Sunday, April 20, 2014

When Your Pulse Ox Won't Read Properly

Kristoff, why isn't my pulse ox working?
Pulse oximetry is one of the most indispensable tools anesthesiologists use to maintain the safety of the anesthetized patient. Though it has become widely used only since the 1980's, it is now one of the monitors that is required by the ASA whenever sedation is being given. Prior to its invention, anesthesiologists could only tell if a patient was hypoxic from an intubation of the esophagus when the patient became cyanotic, which by then could be too late. Giving anesthesia without a pulse ox is like driving a car in the rain without any windshield wipers; it can be done but the picture of the road is much less clear and more dangerous.

I'll leave it to somebody else to go through the technical details of how pulse ox monitors work. I will tell you that it doesn't always operate as well as we would like. The most common cause of a malfunction is if the patient is cold. Inside the frigid operating rooms, a patient can easily lose body heat. When that happens, the body compensates by shutting down circulation to the extremities, preserving the heat for the heart and the brain. This poor circulation to the limbs, particularly the fingers, makes it difficult for the pulse ox to read well.

Likewise if a patient is on some sort of pressors because of low blood pressure from sepsis or hypovolemia, the arterial constriction induced by the drugs will prevent an adequate circulation to the small arteries in the fingers. This will again prevent the pulse ox from operating properly. Some other common conditions that will lead to false pulse ox readings include any pressure on the arm. If the patient's arms are tucked to his side during an operation, a surgeon can easily lean on the arm, preventing an adequate blood flow to the fingers. If the pulse ox reading drops periodically, say every three to five minutes, that probably means the pulse ox monitor was accidentally placed on the same arm as the blood pressure cuff, causing the circulation to fall every time the cuff inflates.

Some patients have a condition called Raynaud's Disease. This manifests itself as poor circulation in the fingers and toes leading to cyanosis when the patient gets cold. This causes the pulse ox signals to degrade. If a patient is shivering or moving his fingers, the pulse ox won't work either. African Americans with dark fingernail beds can throw off the monitor, making it almost useless.

So what can be done to make sure this essential monitor functions properly? First of all, an adequate circulation to the fingers is absolutely mandatory. Therefore if the patient is cold, warm up the room if possible or use a heating blanket and IV fluid warmer to increase the patient's body temperature. If the patient's poor circulation to the extremities is due to hypovolemia, give more fluids. If you suspect the blood flow is inadequate due to the surgeon leaning or sitting on the arm, tell him gently to back off. Remember they don't want any complications to their patients as much as you do.

If none of those measures work, it's time to try something else. Every anesthesiologist always tries a second pulse ox. Some put it on a different finger of the same hand, like the thumb, because it has a bigger nail bed for the monitor to read through. If that doesn't work, another pulse ox may be placed on the opposite hand. Since both upper extremities usually receive the same amount of circulation, this rarely works but we all do it.

When you run out of fingers to place the pulse ox monitor, the next step maybe to try the earlobe. Some people have larger ear lobes than others. If a patient has very small ear lobes, it can be difficult to position the pulse ox light just right to pick up the pulsatile blood flow. There are also special small pulse ox clips that can be applied to the earlobe, negating the need for large stickers that can stick to the patient's hair and which usually fall off anyway. I've also seen people use these clips on a patient's nose too which also works.

Finally always try placing the pulse ox sticker on the patient's forehead, centering it over the bridge of the nose. I used to scoff at the usability of this application, since the light emitting end of the sticker is so far away from the receiving end. But it functions surprisingly well. Even when a patient is cold, there is usually preserved circulation to the head allowing the pulse ox to read the blood flow. The pulse ox waveform may not be as strong as on the fingers, but sometimes any waveform is all we can ask for. Of course when all else fails, and you just have absolutely no idea how well a patient is getting oxygenated, bite the bullet and draw an arterial blood gas. That is ultimately the most definitive answer for how well the patient is receiving oxygen.

Pulse oximetry has truly revolutionized the practice of anesthesia. This noninvasive monitor, along with capnography, has exponentially increased the safety of patients under sedation. No cases should be started without a functioning pulse ox monitor in the room. Any surgery center that skimps on this essential component while lavishing its surgeons with 75 different types of sutures is not a facility any reasonable anesthesiologist should seek employment. A patient's life, along with your medical license, is too precious to risk any sedation without a fully working pulse ox.

Thursday, April 17, 2014

The Insidiously Steady Income Of Doctors

Many people are attracted by the perceived stability of doctors' incomes. Year in and year out people get sick so doctors will always have jobs, right? By contrast lawyers are beset by an oversupply due to law school greed and technology advancement. Wall Street bankers can suffer a massive hemorrhage of jobs during bear markets in stocks. But parents encourage their kids to become doctors so that they will have peace of mind and not worry that their offsprings will want their old bedrooms back after graduation.

But is the stable income of physicians illusory? What if people really understood the truth about how poorly physicians have been doing? As the just released Medscape physician compensation report showed, anesthesiologists' incomes were unchanged last year from the year before. If you look through the entire report, you'll see that almost all physicians showed little growth in their earnings last year save for a few primary care fields that had single digit increases due to raises in reimbursements specified by Obamacare.

In the meantime, doctors will just have to satisfy themselves with another 0.5% increase in Medicare reimbursements that was voted by Congress as part of another temporary doc fix before a permanent solution to the SGR problem can be found. However, the SGR patch is good for twelve months while the Medicare raise is only good until the end of the year. Therefore during the first four months of next year, doctors will once again have zero chance of getting more money from the government.

While a 0.5% increase may sound better than nothing, it is in fact not an increase at all, but a step backwards. The U.S. Federal Reserve has set a target of two percent as the goal for consumer inflation. Therefore a 0.5% increase is actually a 1.5% decrease in inflation adjusted wages. As a report in JAMA pointed out, between 1996 and 2006 physician income remained stable nominally, but actually fell 25% after adjusting for inflation. At the same time, our own government is predicting that medical inflation will increase at an annual rate of 5.8% for the next ten years.

So how do these number affect doctors? Here is a graph showing price increases for ten years starting from a base of $1.00 today. Medical inflation increasing each year at 5.8% for a decade clearly demonstrates prices zooming up and away. In ten years, you'll need $1.76 for the same $1.00 purchase today. Consumer inflation at 2% shows a more modest growth, with a price reaching up to $1.22 after a decade. Doctors incomes, if we continue to get an annual 0.5% raise in Medicare reimbursements, will only reach $1.05 in ten years. If the SGR fix that barely failed in Congress had been implemented, it would have called for an increase of 0.5% per year for only the first five years followed by a pay freeze for the next five. Doctors in that scenario would receive $1.03 for what is worth $1.00 today. Therefore after ten years, a doctor's income would fall by twenty percent when compared to consumer inflation and nearly half when up against medical inflation.

And everybody knows that the consumer price index as measured by the government is artificially kept low because they take out two of the basic necessities of life: food and fuel. Gasoline prices ten years ago in California were barely above $2 per gallon. Today it is over $4. It is not unreasonable to expect prices to double again in ten years to $8 per gallon, especially as the environmental lobbyists continue to flex their substantial muscles in the California legislature to prevent any further drilling for oil.

Other basics of daily life, including utilities and insurance, are unlikely to rise only two percent per year. Office employees are also probably not going to accept such small annual raises. When Social Security raised its cost of living adjustments by 1.5% this year, howls of protest could be heard emanating from nursing homes across the country. Thus one will be unlikely to find good employees without raises that at least keeps up with inflation, even if the physician/owner does not get any himself.

So one can judge for himself whether having a "stable" income is really such a good thing. Sure the number look impressive. But those same numbers two to three decades ago permitted doctors to buy medical office buildings and rental properties in Beverly Hills. Today's doctors can barely afford a single family home on the Westside of Los Angeles. In another twenty years, perhaps they will have to give subsidized housing to physicians so that they can afford to live close to their hospitals for emergency cases. That's what all this nickel and diming in Congress has done to the downtrodden medical profession.

Wednesday, April 16, 2014

Anesthesiology Compensation 2014. Same Old Same Old

Here we go again, the latest physician compensation report from Medscape. I was once again one of over 24,000 doctors who filled out the survey that Medscape emailed out. Unfortunately, just like last year, I didn't win the iPad Mini for taking ten minutes to answer all the questions. Curse you Medscape.

Let's get right to the point here. Anesthesiologists reported a ZERO change in compensation last year. Nada. A big fat goose egg. On average anesthesiologists made $338,000, the same as the year before. That put the field in sixth place behind Orthopedics, Cardiology, Urology, Gastroenterology, and Radiology. Following close behind are Plastic Surgery, Dermatology, General Surgery, and Ophthalmology. Once again the ROAD specialties are well represented in the top echelons of physician incomes. At the bottom of the list are the usual primary care fields: Infectious Disease, Family Medicine, Pediatrics, Endocrinology, and Internal Medicine.

Male anesthesiologists made much more than female colleagues, $350,000 to $295,000. And that has nothing to do with female wage discrimination. From personal experience, male doctors work their butts off while the women tend to work shorter days or part time. So don't go spouting liberal Democrat propaganda on me.

The sections of the country with the highest salaries were in the North Central and South Central states. The least generous compensation was in the Pacific Northwest, followed by the West and the Northeast. Coincidentally or not, the highest paying regions also happen to be where the economies are the strongest due to increased oil drilling activity. Hmm. You think there's a link there somewhere? Maybe doctors should advocate more oil fracking as a matter of self preservation.

Overall, fifty percent of anesthesiologists were satisfied with their jobs, with 54% content with their income and 48% who said they would choose the same specialty if they had to start over again. That compares to an appalling 27% of IM and 32% of FM who would choose their line of work again.

Anesthesiologists also happen to spend the most amount of time seeing patients. Nearly eighty percent said they saw patients at least forty hours per week. That is actually a good thing since we get paid based partly on the amount of time we are treating patients. By comparison, only 27% of dermatologists saw patients for more than forty hours. And they were number eight in total compensation of $308,000. Again, that's part of the allure of ROAD.

This report is the last one that can be compared directly with previous years. From here on out the shadow of Obamacare will loom large in the compensation of physicians. To what extent won't be known until the next few years' worth of survey results are in. Until then, anesthesiologists better enjoy the good thing they have going right now.

The Lego Movie As Inspiration For Obamacare's Job Loss Spin

Have you heard the news, everyone's talking
Life is good 'cause everything's awesome.
Lost my job, it's a new opportunity
More free time for my awesome community.

"Everything Is Awesome" from The Lego Movie

The Congressional Budget Office estimates that the Affordable Care Act aka Obamacare will cause employers to force more of their workers to work on a part time basis. This way they won't have to buy them health insurance as required by the ACA. This will result in the equivalent of a loss of two million jobs.

How does the White House spin this abysmal statistic? It takes a cue from The Lego Movie, which was released the same week the CBO released this bombshell data. They claim the ACA will allow people to choose to work less and spend more time with their families because they will still have health insurance. Says White House press secretary Jay Carney, "individuals will be empowered to make choices about their own lives and livelihoods, like retiring on time rather than working into their elderly years or choosing to spend more time with their families."

I would think that people want to work longer and harder when they are young so that they can retire on time or early. But I guess if you are taking inspiration from a toy marketing movie, logical thinking isn't high on your priority list.

Tuesday, April 15, 2014

Anesthesiologists Will Work For Cheap

The ASA has regularly, loudly, and up to now, ineffectively complained about Medicare's inequitable treatment of anesthesiologists. While other medical specialties receive Medicare reimbursements that are typically about 80% that of private insurance, anesthesiologists receive only about one third what insurance would bring us. This payment disparity is apparent in the just released Medicare doc pay database and it couldn't be more stark or disheartening.

Bloomberg organized by specialty the Medicare reimbursements received by doctors. It then ranked the specialties by the total payments received. Not surprisingly, primary care fields topped the list of most money reimbursed by Medicare. What I found more interesting was the amount given per participating physician in each specialty. According to this categorization, anesthesiologists were the second lowest paid physicians by Medicare in 2012, with a per doctor payment of $27,931. Anesthesiologists came in just above the basement occupied by OB/GYN who each received $13,515. Since Medicare is mainly health insurance for the elderly and disabled, there aren't many expensive deliveries being performed in that cohort.

Anesthesiologists raked in less money than non MD's like speech pathologists ($36,615) and physical therapists ($49,064). We rank just above occupations like optometrists ($26,667) and clinical psychologists ($24,420). Physicians that are closest to anesthesiologists in this hall of shame are pediatricians ($31,319) and psychiatrists ($33,853). By comparison ophthalmologists and oncologists each pulled in over $300,000 per physician that year.

CRNA's faired surprisingly poorly with Medicare reimbursements. They averaged only $12,587 per anesthetist in 2012. Whether that is because they take care of younger and healthier patients than anesthesiologists is hard to say.

Another interesting nugget of information from this list is that only 32,641 anesthesiologists participated in the Medicare program in 2012. The ASA tells us that there are over 45,000 anesthesiologists actively practicing in the U.S. So why are only two thirds of them accepting Medicare? Do they practice in ASC's that don't accept Medicare patients? Do they refuse to accept Medicare into their personal practice? Is this some sort of covert resistance movement against a government that unfairly undervalues our services?

So next time your surgeon ($48,655) complains about how little he is making from Medicare for doing another midnight acute abdomen, just tell him you too can feel his pain.

Saturday, April 12, 2014

Anesthesia Menu Board

In this era of consumer empowerment, people are encouraged to shop around for the best prices. This includes finding the lowest prices for medical care. Unfortunately it is practically impossible for patients to get this kind of data accurately. It is highly variable with a multitude of factors that will affect the final charges. Considerations such as the contract a doctor's group or hospital has negotiated with the insurance company, geographic location of the procedure, the individual's copay and deductibles, and many, many others will ultimately affect what the patient will get in the mail.

Judging by the responses I've gotten from my post about Medicare reimbursements, it appears that most doctors are in the same predicament as their patients when it comes to pricing for our services. We ourselves have almost no clue how much the our patients will have to pay when they come to the hospital. However, with the release of the Medicare physician payments database, it can serve as a good guideline for what doctors can expect to receive for a procedure. Since Medicare is a federal program, the payments should be fairly consistent across the country for a given procedure, give or take a few percentages for geographic variability.

I've taken upon myself to compile a small list of anesthesia services that I randomly chose out of the Medicare database. I've put it into a menu board format so that it will look familiar to anybody who has ever entered a fast food restaurant.

This list is by no means comprehensive. The procedure names may sound vague but they are straight out of the database, not my own words. The prices can also be highly variable depending on things like length of a case and the ASA factor of the patient. These prices also reflect only Medicare prices. Since Medicare severely underprices anesthesia services, private insurance may pay two to three times more to anesthesiologists than what is shown here. If the patient has Medicaid, you are SOL. Medicaid usually pays even less than Medicare, averaging two thirds of Medicare's payments. My state of California pays the least amount in the whole country, with its MediCal program reimbursing only about half the normal Medicare fees.

So next time a patient asks you how much your services are going to cost, you can just grab a copy of this menu board out of your pocket and give a ball park answer. It may not be accurate down to the penny, but at least it will be closer to the actual cost than a random guess like $500 for an arterial line.

Thursday, April 10, 2014

Doctors Should Get Kudos For Accepting Medicare Patients

The government's release yesterday of Medicare payment data has predictably raised an uproar among the public. The conflagration is also being fanned by a media that only sees all the zeroes in the reimbursements but don't care to dig a little deeper into the numbers to understand where all the money is going. Hint: it's not into the doctors' pockets.

While the news concentrates on the witch hunt for doctors who are supposedly raking in millions of dollars from the taxpayers, the CMS database is actually a lot more useful to illustrate how LITTLE doctors make from taking care of our elderly. We should be receiving accolades for how little money we get for treating our nation's grandmothers and grandfathers instead getting smeared with innuendo about our integrity.

If you go to the CMS website, you can download the data that comprise the payment amounts to doctors. The downloads are aggregated by alphabetical order of the physicians' names. Even then each Excel spreadsheet is several megabytes in size. You'll have to be very patient if you have a slow internet connection and an old computer. I loaded just a couple of databases, including the one with my name in it, just to see what kind of information the government is releasing about me to prying eyes. What it tells me is that we are all suckers for accepting such a pittance for Medicare reimbursements.

I only looked at payments related to anesthetic procedures. The horror story is true for all physicians but anesthesiologists already know we receive far less from Medicare as a percentage of private insurance compensation compared to other doctors. This makes the pain of taking Medicare patients particularly acute for anesthesiologists. Since anesthesiologists usually work in a hospital setting, we are all obligated to take these patients whether it makes financial sense or not.

The following is a list of procedures performed and billed by anesthesiologists that I randomly pulled from the spreadsheets to illustrate how little money they made from the program. The first column is the average amount they charged for the procedure while the second column is the average they received from Medicare.

As you can see, anesthesiologists barely make back ten cents on the dollar for interventions that have life and death consequences. Only $99 for an emergency intubation? That is somebody's life on the line. If we failed and the patient dies, or worse suffers anoxic brain injury, that $99 wouldn't even cover the lawyer's lunch bill. A brachial plexus block for only $48? It take at least twelve years of education after high school and thousands of hours of training to be able to confidently and successfully place a block. For all that hard work we don't get paid enough to take a family out to see a movie? If there is nerve injury or a catastrophic complication, that $48 suddenly doesn't seem worth the risks.

The worse news for anesthesiologists though, if it could possibly get worse, is that our reimbursements from Medicare aren't all that different from CRNA's who bill for the same procedures. Again here is just a quick random sampling of the spreadsheet. The amounts that are reimbursed are determined by complicated formulas that is beyond my scope to explain here. This tiny sample does not imply an overall trend, which will require analysis of thousands of numbers for which I'm not getting paid enough to do, as in zero.

Notice how CRNA's make nearly as much money as anesthesiologists, give or take a few dollars? Data like this along with the government's lovefest with nurse anesthetists could make medical students start having second thoughts about going into anesthesiology.

If you think these number look bad, wait until millions of patients start arriving at the hospital doorsteps with their new Obamacare insurance plans. Those reimburse at Medicaid rates, which is even lower than Medicare if that is even possible. Doctors need to show their patients and the media these numbers, not hide from them as if we have something to be ashamed of. If the amount of money we get paid for performing life saving procedures isn't enough to even get a plumber to come to your house to look at your stopped toilet, there is something wrong with the system. And Congress's and the AMA's only solution is to prolong the pain.

Wednesday, April 9, 2014

Do 345 Doctors=1 Geek?

Well if this isn't a slap in the face and a freezing cold splash of reality for anybody who works in healthcare. Sheridan Healthcare, the physician outsourcing company has announced that it is seeking an initial public offering. Sheridan is one of the largest multispecialty physician group in the country, employing over 2,000 doctors in 25 states. It has been on a tear acquiring medical groups left and right. For such a large corporation, the company is seeking a relatively modest valuation of $2 billion for its IPO.

By contrast, Facebook made headlines worldwide when it announced the acquisition of WhatsApp in February for $19 billion. This is a phone app that allows people to text and send each other cat pictures for free, like a multitude of other text apps available for iOS and Android. WhatsApp has almost no revenue and employs just 55 employees.

So let's work out the math. Two billion dollars for over 2,000 doctors equals under $1 million per doctor. Much less if you subtract out the value of all the non-physician employees and company assets. WhatsApp's valuation is $19 billion divided by 55 employees or over $345 million per employee. Three hundred forty-five to one. Doesn't sound quite fair does it?

The market is telling us it values people who allow others to waste their time texting 345 times greater than a person who helps others attain and maintain their health. One company wastes a person's productivity while the other helps a person get back into society as a productive citizen. One company barely requires a college education to be successful while the other needs hundreds of thousands of dollars in student loans and at least twelve years of one's life in servitude before making any actual money and starting a life.

But of course the stock market would value the two companies differently. Healthcare is considered a burden on society. Its only feature is to make people poorer for what should be a universal right that nobody should have to pay a dime. A phone app can reach billions of people around the world and all those eyeballs can be worth a lot of money to advertisers. People willingly pay real money for that.

Is it any wonder that nerds get gourmet food and company gyms for free while we have to sneak lunch into the operating room to keep from fainting from hypoglycemia? Any young person able to write five lines of code would be crazy to want to go into medicine. The cost/benefit calculus barely works for medical schools and private practice anymore. Doctors are the leeches that are sucking the life out of America while the nerds will ride in on their white iPhones to set the country free. Ooh, I like that. Let me put that on my Facebook page.

We're All (Government) Workers Now

As part of being a doctor in this country, most of us are compelled to accept Medicare patients as a portion of our practice. If you want to work in a hospital, you have to accept the government health insurance plan for the elderly. Really the only people who can refuse it are the concierge and cash only physicians. If it weren't for these rules, I think many doctors would have opted out of accepting Medicare patients a long time ago due to the declining reimbursements and cumbersome bureaucracy.

Now that we've made a pact with this devil, the devil has turned around and stabbed his pitchfork right back at us. Medicare today released its database of payments it has made to over 800,000 doctors in 2012. For years this information on physician income was kept private under court order. But thanks to heavy handed lobbying by trial lawyers and consumers groups, Medicare was ordered to open up this data, all in the name of detecting and prosecuting fraudulent doctors who are supposedly milking the system dry.

It is galling that doctors have fallen so far in society's esteem that this most private of information can be forced into view for public consumption and criticism. We are now essentially public contractors who to take care of the government's healthcare obligations yet we don't get the same privacy protection that other government workers receive. Is there a database for the salaries of the people who work at NASA? Or how about the CIA and the FBI? And I want their names and places of residence too.

Still this information can also be quite entertaining. It will probably be used more by your fellow physicians than your patients or their lawyers. It is actually kind of fun to browse through and see how much money your colleagues made off of Medicare two years ago. You can search by name, specialty, and location. For instance the top three anesthesiologists in California each received over $1 million from Medicare. I found out that I didn't even make it into the top 100 best reimbursed anesthesiologists. I guess that proves that I'm not defrauding our government? And don't even think about comparing your Medicare payments to the gastroenterologists or ophthalmologists. With all the colonoscopies and cataract surgeries those people perform, they are the ones who are really raking in the big bucks from the Feds.

So fellow doctors, we accepted this contract with the federal government nearly fifty years ago to help the elderly in this country with their healthcare. Now this is the gratitude that we have received. Along with declining payments and waffling on the fix for the SGR, how much more can they do to repel doctors from accepting anymore Medicare patients?

Tuesday, April 8, 2014

Cameras In The Operating Room. Is It Time?

This blog has documented many cases of shenanigans that can happen in the operating room. From the story of the hungry surgeon, to the Facebook anesthesiologist, to the really stupid anesthesia prank, it seems the range of improper behaviors inside those four cold walls is limited only by human incompetence. It is so prevalent that the state of California publishes a quarterly list of hospitals fined by the Department of Public Health for major mishaps in patient care, many of them occurring in the OR's. Perhaps it is time to consider what has previously been a major taboo among surgeons and other operating room staff--closed circuit cameras inside the OR.

Years ago, our hospital installed cameras in the OR's. This was done without the input of most of the surgeons and anesthesiologists. It was hoped that the cameras would prevent the kinds of misbehaviors I mentioned and serve as evidence for any patient accusations of medical malpractice. Needless to say, there was a huge uproar when they went up. Screams of patient privacy and surgeons' independence were hurled at the hospital administration. The cameras were quickly removed. Though they are gone, the wiring can still be seen up in the corners of our OR's, ready to be reused if necessary.

Frankly, in this litigious society that we live in, I'm surprised lawyers haven't already introduced legislation compelling all healthcare facilities to install CCTV in the operating rooms. As of now, the cause of a medical incident can only be deduced from sparsely written medical records and memory recall made days to weeks after the event. And both are subject to obfuscation depending on who has the most at risk for telling the truth. Therefore patient victims and their families spend years searching for answers that ultimately nobody will confess to.

Then there is the issue of patient privacy. Doctors claim that patients don't want their intimately private procedures potentially leaking out to the world for everybody to gawk. While that sounds very paternalistic, anybody who has ever watched an operation on YouTube knows that it is practically impossible to identify a patient on the operating table. The patient is completely covered from head to toe except for the small area of skin exposed for the surgeon to make an incision. Even if there was a video showing Angeline Jolie having her mastectomies, one would not be able to identify the exposed body parts as her. It could be any patient undergoing bilateral mastectomies. Operating room videos would also be held under the same strict standard for patient privacy as any other medical records per HIPAA rules. It would be no different from a patient's CT scan or EMR. Violations of any and all patient privacy will be punishable in similar manner.

Really the lack of cameras in the OR's is due to physicians being uncomfortable working in a glass cage. We are fiercely independent professionals, detesting any oversight over our skills. We hate second guessing by anybody, including fellow physicians. You can call this leadership or you can label it narcissism but that's just the way doctors have been trained to think. If we are forever questioning our own actions then we have no right being physicians telling patients what they should do to their own bodies.

However the benefits of having video evidence in the operating rooms could be enormous. Think of the abusive surgeon who terrorizes the entire OR staff. Finally there will be evidence for disciplinary action, instead of just another he said/she said in front of some hospital committee. Wrong site surgery can be analyzed so that others can see what went wrong instead of reading through vague medical records which pretty much parrot the hospital's time out protocol and doesn't give any insight into how the mistake was made. Lap sponges left in the patient? The unblinking eye of the camera can show why the sponge was not counted properly at the end of the case. Were the nurses distracted by a shift change? Was the music too loud causing people not to be able to hear each other clearly? Was the count wrong at the beginning of the case and nobody noticed? All these could be answered by a simple video.

I think the time is rapidly approaching when closed circuit cameras will be required in the OR's. When virtually every other aspect of society is being captured on camera, the lack of video in the operating rooms will seem to become an anomaly. In the name of safety, people practically demand that cameras be installed on every corner of the block, "1984" be damned. Malpractice lawyers, patient advocates, and government regulators probably won't put up much longer with the confusion that always surrounds a medical mishap. Whether we like it or not, Big Brother is coming soon.

Saturday, April 5, 2014

House Of GAWD (Giving Anesthesia While Distracted)

This cautionary tale should be a shot across the bow for any anesthesia resident or attending surfing and posting on the web during the middle of a case. It involves Dr. Christopher Spillers, an anesthesiologist practicing in Medical City Hospital in Dallas. Dr. Spillers is accused of neglecting his patient during a routine AV node ablation. His inattentiveness to his charge supposedly caused him to miss his patient's hypoxia for 15-20 minutes leading to her eventual death.

When the cardiologist in the procedure, Dr. Robert Rinkenberger, gave his deposition for the inevitable medical malpractice case, he specifically focused the blame at the anesthesiologist. Dr. Rinkenberger said whenever he looked over at Dr. Spillers, he seemed to be distracted by his cell phone or pad. When asked by the lawyer if the anesthesiologist was watching the patient, the cardiologist replied, "No." Ouch. Dr. Rinkenberger complained about the anesthesiologists he's seen working in his cath lab, "You know, we see this sort of thing with these procedures. I mean, they're long procedures. We see this kind of thing, and usually I--it's not--doesn't seem to be a problem especially with relatively short cases. What can I say? I mean it happens."

As Dr. Spillers took his turn giving his deposition under oath, he initially claimed he always paid complete attention to his patients in the operating room. Unfortunately for him, his initial flat out denial of surfing the net while working in the OR was all too easy for the attorneys to shoot down. He started backpedaling by claiming he only looked on the web to check patient information, email, or schedules.

That's when the lawyers started bringing out the embarrassing evidence. He was asked specifically if he ever posted on Facebook while giving anesthesia. He again denied doing so without qualification. When asked if posting on social media would be an unsafe practice, he replied, "It wouldn't be recommended." Well, why not? In his best oral boards answer, he said, "Because you're supposed to be monitoring the patient. You wouldn't want to be spending time in extraneous activities that were not related to patient care. Is it possible to do so safely? Yes, because we have ways of monitoring the patient. But I don't do that." When asked again whether he ever posted on Facebook while doing a case, he again answered with single syllable certainty, "No."

At this point, they presented their most damning evidence--his own Facebook page. It has since been erased of nearly all posts but at that time was chock full of easy fodder for the attorneys. Dr. Spillers was asked to read what he posted on one Christmas Day, "Just sitting here--sitting here watching the tube on Christmas morning. Ho ho ho." It was accompanied by a picture of an anesthesia monitor with vital signs on it. He conceded that the monitor was attached to his patient at the time he took the picture but denied the patient's privacy was compromised because there are no identifying names or numbers in the picture. He claimed he may have posted the picture after the case was finished, not while doing the case. However when the attorney pointed out that the caption under the picture was written in a present tense, he had to admit that it was placed while he was doing the case. Now he has painted himself into a corner because initially he said he never posted on social media while anesthetizing a patient. Now he has admitted doing so in the past, even some with derogatory comments about his patients.  Check and mate.

I don't know what happened to Dr. Spillers since then. I do know that on his now sparsely posted Facebook page he identifies himself as having "worked" at Tx-An Anesthesia, the name of his anesthesia group. His case is scheduled to go to trial in September.

In this age of electronic media, nearly everything we do can be traced back to us. Electronic medical records keep track of nearly every keystroke we enter. Hospital computers monitor every website we surf to. Personal cell phones and tablets maintain logs of each phone number and web page we use. While those can be considered private information, a smart lawyer can easily get a subpoena for the phone company to release that data.

So don't become another occupant in the House of GAWD. While some long cases may present a challenge to the anesthesiologist to simply stay alert, posting on social media during a case for entertainment is never a good idea. Medicolegally it is impossible to justify and it goes against every anesthesia doctrine about patient safety.

Friday, April 4, 2014

Too Many Anesthesiologists? Let's Take A Look At The Numbers.

The latest issue of the ASA Newsletter has some very interesting statistics about the trend in the supply of anesthesiologists over the last decade. The figures were compiled from physician workforce data compiled by the trusty AMA. Not counting research and academically oriented anesthesiologists, the study showed that as of 2012 there were 45,357 practicing anesthesiologists in this country. They constitute 5.8% of all doctors for that year.

This number has been steadily climbing in the last ten years. Taking 2003 as a baseline, the U.S. population has increased 8.21% in that period. By contrast, the number of anesthesiologists have increased by 16.2%, or nearly double the rate of population growth. The anesthesiologist growth rate also eclipsed the growth rate of physicians in general, which rose 13.4%. Growth in a few specific medical fields include primary care (6.6%), gastroenterologists (20.2%), and surgeons (4.7%).

Where are all these anesthesiologists congregating? During that time, the District of Columbia, Vermont, and Connecticut have shown a >20% increase in anesthesiologists per population ratio (ApPR). Most of the states fall between 0-20% ApPR increase. Where are the anesthesiologists hanging up their shingles? Delaware, Nevada, New Mexico, Alaska, Iowa, Montana, West Virginia, and Idaho all registered lower ApPR. The study does not try to understand why D.C, VT, and CT showed such large increases. Maybe they started from a low baseline of anesthesiologists. Though with D.C. and CT, I find that to be hard to believe. We also don't know why those eight states showed a decrease in per capita anesthesiologists. Bad economies? Poor reimbursements? Who knows?

How many CRNA's are out there competing for anesthesia jobs? The study authors used Medicare claims data to deduce how many CRNA's filed claims compared to doctors. From 2009 to 2012, Medicare showed that the number of CRNA's had increased by 14.7% compared to only 4.4% for physicians. From 2001 to 2011, the number of graduating CRNA's each year increased from 1,159 to 2,447. They estimate that between 2003 to 2012, the number of nurse anesthetists practicing in the country increased by 50-75%, or at least triple the rate of growth of anesthesiologists.

How are all these anesthesia providers going to find work? We better hope there are a lot more GI docs and surgeons in the future. The authors note that the number of cases performed by these two specialties significantly determined the number of anesthesiologists working in a given state. Surprisingly, the change in a state's population had no significant impact on the number of practicing anesthesiologists. They are unable to answer questions such as how work hour changes and inroads made by nurse anesthetists and anesthesia assistants will affect the need for future anesthesiologists. They also couldn't predict whether we are currently at an equilibrium with the supply of anesthesiologists and the work available.

There you go. This is the most current data for the demographics of anesthesiologists. It gives us some numbers but it really can't tell what we really want to know. Do we already have too many anesthesiologists or are we still working off a shortage from the doldrums two decades ago? Regardless, we better hope the gastroenterologists and surgeons stay busy for awhile.

Wednesday, April 2, 2014

Tales Of The Hungry Surgeons

Here is one surgeon who should have taken advice from this blog. A cardiac surgeon in Fresno, CA has been accused of leaving a patient's chest open so that he could go out to lunch. Dr. Pervaiz Chaudhry left the closure of the sternum to his physician assistant after a heart operation. Unfortunately the patient suffered a bleeding complication after he walked out of the operating room. When the OR manager asked him to return, he threatened to pull his business from the hospital. By the time he finally came back the patient suffered a cardiac arrest and is now in a persistent vegetative state.

I remember that I had a similar incident once a while back though without such a severe sequela. The hospital had just hired a young hot shot microvascular surgeon, which we were sorely lacking. One evening, right around dinner time, this surgeon was in the middle of reattaching a partially severed limb when he said he needed a break. We all thought, ok, nothing wrong with that. Surgeons sometimes need to go to the bathroom or get a cup of coffee during a long case. He left the OR while we waited for him to come back. And waited. And waited. When he didn't return after 30 minutes, we paged him and called his cell phone. No answer. We overhead paged him. No answer. Now going on 45 minutes, we called the Chief of Plastic Surgery and the operating room director. The Chief promptly rushed to the OR and starting scrubbing in, grumbling the whole time about these new young surgeons.

Then wouldn't you know it, the young surgeon wandered back to the room. When asked by his boss where he'd been, he said he was down in the cafeteria eating dinner. Why didn't he answer his calls? He didn't like to be disturbed while eating. He wondered what all the commotion was about. This was par for the course where he did his fellowship training. The two surgeons then finished the case together. However, the new surgeon's reputation in the OR had been established. He was gone from our hospital within six months.

Both of these hungry surgeons should have followed my advice on what to eat in the operating room. We all understand that during a long case a surgeon can get hungry and thirsty. And we're cool with them going to the break room for a little refreshment or even getting sips of juice through a straw in the operating theater itself. But as a rule we would prefer the surgeon stay on the OR floor rather than meandering all the way to the hospital cafeteria for grubs. And we definitely frown on them leaving the building while the patient is still under anesthesia. These actions are usually construed as abandonment of the patient and highly discouraged.

That's why as an anesthesiologist being ignored in the operating room can have its privileges. We can discreetly munch on our power bars behind our anesthesia machines without anyone raising a stink. Just leave the double-double animal style outside the OR for when we have time to eat a proper meal.

Tuesday, April 1, 2014

Who Is The Biggest April Fool? My Vote Is On The AMA.

Last week, Congress pulled a fast one on the AMA and decided not to vote on permanently repealing the SGR formula for determining Medicare reimbursement to doctors. Instead, they resorted to their old standby and approved another doc fix for the next twelve months. It replaces a 24% cut to payments for doctors as called for by the SGR with a 0.5% increase.

Who is the biggest loser in this debacle? Besides the doctors who will get a pay increase that again lags behind medical and consumer inflation, I believe it is the reputation of the AMA. It has once again shown itself to be an ineffective organization at promoting the best interests of physicians.

The stars couldn't have been aligned any more perfectly for the AMA to finally get one of its most cherished pet projects passed by the government. Both the House and the Senate were on board for the SGR repeal. They had each passed a version of the bill and only needed to reconcile the two so that it can be voted on by both houses and sent to the president to sign into law. The medical organization sent out massive amounts of email urging doctors to call their representatives to vote for SGR repeal. This despite many doctors' misgivings about accepting a measly 0.5% increase in reimbursements for five years followed by a punishing pay freeze for the next five. The AMA put the full brunt of its PR behind the campaign to finally push this legislation across the finish line, legitimizing its claim as an advocate of doctors' interests.

In the end, it fell short, again. The AMA's lack of clout was fully demonstrated with this failure. The king was once again exposed as the little, shriveled, naked body of an organization it has become, a mere shadow of its former self. When will the leaders of the AMA come down from their academic ivory towers and start listening to the interests of actual physicians? Did they think that doctors want laws passed that will shrivel their pocketbooks? After all the money that was spent by the AMA to get this bill passed, in the end they had to settle for the usual 0.5% increase.  They might as well have saved their money and had a big St. Patrick's Day party over in their Chicago headquarters. The outcome would have been the same and at least they would have gotten some good green beer.

Until the AMA starts taking seriously the issues that doctors confront every day, like the denial of payments by insurance companies and the need for medical malpractice reform it will continue to lack the legitimacy to call itself the torchbearer for this country's physicians.