Wednesday, September 28, 2011

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.

Tuesday, September 27, 2011

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.

Sunday, September 25, 2011

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.

Thursday, September 22, 2011

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.

Wednesday, September 21, 2011

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.

Tuesday, September 20, 2011

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.

Saturday, September 17, 2011

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.

Thursday, September 15, 2011

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?

Tuesday, September 13, 2011

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.

The Elephant In The Room

I was sitting at the nursing station the other day when I overheard our O.R. director having an impromptu meeting with the nurses. The subject of the meeting was why cases were not going into the rooms on time. There were many excuses volunteered. The nurses complained that all the preoperative paperwork slowed them down. The equipment sometimes didn't get cleaned in time. There were not enough transporters to bring patients to preop or take patients out of recovery, causing bottlenecks in the process. There was not enough staff to help get the patient dressed and IV started. The front desk was not registering the patients in a timely manner when they arrive at the hospital. My ears pricked up when I heard some mention that the anesthesiologists were sometimes late. And when they arrive take a long time to preop the patients and ask them questions.

What was missing from all these recriminations was an obvious target, surgeons who show up late. And why was that? The O.R. director himself was one of the main culprits. For this surgeon, a 7:00 AM start means he doesn't show up until 7:20 at the earliest. He thinks nothing of keeping people waiting for him. When he finally does arrive, he makes no apologies. Instead he offers a sly smile, a quick joke, and the nurses and patient just melt under his spell. The patient is promptly wisked into the O.R. and another case is tallied as being late getting into the room. One time I deliberately showed up late to the O.R., about five minutes after this surgeon arrived, to see what effect that would have. The results were not pretty. No amount of grinning or Jay Leno impersonations was going to appease him, who was, let's charitably say, one pissed off M.F.

So this charade continues. The support staff in the O.R. dance faster and faster but the patients don't ever seem to get into the rooms any quicker. Maybe one of these days the surgeons will finally figure out that the cause of much of the delays can be found by looking in the mirror.

Monday, September 12, 2011

Who's More Compassionate, Canada or The U.S.

When people condemn the health care system in America, they point to our friends north of our border for comparison. Here in America, we are rich, greedy, callous doctors and medical industrial complexes whose only goals are to maximize our profits regardless of the consequences to our poor, economically disadvantaged patients. Canadians, with their universal health care, smugly point to their "superior" access to doctors and freedom from anxiety about expensive medical treatments.

One of the flashpoints in this argument is the treatment of illegal immigrants. Here in the U.S., we have millions of illegal aliens in our population. As many as 80% of them, if not more, carry no health insurance. However by law we doctors have to treat them when they show up at the emergency room door, regardless of their ability to pay. Some patients are so brazen as to admit publicly that they are here illegally in the hopes of getting sympathy treatments without fear of being deported. One of my fellow anesthesia bloggers, Bleeding Heart, who hails from the land of the Loonies, commented how we Americans should be helping our poor downtrodden illegals become productive members of society.

While it might be easy to point fingers and reprimand our way of living from a distance and across the border, the reality is that we treat our illegal immigrants far more compassionately than our Canadian brethren. In a Canadian Federal Court of Appeal ruling in July, illegal immigrants in Canada have been ruled to be not eligible for Canada's free health care. Nell Toussaint, a Grenada citizen who overstayed her tourist visa to Canada in 1999, developed multiple medical problems ten years later. She sought to receive free health care by applying for residency after she got sick. Nuts to you, the Canadian courts ruled. First, the courts said that since she waited ten years in Canada before applying for residency, there is a question of why she wants to be a Canadian. Does she want to be a Canadian because she loves hockey and Celine Dion, or does she only want free health care? Legitimate question. Judge David Stratas, writing for the three member Court of Appeal, further noted that had the ruling favored Ms. Toussaint, this would only encourage more people to enter the country illegally to get free healthcare, which I guess is a problem the Canadians would rather not face, unlike the Americans.

Hmm, maybe all that snow and arctic winds does sharpen one's senses. Offering free health care just might encourage more people to come here illegally. One way to stop this unwanted migration is to take away the incentive to do so. Even though our liberal northern friends favor homosexual marriages and medical marijuana, at least they woke up to the chaos that can occur from having millions of illegal immigrants using up scarce resources that its own citizens desperately need. In this regard the U.S. courts are far more compassionate than the Canadians.

Saturday, September 10, 2011

Give Me Your Tired, Your Poor, Your Huddled Masses Yearning For Free Health Care

Our country may have lost its AAA credit rating and is heading quickly down the ditch of fiscal bankruptcy, but it seems like we can't help but keep offering free health care for everybody, even if they're not entitled to live here. Despite annual $1 trillion federal budget deficits (think about that number: $1 TRILLION or $1,000,000,000,000), our generous American hearts can't resist giving more free medicine to anybody who wants it or else get castigated as a scrooge.

The New York Times has an update on the plight of ILLEGAL immigrants who were denied free dialysis services at Grady Memorial in Atlanta. This has been an issue for over a year as funding to dialyse these aliens have become harder to come by. This latest lapse in funding caused the withdrawal of dialysis services on August 31. Since then the illegal patients have shown up in the emergency room to get their dialysis with full knowledge that the ER cannot turn anybody away.

One illegal immigrant named Reina Andrade lost hope of future dialysis services and flew home to her native Honduras. There the family had to use their own money to continue her treatments. Only after she had left the country was an agreement reached whereby the hospital will continue paying for dialysis for illegal immigrants. The family says they regret Reina had left the country with little hope of her ability to come back here, illegally.

Excuse me? These people are here in our country without permission yet they have the gall to demand sympathy for their difficult medical conditions? Grady Memorial pays a dialysis service company $15,500 per patient per year for the treatments. The hospital is facing a $20 million budget deficit this year. Medicare is facing bankruptcy within ten years. In essence the governments of other countries are dumping their sick so that they don't have to take care of their own citizens knowing that we won't turn them away.

Ideas for saving Medicare mostly involve cutting back payments to doctors and hospitals, but not the services they are required to provide by law. Sympathetic articles like this one from the NYT attempts to frame the fiscal crises as the poor suffering patients vs. the rich heartless medical industry. How can we ever rationally discuss saving America's healthcare system when every dollar saved is instantly categorized as another attempt to kill off the sick and elderly while medical providers are always seen as greedy and uncaring? While we are fighting to find money for free healthcare for anybody who walks into the emergency room, hospitals are closing around the country because of the reimbursement cutbacks, threatening access to everybody. Whose side are we on? Money for illegals or access for all? The clock is ticking on deciding this issue.

Monday, September 5, 2011

Gurney Journeys

Anybody who has ever volunteered or worked at a hospital can tell you tales of gurney misadventures. I'm not saying that anything happened to patients on gurneys. On the contrary, patients almost always get from Point A to Point B in a hospital with minimal fuss. It's the people who are transporting the patients that bare the scars of the duty. As anesthesiologists, we do a lot of patient transportation so I have plenty of first hand knowledge of gurney mishaps.

Virtually everybody can relate to a painful encounter with pushing a gurney. Whether it be a crushed toe or a pinched finger, people learn from agonizing experience to watch their digits extremely carefully when pushing a bed. I was once pushing a gurney using the built-in IV pole. I had done that a thousand times before without any repercussions. Then this one time, the IV pump that was attached to the pole suddenly slid down, crushing a finger. It felt like my finger was broken. Luckily that wasn't the case, but my finger was numb for days afterwards.

As our patient population gets bigger, our gurneys are also supersizing. They are now up to a point where they can barely fit through a doorway, with just inches to spare on either side. This creates an ever present hazard for the transporter. It is natural to push a gurney holding onto both sidebars with your fists. Many have suffered the consequences of this maneuver. One nurse was helping me push a patient with the rookie two fisted grip. When the gurney went through a doorway, she didn't move her hands in time. One hand got smashed between the bed and the door frame. The resulting pain was so excruciating she literally had tears well up and she had to take the rest of the day off to tend to her maimed hand. It only takes one incident to grasp the fact that when pushing a gurney through a door, the hands hold the inside of the side rails, never the outside.

One of the biggest dangers to a patient is being moved to or from an operating table. That is the time when a patient is most vulnerable to a gurney accident. It usually requires at least four people to safely move a patient but even that may not be enough. It seems like every month another nurse or scrub tech gets severe shoulder or back sprain trying to move a patient in the OR and has to go out on disability leave. I once had a patient who was over 400 pounds. We had just finished a gastric bypass procedure on him and was trying to move him off the OR table. Even with six people moving him, he got stuck between the table and the gurney. The gurney's brakes started giving way and it started rolling away from the table, with the patient falling into the crack that was forming under him. It took four people to keep the gurney from sliding any further out and about a total of ten people to safely move the patient properly. That was a close call and one I use as a teaching point when we can't get enough people to come to the OR to help move a patient. I'd rather have the patient wait on the OR table than try to move him without adequate manpower. Seriously, I wonder when we're going to get the first gurney with dually wheels.

The gurney stories are endless. There are the accounts about doing chest compressions on a moving gurney as a patient is being moved to the ICU, or the tales of gurneys getting sucked into the MRI machine, or finding residents crashed out on gurneys overnight from exhaustion. I even have an anecdote of getting stuck in an elevator while transporting a patient and the patient's oxygen tank ran out. So many stories, so little time.

Sunday, September 4, 2011

Holiday Calls

One of the most frustrating but necessary duties of being a doctor is the need to take calls. Patients get sick 24/7 so medical personnel are needed no matter what the calendar says. Unless you're one of the lucky few physicians who don't have to take calls, either due to your age, length of work experience, or practice location, nearly all doctors have to take some type of call. Yes even pathologists and dermatologists take calls.

I used to dream about what it would be like to work in a vocation that doesn't require working overnight shifts, weekend work, or holiday work. I'm thinking something along the lines of government jobs or manufacturing. Yes a factory line can close down for a holiday break, but not a hospital's emergency room. And just try finding a government employee to help you on a Friday afternoon after 4:30 PM.

I once complained to a colleague about taking calls while others in our group don't have to take any, a sore point that has created a generational divide within our department. She said to quit whining and just suck it up. The others have paid their dues in the past and now get to reap the fruits of all the labor they invested in the group. Besides, she reminded, it is a  privilege to take care of patients, not a burden. If it becomes too much of a burden to make time to care for them, then it's time to move to another field.

So here I am, at the hospital for another holiday call. Luckily it has not been terribly busy so far today. So what does an anesthesiologist do while sitting around in the call room waiting for the inevitable page to get another case going? Here are some things I've been doing to pass the time.

1. Watching Phineas and Ferb on the Disney Channel.
2. Reading about how a Hurst Lightning Rods Triple Shifter works.
3. Contemplating the intricacies of time.
4. Envying the luxurious lifestyles of current college students.
5. Admiring pictures of my family as they are out having fun without me courtesy of my wife's cellphone camera. Gee thanks guys. I hope you bring back a doggy bag from that yummy looking restaurant.

So as you can see, the life of a physician is not all glamor and fortune. There is a lot of personal sacrifice too. Just another idea to contemplate for anyone thinking about going into medical school.  Suddenly, working in a cubicle doesn't sound so bad.

Thursday, September 1, 2011

Babysitters Doing Better Than Doctors

The latest lunacy from our labor union-backed, Marxist Democratic state government here in the formerly great state of California: the state Legislature has approved a bill that will require workers compensation and meal breaks for all domestic help, including part time workers like babysitters.

The bill authored by Democrat Tom Ammiano from San Francisco will require that babysitters get a break from work every two hours. Parents will also have to pay at least minimum wage as well as workers compensation, overtime pay, and in another version of the bill paid vacations. If employers fail to comply with these new rules there are provisions in the bill for legal action against them, including paying for attorney fees, other legal expenses, and backpay compensation up to $4,000. Naturally the bill has overwhelming support in the state Senate and likely will be signed by the governor.

Good grief. As a medical doctor nobody is giving me any meal breaks despite working for hours on end in the operating room. I have to sneak in an energy bar behind the drapes just to keep from collapsing from hypoglycemia. Work breaks? Overtime pay? That is not even something I can complain about. If I don't like it, they will gladly show me the nearest exit to the hospital. Why are doctors treated so poorly while here in California even illegal immigrants get financial aid to attend our colleges and universities at in state tuition rates? Oh, I forgot. We're "rich". We are independent contractors therefore we're not allowed to form unions to increase our political clout. And most doctors are conservatives. Strike three. You're out. Perhaps being a CRNA would have been a better choice: less expenses, less liability, guaranteed meal breaks, set working hours, and better political representation.

Is it any wonder more and more doctors are gladly selling their practices and finding satisfaction as a "lowly" employee? At least as an employee doctors gain far more rights that are protected by law at the state and federal levels. Seems like a fair tradeoff for (slightly) decreased compensation and independence. As our country moves inexorably toward a single payer system where we are all employed by the government, that maybe something to look forward to.