they are paying too much and not getting their money’s worth.  Of course, this comes at a time when there is a shortage of residency spots given the expansion of US medical schools, and a dire need for physicians, especially in primary care, to meet the needs of healthcare reform.

So, in this perfect storm, 40 medical groups (yes, there was that much consensus) sent a letter to the Supercommittee pleading with them not to cut GME funding.   Now the situation is dire enough that the AAMC advocacy leaders are in high gear encouraging those in graduate medical education to encourage their residents to write to their Congressman.  (And yes, if you live in a Supercommittee state, its even more important for you to do this).

So if you are a resident or future resident or can sympathize with the need to have future physicians, now is the time to take action.   For my fellow medical educators out there, you don’t need to be left out.  The American College of Physicians has a very broad (don’t need to be an internist)  easy-to-use advocacy website to shoot of a quick note to your Representative and Senator about the need to preserve GME funding.

Medical educators have actually started a dialogue about the role of advocacy in medical education.  Specifically, the Editor of Academic Medicine has challenged us to come up with how advocacy should properly be integrated into medical training.  I can think of no other way than advocating for preserving funding for the system by which we train our nation’s future physicians.

Vineet Arora MD

(AAMC email encouraging residents to take action)


Dear Resident:

I encourage you to take a few minutes to  visit the AAMC Legislative Action Center (, select “Residents”,  and send an electronic letter opposing cuts in Medicare funds that support residency programs.   With the zip code you enter, the letter will be sent automatically to your Senators and Representatives urging them to oppose GME cuts as part of deficit reduction.  PLEASE USE YOUR PERSONAL EMAIL ADDRESS (eg,, AND NOT YOUR INSTITUTIONAL EMAIL ADDRESS.

Congress is discussing a deficit reduction proposal that would cut funding by as much as 60%, or $60 billion, for Graduate Medical Education (GME) and jeopardize residency training programs across the country. Given the current and growing shortage of physicians, GME cuts will reduce access to health care and threaten the well-being of all Americans.

It is most important that residents enrolled in programs in Arizona, California, Washington State, Massachusetts, Ohio, Pennsylvania, Montana, Michigan, Maryland, Texas, or South Carolina, voice your concerns.    You are represented by members of the “Super Committee” that will finalize the deficit reduction plan.

Thank you for your help.

Atul Grover, M.D.
Chief Advocacy Officer


Vampires and Urban Legends: Teaching Residents about Healthcare Costs

This past weekend, I gave a talk at the Committee of Interns and Residents, the largest housestaff union in the United States.  The most inspiring moment of the meeting that I witnessed were the 2 standing ovations earned by Dr. Koffler for advocating for residents to get paid in 1936 (her first paycheck was 15 dollars a month!).   How could I follow that…especially with a talk on how to train cost-conscious physicians?   Those who know my work well may even wonder how I got invited to talk about this.  Well, earlier this December, I wrote on the blog about my holiday wish list for medical education and #2 was a curriculum on cost conscious practice for medical trainees.   In addition to lack of a formal curriculum, there were several other barriers on teaching residents how to practice cost-conscious medicine that I discussed.

  • Faculty are not trained.  The largest barrier of course is that faculty don’t know how to do this.  A study in Journal of Hospital Medicine showed that faculty physicians could not identify what things cost.
  • No one knows what the cost of anything is.  Because each hospital negotiates its own prices with suppliers, it is very difficult for residents to know how much things cost.  In trying to find out how much your hospital charges for various tests, you may end up on a wild goose chase until you find the helpful person who may or may not even be in your state!
  • Bad systems promote costly workarounds.  Most of the time, residents are too concerned that they won’t be able to get a test or worse, it will delay a patient’s discharge.  The system is set up to order the test even if the attending thinks about it.  Some of our own data shows that interns learn during internship to misrepresent tests as urgent to get the job done.
  • Rumors and hospital legends spread quickly.  The highly connected residency program can actually spread rumors about how much things cost or give rise to urban legends when patients actually pay and don’t pay.
  • Underordering, not overordering, is penalized.  Due to the highly litiginous environment, most attendings encourage residents to err on the side of getting a test since the biggest fear we all have is of missing the ‘can’t miss’ diagnosis.  More reasons doctors over-order tests here.

So what can we do to teach residents about cost-conscious practice?  Well here are just a few of the things we can do..

  • Empower residents to find out how much their hospital charges for things.  As I said at the conference, we may need to start a support group for those that start down this daunting path – but it is the first step to understanding how to control costs.  Starting with senior leadership could be helpful – after all, how many C-suite leaders would not want to find out how to teach residents to control their costs? There is also a related movement to improve price transparency for patients.
  • Show residents how much they spend.  At least in the case of daily phlebotomy, a recent study dubbed “Surgical Vampires” (due to the daily blood draws ordered by the surgical interns) highlighted that letting residents know how much things cost actually reduced the cost of lab ordering per patient and resulted in 50,000 dollars saved over 11 weeks!  Studies with electronic health records at the point of care show even greater results!
  • Use unbiased resources that promote better cost-effective decisions.  Specialty societies like the American College of Physicians and the American College of Radiology are now starting to create guidelines that encourage cost-effective practice through more judicious use of imaging or other therapeutic modalities.   The popular 4 dollar list for medications is another example.
  • Incorporate discussions of costs into routine educational conferences.  At Harvard, one chief resident started a Hospital Bill Morning Report for the residents to review what a patient bill is like.  In our medical student lectures on radiology, the costs of the tests are also now discussed.
  • Educate patients that less is sometimes more.  Letting patients know about the risks of overordering tests- specifically workups of incidentalomas and pseudodisease may be helpful in explaining your new approach to cost-conscious medicine.   The pushback from patients may be the fear of rationing,  which is of course irrational since it already occurs.  A helpful summary for patients on high value cost conscious medicine appeared in Annals of Internal Medicine.
As with all things, there is the potential for unintended consequences in teaching cost-conscious medicine.  The most egregious of which would be to hide behind the veil of practicing cost-conscious medicine in order to shirk work and avoid getting an indicated test when needed.   This is especially important to watch out for as burnout sets in late in the academic year.  So, as we resist our inner vampire urge to order blood tests and uncover hospital urban legends and myths about healthcare costs, its equally important not to morph into the haphazard and dangerous cost-cutting monsters that we all fear most.
–Vineet Arora, MD

Twitter to Tenure: 7 ways social media advances my career

As part of our SGIM Social Media Workshop “From Twitter to Tenure” our workshop lineup of ‘twitterati’ will be posting each day this week about how social media affected their career.   So yesterday was @AlexSmithMD on GeriPal.   Here is the schedule for the week:  Monday – me (@FutureDocs) here on FuturedocsTuesday – Bob Centor (@medrants) on DB’s Medical RantsWednesday – Kathy Chretien (@MotherinMed) on Mother’s in MedicineThursday – Eric Widera (@ewidera) on GeriPal (and hope to see you in Phoenix for our workshop!)

For the Twitter to Tenure workshop at this year’s Society of General Internal Medicine Meeting, I was asked to think about how social media enhanced my career.  This may sound ridiculous at first- after all, social media is a big waste of time right? Wrong as some of you have discovered.  Social media has opened doors for me by connecting me to a variety of people I would not have met.  Here is just a brief list of the ways social media has impacted my academic career.

  • Media interviews – I was interviewed by Dr Pauline Chen through the New York Times who located me through – you guessed it Twitter!  She actually approached me for the interview by direct messaging me through Twitter.  She was following me and noticed my interests in handoffs on my Google profile which is linked to my Twitter account.  She was also very encouraging when I started the blog which was exciting!
  • Workshop presentations– I presented a workshop on social media in medical education (#SMIME as we like to call it), at 2 major medical meetings with 3 others (including @MotherInMed who encouraged me to start a blog and also is my copresenter at SGIM).  The idea was borne on Twitter…and the first time I actually met one of the workshop presenters (who I knew on Twitter) was at the workshop.
  • Acquired new skills  – My workshop co-presenter who I only knew through Twitter ended up being Carrie Saarinen, an instructional technologist (a very cool job and every school needs one!).  She is an amazing resource and taught me how to do a wiki.  After my period of ‘lurking’, I started my own ‘course’ wiki  dedicated to helping students do research and scholarly work which we are launching in a week.
  • Lecture invitations – Several of my lecture invitations come through social media.  Most notably, I was invited to speak for an AMSA webinar on handoffs and also speak to the Committee of Interns and Residents on teaching trainees about cost conscious medicine.  Both invitations started with a reference to finding me through Twitter or the blog.
  • Committee invitations – I am now on the SGIM communications task force as a result of my interest in social media.  Our most recent effort was a piece about ‘tweeting the meeting’ with @medrants and an older piece focused on the top Twitter Myths and Tips.
  • Grant opportunities – I recently submitted a grant with an organization that I learned of on Twitter – Initially, I had contacted Neel Shah from Costs of Care asking him if they had a curriculum on healthcare costs.  They did not, but were interested in writing a grant to develop a curriculum so they brought my team on board and we submitted together (fingers crossed).
  • Dissemination – One of the defining features of scholarship (the currency of promotion in academic medical centers) is that it has to be shared.   Well, social media is one of the most powerful ways to share information.   In a recent example, we entered a social media contest media video contest on the media sharing site Slideshare.  Using social media, we were able to obtain the most number of ‘shares’ on Facebook on Twitter which led to the most number of views and ultimately won ‘Best Professional Video.’  To date, this video, has received over 13,000 views, which I was able to highlight as a form of ‘dissemination’ in a recent meeting with our Chairman about medical education scholarship.    While digital scholarship is still under investigation with vocal critics and enthusiastic proponents debating the value of digital scholarship in academia, digital scholarship does appear to have a place for spreading nontraditional media that cannot be shared via peer review.

Part of being a good citizen on social media is giving back.  I try to give back when I can through helping anyone who contacts me for something specific – so I have read personal statements, reviewed websites, and offered input to others who are interested in my perspective on their work.  I can’t always keep up since I have a day job and alas, this is an extracurricular activity.  The good news is a tweet is only 140 characters  – so like the blue bird, I can keep it short but sweet.

–Vineet Arora, MD

Physician Advocacy: Staying in Place and Telling Your Story

This month, I have talked to two former trainees who are contemplating major changes in their career- -to leave medicine.  Both are in private practice and are frustrated by many different things that they see in their practice and are inspired to improve the practice of medicine.   While their desire to leave medicine is concerning enough and could be the subject of this entire post,  I was actually struck that both of them contacted me to find out how they could find out more about health policy and get involved.   One of them wondered if they needed to get a Public Policy Degree like I did.  The other one thought maybe she would have to move to DC to become more active in the health policy arena.   I also recall wondering how to get involved many years ago and thinking the same thing.  Fortunately, I was able to find a way to balance my interest in advocacy without giving up my job.  So, before I sent them packing to the Hill or back to school to read seminal texts in public policy and weekly economic homework assignments, I thought there are a few things they could do to engage while they stay in their job if they choose to.

  1. Learn from professional society advocacy experiences.  Some people will react and say that they have a negative opinion about “lobbying” or the special interests of their professional society.  My advice is that if you don’t have a basic terminology of healthcare reform and the healthcare system (i.e. SGR, ACO, etc.), then this is a great place to start -with other physicians who are also learning.
  2. Read the news foraciously – the best way to understand what is happening on the Hill is to keep up with the news.  While this may seem like a tall order, customizing Google news and setting alerts for healthcare reform or whatever it is that you are interested in can be helpful.  In addition, the iPad has amazing news applications that aggregate your favorite news sources and blogs (my personal favorites are PulseNews and FLUD, which even touts itself as the sexy news ecosystem).   My go to sources are still the New York Times Health Section and NPR Health, especially anything written by Julie Rovner.  Another excellent source for health policy which you can add to your reading list include The Healthcare Blog, Kaiser Health News, and the “Bob Blogs” as I refer to them (see the blogroll below) .  Even if you can’t read the article right away, you can often ‘favorite’ it to read later or send to InstaPaper.
  3. Engage in Social Media – Social media has become one of the best ways to stay on top of health policy news, especially thanks to KevinMD and his steady stream of diverse and eclectic contributors that include medical students, patients, physicians, and health policy wonks.  In addition to the usual news sources listed above, you can also keep on top of professional society news (see the medicalsocieties Twitter list) or use healthcare hashtags to stay abreast of the situation.   However, the key to effectively using social media is more than just staying informed, but also interacting and engaging and contributing to the dialogue.  So that brings us to the last way to get involved….
  4. Write – whether it be a comment on a newspaper article or blog post, a letter to the editor to your local newspaper, or a blog post about a specific health policy issue, writing is a great way to get the word out.  Policy narrative has become increasingly valued among physicians.   That is because there is nothing more compelling to the general public or legislators like a personal story. One of our own faculty has specialized in this area and teaches our students how to use policy narrative in their practice.

While some have a natural tendency to write, it may not be intuitive to others.  Fortunately, this year I was lucky enough to attend a session at the IHI meeting led by disciples of Marshall Ganz and dedicated on how to tell your story in a compelling way in 5 easy steps:

  1. Write the story of self (personal narrative)
  2. The story of us (to build a shared vision)
  3. The story of now (to highlight the urgency)
  4. Then present a choice (to raise the tension)
  5. End with asking for a commitment

One of our homework assignments was to practice so I actually chose to write a story to convincing others to come with me to DC for the American College of Physicians Leadership Day since I am leading this year’s Illinois delegation.  So here is my narrative for why you should join me:

When I first went to DC to lobby with ACP Leadership Day, I remember feeling awkward and relying on a medical student who showed me how to approach legislators.  The next year, I remember our student had graduated so I assumed the mentor position for the new people.  Two years later, I got a call that they needed a young physician to testify to Congress about the need for physician payment reform and I was thrilled to be able to do so on my 33rd birthday.  I know you have also wondered about how to get involved with healthcare policy but like me, you are very busy and overcommitted.  The key is that time is of the essence as the future of healthcare legislation is being debated in this election year and your input is critical to shaping the future.  So, I know that this May, you could stay at work and continue your everyday activities or you could decide to take action and go to Washington to witness and contribute to the political dialogue around healthcare.  So, I am asking you to commit to joining me as internists will come together to communicate the importance of affordable healthcare and preserving primary care for Americans. 

Look forward to hearing your stories too.

–Vineet Arora, MD MAPP

Blog ‘Paper’ Anniversary: Reflections & Top Posts of 2010

It’s been one year of blogging or our ‘paper’ anniversary here on FutureDocs! 

I was reminded of this milestone with the receipt of the WordPress blog ‘report card’ below.   While I was excited to learn about the clean bill of health and intrigued by metrics related to shipping containers, I’m not going to lie.   It can be very challenging to stay fresh, write creatively, and keep up with posting while holding down an academic career.          

However, one thing I have learned (and confirmed by @MotherInMed who helped me get started) was that if you are inspired, the post will write itself (like this one).  Therefore, it is critical to pay attention to those moments you are inspired.  This gives rise to a somewhat startling personal observation– blogging can acutally improve your attention span and focus.  Sounds crazy, I know… But, unlike social media sites which can be highly distracting (Twitter or Facebook addicts anyone?), I find that I often pay closer attention to my surroundings so that I don’t miss the inspirational moment around the corner that I can share.   For example, in lieu of walking around aimlessly at medical conferences (a risk at any conference especially in medicine), I found myself taking notes and immediately reflecting on sessions to distill the most salient points, such as the oppressive nature of medical education or expert failure highlighted at the recent Association of American Medical Colleges.

In examining the report card below, the top posts on this blog are both predictable and surprising.  With the explosion of interest in technology and plenty of technophiles in the blogosphere, it is no surprise that posts about Twitter myths for docs and whether the iPad lives up to it’s hype on the wards are at the top.   The other 2 posts relate to career advising, which was a welcome surprise.  They also do reaffirm the need to continue to provide solid career advice to medical trainees, no matter how mundane (like what to wear to the hospital).   In addition to technology and career advising, I’ve enjoyed the ability to highlight various advocacy issues relating to medical education like healthcare reform, resident duty hours, the Match, and women in medicine.  Lastly, I must admit that I do enjoy writing for pure fun — like the posts on movies in medicine or healthcare phobias.   

Special thanks to uber medbloggers KevinMD and medrants who occasionally cross post or reference these posts and all those who subscribe and comment.   I was especially honored to be included in KevinMD’s top 10 posts of the year for this post on shadowing (which curiously did not make the WordPress list below).  

So here’s to more inspirational and informative moments of 2011, both in life and on the blogosphere.

–Vineet Arora, MD

***Blog Report Card From WordPress:

Fortunately, the stats helper monkeys at mulled over how this blog did in 2010, and sent me the following high level summary of its overall blog health:

Healthy blog!

The Blog-Health-o-Meter™ reads Wow.

Crunchy numbers

This blog was viewed about 20,000 times in 2010. If each view were a shipping container, your blog would have filled about 4 fully loaded ships.

In 2010, there were 30 new posts, not bad for the first year!  The busiest day of the year was March 5th with 304 views. The most popular post that day was Top Twitter Myths & Tips.

Where did they come from?

The top referring sites in 2010 were,, Google Reader,, and

Attractions in 2010

These are the posts and pages that got the most views in 2010.

Top Twitter Myths & Tips February 2010

Attending Rounds with the iPad – Hype or Hindrance? August 2010

What Not to Wear: Hospital Edition May 2010

Personal Statement Do’s and Don’ts July 2010


Holiday Wish List for Medical Education

It’s the holidays which means that the students are on vacation and faculty have a little more time to unwind.  Unfortunately, residents are still hard at work but celebrate the holidays in their own way in the hospital as we have discussed before.  I’ll be joining them January 1st but for the moment get to enjoy some time off as well. 

Even though medical schools have closed their doors for 2010 and faculty are getting much needed rest, it is time to reflect on what is needed for medical education in the New Year and beyond.  While it’s been a banner year for healthcare reform, there are still some issues that are looming large for medical education, especially graduate medical education.  It’s important to revisit these issues and especially focus on what the ‘wish list’ as medical education prepares for the ‘twenty-tens’.

  1. Funding to Meet the ACGME 2011 Duty Hour Requirements   With 6 months and counting to the implementation of shorter hours for resident physicians, budgets are getting made now for the new fiscal year.  On top of that list in teaching hospitals is how to make ends meet with residents who work shorter hours.  Residents are low cost labor compared to hospitalists and physician extenders who are their most likely work substitutes.   With the overall price tag set at over 1 billion for duty hour compliance, obtaining funding is not easy.  However, securing the appropriate financing for these solutions is critical to ensuring that residents are not doing the same or more work in less time.  Increasing resident work intensity may undermine any potential improvements in patient safety and resident education.   To make matters worse, funding may be harder to obtain than ever since funding for graduate medical education by CMS is under threat of redirection.  
  2. A Curriculum to Teach Doctors to Practice Cost Conscious Medicine  With an unprecedented focus on how to contain costs and ‘ration’ care, we are missing one key piece of the puzzle – how to teach young physicians and physicians-in-training how to do this effectively.   Most faculty physicians do not know the costs of the tests that they order making it necessary to create off-the-shelf curricula in this area.  To make matters worse, cost of laboratory tests can vary by region and hospital, making a standard curriculum challenging to implement.  Nevertheless, overreliance on medical testing has run rampant in teaching hospitals, largely due to the lamented “demise of the physical exam”.  If one way to teach cost-conscious medicine is invest in the low cost physical exam skills, we can all learn from the Stanford 25 that is being resurrected by acclaimed physician author educator Abraham Verghese.   While we improve physical exam skills and hopefully change the incentives, we will still need new tools and tips for how to train the cost conscious doctors we wish to produce.  One possibility is through the use of narratives – A new group called Costs of Care launched an essay contest to and will be periodically posting stories to help raise awareness. 
  3. More Residency Spots – As we’ve discussed, without more spots for all those new medical schools opening their doors, medical school graduates will soon face unprecedented competition during the Match without a corresponding increase in residency positions.  While the assumption is that the International Medical Graduates will be squeezed out at the expense of the US graduates, this is not entirely a given.  More than a few program directors of IMG exclusive residency programs say they will continue to take International Medical Graduates.  Regardless, it’s the US that loses in the end given the projected doctor shortage and the only pathway to licensure is via a US residency.  While CMS is exploring ‘redistributing’ spots to primary care, the general consensus is that more will be needed.
  4. Student Debt Relief  Medical student debt continues to plague US education.  While some programs, such as the National Health Service Corps, have been expanded to help address this issue, it is still important to expand such programs to reach a larger audience of medical students.  One novel way to do this is to pair student debt relief with service, an idea put forth by the Editor of Academic Medicine as this year’s “Question of the Year.”  Many schools responded, including our own, which created the REACH (Repayment for Education to Alumni in Community Health) Program to help.  To achieve a larger scale impact, more programs on a federal and state level are needed.  In the interim, the AAMC “FIRST” initiative is a terrific resource to help students navigate their debt and keeps up to date stats about the situation.
  5. Making Primary Care as a Desired Career  The shortage of primary care physicians will devastate the US as more patients become insured and the population ages.  One of the central models for healthcare reform is the spread of the patient-centered medical home, led by a primary care physician.   While the future roles of nursing is explored and potentially expanded to meet this need, it will not be enough to care for complex patients with multiple disease and medications which require care coordination.  So, if primary care is so important, why are more students not choosing to go into it?  One striking finding in the recently released 2010 survey results of all entering medical students is the number of students who declared they would subspecialize.  12% were already on the “ROAD” (rads, ophtho, anesthesia, derm) while an additional 9% were budding orthopedic surgeons.  Meanwhile, 8% were interested in family medicine.  Although 18% declared an interest in internal medicine, 2/3 of these will ultimately subspecialize too.   So what do entering students already know about these specialties?  Well, the elephant in this room here is the income gap between primary care and specialists.   As long as this disparity exists coupled with the debt discussed above, it is difficult to dissuade career decisions, especially when they are made this early!   No one wants to discuss this since it pits doctor against doctor but the time for this discussion is long overdue.

While it would not be wise to wait up for Santa to deliver on these wishes tonight, keeping our focus on these issues in the New Year will surely help usher in the next decade of medical education.      

–Vineet Arora, MD

If only healthcare was as easy as getting a manicure…

During the Thanksgiving holiday, I had the opportunity to get my nails done.  As I visited the nail salon, I could not help thinking how easy it was to walk into a new city and find a place to get your nails done.  While I knew of this place primarily through word of mouth, it was also highly recommended on Yelp. As one Yelper writes, My favorite thing about this place should be the amazing decor and time and attention each nail tech puts into his/her work, but it’s actually the owners that make it great. I love seeing them each time I walk through the door. I tend to arrive right before they close, and they never turn me away, or hurry the service along.”   Here are a few things that I noticed that healthcare could learn from.

  • Customer-oriented– As soon as I walked in, I was offered my choice of beverages and asked to pick a color which there were many to choose from. 
  • Access to a technician – As soon as I was done picking my color, my nail technician was ready for me – no wait!  There were over 40 seats and almost all of them seemed filled on this busy Wednesday before a holiday.  This place was not a small shop but a large well oiled machine.   
  • Certification prominently displayed – All the nail technicians certificates were on the wall and actually their state certification number was listed as part of their badge.  For one nail technician who forgot her badge that day (or maybe it wasn’t made yet?), she wore a paper name tag with her number on it.  It definitely provided me with some reassurance that these were trained professionals.
  • Teamwork – The first step in getting my nails done was a lotion and heat treatment which was applied first by one technician.  After that was done, the nail technician sat down and asked me whether I how short I wanted them and I responded with ‘short.’  
  • Benefits of a large employer – I got in a conversation with my nail technician and found out that she had been working there for six years.  In fact, this nail salon was a chain of 12 nail salons all over the country primarily associated with malls.  While she did previously own her own nail salon, switching over to be an employee at the large nail salon meant that she could focus her attention on doing nails and did not have the hassle of running her own business. The benefits were good and she also had flexible hours so that she had the resources and time to care for her sick grandmother.
  • Focus on perfection – Before she applied the nail polish I selected, she confirmed that this was the nail polish that I indeed wanted.  Before she applied the coat, I went ahead and paid as to not ruin my nails.  After my nails were done, my technician walked me over to the nail dryer and brought my shoes and purse so that I would not have to ruin my freshly glazed nails. 
  • Open to feedback – While at the nail dryer, there was a comment card for feedback that you could turn in to reflect on your experience.   
  • Affordable – With all this great service, I was expecting to pay a pretty penny and was pleased that it was only 12 dollars!

Alas, if only healthcare was this simple.  Getting your nails done is also a splurge or luxury and certainly not an essential health benefit.  After all, there are not ‘emergency’ nail salons open 24 hours for nail emergencies that will take anyone no matter how poor or ungroomed they are.  Moreover, the nail technician did not need to take a detailed medical history, reconcile my medications, review my preventive care, and perform a thorough physical exam, and complete additional paperwork to ensure proper payment.  Of course, what’s interesting is that it’s certainly not out of the realm of the possible.  A recent study (aptly named the BARBER-1 trial) showed that men who receive preventive care at the barber shop had lower blood pressure.  The promise of health benefits during barbershop visits has been the impetus for longstanding programs like our own community’s Project Brotherhood.  I doubt we’ll be mixing pap smears and nail salons anytime soon, but it is a place where health screenings have been performed with referral to medical providers.  After all, nails are the window to the certain health diseases and no mention of healthcare and nails would be complete without a run down of some of the famous ones. 

 –Vineet Arora, MD