Wednesday, November 30, 2011

Occupy Orthopedics

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

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

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

Monday, November 28, 2011

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

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

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

Sunday, November 20, 2011

The Beginning Of The End

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

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

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

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

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

Friday, November 18, 2011

World Toilet Day

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

Thursday, November 17, 2011

Visiting The Mother Ship

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

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

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

How The Occupy Movement Misrepresents The 99%

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

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

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

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

Wednesday, November 16, 2011

Why Is The Operating Room So Damn Cold?

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

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

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

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

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

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

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

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

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

Thursday, November 10, 2011

How Much Do Anesthesiologists Make, 2011

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

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

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

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

Tuesday, November 8, 2011

End Of COBRA, The Reason For Healthcare Decline?

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

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

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

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

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

Monday, November 7, 2011

Guilty! Guilty! Guilty!


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

Saturday, November 5, 2011

Why Are Doctors So Depressing?

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

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

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

Worst Excuse Ever

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

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

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

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

Friday, November 4, 2011

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

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

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

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

Thursday, November 3, 2011

Teaching A Cardiologist CPR

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

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

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