Stop The Internal Medicine Residency Charade

I received some interesting news from my medical school alma mater regarding the recent Match Day. Of course they patted themselves on their backs for how well the students matched. In particular, they touted that 43% of the graduating class will be going into a primary care field and nearly 30% of the class had chosen to go into internal medicine.

The National Resident Matching Program also highlighted the great number of students who intend to train in internal medicine. According to the NRMP press release, "This year 1,000 more internal medicine positions were placed in The Match," as compared to last year. In total 3,135 U.S. seniors matched to internal medicine. That's sounds just dandy since for years we've all been getting pounded with warnings about the dire shortage of internists who will be taking care of our growing elderly population.

However, Match Day results do not predict the number of doctors who will practice in a certain field. Residents often change their minds and decide they want to do something else. This is particularly true in internal medicine. One study showed that only a fifth of all IM residents will stay in the field. The rest will move on to a more lucrative subspecialty like cardiology or gastroenterology. Therefore of the 3,135 U.S. seniors who matched in IM this year, only a little over 600 of them will likely end up as an internist. So much for replenishing the dwindling supply of internists who are retiring or quitting at an increasing rate.

We should stop this charade of promoting the importance of internal medicine to the medical students. It's obvious that for most of them IM is just a stepping stone to a more monied career. The real primary care doctors are the ones who matched in family medicine, which only 1,355 U.S. seniors did this year. The NRMP should reclassify IM as a transitional step to the real interests of students. Like surgery residents who work transitional years before going into their urology or plastic surgery residencies, I think students should match into GI, cardiology, pulmonary, or any of the other medicine subspecialties on Match Day. They can then list separately the transitional programs in internal medicine the students will go to first before going into their real careers. This will clearly show how badly we are preparing for the upcoming primary care shortage. Then we can put more emphasis on family medicine if we are serious about training more primary doctors.

Incidentally, my alma mater said that nearly ten percent of the graduating class have decided to go into anesthesiology. That's twice the national average. Smart class they are.

You Can Kiss The R's Goodbye

This is sobering news from the New York Times for the radiology profession. According to the paper, radiology had one of the fastest decline in income among all medical fields. I guess we can now leave the R out of the ROAD to happiness in medicine.

The paper used the example of St. Barnabas Hospital, which is canceling its radiology residency program. The hospital is outsourcing its diagnostic radiology functions to a teleradiology outfit, which can do the same job for less money. Understandably, the new radiology servicing company refused to carry on the residency program. In its attempt to sound politically correct, St. Barnabas said it was shifting the government's residency training money from the radiology department to the primary care residencies, opening up more spots to train internists. Uh huh.

Now the poor radiology residents at St. Barnabas are scrambling to find another residency position, anywhere. They have even been directed to other hospitals where they have to pay for their own salaries and insurance but can continue their training until they graduate. That only adds about $65,000 per year to their six figure medical school debt. What a deal.

Of course many people have seen this coming for some time ever since medical imaging turned all digital. With digital files, anybody anywhere in the world can quickly review a film and type a quick read back to the source. If there is nobody willing to read a CT at 3:00 AM in one hospital, there is probably somebody who will do it in a different time zone for probably less money. Therefore there is less incentive for smaller hospitals to pay for radiologists to staff the costly night shifts.

As a result, radiologists' salaries have dropped ten percent in one survey. This probably isn't going to end well as more hospitals hire teleradiology sweat shops to read their X-rays for them at a lower cost. Without the need for having a living breathing radiologist present in the building, there really is little incentive for hospitals to keep paying the huge salaries currently commanded by the specialty.

Happy Doctor's Day

It's a day earlier than normal, but Happy Doctor's Day. The "holiday" is normally celebrated on March 30 but since that is on a Saturday this year, it was moved up to today. Obviously we can't move it to next Monday, which would make it April 1, or April Fool's Day though some people might think that is more appropriate. Of course some wag in our office said every day at the hospital is doctor's day.

Here is a brief history of National Doctor's Day.

Congratulations To The New Anesthesia Residents

A belated congratulations to the new class of anesthesia residents that was announced on Match Day last Friday. The competition to get into this awesome field was as competitive as ever. In fact, the elite status of anesthesiology residency was specifically mentioned in the National Resident Matching Program press release. According to the NRMP, "Anesthesiology programs offered 1,653 positions, 177 more than last year, and filled all but 62 of them."

The reason there were 177 more residency positions this year was because of the NRMP's "All-In" policy. Programs registered with the NRMP must now offer all their residency spots through the program instead of filling them outside the match. No more special favors or back door deals. This opened up more slots for students which was still barely adequate to meet the high demand. Here's a list of all the medical specialties and how they fared during Match Day. Again congratulations to all the new future anesthesia residents and colleagues. Looking forward to working with some of you in the future.

Don't Fondle A Patient's Breasts And Other Things You Should Have Learned In Anesthesia Residency

Time for another edition of learning from the mistakes of others. The California Department of Public Health routinely issues press reports about penalties they hand out to hospitals who cause preventable injuries to patients. Since I'm a firm believer that those who fail to learn from history are bound to repeat it, I think it is important we all study how these penalties came to be and how we can keep these incidents from occurring in our own institutions. That's why the Morbidity and Mortality conferences are important and have been a mainstay of medical education for decades. So here we go.

First lesson, don't fondle a patient's breasts while she is under general anesthesia. Dr. Yashwant Giri was caught touching a patient's breasts during a hemorrhoidectomy when the surgeon and the nurses were on the other side of the ether screen. Unbeknownst to him, he was being observed through a window in the OR door that was located behind him. An OR transporter noticed the incident and reported him. When she talked to the Chief of Anesthesia, she discovered that this was not the first reported incident of sexual assault by Dr. Giri on a patient. The previous incidents were never reported to security or the police. For this transgression, Placentia-Linda Hospital was fined $50,000.

Next, don't use an LMA during cardiopulmonary resuscitation. A patient at Memorial Medical Center in Modesto had just completed a cystolithopaxy under general anesthesia with an endotracheal tube. The case went routinely. At the end of the case he was extubated by the anesthesiologist. The patient's monitors were removed to facilitate moving him onto the transport gurney. At this point the patient became agitated and started thrashing around. The anesthesiologist then pushed six ml of propofol to calm the patient. The patient promptly became apneic. He was then quickly moved back on to the OR table. When monitors were replaced, the patient had an oxygen saturation of zero, confirmed with a second pulse ox. The anesthesiologist inserted an oral airway and tried to bag mask the patient to no avail. He then inserted an LMA to improve oxygenation but that too did not work. By then another anesthesiologist was found and suggested that the patient be intubated. This was done and CPR was started. By then the patient had suffered severe anoxic brain injury and died eleven days later. The hospital paid $50,000 for this transgression.

Third, don't give sixty milligrams of morphine after foot surgery. A patient was undergoing heel surgery at Adventist Medical Center in Hartford. Postoperatively the patient complained of a lot of pain. In the recovery room he received Demerol 75 mg, morphine 4 mg, and fentanyl 25 mcg. A morphine PCA pump was started by the CRNA and the patient sent to his floor bed. The PCA was set with a basal rate of one mg/hr and 3 mg boluses at ten minute intervals. The patient arrived in his room at 8:00 PM. Over the course of the evening the patient administered himself over 60 mg of morphine. By 3:00 AM the patient was found to be cyanotic and unresponsive. CPR was started but was declared deceased 45 minutes later. Adventist was penalized for $50,000.

So take some time and go through this treasure trove of tragedies nicely compiled by the state of California. You'll learn why patients should be monitored in preop holding even after getting only two mg of Versed. Or why wrong site surgeries can still happen even when we all go through the rigamarole of preincision time outs. (Hint, apathy and routine can negate even the most rigorous safety precautions.) You may just save your hospital a ton of money and your own medical license to boot.

Don't Trust Deceptive Headlines

I was looking through ASC Becker Review and came across this eyecatching headline: "Study: Propofol Colonoscopies May Result In Aspiration Pneumonia". Really? That sounds pretty extreme and scary. The study in question comes from JAMA Internal Medicine titled "Complications following Colonoscopy With Anesthesia Assistance". It is written by Gregory Cooper, M.D., a gastroenterologist from Case Western Reserve University, Tzuyung Kou, PhD., and Douglas Rex, M.D., a well known critic of anesthesiologists in the GI suite. The provenance of this article pretty much sets the tone for the paper.

In the study, Dr. Cooper took a 5% sampling of all the diagnostic colonoscopies without polypectomies that were billed to Medicare between 2000 and 2009. Therefore all the patients are over 65 years old. They found over 165,000 colonoscopies performed during that period on over 100,000 patients. Just over 21% of the cases were given anesthesia. They then looked at the incidence of aspiration, splenic injuries, and colon perforation.

To no one's surprise, they found that patients given anesthesia had a 40% greater chance of suffering an aspiration compared to those who only received moderate sedation. This sounds terrifying until you read the actual numbers. Out of 165,000 colonoscopies, only 173 patients aspirated. Breaking it down further, 0.14% of anesthetized patients aspirated vs. 0.10% of nonanesthetized patients. They estimate that this difference in aspiration risks would have resulted in an extra 518 cases of aspiration in 2009 alone. That is out of millions of colonoscopies that are done in this country every year.

They acknowledge that one problem with this study is that there is no way to compensate for different risk levels in the patients. This is not a randomized double blind study. We don't know what the ASA levels of the patients are that received anesthesia or moderate sedation. To compensate the authors studied a subset of patients that only received their colonoscopies in ambulatory surgery centers, out of the hospital setting where the patients are presumed to be sicker. Here, there appeared to be slightly more complications with the anesthetized group but this did not achieve statistical significance.

Dr. Cooper's study also looked into the relative risks of splenic injuries and colon perforations from colonoscopies. Their presumption is that patients under anesthesia have less pain sensation during the procedure so there should be a higher risk for these devastating complications. Perhaps to their disappointment there was no difference between the anesthetized and sedated patients in developing these injuries.

So what does this study tell us? Contrary to the attention grabbing headline, not much at all. Sure they showed that slightly more patients developed an aspiration when anesthetized during a colonscopy. But this number is so small relative to the total number of procedures that it is almost negligible. When I am discussing risks of anesthesia with a patient, I certainly don't feel obligated to bring up a complication that may occur 0.14% of the time. Especially in this elderly group, they are more likely to suffer a cardiac event than an aspiration. This study also couldn't take into account the different risk levels of patients. When they tried to look only at what are thought to be healthier patients in surgery centers, they found no difference in complication rates. Therefore the higher complications of anesthetized patients overall most likely occurred in hospitalized patients, who presumably are sicker and have more comorbidities. That's usually the main reason anesthesiologists are utilized in the GI suite, for sicker patients. Therefore they are more likely to have adverse outcomes like an aspiration. Then there is their disingenuous attempt to pin the gastroenterologist induced complications of splenic and colon injuries on anesthesia which here showed no such correlation. How lame is that?

When all else fails, bring up the issue of money. The authors casually mention that having an anesthesiologist in the GI suite increases costs by 20%. What I don't understand is the GI docs' obsession with saving money when it comes to discussions about anesthesia. In the meantime they are unnecessarily scoping every Tom, Dick, and Mary in the hospital with a pulse. If a patient derives greater comfort during a procedure with anesthesia, why not let them have it? Anesthesia is considered one of the greatest inventions of modern medicine. Obstetricians decades ago recognized that having a comfortable patient provides better well being and better outcome. Sure women having been giving birth since the dawn of time without the aid of anesthesia. But isn't the world a better place because we can give them that comfort? The cost of providing epidurals is never considered frivolous or wasteful. Why shouldn't giving comfort to a GI patient be considered equally humane?

Let's also not forget the peace of mind we provide for our GI colleagues. As this study shows, aspirations and perforations can happen whether the patients received anesthesia or not. I bet those GI docs who have a patient who aspirated wished to God that an anesthesiologist was there to take the blame, er I mean protect the airway. Perhaps all these reasons are why the authors noted that colonoscopies are increasingly being performed with an anesthesia provider in the room. The extra costs are minimal compared to the comfort and reassurance we can provide the patient and the endoscopist. It is an act of humanity that should not be denied based on dollars and cents.

Is The "Anesthesia Model" The Cure For Medicine?

We all know there is a shortage of primary care physicians in America. At least that's the convention that's been spread by the AMA and politicians over the last several years. So it was kind of surprising to read an editorial in KevinMD about how all this handwringing may be exaggerated. Dr. Peter Ubel, a physician and Professor of Marketing and Public Policy from Duke University, says that there may be a shortage of PCP's in this country, but that doesn't necessarily mean there is a lack of caregivers here.

He explains that PCP's should follow the example of anesthesiologists. We clever anesthesiologists have learned to increase our efficiency by caring for multiple patients simultaneously. What is the secret to our magic? Many of us have hired work extenders to enable our tentacles to reach into different operating rooms without having to actually be there. They are called CRNA's. According to Dr. Ubel, CRNA's are able to deal with the usually routine cases, needing only the anesthesiologist during critical or difficult parts, and we doctors get to enjoy the monetary bonus of our uncanny ability to treat more than one patient at a time.

Dr. Ubel's proposal is that PCP's should welcome nurse practitioners, physicians assistants, and registered nurses into their practices. The extenders can treat the routine coughs and sniffles while the doctors will be responsible for the complex, positive review of systems patients that are beyond the capabilities of such lesser educated caregivers. Thus the shortage of professionals able to see patients will be alleviated.

I had to scoff when I read his idea. I'm not sure if he is serious about opening up this Pandora's box. We anesthesiologists have been battling the encroachment of nurse anesthetists for decades. Many of us do not see their presence as a panacea. Dr. Ubel should take a closer look at the battles that are working their way through the courts and legislative capitols as the CRNA's aggressively expand their scope of practice. First they won the right to practice free from physician supervision. Now they are bidding to take on procedures such as pain management that even an anesthesiologist requires at least a year of extra training to perform but a nurse thinks she can learn to do in some hotel resort over the course of a weekend.

His description of the interaction between a CRNA and the anesthesiologist in the operating room is especially indicative that he doesn't have a clue. He writes about how the anesthesiologist will be present for the more difficult parts of the operation or if the patient becomes unstable while the CRNA can handle all the other mundane parts of the procedure. That is beyond laughable. If only some of our CRNA's were astute enough to realize that they are in over their heads. Many have a militant attitude that practically demands we MD's should butt out of "their" cases. They only want our signatures on their records in case something goes wrong and they can say they had nothing to do with making any medical decisions. Is this really how Dr. Ubel envisions the future of primary care? Before you know it, NP's and PA's will demand that they have the freedom to work independent of physician supervision and start taking over smaller medical offices. Soon, primary docs will be ghettoized into large city hospitals that only treat difficult medical cases. People will soon see that PCP's aren't necessary at all since these complex cases will most likely be seen by a battery of medical subspecialties and the field of primary care will whither and die. That is one way to alleve the shortage of PCP's.

How To Make Even More Money As A Doctor

You would think that doctors should be pretty satisfied with their lots in life. Physicians make up the second largest job category among the top one percent of wage earners. A recent study showed the doctors made up nearly 16% of the top one percent, second only to business executives and nearly twice the number for lawyers. When you break that down on a per capita basis, doctors do even better. About 20% of physicians are likely to be in the top one percent. That compares to less than 15% for lawyers and 12% for executives. But as the old saying goes, there's always room for improvement.

I know many doctors who take time out of their overburdened lives to go make that extra dollar. They may hire themselves out as expert witnesses, sacrificing their souls to persecute a fellow physician for the sake of a fast buck. Some doctors get paid for being "consultants", advising device makers on how to improve upon a product hoping to cash in on fees and possible royalty payments if the company decides to sell it. Then there are the speaking fees that is the bread and butter of many physicians' extra source of income.

Nearly every medical student, resident, or doctor has been to one of these "educational" meetings. You're usually invited to some nice little steak restaurant in a swanky part of town. You get the privilege of eating a meal that you probably would never pay with your own credit card. In exchange all you have to do is listen to a doctor drone through a slide show about a medical condition and how a certain drug company's products would help improve the patients' lives if we would just prescribe it to them. We all thought it was pretty benign. We all knew the presenter was getting paid by the pharmaceutical company for giving the talk. What, you didn't think he'd give a lecture just for a free steak dinner, did you? He gets paid with cold hard cash. Now we know how much.

ProPublica, the website of Journalism in the Public Interest, has a page where you can look up a doctor's name and how much money he is receiving from Big Pharma. All this information has been forced public by Congress to bring more transparency to the murky relationships between drug companies and doctors. As it turned out, you can make a LOT of money giving talks to other doctors. According to ProPublica, the highest paid speaker over the last three years was Dr. Jon Draud, a psychiatrist from Nashville, TN. He made over $1 million during that time giving over 3,500 talks. That is an astonishing number, both the dollar amount and the number of speaking engagements. So on average he gave nearly one hundred talks a month, or three per day, during that time. So he is giving a paid speech with every meal of his day during those three years. How does he have time to practice medicine?

Not to be outdone is Dr. Gerald Sacks. Dr. Sacks enjoys the distinction of being both an anesthesiologist and the highest paid speaker in California, earning over $730,000 in three years. I guess having one of the best jobs in America isn't good enough for some people.

Go try the ProPublica site. It's fun. See how much that nasty surgical attending is making on the side. Look up that snobby cardiologist and understand how he could possibly afford his weekend Ferrari and vacation home in Aspen. You can even look up individual hospitals like the Mayo Clinic in Minnesota and be bowled over by how many millions of dollars drug companies bribe, er pay, hospitals for "research" into their products. I guarantee you'll be looking up names and places all day. I know I did.

The ABA Screws Anesthesia Residents

It's been a busy time over at the American Board of Anesthesiology headquarters. Besides the changes to MOCA recertification requirements, they have also altered how anesthesia residents will be board certified in the first place. Previously an anesthesiologist takes his written, or Part 1, exam shortly after finishing his residency. Once that has been successfully passed, he then takes the dreaded oral, or Part 2, examination. When both exams are completed, voila, another board certified anesthesiologist is christened into the world.

But the ABA has now changed the paradigm. Starting with the CA-1 class beginning July, 2013, the written exam has been split into two parts. The Basic exam will be administered during residency training. This is followed by an Advanced exam taken after residency before moving on to the oral exam. The trick is that the Basic exam has to be successfully passed within two attempts or the resident will be deemed incompetent and will not be allowed to graduate. Thus he could be stuck in anesthesia residency for four or five years if he were so unlucky.

This places extraordinary pressure on already overworked residents. In my time, many of us graduated residency then took a couple of weeks off from work to prepare for our Part 1 exam. Some people even delayed taking the test for a year or more. This only delayed their board certification but they were still able to practice during that time as a "board eligible" anesthesiologist. Now these poor residents can't even get to the starting gate of their careers unless they pass this test. The sadists at the ABA know no bounds.

The ABA Lowers MOCA Requirements

I recently received a pleasant surprise from the American Board of Anesthesiology. In an email that they sent me, they informed me that my Continuing Medical Education (CME) requirements for fulfilling my Maintenance of Certification in Anesthesiology (MOCA) has been substantially reduced. Hurray for small favors. For anesthesia residents who finished after 2004, they now need only 250 hours of CME credits over ten years instead of 350 hours as previously required. According to the ABA, the reason they made the change is because they are trying to align their recertification process with the rules made by the American Board of Medical Specialties, which only requires 25 hours per year.

This seems pretty reasonable. In California a doctor must maintain his medical license by participating in at least 50 hours of CME over a two year cycle. It makes you wonder how they derived the original 350 hour requirement. Did they just pull that number of out thin air? There are obviously no studies out there that will answer the question of a doctor's competency whether she has gone through 35 hours per year of CME vs. 25 hours per year. And then there is still the ginormous elephant in the room, the thousands of practicing anesthesiologists out there who have been grandfathered in and don't need any CME at all to maintain their board certification. Is the ABA telling me that I still need to spend thousands of dollars and hundreds of hours to maintain my certificate but my colleague who works in the next operating room surfing on his iPad is equally competent but doesn't have to lift a finger to keep his? What kind of hypocrisy is this?

Another change in the MOCA process that they wrote to me is that from now on only a maximum of 60 hours of CME per year will be approved by the ABA. Previously that was 70 hours. This is to prevent people from cramming all their CME's into the last year or two prior to the expiration of their certificate. I find it curious they chose 60 as their new limit. It just so happens that the CME courses offered by the American Society of Anesthesiologists, the SEE and ACE programs, will give the participating anesthesiologist 60 hours of CME per year. Just a coincidence? I think not.