My Confession

I have a confession to make. Please don't think less of me after you read it. I'm just being honest with my readers and also making a point about the health care debate. Ready? Here it goes: medicine for me is not a calling. There. I've said it. Do you think I'm less of a doctor now that you know the truth? Don't get me wrong. I love my job. It's a very honorable field and we do good things for our fellow human being. But it is not a religious experience.

The reason I brought this up is because of several articles I've read recently. First there is the opinion piece in the Wall Street Journal by Dr. Ronald Dworkin, an anesthesiologist. He says that to the current generation of upper middle class professionals, a career satisfies an interest and the income sustains them once the interest inevitably subsides.

Then there is this comment to Dr. Dworkin's editorial by a Mr. Thomas Elmo. Mr. Elmo rebuts, "You don't become a teacher, policeman, fireman, minister or doctor if you DON'T think it is a calling." I wondered if that is truly how the public sees doctors, that we are doing this work because it is our "calling" and thus undeserving of higher compensation?

I will bet that 99.999% of people doing their jobs are not in it because of some "calling." Unless one is going into ministry, nearly everybody has an economic or personal reason for making a certain career. Maybe the profession runs in the family. Or somebody wants to make a bucket load of money. Or maybe they were inspired by a mentor. But very few people actually hear a calling, despite what Mr. Elmo says. In fact, other than priests and nuns, the list of people who heard a calling probably starts with Jesus and ends with Martin Luther King, Jr., with Gandhi, Mother Teresa, and Joan of Arc somewhere in there.

I can honestly say I never heard a voice telling me to go into medicine. My father is a physician, as was his father. My brother went into medicine too; it's what we know. Is that any different from the auto plant worker who's children follow them into the factory? Or the lawyer whose children join the same law group? Or the politician whose entire clan gravitates toward the same profession? Do you think President Obama heard a calling to become the POTUS? If so should he work for minimal wage or free since that is his destiny? What about the members of Congress? They like to think they're there to make the country a better place and do what's right for the citizens. Would they be so high-minded if they made less? The truth--they give themselves raises and private jets every chance they get, budget deficit be damned.

Other professionals like lawyers aren't ashamed to say they do it for the money. So why are doctors held to a higher standard? Is it so wrong to say medicine gives me a nice income to support my family and make a nice living? By saying doctors should be completely altruistic it gives opponents an excuse to lower doctors' reimbursements in the name of holding down health care costs. But some doctors are already making less than their local plumbers on an hourly rate. Plumbers (just to use as an example) don't have to answer calls in the middle of the night. They don't work weekends. They don't have to shell out tens of thousands of dollars for malpractice insurance (when was the last time you sued your plumber?). They want cash on the spot, no freebies from these guys. And they didn't go through at least eight years of higher education after high school before even starting residencies. Yet this health care debate revolves around cutting Medicare reimbursements even lower. If the public option based on Medicare rates gets passed, we'll see who really is in medicine because of a calling.

So to wrap up this tirade. I like my job. I like my income. I don't think I'm less of a doctor because I'm not working at the free clinic every day. To those who think doctors shouldn't mind making less money because the work is their destiny, I say come walk in my shoes. Try working 60-70 hours a week, practically nonexistent family time, and the threat of a malpractice lawsuit hanging over your head with every patient you see. Then you can tell me how little income you'd be willing to work for.

God's shoes

Ha ha! Al Bundy did receive a message from God. The NY Times reports on the latest fad in running, barefoot to minimal shoe covering. There is apparently little evidence that the hundreds of dollars that runners pay for their shoes actually improves their performance or endurance. In fact, some people believe shoes impede the ability of feet to adapt to running, making it more prone to injury and dependent on shoes for support.

Thus there is the trend of running barefoot. The "shoes" these runners wear look like foot gloves. And coincidentally, they look just like the golden shoes Al Bundy created when he had a conversation with God.

Case Report #2

I go into preop to see my next case, a transmetatarsal foot amputation due to gangrene. Looking through the H+P, the patient reads like an oral board certification case presentation. Patient is in his 50's with insulin dependent diabetes. He has ESRF, with dialysis the morning of surgery. They helpfully removed 2 liters of fluid that day. He has ischemic cardiomyopathy with an ejection fraction less than 40%. Of course he has coronary artery disease s/p PTCA and stenting but still has CAD not amenable to any further intervention. He had an internal cardiac defibrillator placed a month ago due to his low ejection fraction. His pulmonary artery pressure was 64 mm Hg. And to top it off, the preop nurse told me his blood pressure is 75/26. Huh?

We measure the BP in the other arm and it is the same. We look through his chart and it shows his BP has been in the 70's for the last five days. We call the floor nurse who was taking care of the patient to see if she had brought up this problem with the primary care doctor. She said she was not aware of his hypotension because she was not the one measuring his BP's. I wanted to report that nurse right there and then but thought that wouldn't really make any difference to the patient now. The cardiologist left a helpful note in the chart that was pretty much illegible chicken scratches other than something about patient being fully optimized for surgery. Gee thanks. The surgeon said the foot is causing sepsis and needs to get amputated now. The patient's mental status is best described as drowsy. I couldn't tell whether that's because he has been receiving narcotics for pain or his brain was not getting adequately perfused. Okay.

So a general anesthetic was pretty much out of the picture as well as a spinal. I didn't feel like experimenting with critical hypotension in the OR tonight. So an ankle block was placed. I attempted an arterial line but of course the patient is vasculopathic. No palpable pulses anywhere and my attempts with blind sticks were not successful. I started a levophed drip to get his BP up into the 90's while giving him just enough sedation with versed and propofol to maintain amnesia. The surgery went well but as expected the ankle block was not all that helpful during the bony amputations. At least the patient doesn't remember.

The surgeon and I agree that the patient should go to the ICU at least overnight. I continued his levophed drip in recovery to maintain some semblence of normotension. The surgeon calls the internist to come write ICU orders. I get a page from recovery saying the internist wants to talk to me. I thought he might want some details about such a challenging case. Instead I get a lecture from him about how bad levophed is. He tells me the patient LIVES on BP's in the 70's. I tell him I wasn't going to give anesthesia to somebody that hypotensive and with CAD and cardiomyopathy. He orders the levophed discontinued. The BP promptly drops into the 60's. He said he was fine with that. I throw up my hands in frustration. Who am I to argue if the patient's primary care doctor doesn't mind having a patient with such critical hypotension? In situations like this, the best thing that can be said is that the patient lived through the surgery. What comes afterwards is out of my hands.

Deficits you can believe in

From the LA Times: White House projects bigger deficit, bigger debt.
"Figures released by the White House budget office foresee a cumulative $9 trillion deficit from 2010-2019, $2 trillion more than the administration estimated in May."

From the NY Times: Deficit expected to reach $9 trillion.
"The Obama administration’s Office of Management and Budget raised its 10-year tally of deficits expected through 2019 to $9.05 trillion, nearly $2 trillion more than it projected in February."

From the Wall Street Journal: Decade of debt: $9 trillion.
"Plunging tax receipts, soaring spending and a sluggish recovery will push the nation's deficits dramatically higher over the next decade, creating new complications for President Barack Obama's domestic agenda."

From President Barack Obama at a town hall meeting in Colorado on the cost of health care reform:
"Now, what I’ve proposed is going to cost roughly $900 billion — $800 billion to $900 billion. "

Uh huh.

V.I.P.=R.I.P.?

In today's Well blog in the NY Times, they discuss the curse of the VIP patient. VIP's can be anyone from celebrities to physicians to the mother of the hospital administrator. VIP Syndrome is well documented in the medical literature. Patients considered VIPs frequently wind up with worse outcomes than "regular" patients. It is a well known medical axiom that patients who are doctors and nurses frequently have unforeseen complications during the course of treatment. The Well blog discusses how the extremely wealthy father of a patient arranged to have five different physicians from five different hospitals take care of his son. None of them could agree on a course of treatment since nobody was actually in charge. As a consequence the son received worse care than he otherwise would have.

In the city where I practice, we have celebrities and other VIPs everywhere. You can see them jogging on the sidewalk or bump into them at the Whole Foods Market. Naturally we treat them all the time at our hospital. I've treated rock stars, billionaires, TV and movie celebrities. You can always tell when you are going to get a VIP patient. On the OR schedule there is an unusual pseudonym. When you log onto the hospital computer system to look at the patient's lab work, a warning comes up about how you are being monitored. While preop does not allow an entourage inside, there is usually the Patient Advocate standing at bedside to take care of any needs that might arise. Most of them are really nice, just regular folks, but there are a few that are notorious for being a pain in the ass. They get special cordoned off areas in preop and recovery. People walk on eggshells around them. I have to admit I still get butterflies when I treat a very prominent VIP. I wouldn't want to read in the newspaper the next day that so and so "died in the hospital during a routine procedure due to anesthesia complications." The horror.

Yes we try to treat everybody the same. But we are all human. We will treat VIP's differently despite our best efforts. We just hope we don't wind up being household names like Dr. Conrad Murray.

Genius

"Dr. Z. You're a genius. I felt nothing." said my patient after she had her colonoscopy with propofol sedation. This from a patient who had put off her colonoscopy for years because she was afraid of feeling pain. Ah propofol. A wonder drug in the right hands.

Shakespeare was right

In today's Prescriptions blog in the NY Times, Dr. John Creighton Campbell, professor emeritus of political science at the University of Michigan and a visiting researcher at the Tokyo University Institute of Gerontology (how's that for a title?) discusses the difference between the health care system in Japan vs. the U.S. Despite their more rapidly aging population, the Japanese government has not had to substantially increase its health care spending. Dr. Campbell goes on about the healthy Japanese diet, lack of obesity or violent crime. Everybody there has to buy insurance based on their income and physicians are not rewarded for doing more procedures. Yada, yada, yada.

What struck me like a sore uninsured thumb was that he did not mention the Japanese also do not SUE their doctors like we do. In Japan, there are only 22,000 lawyers vs. over 1,000,000 in the U.S. In the U.S., there is one lawyer for every 270 people. In Japan, it is one for every 5,800. None of the five health care bills floating through Congress mentions meaningful tort reform. The people who make out like bandits in these bills are the lawyers, the insurance companies, and big government. The people who get screwed are the patients, the doctors, and the hospitals.

The insurance companies get a huge new base of customers since the government is going to subsidize everybody to buy insurance. The public option has pretty much been pushed off the table. The feds have a vast new bureaucracy to support itself. More people on government payrolls with lifetime civil service employment and more generous government pensions to fund in the future. The lawyers have more potential patients as clients to sue physicians. With the rationing and long waiting times patients will have to face with "health care reform" you can bet there will be plenty of disgruntled patients who will be calling a TV commercial malpractice attorney.

Whatever happened to limits on punitive damages? What about limits on pain and suffering? What about forming a medical court, similar to family or tax court, that has a medically trained judge presiding over malpractice cases instead of having an uninformed jury make nonsensical judgements which they understand little about? How about a system to credential "expert" witnesses so we can be confident they actually know what they're talking about and aren't just some hired gun? How about a system of "loser pays"?

King Henry VI may have been a little extreme, but he was on the right track, "The first thing we do, let's kill all the lawyers."

Can I have more (drug) cocktail please?

Dr. Murray reportedly told the police he gave Michael Jackson Valium 10 mg, Ativan 2 mg x 2 and Versed 2 mg x 2 before giving him propofol 25 mg the morning he died. This according to the Houston Chronicle. This doesn't sound like a particularly lethal dose, especially given MJ's known addiction to prescription drugs. Something doesn't quite add up in Dr. Murray's statements. Let me quote Dr. Joseph Naples, chairman of Anesthesiology at Methodist Hospital, "The whole story sounds fishy, but who knows?" Curiouser and curiouser.

MJ also reportedly asked a British physician to give him prescription drugs while he was doing his This Is It tour in London. Dr. Susan Etok said MJ asked for propofol and Demerol amongst the list of drugs he requested. She said MJ offered up to $800,000 for her services in obtaining and administering the drugs. Dr. Etok, bless her soul, refused MJ. When she told Michael her decision, Michael emailed back not to worry, he will find some other doctor who would. Hello, Dr. Murray?

HOMICIDE

The LA County coroner's office has ruled Michael Jackson's death a homicide. Surprise, surprise. According to the LA Times, the coroner's office said "lethal levels" of propofol was found in MJ's system which led to his death. Dr. Conrad Murray told the police he usually gave 50 mg of propofol every night to help MJ sleep but on the morning of his death, he only gave 25 mg after valium, ativan, versed, and "various drugs" failed to help his insomnia. After MJ went to sleep at 11:00 am, Dr. Murray went to the bathroom. When he got back, MJ wasn't breathing so he started CPR. At one point he went downstairs to the kitchen and sent Prince Michael upstairs to his dad's room.

There are so many holes in this story it's hard to find the truth among all the fiction. First of all, I don't know what a "lethal level" of propofol would be. Certainly 25 mg is miniscule and I've hardly ever seen anyone fall asleep with that small amount, unless they were 90 years old. Of course Michael had a ton of other drugs on board which would synergistically enhance the effects of propofol. The police confiscated a whole pharmacy of sedatives from Dr. Murray, including valium, tamsulosin, lorazepam, temazepam, clonazepam, trazodone and tizanidine. But Dr. Murray should have known that and not leave Michael alone at any time. Plus 25-50 mg boluses of propofol would put you to sleep for a few minutes only. Dr. Murray says MJ received 50 mg nightly to help him sleep. Unless propofol was given as a drip, that would not help him sleep through the entire night. The police say they found no evidence that Dr. Murray ever prescribed or purchased propofol but propofol was found in his personal belongings. So where did the doctor obtain his supply? Somebody besides Dr. Murray is going to get into a heap of trouble here.

Dr. Murray said he performed CPR until the paramedics arrived. But he already said he stopped CPR to go downstairs to talk with security and sent MJ's son to the room. The police have cell phone records that show the doctor was talking for 47 minutes after 11:18 am. Who was he talking to while MJ died? Who was doing CPR while he was talking on his cell? Why would he stop CPR to go downstairs? And why would he send MJ's 12 year old son to his dead father's bedside?! This is beyond comprehension.

In the article, there are two versions of what happened after MJ fell asleep. One part said Dr. Murray went to the bathroom and came back to find MJ apneic. Another section said he was on his phone talking to his Houston office when he came back and found him apneic. I imagine it was probably a little of both. He went to the bathroom first (get a TURP or some laxatives doc) and started talking on his cell, as the 47 minutes on his phone records would indicate. Who knows how long MJ was dead by then.

Surgical tech passes on hepatitis C

The LA Times reported on a surgical tech, Kristen Diane Parker, who may have infected scores of patients with hepatitis C. She traveled from Texas to Kentucky to Colorado before she was finally caught stealing narcotics in the OR. Now thousands of patients are being tested for hep C and unfortunately a few have come back positive.

This article raises some serious issues. Ms. Parker apparently would go into the OR and switch syringes of fentanyl with dirty syringes, thus passing on her disease. Why were there syringes of narcotics lying around on the anesthesiologists' carts. Were these syringes not locked up or did she have the keys to the carts? If she was able to replace the narcotics with another syringe, why did she use dirty needles for the new syringe? She had access to new syringes but not clean needles? She was in the OR. There are needles everywhere and she couldn't find a clean one? You can bet JCAHO will be all over these hospitals' OR procedures in the very near future.

She says she didn't know she had hepatitis C because she didn't go see a doctor due to lack of health insurance. For goodness sakes she worked in hospitals. They don't provide health insurance for their employees? She was fired from one hospital for stealing fentanyl last April but she was able to move pretty quickly to a surgery center. Don't these places perform due diligence and investigate the backgrounds of their applicants? So many questions that need to be answered and accounted for.

Propofol to MNU stat

Why is it patients about to undergo experimental dissection in movies never receive anesthesia? It would be so much easier and humane. Plus the OR staff don't wind up dead--see Spiderman 2 and Independence Day. Above is a scene from District 9. Loved it.

Can you trust the Feds with your health?

The federal government has announced that the Cash for Clunkers program is going to end on Monday. Is that a surprise? When the program first started in July with $1 billion, it was supposed to run until November 1st. Of course whenever you give away free money people will want it. So the money ran out in about one week. Obama and Congress, in their generous Santa in summer mode, gave an additional $2 billion. This was supposed to last until Labor Day. Well that prediction was wrong too.

So many things have gone wrong with this. First, the feds don't know how to predict demand for a product (money) that is being given away for free. Second, they don't know how to implement this program. Dealers have stopped accepting trade ins because the government is not able to process all these applications quickly enough to reimburse the dealers. Thus the dealers are out thousands of dollars until the feds get their act together. Third they ran out of cars to sell. With free money, so many people wanted cars that the infrastructure was not able to handle the crush of demand. Now there is very little choice of products for these customers.

Now take those three conditions and you can apply them almost directly to the planned government takeover of health care in this country. When the Medicare prescription drug benefit was passed in 2003, the ten year cost was predicted, and propagated by the politicians, to be $400 billion. Only ONE year later, the cost was raised to $500 billion. And you think you can trust Congress to make the cost of health care revenue-neutral? Inevitably there will be higher (much higher) taxes, lower reimbursements, and restrictions on care to keep health care costs from devouring our economy.

The government can barely run Medicare now without severe delays in reimbursement. Doctor's operating margins are already thin. The physician usually has to pay himself last behind all his staff, rent, taxes, utilities, vendors, etc. If we suddenly have a mob of new patients with government insurance and reimbursement slows, who do you think will eat the cost? This would be the end of the romanticized small practice primary care doctors that are so beloved by the public.

Finally, demand for services would be enormous. You can already read about the long waits and denial of services common in countries with socialized medicine like Canada and Europe. Remember what the Canadian Supreme Court ruled--access to a waiting line is not access to health care.

So while universal health coverage for Americans is commendable, a government implementation would be problematic. This Cash for Clunkers program clearly demonstrates the pitfalls that would await us all if the government takes over our health care.

If it sounds like a duck

The police are starting to circle around Dr. Conrad Murray and his use of propofol as the culprit in Michael Jackson's untimely death. They are gathering information to charge him with manslaughter. I say we have all the information they need to charge and convict him. Even Katherine Jackson is contemplating filing a wrongful death lawsuit against the "doctor". Let's review how obvious his criminal acts are.

First of all Dr. Murray is an internist/cardiologist. Neither specialties are particularly experienced at giving propofol for sedation compared to anesthesia providers. Strike one.

Next Dr. Murray was using propofol outside a hospital setting without proper monitoring. As anybody with any experience with propofol knows, patients can go apneic within seconds of receiving the drug. Sure anesthesiologists make it look easy, just push it and the patient falls asleep. But as we have seen, disastrous consequences can occur without proper training. Strike two.

Finally Dr. Murray left MJ's room to make some personal phone calls with nobody monitoring him, his respiratory rate, his O2 sat, his blood pressure. Who knows how long MJ was dead before the good doctor came back in. There have been reports that he called for his storage units in Las Vegas and Houston to be emptied of incriminating evidence before calling 911. So MJ could have been dead for hours before the paramedics got to him. Strike three.

Incredibly he is maintaining his innocence despite his obvious negligence. He has stated he gave medications that should not have caused MJ's death. Yes, in the right hands propofol shouldn't. But with the tragic combination of negligence, incompetence, and hubris, death can occur with the use of propofol. For $150,000 per month, you would think Dr. Murray could hire somebody to watch Michael while he makes his phone calls. Tragically a great artist (musically speaking) has been silenced forever by this charlatan.

What you get for your money

To continue my train of thought on the Wall Street Journal opinion piece from yesterday. The United States spends 17% of its GDP on health care but what do we get for it? I would bet we take care of more sick patients than any other industrialized country in the world. By sick I don't mean just acutely ill, but also chronically ill. We have the highest rate of obesity in the world. We probably have more people with coronary artery disease, diabetes, hypertension, cancer, congenital defects, renal and liver failure, alcoholism, and drug abuse than any other first world country. We take care of more extremely premature infants, and more centenarians than any other advanced nation. Just in the last month I saw an orthopedic surgeon put in a new hip on a 95 year old patient, a gastroenterologist perform an ERCP on a 103 year old, and another gastroenterologist put in a PEG on a demented 92 year old. All those patients got million dollar workups and consultations during their hospital stays. How many other countries in the world can boast that claim?

In this country, where every life, even the unborn, is considered precious, we are going to have to spend more money than anybody else. Our societal expectations, along with our legal obligations, ensures that we will spend top dollar to treat everybody equally. Nobody gets short shrift on health care regardless of their ability, or inability, to pay. Whether they are citizens, legal residents, or illegal immigrants, all patients who walk through the emergency room doors get treated equally.

So what if Japan only spends 8% of its GDP on health care. Or that South Korea spends 6%. I've been to hospitals in Asia. They spend less but they also get less. Most rooms are like the old hospital suites we used to have here, 2-4 patients per room or more. Sure you can have a private room, but you'll pay more for it. They are extremely understaffed. If you want a nurse's attention, you better hire your own private nurse. If the patient doesn't get better, they don't usually call the first malpractice lawyer they see on a TV commercial.

Perhaps spending 17% of our GDP for health care is commensurate with our quality of care for our given patient population. We spend more because we need more. We have sicker patients than most other industrialized countries. Other first world countries in general are healthier than us, with lower rates of obesity, alcoholism, and drug abuse. They can afford to spend less on their health care. If we want to improve the quality of our health care, given our country's health status, perhaps we need to spend even more, not less.

We need to spend more on health care

An interesting editorial in the Wall Street Journal argues that we should be spending more money on health care. Health care currently makes up 17% of the GDP in this country. And what's wrong with that? Nobody argues that manufacturing, with 20% of GDP, is bad for us. In fact we want more manufacturing. When the housing bubble was inflating, nobody complained that construction jobs was consuming too much of the economy and needed to be refrained (though in retrospect it probably should have been). Imagine if information technology spending was growing as fast as health care spending; everybody would be singing the praises of the technology revolution advancing our nation into the 21st century.

Other countries want the medical products that are manufactured here, from pharmaceuticals to MRI's to artificial joints. Is it such a bad thing to invest 17% of GDP in such a robust industry? Why are we propping up the old fading industrial segments, with bailouts to the car companies and their suppliers, while trying to tear down the most innovative companies in the U.S., the drug companies, the biotechnology companies, the medical equipment companies?

The money spent for health care is not wasted money. That's like arguing that money spent on food is wasted. Health care is commonly referred to as a universal right, like having adequate food, clothing, and shelter. The government spends enormous amounts of money on food stamps and housing subsidies to make sure everybody has some sort of food and shelter. We don't mind spending more on those yet spending more for medicine is wrong. And there seems to be a common misconception that health care employees make less than manufacturing employees. I see all around me nurses, administrators, PA's, techs, etc. that make very good incomes. In fact many drive better cars and go on nicer and more frequent vacations than me. I bet there are just as many or more employees in health care who have nice incomes and benefits as there are in manufacturing. Why does the press keep denigrating the addition of employees in health care as if they are worthless jobs? That somehow they don't measure up to the romanticized benefits of manufacturing jobs?

So maybe the medical field just needs better PR. We need to get people over the perception that spending money on their own well being is money down the drain. It is money that will increase their longevity, make them healthier of mind and body, and expand one of the few world class industries still in the U.S.

Porsche Panamera

I feel a mid-life crisis coming on.

I'm finally one of the cool guys.

According to the New York Times, the hipsters in the city this year all dress like slobs and sport round protruding guts. Hallelujah! Now I can stop worrying about my lack of gym time. They call this look the Ralph Kramden, after the Honeymooners character. According to Aaron Hicklin, editor of Out magazine, all that metrosexual manscaping and body sculpting got too precious. It was a sign that somebody had too much time on their hands.

I totally agree with that. In my frenetic world, I'm trying to juggle 12 hour work days, kids times, wifey times, and sleep times. I can't do much about the work hours, and I've already cut family time to the bare minimum, even less according to my exasperated wife. If I cut any more snooze time, I might get into an accident on the way to work. So the gym will just have to wait. And now I don't have to worry about my lack of six pack abs or the huge guns I see on all those ads. I'm finally with the In crowd, and I didn't even have to try that hard.

Match Day

Just got my medical school alumni newsletter. It highlighted the momentous event in every medical student's school years, Match Day. It was wonderful seeing all those pictures of happy faces as they opened up their envelopes. I remember all the seniors would be gathered in a conference room that morning. Everybody was nervous but also anxious to find out their destiny. For the most part, people usually got into the field they sought, if not necessarily the location they desired. Then there were the surprises. Some people matched into fields that were totally unexpected. Then you realized you didn't know people as well as you thought.

I was happy to see that about four percent of this year's graduating class decided to pursue anesthesiology. Good luck to all of them. And I'm sure some of those who matched into surgery will switch into anesthesia, there usually are a few. But we'll welcome the late comers like everyone else as they cross over into the light from the dark side. But they will all start to work harder than they've ever worked, harder than they thought possible. They'll realize that even though medical school was tough, residency is even tougher. The hours, the responsibilities, the lack of personal time.

But maybe residencies have changed since I was in one. As I've previously written, residency hours are being drastically cut back. They may actually have a few free weekends to themselves now without any patient responsibilities. And the new graduates will be entering a medical field that may undergo changes greater than any seen in the last forty years. The great thing about youth is that they will adapt ably and competently while us old geezers complain about the good old days. Looking at all those smiling faces makes me realize how good my life has been, how I should be proud of the privileged life I've led as a physician. So in the last week, I've smiled a little bit more for my patients, tried to not let evil surgeons ruin my day. Yes it's good to be me.

I guess three out of four ain't bad

According to this LA Times article, citing the Archives of Internal Medicine, it takes just four lifestyle changes to decrease your risk of stroke, cancer, diabetes, and coronary artery disease by 80%. These four factors are: avoid smoking, avoid obesity, moderate exercise, and eating a healthy diet. Well duh. We physicians have been preaching this concept for decades. But decades of research into the benefits of diet and exercise hasn't really changed anybody's mind. In all the health care debates, America's higher mortality rate compared to other industrialized nations is repeatedly brought up, as if insuring more people and spending more money will make a big difference.

The article also states that even if you accomplish two of the four factors, avoid obesity and smoking, your risk of getting a chronic disease decreases by 72%. So I guess I'm doing pretty okay. Can I also add attempt to eat healthy? Will an occasional Big Mac worsen my risk improvement to 65%? I promise I'll do better at the exercise part but 72% is already pretty darn good and I'll have more time to spend with my kids instead of being at the gym.

Nowhere are the genes you inherit mentioned as a risk factor. We've all heard of the 45 year old marathon runner who collapses from a sudden MI. Or the college sports player who has sudden death from a cardiac arrhythmia. George Burns lived to be over 100 years old while smoking a cigar. So this has not been taken into account. Since you can't choose your parents, you might as well do what your doctors tell you and diet and exercise, as always.

Is the French system better?

Today's issue of the Wall Street Journal discusses universal health care in France. It talks about how France is now trying to move towards the U.S. model of health care, with higher copays and higher deductibles. France is also trying to cut back ever growing expenditures as health care now consumes 11% of their GDP. Of course people are up in arms about these changes despite an evergrowing financial burden on the country. But as long as somebody else is paying for it, why should their health care be cut back?

What strikes me the most is the chronology of France's system going back to 1976. If you go through the list, you'll see that taxes were raised in one form or another eight times since then. That doesn't include the extra fees and reduced reimbursements that were used to moderate cost inflation. So if other countries have been offering universal coverage for over fifty years and still can't get their costs under control, what makes the U.S. think we can do it here with one legislative session? Once again, we'll have to choose, universal health care or reduced costs. We can't have it both ways.

These are a few of my favorite things

This monstrosity is called The Luther Rory. It is a one-third pound burger between two slices of cheese, four slices of bacon, peanut butter, and two Krispy Kreme doughnuts. YUM! I found this picture courtesy of a great website Thisiswhyyourefat.com. Other food creations featured include deep fried anythings and giant meat and carb creations. Check it out. I am no gastronome. My fanciest meal each year is the buffet line at the Bellagio for our annual Las Vegas vacation. But sometimes, when I'm on call in the middle of the night, I sure could go for a Luther Rory, or a Scooby Snack, or a Hamburger Helper Pizza Burger.

Since this is an anesthesia blog, I should say a little something about how this is medically related, right? Which leads me to the medical lecture I am about to give. Eating Luther Rories or Scooby Snacks will eventually lead to obesity which may require a gastric bypass to correct. For those who are not familiar with inducing anesthesia in morbidly obese patients, here is a video of an awake fiberoptic intubation. It is not pretty. And I have to say it is one of my least favorite and scariest things I have to do in the OR. Patients don't think it's such a great thrill ride either. Think about that next time you go to the country fair and order that fried Snickers.

So there you have it, a blog entry on two of my favorite subjects in the world: food (especially if it's bad for you) and anesthesia.

A new breed of doctors

A patient complains to her anesthesiologist about her anesthesia bill. "Doctor, I can't believe you charge me this much money to put me to sleep." The anesthesiologist replies, "No madam. Putting you to sleep is free. This fee is for waking you up."

While talking with my colleagues, a complaint was voiced that medical, and anesthesia, residents sure have it good compared to when we were in training. While we had to walk six miles to work in hip deep snow and crafted Ambu bags out of the bladders of sacrificial virgin lambs, the current residents' hours are strictly capped at eighty hours per week. And the talk was of even stricter work rules next year. Their work week will be capped at 65 hours a week, with no 24 hour shifts and a required 10 hours of rest between shifts. When a resident's work day is finished, he or she must leave immediately by pulling his car out of the parking lot, swiping his ID card at the gate to signify he is no longer at work. Study at the hospital library after work? No can do. Postop checks? Not if it will violate the work hours limit.

But it is the clinical skills that will suffer the most. The 65 hour work week includes classroom time. So actual OR time will be much less. While the resident will put at least one patient to sleep during the day, he may not be around for the end of the case, the critical time when major decisions are made about extubation criteria, hemodynamic stability with awakening, need for intensive care postoperatively, and PACU complications. And of course the longer the case, the more critical the postoperative period, and the less likely the anesthesia resident will be present to make the important decisions. The residents will have the intellectual knowledge to pass the board examinations, but they will be lacking in the art of anesthesia, the little intangibles that are not taught in books but every anesthesiologist has learned in a successful practice.

These new anesthesiologists may actually be perfect for the future of medicine as envisioned by our politicians. With reimbursement threatening to be lowered even more and millions more patients flooding the health system, all physicians may eventually be forced into salaried positions. At that point, there is no reason to work past your scheduled shift. The evening shift will take over, even if it is in the middle of a case. There is no incentive to work any longer and every incentive to leave. The new residencies are the perfect training grounds for what's coming to the practice of medicine.

Is the public this naive?

In today's Wall Street Journal, there is an article titled "Imagine Doctors, Patients Talking" that demonstrates the naivete of the public, or at least this journalist, on the doctor-patient relationship. The article implies that it is the doctor that is the sole reason for driving up health care costs.

It starts out with advocating more "intimate" office visits with your doctor, like having a dinner conversation. Sure it would be great to spend two hours with each of your patients to discuss their health care but if the new health care bill is allowing more patients to visit their doctors while lowering payments to doctors, those dinner conversations will instead become more like a drive through at the In N Out.

Then the article leads with snarky remarks like "If there's a history of mutual honesty and transparency" and "Doctors should be forthcoming about discussing the alternatives." I would say that in most if not nearly all less-than-honest relationships with patients, it is the patient that lies to the doctor. "Doctor, I'm agonizing. I need more pain meds." "Doctor, I don't have enough money to feed my children. I can't make the copay." "Of course I take all my meds as prescribed doctor but I still can't get my blood pressure (glucose level, acid reflux, INR, etc.) under control." So the writer is implying that doctors are not honest with their patients about available treatments. Has the writer ever heard of informed consents? Before starting any treatments, virtually all doctors discuss the medical plan along with alternatives. We physicians have not dictated to patients their health plans for at least the last twenty years.

Then we get to the laughably ridiculous line "In exchange, patients should signal that they don't necessarily want to act on all the possibilities." Are you kidding me? How many times have I seen patients or their family say "I want everything possible done." I've seen 95 year old demented patients get gastrostomy tubes placed because the family wants everything done. I've seen the whole blood bank transfused into exsanguinating cirrhotic Child-Pugh C patients because the family wants everything done. Walk into the ICU in any hospital and you'll find patients on multiple pressors, ventilated, with feeding tubes and on dialysis long past what is medically indicated because the family wants everything done.

The problem of course is that patients don't know or don't care about the costs of these treatments because somebody else is paying for it. The article states "patients may welcome these developments as they watch their wallets" but that is precisely the problem, the patients and families don't. Most people have insurance through their employer or the government so somebody else is paying for all this. If they had to pay for the real cost of medical treatment, like in Britain where dialysis is out of pocket after age fifty and transplants after age 55, we wouldn't have so much needlessly aggressive care. But of course that would be cruel to the "most vulnerable" people in society.

The article ends by saying it is the doctors who need to upgrade their communication skills to better inform their naive easily impressionable patients. And the patients should have bias free information to make an informed decision. Hello. Patients already have that. But medical care is a very emotional decision. If you read the entire text of Harrison's to these patients, they would still want what they want, regardless of the logic and price of the treatment. No wonder doctors are leaving the AMA in droves. If they can't educate the public about what's really going on, the public will just keep squeezing the doctors until we are all just slave labor for the government. But we doctors are not supposed to say the truth. We're supposed to be all about compassion, treating each and every patient regardless of the physical, emotional, and fiscal tolls on ourselves. Otherwise we're bad greedy doctors who only care about money.