Wednesday, May 28, 2014

The Sweatshop In The Radiology Department

I was talking to a good buddy of mine who is a radiologist at another hospital. To put it mildly, he was really bummed out. The radiologists in his group are all employees of the hospital. It seems the hospital has been telling them they need to crank up their productivity to maintain the hospital's efficiency goals. Otherwise they will not receive any bonuses at the end of the year. All films must have an official reading the day they are taken, even if there is a huge order of MRI's and CT's that got put in late in the afternoon. To save money, the hospital got rid of the transcriptionists so the doctors have to type in their reports themselves. This has been an enormous inconvenience for some of the older radiologists who can't type well. With all the work, my friend says he barely has time to grab a sandwich for lunch before heading back to his office to read more films.

I told him that my impression of radiologists was a bunch of guys who sit together in the darkroom joking around and drinking coffee while they leisurely review images on the lightbox. He said that may have been true a couple of decades ago but not now. He sits alone in his office all day in front of the computer monitor with hardly any interaction with his colleagues. If he had an MI in the office, nobody would notice until the cleaning crew comes in that night. He hasn't seen some of his fellow radiologists in months. Everybody is so busy that people are scheduling more sick time just so they can get a mental break from their work.

This certainly wasn't the future of radiology that I envisioned when I was in medical school. If it wasn't for the fact that I found radiology deadly dull as a medical student, I would have gone into this field. Being one of the ROAD specialties, it still carries great appeal with students who want to practice medicine with a perceived better lifestyle. In the latest Medscape Physician Compensation report, radiologists came in as the fifth highest paid specialty with an average salary of $340,000, ranking just above anesthesiologists.

But radiologists face unique challenges that don't afflict other doctors. The digitalization of radiographic images has made the job extremely portable. Teleradiology makes it easy for hospitals to outsource the job across town or across the country if a group is unable or unwilling to take on the responsibilities that is expected of them. The commoditization of radiology has made it possible for some hospitals to drop their radiology programs completely.

As reimbursements for all physicians fall, radiologists are supposed to compensate by increasing the pace of their readings. Unlike anesthesiologists who really can't work faster than the pace of the slowest surgeon, radiologists are expected to read a few more films each day to justify their income. Medscape's survey shows that radiology is one of the few specialties whose salaries actually dropped last year, by 2%.

I felt bad for my friend. I remember how excited he was when he matched into a radiology residency. I felt a twinge of envy at that time too. Who wouldn't want to sit around, talk to good friends, and look at pictures all day while getting paid extremely well for it? Now every time I talk to him, he sounds more depressed as he complains about his job. I told him he needs to take some time off so he could feel rejuvenated. He said he would, as soon as the twenty other guys ahead of him get their sick leaves first.

Monday, May 26, 2014

California's Solution To The Physician Shortage

Well why didn't anybody else think of this before? While the rest of the country has been mired in despair over the worsening shortage of doctors, the California legislature has come up with a rather unique, and quite possibly illegal, answer to the problem. As our ultra liberal politicians are wont to do, they have decided that it doesn't matter what the law says. They have passed legislation that will make it possible for illegal immigrants who graduate medical school to practice medicine here in California.

Normally, in order to get a state medical license, a Social Security number is required to establish identification. Thanks to our sage California state senators, their bill will allow the use of a federal taxpayer identification number instead of the Social Security number for ID. Besides doctors, the bill also let pharmacists, dentists, nurses, security guards, barbers, real estate agents, and about forty other professions use the FIN to obtain their licenses to practice in this state.

Of course all of this is the logical progression to California's increasing accommodation of illegal immigration. We harbor illegal aliens in our cities and counties and purposefully hide their whereabouts from federal immigration authorities in the name of public safety. California was one of the first states to allow illegal aliens to obtain driver's licenses. Since they live here, they gotta drive to get to work, right? Then of course there is the DREAM act. This law let anyone who was brought here illegally before the age of sixteen to continue to go to school without fear of being deported back to his native country.

Thanks to the DREAM act, the University of California extends financial aid to these illegal alien students to help with their college education. The billions of dollars in cutbacks to education in this state didn't seem to make U.C. prioritize scarce aid money to go to kids who are in this country legally. U.C. also allowed extremely competitive admission spots to go to children who aren't even supposed to be in this country in the first place get accepted over thousands of legitimate applicants.

Once these students get their drivers' licenses, enter college, then finish graduate school, what are they supposed to do after they get their degrees? Why, sue the state to get jobs. The floodgates were opened when the California Supreme Court ordered the State Bar to allow an illegal immigrant lawyer to practice in the state. The conundrum of letting a lawyer, who is violating federal law by simply standing in the courtroom, defend this country's laws didn't appear to deter the Supreme Court justices.

So now let's talk again about letting illegal immigrant graduates practice medicine here in California. One of the steps to obtain my California medical license was I had to go to the police station to get my fingerprints stamped. This was the beginning of a not uncommon feeling that doctors are made to feel like criminals for working our trade. I guess since my state deliberately discourages turning in aliens, they can feel safe walking into any police station without fear of deportation. Whew!

But the tricky part is going to be when they apply for a DEA license. Since the Drug Enforcement Agency is part of the federal system, they still have strict guidelines on what constitutes legal status in the United States, something our two bit state legislature doesn't have to worry about. Right there on the DEA website, in fact the very first thing somebody needs to get a license, is complete identification including Social Security number. Hmm. I wonder if our politicians have thought through this? These newly graduated illegal alien doctors maybe able to see patients, but they certainly won't be able to provide any pain medications. Somehow I don't think these physicians will be very popular with patients or hospitals if they don't have DEA numbers to prescribe narcotics.

I'm sure the liberal administration in the White House will figure out another way to resolve this issue without the input of Congress. The flood of children crossing the U.S.-Mexican border is testament that people on the other side are paying close attention to the lack of enforcement of immigration laws over here. Frankly I think the only jobs that our representatives will forbid illegal aliens from holding will be government union jobs and their own. But how soon will all these aliens who live and work in the U.S. demand equal protection rights provided by the U.S. Constitution? Then will the courts have to let them vote too to gain fair representation? I'm afraid that time is not far off.

Saturday, May 24, 2014

Where Is The Don Corleone Of Medicine?

When did doctors in this country become so whiny? Why are there so many embarrassingly self-pitying tales about the medical profession? Recently there have been a spate of articles where doctors claim to be very miserable or undervalued. How did a profession which is populated by some of the most intelligent people in the country who attended many of the best elite universities succumb to such a sorry state of affairs?

All this public misery disparages the profession and makes it even easier for others to attack what should rightfully be one of the most just and humane occupations one can aspire to. American doctors are probably the best trained physicians in the entire world. We are held up as beacons around the globe as the ideal selfless caregiver who treat the sick regardless of race, religion, or politics. We practice in an environment where, thanks to unprecedented medical innovation, we can order state of the art treatments without worrying about rationing from some government agency. American doctors are also the best paid physicians on earth.

Yet we hear or read almost daily a constant griping about the medical field. Obamacare, malpractice lawyers, ungrateful patients, heartless insurance companies. Our antagonists seem to have infiltrated our very souls and reduced us to a bunch of sniveling high school girls who didn't get chosen to be the Rose Bowl Queen. How pathetic is this?

Whatever happened to the quietly stoic and proud physicians? We didn't have to advertise our virtues by driving fancy cars or wear expensive clothes. People in town KNEW the family doctor who just walked into the room at the local restaurant was one of the smartest and wealthiest individuals in town. That may not have been true but it certainly was the impression. Now thanks to the internet and some tone deaf doctors who just can't help demeaning themselves and the profession, our patients are reading about the difficult plight of living on six figure incomes. Not only is this unfruitful, it also shows a complete lack of grace and dignity.

What we really need is a Don Corleone of medicine. No I don't mean dropping a severed horse's head on Kathleen Sibelius's duvet. We need a group or individual who can quietly exert great power to get what we want without drawing a lot of attention. With the extraordinary financial strength of physicians and potentially millions of patients as our advocates, we shouldn't have to broadcast our troubles for all the world, including politicians and lawyers, to see.

Nobody wants to accommodate a group that is considered weak and ineffectual. They, however, will deal with an opponent whom they respect for its strength. Pity does not get you very far in Congressional budget meetings and insurance contract negotiations.

Instead of writing another quick post in a medical blog on how overworked doctors are, which frankly nobody could care less, how about using that time to write to a Congressman to express a physician's view on how Obamacare can and should be changed to improve medical access for patients? Rather than complaining about how low Medicare reimbursements have become, why not use a few hours worth of income to donate to your local Congressman's reelection committee. He or she may not be your favorite Congressional representative, but at least now you'll have the ear of a person who will listen to your concerns and may actually be in the position to do something about it. Or better yet pool that money with others in your professional society's political action committee to have an even greater effect.

What we don't need is another article about how doctors are so misunderstood by everybody. Wah wah wah. Be a Michael, not a Fredo.

Friday, May 23, 2014

The Truth About Losing Weight

The other day, I met Mike, one of our bariatric surgeons, in the doctor's lounge. I hadn't seen him in awhile and was impressed by the trim new physique he sported.

"Mike," I called out. "You look like you've lost a lot of weight."

"I have." he replied. "Close to thirty pounds."

"That's great. How did you do it?" I nosily inquired.

"Oh, just diet and exercise. The usual." he answered.

"Did you use any kind of special diet or supplements?"

"No. I just at less and exercised more. It's the best way to lose weight."

"You mean besides the surgery you perform on your patients?"

Mike quickly put his finger up to his lips, "Yeah, but don't tell my patients that, okay?"

Alright Mike, I won't tell any of your patients about your fabulous weight loss technique. It'll just be a secret between you and me. Wink, wink.

Wednesday, May 21, 2014

Obamacare As Insurance Industry Bailout

The lies just keep on coming. Earlier, it was the intentional fib the Obama administration told Americans when they claimed they could keep their health insurance plan if they like it. That is until millions of people got their plans cancelled because they didn't meet the minimum requirements for coverage under Obamacare. Then the White House said people can keep their doctors if they want them. That declaration was quickly rescinded when millions more people couldn't use their regular doctors under the narrow networks the Obamacare plans set up to save costs.

Now here is the latest deceit being brought under the blinding light of discovery. Advocates of the Affordable Care Act have long claimed that the legislation will save the U.S. billions of dollars in medical costs. On the surface it just didn't pass the smell test. How can having millions more people attaining health insurance and seeking medical care save money? Now we know who's money is being saved. The White House has announced it is giving the health insurance companies billions of dollars from their Executive Branch kitty, bypassing the budget planners in Congress. But subverting the U.S. Constitution is nothing new when it comes to implementing the ACA.

Why do the insurance companies need a government bailout? As many predicted, most of the early sign ups for Obamacare exchange plans were the sicker and older patients who previously couldn't get health insurance. Consequently the companies are claiming they will lose billions of dollars on these heavy users and will need to raise their premiums drastically next year.

This sequence of events was not entirely unforeseen. Buried deep in the 2,000 plus pages of the ACA is a provision whereby the government's Health and Human Services will give the insurance industry loads of taxpayer money to keep the premiums reasonable. Of course nobody in Congress actually read about this giveaway before they voted for it.

This is just another cynical way for our government to deceive the voters on the actual costs of the ACA right before the midterm elections coming up in November. But everything about the way the ACA has been handled points to short term thinking to gain political points. The employer mandate to provide health insurance for their workers was pushed back until after the election. Likewise the ability to keep one's health insurance despite noncompliance with the ACA rules was extended until after the November votes are counted. All these changes were made unilaterally by the White House despite what has been clearly written into law by Congress. Since the Executive Branch controls the Justice Department, nobody is going to knock on the White House doors to arrest the President for breaking Constitutional laws aka treason.

The ACA has now clearly been exposed as another wealth transfer mechanism in our redistributionist nation. It has nothing to do with improving the health of its citizens. Millions of people lost their insurance so that they are forced to sign up for another government handout. The insurance companies then claim they are losing money with each new customer. But no worries, the White House is there waiting to cushion their balance sheets with taxpayer funds that nobody knew even existed. This despite the fact that most doctors and consumer advocates blame the insurance industry for many of the troubles that plague American healthcare. In the meantime the executives of these companies continue to rake in obscene millions in compensation for DENYING health care to patients. This is looking more and more like the much hated bank bailouts just a few short years ago. But because this time the recipient of government largesse is Obamacare and not Wall Street, you can bet this deception will be quickly swept under the rug and classified as business as usual.

Tuesday, May 20, 2014

There Are No Trigger Warnings In Medicine

There's been a lot of angst recently regarding the increasing use of trigger warnings in college. In case you are not up to the latest in collegiate conventions, trigger warnings are supposed to notify students about topics being discussed in the classroom that may cause discomfort and bring back distant memories of traumatic events earlier in life. Oberlin College gained internet infamy when it advised its professors to beware of speaking to their students in class that smack of, "racism, classism, sexism, heterosexism, cissexism, ableism, and other issues of privilege and oppression."

Well, isn't that special. We are raising a whole new generation of students who have been so protected in their relatively short lives that they cannot tolerate any kind of shock to their systems. They have been led down a preordained path that can't endure any deviance from their self prescribed path through life else their feelings might get hurt.

Let me tell you, I hope none of these students who are rallying for trigger warnings in school ever apply to medicine. If they think reading "Huckleberry Finn" is too appalling, they have no idea what's going to hit them the first day they walk into medical school.

They will quickly realize that the human condition carries no red flags or warning labels. If these kids think reading books that contain scenes of rape is too much to bear, what will they do when they encounter a real rape victim in the emergency room? They won't be able to just walk out the room to skip today's reading assignment. They'll be face to face with the victim's physical and mental injuries, most of which they could never have imagined from just reading a book.

What will these students do when they see a young child with terminal cancer in the pediatric ward? Will they demand trigger warnings be taped to the patients' doors so they can decide if they are able to stomach the scene that awaits them on the other side? No nurse or attending doctor is going to be there to hold their hands as they gingerly step across the threshold to confront the realities of life.

I am personally disgusted at how far down we have spiraled in our efforts to raise our children in the most politically correct fashion. Where will we find our next generation of physicians when these students are cowering in mom and dad's living rooms playing with their iPads, avoiding the real world? If the mere act of reading a subject that goes against their world views can trigger a mental meltdown, how will we find anyone prepared to confront our most pressing healthcare issues? Death, dying, pain, suffering. These are all problems doctors have to face every day. There is no turning away.

Tuesday, May 6, 2014

The Most Vulnerable Anesthesiologists

It's already May and another class of anesthesiology residents will soon descend upon the world as full fledged attendings. Many of you are already so brimming with confidence that you can barely stand doing cases with the attending standing in the same room. Little do you know that the first six months after finishing residency will probably be the most challenging period of your careers.

As the newest anesthesiologists, you will arouse the highest suspicions and given the shortest leashes. With your heads full of hair and wrinkle free skin, patients will inevitably ask how long you've been in practice. There will be an awkward pause as you ponder how best to answer that. Should you tell the truth about your recent graduation or tell a little white lie? You ultimately decide that your integrity and the patient's trust is paramount so you answer the truth--two weeks. You will then get the wide-eyed anxious stare of somebody about to enter the abyss. No amount of reassurance that you have spent years of training will comfort the patient the same way a few strands of gray hair can accomplish. There is no fix for this. You can only continue your usual affable way and laugh about it while proving to the patient, her family, and the entire hospital staff that you are worthy of wearing your hospital ID badge that identifies you as a staff member of the Department of Anesthesiology.

But patient acceptance may be the least of your worries. When surgeons find out there is fresh meat in the OR, it's like a seasoned lion about to pounce on a naive young gazelle. The surgeons know that the newest anesthesiologist will not want to be labeled a trouble maker right out of residency. They will take advantage of your willingness to please even if it is against your better judgement. They will make you do anesthesia that would get you thrown out of your oral board exams in a heartbeat. I once had a patient who simply couldn't help himself and ate a bagel on the way to the hospital the morning of his surgery. Naturally I cancelled the case when I heard about his transgression. But guess what. The surgeon went down the hall and asked one of our youngest anesthesiologist to do the case. And he took it. Whether all the big dollar signs that were flashing in his hungry eyes made him do it or he was intimidated by the surgeon, he just turned himself into a CA1 as far as anesthetic judgement was concerned. You think that this will never happen on your watch, but believe me, it happens all the time.

What's worse than the surgeons taking advantage of you will be your fellow anesthesia colleagues doing the same. Everybody knows that when you start in a new group, you want to be known as the team player. You don't want to rock the boat and make any sorts of demands that will stigmatize you for as long as you work there. Every new anesthesiologist is so insecure that he will do virtually anything if asked by one of his more senior partners. Within days of getting your call schedule, your phone will be ringing off the hook from your fellow anesthesiologists asking to trade calls, usually for a weekend or holiday call. Some may even ask you, ever so slyly, if you could simply just take his call that night because he suddenly "remembered" he had a family event planned and can't be at the hospital. Not wanting to appear to be difficult, and hoping this little favor will grant you more job security, you will bite your tongue and agree to take it. Of course this tiny act of kindness is quickly forgotten by the other person and your job security is no better off than it was before.

You will also quickly understand what it means to have patients get dumped on you. As an eager, indebted physician, the entire OR knows that you are hungry for work and money. Therefore don't be surprised when another anesthesiologist asks you to do his last case for him since he says he doesn't want to stay late. Thinking that you could use a few bucks, you quickly agree. Then you see the patient that rolls into the preop holding: 78 years old with CHF, ejection fraction of 20%, morbid obesity, diabetes, hypertension, renal insufficiency, hemoglobin of 8, for an exploratory laparotomy for small bowel obstruction. You curse under your breath that no amount of money is worth this medical risk. But since you have already agreed to do it you bite the bullet and do the best you can with what modern anesthesia has to offer you. You notch it up as one more scar on your way to becoming a seasoned, respected anesthesiologist.

So enjoy your last few weeks of residency while you still have the chance. You are currently at the pinnacle of your medical career for the next few years. You may strut around the OR's like you're the second coming of Ralph Waters, but in the next few months you will get beaten down until you barely know which direction of the epidural needle is up. You will question everything that has been taught to you in the last three years. Not until you have answered all these internal doubts will you at last truly be known as an equal partner in your department. Or until the next year's class shows up.