Friday, August 30, 2013

We Treat Zoo Animals Better Than People

Sad news out of New York City today. Gus, the celebrity polar bear at the Central Park Zoo, was euthanized yesterday. Zookeepers had noticed that his appetite was not as healthy as it used to be. When zoo veterinarians went to examine him, instead of a bad tooth that they had expected, they discovered that he had inoperable thyroid cancer. Rather than allowing him to suffer, they decided that Gus should have a dignified death before he suffered from his terminal illness.

What a refreshing attitude. We can learn so much from how Gus was allowed to exit this Earth while still relatively healthy and in comfort. Instead of watching an old dying bear suffer from treatments that would only prolong his misery, the zoo did the right thing and allowed him to die gracefully so that we can still reminisce about what a wonderful bear he was and how much happiness he brought to the world.

Why can't we do the same with our fellow human beings? All too often patients with end stage disease are almost forced to linger on through their misery. Various tubes are inserted into nearly every single external orifice of the body. If that isn't enough, we iatrogenically create new ones. I've seen countless patients who are demented, emaciated, contracted, and end stage with no hope of ever recovering a meaningful existence get brought to the hospital for a gastrostomy tube placement. Why? Is it really more humane to force feed this moribund person than to allow him to pass away peacefully with a morphine drip?

Our ICU's are filled with patients who only exist because of machines. They have mechanical support for their respiratory, kidney, and cardiac functions. Their blood pressures are supported by multiple chemical agents. The hematologic functions are boosted by frequent transfusions. When the body tries to take its natural course into oblivion, we hurriedly rush them off to the CT scanner or the operating room, hoping desperately to maintain a pulse on an otherwise inanimate lump of carbon tissue.

We should all consider the legacy of Gus the polar bear and what he can teach us about humanity. Our last memories of our loved ones should be of the times when they brought vibrancy and joy to our lives. We shouldn't have to hold out desperately for a miracle treatment that may prolong life by an extra two months according to some drug company sponsored study. When we make medical decisions based on the uneducated wants of family members and fear of lawsuits, we aren't serving the most important person on our service, the patient.

Wednesday, August 28, 2013

We Love MOCA Simulation Exams. As If We Had A Choice

In 2010, the American Board of Anesthesiologists made yet another change in how anesthesiologists get recertified ten years after getting their initial board certification. After conducting a survey of ASA members in 2006, they claim that greater than 80% of respondents felt a simulation component to MOCA would enhance their skills as anesthesiologists and are interested in trying it out. Thus the simulation portion was instituted.

In the MOCA simulation, the anesthesiologist travels to one of 34 centers around the country that conducts the test. He or she is placed in a team of four to six other test takers. Then scenarios similar to the oral board exams are conducted with each anesthesiologist taking turns being the team leader. Afterwards, each member is supposed to identify three improvements he can make in his practice because of the simulations and submit the plan to the ABA. A few weeks later the ABA will contact the physician to see how his practice has changed because of the simulation. That's it. There is no pass/fail or grading curve.

According to the ABA, follow up surveys of simulation participants showed that 95% would recommend the course to their colleagues while 98% thought it helped them improve their practice. Those are pretty impressive numbers. Almost too impressive if you ask me. I can't think of anything else in American society where 98% of us agree on one thing. Those numbers sound like election results coming out of North Korea or Cuba.

I wonder how honestly the survey participants answered the poll questions. The fact is that anesthesiologists like myself who hold time limited board certificates are completely beholden to the ABA and its policies on MOCA to keep our board certificates and our practices. How many people are going to say on an ABA survey that they thought the simulation was a total waste of time and money. And we're talking big money. These tests cost thousands of dollars and that doesn't even include money for lost wages and travel expenses. Any anesthesiologist who remembers studying for the oral board exam will also recoil with horror the amount of time spent studying for it and the extreme anxiety that comes with preparing for it. After suffering through all that, are survey participants likely to say it was so not worth the effort or will they try to attempt to make the best of the situation by stating that it was a truly glorious and absorbing experience?

Of course the elephant in the room is that only some anesthesiologists are required to go through this hassle to keep their jobs. According to the ABA and ASA, "Physicians are being asked by local, state, and federal agencies to do more to maintain their licensure and medical staff credentials in order to demonstrate their commitment to lifelong learning. Our patients deserve physicians who can deliver the most appropriate evidence-based care and document the quality of their practice." Okay, I'll buy that . We should all commit ourselves to lifelong learning to ensure quality care for our patients. Agree 100%. Then why is it that anybody who got board certified before the year 2000 have a lifetime certificate that never needs to be renewed? They can coast through their entire career with only what they learned in residency two, three, or even four decades ago. If anything, it is the older generation of anesthesiologists who are in most need of simulation exams so they know the most current anesthetic techniques. They shouldn't be hiding behind their yellowing and fading certificates and proclaim board recertification is good for all doctors and patients, except themselves. The ABA should stop this hypocrisy and either admit that MOCA is a sham or make it universal for the good of our patients.

Tuesday, August 27, 2013

Sometimes I Wish I Can Stop Learning New Things

Twerking. That is a term that I had never heard of before last weekend but it must be the hottest buzzword in the news today. After Miley Cyrus's scandalous dance routines at the MTV Video Music Awards program last Sunday, that's all anybody is talking about. Even normally staid reporters at respectable publications are talking about twerking. When did non entertainment reporters suddenly get so hip?

The Urban Dictionary defines twerking as, "When a woman slams her bottom on a man's pelvic area while dancing." In my youthful days, it was known as dirty dancing or grinding. But somehow the act appears far more outrageous today. When Patrick Swayze and Jennifer Grey were gyrating their hips in "Dirty Dancing" in 1987, it didn't feel like you needed to take a shower after watching the movie.

Perhaps I'm just getting old. When Madonna sang "Like A Virgin" at the VMA's in 1984 in a white wedding dress and rolled around the floor moaning, I thought it was entertaining but hardly earth shattering. But I was merely a teenager then. However its shock value to adults in the audience has transcended time and is now mentioned as one of the signature events in the history of the VMA's.

Somehow I feel that my world would have been better off if I had never heard of twerking. It scares me to think how much more debased our culture will become in the future. If this is what it takes to get grab attention these days, I shudder to think what my children will be subjected to when they become teenagers themselves. If teens consider sexting to be just another form of communcation, are we surprised by what we saw on TV over the weekend? How soon will it be before MTV moves the VMA's into the late night hours so that can show full on coitus on TV to attract attention?

Does The ASA's New Headquarters Signal Peak Anesthesia?

There is a well known theory that when record setting skyscrapers are built, it is a signal that a major economic downturn is about to begin. This has been true throughout the history of skyscrapers. The Empire State Building was finished in 1931, near the onset of the Great Depression of the 1930's. The original World Trade Centers were built as the U.S. was entering into the severe economic malaise of the 1970's. The tallest building in the world, the Burj Khalifa in Dubai, was completed just as the Great Recession of this century took hold. It is thought that the reason skyscrapers and bad economies coincide is because skyscrapers are designed during times of great economic optimism and expansion. By the time it is finally completed years down the road, the economy has usually started on its inevitable down cycle. Thus these giant monuments of human ingenuity open just when it seems most foolhardy to build one.

I was thinking about this when I read my latest copy of the ASA Newsletter. Inside is a large spread reporting glowingly on the ASA's brand new headquarters being constructed in the suburbs of Chicago. There are pictures of smiling people holding shovels and gorgeous architectural renderings of the new building. The 70,000 square foot building will better house ASA's employees, which have doubled in number since 2007. This is all in the name of adding "value to its 50,000 members."

Well how nice for the big honchos at the ASA to get new offices. Is that why my annual membership fee is now over $600 per year? While they are admiring their views from their new corner offices, they also keep raising the cost of the CME's they offer. The ACE program that I use to maintain my CME's and MOCA has risen in price over 50% in the last two years. Why does the ASA need to double its number of employees in the past five years? Membership in the ASA has not doubled in that period. I don't feel any better served by my society by having a larger overhead.

The number of anesthesiologists reached its recent nadir in the mid 1990's when high malpractice premiums and low job availability scared medical students away from the field. Opinions changed when more surgeries began to be moved to surgery centers, necessitating more anesthesiologists. Medical malpractice was also helped by payout caps legislated by multiple states. Since then anesthesiology has become one of the hottest fields in medicine.

But now we may be reaching a peak in the number of anesthesiologists in this country. The ASA is fighting tooth and nail to prevent more states from opting out of physician supervision of CRNA's. Alas it is not having much success as 17 states have already taken that step while others are increasing the scope of practice of the nurses. The lucrative field of anesthesiology is starting to feel mighty crowded. With the advent of Obamacare in two months, more anesthesiologists may start contemplating retirement to avoid having to wrestle a new government bureaucracy to get reimbursed for their services. So there is a real danger that the number of anesthesiologists in practice may start to decline.

We shouldn't be shocked by all this. The number of physicians who train in different specialties are cyclical, just like the economy. Anesthesiologists may currently be peaking. Meanwhile, general surgeons could be hitting a bottom. In the 1990's a good categorical surgery residency was a tough get. Now surgery residencies have trouble filling their spots without hiring foreign medical graduates. Primary care appears to be starting its ascent after years of neglect by the government and insurance companies. So don't be surprised if anesthesiology starts to wane again as a specialty. It wouldn't be the first time. But at least the ASA officers will have new offices in which to cry into their Starbucks.

Monday, August 26, 2013

Everybody Has A Price

You may not realize it, but the Michael Jackson trial is still ongoing. While the country has seen the George Zimmerman trial come and go, the Jackson family's $40 billion wrongful death trial against his concert promoter AEG has steadily marched onward. I normally would not bother with this sad specter of celebrity self destruction, but some news came out of the courtroom last week that I thought was worth mentioning.

As it turns out, Mr. Jackson's personal physician, Dr. Conrad Murray, realized that he was not qualified to give his client the propofol he craved to help him overcome his insomnia and drug dependency. In 2009, he contacted Dr. David Adams, a "roving anesthesiologist" who had given Michael propofol on four separate occasions for dental work. Dr. Murray asked Dr. Adams if he wanted to join Michael on his world tour. Dr. Adams naively and amusingly testified that he didn't initially understand the question since he could neither sing nor dance. When it was explained to him that Michael needed an IV to help him sleep, he finally started getting the picture. He was asked how much money it would take for him to close his practice and follow Michael on his concert tour to treat his insomnia. After taking a short time to consider, he came up with a number: $100,000 per month for three years. When he relayed his demand to the Jackson camp, his calls were never returned. Dr. Murray was then signed up for $150,000 to work as both the personal physician and anesthetist; probably the worst bargain he ever made.

We can all see how unethical it was for Drs. Murray and Adams to even consider treating Michael with propofol. But when faced with offers of unbelievable riches, who can blame them? I've never had anybody proposition me with a blank check for administering anesthesia. I would like to think that I would refuse the money if the task was not medically sound, but who knows. There is always another human need or want that could be easily sated with just a few more dollars in the checking account. When we all took our Hippocratic Oath after graduating medical school, nowhere did it mention that we should stay away from celebrities wishing to toss money at us to do whatever they want.

Medical Care Is Expensive, But Not Because Of The Doctor

The New York Times has published its latest article in its quest to understand why medical care is so expensive in the U.S. Previous articles remarked on how expensive colonoscopies and child birth are compared to the rest of the world. This time, the offender is the humble IV solution.

The writer followed cases of food poisoning that occurred in upstate New York in 2012. She noted that hospitals were charging hundreds of dollars just for intravenous fluids in these severely dehydrated patients. While IV solution can be made for less than one dollar per liter, hospitals were billing hundreds for "IV therapy." In particular, a Chinese-American grandmother and her granddaughter were charged $4,000 and billed for $1,400 for their hours of treatment in the emergency room even though they were on Medicaid and should not have received a bill. The author noted that IV fluids for the grandmother cost $787 while the granddaughter's IV fluids cost $393, suggesting the IV solutions cost hundreds of dollars if you assume the labor cost of inserting the IV were equal between the two.

Clearly somebody is making a huge amount of profit from IV fluids. Middlemen that act as distributors for the manufacturers are implicated, as well as hospital profit margins. Unfortunately due to confidentiality agreements there is no way to know for sure who is making off with all the loot. One thing that clearly stood out for me was how little money the doctor is actually making for taking care of sick patients. Medicaid eventually reimbursed the hospital $119 out of $2,168 for the grandmother's portion of the medical bill. It paid the doctor who treated her life threatening illness in the emergency room a paltry $66.50. You read that right. For treating a patient who could have died if not properly tended to, the doctor will get less than $60 per hour from Medicaid.

Do you know how little that is? My children's piano classes cost more than that. The dishwasher repair man who came over for 30 minutes just to tell me that my old dishwasher was dead and I'd need to buy a new one charged $130 for the visit. But for the privilege of slogging through college and medical school, racking up hundreds of thousands of dollars in debt, then working as a slave/resident for several more years only to be paid less than $60 per hour as a doctor is beyond insulting.

Pundits complain that doctors make too much money. The government's formula for calculating SGR projects a further cut to physician payments of 25% next year. Yet how demoralizing it is to make so little as a doctor, with all the hardships that one puts up with, not just for himself but for his entire family, and people still criticize doctors for being "greedy." That level of reimbursement isn't even enough to repay student loan debt much less maintain a practice.

Thanks to Obamacare, payments like this could be the norm very soon. Millions of people are about to be enrolled in the system that is set to pay doctors at Medicaid rates. Even if the government wants to be generous and raise reimbursements 73% to make it equal with Medicare rates, that fix is only good for ONE year according to government legislation. Obamacare has no funding plans for maintaining physician reimbursements at that level after 2014. I think in legalese that is called bait and switch. And doctors got baited really good.

Monday, August 5, 2013

Is Being A Virgin A Social Pariah?

I've been seeing billboards of this new movie popping up all over town. While I haven't seen its trailer or heard anything about it, I am more concerned about the message it sends regarding sexual attitudes in this country. The movie poster appears to suggest that the family in the movie is a bunch of social pariahs you wouldn't want living next door to you--a father figure who may be a drug dealer, a mom who may be a night club stripper, a daughter whose antisocial behavior has turned her into a runaway (check out her I-don't-give-a-f*** facial expression). But the last member of the family is an innocent looking boy who has a big black arrow labeled "virgin" pointing straight at his head. Really? Is being a virgin in America nowadays the equivalent of a neighborhood drug dealer?

Has Hollywood's portrayal of virginity reached such scorn that it is almost unacceptable for a male to remain a virgin? In the "40 Year Old Virgin", the main character had remained a virgin because of several sexual misadventures in his past. But he was perfectly satisfied with his current social situation, even if it is nerdy to the extreme. However his buddies just knew that nobody can be right if they haven't had any sex, even if it is only with a one night stand. Spoiler ahead. Once he does lose his virginity, he does a little happy dance to a Bollywood style musical. So losing it will solve all of life's problems and make you a complete man?

Hollywood's cultural influence doesn't just affect immature and vulnerable teenagers. A few weeks ago there was a Craigslist help wanted ad from a mom in Philadelphia who wanted to hire a girl to help her son lose his virginity before he leaves for college (Harvard just in case you think the kid is some low life loser). She goes into great detail about how handsome and fit her son is but is just too shy to approach girls to lose his cherry. The mom even offers to pay off any prospective candidate's debts if she is successful in this scheme. How creepy and sickening is that?

Perhaps if we had a more conservative attitude towards sex in this country, we wouldn't be having so many problems with teenage pregnancies. If teen boys are conditioned in this country to start their sexual activities early, guess who they are going to jump on. That's right, teen girls Maybe if we didn't associate virgins with a social misfits, we wouldn't have to give every girl an HPV vaccine to prevent cervical cancer down the road. If virginity was not a dirty word, maybe we wouldn't have millions of new cases of STD's every year.

I know I sound like a prude, somebody who is still living in the 1950's. But this blatant movie poster just drew out my moral outrage. There are many problems in our country. Keeping one's virginity is not one of them. Losing it the wrong way just for the sake of getting rid of it to fit into societal expectations is. How refreshing and original would it be to poke fun at sexually promiscuous movie characters instead of holding them up as an ideal. Sometimes doctors can only treat the consequences of bad choices. We all need to do our parts to help promote a healthier population.