Propofol For State Executions. MJ Proved It Works.

 Missouri Lethal Injection Protocol Propofol
The state of Missouri has decided to use propofol for its capital punishment cases. This after prison officials were unable to locate supplies of sodium pentothal to carry out its executions. There are no domestic suppliers of pentothal and foreign imports of the drug were banned by the Federal Drug Administration because they have not been tested for executions.

I wonder how propofol will stand up under the inevitable court challenges by prison inmates. The previous standard three drug regimen was banned after prisoners filed suit stating it was cruel and unusual punishment to be executed with drugs that can cause pain and suffering before it fully takes effect. If that is the case, the courts will have a field day when patients, er, inmates, scream in pain from the propofol burn right before they die. I've had patients who have received propofol in previous operations who liken the pain to having their arm falling off. Many prisoners already have difficult IVs to start with because of their histories of IV drug abuse. Those tiny veins are exceptionally sensitive to the pain from propofol injection.

There is also the contention that the use of propofol for executions is "untested". Says Joseph Luby, an attorney with the Death Penalty Litigation Clinic in Kansas City, "Propofol has no track record in executions." Well that's a kind of circular logic. Propofol would have to be used at least two times in order to form a track record in executions. If nobody is willing to start using propofol, then it will never have a track record. As far as doing a rigorous scientific test for propofol's efficacy in capital punishment, I'd love somebody to figure out how to do a standard double blind study to accomplish that.

It's true that going with a single drug method of execution with propofol probably won't be as quick as the old three drug method. Especially with drug abusers, I've had patients who require hundreds of milligrams of propofol just to keep them sedated. I can't imagine how much some of these inmates will need before they go apneic, and stay apneic until their brains die from anoxia. But of course it can be done. As for Missouri, they've settled on two grams of propofol for an initial bolus. If that doesn't work, it can be repeated one more time. Since there are no scientific studies regarding the proper dosage of propofol for executions, this is pretty much a wild guess.

But we already know propofol will kill its victims if used improperly. Numerous health care professionals have died from propofol abuse. Then of course there is Michael Jackson's sensational death from propofol, which made the drug a household name.

AT&T Workers Must Really Hate Their Employer

Click picture to enlarge

This is totally not medically related but I can't help putting in my two cents. I saw this while driving home and I had to do a double take. Here is an AT&T utility truck going down the road. You can tell it belongs to the phone company by its corporate insignia on the driver's door. You'll also notice on the back of the truck another AT&T corporate logo, this time with a thick black bar across its iconic blue and white globe. I was flabbergasted when I espied this truck.

Here are AT&T employees driving a company owned vehicle. Yet at the same time they have defiled their own company's logo as a political statement against the very company that is paying their paychecks. That is the definition of brazen. They essentially have turned a company car into a rolling billboard for their disgust with management. That would be the same as me walking around the city in hospital owned scrubs with a big slash across my hospital's name printed on my back.

Now I know union members can have confrontational relationships with their employers. How do I know the truck's occupants are union employees? Witness the blue and red sticker featured prominently on the back that reads "Live Better Work Union". But as far as I know there are currently no labor issues at AT&T. Also usually once a labor agreement has been reached the animosity is set aside, especially in public situations. There's also the question of employee loyalty. Even after the worst UAW strikes against the American auto makers, the employees still purchased the cars of the manufacturer they worked for, be it Ford, GM, or Chrysler.

When there are labor relationship issues in hospitals, public show of confrontation usually last only one or two days. Picket signs are confined to hospital sidewalks then promptly put away. Hospital employees don't drive around with inflammatory statements pasted on their cars, especially hospital owned vehicles. Either AT&T management doesn't mind how their employees are disparaging them in public or their employees don't care about how the airing of their dirty laundry can create a public perception of corporate chaos. Could this be the heart of the public perception of bad service at AT&T?

Medicine Is A Great Career

It's over. After much anticipation and hoopla, the great annular eclipse of 2012 has come and gone. We didn't get a complete ring of fire here in Southern California. Instead we got about an 85% blockage of the sun's surface. Still it was pretty neat.

The event reminded me how much I loved astronomy as a boy. I'll always remember the first time I peered into my friend's telescope in his back yard and spied the rings of Saturn. While I had seen multiple pictures of the rings in science books, there is nothing like the revelation of seeing them the first time in real life. I was hooked.

Luckily I grew up in a rural Midwestern town where the night skies were inky black and the neighborhoods safe enough for kids to be out at night without adult supervision. At first I didn't have enough money to buy a telescope of my own so I would have to go to my friend's house or use my dad's war surplus binoculars. Though somewhat limiting, it still allowed me to watch the Jovian moons around Jupiter or gaze at celestial objects like the Orion Nebula or the Pleiades star cluster.

By the time I had saved enough money to buy my own telescope, I was well into high school and thinking about what I wanted to do when I go to college. Astronomy was so much fun, but then being a total science geek, I thought medicine was fascinating too. I was torn about which direction I should take. I'll never forget my mother's sage words of advice when she saw I was facing this dilemma. She counseled, "You can always be a doctor and have a hobby in astronomy, but you can't be an astronomer and dabble in medicine." She was so right.

In retrospect, the choice could not have been clearer. Astronomy is fascinating to read about. But the life of an astronomer is not for me. It's great to look at all the pretty pictures in NASA and JPL press releases, but these scientists might work on one single topic, like the chemical composition of Titan's atmosphere, for years at a time. I'm not sure I have the patience and the passion to stick around for that.

Being a doctor, especially in the surgical fields, offers job satisfaction and near instant gratification when it comes to seeing results. It allows me to learn from my experiences then move on to the next challenge. It also affords me the resources to try other activities, as so many physicians do. From traveling, to photography, to wine making, to car racing, all these are diversions that doctors I know have taken up. By contrast, like my mother said, you can't be a professional car driver and practice medicine during your off time. Medicine is truly a wonderful career.

Anesthesiologists Are Still Number One

Here's the moment we've all been waiting for, the latest update on how much money anesthesiologists make. The numbers are courtesy of the Bureau of Labor Statistics' Occupational Employment and Wage Estimates Survey. The numbers are derived from data gathered in May 2011. The BLS has determined that anesthesiologists make the highest salary in America. The average anesthesiologist makes $234,950 a year. That works out to $112.96 per hour. The yearly salary is an increase of $15,000 over last year. For comparison, my previous post about the BLS survey conducted in May 2009 showed anesthesiologists averaged $211,750. The average hourly pay was $101.80.

The second highest paying job in America was general surgery. They averaged $231,550 per year, an increase of $6,000 from 2010. The hourly wage works out to $111.32. Filling out the top five are OB/GYN with $218,610; Oral and Maxillofacial Surgery with $217,380; and Orthodontists who made $204,670.

Looks like anesthesiologists are still doing pretty well in these tough economic times. Not only are we the highest paying profession in the country, we are pulling away from the number two surgeons. Plus we are among the happiest doctors you'll meet in the hospital. Meanwhile the sad sack surgeons are wallowing in self pity. In a Medscape poll, 29% of surgeons reported their incomes dropped in 2011, with 19% of them making less than $100,000 a year, twice the number who reported that income in 2010. It's no wonder 57% of them are unhappy with their compensation. Less than half of surgeons would choose medicine if they had to start all over again. More disheartening, less than one fifth said they would work in the same practice again. Is it any wonder more surgeons are turning to alcohol abuse to alleviate their suffering?

But we shouldn't dump on our surgical colleagues. We should just revel in our good fortune to be in one of the best jobs in the U.S. How much longer this good fortune will last is impossible to say. With all the changes in medicine coming, with or without Obamacare, the outlook for the medical profession is particularly cloudy. So let's just enjoy the moment while it lasts. Congratulations to all the hardworking anesthesiologists out there. You're doing good!

Fear And Loathing Of MOCA Is Spreading

I have mentioned many times about the widespread disgust many anesthesiologists feel toward the Maintenance of Certification in Anesthesiology (MOCA) program instituted by the American Board of Anesthesiology. In particular, people resent the ever changing requirements imposed on different graduating classes and the hypocrisy of allowing older anesthesiologists to keep their certificates without having to go through the process. This despite studies that have shown that these doctors are precisely the ones who need to be retested to check for their medical competency. Now that animosity is becoming more public.

In two recent issues of Anesthesiology News, Dr. Tania Haddad, MD from Phoenix, AZ, provided more substance to this bitterness. In Part 1 of her editorial, she recounted how MOCA came to be. It was patterned after the Maintenance of Certification that was started by the American Board of Internal Medicine in 1990. It too imposed a ten year duration for new board certificates. After MOCA was created, efforts were made to try to improve upon the testing methods in order to assure competency of the test takers. As a result the ABA has required 140 more CME credits than when MOCA first began. It has also added a simulator session that was not imposed until just recently. This begs the question; does all this testing make somebody a better anesthesiologist? Are the anesthesiologists who undergo the simulators better physicians than me who didn't suffer through all that? Are all MOCA candidates better doctors than the exempted anesthesiologists or is the ABA simply blowing smoke up our asses?

In Part 2 of Dr. Haddad's editorial, she highlighted the costs of keeping the board certificate one has already received after investing years of blood, sweat, and sleepless nights. The price of CME credits alone can easily top $1,000. Participating in the mandatory simulation sessions will set back the anesthesiologist $2,000. Taking the written test will cost another $2,100. All these are current rates subject to change, upward, at any time. By comparison, the MOC program as administered by the ABIM costs only $1,675 which includes the CME credits, computer simulation, and the written exam. Is the MOCA better and more effective than the MOC because it's more expensive? If something costs more because it is better, are board certified anesthesiologists three times better doctors than board certified internists? If not, are anesthesiologists being gouged by the ABA in order to keep their certificates?

Besides the expense of maintaining the board certificate, there is the time and emotional stress too. It takes time to complete all the CME credits. These are precious hours that should be spent with family and friends instead of sitting in front of a computer answering multiple choice questions. Weeks are spent studying for the simulation exam and the written exam. Even though greater than 95% of all first time recertification test takers pass the test, that doesn't lessen the apprehension people feel. After all, failure will just cause more anxiety as one will have to prepare for the test over again at a future date with a higher statistical probability of repeating the same result. Nightmares of losing one's practice because of the inability to pass recertification goes through everybody's head at some point.

Then it all comes back to the grandfathered status of the anesthesiologists who have escaped this ordeal due to their God given status of being born earlier than the rest of else. If MOCA is all about ensuring patient safety by checking the competencies of anesthesiologists, why is anybody exempt from taking the exam? Is the ABA afraid that the older generation may decide to file a class action lawsuit if their lifetime certificates are revoked? Would the public agree with these doctors that they don't need to prove their capacity to provide anesthesia safely decades after their training ended? If capabilities don't diminish with time, what is the point of having MOCA in the first place?

Medicine Is Getting Squishy

I recently went to preop a patient who had one of the longest lists of medications I'd ever seen. But if you think this was another ASA IV disaster with a positive review of symptoms, think again. There was not a single antihypertensive, anti-arrhythmic, anti-diabetic drug on the list. Instead it was populated by anxiolytics, antidepressants, and antipsychotics. You see, this patient had a litany of diagnoses that made her medical problems difficult to define. She had generalized anxiety, chronic fatigue, panic attacks, and a host of other anxiety disorders that made it hard to understand the nature of her medical issues. Goodness, they didn't teach most of this stuff when I went to medical school.

A long time ago, when doctors first started treating patients, most of the medical problems were pretty obvious, clearly visible to the naked eye. There were the broken bones, the wound infections. Though the treatments were crude and frequently misplaced, at least the doctor could see what the problems were, or at least their symptoms.

Much later, when medicine started becoming more sophisticated and scientific, we doctors were able to diagnose patients down to the cellular level. With the invention of the microscope, we could recognize diseases like cancer, coronary artery disease, and acute tubular necrosis.

Once laboratory equipment was cheap enough and widely available, doctors could measure chemical and hormonal imbalances in the body. Diagnosing diabetes, metabolic acidosis, and sepsis became routine. Medicine has now taken its analytical capabilities down to the genetic level, analyzing strands of DNA that were not even known to exist until half a century ago. The miraculous evolution of medical testing is all but taken for granted now.

But now we have this new category of medical problems, the unmeasurable anxiety disorders. They affect a large portion of the population and appear to be growing every year. Chronic Fatigue Syndrome affects at least one million people per year in the United States and millions more with similar symptoms but who haven't been labeled yet with the disorder.  Panic Attack or Disorder will affect 20% of Americans, or 60 million people at some point in their lives. Generalized Anxiety Disorder has been linked to nearly 7 million people in the U.S.

None of these problems can be determined with a microscope, CT, or MRI. There are no blood tests to definitively diagnose an anxiety disorder. Headache, listlessness, and jitteriness? These are pretty amorphous symptoms for an internist to work with. Now, the new heroes of medicine are the neurologists, psychiatrists, and psychologists. Once the patients are recognized to have these issues, they are thrilled that they have finally been found with a "disease," rather than being told it's all in their heads.

When the "disease" has been made, it is easier to start a treatment. Unfortunately most of the treatments are also pretty ambiguous. So now a patient comes to the hospital with a long list of drugs like Celexa, Zoloft, Paxil, Effexor, Xanax, and on and on. The only thing that rivals the length of their medications is their list of drug allergies, which are also usually quite extensive.

I feel sorry for all the primary care doctors out there. As an anesthesiologist, the diagnosis has already been made by the time I see them. I just have to work with all the medications that the patient presents to me and avoid any adverse drug interactions that might occur with all these different medications floating around in the blood stream. We're rapidly gaining the upper hand on traditional illnesses like coronary artery disease, diabetes, and hypertension. These new medical issues are going to require future doctors to have the patience of Jobs and the cunning of Sherlock Holmes. Psychiatry might become the most important field in medicine.

Free Health Care Starts With 9-1-1

Anybody can suffer a medical emergency. It can happen anytime, anywhere, in the most unexpected fashion. That is why we have developed the 911 system so that people can summon for help during a life threatening situation. Yet, because of the convenience of 911, the emergency response team is being sorely abused.

In an article in the L.A. Times today, they document the rampant misuse of 911. Starting off the the lead paragraphs, they write about a person who activated 911 because he needed his gout medicines refilled at a local clinic. When the clinic wouldn't take him because his insurance didn't provide coverage there, he called 911. The paramedics dutifully arrived at the scene where the patient was sitting comfortably in his wheelchair waiting for them. After they checked out his vital signs to make sure he was stable, they transported him to the nearest emergency room. What else are EMT's supposed to do? They're not doctors. That's their job.

Another time, a motel owner called 911 and reported that somebody was shot. When the emergency team arrived, they found that the owner had called for help because he couldn't get one of the boarders to pay and wanted him evicted. The room occupier indeed was shot, nine days before. The person gladly accepted EMT's ride to the ER so that he could get his first physical exam since he was discharged from the hospital.

Los Angeles County received over 543,000 emergency calls in 2010. Most of the calls were not real emergencies. People have called 911 because their babies were crying all night, or they had insomnia, or they just needed medical transportation. The beauty of this system is that it is the responsibility of the paramedics to take the patient to the ER if the patient requests it. They are not physicians who can diagnose an illness and decide if an ER visit is warranted. Many people don't have health insurance so they'll get the ambulance ride for free on the taxpayers' dime. By contrast, if they had called for a taxi, they would have to pay real money before anybody will take them anywhere.

Once the person gets to the ER, they again will get free health care. Thanks to EMTALA, everybody who gets inside the ER door is automatically treated, whether they can pay for it or not. See what a great system we have in the U.S.? Who says we don't have universal healthcare in this country.

Anesthesiologists Overestimate EBL. Were The Surgeons Right?

Somebody has done it. The sometimes contentious negotiations that happen at the end of every operation between the surgeon and the anesthesiologist over the case's estimated blood loss has finally been studied scientifically.

John Stover, MSN, a nurse practitioner out of Duke University, conducted a study on the EBL of 60 multilevel spine surgery patients. The methods they used to recollect the blood after being lost from the body are too lengthy and tedious for me to repeat here. You can read it from the linked article. Briefly, I'll just say that it involves adding heparin to the collection cannister and soaking the surgical sponges with saline.

By the end of the study, they found that anesthesiologists overestimated surgical blood loss by 40%. The average estimate by anesthesiologists was 860 mL while the measured loss was 611 mL. The reason this is important is because if anesthesiologists overestimate the EBL, we also run the risk of transfusing patients when it's not necessary. This could potentially lead to disastrous complications like viral infections, transfusion reactions, transfusion pneumonitis, and poor wound healing.

However, the study's methodology would be impractical to replicate in a real world operating room. As Martin London, MD, professor of clinical anesthesia at the University of California, San Francisco, dryly remarked, the processes involved are rather "labor intensive." Even Mr. Stover agreed. Said the author, "I think the problem is that we still use visual estimation of hemoglobin loss, and it’s very difficult to determine the actual hemoglobin concentration. So at this point there’s not a silver bullet that will give us an exact number."

Personally, I don't transfuse a patient based solely on the amount of blood loss I'm seeing. Yes, while 40% overestimation may seem a lot, I would not transfuse a patient just because I think the EBL is 800 mL when in fact she only lost 600 mL. I also have to take into consideration a multitude of other factors including the patient's physiologic stamina, the stability of the vital signs, and the likelihood of large ongoing exsanguination. All these are important when an anesthesiologist decides to give a blood transfusion.


We do not take this task lightly. We are well aware of our responsibilities to our patients when we decide to give blood. The approach to making that decision is extensively discussed during residency training. We don't give blood just based on a cutoff number. So while this study is interesting, its impractical application is of little help to anesthesiologists. We'll continue to transfuse patients based on what decades of transfusion studies have taught us: first do no harm to the patient.

Anesthesiologists Are Happier Than Most. Joy! Joy!

You know I love bringing good news to you guys as it relates to our beloved field of anesthesiology. From its high rankings as one of the best jobs in America to its desirability by medical students as one of the ROAD specialties, I feel it is my duty to spread far and wide (this blog has been read in over ninety countries) the goodness of our special niche.

Now thanks to the good folks at Medscape, they've done a study to document exactly how happy we are. They conducted a survey of over 29,000 physicians and asked them how happy they are and what kind of lifestyle they lead. On the happiness rankings, anesthesiologists came in at #6, tied with Pediatrics. Rheumatologists were ranked #1 in happiness followed by, not surprisingly, Dermatology and Urology. What is surprising is that so called lifestyle/moneyed fields like Plastic Surgery and Gastroenterology came in below average on the happiness scale. Just goes to prove that there are some things money can't buy.

What do anesthesiologists like to do with all their free time away from the hospital? Their list of activities reads like something out of a Conde Nast magazine. The favorite pasttimes of anesthesiologists are exercising, followed by reading (blogs I hope), traveling, cultural events like movies and museums, and wining and dining. Writing a blog somehow didn't make the list so it must be just me.

When do anesthesiologists have all this time for recreational activities? Fortunately for us, we and radiologists far surpass other medical fields in the amount of vacations we treat ourselves. Almost half of anesthesiologists and radiologists spend at least four weeks of vacation per year. By contrast, less than twenty percent of surgeons and internists have that much vacation time.

Where do anesthesiologists like to go when they do all that traveling? The favorite vacation spots are foreign travel, beach vacation, and cruises. That's not surprising to me as we've had partners travel far and wide, from an African safari to Machu Picchu to Antartica. Having decent incomes and vacation times allow for such luxuries.

Are happy people likely to be healthier? According to this self reported survey, yes. Sixty percent of the anesthesiologists say they have a normal BMI of less than 25. Less than 40% admitted to being overweight or obese. That compares to the general American population where over two thirds are overweight or obese. How do we stay so slender and fit? Over half of anesthesiologists say they exercise at least twice a week, with nearly thirty percent of those over age of 40 exercising at least four times a week. Again, we have the time and income to sustain that level of activity. Less than ten percent claim they don't exercise at all.

How do we like to show off our fabulous income and physiques? By parading around in expensive imported cars, of course. While the top two car choices among anesthesiologists are Toyota and Honda, the rest of the top five are BMW, Lexus, and Mercedes-Benz. Ford, at number six, is the highest ranking domestic car maker on the list. Nissan and Audi follow closely at seven and eight. Among California anesthesiologists, just from personal observation, the domestic car manufacturers would have a hard time even breaking into the top ten. BMW and Mercedes seem to have a lock on our wallets around here.

So is anesthesiology a great field or what? We have more income, better health, and more vacation time than most people in this country, or the world. Can't ask for more than that.

Paying For The Doc Fix With Phantom Money

There is a new bill being introduced in Congress to get around the annual debacle known as the Doc Fix. The Doc Fix is necessary because of the way Medicare structures its payments to physicians. Because of a complex formula known as the Sustainable Growth Rate (SGR), Medicare has threatened to cut compensation to doctors every year. But thanks to interventions from Congress, that has been repeatedly delayed. Consequently the payment cuts accumulate, which by January of next year demands a 30% decrease to physicians as required by the SGR.

The U.S. is likely to see a windfall in its federal budget when we draw down our troops from Iraq and Afghanistan. As proposed by Congressmen Allyson Schwartz (Democrat) and Joe Heck (Republican), their bill would use these new found billions to abolish the SGR.

On the face of it, that sounds fine and dandy. We suddenly have a new peace dividend that we can use to abolish the perennial headache of finding ways to appease physicians angered over the uncertainty of their incomes. As one who has a vested interest in seeing stability in my likelihood, I am all for getting rid of the SGR. However as a taxpayer I am troubled by the how this bill will be paid for.

You see, the so-called "windfall" from declining military expenditures is just fake money. We are running over one TRILLION dollars in annual deficits as it is. So instead of using the political circumstance to reduce our spending, we are using the phantom savings to buy something else. It's like saying you got a loan to buy a new car but then you change your mind. Instead you decide to use that borrowed money to buy a boat. In the end, it is still not your money. You have to pay it back eventually. That's the problem I'm having with this new Doc Fix. While it's good for doctors' incomes, in the big picture it's bad for our country's fiscal discipline (what little there is) and drives us ever closer to economic chaos. Am I just too conservative in my opinion? Should I just declare "Screw you all" and take what I think I deserve? Or should I look out for the common good and say there must be a better way without endangering future generations of Americans? I wished I had taken an ethics class in medical school.

When In Doubt, Blame The Doctor

 

There is a sensational trial underway in Orange County, CA. It regards the beating death of a homeless man named Kelly Thomas by two Fullerton police officers Manuel Ramos and Jay Cicinelli. Mr. Thomas was confronted by Officer Ramos at a bus depot. The incident quickly turned violent with the victim being punched, kicked, Tasered, and pistol whipped with the end of a Taser gun by the police. The episode was caught by a security camera at the bus station.

The victim can be heard pleading, "I am sorry dude. I can't breathe dude." The sounds and images of the violence were so graphic that the presiding judge had to stop the video when several court attendants had to leave the room. He can finally be heard crying, "Dad, they are killing me." After it was over, the victim was taken to St. Jude Medical Center where doctors initially had difficulty intubating his airway. Mr. Kelly died five days later. The coroner's report lists the cause of death as "mechanical compression of the thorax" or his trachea was crushed.

Now we get to the part about the clever, clever lawyers. Officer Ramos's attorney, John Barnett, questioned expert witness Michael Lekawa, M.D., U.C. Irvine's surgical trauma chief, about Mr. Kelly's injuries. Is it possible, Mr. Barnett asked Dr. Lekawa, "The cause of death might be the treatment he got at the hospital?" To his credit, Dr. Lekawa allowed that he initially thought the difficult intubation might have played a part leading to his death, until he read the medical reports and saw the videotaped beating.

Do we need any more reasons to dislike lawyers?

Fetal Cannibalism As Energy Booster

This is so wrong, and so disturbing, on multiple levels. Story out of South Korea is that over 17,000 capsules intended for human consumption have been seized by the government because they contain the dried remains of human fetuses. They were being marketed as energy enhancers, increasing the vitality and libido of its users. YUCK!

The pills were manufactured in northeastern China, which abuts the Korean peninsula. The contents are believed to be aborted fetuses that had been chopped up and dried in an oven to turn them into powder, ie/ cremated. DNA evidence from the powder have proven that they are of human origin. So far the pills have been found in international mail packages and tourists traveling out of Korea.

This story has a life imitates art quality to it. I'm reminded of a late night movie on cable called "Dumplings" that I saw recently. It is a Chinese movie about an abortionist turned dumpling maker. Her dumplings were filled with the chopped remains of her clients' fetuses. She marketed herself as selling the fountain of youth and convinced a rich older couple to partake of her offerings because of their insecurities with their ages and marriage. Not for the squeamish.

It's amazing what people will do in the futile attempt to stay forever young. Countless animals have been hunted to near extinction for the supposed aphrodisiac quality of their anatomies, such as tiger penises and rhino horns. Since those creatures have now been strictly protected by international laws, they are now resorting to consuming human babies. Why people, why?

This Disorderly House

Why is medicine so hard? Many people don't exactly understand what doctors do other than some vague concept of "healer". Consequently they can't sympathize with the plight of medical students and residents when it comes to the length of training involved and the years of sleepless nights that are part and parcel of medical education. I was thinking about how we can teach people the complexities of the human body when a thought occurred to me. The human anatomy is really just an old and disorderly house.

While most people may not grasp the relationship between an ejection fraction and a Starling Curve, the majority do know how a home functions since most of us have lived in a home of one type or another at some point in our lives. This is as good an analogy as any for getting people to understand the intricacies of our physiology.

Let's take one of the most basic of features of a house, the plumbing. Imagine a chaotic house where there are no rules regulating the sizes of the pipes inside. Every house will have different diameter pipes running willy nilly. The pipes, besides being of different caliber, will have different stiffness. Some may be as sclerotic as rock while others as soft as a rigotoni. Now think about the water that runs through this mishmash of plumbing. The water that flows through these crazy conduits will have different pressures and even different viscosities. Imagine a plumber called to service such a house. Do you think the plumber can perform a repair job in this house and get nearly 100% success rate? He would be the most wondrous plumber of all time.

Or how about the ventilation elements of this imaginary house. Would an HVAC repairman found in the Yellow Pages be able to repair ventilation pipes that must be constantly suctioned to get rid of chronic mucus production? Or filtration system so clogged with debris that nothing short of replacing the entire ventilation system will do. Yet doctors routinely treat people with severe pulmonary diseases similar to this.

Let's not forget the nervous system. How would an electrician feel about finding a fuse box to a house with no markings indicating which room each fuse controls? And suppose people have been working on this problem in this house for decades and the answer is still not clear. Can an electrician repair electrical problems in houses where each house has nonstandard caliber of wires and different voltages?

These are some of the difficulties that physicians face every single day when treating patients. Because no two patients are exactly alike,  it is astonishing that doctors are able to properly care for anybody at all, much less with the success rate that is now taken for granted by patients. Yet unlike plumbers and electricians we are expected to be reachable nearly 24 hours a day, with no extra compensation for getting called at 4:00 AM. Is it any wonder that doctors resent all the armchair quarterbacking from the legal vultures and the decreasing compensation thanks to our politicians? We doctors may not have the screen recognition or the star power of a Bob Vila, but I bet most patients are thankful we are more than mere plumbers and other tradesmen.