Sunday, October 17, 2021

Doctors Should Make Passive Income A Priority


Doctors are always complaining about being overworked and underpaid. They dream of accomplishing the gospel of FIRE, financial independence/retire early. Yet few physicians are able to execute that plan because it calls for massive financial deprivation (saving 50% or more of your income) and social hardships (no fancy cars or vacations to pay off debt). All this to retire by the age of 50 and worry whether your portfolio will last the next 40 years. 

Yet you regularly read news of people who are able to parlay their smarts and sweat equity into substantial passive income. There are the two children from Dallas, 14 and 9, who are now making $30,000 per month mining cryptocurrency. Ishaan Thakur and his younger sister Aanya started by converting their gaming computer to mine ether after watching YouTube videos. The first day they made $3. Just like that they made money from thin air. Satisfied with their results, they added more processors and made $1000 their first month. As they made more crypto income they kept adding more processors. In four months they were making $36,000 per month! Their only expense is paying utilities to a data center which is about $3000 per month. These kids are doing the ultimate FIRE and could retire before they finish high school.

Then there is this story of an ex-pastor and his wife who are now living comfortably on their rental income generated from 30 properties. They started with nothing and were able to accomplish this feat in two years. (Business Insider subscription required.) The young couple were living paycheck to paycheck in Denver when their daughter had a medical emergency. They realized how little safety net they had. So they started watching house flipping shows on HGTV and read real estate investment books. They sold their house in pricey Denver and bought a house in St. Louis, saving hundreds of thousands of dollars. The family began with one house where they did all their own rehab to save money. Before long they were renting out the property, earning a small income. With that cash flow they kept buying more houses, fixing them up, and renting them out. Within two months they were renting out three properties making $1000 per month. Now less than two years later they have thirty properties and live comfortably on their rental income.

It seems like doctors should be able to generate this level of passive income easily with our high levels of education and large salaries to start. These people did not go to school as long as us and basically started out with nothing but their smarts and hard work. Why can't doctors routinely do the same thing?

Is it because with our high salaries it takes a lot of passive income to move the needle and so many doctors don't think it's a worthwhile endeavor? If you're making $4000 per month and generate an extra $1000 per month renting houses, you've substantially increased your earnings. However if you're earning $40,000 per month as a doctor, making another $1000 per month doesn't seem worth the trouble.

Or maybe it's because we're too busy to think about starting a second income stream. When you're working sixty hours per week, the last thing you want to worry about is going to a rental to fix a leaky toilet after getting off work at 7:00 PM. If you hire somebody to do all the repairs then that destroys your cash flow and you wind up losing money on that property. So perhaps doctors would rather spend their off hours resting at home than running off to fix a tenant's complaints.

Maybe our education narrows our mental focus. All those years of medical school blinds us to business opportunities when they present themselves because we're concentrating so much on running a medical practice. Any thought about earning extra money invariably is medically related, such as becoming an expert witness for malpractice cases or getting honorariums giving talks for pharmaceutical companies. We should broaden our scope and look beyond the medical industrial complex. With our ample incomes, why can't doctors also buy a bunch of crypto miners and start generating crypto money? If two children can do it, surely physicians with over a decade of higher education can too. 

Next time, before buying that new Mercedes to replace the three year old Mercedes, maybe think about keeping the old car and use that money for creating a meaningful change in your life. Plenty of people are able to create wealth for themselves with far less education and cash flow. Perhaps we should get on this gravy train too.

Anesthesiologists Are Better Than Nurses At Rapid Response Resuscitation

In a presentation made at the just finished ASA annual conference in San Diego, Faith Factora, MD of the Cleveland Clinic showed data that pointed to anesthesiologist-led rapid response teams produced better outcomes than ones that were led by nurses. 

She examined data from 2010-2012 when nurses led rapid response teams vs 2012-2018 when anesthesiologists were in charge. There were 1437 cardiac arrests and 7727 deaths involved during that time. Cardiac arrests and deaths were found to be lower when anesthesiologists were involved in the care of the patients.

Of course having an anesthesiologist available to go to all the rapid responses in the hospital can become very expensive and it ties up a scarce anesthesiologist from working in the operating room. However it may be worthwhile in cases where the patient is having complex problems like a cardiac arrest vs. somebody who is having a vasovagal syncopal episode.

The irony is that most anesthesiologists would probably rather not be leading rapid response teams in the hospital. We very much prefer to be left alone in the OR's and devote our full attention to the one patient on the table, not running all over the hospital putting out fires. If we could pawn that job off to nurses and have hospitalists lead the RRT's then most of us will be okay with that arrangement. 

Saturday, October 16, 2021

Happy Dodransbicentennial Ether Day!

Morton inhaler

I did not make up that word. Dodransbicentennial means 175th and today is the 175th anniversary of the first public demonstration of ether. It's a real word because Wikipedia says so and Wikipedia is the source of all knowledge in the world now.

On October 16, 1846, William Morton showed how ether can induce unconsciousness in a patient undergoing surgery at the Massachusetts General Hospital. The event was published in the New England Journal of Medicine and recently voted the most important article in the history of the publication. The operating room where the event took place is now called the Ether Dome.

So if you need another reason to party this weekend, raise a cold one to Dr. Morton and the invention of anesthesia. That was truly a seminal moment in medicine and I wouldn't be exaggerating to say that it changed the course of humanity forever. For more information, check out the Wood Library-Museum of Anesthesiology

Wednesday, October 6, 2021

Anti-Vax UCLA Anesthesiologist Removed From Hospital


UCLA anesthesiologist Christopher B. Rake, MD was escorted out of UCLA Medical Center for refusing to take the Covid vaccine. He filmed himself as he was led out of the building.  As he's leaving, he says to the camera, "This is what happens when you stand up for freedom. This is the price you have to pay sometimes. I'm willing to lose everything, my job, paycheck, freedom, even my life. United we stand, divided we fall." The hospital has placed him on unpaid administrative leave, which is just fancy words for getting fired. 

Dr. Rake, NOT an ASA member, graduated from Tufts University School of Medicine in 2004 and completed his residency at UCLA. He has been a prominent spokesman for the anti-vax movement in Southern California. He was filmed in Santa Monica at a rally against the vaccine and talking about Q-Anon. He is so adamant against the vaccine mandate that he hasn't even tried to use a medical or religious exemption. 

One one hand, he can be admired for standing up so strongly for his principles. He's willing to lose his reputation and livelihood for something he truly believes in. For most of us, it is far easier to just give in to these mandates and take the shot. It's not that different from the flu vaccine that all healthcare workers in LA County are required to get each year. Get the shot or get fired. 

However, I wonder what Dr. Rake thinks about all the other rules we willingly follow to improve our lives and those of others. What about childhood vaccinations for measles, mumps, rubella, tetanus, etc.? How about seatbelt laws? Rules against driving while under the influence? Airport security inspections? All these things are personally uncomfortable or restrictive. Yet we tolerate them because we know they help the greater good.

Good luck to Dr. Rake finding another anesthesia job. He will probably have to move out of California since we have some of the strictest rules against anti-vaxxers in the country. However, hospitals all over the country are requiring their healthcare workers to get vaccinated so it won't be an easy job search. 

Anesthesiologists, Stop Wasting Oxygen!


The Covid pandemic feels endless. As soon as one area starts controlling its rate of transmission, the virus seems to pop up elsewhere to ravage the population. This has led to various states of emergencies at different times and locations. It's like a deadly game of whack-a-mole.

One thing all these virus affected areas have in common is that there is a great need for large amounts of oxygen. Virus victims often present to the hospital gasping for air. They're frequently placed on high flow nasal cannulas or BiPAP to assist their breathing. If it's severe enough, they may have to be intubated and mechanically ventilated. All these devices require massive amounts of oxygen flowing 24 hours a day.

With thousands of people requiring oxygen to keep them alive, oxygen shortages have been reported in this country and around the world. Some hospitals in the state of Florida reported having less then 36 hours of oxygen left. India has run out of oxygen in some cities, resulting in hundreds, perhaps thousands, of people dying needlessly.

So it ticks me off when I come in to work in the morning and see the gas flows on the anesthesia machine turned up to maximum with no patient in sight. It's especially aggravating on a Monday morning when one wonders if that machine has been turned on like that the entire weekend. 

Not only is this a huge waste in a time where there are shortages of oxygen in many places, it is also detrimental to the patients that might be placed on that machine later in the day. High gas flows will dry out the CO2 absorbant. The dessicated absorbant can form a chemical reaction with the volatile anesthetics to produce carbon monoxide which is then absorbed by the patient. 

It is so easy to prevent this from happening. I make it a point to turn off all my gas flows right before I take my patient out of the room. There's no need for the machine to be pumping out ten liters of oxygen per minute between cases. At the end of the day, just push a button to turn off the machine so that no gas flows are present to dry out the CO2 absorbant. 

In a time when anesthesiologists are debating whether sevoflurane or desflurane is better for the environment, something as simple as turning off the gas flows after each case can produce real tangible benefits for all mankind during this health crisis. So do it! Turn off the gas when you're done. Even if you don't live in a high Covid infection area, this simple consideration can help patients all over the country and around the world.

Sunday, October 3, 2021

Are Anesthesiologists Just Glorified Nurses?


In a provocative op-ed in Anesthesiology News (free membership required), Dr. Karen Sibert, past president of the California Society of Anesthesiologists, dared to ask if anesthesiologists are truly practicing like physicians, or merely doing nurses' work. Full disclosure: I know Dr. Sibert personally and have worked with her in the past.

She asks why are anesthesiologists responsible for drawing up drugs? Why are anesthesiologists the ones to hang medications on IV pumps? Why are anesthesiologists charting IV fluids and urine outputs? Do you ever see internists grab a syringe and check out drugs from a Pyxis to give to a patient? Of course not. They write an order and the pharmacist and nurse carries it out. Oncologists don't hang drugs themselves. They give orders to a nurse who then loads the IV pump to give to the patient. When a surgeon asks for preincision antibiotics, who does he give the orders to? That's right. It's the anesthesiologist who mixes it up and administers it to the patient. How did anesthesiologists' duties become so mundane and nursing oriented?

Dr. Sibert goes goes into a little bit of history of anesthesiology to explain the current conundrum. In the early 1900's, most surgeons would use a nurse to administer sedation in the operating room. The same nurse might then follow the surgeon to the office later in the day for office duties. There was no such thing as an anesthesiologist involved. Then along came Ralph Waters, MD. 

Dr. Waters was one of the pioneers of anesthesiology, a lion of the specialty. He treated anesthesiology as a true science, with rigorous research and observations. He began the first anesthesiology residency in the United States, at the University of Wisconsin, Madison in 1927. 

But unfortunately the practice of providing anesthesia had by then been strongly established as a nursing duty supervised by a surgeon. It took decades of work before anesthesiology was officially recognized as a physician specialty and fully independent of a surgeon's purview. 

Dr. Sibert noted the difference between the European model of giving anesthesia versus the American one. Europeans require two professionals present during critical phases of the case, either an anesthesiologist and an assistant or an anesthesiologist and a nurse. The US does not have this requirement so a CRNA can do the job all by themselves without any supervision of an anesthesiologists.

European anesthesiologists are also much more involved in the patient care throughout their hospitalization, not just in the operating room. Patients are evaluated by anesthesiologists preop. They are then followed through the operating room, possible ICU stay, postop recovery, pain management, and even after discharge. The anesthesiologists act as a hospitalist or internist for the patient. This is the aim of the Perioperative Surgical Home that was so in vogue a few years ago. But most American anesthesiologists would rather quit than to have to follow their patients that thoroughly. ("If I wanted to be a hospitalist, I would have gone into medicine and become a hospitalist!")

Those are the kinds of responsibilities that medical students and residents are trained to excel. We're experts at evaluating the big picture to determine whether a patient can safely undergo anesthesia and to take care of them perioperatively. Why do so many anesthesiologists not want to broaden the scope of their practice and are satisfied with drawing up syringes of propofol and just get through the day? 

Because it's easy, that's why. It takes hard work to really think about how to navigate a patient through preoperative preparations, surgery, and postop recovery. It's so much easier and more lucrative to just sit in the operating room and push syringes of drugs while a computer automatically charts all the vital signs. We're being paid to do nurses work while making a doctors salary

Is it any wonder that surgeons look on with disdain when they peer over the ether screen and see anesthesiologists staring at their cellphones? Do you think surgeons care whether the person on the other side of the screen is a physician anesthesiologist or nurse anesthetist as long as somebody is paying attention to their patients? It's only a matter of time before the insurance companies and hospital administrators realize this too and make their own adjustments.

Wednesday, September 22, 2021

Doctors Are Not As Essential As They Think They Are


Remember at the height of the pandemic last year when people were hanging outside their windows applauding healthcare workers for their selfless sacrifices to treat Covid patients? That was quite an ego boost and seemed to signal that people finally realized how essential doctors and other medical workers are to the well being of a nation and the world. But now, when it's time to match the rhetoric of appreciation with cold hard cash, all the applause is silenced.

The federal government is on schedule to cut Medicare reimbursements to doctors close to ten percent next year. The complicated formula for this involves the expiration of bonus hero pay of 3.75% enacted last year. Then there is another 5.75% cut to meet budget neutrality rules that were put into law back in 2011. Altogether, that plus other scheduled pay cuts add up to a nearly 10% reduction in Medicare reimbursement next year. This is happening even though doctors are already making less than plumbers. (Many readers have pointed out that Medicare actually pays doctors around $80-90 per hours rather than $45 that I wrote previously. Well, $90 per hour after years of higher education and hundreds of thousands of dollars in student loans still stinks. After you take out taxes, it's closer to $45 than you think).

How pernicious are these annual drip drop reductions in physician pay? Since 2007, GI doctors have seen their Medicare reimbursements drop 6%. Cardiac surgeons are down 8%. And cardiologists are lower by 22%. What other professional field has seen their pay actually go down over the last 15 years? 

Meanwhile, the cost of running a medical business keep rising. Staffing salaries are higher. Utilities are higher. Insurance is higher. Taxes are higher. Yet doctors are expected to pay all that with less income coming in. 

You want to know who the government considers the real essential workers? All you have to do is follow the money. The Biden administration announced they are increasing federal workers' pay over two percent next year. That may not sound like much but it's still better than the cuts doctors are facing. On top of that, the federal workers also get a brand new paid holiday to enjoy their new money, Juneteenth. Could you imagine the uproar if the government unilaterally cut their workers' pay ten percent and they had no say in its implementation? The entire federal government would shut down within 24 hours as they all go on strike and stay home.

Yet doctors continue to act as martyrs and just accept the reductions in reimbursements year after year. This makes it necessary for them to run faster than ever just to stay in place. Or more commonly, most doctors now don't run independent practices anymore. Many have gladly sacrificed their independence by working for large medical corporations. Independent doctors just don't have the resources and time to be fighting behemoth entities like insurance companies and the government. 

You would think the five trillion dollar budget supplement that Congress is haggling over could include more money to treat the country's population. Unfortunately clean energy and immigration reform for illegal aliens seem to take precedence over caring for sick people in America. They do it because they know they can and we doctors won't put up much of a fight just as we have not done so for the last fifty years.

Saturday, September 18, 2021

Nimbex Is Dead. Long Live Sugammadex



I've been a lifelong fan of cisatracurium (Nimbex). It has been my neuromuscular blocker of choice ever since residency. Why do I love it so much? Let me count the ways.

I've found that Nimbex is very predictable in its metabolism. I've been burned badly before when I used another agent like rocuronium on a patient with renal insufficiency and the patient had incomplete reversal at the end of the case that necessitated reintubation. Not good for the patient or your reputation as an anesthesiologist.

Thanks to its Hoffman elimination, I don't have to worry about a patient's kidney or liver function. The drug just metabolizes at a very steady and predictable manner. This is particularly important when a patient may have an unknown issue with their renal or hepatic functions and suddenly you're wondering why the patient isn't waking up. Nimbex is also very easy to reverse. Neostigmine easily takes care of the drug and the patient emerges quickly. 

Sure you can't use Nimbex for rapid sequence induction but that's okay. Most cases don't require RSI anyway. Due to Nimbex's property of predictable reversal, I've stuck with it long after many of my colleagues switched to roc. But now that's all changed thanks to the miracle of sugammadex.

Sugammadex (Bridion) is a drug invented specifically to reverse the paralysis induced by rocuronium. But it also works with other aminosteroid compounds like vecuronium. I feel it has revolutionized NMB reversal the way propofol transformed the induction of anesthesia.

First of all, Bridion works very fast. I'm always amazed by how quickly a patient starts moving after it is given, even if there is still a fair amount of inhalational agents on board.

Rocuronium no longer needs to be carefully titrated in order for it to be reversible at the end of the case. This is especially relevant in procedures that finish rapidly like in ENT. Those cases always present the conundrum of the need for deep paralysis followed by a quick emergence. There's no greater predicament for the anesthesiologist than staring down at a patient with zero muscle twitches and an impatient surgeon wanting to get his next case started ASAP. Prior to sugammadex there was no way to reverse a deeply paralyzed patient effectively.

One can give roc to anybody with sugammadex. Before, I was always leery of using Bridion in dialysis patients because there was always a small chance that the reversal agent would wear off before the body has cleared the NMB. I have yet to see that happen. It's just as easy to wake up a patient with renal failure as a patient with normal kidney functions.

With all these advantages, rocuronium and sugammadex have become the combo of choice in our department. Nimbex use has practically disappeared. Bridion is in such high demand that our pharmacy is complaining about the high cost of the drug. Whereas one 200 mg vial of sugammadex costs about $100, one vial of neostigmine costs $10, and that can be used with multiple patients. Our sugammadex costs are now disrupting our pharmacy's budget because people are using it so often. In addition, the anesthesiologists frequently use more than one vial per patient as some are now becoming too lazy to titrate their NMBs properly.

Are there costs that are saved because we use so much sugammadex? One has to consider the cost benefit analysis for a weak patient in PACU that requires reintubation. What are the costs of prolonged OR use because the patient took a longer time than anticipated to wake up? What is the cost of the psychological trauma in a patient who is gasping for breath because he is too weak to breathe? Or the patient who is too weak to protect his own airway when extubated too early and she aspirates, requiring hospitalization for pneumonia? All these should be taken into consideration when calculating the cost of using sugammadex.

Are there downsides to sugammadex? I've already mentioned the exorbitant price of the drug. That hopefully will come down in a few years when the drug goes off patent and generics flood the market.

Worse than that though is that I think sugammadex makes anesthesiologists lazy and they lose an essential skill. It's a real art to titrate paralytic agents properly so it can be reversed quickly at the end of a case. It's not something that can be taught in a book since each patient is unique in their ability to metabolize NMBs and every surgical case is different. With sugammadex, it doesn't matter at all. This is particularly detrimental to the anesthesia residents. It is just as easy to wake up a patient with zero twitches as one with four twitches. There is no learning there. Just give more sugammadex! But they didn't learn anything about the art of controlling anesthesia.

This is all part of the long standing trend of making anesthesia ever faster and easier to use. From halothane to desflurane. Pentathol to propofol. Pancuronium to rocuronium. If we're not careful, anesthesia could become too easy to administer. There are plenty of people who would love to get anesthesiologists out of their procedure rooms. From gastroenterologists to cardiologists, having one less physician in the room would be a dream come true. If anybody ever makes reversal agent for propofol, anesthesiologists would soon be unemployed.

Thursday, September 16, 2021

How Much Do CRNAs Make And Why I'm Totally Jealous

US Bureau of Labor Statistics

The U.S. Bureau of Labor Statistics has released the numbers for the average salaries of CRNAs. You better sit down for this. They are quite astonishing. Remember when nurse anesthetists first broke into six figure incomes and everybody thought that was amazing? Well now they are doing much much better. According to the federal government, the average CRNA income was $189,190. However many CRNAs are doing even better than that. The nurses in Oregon are doing the best, with annual incomes of $236,540. As a matter of fact, CRNAs from eleven states earn over $200,000 per year. 

Why should I be jealous of this when the average income for anesthesiologists is twice as much? Medscape's annual physician compensation survey this year showed that anesthesiologists reported earning over $370,000 per year. I shouldn't be upset that somebody makes half my income, right?

Remember that CRNAs also have work schedules that resemble any other nurses in the hospital. They have a set schedule during the day that are practically inviolable. If they have a 12 hour shift, by golly they are only working 12 hours that day. We've had an instance where the case reached a critical period and because it happened right at the end of their shift, the anesthetist simply walked away from the patient and boogied their way to the parking lot. The anesthesiologist was the one who stayed behind to finish the case and make sure the patient was satisfactorily taken to the recovery room.

The anesthetists also have guaranteed morning and afternoon breaks along with a luxurious lunch break. We've had CRNAs literally quit because they didn't get their required lunch break one day. I've had days where I'm lucky to get a two minute run to the bathroom between cases. Getting a daily 30 minute lunch break is the stuff of fevered dreams.

CRNAs also don't work as many hours. Like other nurses, they work three days a week. Ours also don't take any calls or work any weekends. So with all that free time they can work at other locations and double their salaries if they so choose.

I've been told by CRNAs that not all of them have such schedules. Many of them work in remote or dangerous places unlike anesthesiologists who prefer to congregate in nicer locations. Some also take calls and work long unpredictable hours like anesthesiologists. But I suspect those work conditions are fairly uncommon and they always have the option of moving to a different job with all the perks.

So yes I'm jealous of the CRNAs. I know many anesthesiologists who would gladly take half their incomes for a work schedule that includes guaranteed breaks, guaranteed hours, three day work weeks, no calls or weekends, and the most important thing, little liability for any incident. I would say that's a fair trade. Wouldn't you agree?

Sunday, September 5, 2021

Medicare Pays Anesthesiologists Less Than Plumbers


American doctors may be among the highest paid physicians in the world, but that wouldn't include anesthesiologist who receive their patient reimbursements through government healthcare. 

In an interview in Becker's ASC Review, Dr. Scott Harper, Assistant Professor of the Department of Anesthesiology and Perioperative Medicine at the University of Alabama Birmingham, noted that Medicare pays anesthesiologists the equivalent of $45 an hour for their services. That's less than what your local plumber charges you to come in and look at your clogged toilet.

With new federal laws prohibiting doctors from balance billing, which is charging patients for the balance of a medical bill not fully paid for by insurance, the problem is only getting worse. Insurance companies have no incentive to reimburse doctors fairly because they don't have to deal with irate customers who have to pay out of pocket anymore. Now these companies are canceling contracts and lowering thier reimbursement rates, getting closer to Medicare rates.

Anesthesiologists already have to put with Medicare payments that are only about one third of private insurance reimbursements. Medicaid, which is government insurance for the poor and indigent, pays even less. The wide expansion of stingy Medicaid is how the Affordable Care Act aka Obamacare is able to insure millions more people, on the backs of doctors and hospitals. 

If the private insurance payments keep going lower, anesthesia private practice will be a thing of the past. We will all become hospital employees like emergency medicine or pathologists. Only hospitals will have the leverage to negotiate fair contracts with these behemoth insurance corporations. Individual anesthesiologists will not be able to sustain a viable business model with payments that rival the plumbing profession because plumbers don't have to pay back six figure student loans and five figure malpractice insurance premiums as part of their business expenses.