Tuesday, May 24, 2016

California Wants Its Money Back From Radiologists

Imagine when you were a teenager and you mowed your lawn to earn your allowance every week. Then suddenly your parents announce that they think they've been paying you too much and will withhold a portion of your money until the overpayments have been returned. How would you feel? Would you continue to mow the lawn or go on strike? What if you can't go on strike and have to keep mowing that lawn with the reduced payments?

That is exactly the predicament facing California radiologists now. Back in 2010, California was facing an historic state budget deficit, mainly due to its own fiscal incompetence. To help balance the budget, the legislature enacted cuts to Medi-Cal payments to doctors, the state's Medicaid program. The law said that no radiology services could exceed 80% of Medicare's already measly reimbursements.

Unfortunately the Department of Health Care Services did not get around to implementing the new rule until July 20, 2015. Now the DHCS wants to claw back money from radiologists to right this oversight. It wants the radiologists to return the excess money they've been receiving since October 2012.

Normally when the government says they've overpaid you, they want the whole amount returned in one big lump payment. But since they feel for the little guy and understand that would probably bankrupt most of the radiologists in the state, the DHCS has decided that they would reimburse the doctors 20% less than what they should be receiving until the money has been returned whole to the state.

The irony is that now the state is swimming in a budget surplus. Every special interest group is hungrily eyeing that extra money for themselves. Yet they are taking back money from doctors for services fairly rendered years ago. And the radiologists have no say in this travesty. Goes to show that when you sleep with snakes, you're gonna get bit.

Saturday, May 21, 2016

Tank For The Memories

One of the really cool things about living in a major city like Los Angeles is that you can get experiences that are unavailable anywhere else. Today, the very last space shuttle external fuel tank is being moved from a barge in Marina Del Ray to its final resting place at the California Science Center. I took the opportunity to drive down to Inglewood to take a few pictures. Memories of past American space program glories almost brought tears to my eyes.

Once at the museum, it will be rejoined with one of four existing space shuttles in the country, the Endeavor. Eventually, the display will look like this for kids too young to know what the space shuttle looked like.


This will be the only place in the whole world where one can see the entire space shuttle launch configuration intact. Gosh it's good to live in LA.

Saturday, May 14, 2016

Cheating Your Way Into Anesthesia Residency

You would think that anybody who enters medical school would hold the highest ethical standards. Their integrity should be above reproach. After all, they are making life and death decisions about their patients every single day. Nobody wants a shady doctor with questionable credentials. But alas that is not always the case.

In the February issue of A&A Case Reports, researchers at West Virginia University Anesthesiology Residency Program evaluated the personal statements of all their residency applicants after the 2014 Match for signs of plagiarism. What they found was discouraging.

They used plagiarism scanner software to look through 472 applications to their program. These were split between 228 U.S. applicants and 244 international applicants. Five were eliminated for technical reasons. The plagiarism program pulled out 82 out of 467 personal statements for possible plagiarism. These were then reviewed by the three authors of the study. At least two of the three had to agree that the statement was plagiarized from another source.

After the human review, the authors concluded that nine American applicants (4%) had plagiarized their statements while 33 international applicants (14%) had some plagiarized material. Overall 9% of the personal statements had unoriginal passages. Two of the U.S. and 17 of the international applicants contained more than 10% plagiarized content. One student's personal statement had more than 58% plagiarized material. The most common source for plagiarizing passages were from www.medfools.com/personal, a collection site of personal statements.

Sadly, some people either don't care about honesty and personal integrity or they don't think they are smart enough to get into residency without cheating. You have to wonder how these people got through college and medical school in the first place. For international students, they may think their English is not good enough to get them into an American residency so they hope to sneak in by copying other people's material. But with the advent of scanning software, students will hopefully realize that a bland but honest personal statement is much more acceptable than a stellar one written by somebody else. Nobody should ever have to question the trustworthiness of their doctor.

Friday, May 13, 2016

When To Call For An Orthopedic Consult

Remember how we belittled orthopedic surgeons in the hilarious Orthopedics Vs. Anesthesia video? It was a perfect encapsulation of the stereotype about the big dumb orthopedic surgeon vs. the intellectual anesthesiologist. Now the orthopods have returned the favor. In a GomerBlog post, the "College of Orthopedic Surgery" sets out guidelines to hospitalists and emergency physicians about when it is appropriate to call for an orthopedic consultation.

It mentions with obvious glee that orthopedic surgeons are probably a lot smarter than the people who are calling for the consults. Since it is such a competitive match, they most likely have higher USMLE Step 1 scores than anybody else.

The list asks that somebody review the X-ray first before calling in a consult. Don't just order it and call the surgeon before looking at it. And try to remember the name of the bone that is broken. "Tibula" is not an actual bone. If the radiologist reads the film as "Unremarkable study" then don't call the orthopod. If the patient has a diabetic foot ulcer or foot celllulitis, call podiatry. That is not an orthopedic problem.

There are more funny guidelines in the post to help us clueless non-orthopods figure what is an orthopedic injury.

I'm Tired Of Reading About Physician Burnout


You drag it around like a ball and chain
You wallow in the guilt; you wallow in the pain
You wave it like a flag, you wear it like a crown
Got your mind in the gutter, bringin' everybody down
Complain about the present and blame it on the past
I'd like to find your inner child and kick its little ass.

Get over it
Get over it
All this bitchin' and moanin' and pitchin' a fit
Get over it, get over it.

"Get Over It" by The Eagles

Sometimes it feels like the phrase "physician burnout" is the most important medical topic among doctors. It seems to appear at least five times a day in KevinMD. Medscape has an annual survey just for this subject. The current issue of the ASA Monitor has an article devoted to anesthesiologist burnout. According to a Mayo Clinic study, anesthesiology is one of the unlucky seven medical fields with both a high burnout rate and low work/life balance. The other specialties with this dubious record include radiology, internal medicine, orthopedic surgery, family medicine, urology, and neurology. Though to anesthesia's credit, we are just barely on the burnout and work/life imbalance quadrant of the graph. Does that mean anesthesiologists are almost but not quite happy with their chosen lifestyle?

Personally I'm burned out from reading about physician burnout. As I mentioned years ago, doctors can whine and complain about how hard it is to practice medicine, but frankly nobody else gives a damn. Why should they? Even the lowest paid physician is doing better than most of the rest of the country. Unemployment among doctors is virtually nil. A medical degree still carries with it respect and admiration from most people. Doctors have the privilege and responsibility to query their patients' personal lives in ways that the CIA or the FBI can only dream about.

Yet physician misery seems to becoming more ubiquitous. I don't think it's a mere coincidence that this talk about job dissatisfaction has arisen shortly after the change in resident work hours. Whereas before one was supposed to lament about missing half the cases when they're on every other night call, now the residents expect to have nap times during the day and weekends off. Is it any wonder that when they finish their training and start working in the real world that they become overwhelmed? Suddenly having the day off post call is not automatically granted anymore. Patients don't care if you've been up all night. You're the responsible physician and they will call you to take care of them even if you only got two hours of rest the night before. The ability to learn from hardship has been removed by the benevolent but misguided government bureaucrats.

Now the poor dears don't know what to do but gripe about how difficult their professional careers turned out to be. As the Skeptical Scalpel points out, all this grumbling may be infecting others who before may not have given a second thought about workplace difficulties but now find it socially acceptable to cry like a child who doesn't get his way.

So you know what all you complainers? Your patients, your hospital staff, and your physician colleagues don't owe you a damn thing to make your life better. Just pack up your sad sack and take it back to your momma's house where somebody may actually care. If you don't find satisfaction with your hard earned career choice, then find solace outside of work such as your family, your church, your hobbies, your exercise routine. Take a vacation. Go on a sabbatical. Do some volunteer work in an underprivileged neighborhood to come face to face with what real hardship looks like. Don't bring me down to your level because you don't know how to deal with stress. Being a doctor has always been stressful. Nothing has changed but the embarrassing complaining.

Thursday, May 12, 2016

If Only They Had Listened To The Anesthesiologist

A settlement has been reached in the medical malpractice case involving the death of comedienne Joan Rivers. If you recall, Ms. Rivers died in 2014 while undergoing an endoscopy to evaluate her hoarse voice. The circumstances were pretty murky but somewhere along the line, Ms. Rivers' personal ENT doctor was allowed to evaluate her larynx during the procedure even though the surgeon had no privileges to operate at the Yorkville Endoscopy Center and there was no consent for it to be performed. Presumably during the laryngoscopy and possible cord biopsy, Ms. Rivers suffered laryngospasm, causing her to become hypoxic and go into cardiac arrest. Her heart was revived but she never regained consciousness. Life support was removed by her daughter one week later.

The terms of the settlement were not disclosed though supposedly the monetary compensation is quite substantial. However, more details about the events of that day have been released. Apparently, Dr. Renuka Bankulla, the anesthesiologist in the room, rightfully feared that she would face a malpractice suit after her patient's death so she wrote a lengthy five page note about what happened in the procedure. This proved to be invaluable for Ms. Rivers' lawyers during the case.

According to Dr. Bankulla, the doctors in the procedure room were so enamored of Ms. Rivers' celebrity status that they violated normal protocols of conduct, including taking pictures of the patient while she lay on the operating room table and allowing a surgeon to do a procedure who had no privileges at the facility.

The anesthesiologist documented that she told the surgeon the patient's vocal cords were swollen and they might close off. Dr. Lawrence Cohen, the gastroenterologist in the procedure, replied, "You're such a curious cat." and ignored her warning. He called his anesthesiologist "paranoid" and allowed the ENT surgeon, Dr. Gwen Korovin, to proceed with the laryngoscopy.

Sure enough, Ms. Rivers' cords snapped shut, closing off her airway. When Dr. Bankulla asked for help in performing an emergency cricothyrotomy, Dr. Korovin had already hustled herself out of the building, leaving the anesthesiologist and her colleagues by themselves to try to reestablish an airway. When they finally did, it was too late to save Ms. Rivers' life.

One has to wonder what might have been if Dr. Bankulla had been more forceful in her warning about Ms. Rivers' precarious airway status and stood up for her patient to prevent the laryngoscopy from proceeding. Was she intimidated by Drs. Cohen and Korovin? Was she in awe of Ms. Rivers and let her better judgement slip? We may never know.

The lesson here to all surgeons is that they need to listen to their anesthesiologist. If the anesthesiologist suspects trouble, it is time to back away from the procedure. Our only responsibility is the safety of the patient. Nothing else in the procedure room matters.

How To Be A Star On Your Anesthesia Rotation

Another academic year is almost done and the number of medical students rotating through their anesthesia rotations has slowed to a trickle. As we wind down towards graduation, this is a good time to reflect on the qualities of what I thought made certain students really shine during their brief visits to this side of the ether screen.

Many of our students weren't even going into anesthesiology. It was usually part of their surgery rotation and they wanted a little taste of what anesthesiology is all about. This year it seemed like most were either going into emergency medicine or internal medicine. One thing they all had in common though was that they thought an anesthesia rotation was an exercise in learning how to intubate. When asked what they hoped to get out of this rotation, that was probably the most frequently mentioned objective.

Let me just say right off the bat that intubation skills is probably one of the least important reasons to rotate through anesthesia. One doesn't go through four years of medical school and four more years of anesthesia residency to learn how to intubate. It is a simple mechanical motion that anesthesia residents pick up in their first month. It is like taking driver's ed and only wanting to learn how to start the car. Intubating a patient is just a simple process in the middle of all the analytical thinking that is required for a successful surgery.

Instead, students who are going to do an anesthesia rotation will do themselves a huge favor and study a critical care book. Anesthesiology is essentially critical care outside the ICU. While I am in general pretty lenient about students who don't know the answers to my pimp questions, I have colleagues who will absolutely shut down the student if they can't answer seemingly simple questions about patient care. They will leave the student just standing there alone as an observer and not bother doing any more teaching. I don't expect fourth year students to know anything about anesthesia. That is something I may teach them if we have time but I will absolutely hammer them if they don't know simple patient physiology and pharmacology.

For instance, I had one student, just weeks away from graduating from a top ranked medical school, who couldn't tell me the normal values for an arterial blood gas on room air. After I gave myself the biggest eye roll, I almost questioned my own teaching skills. Am I asking too much of fourth year medical students? Was this something I would have known when I was a student? Then after discussing with other attendings, I decided that the questions was not unreasonable. Students who are about to get their M.D. should know what normal blood gas values are since that stuff was taught in physiology class back in the second year. There is no reason to not remember it just because they have already taken their physiology tests and passed the class.

Likewise many students don't know what a normal A-a gradient is or, even harder for them, how to calculate it. The ability to draw for me the oxygen-hemoglobin dissociation curve also eludes quite a few of them. These are not anesthesia questions that I use to stump students. This is basic knowledge that I feel every doctor should have a firm grasp of when they start their residencies regardless of their field.

And please know critical care pharmacology. When I ask students what drugs they would give to treat intraoperative hypotension, it always amazes me that so many of them say either dopamine or dobutamine. However not many know the mechanism of action of those drugs or indications for using them. If I gently remind them about other drugs like phenylephrine or norepinephrine, again I get a blank stare when they're quizzed about how they work.

This is essential information that all doctors should possess, not just anesthesiologists. If they know the answers to these questions, then I might move on to more anesthesia specific questions like the mechanism of action of volatile agents or the molecular structure of succinylcholine and why it's a depolarizing instead of nondepolarizing muscle relaxant. But if they're list of IV antihypertensives starts and ends at metoprolol, then I know they did not come prepared to learn on their anesthesia rotation.

So for anybody who is going to do an anesthesia rotation, forget about how many patients you're going to intubate. That is one of the least important things you will learn. You will gain an understanding of how to take care of critically ill patients who are on the verge of dying every minute they are under the knife and how anesthesiologists are there to keep that outcome from happening. Get yourself a condensed pocketbook on critical care and get a headstart on your colleagues who didn't bother to do a little homework before starting the rotation. We may actually move past the simple student questions and actually start learning anesthesia at a more advanced level.

One last thing. Please, PLEASE, don't whip out your smartphone and start searching Up-To-Date or Wikipedia if I ask a question you don't know. That just annoys the heck out of me and again shows me the student is unprepared to become a doctor, much less an anesthesiologist.