Thursday, January 31, 2013

The Anesthesiologist's Perspective On The Kristen Diane Parker Tragedy

A few years ago, I wrote about the horrible story of Kristen Diane Parker, the drug addicted surgical tech who stole fentanyl off anethesiologists' carts and exchanged them with dirty syringes of her own. The anesthesiologists she worked with inadvertently infected several patients with her hepatitis C. She was found guilty in 2009 of illegally obtaining controlled substances and will serve 20 years in prison.

Now quite serendipitously I have come across the writings of one of the anesthesiologists that works at that Colorado hospital where this crisis transpired. Her name is Kate O'Reilly, M.D. and she too writes a blog. She describes the years of litigation that followed the incident. The ordeal was worsened by local media that portrayed the doctors at the hospital in a negative light. In the end she settled with the plaintiffs and was never dragged into court but now she is emotionally drained and embittered. She doesn't feel she did anything wrong, or at least negligent, but she and her partners are the scapegoats for something they had nothing to do with.

Keep your chins up Dr. O'Reilly and all the anesthesiologists at Rose Medical Center. This too shall pass. 

Healthcare In America Is Not A Marketplace

$100? Yes if your insurance is buying it for you.
One of the ideas that gets batted around when politicians discuss ways to reduce healthcare costs is to have patients shop around for the cheapest services they can find. After all when people buy a car, they usually visit several dealerships and try to negotiate the best deal possible. Pure American capitalism. Shouldn't medical care work the same way? Unfortunately it doesn't. Imagine if you went to a McDonald's and ordered a Quarter Pounder with Cheese but there are no prices listed on the menu. One McDonald's might say the burger costs $2.99. Go down the street to another McDonald's and they charge $29.99. Go yet to another McDonald's and the Royale with cheese costs $99.99. And you wouldn't know it unless you went to every single McDonald's to compare prices for yourself. That's more reflective of how health costs work here.

Previously I wrote about the ridiculous charges hospitals bill to uninsured patients in California for healthcare. These prices include outrageous sums like $11,000 for a colonoscopy or $110 for a simple plastic tubing to hang blood. But don't think that only the uninsured get shafted in this system. The insured patients also get a royal screwing. They just don't know it because the insurance company pays for it. But in the end we all pay through higher insurance premiums.

The L.A. Times reported on a teacher by the name of Lynne Nielson who went to Advanced Surgical Partners, an ambulatory surgery center, for a simple knee arthroscopy. The procedure lasted about twenty minutes. A few weeks later, the insurance company mailed Ms. Nielson the check for the procedure which she was supposed to forward to the center. The ASC had billed her insurance $87,500. This for a procedure that usually cost $3,000. The charge did not even include the surgeon's or anesthesiologist's fees. She was so astonished and angered by the amount that she refused the pay it and referred the matter to the attorney general, for possible fraud.

Part of the reason the bill was so high was because the ASC did not belong to her insurance company's network. Her teacher's union had negotiated a deal with Blue Shield, her insurance carrier, that it would pay all costs, even for out of network service providers. When confronted by this angry patient and possible legal repercussions, Advanced Surgical's lawyer, Henry Fenton, agreed that there was a mistake in the bill. They and Blue Shield negotiated the bill down to $15,000. That's still far above the $3,000 that a knee arthroscopy normally costs but now everybody's happy. Except of course you the insurance holder who will just see another jump in your premiums next year.

Tuesday, January 29, 2013

The Disgruntled Patient

Dr. Ronald Gilbert, M.D.
Shocking news out of Orange County, CA. Yesterday a patient by the name of Stanwood Elkus went to his urologist's office at the prestigious Hoag Hospital in Newport Beach and shot him to death. Dr. Ronald Gilbert had been treating Mr. Elkus for his long standing prostate problems. According to his neighbors, Mr. Elkus would frequently complain about his medical issues. It is unclear how long he had been a patient of Dr. Gilbert.

Dr. Gilbert had once been the Chief of the Department of Urology. He had been practicing at Hoag for twenty years. Tomorrow would have been his 53rd birthday. He leaves behind a wife and two children. R.I.P.

Monday, January 28, 2013

The Paranoid Life of Doctors

We've all heard of the medical student syndrome. That's when new medical students start imagining they possess the diseases they are currently studying in medical school. Every student goes through this period of hypochondriasis. You study the chapter on skin diseases and every mole on your body is suggestive of melanoma. Every lump you palpate under your skin becomes a potential lymphoma. After reading about pulmonology, every cough you have suddenly manifests itself as a contagious or cancerous lung ailment. It never fails. After awhile, you learn to brush away those fears as mental and learn to focus on the people who really do have medical issues, the patient in front of you.

At least that's what I thought was supposed to happen. Now that I am into my second decade of practice, these fears of personal medical crises still rear its head. But now I project those fears to my closest family and friends. As a doctor who has seen thousands of patients, I have seen how illnesses can manifest and I can't help seeing them in the people around me.

When my son fell and bumped his head, alarms started going off inside mine. Even though he never lost consciousness, I started thinking about all the worst possibilities. Does he have a subarachnoid hemorrhage? Should I take him to the emergency room? Why is his appetite not as good after the fall as before? Should I wake him up every couple of hours tonight to perform a neuro exam? The paranoia knows no boundaries.

My daughter recently had abdominal pain with nausea and vomiting. There goes the red alerts again. Does she have early appendicitis? Does she need a CT scan of her belly? Maybe she has some sort of bowel obstruction without previous history of abdominal surgery which leads to all kinds of implications? Will my delay in whisking her to the ER cause her to rupture her appendix, develop septic shock, and die? Could I live with that kind of guilt?

Of course both kids were fine. Neither of them had any crippling medical issues. My daughter only had the flu. As for my son, sometimes a bump on the head is just a bump on the head. Those fears were only in my overly educated paranoid brain. It's easy for doctors to dismiss most symptoms that patients complain about because we have seen it all before. Yet by being so jaded we let the occasional Rory Staunton slip through. That's why I am especially on my guard against such carelessness when it's my very own family. But goodness it's not easy to live with.

Friday, January 25, 2013

The Lift Team

Hospitals can be dangerous places to work. According to government statistics, thousands of people are injured in hospital settings every year. We've had doctors and nurses who had to temporarily stop working because of workplace injuries. One nurse I know was out for weeks when an O.R. patient almost fell off the operating table. He saved the patient just in time but wrenched his back in the process.

It doesn't help that patients in general are getting bigger. Much bigger. It's not unusual for our patients to have BMI's into the 40's. These behemoths can be quite a challenge to move without injuring the patient or ourselves. Because of that danger, the hospital hired a bunch of strapping young men to form a Lift Team to help transfer patients safely. It doesn't take much cognitive skills to be a member of the Lift Team. You just need to be big and strong. A few years of high school football experience is a definite plus.

One day, I was transferring a postop patient to the ICU. The patient was BIG. He was also intubated with multiple lines coming off him. Luckily we now have motorized gurneys that drive themselves so we don't have to push too hard. Just avoid steering into a door frame along the way. Once we got to his room, we called for the Lift Team to transfer the patient from the gurney to the ICU bed.

"Sorry," the charge nurse said, "The Lift Team is out."

"What do you mean they're out?" I asked.

"They're all on leave because they got injured," she replied.

"All of them?" I asked incredulously. She nodded in reply.

Sigh. The big young guys are at home relaxing their backs and getting paid for it while we have to move the patient ourselves. They're a lot smarter than I give them credit for. So now we have to move this nearly 300 pound patient into the bed without injuring the patient, ourselves, or pull out any of his lines and tubes.

Looking around, I knew we needed more people. A lot more. As the anesthesiologist, it is my job to make sure the endotracheal tube or lines don't get dislodged during the transfer. Therefore my role is to hold the head during the transfer; the rest of the patient has to be moved by other people.  Anyway, my weak little anesthesiologist arms can't handle more than ten pounds. So I stand at the head of the bed as they rounded up six nurses to help. Holding the head steady with both hands while stabilizing the ET tube and making sure all the lines and Foley catheter were ready, we gave a count of three and heaved the patient into the bed. No arterial line got pulled out. No Foley catheter got removed. And nobody collapsed on the floor writhing in pain. A successful move in my playbook.

Who needs the freaking Lift Team? Somebody has to move the patients in the hospital. If the Team can't do it then the rest of us will have to. I just wish I had thought of signing up for that job when I was younger. I could have used a few bucks while sitting at home taking a bunch of Advils. I guess those kids are pretty bright after all.

Thursday, January 24, 2013

Why Do Women Get Paid Less Than Men In Medicine?

A recent posting on KevinMD lamented the lower pay that female doctors make. Written by Dr. Linda Brodsky, it listed the following statistics: women make $0.62 for every dollar a male doctor makes. Women start their medical careers already in the hole by $17,000 compared to men. Mid-career female medical researchers make $12,000 a year less than their male counterparts. Her solutions to the problem are for women to understand their market values better and learn to negotiate a better contract.

While having sharp negotiating skills is valuable, I doubt that that alone will bring equality to female physicians' incomes. Here is what I see when people complain that women make less money than men.

The female doctors in our group have a predilection for calling in sick on the day they're supposed to take call. Then the male doctors, because we really don't have a choice, have to step in and take call for them. The after work plans we had made to be with our own families are discarded because somebody has to step up and take responsibility for patient care. It wouldn't be so bad except the favor is rarely returned.

Our female colleagues often seem to have an excuse to want to leave work early. Either their babysitter cannot stay after 5:00 PM or they have to attend the Women in Medicine Book Club and discuss Fifty Shades of Grey. Oh my! Thus cases are left hanging in the operating room for the men to pick up.

New female colleagues are always eager to start working. But lo and behold, many soon get pregnant shortly afterwards. Then they cannot work in rooms that are too strenuous, require exposure to X-rays like spine cases or interventional radiology, or last too long into the evening. On top of that, they expect to take a month off for maternity leave. Naturally the work load and call schedules then have to be covered by the guys to make sure the O.R. runs properly.

Even though they work fewer hours than their male comrades, they also want the same year end bonus that the men get. Is this the part where Dr. Brodsky's advice for better negotiating skills comes into play?

Call me sexist. Call me a chauvinist. You can even make oinking noises at my expense. I'm just calling it like I see it. Women make less money than men in medicine, but there are good reasons for that. And it has nothing to do with sex discrimination.

Tuesday, January 15, 2013

What Watching "Amour" Can Teach A Jaded Doctor

We've all had the same experience. You see the decrepit old patient in the hospital who you know doesn't have a chance of having a meaningful life yet the family wants everything done. You just want to shake the family members by the shoulders and ask them "Why are you putting her through this ordeal?" Why is she being scheduled for a feeding tube? Why are they ordering another CT? Why, why why? The cynical answer is that the family is not paying for it therefore they want all means of treatment possible to prolong life regardless of the suffering of the patient.

I just watched a powerful French movie called "Amour". It has been nominated for multiple Oscars this year and I can see why. It is the story of an old Parisian couple named George and Anne. During the course of the movie Anne suffers multiple strokes which renders her increasingly helpless and dependent, the antithesis of the vibrant woman we see at the beginning who likes dancing and going out to concerts.

The film delves into the anguish the family confronts as they try to find out the best way to take care of her. The children want to stick her in a nursing home. George had promised to Anne early while she was still able to make her own decisions that he would never take her back to the hospital no matter how bad her disease progressed. He keeps this promise despite the expense of paying hundreds of euros to hire nurses and doctors to come to the house to take care of her. There are depictions of Anne's disappointments as she tries to hang on to her dignity even as her body and mind fails her. "Amour" even shows the abuse of the elderly as those around them are exhausted from taking care of them.

This movie is a typical art house type of film. It will never win for best score because, well, there are none. Unlike a Hollywood production, there is no soaring music to guide our emotions about what we're seeing on screen. The raw images alone are more than enough to make you feel for this unfortunate family. After watching this, you'll have a different view of that patient in the ICU that the family wants to have every treatment medicine can offer. It may even bring back a little of the idealism and humanity you had when you entered medical school but lost after years of physical and mental abuse in residency and practice. Highly recommended.

Thursday, January 10, 2013

What Canadian Medicine Says About The Future Of American Healthcare

The practice of medicine in the United States is in trouble. Everybody knows that something has to be done before the entire house of cards falls under the weight of rampant medical malpractice suits, rocketing health insurance premiums, noncompliant and demanding patients, and dissatisfied physicians. Much has been made about Canadian medicine and how it can be a model for us to emulate, or avoid depending on one's perspective.

I have to admit that I know little about how healthcare works up north other than hearsay and what I've read in lay periodicals. Now Bleeding Heart has a nice summary of what Canadian doctors face in their single payer system the we here are inexorably driving towards.

Do the Canadians have the perfect system? No of course not. Nobody does. They face similar income inequality between specialties that we confront here, and its inherent jealousies and finger pointing. In a single payer system, everybody essentially gets the basic medical necessities for free. He doesn't go into the stories of long waiting times for elective surgeries and procedures that are the bedrock of skeptics of the single payer program. However he does confirm that in an ill advised attempt at saving money, Canadian doctors once had their incomes capped. This of course led to people working up to the cap then taking the rest of the year off. Apparently that is no longer the case.

It seems like the whole arrangement is a cat and mouse game, with doctors trying to earn maximum compensation, the patients wanting maximum treatment, and the government attempting to pay the least amount they can get away with. While their doctors have union representation, since they're all considered employees of the state, that doesn't mean they get a larger voice in how precious loonies are divvied up. The state can still raise or cut reimbursements on the whims of politicians.So the budget for physician pay may go up three percent each year. But that three percent isn't distributed equally amongst all doctors. Some specialties may get more and some less, with some taking a pay cut. All this is negotiated between the doctors' unions, otherwise known as medical associations, and the federal government. Sometimes no negotiations are done and the government rules by fiat.

Has this been a hardship for doctors? Apparently it has been very traumatic for physicians who are used to the compensation they once received before the implementation of this structure and are now saddled with large or multiple mortgages and unrealistic family budgets. However the younger doctors who have never know any other way of practicing medicine will be more realistic with their income expectations and should do just fine.

Let this be a cautionary tale for U.S. physicians as we sale into the uncharted waters of ObamaCare.

Wednesday, January 9, 2013

Intellectual Musings In The Doctors' Lounge: Why Pizza Is Better Than Sex

What do doctors talk about when they are gathered together? Do they discuss the latest therapies in cancer treatment? Are they deep in thought on the current treatment of heart disease? Yes, sometimes. But physicians are people too. We have a wide variety of interests that doesn't necessarily revolve around medical science.

For instance, the other day somebody brought pizza to the doctors' lounge. Naturally the conversation quickly degenerated into the pros and cons of pizza vs. sex. Surprisingly, or maybe not, pizza won out on this debate. Here are the reasons why:

1. Pizza is good hot or cold.
2. You don't have to beg anybody for it.
3. If you can't find anybody to share a slice with you, it is legal to go out and buy one.
4. It's easy to find more than two people to share a pizza with.
5. You don't need a shower after eating pizza.
6. You actually enjoy licking your fingers after having pizza.
7. You can have more than one flavor of pizza and it isn't considered weird or perverted.
8. You don't feel obligated to call anybody the next day after sharing pizza.
9. There's no need to rush out and get the morning after pill when you finish eating pizza.
10. You know you can get more pizza the next day or any day, if that's what you desire.

So there you go. Based on a survey of medical doctors, real doctors, not the actors that play one on TV, pizza is better than sex. And that didn't cost the NIH anything in research money.