Tuesday, May 3, 2016

Free Healthcare But Not Free Water

The poor people of Detroit are getting their water turned off. This week, Detroit's Water and Sewage Department will begin shutting off water to 20,000 residents who have been delinquent on their water bills. Even though the average bill is only $75, thousands of people are months behind in their payments.

What I find ironic is that the government is allowed to turn off water to its citizens when they haven't paid for it. Water! Isn't that one of the most essential necessities of any living creature? Yet people who don't pay for it can have it removed by their own representative government. Meanwhile hospitals and doctors are forced to treat patients regardless of their ability to pay thanks to EMTALA. While hospitals around the country are declaring bankruptcy because of all their unreimbursed free healthcare, the government is free to turn off a service that is even more important than access to a doctor--the free flow of water.

How much would the healthcare industry improve if we had the same flexibility as our elected leaders? We would no longer have to watch patients Snapchatting on their smartphones in the waiting room while declaring themselves too destitute to pay for an emergency room visit. Improved financial results can lift healthcare for everybody. But by mandating that anybody should receive treatment regardless of ability to pay, then obviously only losers will pay for it.

The government should just declare that free access to water is an essential universal right and give it away for free. Then they will finally understand the economic strains that bedevil healthcare providers. But it's easier to force the pain onto somebody else than onto themselves.

Monday, May 2, 2016

Why Do Hospitals Change Anesthesia Groups?

From Enhance Healthcare Consulting
In a survey of hospital administrators conducted by Enhance Healthcare Consulting, 49% of all hospitals have sought to change their anesthesia providers over the last three years. Eventually one quarter of them did just that. To me that sounds like an astonishing large number of hospitals who are not satisfied with their anesthesia services.

What are the reasons hospitals want to change anesthesia groups? Forty percent wanted to change their subsidy level to the anesthesiologists. In other words they wanted cheaper anesthesia. Thirty-four percent said the anesthesia group was not providing adequate coverage. That is usually the case when an anesthesia group is unable or unwilling to provide services that the hospital and its staff requested. The survey also found that 26% of the respondents claim they are changing anesthesia providers because of problems with the anesthesia leadership. This is why political acumen is so important for any anesthesia group hoping to have a long term future with their hospital. If the group's chair does not get along with the hospital, then no matter how well the group performs, the door is already open for them to get kicked out.

So what happened after the hospitals hired new anesthesia groups? Surprisingly, the new hires didn't always provide any cost savings. Twenty-eight percent reported an increase in subsidies for anesthesia services while only 32% resulted in savings. This is probably the result of the hospital kicking out the old anesthesia group not to save money but because of inadequate services or poor relationships with the anesthesia leadership.

The takeaway message here? A shockingly large number of hospitals are always on the lookout to replace their anesthesia providers. This means many anesthesiologists only have a very tenuous hold on steady employment. Therefore it behooves anesthesiologists to play nice with the hospital staff and not act like some spoiled prima donnas when asked to pick up another case at the end of the day or cover a weekend call. The hospital administration is constantly on the lookout for reasons to change anesthesia groups if it will help their bottom line.

Friday, April 29, 2016

The Seven Deadliest Emergency Surgeries

This is rather surprising news. In a study published in JAMA Surgery, researchers from Brigham & Women's Hospital in Boston have concluded that just seven types of operations account for eighty percent of all complications and deaths from emergency surgeries.

The researchers collected data of 421,476 patients from 2008-2011 who underwent emergent operations. They found that the following procedures accounted for the vast majority of all morbidity and mortality from emergency surgeries: partial colectomy, small bowel resection, cholecystectomy, operative management of peptic ulcer disease, lysis of adhesions, appendectomy, and exploratory laparotomy.

To me it's interesting that other emergency cases like ruptured abdominal aortic aneurysm, ischemic leg, ectopic pregnancy, D+C, subdural hematoma, trauma, open fractures, and many others did not get on the list. I guess their numbers are much smaller than the GI cases and thus didn't make it into the top seven.

I can understand why partial colectomies and small bowel resections would be in the top seven. Seems like almost every night I'm on call there is some octogenarian patient who comes in with perforated diverticulitis or small bowel obstruction who needs a repair. The patient's systolic blood pressure is in the low 90's while the heart rate is in the 110's and the surgeon's yelling "Go, go, go!" Of course the complication rates would be high.

But who would have thought that appendectomies would contribute to the overall morbidity and mortality of emergency operations? They are considered so benign that they are used as training procedures for surgical interns. Lap choles are also fairly gentle operations that rarely get complicated. Though I suppose if one is going to do an emergency lap chole the gall bladder is probably pretty socked in making the operation more difficult. I guess since they are done so frequently, hundreds of thousands are performed every year, that it is inevitable they would make the list even if there are rarely any complications.

So next time you are called to do an emergency appendectomy at 3:30 in the morning, just remember that it is considered one of the top seven procedures with the most deaths and complications. Doesn't that make your loss of sleep feel more worthwhile?

ASA Internships Available

Want to work for the American Society of Anesthesiologists? The ASA is looking for summer interns who are willing to toil for them for the princely sum of $15 per hour. You can choose to intern either at their headquarters in Schaumburg, IL or in their more cosmopolitan political offices in Washington, D.C. Hurry before this lucrative offer expires in 3,2,1...

Tuesday, April 26, 2016

To Pee Or Not To Pee, That Is The Anesthesiologist's Question

How many times per day is it normal for somebody to urinate? Don't tell me that you've never thought about it. CNN reached out to Neil Grafstein, M.D., assistant professor of urology at Mount Sinai Hospital in New York for the answer. According to Dr. Grafstein, a person usually pees about four to seven times per day. (There are also some nice pictures of exotic loos around the world, including one at an 18,000 foot elevation in Nepal in the article.) But of course there are large individual variations.

We anesthesiologists have learned to hold in our bladders for extended periods of time. Some days, either because I'm doing a very long case or the schedule is so tightly packed I have no chance to run to the bathroom between cases, I may only go to the bathroom once or twice during a twelve hour day. Days like that pose a dilemma. Should I drink fluids to keep myself hydrated or refrain from drinking so I don't distend my bladder?

That is not as superficial as it sounds. I know many of my partners who developed kidney stones because throughout their careers they didn't drink enough fluids. Almost to a man, they all say it is the worst pain they've ever experienced in their lives. I certainly don't want to have to suffer through that kind of agony for the sake of my job. But bouncing around in the OR with my legs crossed because my bladder feels like it's about to burst isn't very pleasant either. In case you're wondering, this is what happens when you do your own cases and not supervising CRNA's. Full control of a case includes controlling your own urinary urges.

So on days where I know my opportunities for toilet relief will be limited, I try to minimize the liquids I consume. It's not that hard anyways since hospitals are getting stricter all the time about consuming foods in the operating rooms. Then at the end of the day, after I've relieved my minimal dark brown urine into the toilet, I grab an extra large Trenta sized Starbucks drink to rehydrate and encourage urination. Kidney function saved for one more day.

The Most Hypochondriac Patient In The World

I was reading an article in the New York Times about the latest research into peanut allergies. It states how doctors now encourage patients to expose themselves to small amounts of allergens to prevent severe allergic reactions. As I always do, I looked over at the comments section. I do this mainly for my own entertainment as some of the hysterics expressed in these anonymous remarks are frequently quite funny.

But this one really took the prize for blowing me away by its sheer paranoia. Written by commentator2357 from the Bay Area, they wrote that, "I have a kind of allergy cancer that is like a peanut sensitivity, and which causes continual anaphylaxis triggered by mild heat, cold, exercise, stress, scents, foods, and many other things."

My goodness. How does that person manage to survive 24 hours? They get anaphylaxis to heat and cold? They can stop breathing in the middle of zumba because of an anaphylactic reaction to exercise? While I'm sure they truly believe they are that sensitive to their environment, I question the doctor who enables this type of behavior and belief.

We've all seen patients who tell you about their bizarre "allergies" but are in fact just known side effects. I've lost track of the number of patients who told me they are allergic to epinephrine because it made them tachycardic. How many times have patients told you they're allergic to narcotics because it causes constipation and itching. Then somebody somewhere dutifully lists that in the patient's EMR under the allergy section where it will reside for all eternity.

None of these patients would hold such thoughts if their doctors at some point educated them on what is a real allergy and what is just a side effect or maybe even mere coincidence. That would save so many other doctors from doing an eye roll when they meet them in the hospital. Having such a large number of allergies in one patient also harms the patient as maybe the best treatment for them is not available because someone years ago said they were allergic to it without any real concept of what a true allergy is.

I feel sorry for commentator2357. The blame for her hypochondriasis really belongs to her doctor who encourages this type of conduct. Physicians who enable these problematic patients just makes the rest of our lives that much more miserable in an already challenging work environment.

Sunday, April 24, 2016

MOC Tyranny Coming To An End?

Has the American Board of Medical Specialties finally overplayed its hand? There may finally be some movement to remove the shackles of the Maintenance of Certification programs that have bedeviled physicians. On April 12th, Oklahoma became the first "Right to Care" state by banning the use of MOC as a prerequisite for a doctor to practice medicine in the state. According to SB1148, "Nothing in the Allopathic Medical and Surgical Licensure and Supervision Act shall be construed as to require a physician to secure a Maintenance of Certification (MOC) as a condition of licensure, reimbursement, employment, or admitting privileges at a hospital in this state."

So there you have it. Oklahoma has legislated that no doctors can be denied their right to pursue their profession just because they don't have a piece of paper saying they paid thousands of dollars to take exams that are barely relevant to their jobs. No insurance companies can deny reimbursements to physicians who have not put up the extortion money to their medical societies to take meaningless simulations and tests. No physician needs to live in fear of losing their medical license just because they refuse to bow down to the overlords at the ABMS and put up with their greedy nonsensical plans.

This train doesn't seem to be stopping. Kentucky's SB17 is also on board with abolishing the requirement to participate in MOC to work as a doctor. "The (medical) board shall not require any form of specialty medical board certification or any maintenance of certification to practice medicine in Kentucky." It further states that "The board's regular requirements, including continuing medical education, shall suffice to demonstrate professional competency." Boom. Kentucky's bill forbids their medical board from requiring MOC as a prerequisite for obtaining and keeping a medical license. Though I question their wording where it sounds like one doesn't even need a specialty certification, like a certification from the American Board of Anesthesiology to practice anesthesia in the state. Unless I'm misreading the statement, it would seem that any doctor can practice any form of medicine there without needing board certification.

Other states are also seeing the light. Missouri's legislature is currently debating a bill similar to Kentucky's. Michigan is working on a law the specifically prohibits hospitals from denying admitting privileges and insurance companies from refusing reimbursements to doctors who don't participate in MOC.

The ABMS and all their minions in the other specialty boards thought they could push doctors around when they first required ten year recertifications. But then their megalomania could not be stopped as they required an ever increasing number of expensive and pointless hurdles to cross for doctors to keep their jobs. The final straw was when they requested that previously lifelong certificate holders should participate in MOC or their certificates would be diminished in the eyes of the ABMS. We may finally be witnessing some sanity returning to the medical licensure and certification process. Keep pushing your state medical societies to advocate for similar laws in your state. This was passed with bipartisan support, actually unanimously, in Oklahoma. There is no reason it can't work in other state legislatures. Hope all states eventually follow Oklahoma's lead before my next recertification exam.