Public Transit In L.A. Not For Most Private Citizens

Don't know about the rest of you, but gas prices here in California have been skyrocketing. The local stations are now selling regular gasoline for over $4.00 per gallon and premium gasoline for over $4.25. Darn you Mideast unrest and Chinese economic boom. So you would think that people would be stampeding toward their closest bus or train station to ride the public transit, right? Well, not so fast.

I calculated the time it would take for me to use public transportation to travel from my house to my hospital. A nifty little free website called Google Transit calculates your bus route from your home to your destination based on actual bus routes in your city it possesses in its records. I live about 25 miles from my work. Some of you may blanch at that commute. But here in L.A. it's par for the course. In fact I know some people who drive over 50 miles each way to get to the hospital every day. Why do we do this? First of all out in the suburbs we get a lot more for the money compared to central L.A.: more housing, more land, more parks. It is just a better quality of life. The second important reason is the public school system is much better. The only doctors I know who live close to my hospital are either older doctors who bought their houses decades ago when housing was still reasonable and doctors' salaries were multiples of what they earn today, or they have kids who attend expensive private schools while living in small, congested bungalows. Not exactly the kind of situation that would make your parents proud they raised a doctor.

How long would it take for me to take public transportation to get to work? I entered my home and my hospital addresses in Google Transit. I thought maybe, just maybe, if the public transit was reasonable I might try it just once. I entered my arrival time at the hospital as 6:30 AM, which is reasonable for my 7:00 AM O.R. start time. In less than a second, the program had an answer for me: one hour and 58 minutes! Are you kidding me? First of all, it instructed me to walk to the closest bus station from my home, 28 minutes away. Then I had to ride two separate bus lines, each one with over thirty stops each. Finally the last stop still left me short of the hospital by about two blocks. Yikes. Therefore to get to my work on time, I would have to leave the house by 4:30 AM, walk in total darkness for half an hour, then endure over sixty bus stops along the way before I have to schlep the last half mile to work. Thanks but no thanks.

Los Angeles has never been a subway or busing city like Washington or Manhattan. All the work are located where people can't afford to live and all the housing are where companies don't want to locate. This is why my next car is going to be a hybrid. Now if I can just ask the government to give me a raise by increasing our reimbursement rate...

Bleeding Heart Cake

From the Hannibal Lechter department of baking, here is a bleeding heart cake in all its oozing, hemorrhaging glory. It was being sold by Lily Vanili for a good cause (pediatric cancer). It is unfortunately sold out. Maybe if you call her and begged hard enough she will bake some more. If not, she helpfully provides the recipe. It would be perfect for your next cardiac anesthesia Halloween party or Tea Party gathering. Now go eat your heart out--sorry I couldn't resist

Want To Know Why Anesthesiology Is Such A Popular Field? Try $5,000 Per Hour

L.A. Times columnist David Lazarus recently wrote about an outlandish hospital bill from one of our local premier hospitals, Cedars-Sinai Medical Center. One of his readers sent him her hospital bill after she had a laparoscopic assisted hysterectomy at the facility. She was in the hospital for about four hours, with probably only two of those hours actually in the operating room. Her charge from the hospital came to over $65,000.  Granted the hospital she went to was Cedars, on par with some of the best hospitals in the country like Brigham and Women's or Mayo. Still $65,000 seems excessive. For comparison, a study in 2007 at Thomas Jefferson University Hospital in Philadelphia showed the total hospital charges for a hysterectomy there average $5,707.

Now this was the upfront fee. Through her insurance company the charges were cut by 50% while the patient herself only had to pay $800 as her deductible. She herself has no quibbles about either the hospital or the insurance company. She just wanted the world to know about the dystopian world of medical billing in the America.

The interesting aspect about this article that fascinated me was the breakdown of the hospital charges. For a four hour stay, she was billed over $35,000 for the operating room, $13,000 for OR supplies, and get this, over $10,000 for anesthesia services. Ten thousand dollars for a case that may have required two hours of operating time. Even if the anesthesia bill was reduced by half like the rest of the hospital charges, the anesthesiologist made $5,000, or $2,500 per hour. Not bad for two hours of work on what sounds like a healthy patient. A few more cases like that and this anesthesiologist will be able to make his house and Porsche Panamera payments with only one day of work. Of course most anesthesiologists don't get the money they bill. Only people without insurance actually face the full charges and those are the patients least likely to pay any of their medical bills. And after deducting expenses like insurance and office overhead the take home pay is much much less than this. But still the amount on this lady's hospital bill is breathtaking.

Anesthesiology IS the ROAD to success. Congratulations to all those medical students who recently matched into an anesthesiology residency. You're well on your way to being the envy of the operating room.

Dream Dashed

My fantasy of buying the perfect Porsche has been dashed. At the Geneva Auto Show last year, Porsche displayed the 918 Spyder Hybrid. It is a Porsche with 500 HP that also gets 78 miles per gallon. I described it as a "dream". I certainly wasn't living in this reality. I unrealistically hoped the car would be affordable even for a physician. Now the reality has struck me with a giant two by four on both cheeks, and all cheeks.

At this year's Geneva Auto Show, the company has announced the price for this environmentally conscious Porsche--$845,000.  As a bonus, Porsche will allow the buyer to purchase a special limited edition Porsche 911 Turbo S for the exclusive price of $170,000. Who can pass up such a deal? Despite the public's perception that all doctors,especially anesthesiologists, are fat cats, I don't know of too many physicians who have the discretionary income to afford this car. In fact, the only medical people who can buy cars like this are hospital administrators and their ilk. Surely the CEO of New York Presbyterian Hospital, 2007 salary of  $9.8 million, can purchase this car. If he is reading this, let me just say that donating a car shows generosity of heart, even if it is given to little ole me. I'm just saying.

Please Call Me Z

An interesting commentary appeared in the Wall Street Journal the other day. The author wrote about the difficult experience of calling her previous superiors by their first names as a rite into adulthood. Reading the article brought back awkward memories for me too. Medicine is a very hierarchical profession, almost equivalent to being in the military service. Not to disparage anybody, but at the bottom of the pyramid are the interns (medical students are actually held in higher esteem because attendings want the students to like their particular field and encourage them more so than interns who are already captive). One step up is the resident followed by the senior resident, and depending on your specialty, the Chief resident, Fellow, and finally the Attending. Everybody has his place in this business. Attendings are always addressed as Dr. So and So. The residents relax and talk shop with other residents. The interns are too busy (at least in the old days) to fraternize with anybody except their own.

The awkward moment comes immediately after completing the residency. You're suddenly a full time attending of your own. The instructor you have always addressed as Dr. So and So can now be called by his first name. But for me it felt extremely uncomfortable to do that. Some other residents who were bolder or had social interactions with their attendings outside of work or were more blatant brown-nosers seemed to transition through this quite easily. For me, I literally had to spit out the first names of my new colleagues. I had to remind myself every time not to call them Dr. So and So and talk to them as an equal, which was expected. It was a difficult transition. I even had to learn to call the Chief of my department by his first name. After of 20+ years of education, where I've always called a superior by a title, now there are no more titles. I am the Man. Now if I can just convince my wife and kids to treat me as the Man, not as their Workhorse.

New "Tourists" In Los Angeles

One of the bedrock industries in L.A. is international tourism. We have folks from all over the world here visiting Hollywood, Disneyland, Venice Beach, etc... Now we learn there is a new tourism industry that has sprung up. It is called "birthing tourism". Some entrepreneurs in the San Gabriel Valley suburb of L.A., which is predominantly Asian, have set up private residences for women from Asia to give birth so the child can be automatic American citizens.

In this particular case, people in this quiet part of town were wondering why there were suddenly so many pregnant women in their neighborhood. When the police raided the nice looking townhouse, they saw ten women sitting around having dinner while seven newborns were laying in bassinets, being taken care of by a nurse. The police fined Dwight Chang, the property manager, $800. They could only fault him for remodeling the townhouse without the proper permits. After all, giving birth in a private residence isn't illegal, even for the purpose of delivering an anchor baby. Capitalism at its best--find a need and fill it. And make a profit out of it if possible.

How You Know Your Wife Loves You

Here on the West Coast, we are dealing with radiation fallout from the stricken nuclear power plants in Japan. There has been a run on iodide pills and face masks. At least we haven't reached the level of panic where people are stockpiling iodinated table salt like they are doing in China. Some outdoor activities have been curtailed because of parents' concerns about exposing their children to falling radioactive particles.

My dear wife has gotten caught up in this hysteria. Though the amount of radioactivity from Japan has been officially described as minuscule, she has decided to stock up on emergency supplies in case the family can't go out due to more radioactive contamination or a major earthquake. And guess what she bought to prepare the family for the apocalypse?  Just my favorite snack of all time--a big giant box of Cheez-Its. And the funny thing is that is the ONLY food item she got. No canned items. No dried goods. Oh, she did get extra bottled water. You have to wash down the Cheez-Its with something. That my friends is true love.

Surgeon's Pet

I was on call when I was asked to go do a routine case. At least on paper it sounded routine. Upon further inspection the patient was quite sick and warranted further medical workup. Though I will give anesthesia to virtually anybody, I had to balk at this case. I strongly expressed to the surgeon, whom I rarely ever work with, that the patient needs more workup in order to undergo a safe anesthetic. The surgeon was not amused. He was outraged that I was holding up the case when he and the patient's primary care team had already discussed and agreed to the procedure. I calmly reiterated my cautionary stance with this patient. He then told me he will find an anesthesiologist who will do the case and hung up the phone. Later I found out the surgeon found an anesthesiologist he works with frequently. That anesthesiologist, despite obvious contraindications for surgery, proceeded with the case and the patient did well.

What does this episode illustrate? Is anesthesia so safe nowadays that it can be given to anybody at anytime with little consequence? No. In my mind, it tells me that some anesthesiologists will do cases for "their" surgeons despite our duty to be the patients' advocates. I think it's part of human nature. Probably all anesthesiologists have at some point done a case for their favorite surgeon when it was against their better judgement and certainly not what they would do if the case was an oral board question. It's like the good friend you have known for years who suddenly wants to borrow money from you to start a small business. Against your better instinct you do it anyway, hoping and praying everything turns out well and nobody (especially you) gets hurt in the end.

While surgeons love the loyalty of their pet anesthesiologist, guess what happens when the turd hits the fan. The pet is suddenly left out in the cold, at the mercy of the lawyers and insurance companies that come looking for the criminal doctor who messed up the patient. What will the good buddy surgeon say when the attorneys come knocking at his door? He will point the finger straight at the anesthesiologist. "He said it was okay to do the case," will be his deposition.

It took me a few years of practice to understand this relationship with surgeons. Life is too short to be worrying about what the surgeon thinks of your anesthesia skills. No amount of money is worth the heartache and guilt when the patient crashes on the OR table, or worse, in the Recovery Room. Like a good friend who has your back, a good surgeon will never pressure his anesthesiologist to do a case against his will. If there is any arguing with the surgeon, it is probably best to resign yourself from the case and have him call for his pet, I mean, anesthesiologist. Hopefully, if they have any integrity at all, they too will deem the case not acceptable to take to the OR and the surgeon will finally realize we are all looking out for the welfare of the patient.

Who's Next?

2/27/10 Bio-Bio, Chile. Magnitude 8.8

9/4/10 Christchurch, New Zealand. Magnitude 7.1

2/22/11 Christchurch, New Zealand. Magnitude 6.3

3/11/11 Sendai, Japan. Magnitude 9.0

Anybody notices a pattern here? Three corners of the Pacific Ocean have been struck by severe and deadly earthquakes in the last year. Guess which corner is long overdue for a major one of its own?

Not So Evil Anymore

Many of you read have read my rants against my evil iPhone. In my mind, the iPhone was a method by which the messiah Steve Jobs ensnared his victims into the world of Appleology. All the technology geeks out there who bemoaned the monopolistic practices of Microsoft suddenly couldn't get enough of the tightly controlled ecosystem that is the iPhone and iTunes. The Jesus Phone appeared to be a device by which the weak minded go trapped into its cult. I shuddered at what I was getting myself into. Would I soon be brainwashed by this technologic orthodoxy and start knocking on strangers' doors to convert the heathens to this new religion?

But now I've changed my mind. The iPhone isn't merely a really bad cell phone with a great ability to waste away your day playing Angry Birds. (Full disclosure. I did download that game, but only the free versions. I'm not about to give more money to the high priest.) But I've discovered apps that can actually save me money. I found an app that can download books for free. Now these books are only in the public domain, ie/ before 1923. But that covers a lot of territory. So if you ever wanted to revisit your Western Literature class in high school, this is the perfect program. I've read books by Lewis Carroll, Arthur Conan Doyle, and Edgar Allen Poe since I've downloaded this program. I never have to buy another paperback anymore if I want to catch up on my literary classics. At about $10 per paperback, my savings are really adding up. Anna Karenina or Romeo and Juliet anyone?

I've also found the iPhone to be the best babysitter. You see it everywhere you go. At restaurants, children no longer take part in conversations at the table. They're all staring down at their iPhone/iPods playing games or texting each other. I've converted my DVD's into the iPhone format. Now the kids can watch Cars, Toy Story 3, and any other of their favorite DVD's at home and watch it outside when I need some peace and quiet. I normally wouldn't condone this sort of activity but sometimes we all need just a few minutes of respite from the whining and complaints that accompany small children when they go out..

So here's another paean to the Almighty Mr. Jobs. My iPhone still gets awful reception at my home. But its other uses makes it completely indispensible. Goodness I hate you for that.

Happy National Pi Day

For all you geeks out there, today is National Pi Day. You know, 3.14. I think every doctor, who after all are really health scientists, find math and science fascinating to a degree, with the exception probably of orthopedic surgeons. If you can't get enough of pi, you can find all sorts of facts and trivia here and here. Have fun. And go out there and make it a really good pi day.

How Running A Hospital Is Different From Any Other Business

You know those ubiquitous signs in restaurants, shops, and virtually every business you've ever walked into that read "We reserve the right to refuse service to anyone"? Have you ever seen a similar sign in any hospital? Wouldn't life be grand if doctors could post such a sign right smack in the middle of the hospital front entrance?

A legal website I happened upon discussed the ramifications when restaurants hang up these signs. It makes several points about the rights of restaurants to refuse service to patrons. I had to chuckle when I read the conditions. I'll list them here and contrast how hospitals are operated differently from food purveyors.

Patrons who are unreasonably rowdy or causing trouble. Have you ever been to the Emergency Room on a Saturday night?

Patrons that may overfill capacity if let in. Patients are lined up in the hallways in gurneys and wheelchairs and yet we still admit more into the hospital. Isn't amazing how the fire department will conduct strict capacity inspections of establishments like restaurants, movie theaters, and Cowboy Stadium, yet turn a blind eye to fire safety when hundreds of people are packed into ER's?

Patrons who come in just before closing time or when the kitchen is closed. Well, we never close. Even when every hospital bed is full and nurses are walking off their jobs from sheer exhaustion. Unlike waitors and busboys, we are expected to keep working no matter how many patients we can care for safely.

Patrons accompanied by large groups of non-customers looking to sit in. If we did this every extended family member and gangbanger bro who tries to come in with their "innocent bystander" gun shot wound victim would get locked out, leaving a terrible situation for our overwhelmed and underpowered security officers to keep peace. So let them all in.

Patrons lacking adequate hygiene (e.g. excess dirt, extreme body odor, etc.) Ha ha! You haven't lived until you've smelled pus and stool and who knows what other body fluid on a homeless man who hasn't bathed for weeks and comes in with wet gangrene of his crotch.

Now which business would you rather be running, a restaurant or a hospital? I think opening a Burger King franchise may not be such a bad idea.

Devastating

Our sympathies go out to the people of Japan who just suffered an 8.9 earthquake and devastating tsunami destruction in the aftermath. The videos are terrifying, even when filmed from hundreds of feet in the air by helicopter. No Hollywood special effect can match the horror victims must have felt when the giant walls of water came crashing down on them.

Living in SoCal we are acutely aware of the perils of living in earthquake territory. School children undergo regular earthquake drills. There are annual mock earthquake readiness practices conducted by the safety officers and hospitals. Yet when the real thing happens, I wonder how prepared we will really be. Can anyone really be ready for destruction on such a large scale as we're witnessing in northern Japan? Here's a page from the Huffington Post on how to donate for earthquake relief.

Yes You Can Abuse Me. I Am Your Doctor.

Doctors, why do we do this? We let our patients abuse us to a degree we wouldn't tolerate from acquaintances, friends, or even family members. You all know what I'm talking about. The verbal abuse we receive from our patients would make their mothers cry in shame and their fathers break out the hickory switch for a quick swat to the behind. Yet we just smile and continue with our jobs as if nothing happened instead of correcting this misbehavior.

I've been kicked, grabbed, spat on, and swung at with a closed fist. And I'm just the freaking anesthesiologist. If our patients attempted any of these aggressions on a police officer, they'd be hauled off to jail faster than they can scream "Don't Taze me bro'!" Why don't they understand I'm here to help? I'm supposed to be their friend and ally. I'm here to protect them from the dastardly deeds being concocted by the surgeons to rid their body of bad humors.

Sure you can say the patient's bad attitudes are a consequence of their ill health. But that is not always the case. Some of the most humiliating verbal abuse I've received have come from perfectly oriented patients, or their family. The complaints. The whining. The threats, both physical and legal. They'll think they can influence my medical judgement by declaring they have a family member who is a lawyer. Or they have a good friend who is on the hospital's board of directors.

Yet through it all we doctors continue to perform our duties. We bite our tongues and laugh about our abusers after we've treated and saved their lives. We don't need to be canonized for the work we do. But we should expect a little respect. Otherwise we just might take out our revenge by writing about it in a medical blog.

Wacky Doctor's Note

Doctors are notorious for writing illegible notes in the charts. Sometimes you have to wonder if they even bother proofreading their chicken scratches. Take this note I saw. While clearly legible, it raises the question whether the doctor or patient is the one that is altered. Under the subjective examination, the physician described the patient as being both "alert" and "confused". Hmmm. Now I'm confused. Or maybe I'm alert and the doctor is confused. Or maybe the patient is alert to the fact that he is confused. A conundrum indeed.

Another Insurance Scam

I hate insurance companies. But this one is personal. It's not because of the negligible reimbursements they try to deny doctors while paying their company officers millions of dollars a year. No, this time it's about how they treat me as a health insurance member.

As some of you readers may know, I recently moved into a new house. It is a very nice house. It is a very lovely house. It also moves my family into a new zip code. A "better" zip code with better schools, better streets, better crime statistics, and just all around better. As part of the process of moving, I notified my insurance carrier about my change of address. "No problem," said the customer service rep who helped me over the phone. "Oh, by the way," he said at the end of the conversation, "your insurance rates will go up with the move." "Why?" I asked dumbfounded. "It's because of your new zip code." Huh? "What does my zip code have anything to do with my health insurance premiums? I have never used my insurance for anything. I've never been hospitalized a single day in my life. I don't take any prescription medications or have any chronic illnesses. Why are the premiums being raised?" "I don't know," was his reply. "I'm just letting you know about the increase. Will that be alright?"

Naturally he wouldn't know the reason for the rate increase. He's just a customer service rep, not the actuary who crunches the numbers to come up with the real reason for the rate hike. My personal suspicion is that my new neighborhood has an older population than the previous one. Therefore people probably use their insurance more often here than in the old neighborhood. But I'm still miffed. California has a law prohibiting insurance companies from using zip codes to determine car insurance rates but somehow the lawmakers didn't make the same rules for health insurance. Then I got a letter from the insurance carrier last week that my health insurance rates are going to go up 17% in a couple of months on top of my already increased rates. They cite the usual blah blah about rising medical costs, higher utilization rates, sicker patients...

What happens when ObamaCare kicks in and everybody is forced to purchase insurance from these rascals? What will happen to the country when insurance companies continue to raise rates every year on a product people are legally obligated to purchase? Either you pay the insurance companies a ransom to stay within the law or you're fined by the government and have to pay a penalty because you can't afford their rising premiums. Will there be a debtor's prison for people who can't afford rising health insurance premiums and can't or won't pay the government penalty? Where will this madness end?

Colonoscopy With Friends

Did you know March is Colorectal Cancer Awareness Month? I didn't either. Then I got this email in my inbox. The company that sent the spam is in the business of helping the elderly with living assistance in their own home. I guess as part of their public service, they are promoting the concept of colorectal cancer screening as a bonding experience amongst friends. (I am not endorsing this company. I just thought their email is amusing.)

The idea certainly has merits. Imagine sitting around with your buddies the night before your colonoscopy in front of the giant screen TV watching Ultimate Fighting Championship. Instead of chugging beer, everybody is downing ice cold drafts of Golytely. Yum. Then you can chase that down with shots of green jello. You could even make some kind of drinking game out of it. Every time somebody gets body slammed into the cage everybody has to drink another pint of the bowel prep.

The next day, have a bet who has the cleanest colon. The loser has to buy an In N Out triple-triple animal style for everybody in the group after the procedure. I think with with a game like this there would be greater compliance with screening for colon cancer, the second leading cause of cancer deaths in the United States. So be creative. Have fun. Anything you can do to make this milestone in life more amusing is worthwhile.

How You Know You Are Paying Your Nurses Well

How do you know if you are paying your nurses in the hospital well? When the nurses' break room resembles a Louis Vuitton showroom. These large LV bags on the table easily cost over $1000 each. I'm glad our nurses can enjoy a nice reward for all the hard work they put in around here.

Dr. Emery Neal Brown

It's not often anesthesiologists get a write up in the press. It's even rarer that we are mentioned in an article that's not about impaired physicians or enablers of prescription drug abusers. So it is quite refreshing to read a New York Times article about Dr. Emery Neal Brown, a professor of anesthesiology at Harvard Medical School.

Dr. Brown is very frank about why he chose anesthesiology. He states he likes the fast pace of the profession. Unlike most other medical fields, anesthesiologists also have relatively more predictable work hours with which he can indulge in his other love, research. That line should be used for every medical student aspiring to get into an anesthesiology residency.

He talks about his work into the neurophysiology of anesthesia. He frowns on telling the patient they are being put to sleep. Instead he prefers the euphemism reversible drug-induced coma. Being put to sleep is for the veterinary hospital, not the Veterans Hospital. He also discusses the difficulty of conducting anesthesia research on live human beings. I never really thought about the ethical dilemma of conducting research in anesthesia--is it proper to give a patient anesthesia only for research purposes if the patient is not undergoing surgery? He has a very interesting, and ingenious, solution to that problem.

So go ahead and surf over to the NYT. Feel good about all the great men and women who keep our field at the forefront of medical research. Perhaps you too may feel a little inspiration in becoming a better anesthesiologist.