Monday, October 29, 2012

CNA vs. CMA. Political Activism vs. Patient Advocacy

We are in the home stretch of the 2012 election. Every time I turn on the TV or listen to the radio I hear another political ad telling me to vote yes for something or no for something else. At the end of the commercials there are always a list of sponsors who paid good money to put this drivel on the air.

Curiously, many of the ads list as a sponsor the California Nurses Association. Their endorsements in the election include such non-nursing issues as how car insurance premiums are calculated and how out of state corporations are taxed in California. I wondered, why in the world would the nice nurses at my hospital care about such topics? We discuss subjects such as patient safety in the operating room and improving hospital efficiency, but never about changing the definition of California's three strikes law.

Finally I decided to go to the source of this political activism, the website for the CNA. I was immediately struck by how political the CNA is. Throughout the home page are advice on how to vote next week. There is a link that takes you to a page that contains a nice little cutout you can take to the polling booth to show you who to vote for and how to vote on each California proposition. In addition to all the voting directives, the home page also contains pictures of nurses holding picket signs and kudos to nurses who were able to negotiate higher paying contracts. There is virtually nothing on the home page about improving patient health, as one would expect from a website run by nurses.

By contrast, when I go to the California Medical Association website, there is almost nothing on the home page that directs physicians how to vote in the election. As a matter of fact, you have to scroll down a bit before you even see any news about political activism, a little tidbit about how the CMA supports California's climate change law. (As an aside, I think the CMA is trying to kiss some legislators' asses by endorsing this measure. California is already losing major corporations to other states because of onerous and over the top taxes and regulations. This ill conceived climate change law will do nothing to help global warming around the world but will make companies think twice before opening another factory here in the state. When good companies don't come here, their well insured employees don't either. Does the CMA think we doctors prefer to treat MediCal patients instead of privately insured ones? There must have been a medical marijuana shop nearby blowing their fumes into the CMA's conference room when they endorsed this law. This message fully endorsed and sponsored by ZMD.)

Anyway, I go back to the CNA's website to see what's going on. To get to the bottom of the story, you have to click on the About link. Then right there, in the first sentence, is the answer. "Founded in 1903, the California Nurses Association/National Nurses Organizing Committee/AFL-CIO is a premier organization of registered nurses..." So the CNA isn't really an organization for patient teaching and nurses training. It is a political union no different from the Service Employees International Union or the United Autoworkers Union. It's no wonder I have an almost totally opposite viewpoint of how I will vote next week. They have hijacked the good name of nurses to promote their political causes. They are using the trust patients have of nurses and abusing it for their own motives. For shame.

The CNA should stop deceiving people about what kind of organization they are. Virtually none of our nurses are the activists the CNA would like the public to believe. They work long hours, do jobs we doctors wouldn't want thrust upon us, and take crap from patients and their families all day long. Yet they are still able to show compassion and respect that many of those patients don't really deserve but still receive. To me, that's what the nurses are all about, not how they will vote on genetically modified food labeling. I bet the CNA would be much less successful in persuading voters if they really knew that they are just another arm of the AFL-CIO.

Thursday, October 25, 2012

The Easy Way To Decide What Kind Of Doctor To Be--Take A Test

It is an eternal fear and frustration faced by all medical students: what kind of doctor should I be. For me it was both gut wrenching and emotionally exhausting. Though I had some inkling that I wanted to be an anesthesiologist while in medical school, I was led astray that took years of soul searching before returning to my true love and destiny. Little did I know that, though it might not have existed at the time, there is an online test to help students navigate through these treacherous waters, the Medical Specialty Aptitude Test.

Hosted by the University of Virginia School of Medicine, this test has been around for awhile. You can surf through various medical blogs and it will keep popping up time and time again. It is a nice resource that every generation of medical students, especially the current technologically astute classes, keeps coming back to. The test consists of 130 questions you answer based on how strongly you agree or disagree with a statement. Many of the questions seem to repeat themselves, such as variations on if you're a thinker or a doer. How much do you like working with people? Do you like to see immediate results? Only a few questions were truly unique, like do you enjoy research? Or are you mechanically adept?

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The test says it should take about 15 minutes to complete but I did it in less than five. I tried not to think too hard about the questions and answered what came to my head first. So here are the results. As you can see I knew myself in medical school better than I thought. The specialty that I matched best with according to the MSAT is in fact General Surgery. Surprise, surprise. In fact, of the top ten choices, five are in the surgical field. But my instincts weren't entirely baseless. Anesthesiology ranks right near the top at number four. This confirms my feelings that I still love being in the operating room. It's just the lifestyle of general surgery that I detest.

What's also interesting about my results are what's at the bottom of the list. According to the test, and the last two got cut off on this screen shot, the specialties I would be least likely to succeed and find solace in, are: Family Practice, General Internal Medicine, and Pediatrics. They were all fields that I had absolutely no intention of entering.

One specialty that I'm surprised by the ranking is Psychiatry. As I mentioned in a previous post, I loved psychiatry as a student. But here, the test ranks it fourth from last. As many students know, a good attending can make a clinical experience better than what it really is. My psych attending was excellent and made me seriously consider it as a career. Ultimately it looks like I made the right decision by not going into it.

Right now medical students all around the country are getting ready to apply for residencies to fields they hope they will like but really don't understand. It has always been a guessing game based on clinical experience, mentor's advice, and gut instinct. Here is one more resource that can serve as an aid in this life changing decision.

Wednesday, October 17, 2012

EMR Is Destroying The Nursing Profession

We've all seen this before. You're walking through the wards of the hospital. All around are the beeps of IV pump alarms blaring from the rooms. The call light has been activated from a room where a patient wants some medical attention. Yet all you see are the nurses sitting at their stations, noses pressed up close to the computer screen or down at their keyboards, busily charting their patients for the electronic medical record system.

It has become all too common to see this as nurses are so busy documenting their patients on the computer that they have little time for actual patient care, or even recognition. When we implemented our new EMR a few months ago, it brought a dramatic slowdown in admission of patients into our outpatient surgery center. The electronic implementation of the preop admitting note is so onerous that the nursing manager told the nurses to cut corners, not all of it beneficial to the patient.

The EMR was forcing the nurses to ask their patients many nonessential questions that delayed admissions but had no practical implications for the patient' hospital stay. Questions that had to be answered on the computerized records include: Do you always wear your seatbelt when riding in a car? What religion are you? Do you use contraception when you have sex?

Because all these mundane questions were delaying the start of cases, the nursing manager decreed that some questions don't need to be asked. You know, such trivial stuff like what kind of meds the patient is taking. Some patients were taking fistfuls of medicines every day. All these drugs had to be entered into the EMR individually, along with the dose, the frequency of intake, and the last time the drug was taken. This could easily eat up fifteen to twenty minutes of preop time. Therefore the manager said that was not important for nurses to know. That information was for doctors to get from the patient and should not take up any nursing time.

Another time saver that was cooked up was the disregard for a patient's lab work. The preop nurse was not to waste any effort looking up a patient's labs. That information too was not worthy of a nurse's time. Laboratory work was the responsibility of the surgeon and anesthesiologist to look up and analyze before surgery, not the nurse.

As you can imagine, many of the nurses were appalled by the new rules. They had just been demoted to being computer entry clerks. The job of the preop nurses was no longer to evaluate the patient for appropriateness for surgery. Instead they're supposed to find out if the patient had gone to the bathroom that morning and enter it into the computer. Everything else squandered too much time to be bothered with.

How sad for our nurses and the nursing profession.

Tuesday, October 16, 2012

What Your Breath Reveals To An Anesthesiologist

Apparently breath analysis is becoming a hot research topic. By studying the contents of a person's breath, multiple medical maladies can be diagnosed. For instance, nitric oxide levels in the breath are elevated when the airways are inflamed thus signaling an asthma attack. Irritable bowel syndrome sufferers may show increased hydrogen levels due to bacterial overgrowth. The possibility of making meaningful diagnoses without expensive invasive procedures or painful blood draws certainly merits more research.

However we anesthesiologists are already experts at evaluating a patient simply from the odor of his breath. As masters of the airway, we are frequently up close and personal with a patient's exhalations. Thus after years of experience I can tell you what somebody's breath reveals about their health.

You tell me you haven't smoked in six months just so you can get that transplant? Then why is it that as soon as I open up your airway during direct laryngoscopy, I feel like an ashtray has been emptied into my nostrils? I may not be able to tell whether you've been lighting up with Marlboros or Winstons but I know you haven't quit smoking like you claimed to have done. Case cancelled.

How about your claim that you haven't used marijuana and are now living a clean and sober lifestyle. Again one peek down your airway and my face is assaulted by the atmosphere from a Grateful Dead concert. You just couldn't make it down for your surgery without a quick stop at the local "medical' marijuana shop? Don't tell me it's to alleviate postop nausea either.

Then there is the trauma patient brought emergently to the operating room after driving into a tree. What a freaking mess. I do a quick rapid sequence intubation to get the case going. As I do so, my nose is confronted by the uniquely rancid odor of blood, alcohol, and partially digested food emanating from the mouth. As soon as I drop down an orogastric tube into the stomach, I am proven right. Out comes hundreds of cc's of the patient's last pitcher of beer and what looks like a pureed mixture of nachos and pepperoni pizza.

Yup we anesthesiologists have developed quite an acute awareness of our patients and their breaths. We don't need any special sniffing equipment either to tell us what we already know from years of experience. And we even do it for free.

Monday, October 15, 2012

I Am Not A Cocktail Waitress

As doctors continue to lose control of their livelihood, the politicians are ratcheting up new ways to make life miserable for us. One scheme is to make sure our patients are happy and satisfied with their medical care. This year, Medicare will take away 1% of hospital reimbursements and redistribute the money to the facilities that make their patients happier based on a questionnaire developed by politicians. Starting in 2016 that goes up to 2%.

The public may not understand it, but hospital pretty much run on profit margins that would make most other businesses run away from this industry. Between all the free care hospitals by law are supposed to give and the decreasing reimbursements from the government and insurance companies, most hospitals have profit margins of about 1% or less. At Grady Hospital in Atlanta, they made $1 million on revenue of $650 million this year. That's a profit margin of 0.15%. After Medicare reduces reimbursements due to low survey results, the hospital will lose $230,000 from the government. By comparison that iPhone 5 you hold covetingly in your hands probably gives Apple a 50% profit margin.

Questions on this patient survey include subjective inquires like, "How often did doctors treat you with courtesy and respect?" And, "Did you receive help as soon as you wanted it?" To indulge the patients, doctors are being cajoled into pulling up a chair and sitting down next to the patient when talking to them.

Excuse me? I am not some cocktail waitress who sits next to you when taking an order in hopes of getting a fatter tip. My life does not revolve around making you feel you had a delightful experience at the hospital. I am here to treat your illness, not feed your id.

As anyone who has ever worked in the service industry knows, it is impossible to please everyone all of the time. Some people just can't be appeased no matter how hard you try. Especially in a hospital setting, the nature of human illness makes people even less likely to see the sunny side of their stay. As one nurse related at Grady Hospital, a patient they had rescued from a massive stroke and managed to walk out of the hospital gave the facility low evaluations because the food was not to his liking. This is the kind of mentality we are supposed to kiss up to?

One hospital here in Los Angeles tried to make patient happiness the center of its mission. When Century City Hospital opened in 2007, there was much fanfare about how it would steal patients from the nearby powerhouse hospitals Cedars-Sinai and UCLA Medical Center. They were going to do it with state of the art surgical facilities, fancy flatscreen TV's in every room, and gourmet meals conceived by none other than Wolfgang Puck himself. Well the idea was nice. But they forgot one thing: people like nice things but they don't want to pay for it. Century City went bankrupt in 2008, taking millions from the physician investors who bought into the concept. Perhaps their doctors didn't pull up a chair when they were talking to their patients. Maybe their nurses should have performed lap dances to raise their patient satisfaction scores. At least patients might willingly pay for that.

How can we reverse this situation?  We need to vote these rascal politicians out of office. But wait, these incumbents are usually entrenched in their positions, using the millions of dollars they have at their disposal from political donations provided by special interest groups. We doctors on the other hand aren't even allowed to receive lousy pens and notepads from drug reps anymore because somehow that will influence how we treat our patients. Looks like doctors better get familiar with service with a smile. And learning a few lap dance techniques can't hurt.

Tuesday, October 9, 2012

Worst History And Physical Ever, Thanks To EMR

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I was looking for my preop patient's history and physical written by a consultant in our new fangled EMR system the other day. Scrolling down hundreds of notes from physicians, residents, fellows, nurses, physical therapists, social workers, etc. I finally located what I wanted. At least I think it's the preop clearance note that I wanted.

Reading through this note felt like the worst case of cutting and pasting I have ever come across. It appears to have come straight from the hospital billing office. The only thing the note was missing were the ICD-9 codes after each unspecified diagnosis. How can a physician produce a history for a patient and label virtually every diagnosis "unspecified"? It makes you wonder if the patient actually has the disease or whether the consultant was too lazy to write more specifically in his note. In other words, this H+P was total garbage. Thanks to our new EMR, this kind of shenanigan is all too common.

Yes we can read doctors' notes more easily now. Unfortunately, what's typed in makes even less sense than before.

Monday, October 8, 2012

Finally, My New TV

Some of you may have been following my saga of buying a new 3D TV. After years of waiting for the perfect combination of size, price, features, price, picture quality, and price, I finally settled on the Samsung 65ES8000 to fill out my newly remodeled home theater. Alas, when my TV arrived from Amazon, it was immediately obvious that somebody had dropped the bloody thing. There was an internal crack in the screen, not visible with the TV off, that severely marred the picture. Well, back to Amazon it went.

Unfortunately, a couple of months ago this TV was in severe short supply. When I sent the TV back, they had no others to replace it. Not until just recently did Samsung have more of this model to ship out and I finally got my replacement. But thanks to the delay, I got a free Samsung 7 inch tablet thrown in for free. Yeah. As you can see, there are no more cracks or rainbow distortions in the screen. The picture is gorgeous. The family and I are watching more TV than ever, which of course is a mixed blessing.

However, despite the price, the set is not perfect. The 3D is cumbersome to implement and rarely used. It has a feature called AnyNet that automatically turns on my home audio whenever I turn on the TV. It is supposed to be an asset but in fact is a pain in the ass because if I don't want to turn on the surround sound it will get turned on anyways. But the biggest drawback is what the folks at AVS Forum call vertical banding. That's the dark vertical shadows visible when there is a uniform background color on the screen like this snowy picture in the movie "Ice Age". I'm probably the only person in the household to notice this since I read nerdy forums like AVS. The bands are not visible during motion scenes, which is most of the time, or with mixed colors, again most of the time.

So after years of saving and scrimping, I finally have the TV of my dreams. But this thing is already obsolete. From what I've been reading, the next big thing is no longer 3D, or even glasses free 3D. The next revolution in television will supposedly be in wide circulation at next January's Consumer Electronics Show: 4K TV. That's a TV with four times the resolution of today's 1080P.

Sigh. Time to start saving my pennies again.

Wednesday, October 3, 2012

Are CRNA's Better At Treating Chronic Pain Than Most Anesthesiologists?

That seems to be the question the Centers for Medicare and Medicaid Services is trying to answer. CMS has until November 1 to decide whether Medicare will reimburse CRNA's at the same rate as physicians for treating chronic pain, including invasive injections and prescriptions for narcotics. If Medicare does approve this plan, then the consequences will snowball as private insurers follow the lead of the federal government.

It appears that the main excuse for allowing CRNA's to start independently performing and billing chronic pain procedures is the lack of access of many patients to board certified pain specialists. As always, they pull up the old canard about having few anesthesiologists willing to work in rural settings, forcing patients to travel hundreds of miles to see one.

So from the logic of the discussion, the CMS will conclude whether 45,000 CRNA's are as qualified to perform pain procedures as 2,000 pain specialists board certified by the American Board of Pain Medicine. These 45,000 CRNA's will intuit on their own whether they will inject drugs into somebody's back with potentially life threatening complications, something that most general anesthesiologists who have had training in treating chronic pain but are not board certified to do so, would rather not touch. When the lone CRNA working in some rural clinic a hundred miles from the nearest specialty pain center encounters a patient complaining of low back pain, he or she is now suddenly able to diagnose and treat chronic pain right then and there because the government has given the green light to do so since the patient otherwise won't have "access" to more specialized professionals.

Does this make any sense at all? The CMS is saying it's okay for rural and poor patients to be subjected to minimally trained nurses injecting drugs into their backs and joints just because, well, there is nobody else around who will do it. The key to increasing the availability of well trained board certified pain specialists is not to go downmarket by using lesser trained nurses (two years of nursing and two years of CRNA schools vs. four years medical school, four years anesthesiology residency, and one year pain fellowship). Instead the CMS should be increasing the Medicare reimbursements for anesthesiologists, thus making Medicare patients more attractive. As it stands, Medicare screws anesthesiologists with the lowest reimbursement of any medical profession, just 33% of what a private insurer pays for the same service.

The CRNA's who are clamoring to get into the specialty pain business may regret doing so. They are going to find that Medicare reimbursement isn't that great. Their malpractice insurance will surely skyrocket. And in a few years, well, Medicare may decide that even CRNA's can't work cheap enough for all patients to be seen. They may decide that PA's are just as qualified as CRNA's to diagnose and treat chronic pain. They are starting a downward spiral that could hurt chronic pain patients most of all.

Monday, October 1, 2012

Anesthesiologists Do More By 8:00 AM Than Most People Do All Day

It is dark when my alarm clock blares. 5:15 AM. I have gotten up at this time so often that my internal alarm clock had already brought me back to consciousness three minutes ago. Quietly I slip into the bathroom for a quick shower and shave. I dress silently so as not to disturb my wife still dozing comfortably in the warm bed. She too is so used to my routine that my noises don't even disturb her anymore.

As I leave the house I wonder if it will be dark again before I get home. Hopefully I'll return before the kids go to bed tonight or it'll be two days that I won't see their smiling faces. I'd like to think that they miss my company but this has happened so often that I think they hardly notice anymore.

The streets are still fairly deserted when I get on my way. Other than the lone exercise fanatic or the dog walker who irritatingly changes my green stoplight to red when he pushes the crosswalk button, there are only a handful of cars sharing the lonely asphalt. The freeway is a whole different story however. It is already starting to get congested. If I leave the house ten minutes later my commute would take twenty minutes longer. Such is the traffic calculus of Los Angeles.

Pulling off the freeway I see all the same usual cars going to the same destination as me. The hospital is like a self-contained city, with hundreds of people with different responsibilities all converging to make sure it runs efficiently and on time. I recognize fellow anesthesiologists, nurses, and various hospital staff all pull into the parking lot ready to start another day.

I go straight to my assigned room to get started. I have a difficult case this morning. No time today to go to the doctors' lounge to chit chat and grab a coffee and bagels. After preparing thousands of cases over the years the basic setup is rote. Do an anesthesia machine check. Make sure there is enough inhalational agents in the vaporizers. I hate it when some fool of an anesthesiologist leaves his last case of the day without turning the vaporizer completely off and the oxygen still gassing out eight liters per minute all night. Check the suction. One of my worst weaknesses is failing to remember to have a proper suction in place. It was a problem during residency and it still dogs me to this day. So suction? Check.

I notice that the anesthesia tech has already set up the arterial and central line transducers. Thank goodness we have such great techs, always thinking ahead to what the patient will need instead of my having to ask them for it.

Now for the drugs. I draw up the induction agent, the paralytics, the antibiotics, the resuscitation drugs. Almost ten syringes in all. Then I mix a couple of bags of pressors and hang them on the IV pole. Taking one last look around I don't think I'm missing anything egregious. Glancing at the clock, it is now 6:45 AM. Time to go meet the patient.

Like an actor about to walk out onto the big stage, I take a deep breath, put on my happy face, and enter preop holding. The room is its usual morning chaos. Patient beds are lines up against the walls. Nurses, residents, medical students, and staff are all trying to talk to the same patients simultaneously. Some patients have compared the din to the aural assault in a too-hip dance club.

If the nurses aren't too busy or they're feeling extremely generous, they may put in the IV for me, or at least have the IV supplies ready. No such luck today. I go into the IV fluids cabinet and assemble my favorite bag of crystalloids, taking up precious minutes. Then I go to the IV supply cart and get the things necessary to start one: tourniquet, local anesthesia, IV catheters, alcohol pads, and tape. More minutes tick by.

Arms fully loaded, I walk over and introduce myself to the patient. In order to save time, I go over the patient's history while simultaneously starting his IV. Sure I had perused his chart the night before but surgeons' H+P's are notorious for being next to worthless when it comes to describing anything about the patient besides the chief complaint. I've been surprised by undocumented cardiac disease, adverse previous surgical experience, or even wrong site surgery on the schedule.

With just minutes to go I rush to the closest computer workstation to enter my H+P. New Joint Commission rules say the patient cannot enter the operating room before the anesthesia note has been written. I then go to the Pyxis and wait in line for my turn to get the narcotics. Luckily the surgeon is late, surprise surprise.

Finally he arrives. He says a quick greeting to the patient then asks why he isn't in the room yet. The patient gets a quick squirt of Versed, which nearly all patients appreciate, and is moved to the OR. The anesthesia tech is already waiting for us. Once the patient is on the table, the tech prepares him for an arterial line. By the time I have put on the usual standard anesthesia monitors, the patient's wrist has been prepped and draped for my a-line insertion. Luck is with me today as I feel a strong radial pulsee and put in the line on the first shot. Few things are worse than holding up the case trying to futilely find a pulse to get an a-line in.

I then walk back to the head of the bed and put the oxygen mask over the patient's face. In my most soothing voice I ask the patient to imagine himself relaxing at his favorite vacation spot as I start the induction. In seconds he is unconscious. Intubation is a cinch. I tape the tube securely along with the eyelids. I make sure the anesthesia gas has been turned on. The patient returned his twitches so I push some muscle relaxants. The tech is now preparing the neck for a central line.

A quick check of the monitor shows the patient is hemodynamically stable. An ultrasound machine is rolled towards my line of sight. To me this contraption still feels novel as I grew up when men were men and anesthesiologists could place central lines by anatomic landmarks alone. But it does make the procedure easier and with more certainty, like today.

Another brief glace at the computer screen shows the patient continues to do well. I quickly give a push of IV antibiotics before I forget. One last review of the patient. Vitals? Check. Anesthetic? Check. Twitches? Check. Fluids? Check. The surgeon calls a timeout. Yeah yeah, we all agree on the procedure. The scrub nurse then hands the surgeon his scalpel and makes the incision. Another life about to be improved at the point of a knife.

I finally sit down and start documenting my day so far. It is 8:00 AM.

How An Apple Store Is Mightier Than A BMW

Okay this one gave me a good laugh on an otherwise dreary Monday morning. Last month burglars rammed into the Apple store in Temecula, CA with their SUV and absconded with a bunch of store display iPhone 4s and iPads. Unfortunately for them, despite the massive BMW X5 they were driving, they had quite a bit of difficulty getting out of the store, as you can see from the video.

In the process of trying to escape, they lost their license plate and blew a couple of tires. Once they got out, they stopped at a nearby convenience store to change a tire and then rob the 7-Eleven of a can of Fix-a-Flat. When they realized they had lost the license plate, the owner of the BMW went back to the store, with the keys of the car in his pocket, to retrieve the plate. The police were very happy to see him return to the scene of the crime. Easiest arrest they've made all year, I bet.