Saturday, October 31, 2009

Halloween candy economic indicator

Another year, another trip around the block with my daughter for trick or treating. This year she was Snow White, another princess costume brought to you by the great corporate conglomerate called Disney. I noticed this year that more houses had their lights off than before. Therefore we had to walk a longer distance to get candy. The candy was also of lower quality. During the good times people were passing out oversized bars of chocolate. This year it is mostly hard candies or minibars of chocolate. Some people even gave out homemade cookies, just like the old days. I ate those, as the official family food safety inspector.

I get the feeling the economy around here is not quite as rosy as the news media is portraying. With so many houses turning kids away from this Halloween tradition and the cheap candy being passed out, I think there are still many people not doing well. Handing out free candy is one way to cut back. By turning out all their lights, it also saves on their electricity bill. I long for the day when we get giant sized bars of Snickers again. Then I'll know that we are doing well as a nation.

Thursday, October 29, 2009

Medical marijuana, a new line of work

If doctors' incomes fall substantially after the passage of ObamaCare, there appears to be a promising new line of work. In the LA Times, a columnist writes about his visit to a doctor to get a prescription for medical marijuana. Now you have to know that in Los Angeles there are close to 800 marijuana dispensaries throughout the county. I see several on my way to and from work; the telltale sign being a green cross over the front door. And thanks to President Obama, the feds will not be raiding any of these places anymore since Californians have legalized medical marijuana.

The writer of the article is initially concerned that he may be turned down, that he isn't sick enough to warrant a prescription for marijuana. When he goes to the "doctor's" office, he talks about his long history of back pain. The doctor "examines" him visually, never laying a hand on him or even getting out of his chair. When asked about the anatomy of the back, the doctor confesses he has no clue, he is a gynecologist by training. And just like that, he is given a recommendation that he can take to any dispensary for legal marijuana.

The great part for doctors is that the writer hands over $150 in cash to the clerk at the end of the ten minute exam. No complaints about copays. No sob stories about how he can't afford his medications. In this office all the patients willingly pay cash for the visit and dutifully fill out their prescriptions ASAP. This could be the greatest line of business for physicians since Botox.

Tuesday, October 27, 2009

Doctors are not a systemic risk

President Obama proposes giving every senior citizen in America a $250 bonus check because, gasp!, they will not get an increase in their Social Security checks due to lack of inflation.

Congress wants to extend the $8000 first time home buyers tax credit into next year, possibly including all home buyers.

Legislation is likely to be approved to extend unemployment benefits for another 20 weeks for the long term unemployed.

There is not a single major medical tort reform legislation in the works during this health care reform debate.

GMAC is likely to get another $2.8 billion to $5.6 billion from the government because it can't stay solvent and nobody would be able to buy the GM cars the government is manufacturing for the benefit of the UAW without it.

The health insurance companies are likely to get millions of new subscribers as everyone will be required to have health insurance under the health reform bills.

Doctors will face a 21% cut in Medicare reimbursements next year because Congress doesn't think losing access to physicians poses a systemic risk to our country.

Carnegie Hall followup

Here's a follow up to my blog about the enormous salaries of stagehands working at Carnegie Hall in New York. In today's New York Times, they interview Clive Gillinson, the executive and artistic director of Carnegie Hall. He justifies the stagehands' six figure incomes by stating they work over 80 hours per week. Anything over 40 hours is 1 1/2 to 3 times base salary. The men (they're all men) also don't take much vacation time off so that gets paid back in income. Their salaries also include a share of money off of recordings made at the Hall (nice).

The men are responsible for setting up 800 performances a year in the three stages within Carnegie Hall. He goes on to say that hiring extra crew would not lower the total crew expense to the Hall. Plus since it is the same performer rehearsing in the morning and then playing for the evening performance, it doesn't make sense to have a different crew for day and night work. Their salaries aren't that beyond reason when compared to other stages in New York, where the average stagehand at Avery Fisher Hall makes $290,000 per year.

They describe the stagehands existence as rather tortured. According to James Nomikos, a former supervisor of the Carnegie stagehands, “They sacrifice their family life, their time. By the time their careers are over, they’re broken, with all that lifting.” Hmmm.

So how many of you are out there working 80+ hours per week, sacrificing family life for your meager red-taped, overscrutinized, hassled existence without making $500,000 a year like a Carnegie Hall stagehand?

Monday, October 26, 2009

Insurance coverage for anesthesia

Here is an interesting comment (#25) on the Prescriptions blog of the New York Times. I copied it in its entirety.

Rein in the anti-competitive practices of the anesthesiologists

One of the overlooked issues in the entire health care debate has been the fact that most anesthesiologists who work at hospitals choose not to “participate” in the health insurance programs that the hospital accepts. So, wise consumers can choose a “participating” hospital and also select a surgeon who “accepts:” their insurance but find that they will have to pay the anesthesiologist whatever is charged. And, they cannot elect to bring in an independent anesthesiologist. All who work at a hospital either are in one large group practice or choose to accept the same insurance programs.

Therefore, the only insurance coverage for the anesthesiologist will be “out of network” coverage. This requires a “first dollar” expense each year and then only reimburses about 70% or “usual and customary” charges — regardless of the actual bill. This means that an operation that, is in-network for the hospital and the surgeon, might result in a bill from the anesthesiologist for over $5,000. Of this amount the patient might have to pay $3,000 or more.

The simple solution, in the sprit of cost containment, full price disclosure and anti-monopoly practices, is to require all medical procedures done in the hospital, by any personal, be covered by the same set of insurances. So, if a patient inquires of a hospital, “Do you accept the XYZ medial plan?” an affirmative answer will mean that all doctors, nurses, lab technicians, and anesthesiologists will be covered by the same reply. People and firms who do not agree to accept the fees of that plan will not be allowed to work at the hospital. They can choose to work elsewhere.

The reason this is critical, is that once admitted to the hospital, a patient does not get to choose which anesthesiologist will participate in the procedure. One meets the anesthesiologist minutes before being rendered unconscious. The anesthesiologists who practice at the hospital have a monopoly on all the anesthesiology business and should be regulated and required to “accept” the insurance programs that the hospital itself accepts. If they do not like the requirement rates of the insurance programs accepted by the hospitals where they work, they can seek changes or they can choose to work elsewhere.— steven epstein

While this rant sounds like it came from a disgruntled surgeon, it could just as easily have come from a patient suddenly faced with a large anesthesia bill they were not expecting. I've had patients ask me whether I accepted their insurance. If it's Medicare, that's a no brainer. But unless I call my business office, I really couldn't tell you which insurance companies, other than one or two offhand, that our group accepts. I've never had a patient write me a nasty letter afterwards saying they felt deceived by our insurance acceptance so I presume they were fine with our insurance coverage.

What has been the experience of anesthesiologists out there in regards to this issue? Are we being needlessly criticized for not accepting the same insurance policies as the surgeons? Would we then be beholden to the surgeons and the hospital to accept some insurance contracts but not others thus limiting our ability to negotiate a fair rate of reimbursement?

Sunday, October 25, 2009

I love this bumper sticker.

Anesthesia Shit List

Sorry if the title sounds so crude, but that is a pretty succinct description of the list of surgeons who have angered me so much that I refuse to work with them. Luckily our group is large enough that I don't have to work with these people ever again if I don't want to. Some of these surgeons have such bad reputations that only a select few anesthesiologists will even step into their OR. And we're all grateful to them for walking into the lion's den every day.

Why do surgeons like the ones on my ASL continue to hold positions at the hospital? Despite all the lecturing by Human Resources about how we all should treat each other with respect, some individuals seem to be above the law, untouchable and unimpeachable by all. They either bring a lot of well paying patients to the hospital. Or they have a special skill set that would be hard to replace if they went to a different facility. Or they have support from higher ups in the hospital system.

I'll always remember one of my early cases with one surgeon. He was about to do a thoracoscopic procedure. After I intubated the patient and positioned the double lumen tube, I turned away from the patient to draw up some drugs from my cart. When I turned back, the surgon had lifted the patient's torso and turned him lateral, with NOBODY supporting the head. The head was just dangling in midair, flopping around while that carefully placed double lumen tube was in danger of falling out of position, if not out of the patient entirely. He obviously had no respect for the patient, me, or my job. So he was the first surgeon on the ASL.

Through the years, I've had many opportunities to work with mean or bad surgeons. There was the surgeon who screamed "Get the F*** out of my OR!" when he started manipulating a broken extremity and the patient moved about ten seconds after I had placed an LMA into a patient. He of course thought it was my fault the patient moved before the patient was completely under. A**hole. Automatic ASL. Another surgeon arrived forty-five minutes late for his first case of the day. When asked why he was late, he response was "I'm calling the anesthesia director. I want another anesthesiologist NOW!" ASL. Another surgeon, thinking that I was his anesthesiologist even though the OR schedule had changed overnight, physically grabbed me by the arm and said "Let me introduce you to your next patient" even though I had just finished seeing my real patient. When I told him I was not his anesthesiologist, he got verbally abusive. That's one of the few times I yelled back at another physician colleague. I let him know very loudly, and I'm sure within earshot of his patient sitting in preop, that I thought he was a sh***y surgeon and nobody f***ing likes him in the OR. He said he never wanted to work with me again and I said I'm glad the feeling's mutual. ASL.

There are some surgeons who are just marginally on the ASL. But I'm sure with more exposure to them, they will become full fledged members of the list. Maybe that's when I'll know when to retire, when every surgeon in the hospital is on the ASL, then I'll know it's time to go.

Thursday, October 22, 2009

How much did you make last year?

This from

Dennis O'Connell, the man responsible for moving around props at New York's Carnegie Hall made $530,044 last year in income and benefits. Four other crew members made an average of $430,543. Artistic and Executive Director Clive Gillinson made $946,581.

What do the stagehands do to earn this much money? According to the report, the crew "move equipment in and out of the hall, prepare the three stages for performances and operate audiovisual and sound fixtures." If that doesn't sound like the responsibilities fit for a six figure income, you forget that they have a trump card, the International Alliance of Theatrtical Stage Employees. The union shut down Broadway for three weeks in 2007, resulting in losses of millions of dollars. (Shrek the Musical just announced it is closing because they couldn't make a profit with gross weekly receipts of over $500,000.) Since nobody else in the world appears to be capable of doing the same tasks as this stage crew, management felt they had to appease the union with this ridiculous salary and benefits package.

How much do you owe on your medical school loans? Maybe you can get a handout from the Carnegie Hall stage crew.

Wednesday, October 21, 2009

Malpractice insurance disclosure too great a burden for lawyers

In a hilarious post from White Coat's Call Room, the Texas Supreme Court has asked the State Bar of Texas whether it would be too great a burden for lawyers if they had to disclose to their clients whether they carried professional liability insurance or not. Mind you, this doesn't mean the lawyers have to spend thousands of dollars and actually pay for insurance. This is just about whether they should tell their clients if they carried it. The outcry among the legal community is deliciously ironic. The complaints range from the inability of small practices to buy expensive insurance to having insurance will invite more frequent and bigger lawsuits. You can go to the post to read the complaints.

The Congress that can say no

Well it eventually had to happen. After a decade of relentless spending by the federal government, Congress has finally decided that an unfunded mandate for a lobbying group was too much and they voted it down. When the music stopped, the group that was left without a chair was...doctors. This afternoon, Congress didn't approve an AMA supported bill, S1776, that would have prevented a 21% cut to Medicare reimbursements for next year and abolished the SGR system that has driven down physicians' incomes every year. Though it was a bad bill, just the thought that physicians, of all the special interest groups, would come out on the losing end is galling.

The Republicans in the Senate decided that they are the party of smaller government and fiscal discipline after all. This despite the trillions of dollars spent in the last ten years for two wars and the new Medicare drug entitlement program. They unanimously voted against S1776. They just couldn't stand the thought of spending another $250 billion over ten years ($25 billion per year out of a $2 trillion federal budget) for doctors unless some way was found to pay for it.

The Democrats came to the conclusion that enough was enough. They had to draw the line somewhere on federal spending. This after spending trillions in the last year on bailouts for: banks, insurance companies, brokerages, auto companies, auto suppliers, car dealers, home builders, unions, etc. The Blue Dog Democrats decided to live up to their reputations as "conservative" Democrats and said no to more spending without limits.

I wouldn't be too concerned about the welfare of doctors though. We won't get our Medicare reimbursements cut; Congress will issue their annual "doc fix" to make sure we continue to subsist off the crumbs of the federal budget while a more permanent solution is found. The reason they will do this is not because they are afraid of angry doctors and the AMA, which has proven itself to be a paper tiger. No, it will be because they are afraid of all the elderly voters and the AARP, who will be up in arms if they have trouble finding a physician to take care of them. Doctors, the biggest losers so far during this health care debate.

The AMA is not your friend

In an eye opening editorial in the Wall Street Journal today, they dissect how the AMA is selling out the medical profession, particularly by AMA president J. James Rohack. The daily emails I get from the AMA on how I should support their efforts to pass health care reform fail to mention many of the punitive clauses that will hurt doctors in the long run.

The AMA has maintained that their primary goal is to do away with the SGR, sustainable growth rate, that punishes doctors every year by potentially lowering Medicare reimbursements. But the current bill that moves the SGR fix off the health care reform bills only delays SGR cuts for ten years. In fact, some in Congress would lock in current Medicare rates for the next ten years. Can you imagine how that would devastate physicians' inflation adjusted incomes? Health care inflation is usually twice as high as the consumer price index so the cuts in incomes would be far greater than the general population.

There is also no longer a demand for some sort of tort reform even though it is high on virtually every doctors' priority list. Don't even mention Obama's laughable $25 million for pilot projects to "study" tort reform in states. This is the kind of bill the AMA wants doctors to write to their Congressmen about in support? As I've mentioned before, the AMA has only a minority of physicians in the country amongst its membership. It hardly speaks for physicians as a whole. Yet it promotes itself to Congress as the voice of doctors everywhere. Its advocacy of these flawed reform bills will be a detriment to all physicians.

Tuesday, October 20, 2009

My pet peeve

When my surgeon finally walked into preop holding this morning for the first case, thirty minutes late, the first thing he said to me was how he wanted his anesthetic performed. That automatically raised my ire and soured my mood for the rest of the case. When he started injecting local anesthesia into the nose for the septoplasty case, rivulets of blood started streaming down the patient's face. He then turned to me, asked me what anesthetic I was using, and asked me to use a different one since I was causing his patient to bleed excessively. Then I thought this guy doesn't know what the f*** he's doing. I've seen hundreds of nasal injections for septoplasty and not once has another surgeon blamed it on the anesthesia.

That is just one thing I can't stand to hear and immediately lowers my attitude toward the surgeon. I don't understand why surgeons don't get it that they are not anesthesiologists. I am not their CRNA, there to be directed by an MD on how to do my job. Do I ever tell the surgeon where to make the incision? Or what sutures to use? Or which rod to insert? They would just as soon kick me out of the room for demanding that they follow my instructions.

I try to stay professional by acknowledging their "request" and will try to fulfill it if it is not detrimental to the patient. But some surgeons will repeatedly look over the drapes to check on the vital signs or ask if the patient is "completely paralyzed." Some have even asked what muscle relaxant I was using, as if they knew the difference. Then it just gets annoying and I blow them off with a dismissive "uh huh." But I'm passive in that way. I know some anesthesiologists who wouldn't blink an eye at talking back directly, setting up a confrontational atmosphere in the OR. We even have anesthesiologists in our group who are known to have such anger issues that nobody dares mess with them. Bravo I say. If I only had the guts myself. But in the end, the case finishes soon enough and the surgeon never knows my true feelings about his professional conduct. And we each go our separate ways.

Saturday, October 17, 2009

My iphone, seduced by the dark side

Sorry I haven't posted in quite some time. I'm being initiated into a cult. I consider its insidiousness right up there with Scientology and the Theory of Global Warming. Of course I'm talking about my new Apple iphone (or iPhone?). I couldn't stand it anymore. I watched day after day as legions of residents and attendings stand like zombies in the hospital hallways and elevators, flicking their fingers over that seductive glass surface, completely oblivious to the patient gurney about to run over them. At meetings, everybody is furtively glancing down at their iphones, trying to be inconspicuous in their contempt of the speaker and his topic at hand. It all reminds me, ironically of Apples infamous 1984 commercial. Except this time the face of the Supreme Leader on the screen is Steve Jobs and as yet there is no pretty blond lady to smash the spell the Leader is casting over his lemmings.

I tried to console myself by stating the obvious; there are millions of dollars worth of computer monitors all over the hospital. All I need out of my cell phone is a phone. I don't need no freaking internet browser, music player, compass, GPS navigator, gazillions of apps, etc. in my pocket. Why do I need to pay a mandatory extra $30/month for a data plan and even more money for simple text messaging? Why doesn't an unlimited data plan cover texting also? But my cell phone was over two years old and starting to do funny things, like rebooting itself in the middle of a conversation. Plus my wife freaked when she found out her phone had above average radiation emission and wanted a new phone. So my decision came down to two phones, get a Blackberry with its higher learning curve and radiation exposure or succumb to the dark side.

To the dark side did I befall.

So far, it has been...okay. When I downloaded itunes (iTunes?) for the first time, it promptly reconfigured my entire music collection from WMA to AAC, which believe it or not took about 20 hours. I had to tell everybody in the house not to touch the computer during that time, just in case somebody forgets and accidentally turns it off. What can I say, I have a huge music collection on my computer. So now I have two sets of files for each song on my hard drive. The iphone has an annoying safety feature where I have to type in a Passcode to unlock the phone so I can make a simple phone call. It's nice in case my phone ever gets stolen but downright dangerous when I'm trying to call somebody while driving in rush hour traffic. Remember the iphone has no keyboard so my finger is just kind of hovering over where I think the keys should be to type my password while trying to maneuver in urban traffic. My final criticism that I'll bring up here, though by no means the last criticism of the iphone, is that the apps are WAY overrated. There is an entire category devoted to the medical field but the anesthesia subcategory is woeful. There are a few anesthesia handbooks for downloading. But rather than flicking through my phone, wasting battery life, it would be much easier for me to carry a copy of an anesthesia handbook for referral. As far as games are concerned, who has time for games? Certainly not at work. And I've got plenty on my plate at home to have time for games.

So that's what I've been doing with all my free time in the last week. The exercise program has taken a temporary break for now (but also because I came down with a cold but that's another blog entry for later). I've got the iphone functionally just about where I want it. My wife's days and nights of being an iphone widow is almost over. And I can start blogging again about the crucial health care reform votes that are coming up along with how they are going to continue to screw the medical and anesthesia professions.

Sunday, October 11, 2009

Another lawyer's wallet biopsy

I had previously posted a case where an attorney decided to drop a high profile case because the defendent apparently could not afford his legal fees. In today's news there apparently is another lawyer that felt his time and money is more important then protecting a client facing murder charges.

The defendent is Andrew Thomas Gallo, a 22 year old driver accused of DUI and running into another car killing Los Angeles Angels pitcher Nick Adenhart along with two other people and seriously injuring a fourth person. According to the paper,

"The Orange County Public Defender got the headline-making case earlier this month after private attorney Randall T. Longwith bowed out when he could not get court funding to hire additional investigators and medical experts."

Again I ask, why is it illegal for physicians to turn away patients facing life and death situations if they cannot pay yet lawyers are allowed to turn away clients facing murder charges apparently because the government will not pay his expected legal fees? Is it any wonder hospitals all over the country are closing their emergency rooms, if not the whole building, because their indigent patient expenses are not being adequately compensated by the government?

Friday, October 9, 2009

Nobel blinded by The One

This blog normally doesn't delve into politics ouside of medicine, but this morning's announcement that President Obama has been awarded the Nobel Peace Prize is quite shocking. It puts to rest the idea that the Nobel Committee judges without prejudice and awards based on merit. This is a president who has been in office only nine months and two years ago was a little known senator from Illinois. He has been very good at talking about wanting peace but his accomplishments so far are pretty thin. Now I don't blame him for that since, again, he has been in office for only nine months. His policies for the Mideast, Iraq, and Afghanistan pretty much mirror President Bush's policies. Iran is still developing nuclear weapons. Hamas still presides over Gaza and terrorizing Israeli border towns. So far his one main foreign policy difference from the previous administration has been the withdrawal of defense missiles from Eastern Europe, to the delight of autocratic Russia and fanatical Iran.

If you look at a list of prior Peace Prize winners, there are some pretty dubious choices. In 2007 Al Gore won for promoting the doctrine of global warming. In 1994 Yasser Arafat won for promoting "peace" with Israel. Henry Kissinger and Le Duc Tho won in 1973 for attempting to bring peace to Vietnam with the Vietnam Peace Accord. Several deserving public figures have been denied the prize, including Mahatma Gandhi, Pope John Paul II, and Corazon Aquino, who brought down a dictatorship in the Philippines with the nonviolent People Power movement.

Is President Obama as deserving of the Nobel Peace Prize as Dr. Martin Luther King, Jr.? Or Mother Teresa? Or Desmund Tutu? Or Aung San Suu Kyi? When Lech Walesa, the leader of the Solidarity movement in Poland and a Peace Prize laureate, was told of Obama's win, he seemed confused, "Who? What? So fast? Well, there hasn’t been any contribution to peace yet. He’s proposing things, he’s initiating things, but he is yet to deliver." I'm sure even Obama will say there are other candidates more deserving of this award than he. But the Nobel Committee apparently has awarded him the prize based on his potential for promoting peace, not for actually accomplishing it. So while Obama's poll numbers are falling in the U.S., he can still dazzle those who don't have to live under his spendthrift socialist policies.

Thursday, October 8, 2009

A Doctor's Sacrifice

I admit that I'm a newbie to this whole social networking phenomenon. I skipped the whole MySpace fad but couldn't resist signing up for FaceBook. I heard so much about people catching up with long lost friends on FB, and for the most part that is true. I've reconnected with friends from decades ago that I thought I'd never hear from again. It's fun to see how our lives have all taken different unexpected turns. In general, everybody's gotten a little heavier and a little balder (at least the men).

What struck me though was how different my physician friends are from my high school friends, specifically how we doctors delay our lives until much later to further our education and careers. Nearly all my medical school classmates have very young children like mine. We are all in our early forties but very few have children older than ten. Meanwhile, many of my high school friends have children that have graduated from high school and are now starting college. They have albums full of pictures of prom nights, high school field trips, first dates, first cars, first sports trophies. I'm still changing diapers at two in the morning and watching Elmo on Sesame Street.

By the time my youngest one finishes college and (if I'm lucky) graduate or professional school, I'll be eligible for Social Security. If they follow the same path as me, I won't see any grandchildren for another thirty years. My old high school friends by then will be posting pictures of their great grandchildren. Why do we do this to ourselves? Is it for prestige? Is it for the money? The way the political climate is blowing, we'll have neither in the near future. Can we really say we have more satisfaction treating sick patients rather than starting a loving family of our own? These are all points to consider if my children ask me whether they should follow my footsteps and go into medicine.

Tuesday, October 6, 2009

Make mine monkey ass red

This one is just too funny. From Autoweek, a report on Toyota's new concept sports car.

“Sports cars have to be red, but we wanted a new red,” chief engineer Tetsuya Tada said. “So we came up with shoujyouhi red, the traditional red color of a Japanese monkey's” backside.

Somehow I don't see Americans ordering their sports cars in the shade of a monkey's butt.

Monday, October 5, 2009

The hospitalist will be happy*

An op-ed in the Wall Street Journal details how the health care reform bills will punish medical specialists will helping the primary care doctors. It is widely believed that primary care physicians in this country are grossly underpaid relative to their specialist colleagues. Thus very few medical students, 5%, report wanting to go into primary care. But if everybody gets health insurance, there will be an acute shortage of doctors to take care of all these new patients. So the reform bills will increase reimbursements for primary docs.

But the pool of money is static. Thus reimbursement will be a zero sum game. If primary doctors get more money, somebody else will get less, much less. The article details some of the proposals, highlighting cardiology and oncology specialties. In 2010, cardiology will receive 11% less money while oncology will get 19% less. Echocardiogram reimbursements will fall 42% and cardiac catheterizations will drop 24%.

I shudder to think how much less anesthesia will receive. We already get less from Medicare than nearly all specialties. On average anesthesiologist are reimbursed only 33% of private health insurance payments versus 80% for other medical fields. Maybe anesthesiologists can reclassify themselves as the internists of the operating room, which we are. Then we can convince Congress to reimburse us better.

*With all due respect to A Happy Hospitalist.

Thursday, October 1, 2009

This is a healthy Michael Jackson?

From the Associated Press:

"The [autopsy] report says Jackson's arms were covered with punctures, his face and neck were scarred and he had tattooed eyebrows and lips. But overall he was a fairly healthy 50-year-old."

Arms covered with puncture marks with neck and facial scarring (from previous surgeries?) don't sound that health to me, regardless of age. Yuck.