How Much Do Anesthesiologists Make, 2010 Edition

Here is the latest statistics on compensation for anesthesiologists, courtesy of LocumTenens.com.  My previous write up about this was from the U.S. Department of Labor whose numbers are drawn from 2009. This survey was conducted for the current year so hopefully it will be much more relevant.

According to the report, anesthesiologists on average are paid $362,450 per year. Partners in an anesthesia group averaged a whopping $405,346 while an employee anesthesiologist made $337,187. Male anesthesiologists as usual made more than their female partners, $368,654 vs. $313,529.  As expected, the years of experience also weighs in on compensation. Those with less than five years made $339,055. For those with six to ten years of work, they averaged $330,192. The most experienced anesthesiologists with greater than ten years of experience made $377,121.

Is it any wonder anesthesiology residency is still highly coveted by graduating medical students? The ROAD to success in our field has not diminished. If the ASA is ever successful in convincing Medicare to compensate anesthesiologists fairly (33% of private insurance payments for anesthesiologists vs. 80% of private insurance for other physicians), we will have one more great story to tell the best and brightest students to join our esteemed profession. Hint: contribute as much as you can to ASAPAC, the most successful medical PAC in the country.

A Colleague's Betrayal

We like to think that anesthesiologists are all congenial, selfless individuals looking out for each other and our patients. Anesthesiologists get accustomed to being screwed by the surgeons or the operating room. It can be pretty exhausting during the course of a day dealing with all the nonmedical issues we have to put up with. It is nice to believe your partner has your back and can be depended upon to help out. Therefore when you get the shaft from your own anesthesia colleague, it can be really disappointing.

I'm not talking about patient related emergencies like a difficult airway. I like to think I can still depend on them to help out in such a dire situation. I'm thinking more about personnel issues that should be the last thing we have to worry about. For instance, we have an overnight call team that starts their shift at 3:00 PM and is responsible for all the appendectomies, D+C's, traumas, etc. that roll in through the course of the evening. When we're on that shift, we usually can count on having the day free to run errands, take the kids to school, or just sleep in. But on more than one occasion, when I've been on the night shift, a colleague will simply not show up for work and all attempts to reach them are futile. So guess who gets called in to do the morning cases and still have to work all night, essentially a 24 hour shift?

Sometimes it's the other way around. The surgeons may decide to keep adding cases far into the night. As the anesthesiologist in the room, I have the option of having the on call person take over the room so I can leave at a reasonable hour. However I've had instances where the call person (not the overnight shift) has refused to accept this responsibility. He might argue that he's already home and doesn't want to drive back to the hospital. Or he has a long line up of cases the next day and is too tired to take on more cases that night. That's when you dishearteningly realize you are on your own and are stuck with the cases until the overnight person is free and can finally take over your room which might be anywhere from 10:00 PM to 2:00 AM.

Granted this disgraceful behavior is decidedly uncommon within our group and is relegated to a few usual suspects. Complaints to higher ups usually get a "we'll deal with it" reply and not even a noticeable slap on the wrist. The fact that this happens at all though is frustrating and adds another level of stress to our already taxing profession.

Stages of Grief, Computer Crash Edition

Denial--(Turn on office computer and screen stays blank.) Hmm, I guess I didn't push the ON button hard enough. Push a little harder this time. Still nothing? Is the monitor off? No. Check the plug at the wall outlet. No that's still good. Try pressing the ON button again.

Anger--Goddammit! Who's been messing around with my computer? Did somebody in here touch my computer?  This is f***ing unbelievable. I have a talk due next week and this stupid piece of s*** decides to die on me. Who in the office last used this computer? I want to know exactly what you did to cause this mess.

Bargaining--(Call in IT help) Please, please you have to rescue my computer. I've got all my slides and presentations in there and I need to have this thing working or I'm up the creek. Dear God of Gentle Mercy, if you bring back my computer I promise I'll back up my hard drive every night and tithe 25% of my income to the church. Oh Lord can't you bring it back just long enough for me to offload my files?

Depression--Why is this happening to me? What did I do to deserve this fate? I take such good care of my computer. I never drop it or spill coffee on it. I always have the latest antiviral software loaded. I even use a surge protector. Why did this have to happen to me at the worst possible time?

Acceptance--I'm so stupid for not backing up my hard drive more often.  I think I may have older copies of my work on my home computer. Hopefully I can reconstruct my presentations from those. I never did like that one talk anyway. Now is a good time to improve on it. Que sera, sera.

December Stampede

Christmas shopping isn't the only thing people rush to complete in the month of December. Seems like many are also trying to squeeze in their medical care at this time of year. You would think that getting sick would not be a seasonal event, other than getting the flu. But our hospital is always incredibly busy from late November to New Year's Eve. Every operating room is booked for the entire day. Post call personnel are asked to work instead of getting their usual day off. Don't even think about calling in sick unless you are on a vent in the ICU somewhere with multiple pressors running. Everybody complains about the lack of rest and not having enough time to see their families. Then once the clock strikes midnight on New Year's Day, O.R. volume drops precipitously. Suddenly they are requesting, if not scheduling, people to take time off. People finish their O.R. line up by 1:00 PM or sooner. Anesthesiologists are begging for more cases to do. Everybody grumbles about not making enough money to pay their mortgages and children's private school tuitions.

What accounts for this annual health care stampede? I don't have a definitive answer but the consensus around here is that it's all about the money, or to be more precise, free health insurance money. The theory is that by December, most patients have already paid in full their deductibles for the year. At this point, all medical treatments are being paid by the health insurance company from the first dollar. Therefore smart logical people will try to get as much done as possible before the calendar rolls over. Everything semielective and expensive such as surgical procedures are put off until the end of the year. This theory also explains why the number of scheduled surgeries plummets in January. Suddenly people have to start paying their deductibles again. Unless it is an emergency or a necessity, medical treatments are put off as much as possible.

I have no concrete evidence to prove this theory but it makes sense. Rational people will make decisions based on their best self interest. If somebody will pay for your health care for free after a certain set deductible, why not use and abuse it as much as possible? That's why health care is rationed in countries with universal health care, like England. Patients will consume as much medical care as they can get away with if nobody is paying for it. In this country we don't have universal health care; everybody gets to have their goodies for only one month until December 31st. Then a more rational medical consumer reemerges and we anesthesiologists finally get to go on holiday vacation.

Most Family Stickers I've Ever Seen On A Car Window

I was driving to work early one morning and saw this minivan with the most number of family member stickers I've ever seen stuck to one window. I don't think the whole family would fit in the minivan at the same time. Sorry about the quality of the picture. You can blame Apple and its evil iPhone's wretched camera.

Trivialization of Anesthetic Risks is International

By now we're all familiar with the fatal consequences of downplaying the risks of anesthesia. This blog has expounded multiple times on the deaths of patients who were administered anesthetics without the proper anesthesia training or monitoring. There is of course Michael Jackson's untimely demise at the hands of a distracted cardiologist. Then there's the case of Dr. Osathanondh, who gave a general anesthetic for a D+C without a single monitor on the patient. Absolutely shameful and without reason.

Now there's news that this underappreciation of anesthetic complications is a shared trait amongst surgeons worldwide. In China, a reality show contestant by the name of Wang Bei was undergoing facial plastic surgery. During her procedure, her airway was apparently not protected. She aspirated blood from the surgery and could not be resuscitated. The Chinese government is now looking at tighter regulation of their burgeoning plastic surgery industry.

When will all surgeons realize the importance of patient safety before they make a cut? Remember, you won't have any referral business if your patient is dead.

Flying Car Caught In Los Angeles

Here's something you don't see very often. A drunk driver in San Pedro, a suburb of Los Angeles, lost control of his car and literally flew off the road. He and his passenger wound up wedged between the sides of two adjacent homes. According to the newspaper article, there were no skid marks on the road leading up to the accident scene. Luckily nobody was killed and the car passenger was well enough that he tried to run away from the car. Bizarre but not surprising in a city where car chases are a secondary form of TV entertainment and driving mayhem has been immortalized into a video game.

Brain Dead Interventions

The conversations in the operating rooms are not always that interesting or informative. But sometimes it is amusing to hear the surgeons complain about their work. The other day, they were whining about the inane consultations they sometimes receive from internists. They seemed to be trying to top each other with clueless internist referrals.

The first surgeon said she received a call about a patient who had a hematoma under the arm where the blood pressure cuff was wrapped. She goes to see the patient and evaluate the arm. The patient turns out to be ventilator dependent, brain dead, and was about to be terminally extubated per family request. Needless to say she did not drain the arm hematoma.

The next surgeon said he could top that. He got a referral from an internist for a patient with dry gangrene of a leg. The leg was literally black and mummified. The doc wanted to know if the surgeon can do something about that hideous leg. The kicker was that the patient has anoxic brain injury, is ventilator dependent, and is fed through a gastrostomy tube with no hope of being ambulatory ever again. The patient's family was pressuring the internist to do something, anything, for the leg. The surgeon rightly told the internist that since the leg has dry gangrene, nothing needs to be done. If it gets infected and turns wet then an amputation will be necessary. The internist couldn't go back to the family with that answer. Therefore the surgeon acquiesced and ordered a vascular study of this vegetative, bed-ridden patient to appease the primary doc and the family with no intention of ever following up.

Besides what these stories say about the economics of health care in this country, I'm just so glad I decided to become an anesthesiologist.

What Nurses Really Think About Their Patients

I saw this funny (?) sheet posted up in our ICU. It is a sample page on how to admit a patient into the unit. I noticed the pseudonyms given to the pretend patients. Instead of the usual "John Doe" or "Jane Smith" they use the names "Harry Bumm" and "Crazy Old Lady." Hmmm. I wonder if somebody was having a bad day when they printed this out.

Simple Way To Reduce Medication Errors

Take a close look at the picture above. If you were looking down into the anesthesia cart drug tray, this is what you would see, a whole drawer of lookalike drug caps. The four drug bottles on the left are different from the ones on the right but you would be hard pressed to tell the difference with a quick glance. The green cap on the left belongs to a bottle of oxytocin while the green cap on the right belongs to dopamine. Think there would be major repercussions if those drugs got mixed up and was given to a patient? The gray cap on the left is metoprolol while the cap on the right is potassium. If you were in a hurry and reached for the metoprolol but accidentally pushed potassium, think the patient will have a problem with that?

Well, you might ask, how about making the bottles of different shapes and sizes. Unfortunately many of the drugs come in one milliliter quantities so even the bottles are practically identical. The picture on the left shows a bottle of phenylephrine next to a bottle of metoclopramide. Identical white caps, identical sizes and shapes of containers. Occasionally I've caught the pharmacy put the wrong drugs into the wrong section because they look almost exactly the same.

I don't understand why drug companies have to choose the same color caps for their medications. With a whole rainbow of colors to choose from they select the same shades of gray or green or blue or yellow. Or they get lazy during their marketing meetings and simply choose white. They could certainly make the bottles different too. Use a colored glass instead. Perhaps the pharmas could even dye the drugs a certain color to make it more noticeable if you're drawing up the wrong medication. Right now it's easy to tell if you're giving a patient propofol because it's the only white opaque drug. (Don't get me started on how it can get confused with intralipids.) What if all the drugs had different colors. Make all the muscle relaxants red. The antihypertensives green. The vasopressors orange. The possibilities are endless.

You say it will drive up the cost of manufacturing these generic drugs? Well, what is the cost of giving the wrong drug to a single patient? Besides the harm to the patient, the cost of taking care of the patient after a major medication error along with the inevitable lawsuit can reach into the millions. With healthcare mistakes causing thousands of deaths a year, I think this is one area that can easily be corrected with minimal expenses to everyone.

Old School Anesthesia Assessment

Once in a while, when I have a few precious minutes to spare from my work and family, I'll get around to reading piles of old material sitting on my desk. Sometimes I'll even discover something interesting and useful in all those unread pages. The other day I finally perused a recent issue of the ASA Newsletter. In a column by Dr. Douglas Bacon, editor of the newsletter, he discusses how anesthesiologists assess the risk for a patient about to undergo surgery.

In the era of modern medicine, we anesthesiologists have a wide assortment of choices to help determine if a patient will survive an operation. Who amongst us hasn't requested that a patient first get a stress echocardiogram or a pulmonary function test to see if we can administer an anesthetic safely? But what if these state of the art examinations were not available to us? How can we assess the health of our patients with something more objective than asking them if they can walk up two flights of stairs without getting shortness of breath? What if they live in a one floor house? How many steps are on their stairs? How tall are the stairs? What is the pitch? Not very objective is it?

Dr. Bacon describes two tests that used to be conducted by anesthesiologists in the early years of the last century. The first one he describes as :

pulse pressure/diastolic pressure

If the answer falls within a ratio of 0.25-0.75 the patient is considered healthy enough for surgery.

Another test he relates is called the energy index:

(pulse rate * (systolic pressure + diastolic pressure)) / 1000

If the number is less than 13 the cardiovascular system is considered weak. If it is greater than 20, it is considered to be carrying an excessive load.

I've never tried these algorithms before when interviewing a patient in preop. I'm going to give a few tries to see how astute the old timers were without resorting to 21st century medical technology. If it works, it certainly would be more expeditious and cheaper than delaying a case to order a stress thallium scan.

Elizabeth Edwards

Cad

=

John Edwards: medical malpractice lawyer, failed presidential candidate, philanderer

Elizabeth Edwards: trusting wife, mother of four, cancer victim

R.I.P. Mrs. Edwards

Do Anesthesiologists Make You Want To Go Pee?

Dear Patient,

Does the sight of an anesthesiologist approaching you give you an urge to pee? How else to explain the all too common phenomenon when I am about to introduce myself to you that you suddenly have the urge to go to the bathroom? It never fails. You can be sitting in preop holding for 45 minutes or an hour, happily lying on the gurney watching TV or reading your iPAD. But the minute I walk up to you, you have to excuse yourself to go urinate. You may be in the OR for a TURP because your poor bladder just can't expel all that urine past your enormous prostate, but the sight of an anesthesiologist opens up your urethra wide like the parting of the Red Sea.

While I can understand that everybody has to go when nature calls, it never seems to happen with your surgeon. When the surgeon ambles up to the bedside to discuss all the potentially deadly complications he is about to inflict on your innocent frail body, you seem to be able to hold it all in. In reality that should be the precise time you should be hurling and spewing your guts out thinking about what you are about to undergo under the guise of "modern health care".

Instead when I introduce myself, you run off to the bathroom. I am left standing there looking at an empty bed, leafing through your (usually) incomplete chart trying to comprehend the scribble of an H+P written by the surgical resident. In the meantime I'm trying to ignore the wall of eyeballs of your family members zeroing in on my defenseless, self-conscious soul. What are they thinking about me behind those steely probing glares? "How old is he? Which medical school did he graduate from? Should I ask him for his phone number?" Frankly, I don't even like to start the IV after you've been to the bathroom; I don't know how well, or even if, you washed your hands after relieving yourself. Did you do #1 or #2? Actually I don't want to know that. It would just cause me to recoil more. All the while the clock is ticking as the OR finds another excuse to classify a late case start as "anesthesia delay".

When should you go to the bathroom? The obvious answer is when you are changing out of your street clothes into the hospital gown. Take all the time you want then. Nobody will object. If you have to go after that, at least try to wait until I've had a chance to talk to you and get you ready for surgery. That way my precisely honed timing for preoping patients will not be disrupted. Your case will then start on time and you, me, the surgeon, and the OR will all be happier for it.

Sincerely,

Dr. Z

Reflections On A Family Vacation

Well, I'm back. It was the family's first road trip and a nice Thanksgiving vacation.  The children behaved better than expected and we all ate too much over the last week. Time for my ritual diet before the onslaught of Christmas ham and eggnogs. In the meantime, I'd like to share a few observations about our vaca.

People in the South love their buffet restaurants. Everywhere we went there was a Chinese buffet or a Golden Corral. I even saw a place that served a buffet of KFC and Taco Bell under one roof. If I was still in college I would probably live there. Even though this was Thanksgiving and presumably everybody has had their fill of food at home, all of these buffet establishments looked packed.

Children's menus at all restaurants are similar and similarly disastrous for your child's diet. With nary an exception, they all featured (Kraft!) Mac and Cheese, chicken tenders, and corn dogs.  After a week of feasting and eating out, my six year old developed pimples for the first time in her life. Broccoli for the next week now that we are back home.

Children have an endless capacity to ask "Are we there yet?" A DVD entertainment center in the minivan is no use since after a few hours they get restless regardless of what video they're watching. When that gets old, there's always...

Looking out the window, the American landscape is a constant source of fascination, especially for the kids. From the cotton fields in Texas to the windmills of Oklahoma to the snowcapped mountains above Flagstaff the scenery outside the car window offered endless sources of education and enchantment.  Their eagerness to learn about grazing sheep in a roadside field or giant rolls of hay bales makes one proud to be a parent.

After living in So Cal, it was a pleasure to venture someplace more gracious and less crowded. I hadn't taken an extended vacation in years. I think I will do it more often from now on.

Road Trip!

While driving on a multi-day, multi-state road trip to my Thanksgiving destination (no naked scanning for my family), many random thoughts crossed my mind. Here are just a few in no particular order.

Why do so many people in America live in mobile homes? And why do so many mobile homes have piles of junk cars parked around them?

Who assembles those giant radio antennas that dot the countryside? Do they attach the tension wires that keep the antennas erect before or after they are raised upright?

God bless the American pioneers two centuries ago who drove the country westward. I couldn't imagine the hardship of crossing the country in covered wagons going ten miles a day at best. We should all be thankful for them on this holiday.

Whoever invented the terms "wind swept landscape" and "wide open vistas" must have been going across the Texas panhandle. Other words they might have coined include "moonscape", "desolate", and "stark."

Is McDonald's a sign of civilization? When we couldn't find a McDonald's along the main business road of Flagstaff, AZ, my wife commented that this isn't a real town if it doesn't have a McDonald's. We eventually found a McDonald's there.

The GPS navigation is scary accurate. It is a godsend when driving in unfamiliar territory but its ability to track your precise location feels like a precursor to "1984."

Anesthesiology is great training for being a truck driver. Our jobs are very similar. We both sit on comfortable padded chairs all day while scanning our monitors and surrounding environments for signs of trouble. And we both can't go to the bathroom whenever we want.

Happy Thanksgiving everybody.

Surgeons, Nurses, Techs, Cleaning Crew....Anesthesiologists

I was trying to console an anesthesiologist colleague the other day. He was infuriated by how anesthesiologists are treated in our operating rooms. He showed up for work as scheduled for a 7:00 AM start. But once he got to the OR, he was told that the surgeon had rescheduled his case for noon. Nobody bothered to notify him about the change of plans. Of course all the nurses and other OR staff except him were aware of the late start. So now here he is at 7:00 with nothing to do until 12:00. Incensed, irritated, exasperated, and pissed off doesn't even begin to describe his emotions at that moment.

Why is it that we have an MD behind our names and are supposedly an integral member of the OR team yet we are treated so indifferently? This scenario happens more often than I can count. The surgeon will change his start time or cancel a case. Then the OR manager will notify the nurse not to open a room and reassign her to a different room. Then they will tell the OR tech not to open any instruments since the case has changed. Then they may or may not get around to telling the anesthesiologist about the case switch. There have been far too many times where I've gone into my assigned room and started preparing for a case when somebody walks in and tells me, "Oh, didn't anybody tell you? The case has been cancelled." (Slow burning rage begins to rise from my gut.)

Is there anything we can do about this inconsideration towards anesthesiologists? I'd certainly like to hear if other anesthesiologists are routinely treated like an afterthought. What did my friend do that morning when he unintentionally arrived five hours early for his case? He got on the phone with the surgeon and notified him that unless the case started within one hour he was leaving and he will have no anesthesiologists available for his case. The surgeon changed his schedule and brought the patient to the OR early. Quite astonishing my colleague was able to pull that off but nevertheless mucho kudos for him. Bravo.

What It's Like To Be A White House Doctor

Have you ever fantasized about what it would be like to be the doctor to the President of the United States? All the fancy dinners, the exciting overseas trips, and having inside gossip on the president and his staff? Well, a physician who was one has written a book about her experiences. Dr. Connie Mariano, physician to Presidents Bush, Clinton, and Bush, has written an account of her years working in the White House, "The White House Doctor: My Patients Were Presidents--A Memoir."  She tells a story of exhausting work schedules, frazzled nerves, and difficult noncompliant patients (presidents and their families).

Being a White House physician is not like having a normal doctor-patient relationship. Here, the patient outranks the doctor. The president may not follow her orders if it interferes with his tight schedule. Dr. Mariano recounts how she had to threaten Pres. Clinton with Mrs. Clinton's wrath if he didn't follow her doctor's orders to slow down when he had the flu. Mrs. Clinton also wouldn't follow orders when she developed phlebitis during an election year campaign and Dr. Mariano was forced to work around the malady instead of getting Mrs. Clinton to stay at bedrest.

Besides taking care of the president and his immediate family, she and her staff are available inside the White House for anybody who has a medical emergency. During state dinners it is the medical staff, who hover around the edges of the ceremonies, who may have to give a Heimlich maneuver for a choking foreign dignitary.They don't get to drink the champagne or partake of the finger food. Bummer.

Above all, the White House medical staff learned to stay away from the "kill zone". That's the immediate area around a president where somebody is most likely to get shot, either by the enemy or accidentally by the Secret Service. As Dr. Mariano says, "You can't treat the president if you are dead." I guess there is no glamor in presidential medicine either.

Anesthesiologist Quirks

Anesthesiologists are lone wolves. Unlike surgeons who may go in and out of each other's operating rooms to chit chat or observe and assist cases, anesthesiologists pretty much work in isolation. You will rarely find an anesthesiologist walk into a colleague's room to observe their anesthesia technique. When I was in residency I had no idea how I performed relative to my peers. I may hear about some mishap during M&M Conference or rarely a word of praise from an attending but in general we kept to our own rooms and ourselves. What we did in the OR's was known only to our attendings and the staff in the room.

So I find it interesting now when nurses will come up to me and ask why one of my partners will do something they find out of the norm. Recently a nurse asked me about one of our new doctors, "Dr. Z, why is it that Dr. Pfeiffer mixes an ampule of Dilaudid into every syringe of propofol that he draws up?" My first reaction was, hmmm. The only good answer that I could give was, "That must be how he was trained. As long as the patient wakes up without complications, there's nothing wrong with that." The nurse seemed satisfied with that and it has never been brought up again.

Nurses have come up to me and commented about all kinds of conduct. For instance, why does one of our anesthesiologists refuse to let them help put the ECG leads and BP cuffs on a patient? He goes into a tirade when they help him get the patient ready for a case. I have no idea. They've mentioned that one of us likes to pull the IV pole to a height where it literally touches the ceiling of the operating room. Does that help the IV run faster? Sure, but again unusual and bemusing to the nurses. Then there is the anesthesiologist who likes to play house and dance music in the operating room. He sometimes even brings a miniature disco ball into the operating room to lighten up the atmosphere.

Again these are all reports I have received from the nurses. I of course am too focused on my own patient to notice these quirky behaviors. But as long as the patients are safe, who's to say what a "normal" anesthesiologist's practice is?

Who You Gonna Believe, Your Own Eyes Or The Government?

The talk of Los Angeles the last couple of days has been a mysterious missile launch off our coast that was captured on video by a local TV news reporter. The fiery liftoff of the missile occurred at sunset about 35 miles from land and could be seen for miles. Speculation is rampant that our own government was conducting a secret test or a foreign government was flexing its military muscle by launching a sea-based missile within stone's throw of U.S. soil.

What has our government said about this incident? According to the Federal Aviation Administration, review of their radar at the time of the event showed no unusual activity. The local military bases including Vandenberg Air Force Base and Point Mugu Naval Base deny conducting any military activities at that time.  Government officials are now saying the large contrail on the video was caused by an aircraft and appearance of a missile launch is merely an optical illusion. Uh huh. This is the same government that said after health care reform is passed we can all still keep the same health insurance that we already have. Watch the video and judge for yourself if there was a missile launch or just a plane flying off into the sunset.

Dentists and Anesthesiologists, Brothers in Arms

The New York Times recently had an article about the underserved poor in Alaska who have trouble finding dentists. They frequently go for months with excruciating tooth decay because there are not enough dentists to take care of them. In response, the state has certified fourteen dental therapists to perform procedures like extractions and dental fillings to fill in for the lack of dentists practicing in the state. Now ten other states are considering the same action. There is even a study that shows low cost dental therapists can perform safe dental care without a dentist present.

The American Dental Association is naturally up in arms over this idea. The thought that a two year training course can allow a person to perform dental procedures is anathema to dentists. The association, which fought Alaska for five years over allowing dental therapists to work, has instead advocated dental health coordinators to perform teeth cleaning and other noninvasive procedures while referring invasive procedures to licensed dentists.

Does any of this sound familiar? Lesser trained people doing your work with a "study" to support their legitimacy? If you are an anesthesiologist, you would instantly recognize the same issues are being waged in our battle with unsupervised CRNA's. As the economy continues its slow grind and more people seek medical care, it will be hard to push back against the pressure states feel to use low cost health care providers to treat everybody. I wish the ADA luck in protecting its members' scope of practice. They couldn't do worse than the ASA. 

ROAD To Riches Goes Through Anesthesiology

The recent issue of the Archives of Internal Medicine made headlines with an article about the wage disparity between medical specialties.  As expected, primary care physicians made less money than their surgical and specialty counterparts.  Internists and pediatricians were found to make about $50 per hour while medicine subspecialists made about 36 percent more money and the surgeons made about 48 percent more. The highest paid physicians were in neurosurgery, dermatology, ophthalmology, and orthopedics. They make about $50 more per hour than general surgeons who in turn make about $24 per hour more than internists.

What's shocking to me isn't the large difference in salaries between physicians, which is not a surprise. It is how little primary care doctors make. Fifty dollars an hour after four years of college, four years of medical school, and three years of residency? The internist salaries also don't take into account all the time they spend calling in pharmacy prescriptions, taking questions over the phone, arguing with insurance companies, filling out paperwork, and hundreds of other mundane but necessary tasks of being an internist. My accountant charges me more than that on an hourly basis answering my emails. And he expects to get paid too--none of this refusal to pay your copays or insurance denials to ding his income.

One interesting result of the study comes towards the end. The authors specifically excluded the salaries of radiologists and anesthesiologists because the wage disparity between primary care and specialists would have been even greater. Anesthesiologists' salaries would have skewed the results so badly that they were deliberately left out of their study! Got that? We make so much money that they can include the salaries of neurosurgeons in their study but not ours. Is it any wonder that medical students are flocking to the ROAD specialties while abandoning Internal Medicine to their selfless or masochistic classmates?

Congratulations Dr. Harris!

A shout out to Andy Harris, M.D. of Maryland. Dr. Harris has become the first anesthesiologist to serve as a member of Congress, winning in his Maryland district over his Democratic opponent 55% to 42%. He is a former President of the Maryland Society of Anesthesiologists and a current Maryland state senator. Again, mazel tov Dr. Harris! We know you will be looking out for medicine's, and our specialty's, best interests.

People's Republic of Kalifornia

The election last night swept away many Democrats from public office.  It is generally considered a bloodbath for the Democratic Party and a repudiation of President Obama's agenda. Congress returned to Republican control with a gain of sixty seats. The Senate will be welcoming six new Republicans into its chamber. Seemed like everything was going the Republicans' way last night, except for out here on the leftist coast of California. In a period where voter anger allowed a Republican to win Ted Kennedy's former senate seat in Massachusetts and New York's legislature may lose it's Democratic majority, the mood here is "more liberal politicians, please".

How liberal is the state of California? Jerry Brown, formerly Governor Moonbeam when he was first elected California's governor in 1974, has been reelected over Meg Whitman, former CEO of eBay, by 12 percentage points. While Republicans gained six seats in the Senate, California's Democratic Senator Barbara Boxer won her reelction by 10 points over Carly Fiorina.  Throughout the entire higher political state offices, Democrats prevailed. Every position from Lt. Governor to Attorney General to Insurance Commissioner were won by Democrats.

California's unemployment rate is currently 12.4% with an underemployment rate of over 20%. Yet a proposition that would have removed the state's new jobs-killing cap and trade greenhouse emissions law was defeated by 22%.  Even a dead Democrat is considered a more viable candidate than a live Republican. Democratic State Senator Jenny Oropeza, who died unexpectedly October 20th, beat out a very much alive Republican candidate John Stammreich 58% to 36%.

But what do you expect from a state where illegal immigrant students at University of California pay state resident tuition instead of out of state tuition, or deportation? Where in the worst recession since the Great Depression, Los Angeles county officials got pay raises of 45% over the last three years and over 17,000 county employees enjoy salaries of over $100,000 plus benefits and lifetime pensions that start at the age of 50? Where everybody is for solar energy until the panels obstruct the views from their back yards?

Ah, California. This is the utopia that Democrats still cling to for reassurance that the entire country has not turned on them. The whole country may be turning red on the election map, but Democrats will always have their sliver of blue oasis on the western edge of the country to call their own.

How This Anesthesiologist Lowers His Carbon Footprint

Recently an anesthesiologist at the University of California, Davis made headlines when she described how anesthesiologists can help the environment by using a lower carbon footprint inhalational agent (think sevoflurane). I'm a responsible citizen of this planet. I too would like to help the environment and decrease my carbon footprint. (Is it just me but every time I hear carbon footprint I have a mental picture of Han Solo frozen in carbonite in "The Empire Strikes Back".)

I have previously mentioned the Z-Stick. What better way to conserve energy than to spend as little of it as possible? By remaining in my chair but still able to reach all my anesthesia monitors, I can burn off fewer calories and exhale less carbon dioxide. Voila, less greenhouse gases escaping into the atmosphere to destroy mankind.

Now here is another possibility for anesthesiologists to help our progeny stay cool on this planet.  Anesthesiologists face a wall of equipment every single day.  Each one of these run on electricity and generate heat, sometimes lots of it. Some of the monitors can run quite hot to the touch. Therefore I place bags of IV fluid on top to heat them up and keep them warm. Sure there are faster and more expensive fluid warmers you can buy but they cost money and use electricity which most likely will lead to further generation of greenhouse gases. My method uses heat that is already available and wasted every day. This excess heat has to be cooled off by turning up the air conditioning in the operating room. Why not harness it for another purpose?

If you look at the picture, the control box for our monitors has heat dissipating grills on the exterior surface. I can put one or two bags on top of these extensions and they warm up the fluids quite nicely. Most of our screens now are LCD but in the past when we had CRT monitors, the top would get very warm. I could also put a few bags of fluids up there and keep them nice and toasty.

Granted this is a very slow process for warming IV fluids. A Hotline machine will get your fluids hot almost instantaneously. My method requires about one hour for a room temperature (a cold OR temperature) bag to not feel cold to the touch. It takes about another hour for the bag to actually feel warm. But you'd be amazed how even lukewarm IVF can keep the patient's body temperature from scraping 35 degrees Celsius. Plus you're recycling otherwise lost energy in the operating room. What could be greener than that?

Sunrise In L.A.

Thought I'd share with my readers this gorgeous sunrise in Los Angeles today. The picture doesn't do reality justice as my evil iPhone only has a two megapixel resolution but it is still pretty. Hope you all have a nice day and weekend. And remember what your mother always told you on Halloween; don't eat too much candy.

Fastest Way To Wake Up A Patient

One thing that anesthesiology residency doesn't teach you is how to quickly and efficiently wake up a patient from general anesthesia. Sure, we all get grilled on the SAFEST method for emergence and extubation. However, in the real world, safe emergence is a given. Therefore to a surgeon what differentiates one anesthesiologist from another is how quickly the patient is transferred to recovery after a case is over. If the patient is still asleep after the surgeon has written the postop orders and finished talking to the patient's family, then you, my friend, are a slow anesthesiologist.

I've noticed this lack of exactitude results in two different philosophies (and possibly three which I will get to later) on how best to quickly wake up a patient. When I come in to the OR in the morning, I do my anesthesia machine check and I can easily see what the anesthesiologist who last used it was thinking about how to awaken the patient.  The machine usually has the last ventilatory setting of the previous patient still in place. From this, I can deduce two methods that are generally followed by anesthesiologists at the end of a case.

One is the slow and go idea for emergence. The vent settings on the machine will show a respiratory rate of about five with tidal volumes below five hundred. I presume the anesthesiologist is attempting to revive the patient's spontaneous respiration by allowing the patient's pCO2 levels to rise quickly. Once the patient is breathing on his own then the endotracheal tube can be removed.

The other method is the fast and furious approach. The vent setting will have the respiratory rate set in the high teens with large tidal volumes. The anesthesiologist was apparently trying to wake up the patient by swiftly blowing off the inhalational agents accumulated in the blood stream and lungs.  Once the patient is conscious, then the ETT can be safely taken out.

I don't think there has been a study on which process for emergence is better. There are just too many variables and either one works satisfactorily.  During residency I had attendings who advocated one or the other technique and the patients did just fine either way. Again the goal of residency training is safety first. But now in the real job market there is no real consensus on the best and fastest plan for emergence. So some unfortunate anesthesiologists get labeled as "slow."

So finally let me tell you about one colleague's practice for achieving fast emergence. I don't advocate his methods but it sure gets the job done. During surgery he gives absolutely no narcotics. He doesn't believe in preemptive analgesia. He thinks any narcotics given during the case will slow down emergence, which is true. His patients wake up in blinding pain from surgery whereupon he gives liberal doses of pain meds. Unfortunately the narcs rarely work rapidly enough before the patient is transferred to recovery. You can imagine the anesthesiologist is not one of the recovery room nurses' favorites when they are confronted with a miserable postop patient. But he gets the room turned over quickly and is thus well liked by the surgeons. Try it if you dare.

The ASA Fiddles While Anesthesiologists Are Getting Burned

The American Society of Anesthesiologists held their annual meeting last weekend in beautiful San Diego, CA. From all reports, it was a great success. They held an opening day reception on the field at PETCO Park. There were the usual lectures on dealing with difficult airways, difficult patients, and difficult colleagues. Good times were had by all.

But while the party was happening in sunny San Diego, storm clouds are brewing over the nation's anesthesiologists.  Colorado recently became the sixteenth state to opt out of Medicare's requirement for physician supervision of CRNA's. In a public statement, the ASA, "expressed its grave disappointment with the election-year decision of Colorado Governor Bill Ritter to exempt his state from Medicare's longstanding patient safety standard providing for physician oversight of anesthesia services." The statement goes on to assail the governor as a "lame-duck" who went against the strong wishes of doctors and patients in the state.

None of this drama appeared to trouble the celebration at the annual meeting. The president of ASA, Dr. Alexander Hannenberg, gave a written interview on the accomplishments of the ASA over the past year. The Medicare opt out problem was not even mentioned. While perusing through the meeting's thick course catalog, I didn't notice a single talk about the dangers of CRNA's practicing independently of anesthesiologists. Not one breakfast meeting, panel discussion, or symposium was held on how anesthesiologists are slowly and inexorably losing their profession to nurse anesthetists.

By contrast, the nurses really have their acts together. They trumpet their self-sponsored "studies" that tout the safety of their practices that are readily picked up by the mass media. They have strong state and national organizations that are able to persuade government officials to see these issues their way over the objections of the states' doctors. The CRNA's even have meetings that teach the proper method for developing relationships with elected officials.

Where is the urgency to hold back this onslaught? While the ASA elite mingle and laugh it up, anesthesiologists are inexorably being corralled into isolated urban hospital settings. In the meantime the suburban and rural jobs, where two-thirds of surgical cases are done, are being usurped by CRNA's. The ASA calls these opt out decisions by the likes of Gov. Ritter and Gov. Schwarzenegger politically motivated. That raises the troubling question of why the ASA and physicians in general are so politically disconnected and impotent when compared to the AANA, the trial lawyers, or the government employee service unions. The ASA trumpets their accomplishment in reversing the Medicare teaching rule bias against anesthesiology residencies, but if these residents don't have anywhere to practice when they graduate, the whole battle would have been Pyrrhic indeed. We can try to convince the CMS about the unfairness of Medicare reimbursements to anesthesiologists, but at the end of the day, if we don't have jobs to go to, the viability of anesthesiologists will be in doubt.

Why Do Anesthesiologists Use Cheap Drugs?

Got another email from our hospital pharmacy. Succinylcholine is currently in critically short supply. Therefore they are going to stock only one 10 ml bottle of sux in each anesthesia cart. Any leftovers at the end of the day will be collected by pharmacy, even if there is only one ml of drug in the bottle. Sigh. This is just the latest in a series of drug shortages that has afflicted anesthesiologists.

So far this year we've faced an ongoing scarcity of propofol, especially after Teva pulled out of the market following the bone-headed $500 million jury verdict against the company in Las Vegas. We've been discouraged from using TIVA if gas will do. We are also facing a shortage of morphine. If we order morphine for our patients, the pharmacy will kindly substitute a dilaudid equivalent dose. Last year there was a deficit of protamine. They were only stocked in the vascular and heart rooms unless requested from pharmacy.

Why do these problems keep recurring in anesthesia? I suspect it is because we anesthesiologists seem determined to undermine our own self interests by using the cheapest drug available. The aforementioned drugs are all generics, costing just pennies per dose. There really is little incentive for drug companies to stay in that sort of market. As Teva demonstrated, one adverse event can devastate the cost structure of generic drugs and cause these companies to withdraw their products.

You certainly don't see other specialists racing to be the most cost efficient provider. Pharmaceutical companies spend billions every year trying to persuade internists to prescribe their latest treatments for hypertension and hyperlipidemia with great success. Orthopedic surgeons are feted by the hardware manufacturers to use their newest implants. General surgeons frequently demand to use the latest and most expensive laparoscopic equipment. They never seem to run short of those in the OR.

Newer drugs like Precedex and Lusedra are just subjects I read about in anesthesia journals. Our pharmacy refuses to stock them because of the price. We don't have patients coming into preop to demand that we give them fospropofol for their anesthesia. Anesthesiologists, in their attempts to appease the hospital administration, try to keep costs low by using generic drugs whenever possible. But this discourages drug companies from conducting research on the latest anesthetics. There aren't twenty pharmas in competition to develop an alternative to succinylcholine the way there are for the next ACE inhibitors.

So maybe we can do ourselves a favor and start administering the newest drugs on the market instead of one that have been generic for a decade or two, or four. This will show the drug companies our commitment to make sure their drug research pays off and we can finally stop having these regular drug shortages.  And maybe we'll get a few free dinners and golf games along the way.

Bizarre Piercing Ritual

At the Phuket Vegetarian Festival in Thailand, it is a custom to pierce one's face to ward off evil spirits. Now I've seen strange piercings in the U.S., but these guys really take the cake. Besides looking awfully painful, the piercings present the practical dilemma of how these people eat or drink. I hope none of them need surgery because it will be impossible to mask ventilate with the giant holes in their cheeks. Ouch

Willie Sutton Lives..At The American Board of Anesthesiology

I recently received an email from the ABA. In the letter they clarified the requirements for board recertification through their Maintenance of Certification in Anesthesiology (MOCA) program.  They included a convenient chart listing the CME hours necessary for recertification based on year of completion of residency. What struck me is that the requirements are different depending on year of graduation.

Here is the chart showing what an anesthesiologist who finished residency in 2004 has to accomplish before he can recertify. You'll have to click on the image to magnify it and make it legible.

And here is the chart for somebody who finished in 2010:

You'll notice that the total CME necessary to satisfy MOCA recertification are the same, 350 hours over a ten year period.  But for the class of 2010, ninety of those hours have to come from the American Society of Anesthesiology's ACE or SEE at-home study program at a cost of $250 per year for ASA members.  In addition, twenty hours of the required CME have to be on Patient Safety offered by the ASA for even more money.

Now I ask, why would the ABA require that anesthesiologists achieve part of their CME obligations by purchasing ASA programs? Were the CME credits from non-ASA sources not good enough to guarantee knowledgeable anesthesiologists? I think it is because they are following Willie Sutton's famous philosophy, "Go where the money is..and go there often." I suspect this is another method for the ABA and ASA to raise more funds from their captive audience.  There is no other avenue for recertifying your board certificate.  All the rules are made by them.  Therefore it is very easy for them to say, "You now need to buy 90 hours of CME from us in order for us to renew your certificate. If you don't like it, too bad."

Granted I use the ACE as my CME not just for MOCA but also for my state medical license fulfillment. It is very good for reviewing information that I haven't read since residency. However the idea that the ASA and ABA will require thousands of anesthesiologists to purchase them in order to meet a requirement that was forced on all anesthesiologists who started after the year 2000 to me smacks of unscrupulousness and greed. This policy is also a financial penalty on all recent anesthesiology graduates. Older anesthesiologists with lifetime certificates won't have to shell out thousands of dollars to fulfill MOCA obligations and recertification examinations ($1500 last year and $2000 next year). Is this fair? Are the majority of anesthesiologists, who happen to graduate in the last century, discriminating against the graduates of this century?

What would be more fair, and give credence to the idea that recertification is good for everybody, is to make all anesthesiologists recertify their board certificates. What is the ABA afraid of, that some anesthesiologists might be forced to retire because they couldn't pass their exams? Perhaps we might find out that other than pushing big syringe, little syringe, and intubate, some anesthesiologists know more about yesterday's issue of The Wall Street Journal than how desflurane works? Maybe those people shouldn't be practicing anesthesiology and possibly endangering patients' lives. If maintaining knowledge of anesthesia is good for younger anesthesiologists, shouldn't it apply to all anesthesiologists, especially older generations who probably haven't picked up a journal in 15 years? Or is this only about the money?

Want A Ride In My Suppository?

2011 Honda Fit

A homely little lozange of an automobile beloved only by the frugal and the practical.  On the other hand, my tastes run more towards:

2011 Bugatti Veyron 16.4 Super Sport

Even though it is ugly as, well, a rectal suppository, I wouldn't mind if somebody offered me a ride in this $2.4 million, 1200 horsepower insanely awesome supercar. Here's a video on how Bugatti assembles these cars/rockets-on-wheels.

You Expect Me To Examine My Patients? I'm An Anesthesiologist.

Do anesthesiologists perform physical exams? And is it necessary? These questions came up when I read a really interesting article about Dr. Abraham Verghese in The New York Times. This Indian born doctor's mission is to reintroduce the art of the physical to Stanford's medical students. In an era when no patients make it out of the emergency room without a CT scan, the idea of actually examining a patient seems quaint and antiquated.

We anesthesiologists are probably the worst physicians at doing an H+P (except maybe pathologists). In fact, I rarely see anesthesiologists with a stethoscope around their necks. The difference for anesthesiologists is that by the time the patient makes it to preop, the patient has had at least one, and frequently multiple H+P's in the chart. Besides the primary care doctor's, there's a physical by the surgeon and probably physicals by the cardiologist, nephrologist, ID, pulmonologist, etc.. What could anesthesiologists possibly add to the patient's workup that was missed by all these subspecialists' probing exams? Sure if the patient shows up orthopneic, wheezing, with an O2 sat of 91% on 6L face mask I might dust off my stethoscope and listen to the chest. But if the patient is a young healthy adult for outpatient surgery, do you expect me to do an independent H+P that will be substantially different from what's already in the chart? I'm more likely to browse through the history, glance at the labs, and wheel the patient to the OR than to slow down the turnover time by percussing the chest and palpating the belly for virtually zero gain in patient safety.

Anesthesiologists are probably one of the guiltiest physicians for demanding multiple lab tests be performed in place of the physical exam. Does it make sense to order an ECG on an otherwise healthy 56 year old even if the guidelines are anybody over 50 gets an ECG before receiving an anesthetic? Do surgeons reflexively order CBC, Chem 7, PT/PTT on young healthy patients because they fear their case will be cancelled by the anesthesiologist if everything is not in the chart? Is it logical that chest x-rays are frequently ordered and not seen by anybody just so the surgeon can tell the anesthesiologist that a CXR was completed?


Yes there is the rare occasion where I discovered a poorly controlled atrial fibrillation taching away at 135 beats per minute in preop.  But more often than not this will be found by the nurse during her preop documentation. The combination of a surgeon's history and the nurse's examinations appear to be sufficient for most anesthesiologists to proceed with a case without physically examining a patient. Sloppy? Yes. Dangerous? Probably not. However, as Dr. Verghese points out in the article, the laying of hands on the patient forms a sacred bond between physician and patient. When anesthesiologists skip this crucial step, it reinforces in the public's mind that we aren't really doctors.  Thus we are reduced to little more than stereotypes like "gasmen" or "gas passers". Or, horrors, nurse anesthetists.

Congratulations Chile!

As I am sitting here writing my blog, the Chileans have just pulled the fourth trapped miner from underground. It is an incredible demonstration of a nation's will and persistence that they are able to perform this feat. It boggles my mind that they were able to drill a rescue tunnel seemingly blindly on the surface and somehow reach the miners' survival shaft thousands of feet below ground a couple of weeks later. How could the miners down there even have the will to survive that long when there seemed to be no hope of escape for them at the time? And then having to wait for two whole months before this rescue could begin. Simply incredible.

This mining accident in Chile also sadly reminds me of how antagonistic life and government has become in our own country. The era of pulling together for the common good seems to be as passe as doctors making house calls. Every facet of life in the United States now involves conflict and accusations. From the Gulf oil spill to repairing the economy to health care reform, every issue in this country seems mired in finger pointing and mudslinging. Americans are defined by hostile factionalism: Republicans vs. Democrats, men vs. women, gay vs straight, anesthesiologists vs. CRNA. There seems to be nothing that can ever bring the citizens of this country together anymore. Presidents are just another figurehead waiting for us to tear down. Captains of industry are vilified for their greed. Physicians are rich, money grubbing, drug pushing whiners who only care about their Medicare reimbursements. Even when our nation was attacked by terrorists on 9/11, the sense of unity lasted only a few precious months. This harmonious period only appeared to temporarily suppress the desire for us to rend each other apart, which quickly reappeared and became the political theme for this decade.

Perhaps the Chileans will also display the same level of antagonism against their government and industries after all the miners are rescued. I hope not. I hope they relish their proud achievement in the face of impossible odds. Their national unity is a pleasure to behold and something we can learn from here in the Disunited States of America.

Dirtiest Joke I've Heard In The Operating Room

This is one of the dirtiest jokes I've ever heard in the OR. Tell it in mixed company only if you all are good friends. Otherwise risk being accused of sexual harassment.

What bird represents Thanksgiving?    Turkey
What bird represents wisdom?      Owl
What bird represents peace?      Dove
What bird represents birth control?

Swallow

Peter Orszag, You Ignorant Slut

Peter Orszag's editorial in The New York Times today perfectly illustrates the ignorance of the government when it comes to America's health care industry and how dangerous it is these people are deciding how, when, and to what capacity we doctors are to treat our patients. Mr. Orszag's self incrimination of his inexperience with how medicine operates in this country starts in the very first paragraph.  He likens doctors not wanting to work weekends with drug stores that are open only five days a week. He goes on to say,

And then there are the economics of a $750 billion-a-year industry letting its capacity sit idle a quarter or more of the time. If hospitals were in constant use, costs would fall as expensive assets like operating rooms and imaging equipment were used more fully.

So the director of the White House OMB thinks hospitals are essentially closed for the entire weekend, with no work getting done. He obviously has never stepped foot into a hospital, and particularly the emergency room or the ICU on a weekend.  If he did he would know what a fallacious lie that is. Hospitals are fully staffed on weekends to handle patient care. Just because there are fewer people physically in the building doesn't mean staff is not available. That's why people take call. 

Anybody who has worked with or been married to doctors know how hard they work, to the point of self exhaustion and personal detriment. I would compare the hours worked by doctors to your average government employee, who shut down their work stations promptly at 4:58 PM.  And don't forget all the time Congress and the POTUS take off for their multiple vacations each year. So Mr. Orszag, before you spout off on how much more efficient healthcare can be if we all just work seven days a week, why not improve the efficiency of your own employees and have them work 24/7? Wouldn't it be so convenient for us taxpayers if we can make it to the DMV or other government offices on weekends rather having them sit dark and empty for at least quarter or more of the time?

Seeking Personal Redemption And A Good Night's Sleep

If you're going through hell
Keep on moving, face that fire
Walk right through it.
You might get out
Before the devil even knows you're there.
Rodney Atkins, "If You're Going Through Hell"

Now I conclude my series on why I chose anesthesiology as a career.  It took years of self immolation to wake me up to the fact that I hated the surgical lifestyle. But if not surgery, what else should I do? I knew that I still didn't want to treat chronic diseases. That eliminated Medicine and other primary care fields as my next career move.  I also knew I wanted to stay in the OR. But what kind of doctor works in the operating room but is not a surgeon?  There really is only one answer--anesthesiologists.

Luckily for me during the late 90's it was relatively easy to find an open position in an anesthesiology residency. It was not the highly competitive field it is today. I was afraid I would have to hang out for a year to wait for a spot in a training program. But I was able to locate an anesthesiology residency nearby that had vacancies to fill and I could start immediately.

Anesthesiology was everything I expected residency to be and everything my old surgery program was not. The work was intellectually stimulating. The attendings actually seemed to care about the well being of the residents.  The idea of getting breakfast and lunch breaks was a revelation. The other residents felt more like my kindred spirits, not competition ready to pounce at the slightest stumble.  And of course anesthesiology residency allowed a much saner lifestyle. While the other anesthesia residents complained about taking five calls a month, I reveled in the luxury of having three of every four weekends off.  Slowly I regained the self confidence I had lost after years of humiliation and abuse. I could see that I was not a worthless piece of human excrement. Nobody is perfect and anesthesia attendings didn't make me feel like s*** if I had a difficult day. I was finally able to enjoy living in Southern California, something I didn't have a chance to do in the years holed up in the hospital before. I went to the beach without concerns about how my patients were doing in the ICU or dreading another call the next day. I lost 30 pounds by the time I finished anesthesiology training. Life was good at last.

All those years of surgical training were not in vain. I had already placed hundreds of central lines and arterial lines as a surgeon so those presented no problems for me at all in anesthesia. I once impressed an attending when I was able to use a long alyce clamp to retrieve a broken tooth during an intubation (not my intubation). The one procedure I needed the most practice on was starting an IV. Never had to start one in surgery; either the nurse did it or we put in a central line.

I found that about 70% of my experiences in surgery were applicable to anesthesiology. The main things I had to brush up on ironically were all the different chronic disease processes an anesthesiologist is likely to encounter in preop. But that's okay because we only need to take care of these maladies for the duration of the case.  Anesthesiologists don't have to follow the course of the illness for the patient's entire life, or even the duration of the hospital stay. Once the patient makes it safely out of the PACU the problems were no longer mine to deal with.

This is of course the main attraction of anesthesiology. At the end of the day, when the patients are safely out of surgery, I can turn off my pager and go home to enjoy time with my family. There is no need to worry about how my fifteen patients are doing in the hospital. I don't get awakened at 3:00 AM because somebody on the floor needs a sleeping pill, or my patient in the ICU is suddenly desaturating. I am not tethered to the hospital or the answering service. I can enjoy life without fear of getting called back to the hospital for an emergency. Freedom of mind far exceeds the so called prestige of being a surgeon.

So that is my story of why I chose anesthesiology as a career.  I entered a dark tunnel in search of surgical glory and emerged into the light as an anesthesiology professional.  Yes surgery was fun, but there is more to life than the hospital. I give kudos to doctors who can tolerate such a work environment but I belatedly realized that was not for me. I have now been in practice for nearly a decade and love my job more than ever. I make a decent salary and have a devoted family I can go home to every night.  Hopefully the medical career you choose will be more straightforward than my circuitous path but ultimately you have to be satisfied both professionally and personally with your choice. It's alright to start over if you decide you went down the wrong road; there is no shame in realizing you made the wrong career decision. In the end it doesn't matter if you trained at a "prestigious" training program or authored fifty papers or make half a million dollars a year. If you can find job satisfaction, that is all that matters.

Surgery, A Siren That Will Break Your Heart And Crush Your Soul

Continuing my autobiography of why I became an anesthesiologist, I will now recount My Lost Years as a surgery resident. This is a long sad story of lost opportunity and spirit crushing rejection. So let's get started, shall we?

Let me just say right off the bat that surgery residency was probably the hardest thing I have ever experienced. Internship is just a blur of calls, rounds, scutwork, more rounds, more scutwork, and getting pimped and yelled at a lot.  Few things in life compare to the dejection of getting up at 5:00 AM to pre-round on your 10-20 patients then round on them again with the team in time for the senior residents to make it to the OR. After rounds, I was usually left with about 50-75 items I needed to get done on my scut list before afternoon rounds around 5:00.  After that there was usually another list of things that had to get finished before going home. If something didn't get done, the usual question was "Why not?", not "How can we help you?" It was not excusable to say the Radiology File Room couldn't find that one CT scan that was vitally crucial for this patient's surgery the next day. Or why the lab results haven't come back. Or why lines haven't yet been put into a patient, despite the fact that I've been running around like a rabied dog trying to get as much of the scut completed before tackling a time consuming line placement.

This certainly wasn't as much fun as I remembered as a student. Of course as a student I was shielded from all this tediousness. We got to go to the OR after rounds to watch the cases. When we were done in the afternoon all the work had been magically completed by the interns. I never paid enough attention to the dark side of surgery training. The few times I actually got to do cases were not that much fun either. Every surgery intern remembers their first case. Mine was a butt pus. I remember being on call and getting summoned to the OR at 2:00 AM to perform an I+D of a perianal abscess. The case took all of five minutes, but the stench will last me a lifetime. When the senior resident asked how I liked my first surgery, I had to force an eager smile and enthusiastically announce, "Great case!" then trudge back to the call room to try and get a few more minutes of sleep before getting up again to preround on my patients. Not a great start.

Okay, so internship isn't the surgical career I had envisioned. If I make it through internship, things will get better, right? I'll go to the OR and actually perform real surgeries my second year, correct? While I did start doing lots of cases the next year, sadly the overall residency experience was not an improvement. This was in the days before all the rules against residency abuse. There were rotations where I was on call every other day for months at a time. And it wasn't just 24 hours on/24 hours off. No, this was more like 36 on/12 off. You see, I couldn't just leave the hospital at 7:00 AM post call. I still had to round to explain to the team what happened overnight, which took hours. Then there was usually an emergency that required I stick around to help out before I could leave. I recall one time I didn't get home until 2:00 PM. I just collapsed into bed after an all night session of traumas and other emergency cases. I suddenly woke up and looked at my clock, which read 7:00. I panicked and jumped out of bed, ready to throw my scrubs on and try to explain to the team why I was late for morning rounds. It was not until I was halfway out the door that I realized it was 7:00 PM. Then I crawled back to bed and slept until the following morning.

All this stress took a physical toll on my body. I gained about 20 pounds. You would think so much running around will cause one to lose weight. But just the opposite happened. I didn't get any proper exercise. Every chance to eat was quickly wolfed down in about five minutes.  I developed anal fissures because I was so uptight all the time. I had a bad case of irritable bowel syndrome, particularly right before M+M Conference. That's where residents were publicly grilled and humiliated in front of the whole surgery department, particularly if you weren't a Chosen Resident, someone who could perforate the left ventricle while putting in a chest tube and still not get shredded by the faculty wolf pack. One time I was so exhausted post call that while riding in an elevator my pager went off. In my sleep deprived haze I looked around asking people "Do you hear that noise? Where is that coming from?" They looked at me like I was an escapee from the Psych ward.

Okay, so surgery residency was exactly what everybody warned me about. Well, it will be better once I'm an attending, right? While several of my fellow surgical residents bailed out into anesthesiology, plastic surgery, and medicine, I was going to tough this out. I've never quit anything I started in my life and it was not going to happen now. But the higher I got through residency, the more I could see what a horrible lifestyle surgeons suffer. Sure it was still fun to do cases in the OR; by then I'd done hundreds of lap choles, appendectomies, and assisted multiple CABG's, Whipples, and AAA's. But as I moved away from the scut, I could see how the attendings lives were miserable. Being in the OR only constituted about 30% of their time. The rest of the time they were in their offices seeing patients, or doing consults for clueless internists, or being called to the ER. I saw how irritated and tired they were when they were operating all day and being paged constantly by their office, a floor nurse, or the ER. There is nothing more miserable than finishing a long line up of cases at 8:00 PM then having to go see three consults in the ER and the ICU. Do I want to have that kind of lifestyle for the rest of my medical career?

Plus surgery isn't all just acute disease either. Sure it's exciting to rush a patient to the OR to fix an acute abdomen. But there is a lot of chronic diseases that are overseen by surgeons, which was why I didn't want to go into Medicine to begin with. We had the Diabetic Foot Clinic. You've never seen so many black toes or nonhealing foot ulcers in your life. Then there was the Breast Clinic. For hours we were palpating large sweaty stinky breasts to find breast cancers. Sometimes they came in with advanced Stage IV massive breast masses that were oozing pus and blood because the patient neglected this thing for the last nine months. Then who could forget Colorectal Clinic, otherwise known as Butt Clinic. If I never had to do another anoscopy and hemorrhoid banding in my life it would be too soon.

I think the final realization came when I started looking longingly at the happiness of the anesthesiology residents. I remember an incident where my patient coded in the ICU. The anesthesiology team came down and intubated the patient. Then they were off on their merry way while I had to stay up the rest of the night to stabilize the patient and explain to the team why he went into arrest. "I wish I could just walk away like that," I thought.

Finally I was at a crossroad. With constant delusion and denial I had completed FOUR years of clinical residency. But now I wasn't sure I wanted to be a surgeon. Just stick with it, I was told. I only had one more year to go then I can get boarded in Surgery. But what's the point of going through one more year of surgery residency then studying like a madman to pass the surgery boards when I didn't want to be a surgeon anymore? The surgeries were still fun. However the constant paging by the office and hospital, the long unpredictable hours, and the chronic anxiety made surgery much less glamorous than I had envisioned. Do I still want to live like this when I am fifty? That's when I made the hardest decision in my whole life. I told my chairman I wanted to quit. He asked me what I wanted to do. Urology? Plastics? "No," I said. "I want to go into Anesthesiology."

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The Seduction Of An Impressionable Med Student

In a previous article I wrote down the spiel I usually give to medical students when they ask why I went into anesthesiology.  I listed all the medical fields I considered and rejected. Now I will discuss the profession I did match into after med school.  That would be General Surgery.

Imagine me, an introverted, bookish nerd wanting to enter the exalted world of surgery.  On Match Day when our results were revealed, there was an audible gasp in the auditorium when classmates found out I had matched into surgery. It wasn't just any surgery residency either--it was a highly coveted categorical program, which meant that I had a clear path through the entirety of residency.  I wouldn't have to compete for an open position each year like the transitional residents stuck in the pyramidal side.

Why did I choose surgery? Let me count the ways. Surgery was the complete antithesis of everything I disliked about Internal Medicine. The consequence of treating a patient was immediate and understood. It's a great feeling knowing that you are taking a sick patient into the OR to make them better. No more waiting for the patients' symptoms to improve by mere watching and waiting. When in doubt cut it out. I loved that philosophy.

There's also a certain hero complex involved when entering the surgical realm. It seemed you got a certain level of respect when people knew you were a surgeon. Surgeons are frequently the physicians of last resort when a patient is on a downward spiral. When the Medicine docs can't understand why a patient's septic and all the labs and scans come up equivocal, the surgeon is the one who gets paged. After days of watching an ICU patient slowly deteriorate, the surgeon swoops in, rushes the patient to the OR, and makes everything better. "Those dumb ass internists. What the f*** were they thinking watching a patient for a week when it was so obvious what the problem was. If they had waited one more day, the guy would be dead." Mockery of other specialties was a frequent and bonding experience with surgeons. Fun times.

Finally I had several groups of great guys as mentors while doing my surgery rotations. Med students gravitate to fields where they are led by talented attendings and residents.  Who wouldn't want to grow up and be just like them? The surgeons I rotated with made their work seem so much fun and important. Their intellect and confidence was everything I wanted to be as a doctor. I was hooked.

So why am I an anesthesiologist now? That will require a long answer best reserved for the next article in this series.  It is not for nothing that I call my surgical career My Lost Years. Stay tuned.

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Doctors May Whine But Nobody's Listening

Physicians are up in arms over the advent of ObamaCare and the imminent increase in taxes for people making over $250,000 per year (the rich).  We complain about the tightening of reimbursements from the government and insurance companies.  We decry the escalating costs of running a business.  We bemoan the unfairness of rich Wall Street bankers being bailed out by the government to the tune of billions of dollars for pretty much destroying the world economy and wrecking everybody's retirement savings while we can expect a $500 billion cut in Medicare reimbursements.  You know what, nobody cares.

The Happy Hospitalist recounts an enlightening exchange at a restaurant with an acquaintance.  When asked how they were doing, the friends were surprised that Happy and his wife were not driving a Lamborghini.  Why would he be driving a Lamborghini?  Because he is a doctor, and aren't all doctors rich and self important and drive expensive and exotic cars like a Lamborghini?  Try explaining the trials and tribulations of being a physician and nobody will believe you.  Happy did, and I'm sure it fell on deaf ears.

Todd Henderson, a University of Chicago law professor, recently blogged about how President Obama's planned tax increases on the wealthy (income greater than $250,000/yr) is going to severely affect his family's lifestyle.  He and his wife, a pediatric oncologist, claim to make just over the arbitrary definition of rich.  With both of their student loans totally over $250,000, taxes, childcare, private education for their children, and various domestic help, they claim to save only a few hundred dollars a month.  This blog was ridiculed by hundreds of readers for its self-pitying tone and unrealistic expectations.  You're not going to get any sympathies for having to cut back on professional lawn care services.

According to the U.S. Census, the median household income in 2008 was $52,029.  I bet greater than 90% of physicians make more than $100,000 a year.  When doctors grouse about the enormous debt burdens they carry or how they are operating at a loss from pitiful Medicare payments, most people don't believe it.  They still think we all drive around in expensive imported sports cars, and judging by the profusion of BMW's, Lexuses, and Mercedes in doctors' parking lots, who could blame them?  When families of four have to survive on $40,000 a year, this moaning by "the rich" doctors just sounds petty. 

Does that mean we just roll over and accept whatever punishment is meted out to us?  No. We can work within the system by contributing to various medical PACS and medical societies.  We can write letters to our congressmen and attempt to influence legislation that will benefit physician interests.  Physicians can contribute to candidates who expresses sympathy in helping our causes.  But for God's sake, stop fussing publicly about how we can't live on a six figure salary.  Nobody is listening.

Why I Chose Anesthesiology

Fall is the traditional time of year when medical students finally decide on which residency they want to apply for.  It is not an easy decision.  You are racked with anxiety and uncertainty. "What if I go into this field and realize I made a mistake?  Will I be miserable for the rest of my life?" I field many questions from students about why I went into anesthesiology.  Like everybody else, it was not a clear cut choice for me.

I actually thought I wanted to be an anesthesiologist when I started medical school.  But once you're in school, you are dazzled and distracted by all the different specialties students rotate through. What made it even harder was that my medical school didn't even offer a rotation in anesthesiology, not even as part of the surgery rotation.  So anesthesiology quickly dropped out of consideration, more out of default than anything else.  As I explain to med students, anesthesiology is not a field that is easy to love.  There is no glamor in this field.  There are no TV shows or movies about the bold, courageous, caring, handsome, intelligent anesthesiologists.  Instead we are only mentioned when something goes wrong, like a patient having surgical recall or the anesthesiologist who is caught behind the drapes shooting up and passing out. I think the easiest way to understand why I chose anesthesiology is to first explain why I didn't go into other medical specialties. Then I will discuss all the positive aspects of this terrific and maligned field and why it is the perfect medical practice for me.

Internal Medicine. Are you kidding me?  Couldn't stand the constant rounds every morning during med school.  The endless mental masturbation on the eighteenth differential diagnosis of hemoptysis and fever just bored me out of my mind.  What's worse, once you're in private practice, you are perceived as a mental midget by the subspecialists, someone who couldn't cut it in a subspecialty field.  You are left with the hypertensive, diabetic, COPD, poorly compliant patients that nobody else wants to handle.  Definitely out.

Pediatrics. Love the kids. Hate the parents. (Same reason I don't like to do pediatric anesthesia.)

OB/GYN. There really was nothing I liked about this field.  All the different STD's I saw every day in clinic made me want to scrub my eyeballs and nostrils raw after work.  The birthing process may be a miracle, but it can be really disgusting when feces and urine start flying out with every contraction.  Plus this is becoming a female physician only field.  Sorry guys, you may have a thriving practice now but you are a dying breed.  Most women prefer to have other women examine them and deliver their babies.

Emergency Medicine.  Loved this rotation as a student.  I think most med students get a tremendous thrill in the ER.  You are finally doing fun things like suturing up lacerations or diagnosing and treating acute MI's and DKA's. It was a blast. Unfortunately I didn't have it until April of my senior year, much too late to change residencies. In retrospect, I'm glad I didn't do ER.  I'm not the kind of person who likes to juggle fifteen patients at a time while dealing with the latest trauma that rolls through the door.  This pace leads to pretty fast burnout.  Want proof? You rarely see old ER docs.  I have no idea what happens to them when they turn fifty.

Family Practice. Our school had a huge emphasis on turning out FP physicians.  We had several required rotations in this field.  To me it felt just like Internal Medicine but with added Pediatrics and OB/GYN, which made it a triple negative in my book.

Medical subspecialties. The three years of Internal Medicine pretty much knocked these out of consideration.

ROAD (Radiology, Ophthalmology, Anesthesiology, Dermatology). Radiology was one field I hoped I would love.  Instead I was extremely restless sitting in a dark room every day looking at the same films from the same ICU patients; one day the only change maybe a new line was placed, or the patient was intubated overnight and then extubated a few days later.  That was one rotation I dreaded going to every morning. Ophthalmology, too competitive and really gave me no intellectual stimulation.  Seriously they have a sub subspecialty in vitreous humor? Dermatology was again too competitive.  Why is this field in such high demand?  Are there that many slacker med students who only want 9-5 jobs looking at eczema and prescribing topical steroids?

Pathology.  Didn't like looking into a microscope all day evaluating purple and blue spots.  Hated cadavers.  Cant. Get. That. Smell. Out. Of. My. Hair. Yuck.

Psychiatry.  I actually loved this field.  I had a terrific attending during this month.  He made psychiatry seem so much fun.  You can definitely have great stories to blog about if you are a psychiatrist.  I seriously considered Psych until I realized there was very little we could actually do for these patients.  Seemed like we would try to treat a patient with a drug. If that didn't work we'd try another drug. If that didnt' work, we'd try another one... They all seemed to cover up the symptoms without ever really curing them.  This was a couple of decades ago.  Hopefully newer treatments have been developed since then to improve these patients' lives. This is a field that still makes me think, "What if?"

This is running pretty long.  My feelings about blogs is that they shouldn't take more than two minutes to read so I'll continue this topic in another installment later.  I'll talk about which residency I did match into after graduation from med school, and it wasn't anesthesiology, GASP!

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