Thursday, August 25, 2011

Doctors' Cries Of Poverty Ring Hollow To Many

Doctors have been complaining for some time that they aren't really rich. Between the extraordinary student loan debts physicians face, the declining reimbursements by payers, and the escalating practice overhead, doctors have been crying a river over their declining fates.

Yet to many observers, these lamentations don't sound sincere. It's easy to look around and witness examples of doctors who are much better off than the average person, or even professional, in America. The accompanying clip is a screen shot from of recent real estate transactions in one local Los Angeles region. As you can see, it is not difficult to find primary care doctors buying and selling multimillion dollar homes in Southern California. They're not exactly scraping by down here.

Another anecdote about the extravagant lifestyles of doctors can be found in the cars they lease. recently revealed that many professionals were downsizing their leases because of the economy. Doctors were the number one profession to change their leases. And what kinds of cars were they leasing? Mainly Mercedes S Class, BMW 7 series, and Maseratis. What are they slumming down to? Mostly smaller Lexuses and BMWs. After all, doctors have to maintain their images. As Archie Bunker once said, would you trust a doctor who drives a Plymouth?

Physician compensation may be weakening, but that doesn't mean doctors want to lower their standard of living. Despite crushing school debt, many residents' first cars are BMWs and Audis. Doctors live in nice neighborhoods so that they won't be embarrassed when they invite their colleagues over for a barbeque. They send their children to private schools since that's what their partners recommend. In the hallways they discuss the latest Barron's article about current stock market conditions and whose financial adviser is best. Whereas ordinary people may vacation at Disneyland, Las Vegas, or Santa Barbara, doctors bring back slideshows of their trips to Machu Picchu, Komodo Islands, or Petra Jordan.

So yes doctors may not be making as much as they used to. But perhaps the only ones who will notice are the older doctors who were able to milk the insurance system for all the money they could get. Nowadays the younger generation have to make do with more regulations and less compensation. But that doesn't mean they'll be buying their groceries with food stamps anytime soon.

Wednesday, August 24, 2011

Maybe Medical Malpractice Lawyers Aren't So Bad

Imagine one of your patients had a bad outcome in the hospital. Instead of facing a malpractice suit from the family's ambulance chaser, you are confronted with an angry mob carrying bats and pitchforks. That is the situation in China confronting doctors when their patients don't do as well as their families had hoped.  According to a report from the Los Angeles Times, doctors at a hospital in the city of Nanchang were warring in hand to hand combat in the lobby of the facility with the family and "friends" of a patient who died there. Doctors in their white lab coats were carrying sticks and cans of mace while security guards donned riot gear as they battled family brandishing pitchforks and clubs.

This appears to be a widening phenomenon over there. In a land where court justice depends on who you know, many people feel they have little recourse but to stage a confrontation. Their only hope is to extort the hospital and doctors for monetary damages by causing as much fear and destruction as possible. Some of these protesters are actually paid thugs, called yinao, who get a 30%-40% cut of whatever money the family is able to get from the hospital. As one yinao says, "If you start a big disturbance, you'll get a bigger compensation package. If you start a smaller disturbance, you'll get a smaller package. And if you don't do anything, you'll get nothing."

So next time you receive a summons from a malpractice lawyer, try to look at it with a little perspective. At least you don't have an rioters banging down your office door.

Friday, August 19, 2011

Preventing Surgical Recall

The New England Journal of Medicine has published a terrific study on the effectiveness of preventing intraoperative awareness or surgical recall. It is estimated that up to 1% of surgical patients will experience recall of their operation, or 20,000 to 40,000 patients. That is a tremendous number of people who may suffer severe psychological damage and post traumatic stress disorder from a routine operation. There has been no absolute method to prevent recall. The BIS monitor was developed that measures the EEG waves of an anesthetized patient. Through a proprietary algorithm a number between 0 and 100 is determined. A zero indicates a flatline in brain activity while a 100 means a fully awake patient.

The study was conducted as part of a multicenter trial involving over 5,000 patients. Half the patients would have their anesthesia monitored with a BIS monitor. The other half were monitored for awaress with the traditional end tidal anesthetic agent concentration (ETAC) monitor. To prevent surgical recall, the BIS monitor was kept at a reading between 40 and 60. For the ETAC patients, they were kept at 0.7 to 1.3 age adjusted MAC for the inhalational agent. Afterwards, the patients were interviewed at 72 hours and 30 days post surgery for any memory of intraoperative awareness.

To the surprise of the researchers, there were no significant differences in surgical recall between patients monitored with a BIS vs. patients who had an ETAC monitor. In fact, there was a trend for more patients using a BIS to have recall. Of 2,861 patients using a BIS, 7 patients definitely had intraoperative awareness and a total of 19 had definite or probable recall. Of the 2,852 patients who had their ETAC measured intraoperatively, two patients had definite recall while eight had definite or probable recall. Again neither number proved to be significantly different. It's interesting to note that premedicating the patient with a sedative like a benzodiazepine made difference in incidence of recall. Nor did a history of alcohol or drug abuse, ASA classification, or any other criteria looked at by the researchers make a difference.

Surgical recall is one of the most feared complications of surgery for a patient. Questions about it is probably brought up to me during a preop interview more often than almost any other anesthesia subject. The topic is so serious that the American Society of Anesthesiologists has a registry to document all cases of intraoperative awareness in this country.

This study only shows what has long been suspected, that BIS monitoring is not a definitive way to prevent awareness. It probably works better at preventing medical malpractice claims for surgical recall than it is at preventing the recall. You can always tell the patient and his lawyer that you did everything in your power to prevent the awareness, including attaching a BIS monitoring. Thus there really is nothing more that an anesthesiologist can do with current medical technology to prevent this tragic event. Improvements in measuring consciousness in real time is still in the research stages. In the meantime, the best way to prevent awareness is education and studious observation of the patient.

Thursday, August 18, 2011

The Most Powerful Person In Anesthesia

Who is the most powerful person in an anesthesiology department? You might guess that it would be the chairman of the department. If you did, then you would be wrong. As a matter of fact, the chair of the department is rarely involved with the nitty gritty of the daily grind that goes on in the operating rooms. He or she is too busy attending hospital committee meetings and hobnobbing with the other departmental chairs to really have an effect on the daily lives of anesthesiologists.

No, the real seat of power in an anesthesiology department is the person who is assigning the daily OR coverage to the other anesthesiologists. The scheduler, usually another anesthesiologist within the group, is the real godfather--he decides the fates of all the anesthesiologists on a day to day basis. If you are on his good graces, life is bliss. You could be placed in a room with the nicest surgeon who is doing three lap choles on healthy well insured patients as your lineup. If you're not, well woe to you. Your schedule for the day may be a single cardioversion scheduled at 2:30 in the afternoon. Or maybe an EGD at 8:00 AM followed by a second EGD at 1:00 PM.

If you're on the scheduler's disfavored list, this mental and fiscal torture could drag on for days, even weeks. You'll start pondering how you're going to pay next month's mortgage since billing a couple of pacemaker placements a day will not be adequate. You'll go through mental anguish as you try to figure out how you got on his bad side. Was it something you said to him at the last departmental meeting? Did he hear through the grapevine what you thought about his leadership qualities? Was it because you didn't invite him to your last barbeque? You'll start pondering about that great surgery center job you heard about a few months ago. You may start composing a resignation letter to the department and stress over explaining why you left without burning any bridges.

This self flagellation continues until one day, you receive your work schedule for the next day and you're working a full day again. In fact, you'll be working for at least fourteen hours the next day but you don't care. Your punishment has ended. The scheduler has brought you out of the ninth circle of hell and let you earn a real doctor's wage again. Hallelujah.

So as you can see, the anesthesia scheduler is rightly the most powerful person in anesthesiology. He can literally make or break your career and personal life. Get on his bad side and anesthesiologists have been known to disappear from a department almost overnight. Stay on his good side and now you can consider that Mercedes CL65 that you've been coveting to grace your circular driveway.

A Vast Majority Of Doctors Will Get Sued

The New England Journal Of Medicine published a revealing study about malpractice claims against physicians. The data are from a professional liability insurance carrier and covers over 40,000 doctors over a fifteen year span. The results show that in certain high risk fields, a doctor will almost certainly face a malpractice claim at least once in a career. An average of 19.1% of neurosurgeons faced a malpractice claim in each year of the study. Therefore over a fifteen year span, some were sued multiple times. Other high risk fields include cardiothoracic surgery, where 18.9% were sued each year, and general surgeons, whose ranks showed greater than 15% were sued annually. The lower risk fields, as one would imagine, were in the primary care fields. Only 2.6% of psychiatrists, 3.1% of pediatricians, and 5.2% of family practitioners encountered lawsuits on an annual basis. The high risk physicians were calculated to have a 99% chance of getting a malpractice claim in a career while the low risk fields still has a 75% chance of getting sued.

What about anesthesiologists? We as a specialty did surprisingly well. After the massive destruction to the field in the 1980s and 1990s from skyrocketing malpractice insurance premiums that discouraged the number of medical students entering anesthesiology residencies, anesthesiologists are about average in the number of malpractice claims filed against us. Click on the charts from the NEJM to the left to get a bigger picture.

Roughly 8% of anesthesiologists will face a malpractice claim each year, right about average for all physicians. The median payout from a malpractice suit was under $100,000 and the average payment for a suit was under $300,000. Both those numbers are below average for all physicians. Those are pretty good numbers considering that anesthesiology was once considered one of the most high risk fields in medicine with malpractice insurance premiums to match. Maybe it's thanks to our continuous improvements and advocacy of patient safety that is making the difference.

Monday, August 8, 2011

TENS Procedure, Indonesian Style

Transcutaneous electrical nerve stimulation (TENS) is a noninvasive form of therapy for chronic pain patients. Performed by pain doctors, electrodes are attached to the areas of the body that are causing pain in the patient. Small electrical currents are then sent from the TENS device into the patient to help relieve chronic pain. It is usually most effective as part of a multi-modality therapy for these patients.

Well in Indonesia, the people have discovered their own method for administering TENS procedure. According to local lore, a paralyzed man was tired of living his decrepit life. He decided to commit suicide by laying on the railroad tracks. He felt a small electrical current go through his body after a train had passed and supposedly he completely recovered his motor functions. How much if any of this story is true is impossible to say, but now there is a small crowd of people who converge on the railroad tracks to feel the electrical currents.

Now people are laying down on the tracks in the hopes of also receiving a miracle cure for free. They believe the train induced TENS will cure everything from diabetes to insomnia. These people are mostly poor, who can't afford decent medical care. They also don't trust the care they receive at the government run medical clinics. Therefore they cluster around the railroad tracks. The trains, which run on overhead electrical wires, supposedly give off an electrical jolt in the tracks before and after its arrival. This dangerous practice has been banned by the Indonesian government, but it is difficult to police all the tracks that run through the countryside.

If these people feel they are getting better from this, then so much the better. At least the Indonesian government isn't paying anything for its peoples' healthcare treatments.

Sunday, August 7, 2011

Respect Local Anesthesia

Dr. Roberto Bonilla
There is a surfeit of news stories recently about the lethal consequences of local anesthesia. First is the followup to the saga of Dr. Roberto Bonilla. Dr. Bonilla is the Inglewood, CA surgeon who killed his patient while performing a cholecystectomy under local anesthesia (!) in his home converted to a medical office. His lawyer claims that the patient died because of an accidental injection of lidocaine into the patient's blood vessel "which can happen to any doctor." Except hardly any doctor would perform a cholecystectomy using only lidocaine out of a private home even if it is converted to a "medical office". Dr. Bonilla lost his medical license last week.

In Las Vegas a few months ago a patient died during cosmetic surgery due to an allergic reaction to tumescent anesthesia. Ruben Matallana-Galvas and his wife Carmen Torres-Sanchez, neither of whom are licensed to practice medicine, were performing cosmetic surgery from an unlicensed facility when they were giving Elena Caro tumescent anesthesia for a buttocks enhancing procedure. The coroner's office ruled her death accidental due to an adverse reaction though with the large amount of local anesthesia necessary for this procedure who knows if she might not have had an overdose instead. They are being charged with murder though they may plead to the lesser crime of manslaughter.

Finally a five year old Georgia girl died from an overdose of local anesthesia while being treated for a broken arm. Kensley Kirby was taken to the Family Medical Clinic in McDonough by her parents after falling and breaking her arm. Instead of sending her to a hospital's emergency room, the doctors there injected lidocaine to help relieve the pain while setting the arm. They apparently gave too much to the little girl who subsequently died from the procedure.

So many people, not just doctors, think local anesthesia is so safe as to be without consequences. Well there is a reason why injectable lidocaine is not sold over the counter. It can have fatal results in the wrong hands. During anesthesiology residency, we are taught the consequences of intravascular injection of local anesthesia, the maximum dose of local that can be given to a patient, the pharmacodynamics of local anesthesia, the mechanism of action of local anesthesia on nerve impulses and on and on. How many surgeons, internists, or FP's have a complete understanding of the drug? Like any pharmaceutical given to a patient, there are always potential complications. But without a full comprehension of the qualities of locals, the risks for a fatal error are that much greater. So let me repeat this one more time people. Without proper training and monitoring, ANESTHESIA IS NOT EASY. In these unfortunate patients' cases, it was also deadly.

Anesthesiologists Are Screwed

Friendly Workplace Linked To Longer Life, New York Times.

"Researchers at Tel Aviv University found that people who felt that they had the support of their colleagues and generally positive social interactions at work were less likely to die over a 20-year period than those who reported a less friendly work environment. Over all, people who believed they had little or no emotional support in the workplace were 2.4 times as likely to die during the course of the study compared with the workers who developed stronger bonds with their peers in other cubicles."

Mortality Rates Among Swedish Physicians: A Population-Based Nationwide Study With Special Reference To Anesthesiologists, Acta Anaesthesiologica Scandinavica.

"Anesthesiologists had a 46% higher mortality rate and pediatricians a 24% lower mortality rate than other specialist groups; both deviations being statistically significant. All other specialities had a mortality risk within the expected range. Anesthesiologists tended to have higher rates than other specialists for most underlying causes of death."

Anesthesiologists are screwed.

Thursday, August 4, 2011

Surgical Complications Include Bleeding, Infection...Pedophilia?

An official of Los Angeles County has been investigated for possession of child pornography. Albert Abrams, president of the Board of Neighborhood Commissioners, resigned from his post after his house was raided by the FBI. In his defense, Mr. Abrams declared that he had back surgery earlier this year. This led him to have "behaviors that were completely out of character." Uh yeah. L.A. mayor Antonio Villaraigosa, in a delicate defense of his appointee said he didn't, "think it's something I've heard before as a reason for this type of thing."

Okay Mr. Abrams. Own up to your deeds. Don't associate the good doctors who helped you get better with your nefarious perverted activities at home. If you go to prison for this, your new friends will help you man up real fast.

The AMA During The Debt Ceiling Debate Or The Silence Of The Lambs

Oh, AMA, wherefore art thou? During the crucial debt negotiations just concluded, nary a peep was heard from your fine organization. You claim to represent the aspirations and political muscle of doctors in the country. Yet at the time when the voices of physicians would have been critical in shaping debate, you disappeared, mute and impotent.

So what did doctors get out of this debt deal once the dust settled? If a Congressional special committee is unable to find $1.8 trillion to cut from the budget, the deal calls for an automatic $1.2 trillion to be slashed, half from the Defense budget, half from Medicare providers. Not cuts to Medicare and Social Security benefits, federal employee pensions, ethanol subsidies, foreign aid to the likes of Pakistan and Egypt, bizarre federally sponsored research, and on and on. That's right. Half of the responsibility of keeping the United States from becoming the Greece of the Western Hemisphere will fall on the shoulders of doctors and other health care providers. Less than one percent of the people in our country will be responsible for making sure the U.S. keeps its coveted AAA credit rating. In the meantime the other 99% of the population can continue to drive up the usage and costs of healthcare with impunity.

It is calculated that this will mean an automatic 2% cut in Medicare reimbursement to doctors. Though that may not sound like a lot, Medicare is already causing doctors and hospitals to operate at a loss taking care of its patients. If a public company was to announce that it's revenue will drop 2% the next year, you can imagine how investors would bail out of its stock. Not exactly the picture of a growth company, or even a value company.

Let's not even talk about what we're going to do about the SGR that is threatening to cut 30% from Medicare reimbursements next year. If the AMA was not able to affect a permanent fix to the SGR last year during the Obamacare debates, how are they going to convince Congress to dismantle the SGR that could potentially cost taxpayers $500 billion over the next ten years?

So once again American Medical Association, thanks for nothing. You've shown time and time again why the power brokers in Washington treat you with such disdain. With uncommon regularity you have proven why only about 25% of doctors belong to the AMA. You have not given doctors any reason to join your organization, even with your frequent half off membership sales. AMA=Fail.