Thursday, February 26, 2015

ASA Loves All Nurses, Except CRNA's

The American Society of Anesthesiologists sent out a crowing email yesterday announcing a new bill introduced in the Senate by Mark Kirk, Republican Senator from Illinois. S. 297 would allow most nurses in the VA to practice independently of physicians. These independent nurses include: Nurse Midwives, Clinical Nurse Specialists for mental health, and Nurse Practitioners.

Notably absent from this list of nursing professionals are, of course, CRNA's. The email proudly states, "The ASA is pleased that S. 297 appropriately excludes nurse anesthetists. The legislation reflects a growing Congressional consensus that the surgical/anesthesia setting is a high-risk health care environment requiring physician involvement in care."

Naturally the AANA is not taking any of this lying down. They also sent out their own press release, "Please help stop this damaging course of action by contacting your U.S. Senators today. We have reason to believe that the ASA is now behind S. 297 as a political maneuver to halt further Veterans Health Administration action." Gee I wonder how they figured out that the ASA was behind this bill?

I'm not sure what the ASA's strategy for this legislation is. In my opinion, by endorsing a bill to allow other nurses like NP's to have independent practice taking care of our nations veterans, it weakens their argument that CRNA's are not able to perform their duties without physician oversight. If the ASA thinks NP's and Midwives are good enough to see patients on their own, how can they make a distinction with CRNA's? And how thrilled are the Internists and OB/GYN's with Congress allowing nurses to compete with their practices? Did the ASA just make enemies with these two large physician organizations?

Of course this battle is far from over. This is only one bill that has yet to make its way through the entire Legislative branch and hopefully avoid the President's veto pen. There is still a long ways to go before any of these new rules become reality.

Wednesday, February 25, 2015

It's Pediatric Anesthesia's Turn Under The Gun

Uh oh. Is anything in medicine really safe for patients? Michael Jackson exposed the dangers of propofol to a public who were previously complacent, if not ignorant, of anesthetics. Then last week we were all exposed to the panic from drug resistant bacteria that may find safe harbor inside sophisticated GI endoscopic equipment. Now the New York Times has printed an article pointing to the dangers of anesthesia to childhood brain development.

The paper talks about two types of research that points to potential pediatric brain injury under anesthesia. Animal studies have shown that anesthesia can kill brain cells and impair learning in young monkeys and other mammals. Human studies of children who have undergone surgical procedures have shown that multiple exposure to anesthesia can cause learning difficulties in the future. However single exposure to anesthesia hasn't been found to be a detriment to brain development.

These ambiguous results have resulted in pediatric anesthesiologists trying to awkwardly explain the risks of anesthesia to concerned parents. Says Dr. Randall Flick, director of the Mayo Clinic Children's Center and a pediatric anesthesiologist, "On the one hand, we don't want to overstate the risk, because we don't know what the risk is, if there is a risk. On the other hand, we want to make people aware of the risk because we feel we have a duty to do so."

Boy that's an awkward conversation to have with a concerned parent. We want to warn parents about potential brain damaging risks of anesthesia on children, but we don't really know if that risk really exists. Do you think most parents, when they hear an explanation like that, will believe there is no risk? Or will they most likely assume that the doctor is not telling the whole truth about the dangers of anesthesia? My feeling is that many parents will automatically assume the worst and start stressing about the surgery even more than they already do.

What gets lost in the conversation is that almost all children have surgery because they have a medical necessity. They're not like adults who can decide to have an unnecessary surgical procedure like plastic surgery just because they want it. No surgeon will operate on small children unless there is a sound medical reason to do so. Also most children will not have multiple operations at that age. Common operations like hernias and appendectomies are one and done. The children who have multiple operations like spine and cardiac cases probably already have a predilection towards other abnormalities that can lead to a higher incidence of learning difficulties in the future.

The Society for Pediatric Anesthesia recognized the confusion about the safety of anesthetics given to children over two years ago and released a statement that was endorsed by both the American Academy of Pediatrics and the Food and Drug Administration. It encourages anesthesiologists to, "Discuss with parents and other caretakers the risks and benefits of procedures requiring anesthetics or sedatives, as well as the known health risks of not treating certain conditions." Also, "it must be recognized that current anesthetics and sedatives are necessary for infants and children who require surgery or other painful and stressful procedures."

That in essence is the bottom line. Children almost always receive anesthesia only when they need it. We don't administer anesthesia just because we enjoy watching children fall asleep and getting paid for it. Anesthesia is risky in even the healthiest adults, more so with children. Anesthesia is a necessity for surgery and is one of the miracles that makes modern medicine possible. Parents can talk to the anesthesiologist about the risks of anesthesia to children but the only alternative is no anesthesia or sedation for a frightened child in an extremely stressful and potentially painful event.

Tuesday, February 24, 2015

Anesthesia Has Become A Zero Sum Game

Anesthesiologists are under siege. Compensation is being attacked by payers from the insurance industry and federal government. CRNA's are rapidly encroaching on the livelihood of anesthesiologists. Why do you think the American Society of Anesthesiologists is trying so hard to promote the term "physician anesthesiologist"? If there were plenty of anesthesia jobs around, we wouldn't care about the nurses scrapping for our throwaway cases. But there aren't an infinite amount of jobs available. It has become a zero sum game where somebody who has a job is keeping somebody else unemployed. It's eat or be eaten.

In order to enlarge the trough from which we're all feeding, the ASA is attempting the popularize the concept of the Perioperative Surgical Home. In a nutshell, it's designed to keep anesthesiologists involved with patient care, from the moment a case is scheduled, through the preoperative workup and operation, then guide the patient to a successful postop and discharge with a thirty day followup. This new role has been coined the tongue-twister "perioperativist". It is modeled after the concept of the Patient Centered Medical Home advocated by Obamacare where the internist takes charge of a patient who is admitted for a medical issue, guiding the care and the consultations that the patient may require while in the hospital.

Some studies, conducted by anesthesiologists of course, have hinted at improved cost savings when surgical patients are taken under the anesthesiologists' wings. The PSH program at the University of California, Irvine Medical Center reduced the cost of a total knee replacement from a nationwide average of $16,267 to UCI's $9,952. Much of the cost savings was derived from being able to discharge the patient three days postop versus the national average of four days. The UCI PSH also had fewer readmissions after discharge.

Oschner Hospital also started a PSH program. Last year, their length of stay after a total hip dropped from 3.5 days in 2013 to 2.1 days in 2014. This allowed the hospital to admit additional patients, giving it an extra income of $201,931.

However, we already have doctors who see surgical patients before and after their procedures. They are called hospitalists. Surgeons have been relying on them for years to optimize their patients prior to surgery. There have been calls for anesthesiologists and hospitalists to work together and complement each other's abilities for the good of the patient. That's sounds just a wee pollyannish to me. Let's face it, the payers are not going to give more money just because there are now TWO doctors taking care of the patient perioperatively. Ultimately the same check that is being issued for one procedure will have to be shared between more interests. Right now, the medical team, usually chosen by the surgeon, makes sure a patient is ready for surgery. Are they going to abdicate their traditional roles and give up that lucrative consult just because a new doctor waltzes in with some less than impartial studies about cost savings? I find that highly unlikely.

I would expect that the hospitalists are going to come out with some studies of their own showing how they are the better perioperativists for a patient. They will find some way to show that anesthesiologists really aren't qualified to take care of all the medical issues a patient has without seeking multiple consults for specialists. Then they will trumpet their findings to the feds and the insurance industry so that they will maintain their position as the real perioperativists. If the ASA thought fighting the AANA was hard, wait until they have to duke it out with other physicians.

Monday, February 23, 2015

Anesthesia Causes Global Warming. Research Grant Bait Or PC Think?

According to their mission statement, the Anesthesia Patient Safety Foundation's goal is to, "improve continually the safety of patients during anesthesia care by encouraging and conducting safety research and education." It certainly is a lofty and worthwhile principle to live by. To further that endeavor, the APSF's last newsletter announced a large grant totaling $450,000 to three researchers for projects to improve patient safety.

While I'm not going to argue the merits of the research that the grant recipients are conducting, since I'm sure they've all been vigorously vetted by an experienced and selective committee, one of the projects rubs me as too much politically correct thinking. In fact I can't help feeling that the grant proposal was written to specifically warm the souls of the typical liberal academic mentality that pervades the ivory towers in order to receive the big bucks.

Dr. Jodi Sherman of the Yale School of Medicine is one of the three receivers of the APSF grant. She starts with the premise that, "The large global warming impacts of inhaled anesthetics, particularly compared to intravenous propofol, are established." Wait. What? Inhaled anesthetics have a LARGE impact on global warming? And it's been clearly and scientifically established? Compared to all the pollution coming out of the millions of cars traveling around Los Angeles, the massive emissions from giant factory smokestacks in China, the clearcutting and burning of the Amazon rain forest, my volatile anesthetics is causing a LARGE impact on climate change? Did anybody notify the United Nations about this climate disaster emanating from our operating rooms?

Unfortunately this line of thinking is starting to pervade the anesthesia membership at large. It all started with a paper by Dr. Susan Ryan from U.C. San Francisco in 2010 titled, "Global warming potential of inhaled anesthetics: application to clinical use." In the highly speculative article, she compared anesthesia to the amount of pollution from driving a car a certain number of miles. When you multiply the number of cases being performed each day by the number of operating rooms working, this adds up to a potentially catastrophic impact on global warming.

Bull, I say. And one of the best rebuttals I've read is this paper from Dr. George Mychaskiw, an anesthesiologist from University of Central Florida School of Medicine in Orlando. He starts out with a great quote, "There are three kinds of lies: lies, damned lies, and statistics." By his calculations if the total amount of CO2 generated in the world each year is equivalent to the area of the state of Kansas, 82,282 square miles, the amount of pollutants caused by desflurane, the anesthetic most often implicated in global warming, would be equivalent to 300 square feet. If the total CO2 produced annually is equal to the Empire State Building, desflurane's contribution would be only 0.3 millimeters tall.

Does that sound like anesthesia is making a deleterious impact on global warming? Dr. Sherman's research is going to go much further to demonstrate the harmful effects of anesthesia on the global community. She is going to delve into how regional anesthesia, sedation, general inhaled anesthesia, general IV anesthesia, and all their different combinations and permutations will cause the demise of mankind as we know it. PLUS she is going to track how all the various equipment anesthesiologists use to administer these different forms of anesthesia are going to drown all of us in an uncontrollable mountain of refuse. That's a highly ambitious project with a grant of only $150,000. But personally, as soon as I read the first sentence of her research proposal, which is based on a bogus PC mindset, I would have given her $0.

Sunday, February 22, 2015

I Am Stunned By How Magical iPads Really Are.

I love my iPad. Apple describes them as magical devices. I didn't realize how magical they are until this magician demonstrated his skills with the device on the Ellen show. Amazing.

Heartbreak For A Ferrari Owner

Many people, including doctors, aspire to owning a Ferrari. Most of us guys have had Ferrari posters up on the walls of our childhood bedrooms, an aspirational image to goad us to work harder so that eventually, hopefully, we will some day make enough money to buy one. If not, that poster of a Porsche 930 Turbo with the whale tail next to it would make a nice consolation prize.

As an adult who has the privilege of driving into the doctors' parking lot every day, I have seen several physicians who actually made their fantasies come true and purchased, or leased, Ferrari's. The owners are usually the more flamboyant plastic surgeons or neurosurgeons. I can't help but think life is very good for them. But now a writer at Jalopnik has chronicled the heartache of actually owning a Ferrari.

The writer is Doug DeMuro. He chronicles his year of owning the Ferrari and why he eventually had to let it go. He had purchased a used 2004 Ferrari 360 Modeno but over the ensuing year, he encountered various unexpected issues. Filling up the car at the gas station always involved receiving attention like he was a Hollywood celebrity. People wanted to take pictures of the car both inside and outside. He got peppered with predictable questions about how much it cost, how fast does it go, and what kind of mileage does it get. It was fun for a while but it got old fast.

Taking the Ferrari out also required careful advanced planning. He couldn't go anywhere that had large speed bumps that could scrape the bottom of the car. That would be true in our own parking lot. He couldn't park it on the side of the street lest it got damaged intentionally or accidentally. He had to make sure there was no steep entrance or exit out of a parking structure or it would damage the front of the car.

Eventually the Ferrari was only good for driving a couple of hours a month, during good weather and he had the time to take it out into open country roads with no traffic around. He got 5,000 miles out of his vehicle that year, which is pretty good when most Ferrari owners get around 2,000 miles per year.

As one of his friends astutely noted, "It's a Point A to Point A car. In other words: this isn't a car you use to go somewhere. It's a car you take out of the house, and drive around for a while, before you return it to your house. You don't go to the mall in it. You don't take it to dinner. You can't pick up anything large, and you can't transport more than one person. It's not a vehicle you use. It's a toy to be played with."

So for all you doctors out there who fantasize about purchasing a Ferrari, this article explains why you shouldn't. If you absolutely must scratch that midlife crisis itch, just rent one from a luxury car rental agency for a weekend. It will be a lot cheaper and you won't have as many regrets as real Ferrari owners. This truly is a toy that one buys with discretionary income after everything else has been funded, like your home's mortgage, children's college education fund, and all the other necessities of life. Until then, don't buy a Ferrari.

Medical Education Is Changing. But Is It For The Better?

American medical doctors have been considered the best physicians in the world for over a century now. People come from all over the world seeking a medical education in this country because it is universally accepted as the most highly developed. Yet the Wall Street Journal recently wrote about how medical schools are changing their academics to graduate doctors who are more in tuned with the current fiscal and political climate. My question though is if this will produce better doctors.

At Hofstra North Shore-LIJ School of Medicine, freshman med students spend their first eight weeks being trained to become EMT's. They will supposedly become more proficient at dealing with fast moving, life or death situations. There are so many things wrong with this. I know plenty of fast thinking physicians, including surgeons, emergency physicians, and internists who make critical decisions without having gone through EMT training. I think EMT's have an essential role in the healthcare system. I did one night of ride-along with an EMT during my ER rotation and it was kind of cool and fun. But with so much information med students have to cram in with only four years to do it, it seems such a waste of time and resources for these students to be taking eight weeks off their harried lives to do what requires mainly a high school education to complete. If I am paying $50,000 per year to attend medical school, I would feel really screwed having to spend one sixth of that for EMT school, which costs far less.

At NYU Medical School, students are required to look up every charge that a patient receives during his care at the hospital. This is supposed to help them understand why healthcare costs so much in this country. Says Marc Triola, NYU's associate dean for educational informatics, "This isn't a textbook exercise. This is real life and students love it." The problem is that doctors actually have almost zero responsibility for how much hospitals charge their patients. That is negotiated between the hospital and the insurance companies. How can med students learning about ridiculous $11,000 colonoscopies make them better doctors? It just takes more time away from actually seeing and taking care of patients.

Even the MCAT has changed to this more politically correct medical training. The new test starting in April last two hours longer than the old one--six and a half hours long. Holy crap. Who can take a test for nearly seven hours without their brains melting? And the test now includes subjects like behavioral and social sciences. Thus you get questions like which choice "is most consistent with the sociological paradigm of symbolic interactionism?" What the hell did I just type? What kind of weird ass question is that for future doctors? Will patients prefer to go see a physician who answered that question correctly?

Schools don't even want their future graduates to memorize as much data anymore. We used to cram for nights on end to make sure we didn't look stupid during morning rounds when we got picked on by the attending. Now, says NYU's Dr. Triola, "The fund of medical knowledge is now growing and changing too fast for humans to keep up with, and the facts you memorize today might not be relevant five years from now." Instead they are interested in making sure their student display "information seeking behavior." In other words, do the students know how to use Google. You know what? If doctors know how to use Google to look up medical problems, their patients surely do too. Who needs physicians if everybody is googling the same information? And what happens when the physician has to make split second life and death decisions? Between their EMT training and lack of internalized medical knowledge, the doctors will have to make a blind choice without the crutch of the internet. Is that a doctor you want to treat your family?

This is just one more way that American medicine is losing its way and becoming more irrelevant. No good can come out of this when medical schools are more worried about teaching their students the costs of medicine instead of how to treat their patients. If memorizing medical information that has accumulated over centuries of intense research is considered too burdensome and old school for students, then surely we are not graduating students who are worthy of being called medical doctors.