Wednesday, June 29, 2011

Anesthesiology Haters

By now, many of you have probably read the incendiary op-ed from Dr. Karen Sibert, an anesthesiologist, in the New York Times a couple of weeks ago. In it, she admonished female physicians for taking tax payer money to complete medical school and residency then decide to work part time or quit altogether when their biological clocks start ticking, thus worsening the shortage of primary care doctors in this country. I had originally decided not to comment on it since I had already written a similar post a while back. Of course my article did not get nearly the high profile exposure and discussions that come with being published in the New York Times.

But what I do find worthwhile to talk about is the feedback. As might be expected women physicians were outraged by Dr. Sibert's opinions. All sorts of vitriol have been heaped on her for daring to voice a supposedly sexist point of view. As a matter of fact, my post also received a similar angry comment from a female physician. But now Dr. Sibert has revealed that some of the insults thrown at her have nothing to do with her view of part time working women. Many of the comments have centered on her being an anesthesiologist. Some doctors seem to think that anesthesiologists aren't really doctors and have no idea how hard "real" doctors work.

Dr. Sibert, in a letter to the California Society of Anesthesiologists, wrote that name calling seems to come easily to other doctors when discussing anesthesiologists. One commenter in a medical blog described us as "Gucci loafer, sports car, nanny-hiring anesthesiologists." Another wrote, "Most of their patients are totally unconscious the whole time and they read the newspaper in the operating room, no joke." Another poster described anesthesiology as, "already a lifestyle type choice of medicine--largely shift work, and well reimbursed." Finally, one (ignorant) writer said, "Dr. Sibert is not a clinician! She puts people to sleep and wakes them up for surgery!"

Wow. It appears that the ASA has more work to do in the public relations department. Besides educating the general public about anesthesiologists, we need to convince our fellow physicians too. Their Lifeline to Modern Medicine campaign isn't even getting through into the doctor's lounge, much less the American people. All the work that anesthesiologists do in advancing patient safety, such as proper patient monitoring during sedation, have been taken for granted. The only thing other physicians notice are the big iPads sitting on our laps while we're in the OR and our Porsches in the doctors parking lot. (Sorry Dr. Sibert. You may drive a Volvo, but many anesthesiologists do drive Porsches, and Mercedes, and BMWs, and Lexuses.)

Is it a case of envy? According to Medscape's 2011 Physician Compensation Report (free membership registration required), anesthesiologists are one of the highest paying fields in medicine, with a median salary of $325,000 per year. We are ranked behind only radiologists, orthopedic surgeons, and cardiologists. Is it because we have been on the vanguard of the revolutionary changes in the medical workplace with its increasing focus on shift work? Anesthesiologists long time ago realized that one cannot do their best work when exhausted after being on the job for an extended period of time. Perhaps these anesthesiology-hating doctors can choose to do shift work or part time work to relieve their exhaustion and grumpiness. Or maybe these doctors who are mouthing off on anesthesiologists should just shut the f*** up and continue their daily grind because that is what they decided to do when they were young energetic medical students twenty years ago and now can't handle the rigors of their chosen field. They should just get their own freaking iPads and get over the fact that they made their decisions in life a long time ago and now can't stand to see that the grass is indeed greener on the other side of the ether screen.

Tuesday, June 28, 2011

When A $600,000 Salary Just Isn't Enough

No silly, I'm not talking about anesthesiologists. I'm here to discuss the shenanigans of spine surgeons. They are among the highest paid physicians in America. Their average salary is greater than $600,000 a year. Yet that much money apparently isn't enough for some spine surgeons. First we had reports of surgeons committing Medicare fraud by operating on the same patient's spine multiple times. Now we have this, surgeons who receive millions of dollars from a medical device maker for publishing "research" that are favorable to the company but don't disclose their monetary ties to that company.

According to the Wall Street Journal, Medtronic has been marketing a bone growth device called the Infuse Bone Graft for spinal surgery. Infuse has been written up by multiple surgeons approving of its efficacy and lack of serious side effects. However, many of the surgeons didn't report that they received money from Medtronic. In fact, one editor of the research papers, Dr Thomas Zdeblick of the University of Wisconsin School of Medicine and Publich Health, has received $24 million from Medtronic since 2001. He did not disclose his financial ties to the company in any of the papers he worked on. Other surgeons noted in the article also received millions from Medtronic for producing flattering papers about Medtronic's products without noting any serious morbidities. Dr. Kenneth Burkus from Columbus, GA even solicited Medtronic's input into a draft of a research paper he was writing about Infuse. Dr. Burkus has received $4 million from Medtronic since 2001.

What are some of these side effects that the surgeons are not disclosing in their papers? How about cancer? In a product up for review by the FDA, a similar Medtronic product called Amplify was found to have a 90-95% probability of causing cancer in the patient. That information was not written in the published papers. Infuse related side effects include cancer, sterility, infection, and bone dissolution in up to 10-50% of patients. Again that was papered over.

The surgeons and Medtronic say that their payments from the company are not related to their research. That may be so. But it's hard to tell when there is so much stench emanating from these so called independently conducted articles.

Monday, June 27, 2011

Economic Confusion

President Obama has proposed that cars in the U.S. should average 56.2 miles per gallon by the year 2025. Sounds ambitious but I'll give him credit for having an environmental vision. Yet just last week he decided to release 30 million barrels of oil from the Strategic Petroleum Reserve to lower oil and gas prices. Oil prices have since dropped about ten percent.

Now I'm no economist, but it seems to me one plan negates the other. If I understand the laws of economics correctly, the best way to get consumers to do something is to give them an incentive to do so. Therefore, if the president wants people to drive high mileage cars, shouldn't he allow gas prices to rise? Look how well hybrids and 40+ MPG cars are doing right now with gas prices around $4.00 per gallon. Take a look at the automobile markets in Europe and Japan. Over there, it's not unusual to have gas prices at least double what we pay in the U.S. due to high fuel taxes. Yet the people have a smorgasbord of fun high mileage cars to choose from.

So which is it Mr. President? Are you trying to bolster your environmental credentials by forcing car companies to add thousands of dollars of gas saving technology that nobody wants to buy? Or do you think we could lower our dependence on Middle East oil by letting gas prices go up and incentivizing people to buy fuel efficient cars? I'm not a lawyer like you but I think I know which method will works better.

Thursday, June 23, 2011

The Anesthetized Brain

Researchers from the University of Manchester have presented a video at the European Anesthesiology Conference that demonstrates how a brain slowly loses consciousness when undergoing a propofol induction. Using an instrument called a functional electrical impedence tomography by evoked response (fEITER), they were able to visualize the brain slipping into sleep in real time. Dr. Brian Pollard, the presenter of the paper at the conference, noted that initially propofol inhibits the inhibitory neurons in the brain. The brain thus becomes more excitable, which is seen on the video.Then as more propofol is given, the excitatory neurons are also inhibited and the brain then slips into unconsciousness. Unlike what patient's may say they feel, the brain doesn't become anesthetized like a light switch. There is a gradual decline in the brain function.

I have noticed the same phenomenon when anesthetizing patients. If one pushes propofol very quickly, the brain goes through its stages of sleep rapidly. Therefore it appears the patient is out "like a light." However if you give the propofol slowly, in small boluses, many patients lose their inhibition first. This is manifested as a sudden need to vocalize their thoughts or express their emotions. Many patients are very anxious and quiet as they are about to go to sleep. But once the propofol is started, they will start talking about almost anything, including how attractive their doctors or nurses are. We don't hold it against them though. We know it's just a drug induced euphoria and the patient will have no recollection of it after the surgery.Now we have scientific visual evidence of this state.

Sunday, June 12, 2011

Self Service Medicine

I wash checking out and bagging my own groceries the other day when I started to think, what happened to the good old days? All this self service is designed to save the store more money and increase its profits. But I miss the recent past when full service was not just an option, but the norm. My brother worked as a bag boy at a grocery store during high school. Back then, he not only bagged the groceries, he even took the bags out to the parking lot and placed them in the customer's car. Rain or shine, snow or stifling heat, he walked back and forth from the store to the parking lot dozens of times a day. The customer never had to get her hands dirty touching the grocery bags. Now some places don't even give you a bag to put your stuff in anymore.

Even further back in history, how about the demise of the full service gas station. I'm not old enough to have experienced it, but I'm told gas stations used to fill up your gas tank for you without you ever getting out of the car. Remember in the movie Back To The Future when Marty McFly is transported back to the 1950's and was astonished to see multiple attendants swarm a car as it pulled into the station? They were filling the tank, washing the windshield, checking fluid levels, filling the tires, and doing whatever it took to make sure the customer had a satisfying experience at the station.

That scene reminds me of the present situation in medicine. When a patient is wheeled into the emergency room, a horde of people descend on him to make sure he is treated to the highest possible standard. From doctors to nurses to techs to secretaries, an entire crew of people are there, costs be damned. But as the government and insurance companies relentlessly cut reimbursements to hospitals and physicians, we maybe headed in the direction of self service medicine in order for the payers to save money, even if it becomes a significant inconvenience for the customer.

Instead of complaining about the $5 tablet of aspirin, what if the patient's family went to Walmart and bought a bottle of the stuff for the same price? Patients complain about the cost of medicine because they don't see all the work that is required to bring that one pill to his bedside. Everything from the pharmacist, to pharmacy delivery, to the nurses, to the little paper cup that is used to bring to medicine to the patient costs money and is factored into that $5 aspirin. By buying the medicine themselves, families can save a lot of money by eliminating the middle man. The doctor just needs to tell the family, or write a prescription, and they can go out and find the cheapest source for their meds.

Think how many other procedures can be made self serve to save money. How about the self serve chest X-ray. What could be harder? You just walk up to a plate, take a deep breath, and push a button. Voila. A chest film. Or perhaps self service vital signs. Just have one of those automated sphygmomanometers at the bedside and have the patient or his family caregiver measure his own vitals. If the patient is unable to take his vitals, of course the hospital's nurse will do it for you, at a price.

Think this can't possibly happen? In developing countries, who have far less money to spend for health care on their population, patient's who can afford it already hire their own private nurses to take care of them. The unwashed majority are left to fend for themselves with the acute shortage of medical personnel. It is not unusual for a family to go out and get their own medicines and caregivers since they cannot rely on the hospital to do it. And if they can't afford the medicine? Well too bad for the patient.

Will patients and families tolerate all this hands-on inconvenience? People used to think they wouldn't want to fill their own gas tanks either. But as prices rise inexorably higher, the only thing left to cut is the hospital experience. We've already cut doctor's fees, hospital fees, name brand medicine reimbursements, denial of payment for tests deemed "not medically necessary". The medical supplier end is getting cut to the bone. The only fat left to cut is the patient's. Better start comparison shopping .

Tuesday, June 7, 2011

Can Medicine Be Humorous?

Writing a medical blog can be treacherous. One has to walk a fine line between humor and condescension, particularly when talking about a patient. Some recent events put a spotlight on this problem. A minor firestorm erupted in the medical blogosphere when a physician tweeted about her encounter with a man with priapism. The ensuing discussion focused on the possible HIPAA violations this person may have committed by talking about a patient's medical condition without his consent. Many were also appalled by the possible insensitivity of this doctor toward her patient, especially when she made the "fish or cut bait" remark. This was deemed behavior unbecoming of a medical professional. Just my two cents worth, I fail to see what all the fuss is about over this tweet. I had to reread it several times and follow the discussions afterwards before understanding why people are upset. Personally, I think the anger is an overly sensitive reaction to this particular tweeter's spontaneous and likely innocent remarks.

Then there is the recent news that a patient who had a billing dispute with a medical clinic paid his $25 medical bill by dumping 2500 pennies on the clinic's office counter. The clinic called in the police who arrested him for disorderly conduct. Sure we all may laugh at that man's poor judgement. But perhaps there is a deeper back story we are not privy to. Maybe he tried to negotiate with the clinic's billing department but was given the run around which led to his frustration. Maybe he went to the clinic for help but was not successfully treated to his satisfaction yet was still billed the disputed $25. Perhaps he has an anger management issue which caused him to dump the coins inappropriately on the office counter. Should we all be snickering at this man's emotional eruption? Perhaps it is the medical clinic that should be investigated for causing this man to get so angry he poured thousands of coins onto the counter.

We doctors like to think we are pillars of society. Highly educated, leaders of the community, doctors think people look up to us as unselfish caregivers and benevolent father/mother figures. Then how does one explain the endless stories on the web of the incompetence of each other's medical specialty. These are exemplified by the multitude of cartoonish videos that thrive on this culture of mutual condescension in the medical community. We physicians may think these anecdotes are quite funny. But let's not kid ourselves. The blog is an open public forum. Anybody can watch these anecdotes of medical incompetence. They may wonder if doctors really are that mean to each other and think so little of their colleagues' medical judgements. Are these physician produced videos also acts of betrayal and should be silenced for possibly injuring the reputation of the field?

Where does that leave a medical blogger? Writing about the nutty patient case is uncaring and medically unethical. It may even be a violation of federal privacy laws. Commenting on the acts of physicians and nurses may cause one to be labeled as unprofessional and a traitor to the glory of medicine. All too often, the patient stories I read in medical journals like JAMA are the tearjerkers where a doctor has the profound realization of life's fragility after an encounter with a patient's difficult struggle with disease and death. No humor there. And certainly not the kind of topic I want to expound upon day in and day out, week after week, month after month. I would become the most depressed anesthesiologist in the world if those are the only stories that are sanctioned by authorities to be publishable.

So dear reader(s), you can see the difficulties I face when I witness a situation during the course of my work that I think would be of interest to others. I could write about it with a sense of humor at the expense of the patient or colleague, or I could write a straight up prose which most would find dull and uninvolving but at least would pass muster with the medical censors. This blogging business is a difficult one indeed. Maybe I'll just write about my pet goldfish. I don't think HIPAA laws cover the privacy of aquatic animals.