Medicine. It's A Whole Other (Abbreviated) Language

A+A
VSS
MAE
D/C WS

Do these four lines make sense to you? If it does, then you must be a physician. During our recent TJC inspection, one of the things they were looking for was legible handwriting by doctors. Not only did the notes have to be easily read, they also had to make sense. No bizarre (nonstandard) abbreviations were allowed. If they came across one in your notes, you were tracked down and educated on the necessity of good writing. It has been shown that poor handwriting leads to medical errors. These errors should never happen because the physician couldn't bother to clearly differentiate between "mg" and "mcg" in his orders.

cc: BRBPR
87 y/o AAM w H/O CAD, IDDM, HTN, BPH, ESRF and CVA c/o BRBPR x 7D
PSH: CABG, TURP, AICD, AVF
Soc. Hx: 1 PPD x 30 yrs
NKDA

PE:
HEENT: PEERLA
CV: RRR, -m
Pul: BSE, CTA
Abd: Neg
Neuro: CN II-XII int.

A/P Admit to MICU. NS TRA TKO. NPO. CBC, BMP, ECG, CXR in AM

They don't teach this stuff in medical school. In med school we had a class on medical terminology. It was mostly a semester on learning the different Greek and Latin words that are the basis of medical terms. For instance, it was important to understand the difference between "hypercalcemia" and "hyperkalemia". However, nobody taught us that OLT is short for orthotopic liver transplant or that CLD stands for clear liquid diet.

Why do doctors write such cryptic notes? Is it some sort of conspiracy to keep nurses from doing their jobs properly and thereby blaming them for any mistakes? Of course not. Principally it's about saving time. The above history and physical would be three times longer if no abbreviations were used. We doctors are so inundated with paperwork and phone calls that anywhere we can save a few seconds is worth the trouble. For every patient I see for surgery I have to sign at least five different pieces of paper. Each signature requires a date, time, a printed copy of my name, and my hospital ID number. When the cases are short and the turnover is fast, there is little time to write longhand a patient's medical history, which typically looks like the one above. Frequent use of abbreviations makes the day run more efficiently. If everybody had to write all the words out by longhand, we would be even more bogged down by paperwork than we are now.

Incidentally, the first note at the top of post means:
Awake and alert
Vital signs stable
Moving all extremities
Discharge when stable.
Obvious, no?

An Angry Surgeon Publishes In The Wall Street Journal

"Get this thing out of my operating room!" The colon stapling device exploded into pieces when I hurled it against the operating room wall.

When I read those lines at the beginning of Dr. Paul Ruggieri's book excerpt in the Wall Street Journal, my first thought was, who is this raving lunatic operating in this unfortunate O.R.? When I previously wrote about out of control surgeons, it was done anonymously to protect the reputations of the surgeon and the hospital we were in. Now here is a guy who is so full of himself that he doesn't mind putting his name down in a national newspaper describing what a piece of work he really is. This kind of juvenile hysterics would get a disciplinary action from our hospital. I wonder how dismayed his hospital administrators must feel when they read about how the doctors who work at their facility don't know how to control their own tantrums.

I grabbed the scrub nurse's hand. "See, touch that thing.  Look how inflamed it is." When given the chance, scrub nurses love to touch organs in the operating room.

I don't know about Dr. Ruggieri's hospital, but around here nobody better be grabbing the scrub nurse's hands. They may feign fascination with the anatomy of the patient but they are too busy getting the next piece of equipment ready for the surgeon to use, before he throws another tantrum and shatters it against the wall.

Is it all a ploy to sell more books? After all, publicity is always good, even if it is bad publicity. But how would his patients feel now that they know he blames the patients and their diseases for his difficult cases and bad outcomes?

If the difficulties posed by Mr. Baker's obesity weren't enough, he had been steadily losing blood during the procedure.

Dr. Ruggieri readily admits that the hemorrhaging in the case is caused by nobody but himself. But he goes on to blame the patient's obesity and bowel disease for his inability to gain control of the situation. All the while he is mentally calculating how much money he will make for this difficult operation and ruing the day he didn't get an MBA or become a plumber. Meanwhile the anesthesiologist is busy behind the ether screen trying to pump in blood so the patient doesn't die on the O.R. table. Is there a word of acknowledgement for the O.R. staff who are busy helping this surgeon finish his case successfully so that the patient will live to see another day? Of course not. He is too busy racing home in his new Porsche. Embarrassing. And pathetic.

The Law Med Blog

Many of you readers are entertained by the foibles of so called medical professionals. If you do a search under "medical malpractice" on this blog, you'll find a list of some pretty appalling cases of doctors gone bad. Unfortunately for me and the profession, there are just too many stories of doctors and nurses who show a dereliction of duty or just have questionable personal lives to cover. I recently found one blog that seems to report these tales pretty extensively. I've listed it under My Blog List. It is the Law Med Blog. Here you'll find multiple entries on doctors behaving badly, such as the North Dakota surgeon who is accused of using propofol as a date rape drug, or the North Carolina anesthesiologist who likes to expose himself in public to unsuspecting women. Horrible, yet fascinating at the same time. I'll continue to post stories about malpractice cases that I find particularly interesting and relevant but if you want the dirty laundry on medical care in America, head on over to the Law Med Blog. You'll wonder what kind of people make it out of our medical schools.

The Joint Commission Dementors

Fans of the Harry Potter books and movies are familiar with the characters called dementors. These are creatures who guard the wizard prison Azkaban. Their presence causes one to feel cold and lifeless, losing all sense of hope and happiness. Prolonged exposure to their presence eventually drives one into madness. That is what being inspected by The Joint Commission feels like.

Our hospital recently had its inspection by this nongovernmental agency formerly known as JCAHO. I commented before on the lunacy of some of the rules that TJC imposes on healthcare providers that don't seem to affect the quality of patient care. Many of us feel that in order to justify their existence, TJC kind of makes up stuff along the way in order to sound authoritative and put doctors and hospitals in their place.

For instance, while inspecting one of the operating rooms, one of the members of TJC told us that the trash basket has to be at least five feet away from the dirty laundry basket. Now what is the logic of that? Are there any studies to prove that a dirty laundry basket sitting next to the trash worsens a patient's health? So we dutifully pulled the baskets apart in each O.R. Another inspector decided that clipboards made from wood or particle board were verboten in the O.R. Why? Don't ask me, ask TJC. When word got out on that, the O.R. managers went rushing madly through all the rooms to make sure all the wooden anesthesiologists' clipboards were thrown out and replaced with plastic and metal clipboards. I was amazed how all those brand new plastic clipboards materialized so quickly. Is that insane? I could go on and on about these stories of random acts of lunacy. I can't forget to mention that our bulletin board had to be removed thanks to TJC. Apparently some of the clippings of personal notes and pictures that were stuck on the board were not secured properly. They were pinned to the bulletin board with thumb tacks causing the corners of the notes to kind of droop down due to that force called gravity. I guess TJC doesn't like gravity. They felt that those droopy paper corners could be a potential fire hazard and said all the notes had to come down. However if all four corners of the notes were stuck securely to the board, they were okay. WTF?

Some of the anesthesia related irritations by TJC include the perennial question about locking anesthesia carts. Our particular group of inspectors hadn't gotten word yet that TJC and the ASA had agreed on when it is appropriate for anesthesiologists to leave their carts unlocked. They wanted our carts locked whenever the anesthesiologist leaves the room, even though the O.R.s are considered secured areas of the hospital. They also suggested that we label our syringes when performing regional blocks. Sounds reasonable, you ask? Well how is one supposed to put nonsterile labels on sterile syringes while wearing sterile gloves during the performance of a block? Plus the syringes and medications never leave the sight of the practitioner so why is labeling required?

Our hospital spent months preparing for these "surprise" inspections by TJC. We rehearsed our time outs studiously. Our syringes were randomly inspected to make sure they were all labeled with the drug name, date, time, and initials of the person who drew the drug. Personal effects were banned from the O.R.'s or had to be placed in plastic bags. But you can't prepare for this kind of irrationality. It's a travesty that healthcare providers have to subjugate ourselves to these insulting inspections. They know we do a good job taking care of patients so they come up with these excuses to demoralize us. They are aware that if our facility doesn't get their approval, Medicare and insurance companies will no longer do business with us. How this organization acquired their monopoly on inspecting hospitals and the government's continued reliance on their seal of approval is beyond me. It seems that TJC has a conflict of interest in their business. They don't have a book of all the rules that a hospital has to follow in order to receive approval. If they did every hospital would follow it to the letter and there would no longer be a need for TJC. Instead they make up these random on the spot rules to justify coming to our facility and insult our patient care.

Don't laugh at our frustrations. TJC will soon be coming to your hospital soon. In fact, they are expanding internationally to inspect overseas hospitals thanks to all the medical tourists out there. Let's see if those doctors and nurses in Thailand, India, or Dubai give a darn about droopy corners on their bulletin boards.

Splattered

One of the workplace hazards of being an anesthesiologists is getting splattered by body fluids. Sure we are all keenly aware of needle sticks and drug addictions, but being splashed by contaminated fluids is a far more common occurrence. Somebody who has never been in an operating room naturally assumes that operations are nice sterile procedures where every surgical instrument sparkles and every surface pristine. But that is far from the truth. Once the knife touches the skin, all manners of human liquids can start pouring out. I've been doused by HIV contaminated water, blood, stool, urine, bile, pus, bone fragments, fatty tissue--virtually anything that can come out of a human being.

But aren't surgeons the ones who are most concerned about getting dirtied with human contaminants? Well yes, and that's why they are covered head to toe behind masks and gowns. In particularly bloody cases like orthopedic surgeries (pictured above) some surgeons even don astronaut suits to completely envelop themselves. The same thing with the nurses. The scrub nurse assisting the surgeon wears the same protection as the surgeon. The circulating nurse is usually sitting far away in a corner of the OR, safe from any bloody projectiles. We anesthesiologists however are right in the line of fire. You may think the ether screen separating the operating field from the anesthesiologist is to preserve the sterility of the operation, but it is really there to protect us from the mess the surgeons are creating.

Unfortunately that little ether screen sometimes is not enough. All manners of debris can come flying over the screen at the most unexpected time and direction. I can be innocently sitting at my anesthesia machine documenting my patient's vitals when a stream of blood drops can come shooting over the screen and land on my records or clothing. Unlike the surgeons, we don't usually wear protective gowns in the room to protect our clothing so this can get really disgusting. Some cases like hip replacements are particularly prone to getting spattered by blood just because of the proximity of the operating field to the ether screen and the impact of the surgeon's hammer on the patient's bone and soft tissue. But the spraying can occur in any operation. I had one colleague who was drenched from head to toe with blood during a carotid endarterectomy when the surgeon somehow lost control of the carotid artery. The force of the bloodstream showered her, her anesthesia cart, and the back wall of the OR before he was able to regain control. She was not pleased.

Perhaps one day we can perform our anesthesia from a separate room. We intubate the patient in the beginning of a case then retreat to a safe room where we will monitor the patient and control the vent settings. Preloaded syringes of drugs can be injected into the patient remotely as necessary. Once the case is finished we then reenter the room to wake up the patient and extubate. Until that fantasy comes to fruition, we best learn to wear surgical gowns or raise the ether screen to the ceiling.

How Soon We Forget

I saw this commercial on TV the other day for the Edge of Glory knife sharpener. To prove how effectively it sharpens blades, the pitchman even runs a credit card through the sharpener then effectively slices through a tomato, which everybody knows is notoriously difficult to cut without a sharp blade.

Immediately I had a flashback to the 9/11 attacks on the East Coast. After the terrorist strikes, one of the security concerns at the time was how easily household objects can be weaponized. After all, who knew that a simple box cutter could be used to hijack a plane and lead to the murder of over 3000 people? Now of course box cutters are no longer allowed on airplanes. That's also why we have to take off our shoes before boarding, limit ourselves to three ounces of fluids that can be brought on board, and be subjected to invasive body screenings.

At that time I recall analysts discussing how a credit card can be cut in a way that turns it into a knife blade. It would be a dull blade, but if you cut it at the correct angle, it could have a very sharp point. Now with the Edge of Glory knife sharpener, that credit card can indeed be turned into a weapon. Should credit cards now also be banned from being brought on board the plane? How soon our society forgets the lessons we all learned the hard way about keeping terrorists at bay.

Occupy Orthopedics

Why would any medical student decide to go into primary care when procedurists are raking in all the dough? I already wrote about the incredible compensation of anesthesiologists in 2011. Now there is income data on two of the most lucrative fields in medicine, gastroenterology and orthopedic surgery.

According to MGMA, gastroenterologists on average last year made $496,874. GI docs in the Midwest did the best, averaging almost $540,000 a year in compensation. Orthopedic surgeons did even better, if that can be believed. Orthopods made a minimum of $500,000 yearly, with the exception of foot and ankle surgeons who came in just below that. Spine surgeons raked in the most money, averaging over $760,000 each annually.

We may deride orthopedic surgeons as a bunch of big lunkheads who don't know the difference between CAD and CHF, and are happy to hand off the treatments of such to the hospitalists, but they sure know where the money is. This also points to the long road for politicians who hope to attract more medical students into the primary care fields. Sure they may suggest raising physician reimbursements by 5% for primary care doctors while holding back on interventionalists. But as these huge numbers suggest, internests and other PCP's will still lag woefully behind their procedure oriented colleagues by a wide margin. Even if you cut the average compensation of GI and Ortho docs by half, they would still make more than most PCP's. Little wonder medical students with six figure school loans are still shunning primary care. They are making a rational decision based on market principles and what's best for their own livelihoods. Cause even the dumbest orthopedic surgeon still was smart enough to graduate from medical school.

Surgeons Are Overrated, But We Anesthesiologists Already Knew That

CareerCast.com has come out with a list of the most overrated jobs in America. While a corporate executive was ranked as the most overrated job, surgeons came it at number two. And physicians in general were ranked number three. The company produced this list based on compensation levels, hiring outlook, work environment, stress, and physical demands.

Sure surgeons make the highest salary in this unflattering list but they probably have the highest level of stress and physical and mental demands too. Nothing like a ruptured AAA at 2:00 AM to keep you on your toes and cause your cortisone levels to skyrocket.

We anesthesiologists of course knew that when we decided to go into our field. We saw how the surgeons all looked frazzled and discontented. Any honest surgery attending will tell his medical students and residents about the high levels of stress, lack of sleep, exorbitant medical malpractice insurance premiums, and little to no family life. While the public may be enamored of selfless, heroic surgeons based on Hollywood depictions like Hawkeye Pierce in M.A.S.H. and Richard Kimble in The Fugitive, these are fictional portrayals. The reality is much grimmer for surgeons. Yeah, I loved surgery too as a medical student and resident. I even tried it for a few years. But ultimately, once the haze of chronic exhaustion finally started to dissipate, I saw the light and went into the best field in medicine, Anesthesiology.

The Beginning Of The End

This was going to have to happen eventually. Anesthesiologists in Ventura County, CA, just west of Los Angeles, have decided that they are no longer going to work for below market rate wages. According to the Ventura County Star, anesthesiology groups who work at St. John's Regional Medical Center in Oxnard, St. John's Pleasant Valley Hospital in Camarillo, and Los Robles Hospital and Medical Center in Thousand Oaks have refused to work with Gold Coast Health Plans, which runs the Medi-Cal program in Ventura County. Medi-Cal is California's version of the federal Medicaid health insurance for the poor.

Medi-Cal already has one of the lowest physician reimbursements in the nation. According to one study, an anesthesiologist will get $180 for a one hour C-section and $190 for a two hour hysterectomy. This is not enough to cover the overhead expenses. Medi-Cal patients who want elective procedures done at those hospitals are referred to other facilities where the anesthesiologists will still accept the insurance. A director at one of the regional clinics recalled a patient who had to shell out $550 in cash out of pocket in order to get a hysterectomy at St. John's. According to Denise Templin, "She went with a checkbook and paid out of pocket. She got money from her family and stuff to help. It's just wrong. No one should be put in a position like that."

Oh really? Nobody should be put in a position to do what, pay for a service they want? When the going rate for anesthesia services is $550 and the insurance is only willing to pay $190 but the patient expects to pay nothing so the service is denied, is that truly unfair to the patient or the doctor? What did California Governor Jerry Brown think was going to happen when he petitioned, and got approval, for a ten percent cut in Medi-Cal reimbursements to doctors last month? Does the government just expect doctors to accept the slashing of their livelihood without protest?

Since this is America, the land of the caring, we doctors will still treat emergency cases for almost next to nothing, out of compassion and the law. Nobody will be turned away from the ER who truly has a life threatening medical issue. Try asking a lawyer or an electrician to work for free in an emergency situation. They would be more likely to double their rates for waking them up in the middle of the night, if you can find them at all. But doctors are demonized for complaining about being forced to take on charity cases or asking patients for payments for services rendered.

The most frightening part of all this is that this scenario will soon play out across the entire country if ObamaCare becomes the law of the land. We'll suddenly have millions of patients, many who can pay for health insurance but won't because their iPads are more important than their health, seek medical care with Medicaid level payments. Hopefully by this time next year the U.S. Supreme Court will have given us a clear answer to the future of medicine in America.

World Toilet Day

November 19th is World Toilet Day. No I didn't know that either until just now. In America, we take clean functioning toilets for granted. Most of the world's population do their business into open pits or trenches. We on the other hand insist on a well scrubbed, sparkling clean, aromatically fresh loo within walking distance of anywhere in this country. We have toilets that wash and scrub your butt. We have toilets that will warm up your derriere when it's cold in the morning. We sell toilets that have a built in computer tablet. We even have supersized toilet seats like the one pictured above that can hold 1000 pounds. Think about that. American manufacturers have discovered a market for toilet seats that can hold a half ton human being while he's taking a crap. You wouldn't find any Japanese or Chinese toilets made to such sizes or tolerances. So as you go about your daily business this weekend, planning for your upcoming Thanksgiving holidays, remember to say a special thanks to the toilet. It's a luxury only a small minority of the world's population have access to.

Visiting The Mother Ship

What does an old blogger do when he vacations in San Francisco? Visit the mothership of blogging sites, of course. As part of our trip, we did the geekiest thing possible and drove through Silicon Valley to take a tour of the companies that are remaking our future. One of the locations was the headquarters of Google, the owner of Blogger from which this site is written.

The Google HQ may become the next great tourist attraction, for tech nerds at least. On the front lawn of their visitors center are all the different versions of their Android cell phone software personified. There's a giant statue of Gingerbread, an enormous Android robot made of Ice Cream Sandwich, and all the various other iterations of Android. Most of you Blackberry and iPhone fans probably wouldn't care. But for a tech geek like me, even though I still have my old evil iPhone 3GS, this was like going to Hershey, PA and taking pictures with all the giant Hershey's Kisses. The best part is that these Android statues are out in the open for anybody to visit. They're not locked behind some corporate gates where you need an employee badge to enter. We saw several other cell phone nerds like myself who were there taking pictures.

So next time you are in Silicon Valley, head on down to Google's headquarters and take a picture with a giant plastic food item. It's more fun than eating another bowl of bad clam chowder in a sourdough bread bowl.

How The Occupy Movement Misrepresents The 99%

We were on vacation in San Francisco last weekend. What a gorgeous city. It is a real treat to take some time off from work and just enjoy the beauty of this historic city by the bay. We had some relatives with us who had never been to S.F. so we decided to take a tour bus. We have driven throughout S.F. in the past but a tour bus is a great way to get around and see all the sights without all the driving and parking hassles. You can get on and off the bus at any of multiple stops to take pictures. Highly recommended, especially the open topped double decker buses.

Well we were just cruising along the Embarcadero when traffic came to a grinding halt. We were wondering what was going on. Cars were trying desperately to turn off the main road and get into some side street detours. The bus driver was getting frantic as he had a schedule had had to keep. As we slowly rounded a corner on the road, we saw a bunch of police cars with their lights blazing. Then we understand the source of our delay. There was a street march being held by the Occupy San Francisco movement. They were holding up signs like "Taxes, not cuts" and "Occupy SF. Love is still the answer."

When our tour guide saw what was going on, she went on a diatribe about those protesters. She had absolutely no sympathy for them, even though they supposedly are marching to represent her interests. She said she has been working for over thirty years and these people need to go get a job. Jobs are not just going to be handed to people on a silver platter. The marchers were harming her tour company and countless other small businesses when customers have a hard time reaching them. She continued on about the disgrace of all those tents pitched on public parks. It made the beautiful city look like a shantytown. Because of the protesters, the bus was not able to make one of its regular stops to pick up more passengers.

We later found out that these protesters hid criminal elements. Two police officers were injured when individuals ran out from the crowd and slashed them with sharp objects before running away like cowards back into the protective element of the masses. No matter what their rhetoric is, these people most definitely do not speak for the 99%. They are a bunch of disaffected hooligans who have nothing better to do other than camp out illegally on public property, conduct criminal mischief, and pretend to be angry at society. As our tour guide suggested, "Go get a job."

Why Is The Operating Room So Damn Cold?

One of the most common questions asked by patients is, "Why is the operating room so cold?" It is freezing cold to me even though I'm wearing a few layers of clothing along with a scrub jacket. After a while my fingertips almost turn blue. Sometimes I shiver so much that my abs hurt. Occasionally the circulating nurse and I will get heated blankets from the blanket warmer to drape over ourselves to lessen the misery. Now consider the fate of the poor patient who is lying on a cold operating table, supine, wearing a paper thin hospital gown or nothing at all. It's no wonder they complain about the temperature in the operating room.

There are a few stock answers to give to patients when they ask about the frigid conditions in the O.R. One is that the patient is wearing virtually nothing, so she will feel colder. Another is that the cold temperature helps keep bacterial count down, the way a refrigerator helps keep food from spoiling. This helps prevent contamination and wound infections. Then of course there is the real reason why the O.R. is so cold--the surgeons like it that way.

Sure we tell the patients that we wouldn't want the surgeons dripping sweat into the wound, would we? But is it really necessary to turn the temperature down that much? There are all sorts of studies that show a cold patient has increased risks of poor wound healing, and higher rates of complications. A cold shivering patient in the PACU can potentially have worsened respiratory effort and increased cardiac workload, leading to a more complicated  recovery period.

Does a hot sweaty surgeon really work less efficiently than a comfortable surgeon to the detriment of the patient? No. And the proof is in the cases where the O.R. is deliberately kept hot. Pediatric surgeries, burn cases, and trauma are all procedures where the operating room is kept warm to prevent severe hypothermia in patients who cannot tolerate it. I have never seen a surgeon complain that they just cannot operate properly if they are dripping in sweat after one of those cases. Plus there are no studies to prove that a warm operating room leads to more wound infections from bacterial contamination. So why can't a surgeon work in at least a temperate setting during routine cases?

We spend thousands of dollars on equipment to help keep patients warm. Bair hugger warming blankets are a must in every room. Hotline tubing to heat up IV fluids prior to flowing into a patient are also stocked in every O.R. All these expensive devises can be minimized if we simply turn up the thermostat a few degrees. But then the delicate surgeons will have a hissy fit and demand that it be turned to the lowest setting possible, patient safety be damned. So the thermostat gets set down to 55F, expensive warming equipment is charged to the patient's insurance company, and the anesthesiologist daydreams about how nice it would be to sit in a warm hot tub on the beach in Turks and Caicos.

Benefit #467 Of Working In A Hospital--Free Boxes For Life

One of the necessities of life is the need for more packing boxes. Whether you are moving to a new house, packing away some old clothes, or helping a child move for college, boxes are a must. One of the nice perks of working in a hospital, other than nearly total job security, is that there are unlimited quantities of boxes for the taking, all free, all destined for the recycling bin unless somebody takes them home.

Every day at hospitals around the country, semi trucks loaded with supplies drop their cargo in the loading docks. Hospitals require an enormous amount of equipment for it to run safely and efficiently. And every one of those things are packed in very sturdy, virtually indestructible thick cardboard boxes. Why do you think healthcare supplies are so expensive. One tiny little cap or screw will be packed sterily inside plastic bubble packing, which in turn is contained inside a nice pretty manufacturer's box, which is packed with other caps inside a larger cardboard box, which is further packaged inside a shock resistant outer box. So there are plenty of empty boxes in all different sizes for anybody who wants one.

When I moved to my new house last year, I brought back enough boxes to fill up our garage. The boxes were strong, clean, all the same size, and best of all, FREE. It is expensive enough moving without having to pay a moving company or office supply store precious dollars to buy boxes that you're just going to throw away afterwards anyway. So next time you need some boxes, don't waste your money to buy them. Find somebody who works in a hospital and they can surely get you some great boxes for free.

How Much Do Anesthesiologists Make, 2011

Here's the latest data on anesthesiologists' salaries in 2011. According to a survey by Locumtenens.com, the average anesthesiologist's salary this year is $364,689. That is an 8.4% increase from 2008 when anesthesiologists made $336,375. Women have reaped a huge jump in their salaries in the past three years, going from $296,704 to $349,505. Men are still well compensated, though their salaries didn't increase as much. They earned $367,049 in 2011 as compared to 2008 when they made $344,189.

Anesthesiologists who are partners in their groups made more than salaried anesthesiologists. Partners on average made $394,333 while employee anesthesiologists only made $348,406. Anesthesiologists with the most experience, greater than twelve years, made the most money, averaging $369,424. Those with the least experience, less than five years, made $353,875. The anesthesiologists with intermediate levels of experience made the least, averaging $349,545.

Now the all important question as regards to the future healthcare policy in this country. A full 93% of anesthesiologists say they accept Medicare in their practice. That is not a surprise since anesthesiologists in general have to accept Medicare if they work in a hospital or their surgeon accepts Medicare. However, 66% of anesthesiologists say Medicare reimbursement isn't enough to cover their expenses. How much more depressing will it get when Obamacare forces millions of Medicaid patients to be unleashed on the medical community?

So there you have it. Another successful year for anesthesiologists in America. Tell me again why medical students are shunning Internal Medicine and other primary care fields?

End Of COBRA, The Reason For Healthcare Decline?

Our hospital has been in a slump lately. Starting about September, everybody has noticed a distressing decrease in the number of procedures being performed. This slowdown has not let up since then. Surgeons are bringing fewer cases to the operating rooms. Anesthesiologists are being told to go home by early afternoon, if not before then. I've been told that the hospital's revenue so far this year is down significantly compared to last year.

Naturally everybody is blaming the shortfall on the economy. Here in California, we still have 12% unemployment, the second highest in the country. If you count the underemployed, those who can only find part time work but want to work full time, the percentage jumps up to 23%. But the economy has been slumping for so long, and according to government statistics the recession ended in the summer of 2009, why hasn't the medical community been slammed by the recession until now?

Then I realized that contrary to what the media may portray, people don't lose their health insurance right away after they are fired. The government has a rule called COBRA that allows people to buy health insurance through their company for the same premiums they were paying while they were still working there. This group rate is much much cheaper than the rates that a person would have to pay if they had to go into the individual markets to buy health insurance. The premium reduction from COBRA lasts for fifteen months after a person is let go. Thanks to one of the government's stimulus packages, people eligible for COBRA can continue to pay for the lower insurance premiums for the 15 months after May 31, 2010. Okay, so let's see. May 31, 2010. Plus 15 months. Bingo, now we are exactly at September 2011. Coincidence? I think not.

Want further anecdotal observations? The surgery centers around town have been hurting at least since last year. These are the places where they take cash only. Thus they are the first to feel the effects of the recession and unemployment. Some plastic surgeons have even been spotted here in the hospital, doing cases for insurance, and even, GASP!, Medicare. So you know times are tough all over.

Unfortunately nobody saw this cliff coming last summer. We hired all the recent residency graduates that we could find since we were extremely busy at the time. Everybody was complaining about the lack of rest and lost vacation time. Now we are severely overstaffed and people are grumbling about all the new people taking away the cases, or why the old guys won't retire. The healthcare sector has consistently been one of the top creators of new jobs in the economy. At the rate this is going, with the end of COBRA, this may not always be the case.

Guilty! Guilty! Guilty!

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Dr. Conrad Murray, guilty of "accidentally" murdering Michael Jackson

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Why Are Doctors So Depressing?

I was perusing through my latest issue of Anesthesiology the other day. After briefly skimming through many of the articles that are only tangentially pertinent to my everyday practice, I came across the "Mind to Mind" section, where doctors write in essays and commentary on their life in medicine. What I found was so depressing. Of the three submissions published, all of them dealt with death and dying. The first one is a sort of haiku on witnessing the aftermath of the death of a parent. The second story involved the slow agonizing death of a mother from Alzheimer's disease. The third one is about the death of a beloved public figure in a small Southern town.

My goodness. Is that all doctors can relate to in this world, death and dying and more death? Do doctors think they are more literate and poignant when they write about depression and mortality? Whatever happened to the happy anecdotes that physicians are witness to every day? Famed commentators like P.J. O'Rourke and Art Buchwald did not get rich and famous discussing only the sad details of this cruel world. Life has so much joy and exuberance to express but the publishers of medical journals only seem to accept accounts of woe and misfortune.

It appears that the only avenue for happy and funny reports is through medical blogs like this one. For instance, let me tell you about the time three women walked into an elevator in a large apartment complex. They notice a white stain on the elevator floor. The brunette looked at it and said, "That looks like somebody's semen." The red head touched it and remarked, "That feels like somebody's semen." The blond put some in her mouth and noted, "It doesn't taste like anybody from this building." Ba dum dum. Publish that Anesthesiology.

Worst Excuse Ever

Most anesthesiologists can testify to the frustration of waiting for a surgeon to come in and start a case. We and the operating room staff try our darndest to get a case ready on time. However, the one thing we have no control over is what time the surgeon finally decides to stroll into preop and start barking at everybody to get the patient into the room. Some of the nicer surgeons will apologize for being tardy. Most will not. It is the policy in our operating rooms to document the cause of a late start for a case, whether it be the surgical equipment was not ready, the patient was late showing up for his case, it was an anesthesia delay (the universally acceptable excuse), or the surgeon didn't show up on time. Therefore when the surgeon comes late, he is asked for an explanation. Some say they were delayed by office work. Another popular alibi is they were stuck in traffic, which everybody in Los Angeles accepts as a matter of fact. But for me, the excuse I most despise, and repeated by many surgeons, is that the operating room did not notify them of when the patient is ready.

Whenever I hear a surgeon say that, I can just feel steam rising out of my ears. Especially for a first case of the morning, why does the surgeon think we need to tell him we are ready for him? He knows what time his case is supposed to start. We are not their momma telling them to wake up to get ready for school. Imagine what would happen to OR scheduling if everybody pulled this stunt. The preop nurse finishes seeing a patient. She then calls the circulating nurse to let her know the patient is ready to be seen by her. Once the circulator finishes, she then calls the anesthesiologist. When the anesthesiologist finishes, he then pages the surgeon to let him know the patient is ready. We would maybe get two cases a day into the OR at this rate. The idea as a team is for everybody to show up on time and see the patient within a reasonable period to get him ready for the surgery.

By stating that the operating room did not tell him the patient is ready, the surgeon is passive aggressively blaming the OR staff for a delay in the case. He is totally absolving himself of any responsibility for causing the entire day's schedule to run late. Instead of just admitting that he overslept, or that he wanted one last quickie in bed before heading out the door, he blames the staff. When the patient asks him why his case is not starting on time, he'll repeat the same excuse thereby making himself appear the victim of OR incompetence.

I think all hospitals should institute a policy stating that everybody should show up on time as scheduled to prevent any delays in starting cases. There will be absolutely NO notifications sent out to let anybody know the patient is ready to be seen. It is the responsibility of the staff to call the operating room to find out if a case is starting on time. No one is going to be spoon fed the schedule. If a staff is tardy, he should let the operating room know ahead of time. Blaming the operating room for not keeping them informed of the starting time will not be tolerated. And no, you cannot blame the anesthesiologist for a case being delayed.

Open Access Endoscopy. Is GI Following The Same Fateful Path As Anesthesiology?

An open access GI procedure is when an endoscopic procedure is performed on a patient without a full consultation with a gastroenterologist. Some have advocated this approach as benefiting patients by allowing faster scheduling of cases with less paperwork and hassle. In fact, Dr. Thomas Deas, Jr., M.D., president elect of the American Society for Gastrointestinal Endoscopy, has presented an informative article on how to increase open access procedures for GI docs. Some of the advice he gives include finding and working with the a good primary care doctor who you can trust to refer a low risk patient for an open access endoscopy. He says that virtually any healthy patient between the ages of 50 and 80 is eligible for open access. If a patient have chronic issues like diabetes or respiratory illnesses, then they should undergo a full consultation first before having the endoscopy.

Now why does this line of reasoning sound so familiar to anesthesiologists? Because that is the precise logic GI docs use to preclude anesthesiologists from providing sedation for endoscopic procedures. If a patient is relatively healthy, who needs a fully trained anesthesiologist? The gastroenterologists can give the sedation themselves or in the not too distant future, the patients can give their own propofol with the help of a self controlled pump. No anesthesiologist involved to delay a case, cancel a case, or take any money from their surgery centers.

But the GI guys better be careful what they wish for. Open access endoscopy on healthy patients can easily lead to competition from their fellow health care providers. By not doing a full consultation on a patient, the gastroenterologist has basically reduced himself to a scope monkey. Anybody can take a course in endoscopy and do a procedure on a healthy patient. It may not be as perfect as a regular GI doc's but for a screening procedure it should be good enough. With practice, the outcome might even be comparable. Therefore the internist or family practice doc may decide to pad his income by doing the endoscopy in his own office. Or perhaps in the future a nurse practitioner or physician assistant will take a course in endoscopy and do procedures for the internist in his office, bypassing the need for an expensive gastroenterologist to do the same thing. Healthy patients don't need the full expertise of a fully trained MD to watch over them right?

Teaching A Cardiologist CPR

The trial of Dr.(?) Conrad Murray in the death of Michael Jackson has produced much sad and infuriating details. One of the most egregious examples of his medical incompetence was his lame attempt at cardiopulmonary resuscitation once he got off his cell phone with his girlfriend and discovered that the singer had gone into cardiac arrest. The prosecutors verbally painted an image of Dr. Murray giving Mr. Jackson CPR on the singer's soft bedroom mattress using only one hand. There was no equipment available for properly ventilating the patient with oxygen. In the meantime, he was ordering the security detail to pick up all medical evidence lying around the bedroom and having it hidden in a sack in the closet of another room. Despicable.

Maybe Dr. Murray can learn how to do a proper CPR by watching this video I saw on YouTube.



Notice the proper two "handed" technique. The "patient" is also lying on a flat, hard surface in order to generate enough compression force of the chest. With the correct approach, a patient can be successfully revived, just as the American Heart Association has taught generations of doctors and health care providers. You don't need to thank me Dr. Murray; I'm just here to help you.

LMA Failure

During the just concluded ASA national conference in Chicago, a study was presented that pointed to potential causes of failure in LMA insertion and ventilation. Satya-Krishna Ramachandran, MD and Michael Mathis, MD, both out of University of Michigan, observed 15,795 patients from 2006 to 2009 who had a laryngeal mask airway placed. The LMA was considered a failure if it had to be removed from the patient and an endotracheal tube placed instead. They found that 1.1% of LMA usage failed.

The researchers discovered four factors that could lead to the LMA not functioning properly. They are an elevated BMI, poor dentition, male sex, and the operating table turned away from the anesthesiologist. It's understandable that patients who are obese or have bad or missing teeth have higher rates of LMA failure. The table being turned 90 to 180 degrees away from the anesthesiologist increases the likelihood that the LMA could get dislodged by the surgeon or his assistants. I'm not exactly sure why being male increases the incidence of LMA failure. Maybe the larger oropharynx leads to more air leak around the LMA compromising ventilation.

We were always taught that LMA's shouldn't be placed in patients who are morbidly obese. They potentially have a full stomach despite hours of fasting and worse ventilatory efforts. In fact, lawsuits have been filed because of severe consequences of LMA failure in the obese patient. However I usually find the highest predictor of LMA failure are in patients who are edentulous. When a patient has no teeth, the soft tissue in the oropharynx just collapses, making it difficult for the LMA to seat properly. I asked our LMA rep one time about this. He said he's heard this complaint before and suggested I use the LMA Supreme, a model with a flatter tube and higher angulation. Of course it is also more expensive. When I tried it on my next edentulous patient, it didn't work all that much better. It was harder to place due to the sharper angulation, and it still didn't sit that well in the oropharynx. So the search goes on for the perfect LMA and ventilatory device.

Obamacare Preview--Scarier Than A Halloween Zombie

Want a preview of the state of medicine once Obamacare kicks in in 2014? Take a look at California. The Department of Health and Human Services has just given permission for the state of California to cut Medi-Cal's reimbursement to health providers by another 10%. The state is running a perpetual budget deficit and one of the fattest, juiciest, and lowest hanging fruit is physician compensation. This cut is projected to save $623 million from Medi-Cal's $14 billion budget.

It is so easy for politicians to cut doctors' salaries. They know that by law we have to treat patients regardless of their ability to pay. Consequently any study to determine if patient access to physicians is compromised by lower reimbursments show no such impediments. By comparison, the government is having difficulty deciding how, or if, patients should also shoulder some of the rising costs. Undecided is a proposal that will have patients pay a $5 copay when they see a doctor, $50 for an emergency room visit, and $100 a day for inpatient services. Medi-cal patients would also be limited to seven doctor visits a year. That just wouldn't be right for patients to pay something out of their own pockets to see a doctor even as they gladly fork over cash to buy their cell phones, go to fast food restaurants, and see the latest installment of Transformers at the movie theater.

The California Medical Association has calculated that a Medi-Cal patient will only reimburse a doctor $11 for a visit. Think about that for a minute. If the patient has a fifteen minute visit, which may not be realistic because these patients usually have multiple medical issues, that would work out to $44 per hour for the doctor. Out of that $44 the physician has to pay his office staff, office expenses, insurance, taxes, and finally himself. Clearly a doctor who sees Medi-Cal patients is working for sub-minimum wage despite all the risks of hungry malpractice lawyers and thousands of dollars in student loan debt.

Now multiply California physicians' predicament with the projected effects when Obamacare is implemented. Suddenly there will be 30 to 50 million new patients waiting to see doctors who will get paid at Medicaid rates. What happens when the budget is busted and Obamacare potentially bankrupts the government? Here comes the knife at physician reimbursements. There is no scarier vision this Halloween than the future of American medicine.

Necessity, The Mother Of Invention

In the category of "why didn't I think of that?" comes this brilliant idea from across the pond. Trevor Prideaux of Sommerset, England was born without a left forearm. He was having no problem being a productive citizen despite this disability. However, he found that operating a smartphone with only one hand was challenging. It's difficult to text with one hand while trying to balance the device on the prosthetic.

Mr. Prideaux thought of a plan to place his phone directly into the limb for stability. He contacted Nokia, the maker of his cell phone, and his prosthetic maker. After six weeks, they fashioned an artificial arm with a built in phone cradle. Freaking amazing. Now he can answer the phone by putting his arm up to his ear, or use the speakerphone. Texting and other functions are also much easier with the phone in this stable position. It's too bad the arm doesn't charge the phone at the same time but I'm sure somebody can configure that setup in version 2.0.

Anesthesiologist Behaving Badly, Again

It's a shame these stories about misbehaving anesthesiologists keep popping up. This time, an anesthesiologist in Fredericksburg, VA was arrested for impersonating a police officer. Dr. Gerald Bellotti almost got into a motor vehicle accident when he pulled in front of another driver, causing her to nearly rear end his car. At one point he started yelling at her and saying he had a gun in his car. He even threatened to arrest her. The distraught woman went to the police station who then tracked his license plate. Dr. Bellotti could face up to a year in jail for this stunt. Doctors, can we all just behave like responsible professionals, above reproach, and with the best interest of our professions in mind? Please?

Mandatory Flu Vaccinations For Healthcare Workers. Good Policy or Fascism?

The flu season is almost upon us. In our hospital, there's been talk about requiring all employees to get a flu vaccination. The idea was floated by the Infectious Disease doctors and has received general support from the hospital staff committees. An informal poll of the doctors at our facility revealed that about two thirds of them get a flu shot every year. The CDC recommends that at least 90% of healthcare workers get vaccinated.

In order to facilitate 100% compliance, different ideas have been expressed to "encourage" acceptance of the vaccination. Among the tactics include forcing any medical worker to wear a mask at all times in the hospital if he hasn't been vaccinated, a sort of "scarlet letter" if you will to shame the employee into getting vaccinated. In the "money talks" category, some advocated a financial penalty on those who won't get the shot. Some of the more orthodox staff even recommended suspension from work until the employee gets vaccinated or perhaps even termination from his job.

A firestorm of protests erupted after these draconian measures were made public. Many called these ideas un-American or fascist. Others cited the British Medical Journal article that questioned the efficacy of flu vaccines. Some pointed out that the state allows parents to exempt their children from getting various vaccinations before entering school but the hospital won't let medical professionals decide for themselves if they want to forgo the far less proven flu vaccine. A few simply stated that they had severe egg allergies and could not get a flu shot.

Some pointed to the possible severe side effects of a vaccine. A couple of years ago, at the height of the H1N1 swine flu panic, people couldn't get the flu vaccine fast enough. We had workers going to different departments of the hospital to make it easier for the employees to get their swine flu vaccine. The H1N1 pandemic never materialized to the extent that was drummed into the public. However the adverse effects of the vaccine are real. One of our surgeons, after getting the H1N1 vaccine, developed a Guillain-Barre type of illness. He suffered profound weakness and had to be admitted to the ICU. He was almost intubated due to poor respiratory effort. He was out of work for months while he received physical therapy to regain his strength. Luckily, after a long recuperation, he is back at work and doing an excellent job.

So should healthcare workers be forced to get the flu vaccine? How many vaccination injuries are acceptable in order to protect the public at large? Have doctors lost control of their own bodies, a natural extension of our loss of autonomy from government meddling in our professional lives? Our hospital is still debating the issues.

Best Foods For The Operating Room

Okay, right off the bat, I'm going to give you the official rule about eating in the operating room. NO FOOD IS EVER, EVER, EVER ALLOWED IN THE OPERATING ROOM! Got that? Never, ever, ever.

Now that I have that out of the way, let's talk about eating in the O.R. Yes we all know it is wrong. But sometimes for humanitarian reasons, anesthesiologists are forced to eat in the operating room. We try to eat what we can get in the doctor's lounge in the morning (hence the RAPERS reputation), but that alone can't possibly last through a ten to twelve hour workday. The nurses get lunch and snack breaks because they have strong union rules. The surgeons get to eat between cases, all the while complaining about the long turn around time they are suffering through. Anesthesiologists? Nobody is there to give us a break. When the surgeon leaves after putting in his last skin staple, he is heading down to the cafeteria. In the meantime, we have to wake up the patient, take him to recovery, give report and make sure the patient is stable, come back to the O.R. to set up for the next case, interview the next patient in preop and digest his entire life history in less than five minutes if possible, start an IV, get my medications ready, wheel the patient into the operating room, induce the patient, then call the surgeon to let him know we are ready for him. All in under 30 minutes, preferably under 20. So you can see, there is little opportunity for anesthesiologists to eat outside the operating room. Therefore we have to be creative in order to keep from getting malnourished and hypoglycemic. It would be unseemly to have an anesthesiologist collapse behind the ether screen because his blood glucose is 32.

So what kinds of food work best for munching in the O.R.? There are several rules I think should be followed. The number one rule is the food should emit no odors. Anything that will draw attention to your eating is absolutely unforgivable. Thus something like popcorn is out. Coffee is the rare exception that most staff in the O.R, including the surgeons, have brought in with little protest.  Next the food must be easily handled. No knife and fork or other utensils should be necessary to eat it while working.  The food should be compact in size. It should be able to fit under your mask while eating, preferably bite size pieces so you're not holding a piece of food in your hands between bites. No greasy foods. That means french fries and nachos are out. Leaving greasy fingerprints on your machine and anesthesia records cannot be tolerated. No loud foods. Potato chips commit the double felony of greasy and loud. So they're out. Nothing too watery. That can leave a mess and make you need to go to the bathroom in the middle of the case. Finally, no choking hazards. The surgeons don't like it if they have to unglove to perform a Heimlich maneuver on you.

Okay, so now that we have the basic rules for the kinds of food that should not be eaten in the operating room, let's look at a list of stuff that should pass muster. Some are sweet, some are savory, but there should be something here for everybody.

1. Power bars or granola bars. This is the standard by which all other O.R. foods are compared. There are infinite varieties to choose from. They are small, compact, and easy to eat. They are quiet when chewed and they fit easily into your briefcase. Just remember to get the ones that don't have crinkly wrappers. The wrappers will draw too much attention to your activities.

2. Grapes. They're sweet, healthy, and a good source of hydration in a compact size. Definitely get the seedless variety as you don't want to be spitting out seeds all over the O.R. floor. Just make sure you don't eat too many of them lest you need to urinate during the case.

3. String cheese. A good source of calcium and protein. Small and easy to eat. The kids love them and I do too.

4. Peanut butter and jelly sandwich. This is a surprisingly good fit for the operating room. Cut into small squares, they fit easily into the mouth. It is a quiet food, loaded with protein, satisfies both the savory and sweet tooths, and doesn't leave crumbs behind. Just be sure nobody in the room has a severe case of peanut allergies.

5. Juice box. This is good for a quick hydration and glucose pick me up. The small straw that comes with the juice box makes it easy to drink under your mask. Multiple varieties to choose from. Just try to avoid the slurping sound it makes when the box is almost empty.

6. Fig newtons. An ideal cookie for the operating room. They don't have a strong smell like chocolate chips cookies can have. They are bite sized. And they leave few crumbs behind.

7. Small crackers. Examples include Cheez-Its and bite-sized Ritz crackers with or without fillings. Being bite-sized helps make sure there are no crumbs all around the anesthesia work station. Also little munching noise is made when you can chew a whole cracker with your mouth closed.

8. Small pretzels. Mini pretzels work well. You can fit an entire one in your mouth at one time making little noise and few crumbs. They are loaded with carbs to keep your energy going. They are also low in fat and taste good. What else could you ask for?

Those are my dietary recommendations for replenishing yourself in the operating room. Again, you should never, ever, ever eat in the O.R. But if you have too, you can't go wrong with any of these choices. Have I left anything out? Please give me some of your suggestions in the comments below. I'm always willing to try something new from my fellow anesthesiologists.

The Interminable Hell Of A Medical Malpractice Suit

In Massachusetts, a jury recently found two anesthesiologists innocent of causing the death of their patient. In 2005, Stella Kieras, a 77 year old driver who crashed her car into a light pole, was brought to the Baystate Medical Center suffering multiple bone fractures. Attending anesthesiologist at the time, Suzette Damboise, and her fourth year anesthesia resident, Kamel Ghandour, provided the anesthesia during her orthopedic repairs. Soon after the end of the case, the patient suffered a cardiac arrest and was not able to be resuscitated.

The patient's family sued the anesthesiologists for medical malpractice, complaining that an antihypertensive the doctors gave her caused her blood pressure to drop too low leading to the death. However, an autopsy report showed multiple fat emboli in the patient's blood, not an uncommon complication from orthopedic fractures. After a seven day trial, the jury returned within an hour of deliberations and declared the doctors not guilty of malpractice. Congratulations to Drs. Damboise and Ghandour on their legal victory.

This must have been very traumatic for the both of them, especially Dr. Ghandour who was just starting out on his new career. A recent study published in the New England Journal of Medicine pointed out that a vast majority of doctors will face legal action at least once in their careers. But statistics repeatedly prove that doctors are found innocent about 80% of the time. This is little comfort for the physician.

The case of Ms. Kieras started with an auto accident in 2005. It has taken over six years of litigation before the situation was finally resolved in the anesthesiologists' favor. While most lawyers will point to cases like this to show that doctors are overreacting to medical malpractice and try to deny implementation of any kind of legal reform, it is the doctors who have been put through six years of legal hell. Imagine having the fear of large monetary damages, loss of reputation, and general anxiety about your competence as a physician hanging over your head for years. The idea that your career hangs in the balance over the thought processes of twelve laypersons who may have little medical understanding of the case other than what the mercenary "expert witnesses" have testified is horrifying to most doctors. Is it any wonder doctors order far more tests and procedures than necessary to prevent to the fullest extent possible the chance of a malpractice suit? Screw the government's guidelines and studies for optimal medical practices that maximizes care and minimizes costs. When the lawyers come knocking at your door, the government will not be around to tell the lawyers to back off since you did everything by the book. They're too busy encouraging the lawyers by preventing any malpractice reform legislation from passing and allowing the way for more of their legal buddies to join in on the action.

Will The Physician Shortage Resolve Itself?

Much has been made about a possible physician shortage in the coming decade. Pundits point to the aging population and the large number of baby boomers reaching their golden years with its increased need for medical care. At the same time the large number of baby boom doctors themselves are set to retire. Then there is the fact that there is a very limited number of medical schools and residency programs to train new doctors. Add it all up and who can refute the prediction that the U.S. will face a dire need for more physicians in the near future.

However, statements about the future are rarely accurate. One of the most infamous predictions about the number of doctors needed was in the 1990's. At the time, many were predicting that there was going to be far too many anesthesiologists in this country. Because of these apocalyptic predictions, the number of medical students who chose to enter an anesthesiology residency in 1996 dropped to 325. The percentage of residency positions that were filled fell to only 34.3%. If you could fog a mirror, you could have gotten a residency spot into one of the most lucrative medical fields around. By comparison, in 2011, there were 841 anesthesiology residency positions available for the match. A full 820 of those were filled for a match rate of 97.5%. Today, anesthesiology is one of the toughest residencies to enter. How times, and predictions, change.

Now, we are bombarded by a bunch of Chicken Littles about the severe shortage of doctors in the near future and how it will limit access to health care. As I see it, there are several factors working to alleviate this deficiency. First of all, like the general population, doctors are expected to live longer. Their numbers of productive working years are likely to stretch far beyond what previous generations of doctors were able accomplish. So this bulge of baby boom doctors are likely to work well into their 60's, 70's, maybe even their 80's.

Second, they may need to work longer. Doctors have suffered catastrophic financial losses during the Great Recession. Many physicians have retirement accounts that have been devastated by the stock market. Reimbursements from payers have steadily shrunk, making it difficult to work your way out of these losses. Hoping to live off the interest of your savings is nearly impossible when the Federal Reserve is trying its hardest to keep interest rates nearly zero. So doctors may have no recourse but to keep working, just like everybody else who had hoped to retire soon.

Finally, the Great Recession has had a tremendous affect on the home front. Their kids may be going on five, six, seven, or more years of college education to gain that extra edge when it comes time to finally look for a job. At the same time, colleges are increasing tuition at a double digit inflation rate because of state funding cutbacks. So college expenses are gobbling up a huge chunk of income that would have gone towards retirement. If their kids have already graduated, they may still move back home for lack of a job, or a decent pay. With the kids back home, it is impossible to sell the house to downsize, like a normal retired couple would do. Unfortunately because of the housing market crash, it probably would have been difficult to sell the house at a decent price to move to Florida anyway.

As you can see, there are several major forces working against doctors leaving their jobs. In fact, nobody has retired from our group in over five years. And believe me, many of them should be in a retirement community playing golf at the country club by now. But financially, they can't do it. So now we have all these guys who are not leaving, preventing the younger anesthesia graduates from gaining a foothold in the field. Unless there is a sudden renaissance in the economy, we may have too many doctors trying to chase too few open jobs, just like the current fallout from the explosion in nursing school graduates. Then doctors will be facing a dearth of job prospects like everybody else.

In Los Angeles, Physician Reimbursement Is Heading To $0

You knew this was coming. In these times of worsening financial crises, when the government is running billions and trillions of dollars in debt but the needs of the poor are still growing, they have to cut the money from somewhere. The easiest targets, naturally, are the healthcare expenses of the government budget. Within this enormous slice of the budget, healthcare reimbursements to doctors are the quickest and least controversial areas to slash. Unlike the public employee unions, doctors cannot organize and threaten to shut down the system to prevent payment cuts. They are "morally obligated" to treat patients, no matter if they are paid or not.

In L.A. County, the Health Department has proposed cutting back reimbursements to doctors who treat the indigent population. If the reduced rate is not accepted, they will stop payments to doctors altogether. Health Director Mitch Katz has told the County Board of Supervisors that the department has no choice because it is running a deficit of millions of dollars this year. Currently MediCal, California's Medicaid program for the poor, pays doctors 18% of a patient's bill. That works out to about $50 for a visit. Under the Health Department's proposal, the county will reduce reimbursements to 12% of a bill. If the County Supervisors don't approve, then they will not pay doctors at all.

Notice that no doctors were consulted on this drastic decision that could irreparably harm their livelihoods and the healthcare of millions in the county. No attempt at cutting expenses from other areas of the budget were contemplated in the name of helping the poor. No salary reductions for county employees are in the cards. No changes in their pension plans or their gold plated health insurance will be tolerated in an attempt to give the indigent better medical care. Of course the reason is that everybody knows doctors have no choice but to treat patients for free. Thanks to EMTALA, anybody who walks or is wheeled into the emergency room will be taken care of, whether they have the ability to pay or not. If the care is felt to be substandard, then the patient will just call the first medical malpractice lawyer he sees advertising on the side of the city bus to extort money from the doctor and the hospital, who may not have received anything at all trying to help the patient. 

Some say a single payer system is the eventual endpoint for healthcare in the U.S. If we believe that medical care is an essential element of a civilized society, and frankly it has been elevated to a right like freedom of speech and religion, then the only logical choice is the single payer. However, now we can see that doctors being beholden to a single entity for payments has severe downsides. With no market competition, doctor salaries can be changed on a whim, depending on the generosity and fiscal health of the government. That day may not be as far off as we think.

The Pending Economic Crash

First off, I'll be the first to admit I am a horrible prognosticator of the stock market and economy. I don't have an MBA or an Economics major. I don't have any insider access to the workings of the Federal Reserve or the White House. But just from my gut feeling, I feel that we are approaching a huge correction in the stock market and economy in the U.S.

Ever since the Great Recession was declared finished in the summer of 2009, most people have commented on how little of the subsequent economic growth has helped the general population. Tens of millions of people are still unemployed or underemployed. Housing prices are still falling despite the government's best attempts at keeping interest rates low. It has been widely observed that the only people who are doing well nowadays are "the rich". Not only are the rich accumulating a greater percentage of the nation's wealth. They are also the only ones spending money to keep the economy rolling. Companies that cater to the wealthy like Mercedes-Benz, BMW, Louis Vuitton, Tiffany, and Apple are doing banner business. Meanwhile, corporations that sell to the middle and lower class are struggling, like Walmart and Dollar General.

What is going to happen now with all this stock market volatility? The rich are the first ones to cut back on spending when they fear the stock market is going to decline. If the wealthy are the only ones buying non-essentials while the rest of the population have already cut back spending to the bone, what do you think will happen to the economy? That's right. With no more monetary support it is likely to suffer a painful crash. Think China can bail us out by buying our government debt? Remember they make most of their money by selling to Western consumers. They will suffer a downturn just as much as the rest of us.

If the fundamentals of the economy don't scare you, maybe some technical analysis of the market will put some fear into you. Again, I am not a stock broker or have any formal training in market analysis. However I've read my share of financial journals and there is a basic market pattern called "head and shoulders". A head and shoulders pattern depicts three peaks in the market before a fall. Check out this graphic.

This is a graph of the S&P 500 from 1991 until today. Notice the clear triple peak of a head and shoulders pattern. The first peak represents the apex of the internet bubble of the early 2000's. The middle and higher peak is the top of the real estate bubble. The final and lowest peak is the quantitative easing engineered by the Federal Reserve to keep the banking industry from collapsing. Now the Feds have run out of ideas to help the banks. The government is too broke (of money and ideas) to help the country. The people are too poor or nervous to stimulate our consumer economy. Doesn't seem like there is anything that can be done to keep our economy from washing out. How far the market will fall I can't tell. Maybe somebody with more experience with stuff like "moving averages" or "support levels" might have an answer but I don't.

Again take all this analysis with a grain of salt. I'm just a humble doctor with no formal education in stock charting. I'm just nervous as hell about what will become of our nation and ourselves.

Two Paths

This year will mark a quarter of a century since my high school graduation. It is painful just having to type that. Great plans are being made by our former class president to have a blowout party at our old high school hangout. Thank goodness for Facebook to help organize the event and allow everybody to stay in touch.

FB is an amazing resource for keeping up with old classmates. I can see all the great pictures my old buddies have posted. Their wonderful vacation shots. The proud photos of their sons on their football teams. Their daughters' performing on the cheerleading squads. These pictures leave me wistful, with a twinge of regret. It is apparent that life continued for most of my old classmates while I, and all of my medical school friends, had our lives put on hold while we pursued our medical degrees. Many of my high school friends already have children enrolled in college. Some are already grandparents. I feel like they've already lived a full life of family, personal achievements, and career milestones.

In the meantime, most of my colleagues in my age group have children who are not even in middle school yet. We froze our personal lives in school and residency carbonite while we earned our right to treat other people better than we treat ourselves. Once we do start our families, we subsequently ignore them by our extreme work hours and exhaustion even on our few days off. I've missed countless soccer games, concert performances, birthday parties because of being a doctor.

Has this been worth it? Most of the time I can honestly say it is. There is no greater honor than to help somebody in dire need. This is a sacred trust that few people in society are given. But at the same time, my old friends have shown that work is not life. One can attain great personal satisfaction with wonderful friends and loving families. Sure they may not have the income I have. They may not have the nice cars I drive. Their neighborhoods may not have the same cachet as mine. In the end none of that matters. When one finally passes from this material world, nobody is going to ask if the deceased has an American Express Black Card.

This is something to ponder for anyone who is contemplating going into medicine. You'll come to regret putting your life on hold for ten years or longer pursuing a medical career while all your friends are starting families unless you understand the sacrifices that is inherent in becoming a doctor. It is still a wonderful profession. Just don't go to your 25th year high school reunion expecting anybody to be wowed by your fancy automobile. Others will have much richer life stories to share.

Ether Dome

Talk about an unlikely but intriguing subject for a play. Ether Dome, a new theatrical presentation in Houston at the Alley Theater premiered last weekend. The story revolves around the adversarial relationship between Horace Wells and William Morton, the disputed fathers of modern anesthesia. If you're in the Houston area, check it out. Would love to hear a report from an anesthesiologist there about their thoughts on the show.

I Am An Anesthesia Grunt

I am an anesthesia grunt. A second banana. I'm at the bottom of the totem pole of anesthesia. An untouchable in the caste system of my profession. One may think that doctors, including anesthesiologists, are quite egalitarian. Don't we all have medical degrees hanging on our walls? Didn't we all go through an ABA certified residency training program and successfully completed our board examinations? Aren't we administering similar anesthetics to our patients with similarly excellent results? Though all our backgrounds may be comparable, eventually a hierarchy develops within the field. There are distinct levels of importance within an anesthesiology career and where you fit in determines the quality of your professional and social life.

Let me start by using myself as an example. As I said at the beginning, I am an anesthesia peon. I will probably forever be stuck in what my colleagues charitably call a Level C career step. My lot in life is to come to work day in and day out doing much of the work a CA-3 anesthesia resident could probably perform. The only difference is that with more experience I know how to sidestep the pitfalls that invariably trap a resident or newly graduated anesthesiologist and drags him into M&M conference hell. My job description is not glamorous. You'll never see my work illuminated in the movies or TV. How many people want to see a patient being anesthetized for a colonoscopy or an appendectomy? No, the truly seductive anesthesia cases go to the Level B anesthesiologists.

Level B anesthesiologists in general are the ones who went through subspecialty fellowship training. They're the anesthesiologists who perform the "difficult" anesthesia that a runt like me was not specially trained to do even though we all had some experience with them in residency. Level B anesthesiologists all seem to belong to different anesthesia societies with names like SOAP, SCA, or SPA. They are held in higher esteem within the group and the hospital. Their job security is more assured than a Level C doc like myself. Level B anesthesiologists could probably write their own meal ticket anywhere they want to live and work. This mid tier of anesthesiologist still has to take call, but at least it's a focused type of call. Whereas I have to take virtually anything that rolls in through the emergency room doors, the Level B anesthesiologist only needs to anesthetize a specific type of patient for which they were fellowship trained, whether it be an emergency C-section on an eclamptic, severely stenotic mitral valve parturient, a three year old with life-threatening epiglottitis, or an emergency CABG on a patient who just had his coronary artery dissected by the cardiologists in cath lab. They do much more complicated cases that I wouldn't touch with a ten foot pole. For that reason I don't begrudge them their higher professional standing.

So now you may be wondering who is at the top of the anesthesiology pyramid. Who are the Level A anesthesiologists in a group and how did they get there? They are not necessarily the most skilled of anesthesiologists. However the Level A's are the ones who can do no wrong. It is not possible to fire a Level A anesthesiologist no matter how bitterly the surgeons or OR staff complain about their work. Level A's also don't have to deal with career inconveniences like taking calls. That is far beneath them. How does somebody attain this status? One is through sheer longevity. Work in one place long enough and you gain a certain gravitas despite the fact that your best work was performed about twenty years ago. People just feel bad about getting you fired after so many years. Another way to become a Level A is to be friends with the chairman of the department or hospital board of directors. Friends can overlook multiple professional deficiencies as long as you all are out playing tennis together every Sunday morning. Finally, an anesthesiologist can reach this peak by achieving some level of academic success. A department is loath to fire someone who has published seventy-five papers in their career and gives lectures from Manhattan, NY to Manhattan Beach, CA. An anesthesiologist like this makes their department, and hospital, look good.

So that is my career advise to you anesthesiologists and anesthesiologists to be. We may all seem equally capable, as our surgical colleagues believe, but in fact there are different tiers of professional success within the field. Don't get me wrong. I'm not complaining about my status. I enjoy my Level C work. It's much less stressful than the cases that the Level B guys do. And I hate to get up early Sunday mornings to schmooze my way up to a Level A. I will happily sedate a hernia patient for the rest of my professional life.

Patients Can Make Their $10 Copays. They Just Don't Want To Pay You

The Census Bureau has made headlines the last couple of days when it released its latest statistics on being poor in the United States. According to their studies, there are over 46 million people who live beneath the poverty level in America, defined as a family of four who make less than $25,000 a year. While those numbers sound horrific, poverty is a relative issue.

Sure surviving on $25,000 a year for a family of four sounds pretty dreadful. But the poor in America certainly don't look like the poor you see in third world countries like Ethiopia or Somalia. The poor in America even compare favorably to those living in developing countries like China or Mexico where it is still common to see rural residents live on dirt floors without running water or electricity.

According to the Heritage Foundation, who dug a little deeper into the Census report, the poor in America are in fact relatively well off. Over 96% of poor parents say their children have never gone hungry in the previous 12 months. Eighty-two percent of the poor say they have never gone hungry in the previous year due to a lack of money to obtain food. Judging by the rate of obesity among the poor in the U.S. that statement is probably about right.

The poor in this country are also NOT living in squalor. Two-thirds of the poor have satellite or cable TV. More than 50% of poor families have video games like an Xbox or Playstation. One third have a flat panel TV and one fourth own a digital video recorder (DVR) like Tivo. Half the poor families own at least one computer. Nearly three quarters own an automobile while almost one third own at least two vehicles. The average poor person in America has more living space than a non poor family living in first world countries like Sweden, France, or the U.K. Anybody who has traveled to a foreign country or watched a TV show like House Hunters International can attest to the tiny and expensive spaces the citizens of other countries are crammed into on a daily basis with nary a single complaint.

Many doctors see this paradox first hand. Patients quibble about paying chump change for their office visit. Yet they are gabbing on their cell phones while their kids are playing games on their Nintendo Game Boys. The clothes on their backs are definitely not from the Salvation Army. They drive nicer cars than most medical students. They'd rather continue to subscribe to a broadband internet connection to stay up with their FaceBook friends than to pay you to maintain their health.

That is what's so frustrating about the poor in America. We want to help them escape poverty, but to many people, they are not helping themselves with smart savings and spending. Doctors sacrifice material wants for decades before finally having the funds to truly live a good life. Yet we are the people the government want to take money from because we are "the rich" by increasing our taxes and lowering our pay. In turn the government gives it to "the poor" who its own statistics show live rather well. So next time a patient tells you they can't make their copay, tell them you feel for them. In exchange may be you can make a barter by keeping their cell phone or gold bracelet. Why should doctors be the only ones who work for free?

My Life In Code

Just when you think being a doctor couldn't get any more complicated. Between the vanishing reimbursements from third party payers, the prevalence of malpractice lawsuits, and the almost impossible work-life balance that is heavily tilted towards work and no life, you would think somebody would give doctors a break. Nope. That's not in the cards, at least from the government. The new International Classification of Diseases 10 (ICD-10) is about to be revealed. If an entire mini-industry has developed around helping doctors fill out the paper work properly for ICD-9, ICD-10 is going to require a cloud stuffed full of supercomputers to fully comprehend.

The ICD codes are the way a physician classifies a disease process when filling out insurance paperwork. Whether it be diabetes, hypertension, cholecystitis, meningioma, or thousands of other afflictions suffered by the human body, the doctor has to properly find the correct ICD code in order for insurance companies to determine if the patient received the proper treatment. For whatever reason if the code doesn't match up with the treatment, the doctor can be denied reimbursement. Thus thousands of people in this country are employed for the sole purpose of finding the right code so the doctor will get paid. There are currently about 18,000 different codes in ICD-9. With the new ICD-10, the number of different human problems that has been classified has exploded to over 140,000!

Has the number of human diseases increased that much? No, but the inquisition and persecution of doctors has. The government and insurance companies will now be able to understand what they are distributing the payments to doctors for in much greater detail. For instance, there are separate codes for injuries caused by ducks vs. chickens vs. goose vs. parrot vs. macaw vs. turkey. Each aviary injury is further subdivided into nine finer codes. There are codes separating injury caused by being bitten by a turtle vs. being struck by a turtle.

Third party payers, to an unprecedented degree, will be able to snoop on your daily activities short of actually having a camera follow you around all day and night. There are separate codes for injuries suffered while attending an opera, visiting an art gallery, playing a trumpet, or exercising at a squash court. There are codes to show what a white trash klutz you are, whether you fall down in the bedroom, the bathroom, or in nine separate locations within a mobile home. There are codes for walking into a lamppost and codes for subsequent followup after you walk into a lamppost.

An artery repair after you injury yourself will now require the doctor to enter at least one of 195 separate codes since each artery in the body has an individual code attached. A bone fracture leads to the possibility of sifting through nearly 3,000 codes to find the correct one. If the wrong one is filed with the third party payer, the doctor will be denied payment for his services.

Is it possible to put the entire human existence into a book of codes? And do we really want this level of intrusiveness into our lives? Ostensibly the purpose of having a near infinite number of codes on human activity is to help the government understand possible sources of disease or injuries and develop strategies to prevent them. Think about the potential abuse this system could created. There will be virtually no vice that a human will escape from without driving up their insurance premiums. A previously healthy person can suddenly be reclassified with a potential problem like having a "bizarre personal appearance" or "very low level of personal hygiene." "1984" is upon us and it doesn't involve cameras on every street corner. Through a confluence of government, insurance companies, doctors, and lawyers, the personal lives of every person in America will soon be examined in excruciating detail, starting Oct. 1, 2013 when ICD-10 takes effect.