Thursday, July 29, 2010

How To Choose A Medical Career

Do you have the personality to become an anesthesiologist?  Or are you better suited as pediatrician?  Follow this flow chart to see if you are making, or have made, the right choice.

What A Great Idea

Researchers in Australia have developed a head up display for anesthesiologists to watch a patient's vital signs.  The display is linked to the regular patient monitors. A simulated picture of the anesthesiologist's view is shown above. This idea is a long time coming.  As any anesthesiologist can tell you, there are many times when it is critical to watch a patient's vitals signs but can't. 

The most obvious example is induction and intubation of a patient, particularly a difficult airway.  I can't tell you how many times during a difficult intubation that the only way to monitor the patient is by listening to the tone and the rate of the pulse ox while I concentrate on trying to secure the airway.  The only way to know if the patient is desaturating is when the tone gets down to the baritone level, or the nurse yells "Sat is 75%!". Another example is starting a pediatric IV in the OR.  After the child has been masked down, the anesthesiologist has to concentrate on starting a tiny IV, again compromising the ability to watch the patient's vitals.  A HUD would easily alleviate that issue.  Hopefully in the near future this technology will be another tool in our arsenal for ensuring patient safety.

How Much Do Anesthesiologists Make?

Here is the latest report from the U.S. Department of Labor's Bureau of Labor Statistics.  The numbers come from May 2009, the last reporting period available.  According to the BLS there were 37,450 anesthesiologists employed in the U.S. as of May 2009.  Their mean hourly wage was $101.80.  Their mean annual wage was $211,750.  Anesthesiologists who are in group practice made the most, with a mean annual salary of $221,010.  Academic anesthesiologists made the least money with a salary of $139,490.

The top five states that paid the most money were Washington, Oregon, New Jersey, New Hampshire, and Missouri.  The top five states that are the most crowded with anesthesiologists are Hawaii, Kentucky, Tennessee, Delaware, and Arizona.

You can also create a custom chart on the BLS website.  For instance, you can compare the salaries of California, New York, and Texas anesthesiologists.  Interestingly all three states employ similar numbers of anesthesiologists: 3450, 3220, 3620, respectively.  The mean annual salaries of all three states are likewise similar: $219,000; $220,000; $196,000, respectively.  However the bottom tenth percentile wage earners are significantly different.  The lowest tenth percentile of CA anesthesiologists made $50.53 per hour.  The lowest NY anesthesiologists made only $29.26 per hour.  Then comes poor Texas.  Their lowest rung anesthesiologists made $12.88.  Seriously?  An anesthesiologist that makes only $12/hr?  The mean annual salaries of the three states' anesthesiologists also show a similar discrepancy.  The bottom tenth percentile salaries of the three states are $105,090; $60,850; and $26,790, respectively.  Again, really Texas?  I can't imagine an anesthesiologist that makes poverty level wages.  But then again they may be a leading indicator of where medicine  and doctors' salaries are headed in this country.

Wednesday, July 28, 2010

When 500 Pounds Is Not Enough

We are constantly upgrading our numerous operating room tables.  They wear out quickly after years of nearly 24/7 abuse.  The old tables were rated for safe use up to about 500 pounds, depending on the model.  Check out the specifications from one of our new tables.  1100 POUNDS!  Imagine operating on a patient who weighs half a ton.  Picture intubating and anesthetizing a patient who weighs as much as a full grown horse.  The horror.

Our hospital has to be prepared for whatever comes through the door.  If a morbidly obese trauma patient is rushed into the ER, our facilities have to be capable of delivering the same quality of care as a normal weight person.  If the hottest bariatric surgeon in town wants to bring his enormous (pun intended) case load to the hospital we must be prepared to facilitate his laparascopic gastric bypasses and other weight reduction surgeries.  Therefore that means we have to supersize our equipment, everything from operating room tables, to transportation gurneys, to ICU beds, and CT's and MRI's.  The costs are exorbitant when purchasing the equipment.  Naturally all these expenses are then passed along to the insurance companies and patients.  Besides their numerous comorbidities, these are some of the tremendous costs of the obesity epidemic in America.

Would You Eat Cake Off A Naked Man?

I would say that this cake plate is certainly, uh, provocative.  This plate comes from a line of European china called Anatomica.  It certainly has an appropriate title.  Perhaps you can use these plates at your next anatomy themed party.  Imagine the possibilities...  You might even give your guests some hard earned anatomy lessons that you spent months agonizing over in medical school.  Won't they be impressed with your knowledge and acumen?  Though at 48 euros each I wouldn't let the party get too wild.

Monday, July 26, 2010

Bad Ass Anesthesiologist

Check out Anesthesioboist's blog.  She is totally Bad Ass. We need more people like her in our profession.

Patients That Make Me Go Hmmm

To paraphrase a famous movie quote, "Preop is like a box of chocolates.  You never know what you're going to get." While I try to read the histories of my patients on the next day's operating schedule the night before, sometimes that is not possible, especially the outpatient or add on cases.  Frequently the outpatients don't have their histories dictated in the hospital computer system but instead are brought in by the surgeons from their private office files. Or the surgeon's history only discusses the surgical symptoms, not the other 20 positive review of system pathologies I'm more interested in. Thus it can be dismaying when confronted with an "interesting" patient ten minutes before the case is supposed to start.

For instance, we receive many patients for outpatient EGD's.  On the schedule it just says "EGD" and I'm thinking, "Great a quick 5-10 minute procedure"  But then I see the patient in preop holding.  She is 450 pounds and stands 5' 2".  She is here for an EGD as part of her preop evaluation for her gastric bypass surgery in the future.  "Hmmm," I ponder. "Should I intubate her for a five minute procedure like the textbooks and the ABA would advocate or risk apnea and aspiration by giving a MAC anesthetic?" Weighty question indeed.

Then there are the patients who are allergic to literally everything.  Their list of allergies runs two pages in single space type.  You know it gets ridiculous when they list Benadryl, atropine, epinephrine, all tapes, and half of California's agricultural industries as allergies.  One patient said she was allergic to morphine, fentanyl, dilaudid, and demerol, practically my entire arsenal of post operative analgesics.  "Hmmm," I'm contemplating. "This is going to be fun when she gets to recovery after her surgery. I hope there is some analgesic property in the L.A. smog we're breathing today."

Then there are the patients who are exactly the opposite.  They are taking every narcotic known to man for chronic pain.  Frequently these are the patients scheduled for major back surgery. The spine surgeon has assured them that their back pain will disappear after he does his miracle work.  I'm standing there looking at the patient who is already in tears because she missed her pain medications 30 minutes ago and I think, "Hmm.  She is on Dilaudid 24 mg every 4 hours and has fentanyl patches covering half her body.  This before a single millimeter of skin has been cut. I better punt this to one of our Pain guys. This is why they get paid the big bucks."

Variety may be the spice of life, but in anesthesia all I want is a simple, predictable, stodgy Hershey's chocolate bar.

Sunday, July 25, 2010

Obama Hates Doctors, and Medicare Patients Too

As if we need more evidence that President Obama and Congress despise doctors and the current medical care system in America.  The July issue of Anesthesiology News (subscriber log in may be required) reveals that one of the provisions of ObamaCare states that physician owned hospitals are forbidden from expanding their facilities after March 23, 2010 (yes it is a retroactive law).  No new physician owned hospitals are allowed to be built after the end of the year.  And doctors have to tell patients their financial interests in the hospital or face a fine of $1 million. Because of these new restrictive rules, 39 new hospitals that were on the drawing books have been cancelled.  Another 45 hospitals that are now under construction are not expected to pass certification with Medicare before December 31, 2010 leaving their owners and investors in a quandary.

Is there any more confirmation of antiphysician bias needed than this new law?  What other industry in America is forbidden from expanding its perfectly legal and legitimate business?  The restrictions on boutique hospitals are almost as onerous as those aimed at the cigarette industry.  Isn't it ironic the government would lump doctors into the same class of people as tobacco companies?  Never mind that thousands of jobs have been lost because of the scuttled construction projects.  No hospitals also mean thousands of nursing jobs, back office staff, janitorial services, IT services, and other positions that makes up a modern American hospital have disappeared.  There doesn't seem to be any rational reason for strangling physician owned hospitals. 

Some people say these small hospitals (in general they are all miniscule compared to the behemoths of the university and nonprofit hospitals) siphon away the best paying patients from the tertiary care facilities that have to treat the poor and indigent.  But in my view this is what's called capitalism.  I know capitalism is anathema to this socialist administration but competition will only make the big hospitals more responsive to their patients' needs. 

Is there a way around these restrictive new rules?  Yes there is and it involves denying health care choices to Medicare patients.  Forest Park Medical Center in Dallas was undergoing a $104 million construction project to expand its current 24 inpatient beds by 60 inpatient beds, adding 12 ICU beds and 14 operating rooms.  They are not scheduled to finish until August 2011.  Since it will be illegal under ObamaCare to open the new facility after December 31, the doctors at Forest Park have decided that they are going to stop accepting all Medicare and Medicaid patients, thus exempting themselves from the new law.  The biggest losers are the Medicare and Medicaid patients.  They have just been denied the choice of being seen in a state of the art medical facility by some of the most successful doctors in the Dallas area.  Instead they will have to seek their health care in the older more crowded hospitals that are deemed worthy of government approval.  The big hospitals also just got a giant influx of poorly reimbursed patients onto their daily census, thus weakening their ability to modernize their facilities and compete effectively against boutique hospitals.  Isn't it funny how capricious health care laws written by lawyers have unintentional consequences?

President Obama, we already knew you hated doctors and the medical system with your discriminatory taxes on "the rich" but you just raised a big giant middle finger at the poor and Medicare patients in this country too.

Friday, July 23, 2010


And the cases are lengthy.
The residents are jumpy
And the anxiety is high.

The clock keeps on ticking
And the hours are dragging.
So hush you yapping surgeons
Let's finish by five.

(With all due apologies to George Gershwin)

Summertime, and especially July, can be a very trying and mind numbing time in the operating room.  The former surgery interns are now surgery residents. Now they can spend time in the OR actually being surgeons instead of scut monkeys.  While it's nice to see these future captains of the ship SLOWLY being molded into shape, their inexperience can be a challenge for everybody else.  A thirty minute laparoscopic appendectomy can take an hour.  A one hour lap chole becomes a four hour educational ordeal. 

I think somebody invented wifi especially for anesthesiologists to use in times like these.  While I am ever vigilant in monitoring my patients, sometimes you just don't need to stare unblinkingly at the screen every single second.  The patient is stable enough that I can set the blood pressure cuff to inflate every five minutes and not worry about sudden hemodynamic instability while the surgical resident is being taught by the attending on the proper way to hold a needle driver.  I used to walk into operating rooms where a case had just finished and find piles of used newspapers lying around the anesthesiologist's chair.  Now people use their laptops or iphone/ipad to maintain knowledge of current events.

In the last few weeks, I've personally enriched my knowledge on the lives and motivations of squirrels.  I've read with lust and longing a test drive of my dream car.  I was fascinated by the work of some of the smartest people in America (how in the world do you turn a 32 digit code into a complicated lengthy paragraph?  Even when I read an explanation I couldn't understand it.)  I read as a less than impartial viewer the lack of progress in ending the worst oil spill in America.  I followed the circus that is LeBron James.  And many other tidbits of information.

Don't worry.  During this time all my patients did fine.  By the way, for you anesthesiology residents, you don't get the same courtesy of time-consuming clinical training as the surgery residents.  You still have to learn to intubate a patient or perform a regional anesthetic as if you've been doing the work for years.  Otherwise the surgeons start complaining and the attending will take over for you.  Sorry.  Just reality.

When Doctors Become Employees

I saw this chart posted in the nurses' break room.  Apparently some people needed a little help determining when to go back to work from their allotted 45 minutes lunch break.  For every minute around the clock the chronologically challenged are told when they have to report back to work.  As an employee there is little incentive to return to work as soon as possible for patient care.  This chart was necessary as people were taking far longer breaks than they were allowed.

Is this where physician autonomy is headed?  There has been lots of talk about doctors becoming employees of large health care corporations as a cost cutting maneuver.  Supposedly as employees there is less incentive to order expensive tests and procedures that could line their or their colleagues' pockets.  The Cleveland Clinic has frequently been held up as an example of lowering the cost of health care by hiring physicians as shift employees. 

All the complicated new regulations and reimbursement cuts have also been driving doctors to sell their practices to hospitals and become employees.  As employees they won't have to pay for all the back office work like chart keeping, billing, and liability insurance.  The employee physician won't have to invest in an expensive electronic medical record system that is duplicated by the doctor in the next door office.  They can all use one EMR paid for by the hospital and maintained by a dedicated IT staff.

What is lost is the incentive to work above and beyond the call of duty.  Sure people say doctors should be saints and not even concern themselves with working for nothing.  But doctors are people too.  We have families we want to support with a decent income and spend time with.  As an employee why should I stay until 7:00 PM when my paid shift ends at 5:00?  As an employee I would want to have the same morning breaks and lunch breaks as other employees.  You want me to work weekends and holidays?  I better get time and a half for that.  If I have my own practice, I will work without a lunch break if that is what it takes to see all the patients waiting out in the waiting room.  I will work late if that is what it takes to finish all the paperwork at the end of the day and take care of my inpatients in the hospital.  But if I'm just an employee the shift mentality will inevitable sink in.  That is not cynicism.  That's just a fact of life.  And I'm afraid that's where medicine is headed in the very near future.

Monday, July 19, 2010

Kinky Sex In L.A. Hospital Operating Room

Made you look, didn't I?  Today's New York Times talks about how journalism and its business profitability are increasingly defined by the internet and its voracious appetite for page views.  Journalists used to be caricatured as boozy, tobacco stained, unshaven men working the trenches to expose nefarious activities of human society.  They're up all night chasing down their sources in dark alleyways while attempting to beat the deadline before the paper goes to the presses.  Edward R. Murrow comes to mind.  But now a journalist's day starts before the break of dawn.  Every minute is a potential deadline.  The time for investigation and reflection is nonexistent.  Errors are made in reporting that is corrected in an "update" about twenty minutes later, after the original article has already captured its requisite eyeballs.

The NYT interviewed the editors of Politico, the Washington gossip website, on the frenetic pace of modern day web journalism.  Their work day begins before 5:00 AM.  The key to a political web site is to be the first to get the scoop on the latest policy or personnel issues.  Success is measured by the page views each journalist gets for his article.  Over at Gawker, they have a giant video screen updated every hour of the most frequently viewed web page. At Bloomberg, the journalists' pay are based partially on the frequency of their page views.  Eventually the writers will have to resort to ever increasing sensationalistic headlines to grab a readers attention, like "Kinky Sex In L.A. Hospital Operating Room", in order to get recognized and paid decently.

This is a really sad development for journalism.  Unfortunately because of their pace and the Web's 24/7 qualities, these sites will become the go to places for breaking news.  Already attention grabbing news have been broken by the web, including the death of Michael Jackson by TMZ and Tiger Woods's affairs on RadarOnline.  In Los Angeles the sequence of news gathering starts with gossip websites, which is then expounded by the LA Times, followed by the broadcast media who are left rereading the headlines from the newspaper, with one or two original stories about puppy adoptions thrown in.  The most viewed articles each day in the LAT usually include one or two involving some celebrity in legal or ethical trouble (I'm talking about you Mel Gibson).  Is this how journalists will be compensated, by whomever can write the most exaggerated headline that feeds the capricious celebrity appetite of the public?  It is quite pathetic.  I'm glad I only write a humble blog about anesthesiology, a subject that maybe only 0.0001% of the U.S. population cares about and even fewer know how to spell correctly.  I'm thrilled if I get ten page views a day.  I would not be able to make a living in this business and I'm relieved I don't have to.

One of my patients recently told me she was heading off to college soon to start her journalism major.  She was a bright young patient who had done much work for her high school paper.  Her enthusiasm for her career choice was evident in the way she talked about interviewing at the different journalism schools around the country and how she couldn't wait to get started.  I hope when she reads this article (like all good journlists will) that she won't get discouraged by the sweatshop characteristics of a modern day "news" room.

Orthopedics vs. Anesthesia

This little vignette gives a fairly accurate representation of what anesthesiologists have to face.  It's hilarious for anesthesiologists because we see this almost every day.  Enjoy.

Local Economy Leaves Mall Half Empty

This is a picture from our local outlet mall over the weekend.  Two years ago if you didn't get to the mall by 11:00 AM you would have to walk half a mile from your parking spot to get to the stores.  The picture was taken shortly after noon.  As you can see, the mall parking lot is half empty.  President Obama can say all he wants about how the trillions of dollars spent by the government over the last two years has "saved and created" millions of jobs.  This image graphically belies the authenticity of that statement.  Frankly I was shocked how poor the mall traffic was, especially on a bright sunny weekend.

I guess I shouldn't be surprised.  The Southern California economy is in the dumps.  The state budget is overdue and is projected to have a deficit of $19 billion.  The local unemployment rate is 12.3% with the U-6 unemployment and underemployment rate of over 20%.  Housing prices are still falling after a mild pickup from a now expired federal bailout (so tired of that word).  Taxes are set to rise dramatically in a few months, especially on the people who are most likely to hire the millions of unemployed.  Is it any wonder the country is in an uncharacteristic doldrums right now?

Friday, July 16, 2010

MOCA Changes Exam Rules--Conspiracy!

The American Board of Anesthesiology changed its rules for passing the Maintenance of Certification in Anesthesiology examination this year and I think that is total BS.  The ABA stopped issuing lifetime anesthesiology board certificates after the year 2000.  Now all recently graduated anesthesiologists have to recertify for their boards every ten years with a series of CME credits and this MOCA exam.  Since this process went into effect older anesthesiologist could voluntarily recertify their lifetime certificates by taking the exam.  Their rationale is that anesthesiology board certification rules for employment may change in the future and every anesthesiologist should have recent evidence of anesthesia competency.  Frankly I thought that was a pretty convolulated way to encourage people to pay for an exam they didn't really have to take.  In my group I know of maybe one or two people who took the test even though they had lifetime certificates.  None of the older partners are particularly concerned about not being able to work in the future.

Now ten years after MOCA was begun, the ABA has changed the rules for passing the exam.  Previously, the exam taker could select 150 questions out of 200 that he wanted to answer and be graded only on those.  The other fifty questions, the ones he didn't know the answers to, were simply discarded.  How convenient for the examinee.  I bet the ABA received a lot of exams with 100% correct answers.  When I took my exam in January I had to answer every single one of those 200 questions.  Yes there were some questions that I had no clue the answer to but I couldn't just simply skip them; I had to answer them to the best of my abilities.  Thankfully I was one of the 346 out of 373 examinees who passed the test.  But this change in standards is aggravating and smacks of a double standard against younger anesthesiologists.

It was bad enough that they removed the lifetime certificates two years before I finished residency.  When I started anesthesiology training I didn't know about an impending change in board certification. Now ten years later they changed the rules on me again!  I wonder why they altered the MOCA rules.  Could it be that after ten years of MOCA exams anybody with a lifetime certificate who wanted to take the test have already done so?  Would their pass rate have been lower if the ABA hadn't allowed them to disregard 25% of the exam questions?  Are the new anesthesiologists being held to a higher standard than older anesthesiologists?  What does this say about the competency of older anesthesiologists if they need help from the ABA to cheat their way into a new board certification?  Yes I said cheat.  The ABA's data clearly demonstrates this dichotomy.  Anesthesiologists like me who recertified in their seventh or eighth year after residency had a pass rate of 97% while those who took the test in their ninth or tenth year only passed at an 88% rate.  I wonder what the pass rate would have been for anesthesiologists who were taking the recertification in their fifteenth or eighteenth year of practice if they had to answer all 200 questions?

Think how many tests you have taken in your lifetime.  If you could throw away 25% of the questions in your SAT or MCAT or USMLE don't you think your scores would be higher too?  By allowing the lifetimers to answer only the questions they want to this gives the illusion that these older guys are smarter than they really are and that anesthesiologists around the country are more knowledgeable than they appear. I know plenty of anesthesiologists who could bulls*** their way through a case but who are stuck on pancuronium and isoflurance because that is all they know.  In the meantime we younger guys have to keep jumping through hoops that the older generation created for us just to prove we are worthy of our profession.

Thursday, July 15, 2010

That's Not A Resident. That's Our New Anesthesiologist.

Welcome to your new job, all you freshly graduated, Board Eligible, textbook trained anesthesiologists!  Hundreds of you will descend on hospitals around the country with your Board approved methods of administering anesthesia.  You'll wander around the hospital looking for the operating suite, the scrub lockers, and most important, the bathrooms.  Introductions will be tedious.  After years working in a residency program where everybody knew your name (cue Cheers theme song), you are suddenly the new stranger in the room.  The OR staff will judge you instantly by your appearance, demeanor, humor (or lack of), body odor, and hundreds of other qualities we humans determine if the new person will be accepted into the tribe.  Anesthesia skills will not be one of the factors though.  Remember they think we are all similarly skilled so anesthetic competence is simply assumed, unless of course you knock off your very first patient.  Excellence will only be bestowed on you after about one year of scrutiny.

 Anesthetic decisions that used to come to you without a thought suddenly become onerous, even scary.  Simple determinations like LMA or intubation turn into endless mind exercises.  You will mentally rehearse your rational for everything.  If your training program routinely used morphine but your new hospital uses dilaudid, do you go with the flow or stick to your guns?  And why? And what dose to give a patient with 10/10 pain in PACU but who has morbid obesity and severe sleep apnea?

Actions that you've performed hundreds of times in residency will develop new twists that you never encountered in training.  One of my first spinal anesthetics in private practice developed a complication when the patient complained of paresthesia in one leg hours after the procedure.  I had done innumerable spinals in residency and this had never happened before.  I had already gone home when the PACU nurse paged me about this problem.  I told the patient by phone that the spinal will eventually wear off and she will be fine.  But several hours later the nurse was still calling me.  I finally drove in to examine her.  Her neurologic exam appeared intact but she was still complaining.  I finally called for a Neurology consult and told the attending surgeon that the patient needed to be admitted for observation.  Finally after all this TLC the patient agreed that her leg felt adequate.  She could walk to the bathroom by herself and did not want to come to the hospital.  No neurologic sequela on follow up phone interview.  Never happened before.  Hasn't happened since.  Bizarre, and seems to happen predominantly to new attendings.

The first six months is literally trial by fire.  You come to appreciate the gravity of a job where you literally guide a person towards the path of life or death. There is nobody there to hold your hand, or relieve you for lunch and bathroom breaks.  Your sphincter will feel tight enough to snap a pencil.  There will be days where your pits feel like Niagara Falls.  Then suddenly, the sun will come out.  By around New Year's Day you realize that you are not as nervous about coming to work as you used to be.  Performing anesthesia is actually fun for you again.  You walk into the operating room and can greet everybody by name, and they the same to you.  The surgeon knows your work and is not constantly gazing over the drapes.  You no longer feel the need to stare at the patient monitor every single second. When your case line up is finished, as you walk out of the hospital, leaving your pager and all your worries behind, you remember again why you went into anesthesiology.

Apple's CellPhoneAntennaReceptionEliminator


Apple is finally going to give a press conference tomorrow on the travails of the iphone 4.  Consumer Reports has confirmed the loss of cell phone reception when holding the iphone on the metal antenna.  This is after Apple first blamed its customers for holding the phone the wrong way causing it to lose signal reception.  When they were roundly criticized for their arrogance, they came back with the excuse that the signal bars were wrong to begin with.  We never received five bars of reception that were indicated on the phone; it was just an illusion.  In reality we only received two or three bars worth of reception.  That was widely laughed off as ludicrous.

Now Consumer Reports, the well respected, objective, eight million member strong, product testing organization has confirmed the cell phone antenna reception problem.  It proposed wrapping duct tape around the perimeter of the iphone to keep skin from actually touching the metal antenna.  If that is too embarrassing for the Apple fan boys out there, they tested the bumper that Apple kindly sells for $29, which in their tests eliminated the antenna issue.  Curiously, as many people have pointed out, Apple sells the bumper only for the iphone 4, not for previous models.  Could it be they knew about the reception problems but didn't have a better solution before the phone went on the market? That's why they had to resort to a $29 rubber band as an expensive accessory?  In the meantime I'll just hang onto my 3GS which despite my previously documented iOS4 problems does not have a reception problem, at least no worse than it was before.  (Curse you AT&T for poor coverage around my home.)  When my contract expires next year, hopefully Apple will have had another iphone event in June with all the problems fixed and I can confidently upgrade to the next iphone.  If not, Android is looking better every day.

Wednesday, July 14, 2010

Anesthesiology, The Most Unhealthy Specialty In Medicine

The New York Times Well Blog reported on a study today with particular relevance for anesthesiologists.  Researchers reported that men who sat more than 23 hours per week watching TV had a 64 percent greater chance of dying from an MI than men who watched less than 11 hours per week.  Contrary to expectations, men who watched more TV but also exercised regularly did not decrease their risk for coronary artery disease.

Hmm, which job in medicine has the doctor sitting in a chair all day staring at a monitor?  Which job stresses the doctor to interact, sometimes negatively, with another doctor on the same patient in the same room at the same time?  Which medical specialty is widely known for having an increased risk for substance abuse because of the stress and easy accessibility of mind altering substances?  If you guessed anesthesiology for all three you should proceed to the head of the class and receive your gold star.

The combination of sedentary lifestyle, stress on the job, and likelihood of developing an abuse problem is unique to anesthesiologists.  Some might say radiologists also sit on the job throughout the day.  But the difference is that radiologists can come and go out of the reading room at their leisure.  They also have much less of a risk of developing an addiction.  Anesthesiologists are pretty much stuck inside the operating room.  Let's face it, the only walking most anesthesiologists perform during the day is going to and from Preop and Recovery.  While people may say to just stand up during a case, that's not realistic.  I'm more likely to develop pedal edema and varicose veins standing in a small area all day than to get any benefit from standing vs. sitting.  Eventually all of us succumb to that comfy chair just beckoning us to sit down and relieve our tired feet and back.

I used to think that countering this inactivity with regular exercise will be helpful.  But according to this study it makes no difference.  When I get home I might as well plop in front of the Playstation 3 since exercise did not decrease coronary morbidity.  So for all those medical students who dream about being anesthesiologists, beware what you're getting into.  Though the lifestyle is great, the income is fabulous, and the dating opportunities are dreamy (oops, that was just a dream), anesthesiology may shorten your life.

Tuesday, July 13, 2010

Another Billionaire Escapes The Inheritance Tax

George Steinbrenner, owner of the New York Yankees, passed away today at the age of 80.  While sad news for the family, there is a distinct upside for his heirs.  By dying in 2010, he saved his family $600 million in estate taxes.  Because of the inconsistent way tax laws are passed in this country, anybody who dies this year will not have to pay any inheritance taxes.  This "Bush tax cut for the rich" is expected to expire on December 31, 2010.  Next year the inheritance tax goes back up to 55% with a $1 million exemption.  Some multimillionaire and billionaires who have died so far this year include Glen Bell of Taco Bell fame, Art Linkletter, and Dennis Hopper.

Though money can't buy love, we're talking about a LOT of money for some people.  This has set up some moral dilemmas for families and their doctors.  There are anecdotes of patients who might have died from terminal illness in 2009 who kept themselves alive until 2010 just to avoid paying taxes.  DNR issues become more complex as money is introduced into the equation.

Congress is in no hurry to fix this bizarre tax law.  Since this is an election year they don't want to correct the law and appear to favor "the rich".  It's only July but incredibly they have less than 40 working days left this year before the election so any attempt to lower next year's estate tax rates appears futile.  So watch as the billionaires drop like flies in December 2010.  The Walton family, heirs to the Walmart empire, may suddenly decide to check out for good, not just in Aisle 23.  Warren Buffet may succumb to all the cheeseburgers and cherry diet Coke he's been consuming every day.  Bill Gates may "disappear" in his private jet over Africa on one of his humanitarian missions.  You can't avoid death, but apparently for rich people they can avoid taxes at least for one year.

Wednesday, July 7, 2010

iOS 4 is Apple's Windows ME


I've been snookered by that snake oil salesman known as Steve Jobs.  I, like millions of others, listened with baited breath when Mr. Jobs announced the features and improvements in iOS4 for the iphone.  Multitasking? Who wouldn't want multitasking?  File folder organization?  At last a system of organizing files invented back in the early 1980's.  Better email visualization?  Finally I can check all my different email accounts in one glance and not miss out on the next e-vite to that hot Malibu beach party. But this software upgrade has been tragic.  It is as buggy as a mattress in a cheap Tijuana motel.  I haven't encountered such an unstable piece of software since the infamous Microsoft Windows ME.

I read all the reviews on how great iOS4 will be.  Even though I wasn't planning on upgrading to an iphone 4, most of the functions in iOS4 were supposed to work in my old 3GS.  Then the day came.  Servers crashed around the country as millions of people tried to upgrade their iphones at the same time.  I waited patiently.  I wasn't going to be one of those dorks waiting in a virtual line to get the latest and greatest iphone operating system.  Finally, a week later, during a quiet weekend night, I upgraded my evil iphone.  It was quick.  I was done in about 15 minutes, not the hours of uploading some people reported earlier in the week.

Initially there was little difference from before.  I could now change the wallpaper of my iphone on the home page to something besides black.  The email was great.  With one glance I could tell how many letters were in each of my accounts.  The file folders worked as advertised, though I find the little black squares representing folders really extremely ugly and depressing compared to the bright, colorful, almost playful, icons that used to populate my iphone screen. 

Then the problems started.  Since I don't have the iphone 4, I have not experienced any antenna problems that thousands of people have had.  (I love Apple's explanation--you're all holding the phone in the wrong way! A**holes.  Now their latest excuse is that their method of calculating the number of reception bars was wrong from the beginning.  We never had five bars at all, more like two or three.  So much for AT&T's advertising slogan "More bars in more places". Can we sue both Apple and AT&T for deceptive advertising?)  After a couple of days I noticed that when I wanted to use my phone and had to enter my Pass Code, nothing would show up in the entry bar even though I was pressing the virtual keyboard and hearing the clicks.  The only way I could get the phone to work was to turn it off completely then restart it.  This problem was sporadic and I haven't been able to figure out what triggers it.

The next problem also occurred without warning, although unfortunately it is more persistent and reproducible. Now virtually every time I push the "phone" button, it asks me for my password for voicemail.  First of all, I wasn't even going to use voicemail.  But that little window pops up no matter which phone function I want. The only way to get rid of it is to push the "cancel" button.  And the reason for that is that I have no idea what my voicemail password is.  I don't ever recall setting one up on my evil iphone before.  The window helpfully offers to call "611" for me to get AT&T assistance, but I haven't found the time to sit through that yet.

Finally today the latest bug was my Bluetooth headset wasn't recognized by the evil iphone.  It was set up when I first bought the headset and I had never had problems since.  Then today nothing.  I had to go back and reset the pass code for the phone to recognize it.  This was kind of dangerous and probably illegal as I was driving in rush hour traffic at the time.  That's a real Catch-22:  should I risk an accident trying to set up my hands free head set while driving or should I just continue to drive without using one?

If Microsoft had released software this bad, there would be howls of condescension from the digerati about how the software company has lost its way.  Class action lawsuits would descend on the company.  Acres of newsprint would be devoted to the cluelessness of Microsoft.  But since this is Apple, the fan boys have been keeping silent while waiting for Apple to release an update, rumored to be any day now.  This has retaught me a lesson I though I learned long ago--never get a software program until there is at least one upgrade revision.  In the meantime the Droid X is looking pretty tempting.

Tuesday, July 6, 2010

Strange Future Surgical Procedures

Remember when a laparoscopic cholecystectomy was considered state of the art?  Surgeons could offer patients an operation through "keyhole" incisions that used to require an enormous subcostal cut that put a patient out of commission for months at a time.  The anesthetic plan also became easier to manage.  No longer did we have to worry as much about prolonged operative time, intraoperative hemorrhage, pulmonary insufficiency, or postoperative pain and splinting.

Along those lines, researchers are developing new procedures that practically remove any visible skin incisions.  The following list is by no means comprehensive.  Some of the procedures sound exotic, if not bizarre.  But they all have one common goal, and that is to minimize the morbidity and mortality of patients.  One day patients may be treated without any incisions at all just like in Star Trek.

1. The TOGA procedure is a transoral gastroplasty that aims to replace the standard laparoscopic gastric bypass.  Even though the laparoscopic procedure only requires six or seven tiny incisions, patients still complain about incisional pain afterwards.  A gastric bypass also introduces the complications of increasing the intraabdominal pressure on morbidly obese patients who already have pulmonary compromise.  TOGA is done completely endoscopically through the mouth. The hope is that there is less pain and less pulmonary complications which could eventually make it an outpatient procedure.

2.  Transgastric appendectomy is performed by making several small incisions through the stomach.  A pneumoperitoneum is produced to help visualize the appendix way down in the right lower quadrant of the abdomen.  In this study the patients were allowed to eat and drink as soon as they woke up from anesthesia.

3.  Transvaginal cholecystecomy is the next evolution of laparoscopic cholecystectomy.  Surgeons used standard laparoscopic equipment to take out the gall bladder through vaginal incisions.  The only skin incision required was for the varess needle to access the abdominal cavity to create the pneumoperitoneum.

4.  Transcolonic cholecystectomy sounds even more far-fetched than the last procedure.  This one is still in the animal experimentation stage.  The idea of introducing equipment into the peritoneal cavity that has gone through the colon mucosa doesn't sound attractive.  Is it really possible to sterilize the colon no matter how many Betadine enemas are given?

5.  Transaxillary thyroidectomy was first introduced in South Korea but is now getting some attention here in the West.  A da Vinci robot is used to assist the surgeon guide his instruments from the armit all the way to the neck.  This procedure actually sounds very scary.  As anybody who has ever attempted a central line placement or regional anesthesia will tell you, the axillary and periclavicular regions are fraught with peril.  The risks of tension pneumothorax, brachial plexus injury, and arterial and venous lacerations would keep me from surfing the net during the entire procedure.  That is just too much stress for this anesthesiologist.

Sunday, July 4, 2010

People's Republic of America

I took my minivan to the local car wash the other day.  As the song goes, it never rains in Southern California, but the air is thick with dust and smog so a car wash is still de rigeur every couple of weeks.  I pulled into one of the stalls where they take your order for the kind of wash you want.  There are five choices listed, from "economy" to "deluxe".  I normally go with "economy" but since company was coming over, I decided to splurge a little and chose "standard".  With this package they even asked me what scent air freshener I wanted. After the car came out of the wash, several guys swarmed the car to dry and polish.  This was more attention than my usual cheapo car wash. I have these complicated multispoke wheels on the car that they normally just wipe over.  Not today. They were polishing each spoke individually. Man did the old minivan look sharp.  They even got the dirt that collects under the wind deflector on the rear door.  I should live a little and get this wash more often.

So how does this anecdote relate to health care?  It's all about the choices almost all businesses offer but not in medicine.  In medicine, every choice available is the super duper ultra deluxe spare no expenses package.  I'm betting that none of those workers polishing my car have health insurance.  But if they ever got sick they can go to the hospital and have the latest and greatest technology and drugs available in the United States at their disposal, even if they are unable to pay back a dime.

Medical care is probably the only "necessity" where people think they should be able to get the absolute best available even if they can't pay for it.  Consider the other necessities of life.  Food.  Walk into any supermarket and there are choices galore.  Not everybody can afford the lobster or the filet mignon but if you can't afford it you can always buy something else.  At least you won't go hungry.  Clothing.  We can't all wear Armani, but anybody can buy clothing at Walmart and stay warm.  Shelter.  You have your choice of apartment rentals up to ginormous Beverly Hills mansions.  If you can't afford it you ain't living in a Beverly Hills mansion.  However virtually anybody can find an apartment to live in if they can't afford a house.

Health care is the one industry where everyone demands the best no matter the cost.  Heaven forbid if you should surf the internet and somebody said you should get a PET scan even if your doctor doesn't recommend it.  You will damn well keep nagging the doctor until you get one, or go to another doctor who will.  You read about a procedure that might be considered experimental but a faceless "expert" claims there is a ten percent chance of success.  You'll write to the hospital administrator and threaten a lawsuit if you don't get it.  Heard about a new drug that just might extend your life for another three to six months but costs $20,000 for the treatment?  And you don't have the money for it? There are all sorts of movies extolling the virtues of these patient Davids vs. cost cutting Goliaths.  Of course the movies never say the money that goes to pay for these extremely expensive marginally effective treatments have to come from somebody else, usually you and me in the form of higher insurance premiums and higher taxes.

So next time you go into a car wash, marvel at the smorgasboard of choices available, any levels of waxing, polishing, detailing depending on your desired price point.  There is something for everybody.  That's the capitalistic inspirational shining city on the hill U.S. of A. I know.  Then consider that in medical care everybody demands the same super deluxe top of the line treatments with no incentive to stay healthy and why this country is going broke. With deficits in the trillions of dollars well into the next decade, this egalitarian attitude is quickly transforming our country into the People's Republic of America.  Happy Fourth of July my faithful readers.

Saturday, July 3, 2010

What My Health Insurance Premiums Pay For

Anthem Blue Cross, the largest health insurer in California, has announced they are raising premiums 20% starting September.  Everybody knew this was coming after they withdrew their plans for raising premiums 39% during the ObamaCare debates.  That announcement was made during a period when it seemed ObamaCare would fail in the Senate.  The ensuing furor was the final push necessary to pass it.  Was it just coincidence that passage of the bill will require everybody in the country to purchase health insurance?  Like the ones being peddled by Blue Cross?

Wellpoint, the parent company of Anthem Blue Cross, made $877 million in the first quarter of 2010.  The company's CEO made $13.1 million last year.  I have to buy my health insurance in the individual market since like many doctors I am a self employed small business man with no employer to subsidize my health insurance.  These rate hikes affect mainly the individual insurance market since this is the last refuge of the sick.  Healthy people tend to delay buying individual health insurance at these prices.  I spend thousands of dollars every year on my insurance premiums.  Anthem, despite pleading poverty, continues to waste money on chotchkes like this:
If Anthem Blue Cross will lower their premiums, I'll promise not to take any more free pens from them. Is that a deal?

Friday, July 2, 2010

A Patient's Need To Know

As I walked into Preop Holding, the nurse comes up to me and whispers, "Your next patient is really nervous about anesthesia."  "Okay," I reply. "Thanks for the warning."  When I see the patient she is wringing her blanket in her hands, shaking slightly, and staring with saucer-like eyes right at me.
"Are you my anesthesiologist?" she asks.
"Yes.  I'm Dr. Z.  Your nurse tells me you are very nervous about anesthesia.  May I ask why?  Did you have a complication from anesthetics in the past?"
"Uh huh.  My previous surgeon told me to tell anesthesiologists that I need extra drugs to keep me asleep. In my last operation I woke up in the middle of the procedure."
"My goodness.  No wonder you're anxious.  What did you do?"
"The surgeon said that I was moving during the operation.  He had to tell the anesthesiologist to give more drugs before I was put back to sleep."
"Do you remember waking up during the operation?" I ask skeptically.
"Do you recall any conversations in the operating room or feel any pain?"
"Did you talk to the anesthesiologist afterwards?"

Oy, I thought.  This poor patient has been psychologically traumatized, but not by the anesthesiologist.  Why did her surgeon have to tell her that she "woke up" during her operation?  She had absolutely no recall of her surgery.  Her muscle relaxant had worn off and she started to move but that is not the same thing as "waking up" even though surgeons always yell, "Anesthesia, patient's waking up!" when the patient twitches a single muscle fiber during the case. It was really unfair of the surgeon to say this to the patient without consulting with her anesthesiologist.  How would the surgeon feel if the anesthesiologist told the patient after the surgery that the surgeon lacerated an artery and she hemorrhaged 1000 cc's before he finally got it under control?  I bet the surgeon would not appreciate the patient knowing that detail.  If the patient's outcome was unchanged because of the movements, does the patient need to know the information? I just don't understand the disrespect that surgeon had for the anesthesiologist.

"I can understand your anxiety," I assured her. "It is okay to be nervous before surgery.  That's perfectly natural." She seemed to calm down a little. "I've never had a patient wake up during an operation.  All our operating rooms are equipped with monitors that track your brain waves.  These machines help us determine if the anesthesia is becoming light so that we can give you more if necessary. Do you feel better?"
"Yes. Thank you doctor."
"You're welcome."