Friday, November 17, 2017

Which Doctors Are Most Likely To Get Sued?

Medscape has released its report on medical malpractice in 2017. The survey was taken from over 4000 physicians who responded to their poll. The results show that the top five specialties most likely to be sued are Surgery, OB/GYN, ENT, Urology, and Orthopedics. Over 85% of surgeons and OB have been involved in litigation. Anesthesiology, formerly one of the most notorious specialties for getting sued, drops in at a humble tenth place with 61% having been sued.

Of course the more often one is getting charged, the higher the malpractice insurance premiums will rise. Unfortunately for general surgeons in New York City, their premiums are over $141,000 per year. OB is even great, with almost $200,000 of their hard earned money going to insurance companies. That is an astounding amount of work that's required by the doctor just to pay insurance companies.

Luckily most doctors aren't sued that often. Almost half have faced less than five lawsuits in their careers. An unlucky 2%, have faced ten or more. Maybe those doctors shouldn't be in medical practice at all.

The most common reason a suit was brought against them was failure to diagnose or delay of diagnosis. This occurred about one third of the time. The next most common complaints that lead to litigation are complications from treatment or surgery, poor outcome, failure to treat, then wrongful death. Everything else only occurred in single digits.

A vast majority of the doctors, almost 90%, felt that the lawsuits were not justified. Almost half didn't think the inciting incident warranted a malpractice complaint. They were completely caught off guard when they were filed with the legal paperwork.

It's not just the mental stress that causes physicians to despise trial lawyers and their pesky lawsuits. It takes a huge toll on the time that could be used to see patients or be with families. While many doctors spent 10-20 hours preparing for a case, one third spent over 40 hours to get ready to face the court. A plurality of 39% said they spent 1-2 years involved in one case while an unlucky 10% took over five years to resolve their cases. That's years of their lives they will never get back.

And most of that time was spent for naught. The doctors only lost 2% of their cases, either with a guilty finding or they settled out of court. And when they lost or settled, about one third had to pay out $100,000 in damages. Another third reached $500,000.  Though we often hear about blockbuster malpractice lawsuits that were lost for millions of dollars, only a very small minority of verdicts reached seven figures.

This survey has tons of other data to go over. If you're a doctor who is concerned about medical malpractice, and every doctor should be, it is well worth reading through the entire poll.

Maybe He Can Be A CRNA

The Wall Street Journal has a great article about how quickly one can learn to do things if you're totally dedicated to a single task. Max Deutsch, a 24 year old college grad from San Francisco decided he would set up a series of goals for himself for one year. He would dedicate one month to complete each of them before moving on to the next one. The idea was to make each job so outlandish that he would most likely fail. Surprisingly he has been successful at each item he has tackled. He has taught himself fluent Hebrew, standing backflips, and memorizing a shuffled deck of cards, all in one month each. His college roommate said Max is the fastest learner he has ever met.

His greatest challenge was to defeat a chess app simulation of chess grandmaster Magnus Carlsen. To his surprise, a WSJ reporter relayed this story to Mr. Carlsen who agreed to play Max in person. You'll have to read the rest of the article to see how he prepared himself for this incredible meeting and the surprising result. Heck, if this guy studied anesthesiology for one month, he could probably qualify to be a CRNA.

Wednesday, November 15, 2017

The Hardest Part Of Being An Anesthesiologist, Part 2

In the first part of this series, I opined on how the anesthesiologist is not in fact the patient's savior in Preop Holding, unlike what another blogger may have written. There are much harder and more frustrating aspects to anesthesiology than holding a patient's hand. Here, in no particular order, are what I think are some of the more difficult characteristics of this job to get used to.

1. Early morning work hours. If you're a night owl like me, this is a tough transition that your body never really gets used to. Getting up at 5:00 AM to get ready to go to work is not a natural activity for most people. Even now, on weekends I allow my natural circadian rhythm to get me to bed by 1:00 AM and wake up around 8:00 AM. So weekdays are a struggle to get myself into bed early enough to get a good night's sleep. Of course I know some colleagues who are natural early risers and get up at 4:00 AM to go for a brisk morning run before work. I hate them.

2. Unpredictable work schedule. If you're looking for a 9 to 5 job, anesthesiology is not for you. Sure you can find some locations like at academic centers where you do more predictable shift work and are more likely to go home at a set time. But in academia you have other activities to keep you working long hours like giving lectures and attending endless faculty meetings. Most anesthesiologists in private practice have to do the cases the surgeons are booking for that day. One day your work may be done by 1:00 PM. Another day it could be 8:00 PM. And there is no way to tell more than 24 hours ahead of time what kind of day you'll have. You wind up missing a lot of dinners and occasionally surprising your kids when you are able to pick them up from school. It's just that kind of job.

3. You're not in charge. Surgeons bring in the patients who bring the money to the medical facility. They have all the leverage to run the OR as they see fit. You can't dictate when to start the day or when it should end. You don't get to tell people what kind of case you want to do today; you do whatever is offered. Calling in sick is a huge burden because it's not like they have a spare anesthesiologist just sitting around to pick up the work. So if you're an assertive person who doesn't like being told what to do, this isn't the field for you.

4. You feel more dispensable than you would like. You earned your medical degree like every other doctor. You spent years getting trained and board certified to practice anesthesiology. Yet once in practice you'll often get the feeling you're opinion is not taken seriously. A common lament is that if you try to cancel a case, the surgeon will simply ask for another anesthesiologist. It's as if all your years of medical training to provide the safest patient care means nothing. Unfortunately, some of your colleagues will betray you and agree to do it, making you feel small and stupid. Yes you probably did the best thing for the patient but the patient probably did fine during the case. The same can't be said for your reputation in the OR afterwards. You've now become the anesthesiologist that likes to cancel cases.

5. High stress levels especially when on call. Anesthesiology is a high stress career to begin with. Patients can unpredictably crumple within seconds and you have to know how to deal with it. When you're on call, it is ten times worse. The difference is that elective cases are usually on healthier patients and you've had time to evaluate the cases hours beforehand. When you're on call, it can be anything that rolls through the OR doors. It could be procedures as diverse as a five year old with post tonsillectomy bleed to a ninety year old with a fractured hip. A crash C-section on a drug addicted mother to twenty something year old gangbanger with multiple gun shot wounds to the chest and abdomen. While the surgeon only operates on the part of the body he is trained to work with, the anesthesiologist has to be a master at everything. Talk about high stress.

6. You have to act cheerful all the time. The surgeon and the patient get to be grumpy. But nobody likes a dour anesthesiologist. You can't have mood swings and yell at the OR staff like surgeons can get away with. You're supposed to have a calming pleasant personality that's just borderline dull so that everybody in the room feels reassured. A loud angry anesthesiologist will not last in his job for very long. Same can't be said about surgeons.

7. There is very little patient rapport. As I previously mentioned anesthesiologists are the staff with the least amount of time to spend with the patient. The patient loves their surgeon and that's why they're having a procedure with him. The nurses usually have more time to talk with the patient in preop and establish a relationship. You're lucky to get in three questions in preop before people start pacing impatiently to get the case started. That's why around Christmas time the surgeons and nursing staff get all the gifts from patients and the anesthesiologist (who the patient rarely recalls) get to watch other people open them.

8. And finally anesthesia is a very isolating job. If you're used to the team approach in medicine as a resident, you'll quickly discover that anesthesia is a one man show. While internists and surgeons run around in packs, the anesthesiologist walks alone into the operating room and goes home alone. We have no idea what is going on in the OR next door to us. All our cases finish at different times so it's almost impossible to get colleagues together after work to hang out. So if you feel lost without your posse around, anesthesia is not the job for you.

Now don't get me wrong. I love my job as an anesthesiologist. In fact, anesthesiology is considered one of the best jobs in America. However, anyone contemplating going into this field should go in with eyes wide open and understand that it, like any other medical field, has its advantages and disadvantages. Despite this list, for me the rewards of anesthesiology far outweigh the negatives.

The Hardest Part Of Being An Anesthesiologist, Part 1

When I saw the headline in KevinMD, "For an anesthesiologist, this is the hardest part of medicine," I thought, great. Somebody is finally voicing their frustrations with the the practice of anesthesiology. I figured maybe I can learn something from this person's career difficulties and how they overcame it. What I got from the article was not what I expected.

The article is what JK Rowling might describe in the UK as treacly or here in the US as cringy. Its saccharine depiction of the author's encounters with patients in preop made me roll my eyes until my extraocular muscles felt like they might rip off my eyeballs. Dr. Sasha Shillcutt, a cardiac anesthesiologist, describes that when she shakes hands with her patients, they are so scared that frequently they won't let go. She portrays herself as the patients' and their families' medical hero because, well, the surgeon and the preop nurses are just too busy running around to really listen to their concerns. It's the anesthesiologist to the rescue since nobody else in the entire OR suite has the time or the humanity to sympathize with the abject fear the patients are silently experiencing.

I'm sorry but I don't have the same experience. Yes the author can write whatever she wants on her blog, but let me inject some reality into this situation. It's usually the anesthesiologist who is running around like crazy before surgery. Especially for cardiac cases, we arrive in the OR at an ungodly early hour to check our machines, draw up drugs, mix bags of more drugs, and do fifty other things to get ready for surgery. Then we rush to Preop Holding to do a quickie five minute evaluation with the patient and start the IV. We are the member of the OR team that has the least rapport with the patient and their family. The surgeon will presumable have already had a decent relationship with them when he saw them in his office and explained the procedure to them. The preop nurse has had about thirty minutes of undivided attention to sit there and discuss with the patient their history and other concerns. We are the ones who rush in, say a quick hello, and quickly rattle off the anesthetic plan, which for most patients means they will be sleeping during the case. That's usually as specific as patients want to know about anesthesia.

So, no. The hardest part of anesthesiology is not comforting a scared preop patient by shaking their hand. I'll tell you what are really the hardest parts of anesthesiology in the next article.

Tuesday, November 14, 2017

Sexual Harassment And CPR

Researchers from the University of Pennsylvania have discovered that women are less likely to receive cardiopulmonary resuscitation from a bystander than men. The study, presented at the American Heart Association conference in Anaheim, CA, looked at over 20,000 cases of people receiving CPR following cardiac arrest.

They found that only 39% of women received CPR when they arrested versus 45% of men. The men were also 23% more likely to survive than the women, likely because they were more likely to get the maneuver done. The researchers speculate that people are too embarrassed to put their hands on a woman's chest to initiate CPR. Even though the proper placement of the hands is on the sternum between the breasts, many people would be hesitant to do that on a stranger, even if they are dying in front of their eyes. Virtually all training videos and mannequins show a male torso being given CPR. There are almost no female torsos shown. If the American Heart Association is too prudish to demonstrate CPR on women, is it any wonder the general public would feel the same?

In this era of rampant reports of sexual harassment, when women seem to be coming out of the woodworks decades after a potential encounter to finger blame on a male perpetrator, who can blame them for the reluctance. The question becomes will you watch a woman die in front of you because you are afraid of a potential legal suit if she lives or will you do the right thing and save a life? I think the answer is pretty obvious.

#CanadaWAITS For Single Payer Healthcare

This is for all those people who just love the idea of single payer healthcare. They believe having the government take over a country's medical system is the right thing to do because, well, healthcare is a human right and thus should be free. Well, let's just go back to kindergarten and relearn the concept that nothing is free in this world. Not even your parents'or your government's love.

A new hashtag was created called #CanadaWAITS by a Canadian author, AndrĂ© Picard. He wanted to hear how Canadians fared with their government run healthcare. And did he get an earful. His twitter page is filled with hundreds of people's stories who waited months, even years to be seen and treated by doctors.

In the meantime, over in the UK, where they are so proud of their single payer system that they featured it in the opening ceremonies of the 2012 London Olympics, the government is starting to play its inevitable role as rationer in chief. The National Health Service has decided that patients who are obese or actively smoking cannot have elective surgery unless the patient fixes these defects in their personality. Granted this will take place in only one small district. However, the district is expected to save £68 million. And if you're the government who is paying everybody's medical bills, you're going to try to find savings anywhere you can, even denying healthcare for people who are less desirable because of their social habits.

So next time you attend a Bernie Sanders rally, just remember that single payer healthcare sounds great on paper. But you totally lose control of your medical care to some faceless bureaucrat who couldn't care less if you don't get timely care as long as it saves them money.

The Best States To Practice Medicine.

Physicians Practice has compiled a list of the top five best states to practice medicine (requires membership to read the whole report). The results are surprising, to say the least. They are:

1. Mississippi
2. Texas
3. Alaska
4. California
5. Arkansas

They made their list based on the cost of living, the tax climate, physician density, and the Medicare Geographic Cost Index. Based on these criteria, it's astounding that California isn't at the bottom of the 50 states for desirability. We have some of the highest cost of living anywhere. We have the highest state income tax in the nation. Along the coast where people want to live, it seems like half the kids in good schools have physicians as parents so the competition for patients can be intense if you're just starting out. And the Medicare reimbursement really isn't high enough to compensate for the high costs of everything else in the state. But if you can afford it, and you don't mind having a lower standard of living considering your sizable income, California is a beautiful place to live.