Somebody Needs To Take Advice From Kenny Rogers

A doctor in Texas has been charged with the largest Medicare fraud scheme in history. Jacques Roy, MD of Medistat Group Associates in DeSoto, TX has been arrested for alleged bilking the government program $375 million over a five year span. He was charged with taking money for services that were never rendered.

The doctor and his collaborators would go door to door and offer people cash or food stamps to sign a form stating the doctor had treated them. They sometimes went as far as seeking out homeless people to get their signatures. Brazen doesn't even come close to describing this enterprise.

My question to Dr. Roy is, why $375 million? If you planned to steal money from the government, why not stop at, say, $1 million a year. Or maybe evern $5 million. In a federal Medicare budget of over $500 billion, $70 million per year may not sound like much but it will definitely start raising red, hurricane warning flags to the auditors. Couldn't he have been happy with $5 million and thereby snuck under the radar for what could have been years of a lavish champagne dream lifestyle.

As Kenny Rogers sang in "The Gambler"
You got to know when to hold 'em, know when to fold 'em,
Know when to walk away and know when to run.

Dr. Roy won't be running anywhere for a long time.

Cleviprex And Why We Label Propofol Syringes

One of the many annoying things about Joint Commission rules is their seeming lack of common sense. Waste baskets have to be five feet apart in the operating room? Who made up that one? But the most tedious demands for anesthesiologists are the necessity of labeling each and every syringe we draw up, even something as obvious as a vial of propofol. Let's face it, no other drugs in our arsenal looks like propofol. It is milky white as opposed to all other drugs which are clear and translucent. When asked about this nonsense, the standard response has been that it could get mixed up with intralipids. That is absurd of course because a) we rarely have intralipids hanging in the operating room during an operation and b) we would know if we had drawn up intralipids in a syringe, which is never.

Well now there is a legitimate reason for labeling a propofol syringe. In the latest issue of the Anesthesia Patient Safety Foundation's newsletter, Bruce Kleinman, MD of the Hines VA Hospital pointed out there is a new drug that looks exactly like propofol, Cleviprex. Cleviprex (Clevidipine) is a new calcium channel blocker that is supposed to be specific for arterial smooth muscle. It also has similar characteristics to propofol. It has a limited shelf life after it's opened, 12 hours. It should be avoided in patients with egg or soy allergies. And it can cause acute pancreatitis in patients with hyperlipidemia.

Luckily for me, our hospital is too cheap to offer any drugs that new in our pharmacy. We still have to make do with such lowly substitutes as nifedipine. But we still have to keep labeling our propofol syringes.

The Next Mandatory Operating Room Equipment? How About A Breathalyzer.

Take a look around the OR lounge at your hospital. One out of every six surgeons you see in there may have an alcohol abuse problem. That is according to a study conducted by Michael Oreskovich, MD out of the University of Washington and presented at the Clinical Congress of the American College of Surgeons. According to a survey of over 7,000 surgeons, 15.5% of the respondents had test scores indicating a likelihood of alcohol abuse. What's more discouraging, while 13.9% of male surgeons may be abusers, 25.9% of female surgeons were likely to abuse alcohol. By contrast, only 9% of the American population is thought to have alcohol abuse or dependency.

AUDIT-C questionnaire

Dr. Oreskovich conducted the survey by sending out questionnaires to over 24,000 surgeons with email addresses at the ACS. A little over 29% responded. Using a test called an Alcohol Use Disorders Identification Test (AUDIT-C) that is used by the Veterans Administration and the World Health Organization, alcohol abusers scored greater than five on a scale of one to twelve for men, four for women. They found that younger surgeons, married surgeons, and surgeons without children are more likely to get a higher score. Curiously surgeons who work longer hours were less likely to abuse alcohol, maybe because they don't have as much time to drink. Or perhaps they are less stressed about paying back their student loans and covering office expenses. Women are thought to have higher levels of alcohol abuse because of the stress of trying to maintain a professional career along with a decent home life, something their male colleagues all too often leave to their spouses to handle. Sadly, suicide ideation was doubled in those with high test scores, 8% vs. 3.9%.

We shouldn't make light of the suffering our surgical colleagues must go through that drives them to such painful life choices. But let me give them some advice: if they're looking for more effective substances to alleviate their pain, we anesthesiologists have much better stuff to abuse.

Poker Face

"Doc, how'd it go?"

That's one of the most common things a patient says when he wakes up from surgery. Usually it's a no brainer. You can happily tell the patient his appendix has been removed. Or his hernia is now repaired. In other words, things went as predicted and everybody can live happily ever after.

But sometimes the surgery doesn't go as planned. Maybe the arterial revascularization was not successful and now the patient faces an amputation of a limb. Or the surgeon opened up the abdomen and discovers an unsuspected Stage IV malignancy. Now what do I tell the patient, if anything?

As decent members of society and also as physicians, we have been taught not to lie. It was ingrained in us as children when we learned about George Washington's inability to tell a fib to his father after he chopped down a cherry tree. In medical training, if we told a lie about a patient's history or how we cared for a patient, we were usually discovered quickly and shamed in front of the whole group during rounds. Lying about a patient is simply not tolerated, as it shouldn't be. Therefore when a patient asks how an operation went, it presents a severe moral dilemma. Should I lie to the patient and let the surgeon break the bad news? Or should I inform the patient about some general details and have the surgeon give the specifics of the case?

I usually opt for the former and pretend that everything was fine. But I have a terrible poker face. Patients are usually perceptive enough to know that something is not right. They may start asking me or the OR nurse for more details as the surgeon is usually out of the room by the time they are awake. We all try to put on our game faces but they are not fooled. The more I tell patients the surgeon will come soon to tell them the details, the more frightened they become. They know I'm holding back and that it cannot be good news. Yet if I reveal what happened during the operating, I don't feel I can be the one to give the patient more information about follow up procedures and plans that may alleviate the patient's anxiety over the findings.

What would George Washington do in this situation?

A Cautionary Tale

Anesthesiology may be the best job in medicine. The money is good. The hours are, usually, not as punishing as surgeons' or internists'. And we get to handle all these mind altering drugs with little supervision from others (just kidding). But the field can also have surprisingly little job security. As anesthesiologists, we bring little revenue to a hospital's balance sheet. We are more often considered on the expense side of a hospital's budget as mere leeches sucking up its money. Therefore it is not shocking to find that in an era of ever decreasing reimbursements, hospitals will find any way to cut costs as much as possible. And this includes hacking away at their anesthesiology department.

Last year, all the anesthesiologists from the Visalia Anesthesia Medical Associates (VAMA) were summarily terminated from their contract with Kaweah Delta Medical Center. This despite working diligently for the hospital for sixteen years. The hospital board decided to open up the anesthesia contract to competitive bidding even though the group had fulfilled and exceeded all contractual obligations. Says Chief Operating Officer Tom Rayner, "I think it's common business practice" for hospitals to seek other proposals for anesthesia services. VAMA was allowed to give an oral presentation to the hospital board to defend their contract. Unfortunately, it was widely considered to be a formality as the hospital had already made up its mind to go with a lower cost anesthesia provider. Kaweah eventually gave the anesthesia contract to Somnia Anesthesia Services, a nationwide group that uses predominantly CRNA's to allow it to undercut bids from anesthesiologist-only groups.

What does this say about the state of anesthesiology? First of all, your golfing and fishing buddies from the surgery department are unlikely to help you out. Despite protests from surgeons over their lack of input, Kaweah decided to fire all their anesthesiologists anyway.  Second, if the hospital board is determined to find another anesthesia group to provide services, there is little the group can do no matter the volume of dire warnings about patient safety compromises. Third, unless an anesthesia group is involved intimately in the hospital's political structure, there is no job security no matter how many years its been working at the facility. Just something to keep in mind next time an anesthesiologist in the group complains about the work load in the OR's. It can quickly become lighter before you know it.

Anesthesia History Association

What is that famous quote from George Santayana? "Those who cannot remember the past are condemned to repeat it." Well, not remembering the history of anesthesiology may not have such dire consequences, but you are missing out on a lot of good fun facts and trivia. I'd like to point all you readers to the website of the  Anesthesia History Association. No, don't roll your eyes as you have sudden flashbacks of snoozing through Western Civilization 102 in college. History is FUN, FUN, FUN!

My favorite feature on this site is the "This Month in Anesthesiology" link. Here, you'll find that Samuel Colt was granted a patent for the revolver pistol on February 25, 1836. How is this relevant to anesthesia? Apparently as a side business, Samuel Colt, or as he'd like to refer to himself as "Professor Coult", toured the country giving demonstrations on the use of nitrous oxide. How's that for some far fetched six degrees of separation anesthesia trivia.

Other neat little tidbits include the first use of ether in a wartime setting during the Mexican-American War, which ended on February 1, 1848 with the Treaty of Guadalupe Hidalgo. And don't forget the publication on February 13, 1943 in Lancet by Sir Robert Macintosh and his invention of the Macintosh laryngoscope blade.

Won't you be a hit at the next anesthesia department party?

MOCA Hypocrisy

There is a fascinating article in the March 2012 issue of Anesthesiology. Canadian researchers have correlated the relationship between the age of anesthesiologists and the likelihood they will be sued for malpractice. They used a billing database that covers about eighty percent of practicing anesthesiologists in the country and information from the Canadian Medical Protective Association, which handles all malpractice suits against anesthesiologists there. What they found is quite informative, and throws a harsh light on the hypocritical nature of the board recertification model required by the American Board of Anesthesiology here in the U.S.

The Canadian study found that anesthesiologists greater than 65 years old were 1.5 times more likely to be involved in litigation than those who are under 51 years old. In addition, the severity of the patient's injuries is greater than with a younger colleague. This despite the fact that older anesthesiologists are more likely to be working fewer cases than younger anesthesiologists and the cases less complex.

In an editorial in the same issue, Mark Warner, MD, the former president of the American Society of Anesthesiologists, discusses how he is almost intimidated by the knowledge base of the anethesia residents he helps train. He writes, "I can attest that it is difficult to stay even with our residents, fellows, and younger faculty in current medical knowledge and clinical practices that have changed dramatically since I finished training three decades ago."

So there you have it. The former president of the ASA admits that it can be difficult for anesthesiologists who have been in practice for decades to keep up with the medical information necessary to safely perform modern anesthesia. This brings up the hypocrisy that most of us who are subject to MOCA recertification requirements have been complaining about for years. If staying current on medical information is important to the practice of anesthesiology and patient safety, why is board recertification only required for anesthesiologists who finished residency training after the year 2000? What about the ones who graduated in 1999? or 1979? Shouldn't they also be subjected to the expense and anxiety of having to sit through another exam at least a decade since they last finished formal training?  Dr. Warner laments, "It's not clear how to improve deficiencies identified in older physicians for processing unexpected information or large volumes of information." He goes on to suggest simulations, such as used to retrain airline pilots, can help spot problem anesthesiologists. Simulations are being used now by the ABA as part of MOCA. But again, unfortunately, the ones who are most likely to benefit from it, the older anesthesiologists, are exempt from having to take it.

Is it any wonder the younger generation of anesthesiologists are disgruntled with the ABA and the whole recertification process? It feels like a sham. A total suckup to the ones who are making the rules but don't have to follow them. We finally have a study that shows older anesthesiologists do fewer and easier cases yet are more likely to get sued for malpractice than younger doctors. Is there any clearer indication for MOCA for everybody?

Rise Of The Machines

For practically forever anesthesiologists have been complaining about how CRNA's are taking away our business and livelihood. They are willing to work for less money and hospitals can hire them by the bucketload to staff their operating rooms to the exclusion of MD's. But perhaps our fears are totally misplaced. There is increasing evidence that it isn't the pesky CRNA's that will be taking over our jobs. Instead it is likely to be machines that will be invading our OR's.

In this month's issue of Anesthesiology, researchers in France conducted a study comparing the ability of a machine to maintain a patient under anesthesia versus a human anesthesiologist. They measured a calculated EEG level using a machine called a Spectral M-Entropy monitor. A level of 100 equates to an awake person whereas a zero implies an isoelectric EEG. This is similar to the BIS monitors we routinely use here in the U.S. The goal of the study was to keep the patient at an entropy of between 40 and 60 during an elective procedure with a combination of propofol and remifentanil. Using an off the shelf computer program called Infusion Toolbox 95, the computer took the entropy number from the monitor and calculated how much IV anesthesia to give to the patient to stay within the desired range. The manual group consisted of anesthesiologists who titrated the anesthetic as they felt necessary to maintain the entropy range.

The results should scare the crap out of us human anesthesiologists. The computer was able to keep the patients within the entropy goal 80% of the time. The humans were only able to stay within the range 60% of the time. The machine was also better able to keep the patient from getting too much anesthesia, which is associated with increased mortality. Other measures including time of induction and time to extubation were no different between automated and manual infusion of anesthesia. In conclusion the researchers state that the computer controlled anesthetic "outperforms manual control during maintenance of general anesthesia." Just in case you think the French have some sort of supercomputer than can create this amazing anesthesia breakthrough, this isn't the only study to find that machines outperform men.

Uh oh. The machines in these studies were able to maintain anesthetic depth better than their human counterparts. And with all else being equal, this is a major win for machine against man. The battle is  being heavily waged on these shores too. Witness the relentless pursuit by gastroenterologists and Johnson and Johnson to get the Sedasys system approved by the FDA. This system allows for an automated MAC anesthesia without the need for an anesthesiologist to be present in the room during an endoscopy. The FDA took the unprecedented step of taking a second look at Sedasys after initially rejecting its approval for use. If approved, many anesthesiologists in surgery centers will likely get booted out of surgery centers across the country. Remember, the machines don't have to be better than us at providing anesthesia. They just need to be our equal for them to win. And that doesn't appear to be very far off in the future.

Don't Watch This Before You Eat

Harvard gastroenterologist Dr. Braden Kuo and artist Stefani Bardin have created an art "project" that graphically displays the process of food digestion. In the video, they observe how foods are processed differently by the body using wireless pill cameras that subjects swallow after eating. One subject eats processed foods consisting of chicken ramen, blue Gatorade, and gummi bears. The other subject ingests more natural foods like handmade noodles and hibiscus Gatorade (?).

The videos clearly show that processed ramen noodles take much longer to digest that natural handmade noodles. After more than two hours the ramen noodles still are recognizable as pasta whereas the handmade noodles have pretty much broken down into amorphous starches. Something to think about next time you have that order of fried noodles at Panda Express.

Now you know why anesthesiologists want patients to be NPO before surgery. It's no fun trying to suction this muck out of somebody's bronchi after a major aspiration.

Call Me Insensitive

When you see a deer, you see Bambi.
And I see antlers up on the wall.
When you see a lake you think picnics.
And I see a large mouth up under that log.
I'm Still A Guy--Brad Paisley

Oh Anesthesiology, I guess I'm just not the kind of audience your editors are looking for. Sure your scientific articles are interesting and your review articles are informative, but your selection of pieces published in the Mind To Mind section leave me cold. I thought maybe I was not the right person to appreciate your esteemed journal when I noted the depressing subjects all too often published in your user submitted essays section. Now with your February issue, I know without a doubt that I'm just not the sensitive, aware anesthesiologist you think all of us should be.

I felt something was amiss when I first laid eyes on the cover of this month's issue. Instead of a brilliant scientific graphic or image, there were floating paper boats and--poetry. And not just any poem. This one had a slightly condescending, even admonishing, character to it. Heck, it doesn't even rhyme! Inside the pages, you describe the author, Dr. Audrey Shafer, as a brilliant anesthesiologist whose works have been widely published and is even "required reading in schools across the country." However, to me her "Anesthesia Checklist" on the cover brings to my mind some New Age guru looking over my shoulder as I'm trying to take care of my patient.

Acknowledge:
the patient's fear tethered like a beast in a nearly sealed cavern ready to rouse, frenzied and wild, especially at the call: open your eyes!
the patient's gift, wrapped in wariness by the family yet inside nestles trust, shy at being given to you, a stranger

The scene would be complete if I lighted up aromatherapy candles in the OR and rubbed the patient down with an algae mud wrap. It's all so highfalutin and touchy feely.

Now I'm not saying that Dr. Shafer isn't an incredible talent and wonderful physician. I'm just thinking that I would rather not read essays that would seem to be more appropriate in The New Yorker magazine. If you have to publish poetry, well here is something that I think many of your readers will find more entertaining.

There once was a surgeon with a knife
Who caused the OR much strife.
With the young nurses he'd flirt
While treating others like dirt.
Until his balls got busted by his wife.

Yes you have my permission to publish this in Mind to Mind. Your welcome.

Cost Of Dying In America

The cost of dying in the United States is exorbitant and is bankrupting the nation. We doctors have had all too much experience with this unstoppable spending of other people's money. We have witnessed the endless laboratory exams, the daily radiologic imaging, the dripping of thousands of dollars of drugs into the veins of patients in futile attempts at playing God. Fifty percent of Medicare spending goes towards only five percent of the population. The last one year of life causes twenty-five percent of the federal program's spending. Yet this expenditure goes on every day in every hospital from coast to coast.

While hard monetary numbers can be difficult to come by, a writer's experience with the last days of her father's inpatient care at Stanford Hospital provides a rare glimpse into the actual dollars and cents of watching a loved one die. Lisa Krieger had the unfortunate circumstance of watching her Alzheimer-ridden father, Kenneth Krieger, pass away in typical American fashion, in a hospital, hooked up to thousands of dollars worth of drugs and tubes, all for the faint hope of living one more day. It was not like Mr. Krieger wanted to die in this fashion. He had even explicitly filled out "do not resuscitate" orders so that he wouldn't die an unnatural death, a body kept alive by machines and drugs.

Unfortunately for Mr. Krieger, his dementia becomes progressively worse. One day he was rushed emergently to the emergency room at Stanford for necrotizing fasciitis. Despite his previous requests, the writer and her family decided to proceed with every medical treatment that other people's money can buy. Daily blood work were drawn. Exotic and expensive medications were given. All kinds of fancy consultants were called in. However he was not improving. Even more radical treatments were contemplated, including surgery on an octogenarian with little hope of leaving the hospital and living a productive life. Despite thousands of dollars of care, the inevitability of his death finally sunk in. Mr. Krieger finally passed away with pain killers in a private room, spending ten days at Stanford that resulted in a bill of $323,658. Medicare paid $67,800 of that bill with Stanford eating the rest, or more appropriately, passing the cost to the rest of us with private insurance.

All too many of us have seen that once a patient is unable to make his own decisions, his prior requests are frequently ignored by his family with the best of intentions. Doctors are too lame to tell the straight truth to family members. We hedge our prognoses with terms like "small possibility of" and "there's a small chance" even though in our hearts we know the likelihood of a patient surviving his hospital stay is practically nil. Every body has heard the miracle story where a patient lived years beyond what their doctors predicted and the doctors end up looking like cynical baboons. In a difficult decision like end of life care, families are looking for guidance, and doctors are unable or unwilling to give it. Therefore the family's only choice really is to continue aggressive treatment. This lack of leadership on our part has contributed to the health care crisis we are facing today.