Wednesday, January 29, 2014

The Worst Lifestyle in Medicine

Thanks to the latest Medscape survey, dermatologists were crowned as having the best lifestyle in all of medicine, confirming what every medical student, resident, and attending physician already knew. On the flip side, who did Medscape consider to lead the worst lifestyle? It probably comes as a surprise to no one that family medicine and internal medicine were singled out as having the worst quality of life in the medical field.

What makes FP and IM so lacking in appeal? First of all, they appear to be the unhappiest doctors at work. Only 36% of FP's were satisfied at work, tying with emergency medicine at the bottom of the list. IM was not far behind, with a 37% satisfaction rate, tied with radiology for third/fourth worst positions. All this misery carries over to the home life too, with only 61% of FP's being happy when they leave work. This leaves them below the median of doctors surveyed.

Perhaps primary doctors would feel better if they got away from all that stress at the office. But unfortunately, only 13% of FP's and internists took four or more weeks of vacation last year, near the bottom of the list. By comparison, anesthesiologists were the most generous at giving themselves some R&R, with almost half getting at least four weeks of time off. This has contributed to FP's being the second heaviest group in the survey. Forty-eight percent of FP's say they are overweight or obese, being outweighed only by the other stressful field, general surgery.

To make things even worse, the terrible reimbursements given to primary doctors for talking and listening to patients have left their finances in shambles. FP and IM rank at the very bottom of physicians who feel they have adequate savings stored up. By comparison, the ROAD fields all rank near the very top in amount of money saved up for future retirement. That is not good news for policy makers who are trying to recruit more medical students into primary care.

So all this talk about training more primary care doctors to treat the tsunami of sick patients with their new Obamacare insurance cards is quixotic at best. The law's promise of paying Medicare rates for all these new Medicaid patients for a very temporary two years is laughable. Nobody plans his career for only the next two years. All these patients will still have nowhere to go when they get sick except the emergency room because there won't be enough doctors to see them for the money they are getting paid.

Tuesday, January 28, 2014

Revenge Of The Dermatologists

The New York Times may have been trying to discredit the work of dermatologists with its recent page one character assassination article. However, I think it only highlighted the reasons so many medical students want to go into that field. The paper may fault dermatologists for making over $500,000 per year performing Mohs surgeries, but they are only filling a need that is demanded by the patient population.

Now Medscape has released its physician lifestyle survey for 2014 and guess what? Dermatologists come out on top as having the best lifestyle in all of medicine. Better than gastroenterology, radiology, or even anesthesiology. Dermatologists were found to be the second happiest at home and at work, second only to ophthalmologists. They were also the least likely to be overweight. Over 70% of normal weight dermatologists exercise at least twice a week. They were the most likely to consider themselves to be in good health. And for the icing on the cake, dermatologists were near the top in having an adequate amount of money saved in their bank accounts.

So the New York Times may have thought they were exposing a shameful scandal when they wrote about dermatologists. But I think they did the field a great favor. Though their intent may have been to shame the doctors by exposing their income, I think most medical students will only see all those big fat zeroes at the end of the dollar sign. And if the doctors do a good job, most patients will not begrudge them of their fees. So here is a big fat middle finger to the Grey Lady for trying to smear a medical profession that is only trying to do its job. Next time maybe they should pick on professionals who truly have outrageous incomes, like sports figures and bank executives. But of course they might lose big advertisers if they did which means they never will.

Sunday, January 19, 2014

Doctors Under Siege--Dermatology

The vilification of physicians by the New York Times continues. In the past few months we have seen the specter of gastroenterologists, obstetricians, and emergency physicians being accused of greed and, well, more greed. They have been unfairly targeted as the drivers of exorbitant medical costs in this country. The spotlight now shines on the next medical specialty that will drive the downfall of American medicine--dermatology.

In today's issue of the Times, the paper attacks dermatologists for providing the life saving service of skin cancer removal. Specifically they target dermatologists for overcharging patients for Mohs surgery, a specialized procedure where skin cancers are meticulously removed thin layers at a time so that there is minimal cutting and scarring. The paper highlights the ordeal of one patient, Kim Little of Arkansas, who went to her dermatologist for removal of a basal cell cancer and wound up with medical bills of over $25,000. According to Ms. Little, her dermatologist took 15 minutes using Mohs to remove the tumor. He then directed her to another office for the wound to be closed by an ophthalmologist because it was close to her eye. There she was sedated by an anesthesiologist and given two dozen stitches on her cheek. Her bill included $1,800 for the Mohs, $14,000 for the plastic surgery, $1,000 for the anesthesia, and $8,700 for hospital charges. She claims she felt railroaded into undergoing such an extensive procedure for a small lesion and that she felt drowsy from the anesthesia for five days afterwards. She complains that she didn't feel like she had any choice except to accept what the doctors directed.

Oh my. These statements practically blame her doctors for fraud for charging so much money. It isn't until much later in the article does the paper say how much she ultimately paid for her care, $3,000 out of pocket according to her insurance policy. The piece doesn't bother mentioning that practically no one pays the full cost of a hospital bill. These bills are almost always negotiated down by insurance companies, as the ophthalmologist's 90% reduction in his charges attests to.

The Grey Lady blames dermatologists for stuffing their pockets by doing too many Mohs surgeries. It states that the number of Mohs has increased over 400% in the last decade. Never mind that people have been covering less and less of their bodies in public over the last few decades, leading to higher incidences of skin cancers. But it wasn't enough for the paper to blame dermatologists for America's high medical costs. They go on to wage class warfare by blaming all doctors who make more money than the paper's editors. Of course primary care doctors continue their saintly image by being the lowest paid physicians.

They don't begrudge the huge average salaries of spine surgeons, and neurosurgeons because they can only perform a couple of complex cases a day. They must work REALLY hard for their $800,000 plus annual income. The usual suspects are again indicted: the ROAD specialties. Dermatologists, ophthalmologists, (and gastroenterologists by default because of their high salaries), are accused of padding their incomes by performing multiple minor procedures a day, justified or not. Anesthesiologists and radiologists are lumped into this rogue's gallery of doctors mainly for what appears to be a humane lifestyle. In other words we don't work hard enough for our money. Apparently we specialty physicians fill the majority of seats on the AMA's review board on physician compensation while leaving the poor primary care doctors to pick up the crumbs.

Is it really a sin for doctors to make money? Nobody cares, and they even applaud, when internet companies produce thousands of millionaires practically overnight. Do most of those employees deserve that money? No. They just happened to luck into a job that was anointed the hot company on Wall Street. Meanwhile doctors, who are some of the smartest people in the country, are berated for using their smarts to make money taking care of patients instead of writing lines of code. We keep thousands of people employed at medical offices, hospitals, insurance companies, pharmaceutical companies, and myriad other industries. We don't just make our hard earned money to buy new toys.

The newspaper seems to feel that doctors should return to the age where we accepted chickens and homemade canned goods for compensation. If Bill Gates can have a net worth of over $70 billion for charging money on computer software that is a necessity for almost all computers in the world, well he is the smartest person on earth and deserves his wealth. But it's just not fair that physicians should be making any kind of income on a service that should be universal and almost free of charge.

Saturday, January 18, 2014

Capital Punishment By Asphyxiation

There is a great deal of controversy over the lengthy execution of convicted murderer and rapist Dennis McGuire in Ohio. Since the state did not have access to the usual drugs for completing their capital punishment sentences, such as propofol or pentathol, they decided to use a new untested two-drug cocktail of midazolam and hydromorphone. The results were not what they had hoped.

After injecting the medications, what doses were given is not available, Mr. McGuire at first became still. But shortly afterwards he started gasping for breath. His family saw him clench his fists as his abdominal muscles heaved desperately to maintain respiration and oxygenation. Finally, after about 25 minutes, his body went still for the final time. Naturally his family is shocked at the prolonged and agonizing way the death was carried out. They have vowed to sue the state to halt any more executions.

Forget for the moment that Mr. McGuire's death was far more humane than what he did to his pregnant victim back in 1989. As Ohio's assistant attorney general, Thomas Madden, says the constitution does not guarantee a "pain free execution." But Mr. McGuire essentially died of asphyxiation caused by a large drug overdose of Versed and Dilaudid administered by the state. This is how drug abusers and patients who are overly sedated in the hospital die.

Mr. McGuire's body was doing what it needed to do when confronted by an obstructed airway. He was using his accessory respiratory muscles in the chest and abdomen to try to force his airway open in a desperate attempt to replenish oxygen to his brain. These are motions we anesthesiologists see on an almost daily basis when we induce our patients with anesthetic. The airway obstructs and the abdominal muscles will tense as the patient attempts to inspire more oxygen. Of course the difference is that we either insert an LMA at that point to start ventilating the patient or we paralyze the muscles so we can intubate the airway and provide oxygen.

That is the problem with Ohio's two-drug cocktail. They only have two thirds of a complete recipe to complete a quick execution. In this situation, without adding a third drug to speed up the process, the inmate would have been better off with somebody holding a pillow over his face. That might have been faster. Since propofol is now difficult to obtain for death penalty cases, Ohio was on the right track in using a large dose of Versed. This will produce a profound amnesia so that the prisoner won't remember what is happening. The Dilaudid will help with analgesia and respiratory depression. But for a truly quick death, they need to also inject something more definitive, like a potassium bolus to rapidly induce cardiac arrest. That is the reason potassium used to be routinely injected for capital punishment. Another drug that will almost certainly work is rocuronium. Roc is cheap and extremely fast acting. Its paralyzing affect may take longer to cause cardiac arrest from hypoxia but at least it doesn't burn in the veins like potassium. And the body remains motionless, which will be a relief for the witnesses present at the death chamber.

Frankly, to me, all these concerns about comfortable, pain free executions for our society's worst criminals feels ludicrous. Just remember, dead men tell no tales.

Friday, January 17, 2014

Dr. Vanila Singh, Anesthesiologist, Runs For Congress

Dr. Vanila Singh, a Republican and Clinical Associate Professor of Anesthesiology and Perioperative and Pain Medicine at Stanford School of Medicine, has decided to run for Congress. She will be challenging for the seat currently held by seven time incumbent Mike Honda, a Democrat. The district represents the citizens of Silicon Valley and San Jose.

Dr. Singh's family immigrated from India when she was 15 months old. She was educated in the Bay area and went on to medical school at George Washington University. She completed her residency and fellowship training at New York Presbyterian Hospital.

Her campaign is so new that she doesn't have a website up yet. However she has already raised $100,000 towards her election. She has her work cut out for her though. As a Republican, she is at a distinct disadvantage, being in the bluest of blue states of California. I won't even mention all the billions of dollars that are located in Silicon Valley, home to some of the richest liberal in the world. That largess is unlikely to ever go to her campaign.

I wish her all the luck though. Congress could use another thoughtful anesthesiologist. While Dr. Andy Harris, the only anesthesiologist in Congress, has done well, it  never hurts to have another voice in the halls of power. With all the shenanigans that have been happening with Obamacare and the VA Administration, Congress needs all the help it can get.

Wednesday, January 15, 2014

The Never Ending Residency

The January issue of Anesthesiology highlights changes in anesthesiology residency training that are about to be implemented. And it is not good news for future residents. Because the American Board of Anesthesiology somehow feels that residents are struggling tremendously once they are in private practice, it has decided to begin a protocol called the Objective Structured Clinical Examination. It is basically a series of milestones and simulations that residents must master before they can graduate from residency and become board certified starting in 2017.

After torturing new anesthesiologists for decades with the Oral Boards examination, the ABA is reassessing the actual usefulness of the exam in predicting the competency of the examinees. They have come to the conclusion that Boards Parts 1 and 2 only test a doctors ability to know the disease process and knows how to deal with it. What they are looking for now is any insight into whether a doctor can show how he will treat the problem and actually does it. Thus the new milestone and simulation requirements.

They justify this additional approach to residency teaching by first pointing fingers at Israeli and United Kingdom training programs. The Israeli Board of Anesthesiology has its doctors go through five different simulation stations: trauma management, resuscitation, OR crisis management, mechanical ventilation, and regional anesthesia. The UK authorities have its residents go through a gantlet of sixteen simulations, including communications skills and X-ray interpretations.

But before residents even make it to the simulations, they must first successfully complete their programs, which has become extremely complex. According to the ABA, residency directors have categorized 25 milestones that the residents must achieve before they are allowed to graduate. And here's the kicker: the residents may be stuck in a state of purgatory if they are unable to pass through all the milestones.

It is assumed that not all residents will progress through training at the same rate. Some will show extreme competency in under the three years that are currently required and might be able to finish early. Meanwhile others may be slower to reach the same levels and need more time to finish residency. The authors acknowledge that this sets up a difficult situation for fellowship training programs as new fellows may start their training at almost any month of the year. And they caution that program directors should not stigmatize a resident who may be on his fourth or fifth year of residency training.

But is that really possible? If there is an anesthesiology resident who is going through a CA 5 year because he just can't seem to complete that last milestone even though he has shown his capabilities with everything else, won't there be a natural tendency for the educators and other residents to look down on him? Can a residency really suggest to the lagging resident that he should go into something else after all the time invested just because of some arbitrary milestone developed by those sitting up in their ivory towers thousands of miles away?

Lastly, these new milestones raise the troubling question of how much training is too much. Is the ABA suggesting that thousands of anesthesiologists it has certified in the last century are somehow not good enough and pose a danger to patients? This was before my time, but if I recall correctly, anesthesiology training used to take only two years instead of the current three. Plus they only had to take their certification exams once and never have to be bothered with it again. Is the ABA saying these doctors who received their board certifications with half the training of current residents able to magically demonstrate their clinical skills without going through the series of milestones and simulations that are going to be enforced on new trainees?

I am so glad I finished my training over a decade ago. I couldn't imagine the tediousness of residency today, with its checklist method of training physicians. In the ABA's earnestness in graduating the perfect doctor and anesthesiologist, they possibly are forcing residents to go through a Groundhog Day of repetition until they get their skill set completed as determined by some committee. Somehow I don't think that makes for better physicians, just better test takers.

Tuesday, January 14, 2014

Anesthesia And Erections. Anesthesiologists' Dirty Minds.

People may think anesthesiologists are serious, cerebral people. We are all supposed to be board certified intellectuals who think only about our craft and the welfare of our patients before us. Well that is true ninety percent of the time. What do we contemplate during the other ten percent of our lives? Like everybody else, sex and debauchery, of course.

It's no coincidence that the most popular post on this anesthesia blog by far is "The Dirtiest Part Of The Body". It has been viewed tens of thousands of times even though it really has nothing to do with anesthesiology. Now Anesthesiology News has published its ten most popular articles of 2013. Does it surprise anyone that the most read article last year had the provocative name "Study Probes Anesthesia-Erection Link"? I can almost hear Beavis and Butthead going "Huh Huh Huh Huh. He said probes." just from reading that title.

Now that everybody is awake and paying attention, I might as well give a quick review of this salacious piece. The article in questions is actually quite short. In fact, I didn't even notice it when it was published in October last year. It is a quick review of an abstract that was presented at the ASA meeting that month. The study was published by Chinese doctors who compared the rates of erections in men undergoing urologic surgery who received either sevoflurane, isoflurane, or propofol. Of the 300 men studied, sixteen developed erections during the operation. Isoflurane only caused one erection. Meanwhile, sevoflurane produced four erections and propofol was the most productive, with eleven. That's it. That one little paragraph garnered more views than any articles about Obamacare, CRNA's, Doc Fix, or anything related to anesthesia and analgesia. Just goes to prove that anesthesiologists are not only mentally well endowed, we are also human.

Monday, January 13, 2014

I Have An Idea That Will Make A Billion Dollars

I wanna be a billionaire so freaking bad
Buy all of the things I never had.
I wanna be on the cover of Forbes magazine
Smiling next to Oprah and the Queen.

Oh everytime I close my eyes
I see my name in shining lights.
A different city every night alright
I swear the world better prepare
For when I'm a billionaire.

Billionaire, Travie McCoy ft. Bruno Mars

Today Google announced it is buying a small private company called Nest Labs for $3.2 billion. What is Nest Labs, you ask? Well if you're not one of the digital cognoscenti, you'll be astonished to know that Nest Labs makes...thermostats. But not just any thermostats. These thermostats have a pedigree. Its founders are former Apple executives. Tony Fadell helped develop the iPod when that was still a hot technology. Matt Rogers was an engineer at the computer company. They thought they could build a better mousetrap outside the limiting confines of Apple and set out on their own, forming Nest in 2010 to build internet connected thermostats.

Nest thermostats are all the rage among the digital well to do. They have motion sensors to detect if a room is empty! The temperature can be monitored with smartphone apps! These thermostats are so great they are actually stocked at Apple stores around the world! The company is on the front lines of the next digital frontier called the Internet of Things. In other words, we will all soon be connected by wifi and ethernet to everything we see and touch in the entire world. That has made this company the darling of the same people who love their iPhones and Tesla Model S. These digerati are so enamored of a digital thermostat company that they are spending over $3 billion for a three year old company whose products don't seem to have too much of a competitive advantage if HVAC behemoths like Honeywell decide to get in on the action.

If Silicon Valley billionaires are so willing to throw their mountains of cash around on companies with little to no revenue (I'm talking to you Snapchat), I propose an idea that I'm sure somebody would be willing to pony up at least ten figures to deposit into my checking account: the internet connected stethoscope. Auscultating a person's heartbeat through a couple of rubber tubes is so 19th century. Imagine a little disk that one can place on a person's chest that has an embedded microphone on one side and a speaker on the other. The heart sounds would be recorded digitally, of course. If the doctor wishes, he can listen to the sound through the speaker.

But here's the beauty of the Internet of Things. The device, which I am calling the Zethoscope, will have Wifi or Bluetooth connectivity. The sounds will be analyzed with a smartphone app similar to Shazam, which will contain all known heart murmurs and clicks. The app will be able to give the physician a diagnosis of any cardiac disease the way skilled cardiologists used to be able to do before the echocardiogram was invented. Because the recordings are digitized, it can be readily distributed to the medical students' and residents' smartphones and tablets in the room, or around the world, for educational purposes. Let's face it, the number of people who actually listens to a patient's heart and can give an accurate diagnosis has probably dwindled down to the single percentages. With my Zethoscope, this ambiguity will be resolved and the patient and healthcare system will be all the better because of it. Plus this will bring one of the vestiges of analog thinking up to the 21st century.

So are you reading this Larry Page of Google? John Doerr of Kleiner Perkins, I'm sitting eagerly by the computer awaiting the massive check you are about to electronically send me for this awesomely brilliant idea. It's a can't miss combination of healthcare and internet, two of the largest industries in the world with trillions of dollars willingly spent by consumers and governments. You know my email address. Write me. Z needs a new car.

Sunday, January 12, 2014

Can Anesthesia Prevent Dementia?

Patients often tell me after they have awakened from anesthesia, particularly propofol sedation, that it was the best sleep they ever had. They feel totally refreshed and often jokingly ask for some of the good stuff to take home with them. I always wondered what it is about propofol that makes patients feel so relaxed and carefree after its use.

Now in a fascinating Sunday Review article in the New York Times, researchers at the University of Rochester have identified a crucial neural cleansing function of the cerebral spinal fluid. It appears that the flow of CSF around the brain is significantly increased when the brain is in the sleep state. This is important because it is speculated that the byproducts of brain metabolism, like beta amyloids, if not removed from the nerve tissues and allowed to accumulate, can lead to long term dementia and Alzheimer's disease.

The researchers measured the CSF movement in mice using fluorescent markers. They then measured the flow of the fluids in sleeping mice. It turns out that when the mice were awake, the circulation was only five percent that of the sleep state. The amount of interstitial space between brain cells increased dramatically, allowing the CSF to penetrate deeper into brain tissue and extract the neuronal waste. The increased flow allowed the sleeping brain to be cleared out twice as quickly as the awake brain.

The interesting part is that this clearing mechanism also works when the mice are under anesthesia. The article doesn't specify the type of anesthetic used or how long the mice were anesthetized. But this should be a subject that the ASA and anesthesia researchers all over the world should be swarming over.

Imagine the implications this research could have if it pans out in humans. Dementia in the elderly is becoming an ever increasing burden in our society. Right now there is no treatment. The only things we can do to help these patients are to make sure they don't fall and break something or prevent them from aspirating. All that is a consequence of their worsening mental status which we are helpless to intervene. If anesthesia could lessen or eliminate the neural toxic waste that is thought to be the source of dementia, this would be a huge boon to mankind and a prestigious notch in the belt for anesthesiology, ranking right up there with Morton's first demonstration at MGH.

Imagine an office where patients with dementia would come to get anesthesia to help their brains get rid of its toxic waste. It would be similar to a dialysis clinic but staffed with anesthesiologists or anesthesia assistants. Patients would come a few times a week to get their scheduled anesthetic to prevent their Alzheimer's from deteriorating. The treatments would be expensive, but still cheaper than taking care of millions of debilitated patients that are currently draining our healthcare system. It would truly mark another golden age of anesthesia. I can't wait to see how this line of research works out.

Saturday, January 11, 2014

Job Prospect For Anesthesiologists

The terrible jobs report that was released last Friday again illustrates the importance of finding a career whose prospects remain healthy now and into the future. How can we know which jobs are going to be in demand years from now? Thanks to the federal government, specifically the Labor Department, they have compiled a list of what they predict will be the most in-demand jobs in the year 2022.

Needless to say, most of the new job openings will be in low paying work such as retail and restaurant positions. But if you dig through the table, you will see that medical careers are abundant despite all the dire warnings surrounding the onset of Obamacare. Anesthesiologists in particular should expect to see a 24.4% rise in total employment by 2022. Lest you think that anesthesia jobs are somehow a zero sum game with CRNA's, their employment in eight years is also expected to rise, by 24.9%.

By contrast, pediatricians can only expect to see an increase of 15.7%. Surprisingly, the Labor Department predicts there will be more practicing anesthesiologists in the next decade than general pediatricians. Might they be predicting the increased use of PA's (38.4%) and NP's (33.7%) to handle the more mundane tasks of pediatricians?

What about the person to whom we depend upon for our livelihoods, the surgeons? It looks like they are also predicted to do well over the next decade, with a 23% increase in the number of jobs. In fact, nearly all jobs in the medical field, either physicians, or nurses, or techs and assistants are forecast to do well, far better than average and definitely better than other professionals like attorneys (9.8%) or high school teachers (5.5%).

So if you are somebody who is looking for a stable job, better start applying to a medical school or nursing school. Forget about going for the postal clerk position (-31.8%).