Sunday, April 18, 2021

CRNA's Take Over America

The American Society of Anesthesiologists' worst nightmare is now at hand. Due to clever promotion from the American Association of Nurse Anesthetists, the vast majority of patients in the U.S. can be sedated by CRNA's without any physician supervision. According to the AANA, there are now 42 states that do not require the CRNA's to take direction from any doctor.

The ASA thought they were doing well holding the opt-out of supervision states to just 17. Covid changed that calculus almost overnight. By pushing the narrative that critical care physicians are in short supply due to the pandemic, the AANA was able to convince a panic stricken federal government to drop the requirement for physician supervision during this health emergency. Unless a state specifically keeps the opt-in regulations, in essence the federal government has allowed all states to drop requirements for physician supervision.

This is just a temporary situation, right? Once we have herd immunity and everybody has gotten the vaccine, we can go back to the way we were, amiright? Uh huh. So far, government officials like Dr. Anthony Fauci don't seem to be in any hurry to declare the pandemic under control. Instead there are new variants popping up seemingly each week that require people to keep wearing their masks and consider getting annual booster shots to tame the virus. Though economies are starting to open up, control of the virus appears to be still a long ways off.

The longer the government and payers taste the elixir of CRNA billing, the more they are going to stay with the opt-out model. As our own group has experienced, CRNA's make anesthesia billing more viable as payers relentlessly pursue cost cutting measures. CRNA's can do 90% of the work anesthesiologists can do at half the price. Payers don't care about the anesthesia complications that arise from unsupervised nurses. That is the risk they are willing to take when confronted with the stark economic advantages of opting out. 

For a long time the ASA has had its finger in the dike lobbying to prevent more states from removing physician supervision. Unfortunately for the organization, and all patients and anesthesiologists, there probably won't be a happy ending to this story. The covid tsunami has swamped that wall and the last barrier to removing physician supervision has probably been breached.

Wednesday, April 14, 2021

Pandemic Takes Its Toll On Doctors' Incomes

There's no getting around the fact that the pandemic was devastating to the economic well being of nearly every industry last year. Healthcare was no exception. Between the loss of revenue from cancelled appointments and procedures to the increased expenses of paying for personal protective equipment and scarce hand sanitizer, many people in medicine saw their incomes slashed or evaporated.

Medscape has just released its 2021 edition of its annual Physician Compensation Report. It was drawn from a poll taken from October 2020 to February 2021. It therefore captures all the income made from 2020 and reflects on the continuing difficulty physicians were having during the severe winter surge in coronavirus cases.

The bottom line is that many physicians saw their incomes drop but hardship was not spread evenly. Anesthesiologists took a big hit with a five percent reduction in income compared to the year before. The average salary is now $378,000. However other fields like plastic surgery and oncology saw big jumps in income. So overall, physician income last year was about flat from the year before.

The average income numbers masked some really painful situations for doctors. Ninety-two percent of doctors said covid caused their incomes to decline, mainly due to loss of hours, patients, or even their jobs. In fact, 13% in the survey said they went for a period with no income at all, with the average length of time about three months. That is a scary prospect for people like doctors who have high expenses to meet like student loan debt and office overhead to maintain.

The top three reasons doctors said their incomes dropped were: reduction in hours, no annual pay raise, and reduced staff hours. However 45% said the pandemic didn't affect their salaries at all. If their incomes dropped, about 40% predict it will return to prepandemic levels within twelve months so at least the affects were only temporary.

Unfortunately for my group, our incomes are not likely to ever return to the salad days prior to covid. We dissolved our anesthesia group due to multiple economic weaknesses that became glaringly obvious during the pandemic. As Medscape's survey shows, employed physicians make a lot less than self-employed, an average of $52,000 less.

So our group's plight last year was not unique, even if it was still extremely painful to live through. We, like many other doctors across the nation, and the world, were hammered by the coronavirus both professionally and economically. So far we have made major adjustments and forged ahead to a totally different business model. We can only hope the coronavirus has been contained well enough for now so that we can get some back from what was lost for the last year and hope this truly is a once in a century medical phenomenon.

Tuesday, April 13, 2021

The Medical Boards' Money Machines

The maintenance of certification (MOC) run by the various medical boards is one of the most despised activities that physicians have to endure. The various tests and continuing medical education materials cost thousands of dollars in order for a physician to keep his board certification and stay gainfully employed. The kicker is that there is no evidence that any of these activities actually improve a physician's clinical acumen. As proof, look at the doctors who have lifetime certifications and never have to take any of this crap. These older physicians who grandfathered into these certificates should be the ones who need CME's, not the newly graduated doctors who still freshly retain their recent training. Yet these older doctors will vehemently deny they are any less qualified to see patients than their younger colleagues.

Many doctors have long suspected that the existence of MOC's is just a money making scheme perpetuated by the medical boards. Now Medscape has done a deep dive into the tax returns of the American Board of Emergency Medicine and it shows how lucrative running a monopoly institution can be. 

According to the ABEM's 2018 tax return, the organization reported $19 million in revenue and has $38 million in reserves at its disposal. It also reported $16 million in expenses with a profit margin of 11.2%.  How does this small medical organization with only 41 employees make millions of dollars? 

The ABEM states its major revenue maker are the tests it administers to physicians. New certification costs $4.7 million to administer and brings in $5.4 million. Fair enough. Continuing certification, on the other hand, only costs $1.6 million but hands the ABEM $7.3 million each year. Even Microsoft's profit margins aren't that good.

For comparison, the article looked at the American Board of Radiology. Their revenue numbers are similar to the ABEM so it can be assumed their expenses should be too. The ABR reported initial certification brings $4 million while the continuing certification makes $10 million.

What does the ABEM do with all this money? They lavish their directors with paid vacations to exotic locales, even including their families in on the largess. The company retreats are in lavish settings like Hawaii and Park City, Utah. They fly first class and get virtually unlimited meal expenses. The directors also make mid six figure incomes that dwarf the average salaries of the doctors who they are supposed to represent.

These numbers are only going to go up as more physicians graduate and need board certification and MOC while older physicians who don't make any money for the boards retire. In the years ahead the boards can only look forward to an ever increasing revenue stream, even before they raise prices for their monopoly services. 

Is it any wonder that there is such resentment of the medical boards? Their monopoly status, sanctioned by the government, insurance companies, and hospitals, makes them virtually unaccountable to the doctors who have to pay for their services to keep their jobs. The only beneficiaries of MOC are the boards themselves, not physicians or patients.

Friday, April 9, 2021

Best Anesthesiology Residencies

US News & World Reports has released its annual rankings of medical schools in the country. The list is split between medical schools that primarily focus on primary care and schools that are more research oriented. The research oriented schools are no surprise. They comprise the usual suspects of top universities in the country: Harvard, NYU, Duke, Columbia, Stanford.

The survey also lists the top specialty fields at each school. I'm assuming this means the residencies that are located at the schools. It is based "solely on ratings by medical school deans and senior faculty from the list of schools surveyed." In other words it's a popularity contest. They rank several residencies including internal medicine, radiology, surgery, and anesthesiology.

So let's cut to the chase. Which anesthesiology residency did these medical school faculty think is the best in the country? No surprise here, they closely mirror the top research medical schools. The top ten from one to ten are: Johns Hopkins, Harvard, UC San Francisco, Duke, Penn, Michigan, Columbia, Stanford, NYU, and UCLA. These are almost all the same schools as the top research schools in the list.

What about the best surgery programs? You would think that having a great surgery residency is almost a prerequisite for having a great anesthesiology residency since the two professions work so closely together. Once again, the list closely matches the best research schools. They are: Johns Hopkins, Duke, Harvard, Michigan, UCSF, Penn, Stanford, Columbia, UCLA, and Washington University.

Since these rankings are based on their presumed reputation from faculty members, there is an inherent bias towards well known schools like the Ivies and East and West coast schools. Just remember that, like going to college, it's not the name of the school that you graduate from that matters. It's what you do with your education afterwards that will determine your success in this world. If you graduate from virtually any anesthesiology residency you will be considered to have gone into one of the best jobs in medicine.

Wednesday, April 7, 2021

CRNA's Take Over Wisconsin Hospital

No anesthesiologists work here.

This is the type of news that makes anesthesiologists' blood run cold. Watertown Regional Medical Center in Wisconsin has removed all their anesthesiologists and replaced them with CRNA's. Wisconsin is one of the states that allows CRNA's to work without physician supervision. Therefore they can practice independently without even a surgeon supervising them. How does this cost cutting move by the hospital make the surgeons feel? In a decidedly indifferent comment, Adam Dachman, DO, a surgeon at Watertown, said, "It's a misconception that physicians are required to administer anesthesia." Ouch. Thanks for standing up for physician brotherhood.

This attitude is what I was afraid of when I said the anesthesia care team model will be the end of physician anesthesiologists. With the ACT model, anesthesiologists' roles become more like physician assistants. We're outside the operating rooms, dealing with preop history taking, starting IV's, making sure the patients are ready for their surgeries. Meanwhile, the CRNA's are the ones that are administering the anesthesia. They are the ones the surgeons will interact with 90% of the time. Our interactions with surgeons diminish to the point where they feel the CRNA's are doing all the work and no physician anesthesiologist is needed. This makes the hospital administration's decision to save money by firing all the anesthesiologists that much easier and less controversial with the staff.

The federal government is helping the demise of physician anesthesiologists by allowing the nurses to practice nationwide without supervision. Under the guise of increasing medical access during a pandemic, the CMS is letting CRNA's work independently so physician anesthesiologists can use their critical care skills to treat the maximum number of patients. This provision is supposed to sunset in June as the pandemic eases across the country. Not surprisingly, the AANA has something to say about that. They are talking with the nurse friendly Biden Administration about extending the opt out provision to the end of the year and possibly beyond. 

The coronavirus has been a seismic shift in how medicine is practiced. For anesthesiologists, it may be the final push out the OR doors that we have always feared. 

Sunday, April 4, 2021

Things That Don't Belong In A Human Orifice

The orifices of the human body usually proceed in a one way direction. It either goes in or out. It can be very painful if one violates this law of nature. Anyone who has ever had a Foley catheter inserted or undergone a colonoscopy will attest to that. This hilarious Buzzfeed article lists some grotesque, gag inducing, so unlikely it-must-be-true-stories told by medical personnel of their encounters in the emergency room with foreign objects inserted into different holes of the body. It made me remember one of the most unbelievable and vivid sights I had ever experienced in the ER.

It was early morning and the ambulance dropped off a young man in excruciating agony. He didn't want to talk about it until after we pulled the curtains around his gurney. Once we did that, he pulled back the bedsheet and there was the most enormous, angry looking penis that I had ever seen. It was not enormous in any kind of enviable way. This was not just any ordinary case of priapism either. At the base of his penis was a very tight, very small metal penis ring. It was preventing the blood in his erection from draining back into his body. The penis was purplish in color as arterial blood was not able to enter the organ. It was becoming ischemic. If this was not corrected soon, he could lose his penis. This was a medical emergency.

The urologist on call was notified. When he came down, the man complained that it felt like there was something inside his urethra too. The urologist then ordered an X-ray of the man's groin. What was on the X-ray was even more astonishing. In the film, one could see various objects lodged inside his urethra. There were several fishing weights, paper clips, and even the spring from a retractable pen. Smartphones weren't invented at that time so I couldn't take pictures of that film but I'll never forget it.

Apparently what happened was the man was drinking heavily and doing drugs during his sexual encounter. He then passed out. While he was unconscious, his partner starting doing these masochistic acts on him and left. He finally woke up from the pain and called 9-1-1 since he couldn't drive himself to the hospital.

The urologist carried a small ring cutter for just this purpose. I guess this wasn't his first rodeo. Unfortunately, the penis ring was so tight and the tissue around it so swollen that he couldn't get the ring cutter around it to snap it off, no matter how much lubrication he put on the cutter. It was also excruciatingly painful for anybody to touch the patient's penis, even with sedation.

Ultimately the patient had to go to surgery to remove the penis ring and all the objects inside his urethra. I never found out how the man faired afterwards. I'm sure the surgeon was able to save his penis and urinary function but that is one lesson the man hopefully will never forget. Ask any physician and they will all tell you their stories of patients with some foreign objects inserted into a body cavities. 

For anybody who wants to explore their sexual fantasies by inserting objects into various orifices. Please. Be very careful. Or we'll be seeing you in the ER eventually.

Friday, April 2, 2021

Microaggression In Anesthesiology? Try Macroaggression.


An article published in JAMA Surgery recently listed the level of microaggression present in a group of surgeons and anesthesiologists at Southern California Permanente Medical Group in Irvine, CA. Out of 588 respondents to a survey, a large majority expressed some level of microaggression in their workplace.

The results were measured with different ratings scales. There is the Maslach Burnout Inventory (MBI), the Racial Microaggression Scale (RMAS), and the Sexist Microaggression Experience and Stress Scale (Sexist MESS). I didn't even know that somebody had invented actual legitimate ratings to measure microaggression.

Of 259 female physicians who responded to the survey, 245 of them reported feeling microaggression at work. That's a vast 94%. The most common microaggressive act was "environmental invalidation" or seeing and hearing degrading images about women. This was reported in 86% of female respondents. The next most common microaggression, experienced by 74% of females, was "leaving gender at the door" or having to overcompensate for being female or hiding their emotions and femininity at work. So women feel they are the victims of microaggression if they are not allowed to display their feminine side at work yet are slighted if you complement their looks. Got it.

Among racial minorities, the most common microaggression was not having a role model of the same race at work, which happened to 67% of respondents. This feeling was more prevalent among female physicians (74%), underrepresented minorities (90%), and South Asian physicans (70%). The second most common racial microaggression reported at 51% was feeling like being treated as a foreigner or 'not a true American'. This was most commonly reported by females (58%), Asian (57%), South Asian (60%), and Middle Eastern (54%).

Wow people get their feelings hurt really easily these days. You don't like it when you have to check your gender at the door? Your ego is bruised when the chairman of your department is not the same ethnicity as yourself? Give me a break. How about trying some real macroaggression, the kind of mano a mano conflicts that can happen between an anesthesiologist and the surgeon. Next time you feel like you're depressed because the surgeon told a dirty joke, read about a real life fistfight between the anesthesiologist and surgeon in the operating room while the patient is asleep. That's when men were men and... oops did I step over the line and present too much microaggression for my readers? I guess I better sign up for my hospital's Anger Management class to check my microaggression.

Wednesday, March 31, 2021

Anesthesiology Is An Elite Residency

It doesn't get much more competitive than this. Match Day 2021 has come and gone and anesthesiology has once again shown itself to be an elite residency. Out of 1,893 PGY1 and PGY2 positions available in the NRMP Match for anesthesiology, there were only three unfilled spots. That's a match rate of 99.8%. This is an improvement from 99.4% last year.

How difficult is it to match in anesthesiology? Let's compare it to other programs that are considered extremely competitive. Dermatology had six unfilled spots in the match. Emergency Medicine had fourteen unfilled positions. Radiology, part of the previously exclusive ROAD programs, had eleven.

This news is even better (or worse if you're applying for an anesthesiology residency) when you consider that the number of residency positions has been increasing every year. This year, there were 1,460 PGY1 spots available in the match. That compares with 1,370 last year and only 1,202 in 2017. 

The reason there are so few unfilled positions is that anesthesiology is becoming more popular with medical school students. This year, 5.6% of US MD seniors went into anesthesiology. That compares with 5.2% last year and only 4.6% in 2017. Despite the fact that there are more anesthesiology residency programs offering more positions than ever before, there doesn't appear to be any oversupply of residency spots yet.

The anesthesia residents aren't having any trouble finding a job either when they graduate. The job market right now for anesthesiologists is hotter than ever. From our own personal experience, we can't hire anesthesiologists fast enough, even as we're hiring CRNA's at the same time.

So congratulations to all the medical students who matched into anesthesiology. You have accomplished one of the most difficult tasks in med school. You're on your way to becoming one of the most highly sought after physicians in the medical field. You're not going to regret it.

Saturday, March 27, 2021

My Tumultuous 2020


This is the conclusion of my series on my tumultuous 2020. While I was very lucky and didn't suffer any personal loss from the covid pandemic, the year was nevertheless one of the most unpredictable and contentious in my career.

When 2020 first started, I thought I was going to to have another routine banner year. The operating rooms were full. We were working hard, but getting paid handsomely. I had just run my first half marathon. The Wuhan virus was a disturbance in a faraway land that didn't seem to have any significance on this side of the Pacific. It was so inconsequential that Los Angeles proceeded with their marathon in early March. Then just a few days later, everything stopped.

Our incomes dropped over fifty percent over the next six weeks. The operating rooms practically shut down as images from Italy and New York haunted every doctor on the planet. We learned how to wear N95 masks and don and doff PPE's. Different treatments for covid came and went each week with no clear understanding if any of it worked. We all took out PPP loans from the government to keep from going bankrupt. The stock market had its fastest drop into a bear market in history. It was a darkness that we didn't know when or if it would let up.

Then spring brought a bit of a respite. The state governor allowed hospitals to start accepting elective cases again. Our operating rooms slowly began gearing up to do elective surgeries. But before long there came another surge. This time instead of shutting down the OR's, the administration took a more measured approach by limiting, not eliminating cases. As long as the hospital census was not overwhelmed with covid patients the OR's could continue to run. 

Our anesthesia group could see this was going to be problematic for an indefinite amount of time. We couldn't let a disease dictate the economic well being of the group or the group's partners. It was time to change economic models. The group that I joined almost two decades ago was shockingly disappearing. We were going to get taken over and become employees, no longer the master of our destinies. My dreams of coming to work every day and working the same way for thirty years until I retire had been upended by a virus. Medicine's relentless march towards consolidation of physicians' groups and hospital systems was being abetted by a disease.

It took months of departmental meetings and contentious zoom chats but almost all of us signed on the dotted line and overnight became hospital employees. There were pros and cons to the new job, but the biggest adjustment was the introduction of CRNA's to the department. I think our anesthesiologists needed more education on the new system than the CRNA's. They had worked elsewhere with an anesthesia care team model while we had never had one. This is still an ongoing process within the group as we all adjust and try to make the system as efficient and profitable for the hospital as possible. 

If any of you had wondered why I hadn't posted for several months, it's because of all these changes going on in my life. It was very stressful and caused me physical symptoms like weight gain and flareups of my eczema. We are still adjusting to the ACT model but we don't have a choice anymore. We no longer decide our own careers. It's dictated to us and we have to make it work or leave. This is my first taste of corporate medicine and it's a bitter pill to swallow.

Friday, March 26, 2021

How CRNAs Could Eventually Supplant Physician Anesthesiologists


After working with CRNA's for several months, what is the main problem that I think is going to affect our group? So far, it's not the quality of their work. They're all competent in the OR and some are actually very good, dare I say even better than a few anesthesiologists we have in the department. We haven't had any issues with bad attitudes or incompetence. The problem with having CRNA's in the department is not that there is anything wrong with the nurses per se. It's the way the system is set up so that it diminishes the role of the anesthesiologist. What do I mean by that?

When supervising CRNA's, the anesthesiologist becomes more like a perioperative physician's assistant than a physician. We examine the patients in preop. We make sure the IV's are in place. We go over the findings with the CRNA and implement an anesthesia plan that we don't actually carry out. It's the nurse in the room that is giving the anesthesia. What goes on during the surgery is almost completely unseen by the anesthesiologist who is busy running a perioperative service outside. 

When we talk about an anesthesia care team model, it's usually defined as a team led by a physician anesthesiologist supervising a CRNA. We can call it supervision, but once the patient is inside the operating room, the supervision pretty much stops and the CRNA can do pretty much they please while the physician "leader" is outside keeping the operating schedule flowing smoothly and efficiently. The anesthesia part of the job is very much diminished in the ACT model. At the end of the day, I'm exhausted from running around the OR suites without ever actually intubating or sedating a single patient.

I'm afraid this will lead to more severe problems in the future. Since the physician anesthesiologist is outside running a perioperative service, the surgeons may eventually equate the CRNA that they see in the room as the default anesthesia provider. They're the ones doing the cases and chatting up the surgeons, developing a strong professional rapport. 

While we've had a long history inside our hospital and have strong standing relationships with the surgery department, this won't always be the case as younger anesthesiologists and surgeons start working here. I have nearly two decades of service in our hospital so most of the surgeons know me well. But that is not always going to be true with the younger staff. The new surgeons may only see the CRNA sitting in the room even though the anesthesiologist is theoretically the supervisor in this team model. The new anesthesiologist may never develop a strong relationship with the surgeons. When was the last time you saw a surgeon have a long extended conversation in preop or PACU. They're barely there for five minutes to talk with the patient then they're gone. All the long meaningful conversations take place in the OR, which our younger staff will less of a have a chance to participate in.

Thus the influence of CRNA's will continue to grow in the hospital. It's not because they are any more qualified or more skillful than physician anesthesiologists to give sedation. It is the insidious way that the ACT model pushes the anesthesiologist outside the OR, diminishing their role as the leader in the anesthesia team. Our highly trained abilities to resolving split second complications in the OR will go unappreciated as the surgeons only see the nurses working and appreciating their anesthetic skills, not ours.