Wednesday, November 24, 2010

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.

Wednesday, November 17, 2010

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.

Tuesday, November 16, 2010

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.

Friday, November 12, 2010

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?

Wednesday, November 10, 2010

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.

Thursday, November 4, 2010

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. 

Wednesday, November 3, 2010

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.