Thursday, July 24, 2014

An Obama Visit Is A Public Health Hazard

President Obama is visiting Los Angeles again. This will be over a dozen times he's been here mainly to hit up millionaire limousine liberals in Hollywood for money. After so many visits, why are people still inexplicably giving thousands of dollars for a blue plate special at the local Beverly Hills hotel just to hear him speak?

Obama in L.A.
Every time he comes, the Westside of LA becomes a total traffic nightmare. Congestion is bad enough on a normal day. But when the president and his motorcade arrive, the Secret Service closes off the roads that they will be traveling. This makes the gridlock unbelievably agonizing. As a bonus, for security purposes, the SS doesn't tell anybody where the street closures will be so you don't even know which streets to avoid until it's too late.

While all these visits have been an aggravation and a nuisance, now it has risen to the level of a public health hazard. One of the blockades happened to take place near Cedars-Sinai Medical Center when a woman in labor needed to get to the Emergency Room. The presidential entourage wasn't even anywhere near that street yet but the security detail refused to let the woman cross the street to get to the hospital. The poor woman could not do anything about the situation and resignedly sat down on a sidewalk bench to wait for security to let her cross the road and deliver her baby safely.

We doctors already know the president doesn't have the best interest of the general population at heart. Obamacare was passed not because he cares about the health of his fellow Americans. It was done to gain votes for the Democratic party and to capture voters dependent on government largesse for generations to come. But this denial of one of the most basic needs, to deliver a baby, is beyond the pale. Who knows how many people with urgent medical needs like chest pain or shortness of breath were diverted to more distant locations because their local hospital was made inaccessible by this presidential visit.

I say Mayor Garcetti should refuse the president any more fundraising visits. The only people who benefit from his fundraisers are the millionaires who still flock to see him while the 99% of the rest of us just burn up more fossil fuels, vastly increase our carbon emissions, and get denied basic healthcare needs. No More Bama in L.A.!

Sunday, July 20, 2014

The Revolving Door Of Nursing Managers

Our procedure center is a pretty stable unit. We have employees who have worked there for ten to twenty years. We all know each other like family. We've seen each other's children being born, grow up, and graduate from school. It is a very comforting place to work.

But one position that seems to have constant turnover is our nursing manager. The nursing manager, as the title implies, manages the nurses' activities. She (they have almost always been she) makes the call schedule. She determines what time nurse comes in and when they leave. She makes sure the payroll is made out properly. She plots the yearly vacation schedules. She intervenes in interpersonal conflicts at work. In essence, the nursing manager is in charge of almost all aspects of the nurses' work.

Unfortunately this important position has seen a continual flux in our center. The problem, I feel, is that whoever accepts the job is not really in it for the long haul. Our nursing managers tend to view the job as resume padding, not the final role for a career well done. They always seem to be looking for the next rung up the ladder of their nursing career.

Because so many of them view this assignment as a temporary stop, we don't get the best people to help manage our busy unit. We basically get two types of personalities that accept this appointment. One is the politician. She is always on the go, attending every possible meeting she can to shake hands and have face time with her superiors so that she can get promoted as quickly as possible. Her office door is always locked because she is somewhere else cavorting with people who might give her the promotion she so desperately craves. The job of the nursing manager then falls upon the most senior nurse on the unit, who usually does a pretty good job as she's had to do this many times before.

On the other end of the spectrum is the micromanager. And this one is actually worse. The micromanager will do everything possible to demonstrate to everybody, especially her bosses, that she is fully in charge of the unit. Even if her decisions make absolutely no medical or common sense. For instance, one of our recent nursing manager's first executive decision on the unit was to reverse the order of the bed numbers in the unit. What used to be bed numbers one through ten became numbers ten through one. There was absolutely no reason to do it. It did not improve patient safety or increase the efficiency of patient care. On the contrary, for weeks afterwards people went to the wrong bed because everybody was so used to the old numbering system. But the manager showed that she was the boss and could make people do whatever she wanted.

Another time the nursing manager suddenly decided that every patient who went to the recovery room after a procedure needed to be hooked up to a transport monitor for vital signs during the short traveling distance, which is literally just down the hall. A defibrillator also had to accompany the patient each time. It didn't matter if the anesthesiologist was going with the patient or that the patient was stable, awake, and breathing room air after a short MAC case. The manager insisted that this was the new safety standard being adopted nationwide and we had to follow it. When the anesthesiologists objected, she simply ordered her nurses to put the monitors on the patients themselves. Needless to say, the nurses weren't terribly happy about this either since they were the ones who had to bring all those heavy monitors back to the unit after dropping the patient off in recovery. Many monitors were lost because of her new rules.

But like the weather in the Midwest, if you don't like what you currently have, just wait around a little bit and a new one will show up shortly. The average length of employment of our nursing managers is usually about eighteen months to two years. They have all gotten promoted to a higher position or have been fired unceremoniously after stepping on too many toes. We're still waiting for the one manager who can find satisfaction in her work without constantly longing for a higher position. I'm not holding my breath.

Thursday, July 17, 2014

In Remembrance Of Scott

I just found out my old friend Scott has died. When I got my medical school newsletter, I was shocked to find his name among the list of alumni who had passed away. It just doesn't seem right that somebody so young and vivacious could have disappeared at the prime of his life.

Scott and I started medical school together. He was tall, lanky, with a thick crop of curly brown hair and a deep husky voice. He was also a cancer survivor and one of the most interesting persons I had ever met.

We met each other through a mutual friend when we all decided to be roommates together. I didn't know him very well at the time. But Scott was easy to like. He had a ready smile and a very dry sense of humor. I've seen him annoyed but never saw him lose his temper. Whereas other medical students can be extremely competitive and cutthroat, he was much more laid back. He didn't get the best grades but he wasn't the worst student either. He just didn't take his studies as seriously as the rest of us. He wasn't the type to pull all nighters or dissolve into a morass of self doubt if he didn't ace an exam. He was even keeled when the rest of us were tossed around by our own storms of emotional distress. He knew there were more important things in life than getting straight A's and brown nosing the right professor for a research spot.

My friend also didn't hang out with the other med students much. Medical students can be quite insular and clannish. Instead Scott preferred the company of the music school students at the university. Because they were constantly coming over to our house, I got to know many of them. And they are VERY different from med students. The first giveaway was the alternative dress and piercings. And the tattoos. I don't think any medical student would be allowed in the hospital if they showed up looking so rebellious. But they were all very friendly and seemed to have a lot more fun than us. I could see why he liked to be around them more than with his own classmates.

Besides being more inclusive, there was another reason Scott enjoyed his time with the music students. They were heavily into marijuana. Nowadays, he could probably get some back alley "doctor" to write him a prescription for medical marijuana since he actually had a legitimate reason to take it. But back then, he was simply just another pothead who enjoyed a toke now and then.

He was the first person I knew who used marijuana routinely. He even offered me a puff one time, not in a pushy sort of way but because he knew I was curious. Unfortunately my strict upbringing caused me to pull back from the temptation. In retrospect it was probably a pretty lame choice. Even presidents of the United States now admit to partaking weed in their youths without any apparent consequences to their health or occupation. But I declined and he never asked again.

I was always afraid that when my parents visited they would see or smell the pot in the house. But Scott was very discreet. I never saw him stoned, staring into a lava lamp and uttering nonsense. He rarely smoked his marijuana or cigarettes indoors. He even kept his plants in his room well out of sight. No one would ever suspect he had a weed garden growing there. My parents were never the wiser.

Halfway through medical school, Scott's cancer came back. He had to drop out of school for over a year to start his treatments. Our little household broke up and we each moved on to different roommates and locations. I kind of lost track of Scott after that. But he did come back and complete his medical degree. He went on to train at a prestigious subspecialty in the upper Midwest and had a thriving practice afterwards. He got married and had several children before his cancer recurred one last time.

Thank you Scott for showing me how beautiful life is outside the confines of our parochial scientific institutions. You faced down your illness with a sunny disposition and never wallowed in self pity. I will always treasure how you opened my eyes to all the possibilities that exist if one is willing to step out of family and social expectations and lead a life of one's own choosing. You were truly an inspiration for my young, developing self. Farewell my friend, until we meet again.

Wednesday, July 16, 2014

Saving Medicare Becomes Doctors' Burden

The Congressional Budget Office released a new report yesterday and it was all good news for Medicare. According to the CBO, the government healthcare program for the elderly and disabled will remain financially solvent for five more years than previously predicted. Instead of going bankrupt in 2025, it is now going to fall into the abyss in the year 2030. Hmm, that's right about the time I'll become eligible for the program. But anyway, that's beside the point.

The reasons the CBO gave for increasing the longevity of Medicare aren't anything to celebrate though. The agency states that Medicare will be helped by a lower than projected rate of economic growth. Since people spend more on health care when their incomes go up, a worse economy will cause people to use less, thus saving the government money. Sinking the economy to improve a government program doesn't sound like such a great bargain in my opinion.

The CBO also says that interest rates are likely to fall since the economy won't be as robust as predicted. This will save the government billions in interest payments. I find this hard to accept since interest rates are already being kept at near zero by the Federal Reserve. How can the rates possibly go lower over the next quarter century? Even if they did fall from its current miniscule yield, I'm not sure how much money the government will save if rates fall from 0.25% to 0%.

Then the agency gives the healthcare industry a kick in the guts when it finally states what will help keep Medicare solvent for the next fifteen years--lower payments to doctors and hospitals. It is counting on Congress holding the line on sustainable growth rate reimbursement cuts to take place next April. That means a 24% chop to doctors payments unless they do another doc fix. According to the report, "Evidence suggests that hospitals and other providers may be able to achieve significant productivity gains or to restrain the growth of their costs in some other way."

In other words, work harder, make less money. They are projecting the number of patients using Medicare will increase by the millions every year for the next fifty years. However they are counting on doctors seeing all those new patients for the same amount of money they are getting now. The best deal the AMA could get to fix the SGR formula last spring was for reimbursement increases under the level of consumer price inflation for five years then a pay freeze for the next five. Even with defeatist negotiating tactics like that, the AMA still couldn't get Congress to pass a doc fix, which both political parties pledged they wanted.

So if you think you are working to the point of exhaustion already, the federal government has news for you. This is the golden age of healthcare reimbursements for doctors and hospitals. The situation is likely to deteriorate badly in the near future. And if doctors don't accept their duty to see patients for whatever price is dictated to them, then they will be the ones responsible for the eventual bankruptcy of Medicare.

Thursday, July 10, 2014

Why Being A Doctor Is Better Than Working For Silicon Valley

Click to enlarge to appreciate the enormity of anesthesiologists' salaries.
This graph has been making the rounds on the internet for the past week. It illustrates the best paying jobs in America as reported by the Bureau of Labor Statistics. I made a screen capture to show only the top 25 or so occupations. To see the entire list of 820 job classifications, go here. According to the BLS, anesthesiologists earned the highest salaries in the country with a median income of almost $240,000 per year. This was followed closely by surgeons, oral surgeons, OB/GYN, and orthodontists. In fact, of the top 15 highest paid jobs, only two (chief executive and petroleum engineer) are not healthcare related. It is interesting the the federal government doesn't specifically mention highly paid specialties like neurosurgery, orthopedic surgery, or gastroenterology. If they did, the top fifteen would all be medically related professions.

Even though doctors are listed by the federal government as having the highest paying jobs in the country, we can't help but read about and envy all those young punks who barely graduate from college and become instant millionaires working for some flash in the pan internet company. It's just innate human nature to think the grass is greener on the other side of the 101 freeway. But the reality is that striking it rich in Silicon Valley is more akin to winning the lottery. The vast majority of workers in the tech industry toil away in anonymous cubicles for electronics companies that may never go public. Most of these kids will never cash in on a headline grabbing IPO as their companies labor to attract eyeballs and in-app purchase money 99¢ at a time. Worst of all, the longevity of a career in computer science can be extremely limited as the next crop of graduates who have been trained in the latest technologic innovations quickly supplant the previous years' workers with their eagerness, energy, and knowledge.

By contrast, nearly everybody who finishes medical school is virtually guaranteed a six figure income right after residency. Unless the physician dedicates his life to research or charity work, it is almost a certainty that he will land in the top reaches of the BLS salary list. Now this elevated income comes only after years of training, high student debt load, and delayed gratification. But it is there for everybody once the grueling process to become board certified is completed. There will be no fantastic IPO on the NASDAQ that will vault the physician into the Forbes 400 but it is still a good steady job that can last decades and sustain a nice upper middle class lifestyle. That too is worth something.

Tuesday, July 8, 2014

Anesthesiology Residency Is One Of The Most Dangerous Jobs In America

Among medical professionals, it is widely believed that anesthesiologists are one of the most likely physicians to develop a drug addiction, now known as substance use disorder (SUD). But is that true? And how likely will a person who begins training in anesthesia develop SUD? The July 2014 issue of the ASA Newsletter shines some light on this common idea.

A collaborative study between the American Board of Anesthesiology and the Mayo Clinic examined the incidence of SUD in anesthesiology residents from 1975-2009. They looked at ABA training records, state medical board disciplinary actions, and the National Death Index, which describes causes of death. What they found was that there were 384 anesthesia residents found to have substance abuse out of a total of 44,612 residents during that 35 year time period, or 0.86%. The lowest incidence of SUD occurred in the years 1996-2002, which just happens to be the nadir of anesthesia residency training. Perhaps the residents who went into anesthesiology at that time were just more motivated to succeed. The highest incidence of SUD has been in the last few recent years. Currently about one in 87 residents will likely develop SUD.

During the study period, of the 384 residents who had SUD, 28, or 7%, died during training. Of those who survived, 56% completed residency training. But only 44% of SUD survivors eventually became board certified. Unfortunately 29% will relapse and death was the first indication of the relapse in 13%. Overall, of the 384 resident who developed substance abuse, 53 are now dead. The cause of death are known in 49 of them and SUD was the fatal factor in 44 of them, or 90%.

You may think that those numbers don't sound so threatening. After all, out of thousands of physicians who have successfully completed anesthesia training, only a few hundred have had problems with substance abuse. To get a better perspective on all this data, the study helpfully compared anesthesia residency mortality to other "dangerous" occupations using numbers from the Bureau of Labor Statistics. With 28 deaths found in 177,848 resident-years of training, that works out to an annual rate of 15.7 deaths per 100,000 anesthesia residents. According to the BLS, the most dangerous job in America is farming and fishing, with a mortality rate of 21.2 deaths per 100,000 workers. Policemen have a mortality of 18.6 per 100,000. Firefighters, though each of their deaths is considered a national tragedy, have a mortality of only 2.5 per 100,000. Among all healthcare workers, it is only 0.7 per 100,000. Think about that. You are more likely to die in anesthesia training than you are to get hit by lightening, die from a bee sting, or succumb in a plane crash. In fact, the odds of death among anesthesia residents is almost the same as getting shot with a firearm in America.

To all you CA1's starting your new careers, have a nice day. And be careful out there.

Friday, July 4, 2014

Deliberate Hypotension. The Last Refuge Of A Weak Surgeon

For those who don't know, deliberate hypotension, as the name implies, means to drop a patient's blood pressure on purpose during an operation. The idea is that by lowering the BP, the patient will experience less blood loss and lessen the need for a transfusion. While there are a few scenarios that have a legitimate need for deliberate hypotension, such as a cerebral aneurysm clipping or a patient who is a Jehovah's Witness, I have found that most surgeons who request it usually are just not very good at their jobs.

I'll never forget the first few months after my residency when I was assigned to a particular ambulatory surgery center that our group covered. Many of the orthopedic procedures that were performed there were done by the biggest prick of a surgeon. His specialty was doing half assed arthroscopic operations on shoulders and knees, rarely taking more than fifteen minutes per case. His patients were rarely properly worked up preop. Many had multiple comorbidities like obesity, hypertension, and diabetes but I was lucky to get an ECG in the chart. Worst of all, this surgeon demanded that his patients' pressures be dropped to dangerously low levels.

This was particularly risky for his shoulder scopes. He wanted the patients positioned bolt upright, at ninety degrees. Even though there was hardly any history in the chart on the patient's cardiovascular status, he required systolic pressures down to the 90's. Eighties were even better. He had a tendency of constantly looking at the anesthesia monitor to make sure he was getting the blood pressure he needed. When he began shaving the bone and it started bleeding, he would inevitably scream at the anesthesiologist to drop the BP. During those cases I prayed that the patient was receiving adequate cerebral perfusion and would wake up at the end of the case.

His knee scopes were even more outrageous. Even though the patient had a tourniquet on the leg, once he started shaving the bone and cartilages and the patient bled, he would yell at the anesthesiologist to lower the BP. This despite the fact that the tourniquet was set at a much higher pressure than the patient's systolic pressure. Of course a regional anesthesia was out of the question for this guy since he didn't have time to let any anesthesiologist set up the necessary equipment to perform a proper block.

As a newly graduated anesthesiologist, I felt a strong obligation to comply with his demands no matter my misgivings. It got so bad that at one point I drew up syringes of nitroglycerin and gave tiny boluses of it to the patient right before the blood pressure cuff went up. Of course this played havoc with the patient's pressures and heart rate but at least every time he looked up the BP was in the proper range and I could keep my sanity for another day. Eventually I got sick of these games and asked my boss to move me somewhere else. He sighed and transferred me to a different facility, one of countless other colleagues in our group who have asked to never work at that place again. It was no problem really. He just put the next junior attending into that hellhole.

I didn't realize that what that surgeon requested was not only dangerous for the patient, it was also not necessary. That is until I worked with a different surgeon. Doing the same procedures, I reflexively lowered the patient's blood pressure. When he looked up, he asked me why the BP was so low. I replied that isn't that what surgeons like for arthroscopic cases? He said no. Just keep it near the patient's baseline pressure. BP's that low can be risky for patients. What? An orthopedic surgeon that actually thinks and cares about his patients? I then knew that some surgeons use deliberate hypotension to mask their incompetence.

It's not just arthroscopies that surgeons frequently request hypotension. Some spine surgeons I know always ask that the BP be lowered to prevent blood loss. This sounded reasonable on big spine cases until I started working with one spine surgeon who I highly respected. He told me to just keep the pressures near preop baseline and it shouldn't be a problem. As long as the BP doesn't shoot up to 180's/110's the patient will be fine. And you know what, he was right. His cases did not have any greater EBL's than the surgeons who wanted hypotension.

So now when a surgeon asks me for deliberate hypotension, I'm always extra alert to the possibility that he may not have the best surgical technique. Whether it is spine surgery or hip replacements, good surgeons can make their operations look effortless and remarkably free of blood loss. It is the bad surgeons who will be screaming at the anesthesiologist to drop the BP while the suction cannister fills up with heme.