The Worst Question To Ask When Interviewing For Residency

What do medical students look for when they are interviewing for a residency spot? What sorts of questions should they be asking when they go on their interviews? Should they ask about the intensity of the patient workloads? Does the quality of the weekly conferences make a difference? Should they inquire about how many research papers are published by the program's residents? Or for the truly crass, should the students ask about the vacation schedule and salary?

I was walking through the hospital the other day and passed a whole gaggle of medical students coming for residency interviews. As they were being led by a current resident, she asked them if they had any questions. One intrepid interviewee then boldly asked, "Do you guys have a gym?" I almost stopped in my tracks as I heard that. It took all of my self restraint from reaching out to slap that idiot upside the head. The resident guide kept her cool and gamely replied that the hospital does not have a gym for the residents but that there are plenty of gyms nearby they can sign up for.

The gym question is so wrong on so many levels. First of all, while the ACGME has relaxed the rules for residency hours, it is still a total grind. You will be exhausted like you've never been exhausted before. You think you're tired during medical school but you haven't experienced total and complete mental and physical fatigue until you've gone through residency. What makes that person think he will have time to go exercise on a routine basis?

Second of all, if you did have the time to work out, you probably should be spending that time more wisely doing medically related activities, like reading and research. With restrictions on work hours, residents have even less time during their three to five year residency commitments to gain all the knowledge they should to become competent physicians afterwards. With the vast explosion in medical information, it is almost incomprehensible that anybody can adequately prepare to become a doctor in such a short amount of time. Going to the gym four times per week? Forget about it.

Finally, what does the gym question say about the priorities of that particular student? He is advancing his career to better understand the human condition and help sick people. But one of his main concerns is how the residency program will help him maintain his big guns and six pack abs. Though maintaining one's health is important, that is not the responsibility of the residency program. Find your own time to exercise in residency. Don't expect a program to offer five star hotel amenities. Remember, if the programs had their way they would still make residents work one hundred plus hours per week with every third night call. They couldn't care less if by the time you finish training you've shrunken down to a pale and ghostly 120 pound weakling.

Sure I knew some residents who could have it all. One of the smartest residents I ever met was in my residency class. She just blew everybody away with her intelligence and wit. She knew every question the attendings threw at her during grand rounds. She seemed to write up papers and abstracts on a monthly basis. And she always had great stories to tell about her latest activities, like kayaking around Catalina Island or surfing in Costa Rica. But I also think she was hyperthyroid and a bit manic. She only needed four hours of sleep each night, if that. So unless you plan on cutting your sleep by half during your training, don't plan on having much time for your workout regimen unless you don't mind being a mediocre resident. But at least you will look fabulous in the naked selfies you post on Snapchat.

I'm Already A Relic

If you know what this is, you are old.

At the age of 47, I am now officially an old anesthesiologist, a relic. I had an illuminating conversation with one of our anesthesia residents about the monitoring of patients while under sedation. Now mind you this resident is a CA-3 and smarter than a whip. He'd already easily passed the early board exam required by the ABA nowadays for anesthesia residents. We discussed the role of capnography, the physiology behind the pulse oximetry, and the indications for arterial lines.

Then I asked him about the precordial stethoscope. All I got was a blank stare. I asked him if he knew what a precordial stethoscope was. He replied that he thought he had read about it in a textbook once. Did he ever see an anesthesiologist use one? No. Not even during their rotation through Children's Hospital? No. Oy!

I then fished out my precordial stethoscope from my bag, which for some inexplicable reason I still carry around. He held it and gazed at it with befuddlement and amusement. He asked about how it worked. I explained that we used to have round double sided tape that fit over the bell of the stethoscope which was then affixed to the patient's chest wall. The earpiece was custom made for each of us with an actual mold of our ear canal. I showed him how my candy apple red device fit snugly and perfectly into my ear. With this stethoscope, I explained, the anesthesiologist can hear instant changes in the patient's respiratory and cardiac status without relying on electronic devices.

The resident just looked at me with bemusement and a little sadness. It's the pathetic look you give somebody who still treasures their old eight track tapes or AMC Gremlin. When we have so many electronic wonders at our disposal that precisely measure every important body function then automatically inputs the data into the electronic anesthesia record for permanent archiving, why would anybody still use an old analog stethoscope? How can a simple rubber tube connected to the ear possibly be of any worth to the modern anesthesiologist?

While the precordial stethoscope may not be "better" than all the electronic gizmos that we attach to patients, the level of intimacy we attain with our patients by actually having be physically close to them is itself informative. By sitting or standing next to the patient, we can derive information that is is not picked up by our electronics. Important things like the color of the patient's skin, pressure points that may cause injury, how a patient starts developing increased airway resistence.  Important information like this is easily missed when the anesthesiologist is only staring at his computer monitors or, worse, cellphone.

It makes me wonder about where the future of anesthesiology is heading. Are we all destined to become mere observers of the events unfolding in the operating room, like a security guard watching over a bank of video monitors in a department store? Or is there still a role for us to become more actively involved in the care of the anesthetized patient?

Anesthesiology Is Bad For Your Health

Business Insider recently ranked the least healthy jobs in the country. They determined this list based on data from the U.S. Dept. of Labor. The factors they used included the risks of job exposure to radiation, disease and infection, hazardous conditions, risks of burns, cuts, bites, and stings, and prolonged sitting (!). Without further ado, here are some of the surprising occupations that made the Top 25 list of the most unhealthy jobs in America.

Coming in, tied for 24th place, is Radiology. Radiologists may be surprised to learn that their job is as bad for their body as their 24th place brethren Metal Furnace Operators. I couldn't think of any jobs that could be more disparate. Radiologists work in air conditioned, quiet darkened rooms while furnace operators work near giant vats of molten metal. How could they possibly have the same level of health risks? Well according to the data, radiologists have increased exposure to radiation (unlikely since most of them aren't actually anywhere near machines that emit the radiation unless they are doing an interventional procedure), disease and infections (again not the radiologists I've seen who wouldn't go anywhere within ten feet of an actual patient), and sitting (duh). The risks for a metal furnace operator goes without saying. Between the two, I'd choose radiology any day.

ICU nurses come in 21st place, below Service Unit Operators (oil, gas, mining). These are the guys who make sure oil fields and mining operations are working smoothly. Again there is probably an overemphasis on exposure to disease and contaminants because I'd take an ICU nursing job in a minute compared to working in the oil fields. I'm pretty sure many oil workers would feel the same.

Further down the list we get more incongruous job comparisons like EMT's, which is tied at 17th with Mining Machine Operators and both are considered more unhealthy than garbage collectors, I mean Refuse Material Collectors. 

Finally four of the top five least healthy jobs in America are medically related. Anesthesiology is ranked as the third most dangerous job for your well being. This is mainly due to high exposure to disease and infections, contaminants, and radiation. What, no mention of sitting on the job? At lease we're not the absolute most unhealthy job in the country, which belongs to your dentist. Their daily risks of being subjected to infections and contaminations is without a doubt. However I'm not so sure about the sitting category. Most dentists I know don't sit very much. They are running from room to room checking on their dental hygienists rather than sitting down with one patient for a prolonged period of time.

So take this list for what it's worth. If any medical student is thinking about going into anesthesiology, just realize that you are heading into a field which will damage your health more than a nuclear plant operator, waste water treatment worker, and embalmers. Otherwise just remember that other lists have called anesthesiology one of the best jobs in America. 

A Surgeon's Loneliest Responsibility

We often denigrate surgeons who hold the view that they are the captain of the ship. They think they are fully in charge of the operating room and everyone else has to do their bidding. We scoff at such antiquated thinking. Don't they realize that surgery is a team approach, with the entire operating room staff responsible for the welfare of the patient?

We sneer at such attitudes, but guess what--when the shit hits the fan, the only person in the operating room who approaches the patient's family is the surgeon. When there is a death in the OR, such as a trauma patient, it's not the entire OR staff who walk the long walk to the family waiting room to disclose the passing of their loved one. It is the surgeon alone. The rest of us merely go about our business cleaning up the operating room to get it ready for the next case. But the anguished cries echoing down the hall are not easily ignored.

Worse are the unexpected complications that can occur in the operating room. Whether it be a pneumothorax from a poorly attempted central line by the anesthesiologist or a sponge inadvertently left inside the patient because the nurses didn't do a proper final count of the equipment, the culprit rarely is the one who has to go to the waiting room to tell the family about the complication. We recently had a patient who died on the OR table. Unfortunately, this happened after the case was finished and the surgeon had already gone out to tell the family that the operation was a success. Guess who had to go back out there to notify the kin of this tragic turn of events? While the rest of the OR personnel kept their heads down safely behind the security doors, naturally it was the surgeon who had to face the music and answer all the angry accusations hurled at him outside in the lobby.

So next time before you accuse a surgeon of being an imperious bastard, just remember that great power comes with great expectations. Unless the anesthesiologist or nurse in the OR are willing to go right out there with the surgeon to confront the family after an unanticipated event, we should give the surgeon some slack if he wants to act like the overlord of the OR. I suspect most of us would rather leave that unpleasant task to the surgeon alone.

Happy Ether Day

Today marks the 169th anniversary of the first public demonstration of an anesthetic being used for surgery. The seminal event took place on October 16, 1846 at the Massachusetts General Hospital in an operating theater now known as the Ether Dome. That was when a dentist by the name of William Morton used a new substance called ether to anesthetize patient Gilbert Abbott so that his surgeon, John Warren, could remove a tumor from the jaw. After the operation Mr. Abbott declared that he experienced absolutely no pain. Thus the age of anesthesia was born. The operation was nicely chronicled in a New England Journal of Medicine article published that year, voted the most important article ever published in that august journal. For more interesting historical facts about anesthesiology, head on over to the Anesthesia History Association's website.

Working For Insurance Companies

Medical Liability Monitor released its statistics on the cost of medical malpractice premiums for 2015. It said that premiums have stayed relatively flat for the past year after a slow decline over the previous seven years. The premium changes however aren't spread uniformly. They decreased slightly in the Northeast, Midwest, and West, up 0.9% in the South, and up 9% in Texas, North Carolina, and Georgia. (Whatever happened to the medical malpractice reforms in Texas? Weren't they supposed to deter malpractice claims and decrease insurance costs?)

What astonished me the most was the chart on the difference in prices between the localities with the cheapest insurance premiums and the most expensive. These prices are for $1 million for individual claims and $3 million for any given year. For internists, malpractice insurance only costs $3,375 per year in Minnesota. However if you live in Miami-Dade County, it will set you back $47,707. For general surgeons, the cheapest insurance can be found in Wisconsin, $10,868. However if the surgeon lives in Miami-Dade County, The Doctor's Company will want $190,829 for the same policy. Now if you're an OB/GYN, better move on over to central California, where insurance only costs $16,240. You probably wouldn't want to live in Long Island, New York where it will wring $214,999 from your wallet. I'll repeat that. In Nassau and Suffolk counties on Long Island, an OB/GYN will need to make an after tax income of $215,000 just to buy malpractice insurance.

How can any doctor make enough money just to buy insurance? This doesn't even count all the other insurance that he will need such as health, life, property, etc.  And let's not forget that Uncle Sam wants his fair share from the evil 1% who are obviously preventing the other 99% of the population from a good living because of the "rich".

According to the Medscape Physician Compensation Report for 2015, OB's make $235,000 in the Northeast. General surgeons make $323,000 in the Southeast. Can insurance cost so much that it take away 90% of a doctor's income? How can one make a business case to work there? It's no wonder some physicians elect to go bare and not carry any malpractice insurance at all. It keeps the lawyers from the money grab of frivolous lawsuits while allowing the doctor to maintain a decent lifestyle from all the money they save by not buying insurance. Sounds like a plan.

Truth

What can happen when the anesthesiologist exits the room and leaves the CRNA in charge of the patient.

Anesthesiologists And Lashes

While doing some research on anesthesia and eye injuries, I came across this rather amusing website for eyelash extensions. Now lash extensions are the bane of my existence. First of all, I don't understand people who don't appreciate the natural beauty of their God given physical features. I guess I'm just not into nips and tucks. To me they are more a sign of vanity than beauty. But as an anesthesiologist, fake eyelashes just gives me one more thing to worry about when all I want to do is keep your life safe while undergoing surgery. Instead I have to preoccupy a neuro circuit to decide how best to protect your eyes without disrupting those ostentatious inch long spider legs dangling from your lids.

Nevertheless, I have to admire the earnestness of the writer, Megan, of this beauty webpage. She talks about a job category that I had never heard about, or even gave a second thought to, the "lash artist". There are even expensive courses offered to teach a person how to become proficient in the creative arts of eyelashes. Megan writes, "Many times anesthesiologists are oblivious to the finely placed lash extensions, which is proof of a good lash artist." An inattentive and busy anesthesiologist may not properly appreciate the hard work that goes into these long hairy appendages which leads to, "rough awakening without lash extensions."

Megan's advice for lash extenders is to, "Notify your anesthesiologist of your lashes and talk about the different options to keep your lashes while protecting your eyes." She personally recommends using silk tape over Tagaderm or paper tape. Her reason? She says it's more natural and, "who doesn't like silk?"

In all sincerity, she tells her readers, "Your anesthesiologist will surely be impressed with your knowledge coming into surgery and they might even learn." She signs off the post with "xoxo, Megan". Well Megan, I welcome any discussions my patients have about their concerns with surgery and anesthesia. However while I'm trying to discuss the seriousness of anesthetics and their potential life threatening complications, the idea of putting a priority on keeping lash extensions intact ranks right down there with what shoes you wore to the hospital today. Yes I will listen attentively to your fears of waking up with disjointed lashes, but internally I am rolling my eyes at the preposterousness of the situation. The OR staff too will guffaw with derision when they hear how preoccupied your reader is with her unnaturally lengthy lashes while her body is about to be wracked by the ravages of the surgeon's knife.

I'm sorry Megan. We anesthesiologists and the entire operating room team have a million and one things to worry about besides how your eyelashes will survive surgery. How they will look in postop is the last thing on our minds.

xoxo,
ZMD

What This Seasoned Stock Watcher Thinks About Talking Head Analysts

As the stock market continues its extreme volatility lately, I am seeing a whole bevy of research analysts, hedge fund managers, and general know-it-alls come out on TV and print explaining the causes for the current massacre (which none of them had the foresight to say "sell" a few weeks ago) and prognosticating on what the future will portend. My problem with all these talking heads is that, my god, they all look so young. Seriously some of these guys look like they've just graduated from college. What can these young 'uns teach me about investing that I haven't already learned through the school of hard knocks?

When stocks last crashed in 2008, these guys and gals had barely finished grad school. Their MBA's were probably still inside their unopened moving boxes in their first rent controlled apartment in downtown Manhattan. During the dot com implosion of the early 2000's, these future analysts were still attending toga parties (or whatever college fraternities do these days) and giving themselves serious liver damage and STD's every weekend. As the market swooned in 1994 during the previous Great Recession, these overcompensated chart watchers were probably just trying to fathom the opposite sex. Of course, during the great market crash of 1987, these kids were still clinging to their mothers' legs as they got dropped off at kindergarten.

So what do these people have to teach ME about how the markets work? What can they say that I haven't already seen multiple times in my long grizzled life? Why are they getting paid multiples of my salary espousing cliches about buying and holding for the long term when their very existence isn't even considered long term in my portfolio? How can they be making so much money when they are so frequently wrong?

Maybe I'm turning into the cranky old coot we used to make fun of as we rode our bicycles over his well manicured lawn.

Fun With ICD-10

ICD-10 is almost upon us. In case you don't know what ICD-10 is, it is a list of over 16,000 medical diagnoses put together by the World Health Organization that classifies every potential human health problem. Originally ICD-10 was supposed to be implemented last year. But after an outcry from thousands of doctors, clinics, and hospitals that claimed they weren't ready yet, the program will finally begin this fall.

Our hospital has been ready to use ICD-10 from its original starting date last year so we are set to go. The hospital's electronic medical record has already converted all previous ICD-9 codes into ICD-10 codes. Sometimes when I'm bored, I just type in random activities into the computer to see what kind of ICD diagnoses have been classified by the WHO.

Here, you can see that I typed "boat" into the search bar. What comes up are 120 different items that pertain to a diagnosis involving a boat. This includes falling off a ladder in a boat. Falling down the stairs in a boat. Falling from one level of a boat to another. Getting burned in a fire while on a boat. It is truly astonishing how granular the WHO organizes medical issues.

Other modern day health concerns include the overuse of video games. Here, inflammation of your joints caused by playing Nintendo actually has its own code.

Heavy users of the Playstation also get a category in our EMR's list of medical difficulties.

Xbox users are out of luck. Your inflamed, gnarled hands are not considered significant enough to be categorized by the WHO.

This raises the question of how the WHO decides which health concerns are important enough for the group to assign a specific ICD code. For instance:

Getting struck or bitten by a dolphin carries its own specific ICD number. Don't laugh. You don't have to work at Sea World for it to happen.

However, if you get injured by a whale, the WHO doesn't think that deserves its own diagnosis.

Yet orca injuries do get the blessing of the WHO. Go figure.

And if you work near large aquatic reptiles down in the bayou, you better know whether the one that bit your patient belongs to

an alligator or

a crocodile. The WHO feels these are two separate diagnoses. If you misclassify the injury, your insurance company might deny your payment for including the wrong diagnoses in your billing.

That is just a miniscule amount of medical problems that ICD-10 attempts to organize. Is it a quixotic endeavor to attempt to classify every single medical problem? The bureaucrats at the WHO are certainly giving it their best shot. In the meantime, their work can be used for an entertaining amusement when you are bored out of your mind in the middle of a long tedious case. Makes you realize how lucky you are you haven't fallen down the stairs of a boat while playing your Nintendo DS.

The Operating Room Is Freezing Cold Because Of...Sexism?

We make all sorts of excuses for why the operating room temperature is always so freezing cold. Now we may have a more scientific explanation for this. An article in the New York Times discusses why office buildings are frequently set so cold that many female workers feel the need to wear sweaters and use heating fans at work while their male colleagues still complain about sweating through their suit jackets.

This environment was first studied back in the 1960's when scientists developed a "thermal comfort model" for what temperature makes people to feel comfortable. It takes into consideration factors such as metabolic rate, air temperature, radiant temperature, and clothing insulation to determine the ideal environmental temperature. The equation looks something like this:

PMV = [0.303e^-0.036M + 0.028]{(M – W) – 3.96E^-8ƒ_cl[(t_cl + 273)⁴ – (t_r + 273)⁴] – ƒ_clh_c(t_cl – t_a) – 3.05[5.73 – 0.007(M – W) – p_a] – 0.42[(M – W) – 58.15] – 0.0173M(5.87 – p_a) – 0.0014M(34 – t_a)}

However, as it turns out, this model was based on an ideal 40 year old male who weighs 70 kg. Presumable this applies to the size of surgeons at that time too, who back then were overwhelmingly male. 

This may have been true back in the 60's but most modern men are bigger, frequently much bigger, than this hypothetical male. A 70 kg American male is now a rare minority. Along with an increase in size of the body, the metabolism rate also goes up. Therefore operating room temperatures continue to get ratcheted down as our ever larger male surgeons keep complaining of hot OR's while covered from head to toe in water proof protective gowns.

Meanwhile the rest of us in the OR's who are relatively skimpily outfitted in our scrubs and may not have the same metabolic rate as the surgeons are left chilled to the bone, rubbing our hands to restore circulation to the fingertips while absconding with every blanket available in the blanket warmer. The small female circulating nurses wrap so many blankets around themselves that they look like they're wearing flannel burkas. And the poor patient laying on the operating room table suffers the most of all, wearing nothing except a cold layer of wet betadine that has been applied to the skin. 

Now some people are discussing the possibility of changing the formula to account for the fact that women have metabolism rates that are 20-30% lower than men. There should also be adjustments for the larger diversity of people that work in the hospitals now compared to fifty years ago. Patients should be at the top of the list for reasons to adjust the operating room thermostat. Their health and successful outcomes depend on it. Surgeons should just buy stronger antiperspirants and deodorants for the sake of their patients. 

Our Anesthesiologists Make Too Much Money.

You know the old saying, "You can't be too rich or too thin"? Well, doctors know that one can be way too thin. But apparently some of my colleagues also take issue with the former and feel they are so well compensated that they don't want to work anymore.

This manifests itself almost daily usually around 4:00-5:00 PM. After they finish their lineup of scheduled cases, these anesthesiologists can't get out to the parking lot fast enough. Sometimes they run out the door in such a hurry that they leave all sorts of paper trash, used syringes of drugs, and other refuse lying on the anesthesia machine and cart for others to pick up. But what gets brought to my attention is that there are more cases that need to be done but now no anesthesiologists to do them.

Surgeons will add cases throughout the day to be started after the scheduled cases are completed. The tricky part is that some anesthesiologists don't want to keep working. They saw their schedule from the night before and make plans for afterwork the following day. Nearly every afternoon I get calls from surgeons asking me why there are no anesthesiologists to work in the OR when there are patients to take care of. The nurses are on the clock so they don't care if they work or not.

So now it's time to beg and cajole my colleagues to please stay and take just one more case, even though there may be ten cases on the addon list waiting to get started. But some of these guys quickly turn off their pagers and won't answer their cell phones as they race out of the parking lot in their German luxury cars. They don't care that they are burdening their on call partners and surgical colleagues who now may have to work well into the night to get all the surgeries finished. They have made enough money for the day and no amount will entice them to come back.

This ritual also has a seasonal factor. The beginning of the year is when we have the best work ethic. As fee for service anesthesiologists, we all start January 1 with $0 of income. But usually by midyear, the combination of summer vacations and high compensation lead many of us to start tapering off the work load. By the winter holidays, it is a real chore to find anesthesiologists willing to pick up extra cases. Nobody wants to take on more cases when it just means they'll get bumped up to a higher tax bracket. Unfortunately that is when the hospital is at its busiest.

So if you want to have surgery, try to schedule it near the beginning of the year. Because by Thanksgiving, you could be stuck in the waiting room for hours wondering why your case hasn't gotten started yet. And it's not necessarily because the OR's are too busy, but because there is nobody available to give the anesthesia.

Why Medicine Isn't Like Amazon.com

The New York Times expose (hit piece?) about Amazon.com was definitely eye opening. After reading it, I am both impressed and disgusted at how the online shopping site runs its business. The article even includes a link to Amazon founder Jeff Bezos's guiding principles on why his company has become such an unstoppable success. Presumably anybody who follows his guidelines can surely reap the same accomplishments as him.

However, when I looked through the list, I realized how polar opposite the business of medicine is from Amazon. Maybe this is why the country's healthcare system spends more money than anybody else in the world yet receives poorer marks from its citizens on health and satisfaction. Here are Mr. Bezos's doctrines and why medicine doesn't fit the mold.

1. Customer Obsession--Medical professionals are obsessed that so much medical care is granted for free to our indigent patients/customers. Some figures put the amount at $85 billion annually. Obamacare aims to reduce the number of uninsured. But with Medicaid level reimbursements, the compensation is just enough to keep the system starving itself into oblivion over a longer period of time.

2. Ownership--Doctors don't own the patients. Insurance companies and the government own them. We are just here to do the work.

3. Invent and Simplify--Medicine's rule is to make things more complicated than necessary. Ask doctors how they like their electronic medical record system and you'll get a spiel on the frustrations of the needless complications it has added to their daily lives.

4. Are Right, A Lot--We maybe right a lot, but nobody's listening. Patients google their symptoms and come into the medical office telling their doctors what to do for them. Faceless insurance adjusters second guess physicians daily on the right treatment for patients. Malpractice lawyers? Their whole raison d'etre is accusing doctors how stupid they are.

5. Hire and Develop The Best--You know where the best and brightest youths in this country are heading? Amazon, Google, Facebook, Apple, Goldman Sachs, JP Morgan. Kids aspire to entire fields where they can make a lot of money and/or develop potentially revolutionary products. Medicine is neither. Doctors who become very wealthy don't practice medicine. They're in business administration or life science research.

6. Insist on the Highest Standards--Doctors and patients may insist on the highest standards of care, but the insurance companies won't pay for it. But if doctors don't do it, they will sue the pants off of you. So it's just more uncompensated care that physicians and hospitals have to swallow.

7. Think Big--Medicine wants to think big, but then the Department of Justice brings down an antitrust ruling to keep the businesses as inefficient and fragmented as possible. Good for the payers. Not so much for the medical field.

8. Bias For Action--You try to get patients out the door but then they accuse you of dumping them. Then they penalize you when the patient is readmitted within 30 days. So why hurry?

9. Frugality--$1,000 per pill? Nobody wants frugal medicine. They want free medicine.

10. Learn and Be Curious--That is the mantra being advanced by the American Board of Medical Specialties. But then they force their cumbersome and expensive Maintenance of Certification program on all doctors leading to a nationwide revolt. Doctors don't want to learn and be curious after they have their precious little certification clutched in their hands.

11. Earn Trust--Patients don't trust doctors any more than doctors believe patients are telling them the whole truth. Why do you think there are so many conspiracy theories about children's vaccines and how they are a scheme concocted between the pharmaceutical industry, doctors, and the government.

12. Dive Deep--Clock in, clock out. Eventually we're all going to become employees of the system anyway so why bother.

13. Have Backbone; Disagree and Commit--Pretty soon you'll get a call from the hospital's Patient Advocate office asking why a patient's family is filing complaints about your disagreeable character. Then you'll have to take time off from work to face a hospital committee explaining why that family is a bunch of wackos who is making life miserable for anybody who has to be involved in their relative's care.

14. Deliver Results--Patient survived the operation. I'm out the door to my S Class in the parking lot on the way the gym where I get my real satisfaction in life.

One Million Page Views, Thanks To You.

I know that I've been rather lax in my writing recently. I can't blame it all on my recent promotion. Rather, life just has a way of taking over any snippet of free time that I have. But despite my now infrequent posting, readers continue to come back to this blog to learn about the anesthesiology profession and the random musings of this anesthesiologist.

Thanks to all these readers, I recently crossed the ONE MILLION pageview milestone. I know that that is pretty miniscule when compared to the thousands of websites out there that routinely pull in millions of pageviews each month. However, it has been an unexpected and rewarding accomplishment for me. I passed the 500,000 pageview mark back in December 2013, four and a half years after this blog was started. Now a mere one and a half years later, I doubled that number. Thank you to all the readers who made this happen.

As you can see from the map at the top, my readers hail from all over the world. Like the 500K pageview map, the only countries that haven't had a single reader browse my pages are mainly located in sub Sahara Africa, where they have much bigger problems to deal with, central Asia, and North Korea. One of these days, when Kim Jong-un needs his questions about anesthesia answered, one of his minions will surely visit my blog.

The following is a Top Ten list of my most popular posts. There isn't much change from the previous Top Ten list. People are still obsessed about where their bodies are the filthiest. Medical students and anesthesia residents are still inquiring about the anesthesia profession. As for new entrants into the Top Ten, for a few brief weeks the revelation of the shockingly low rates of reimbursements made by Medicare caused this blog to be shared and read thousands of times around the country.

1. The Dirtiest Part Of The Body.

2. Doctors Should Get Kudos For Accepting Medicare Patients.

3. Why I Chose Anesthesiology.

4. The Easy Way To Decide What Kind Of Doctor To Be--Take A Test.

5. Anesthesia Menu Board.

6. Surgery, A Siren That Will Break Your Heart And Crush Your Soul.

7. How To Get Into An Anesthesiology Residency.

8. The Difficult IV.

9. Do 345 Doctors=1 Geek?

10. Orthopedics vs. Anesthesia.

Anesthesiologists Are Like Herding Cats

I have some good news to share with my loyal blog readers. After working for over a decade in my anesthesia group, I recently received a job promotion. Now instead of just being a worker bee anesthesiologist, I have a more managerial position. Before you congratulate me on my career advancement, let me just describe to you what my new responsibilities encompass.

First of all, I get a small, small pay raise. It works out to about an extra $50 per week. Hooray! That doesn't even cover the cost of taking the family out to the movies. My new job description also doesn't include the ability to hire or fire anybody. That privilege still resides with the current Chief of our group. However what I do get to do is hear everybody's grievances about each other. And there are a lot of that.

I have to entertain complaints from anesthesiologists about nurses, surgeons, and fellow anesthesiologists. If a surgeon doesn't like the way his anesthesiologist is working, I get to hear about it. When a nurse feels one of our partners is too engrossed in his cellphone instead of on the patient, I'm the one who has to convey the message to the offender. Don't even get me started on the petty complaints our partners have against each other.

Before I got this promotion, I was totally oblivious to all this backroom drama. I came to work in the morning, shut myself in the operating room for the next eight to ten hours, then left the hospital after a job well done. Not only do I still have to keep doing those same tasks, but now I'm answering emails and text messages all day. Then there are the meetings. My work calendar has never been so full of meetings. There are conferences that meet regularly to try to resolve earth shattering disputes like how to get the janitorial services to clean the operating rooms more quickly. Or why the break room doesn't have enough shelving for everybody's lunch bags. Or how some anesthesiologists talk too much during an operation.

As any newly promoted manager will tell you, once you are not your peers' equal, you are no longer "us". You suddenly become one of "them". Which means there are no more sharing jokes about the incompetence of the group management because now I am one. The previously chummy relationships have become more formal, even a bit frosty. Edicts on proper conduct in the OR that come from above are now my responsibility to enforce to my colleagues. And that's when I realized why some surgeons dislike anesthesiologists so much.

Managing anesthesiologists can sometimes feel like herding cats. We are so used to working independently in the operating room that we don't take kindly to having somebody telling us what to do. So when I was tasked to pass along a message to a colleague that he is getting complaints about his slow inductions, causing the surgeon and the whole OR staff to wait, I not only got a frosty reception, I was nearly thrown out of the room. Since I have no powers of enforcement, like monetary penalties or job termination, my fellow partners can do that to me with impunity. In fact, some have turned the tables around and complained about me to our Chief, claiming my newly high handed and authoritarian demeanor was not tolerable.

Don't get me wrong. I love my new responsibilities. After working so long in the loneliness that can be the workday of an anesthesiologist, I suddenly feel the added tasks I do make my job interesting again. I enjoy my fellow anesthesiologists coming to me for help when they have a problem they need fixing. Or sometimes all they need is an ear for them to unload their issues. I feel I'm good at that kind of thing. And my bosses think I am too. I would take on these new duties even if I had to do it for free. But don't tell my Chief that.

What Doctors Eat On Call

You would think that doctors, with all our lecturing about healthy diets and exercise, would be paragons of nutritional correctness. But we are human just like everybody else. One of the first lessons medical students learn is that when they are on call, they should eat and drink whenever they can because the opportunity may not present itself again until hours later. So it's not uncommon for us to have the most atrocious diet while at work.

I was on call the other day and hadn't had a chance to eat anything, other than a furtive bite of a granola bar I had in my pocket. Finally, by around 9:00 PM, the operating rooms were starting to settle down. I dragged myself to the break room to get some water and what did I see when I opened the door? A bright red half eaten bag of Doritos was sitting on the table. Now anything that is sitting out in the break room is fair game. I looked around the room but it appeared I was all by myself.

I looked into the bag. There wasn't that much left, maybe a couple of servings at most. I told myself I will eat just one chip, not only because Doritos aren't exactly a health food, but because other people may want some too. I reached into the bag and brought out a perfectly triangular and unbroken chip. When I popped that in my mouth, a rush of endorphins rushed through my body. It felt like the most satisfying morsel of food I had ever eaten in my whole entire life. I didn't realize how famished I was until my tongue was coated with that delectable nacho cheese powder.

Well who can stop with just one chip? But now I wanted more. Not just more. I wanted it all. I don't care if other people working that night didn't have a chance to eat the Doritos. That bag was mine, MINE! Since there was still nobody in the break room, I quickly snatched the bag and headed to my call room. Once in the privacy of my room, I greedily reached into the package and grabbed another chip, followed by another and another. Before I knew it, I was tipping the bag upside down over my mouth to get the last crumbs of Doritos at the bottom. Then I was licking my nacho cheese covered fingers hungrily. If I could devour my cheese powder covered fingers for a snack, I think I would have that night.

Then it was over. The Doritos bag was empty. My orange colored fingertips held no more nacho cheese. And I was left suffering a deep sensation of guilt for absconding with a bag of chips from the break room. And these truly are empty calories. I felt no more fulfilled now then when I first started eating the chips. But my pager started beeping and I had to get back to work. Even if they are empty calories, they're calories just the same, enough to get me through another few hours of work.

Besides, nobody will ever know how pathetic I was when confronted with a bag of Doritos. Unless my Doritos breath gives me away. I kept that surgical mask over my face the rest of the night.

The Scariest Chart A Doctor Will See

This chart should frighten the bejeezus out of doctors. It comes from the July, 2015 issue of the ASA Newsletter. It's included in an article explaining how the new SGR fix, now known as MACRA, is supposed to work. In a nutshell, the graphic illustrates how the government takeover of American medicine is going to decimate the economic livelihood of physicians.

As you can see, during the first five years of MACRA, Medicare will entice doctors into the program with a tiny little 0.5% bonus payment each year, which doesn't even cover the cost of consumer inflation, let alone healthcare inflation. But then, in 2019, once doctors have become fat and happy with the new system, the hammer will start too fall. Medicare will start paying, or more accurately, penalizing physician reimbursement based on a set of bureaucratically selected criteria on "performance".

These factors encompass an entire bowl of alphabet soup acronyms: PQRS, VBM, MU, CPIA. I won't get into the definition of each one as that would take a lot of time and frankly, I'm not even sure of their exact meanings. You'll just have to read the article for yourself. But the bottom line is that if doctors don't measure up to these new government rules, their paychecks will start to shrink, dramatically. In ten years, which is when MACRA will sunset, physician compensation could be cut a maximum of 9% each year. For typical doctors' incomes, we're talking about $20,000 to $50,000 that will be eliminated based solely on how some faceless government workers decide how well you follow their rules. You'll also notice that this is all based on negative reinforcement. There is no bonus for doing well, only penalties for not performing as well as the feds think you should. As a matter of fact, if every single doctor doesn't do what the government wishes, Medicare may actually save more money. So you can see how if Medicare decides it needs to reduce its budget, it can easily complicate the rules anytime it wants to cut physician payments at its whim. Talk about an abusive codependent relationship.

So the American Medical Association may be crowing about how they finally rid medicine of the hated SGR. But out in the real world, working physician will only likely face more pain for years to come.

What Is Anesthesia?

Because we anesthesiologists are so bad at explaining our purpose in the operating room, our good friends from The Joint Commission have developed this colorful poster of what patients can expect when they go in for a procedure. I guess the ASA could use some education on how to effectively teach patients about anesthesia. Compare the TJC's succinct, graphically intensive poster to the ASA's Lifeline to Modern Medicine website that tries to do the same thing:

Yeah the ASA should use some of the millions they receive from our annual dues and hire a better graphic artist.

Anesthesiologist Caught On Recording Insulting Patient

An anesthesiologist in Virginia lost a $500,000 malpractice suit when a patient recorded the conversation inside a GI procedure room. The patient had set his cellphone to record so that he could remember his post colonoscopy instructions. He accidentally left it on when he went in for his study.

What he found was shocking and humiliating. He heard the gastroenterologist, Dr. Soloman Shah, and the anesthesiologist, Dr. Tiffany Ingham. make derogatory comments about his masculinity and anatomy. They snidely remarked about the man's penis, saying a lesion may be syphillis, TB, or even Ebola. The anesthesiologist suggested the patient should "man up" when he was squeamish about getting his IV line started. The anesthesiologist, for no good reason, even lied and wrote on her record that the postop diagnosis included hemorrhoids when in fact the patient did not have the condition.

For these comments, the jury found Dr. Ingham guilty of defamation and awarded the plaintiff $100,000. Then they piled on $200,000 for medical malpractice, even though as far as we know, the anesthetic was fine. And then the jury gave the man another $200,000 for punitive damages. Shockingly, Dr. Shah was let out of the case. This was despite the fact that he too was heard on the audio agreeing with and contributing to the derogatory comments. Either he had a much better malpractice attorney than the anesthesiologist, or he had much worse malpractice insurance.

What's the lesson here? Anesthesiologists should treat their patients as well when they're asleep as when they're awake. In fact, they should take care of their sedated patients even better since they have no way to defend themselves while they are in such a vulnerable position. And if you hear anyone else in the OR making stupid remarks about a sleeping patient, remember that you too can be found liable for being an accessory to defamation.

Preaching To The Choir

There are some scientific papers out there that are so original and groundbreaking that they change the paradigm of science and medicine as we know it. Think about Watson and Crick's discovery of DNA or Marshall and Warren's description of H. pylori. These are truly revolutionary research that changed the course of medicine and well deserving of their Nobel prizes. This paper presented at the recent Digestive Disease Week, the preeminent GI conference in the country, isn't one of them however.

Presented at DDW by Dr. Otto Lin from the Virginia Mason Medical Center in Seattle, the study compared the effectiveness of the Sedasys system of propofol infusion with moderate sedation that GI docs normally administer. The Sedasys patients were first given 50-100 mcg of fentanyl followed by propofol infusion from the machine. The control group of patients received only midazolam and fentanyl. A total of 1,466 patients participated in the study. Of those, 1,013 underwent a colonoscopy, 285 had EGD's, and the rest had both.

So how did the robots do? According to Dr. Lin, the patients and physicians very much preferred propofol over the simple cocktail of Versed and fentanyl. Patients went to sleep faster, woke up quicker, and had better retention of facts after the procedure. Patients reported less pain during the procedure and less grogginess afterwards. However their overall satisfaction between the two modalities was not statistically different. Nine patients reportedly suffered laryngospasm that required mask ventilation to break. There were also cases of agitation and discomfort attributed to "monitoring" issues. Dr. Lin's team was so confident about Sedasys that they even started using the machine for off label uses such as complex colon polypectomies and endoscopic ultrasounds. However they didn't have enough numbers of those complicated cases to make any recommendations.

The researchers and GI docs present at the meeting hailed this paper as strong proof that propofol given by a machine is as safe and effective as one administered by an anesthesiologist. Naturally the GI audience in attendance would only see the results that were trumpeted by their GI colleagues instead of noticing the obvious and serious flaws in the study.

First of all, the study authors compared the use of propofol against a standard cocktail of Versed and fentanyl. That is hardly original work. There have been numerous papers detailing the superiority of propofol sedation against a combination of benzos and narcotics in GI procedures. It is well known that patients wake up faster, feel less confused afterwards, have superior amnesia of the procedure, and are able to leave the recovery room faster. So none of this paper's results are surprising. What they should have used as a control was propofol when given by an anesthesiologist to see if those criteria are any different when matched up against Sedasys. With this fundamental flaw in the study, the paper is essentially meaningless.

Then there is the question of the nine cases of laryngospasm among their patients. Nine episodes of laryngospasm seems excessive to me. The numbers sound even worse when one considers that the laryngospasms probably occurred within the 285 patients who underwent EGD's, not the 1,013 cases of colonoscopies. So nine patients with airway obstruction severe enough to recover positive mask ventilation is a very high rate of this complication.

I also wonder who provided the mask ventilation to break the laryngospasm. Was it the gastroenterologist? Would he have just dropped his scope in the middle of the case to run to the head of the bed to slap the mask on the patient? Was it the GI nurse who probably hadn't masked a patient since her last ACLS course a couple of years earlier? Or did they have to emergently scream for help from the nearest anesthesia provider to rescue their patient before they died on the procedure room table? My guess is that it was the latter since the GI knows that no anesthesiologist would willingly turn away from a patient whom they have never met or discussed the risks and complications of receiving propofol but is willing to help their fellow human being from dying of a needless complication of incompetent sedation.

So yeah the GI docs love the results of this "study" on the effectiveness of Sedasys. It tells them exactly what they wanted to hear. But with an estimated seven million EGD's performed in the U.S. each year, that translates to nearly 25,000 cases of laryngospasm and airway emergencies that require active intervention to keep the patient from dying if Sedasys is used for all of them. Those alarming numbers about Sedasys should be what concerns gastroenterologists and federal health regulators, not how much money they think they are saving from cutting out the anesthesiologists.

Today I'm Ashamed To Be A Republican

I normally consider myself a conservative Republican. My political sensibilities were informed during my formative years by the administration of great Californian, President Ronald Reagan. So it was with some dismay when I read about the political debate in the California Senate over a vaccine bill.

Because of the measles outbreak that occurred last winter at Disneyland, California is attempting to pass a bill that would eliminate personal and religious exemptions to children getting the MMR vaccine. The only excuse for not getting vaccinated would be if a physician states that the child is immunocompromised and can not tolerate the vaccine.

Thank goodness some sanity is returning to the vaccine debate. As you can imagine, hundreds of parents have been demonstrating in the state capitol over this proposal with their usual lame uninformed excuses of autism, personal choice, etc. So it was with sad disbelief when I saw the Republican members of the Senate side with these parents. Senate Republican leader Robert Huff says, "I don't believe the [measles] crisis we have seen rises to the level to give up the personal freedoms we enjoy in a free country." SB 277 passed through the Senate Committee by a vote of 25 to 10 with most Republicans voting no.

It saddens me as a conservative to see these Republican pander to the antivax crowd. They claim the bill will intrude on a parent's right to choose how to raise a child. Well, you know what a country where anybody can do as he pleases is called? It's called anarchy. A civilized country has to set limits on some personal freedoms in order to function. What if somebody decides they don't want to stop at a red light because it would interfere with how he wants to drive? Is it intruding on his personal driving habits even if it means a safer driving environment for everybody else on the road? Suppose I want to carry a gun on an airplane because I don't trust the government to keep me and my family safe? It's clear that if people feel they want to do something regardless of public safety in the name of personal choice, the country would quickly descend into chaos.

Besides, who do these California Republican Senators think they are trying to curry favors with? They must know that most of these anti vaccine parents are part of the limousine liberal establishment that are prevalent in LA's Westside and the San Francisco Bay area. These abortion loving, gun controlling, climate change evangelists will never side with Republican candidates no matter how many times they vote to allow parents to withhold vaccinations. If California Republican elected officials truly believe that personal choice takes precedence over the welfare of the general public, then maybe I need to renounce my GOP affiliation, as have the vast majority of the state's residents, and look elsewhere for intelligent political representation.

Waze Must Be Banned

How can one drive while looking at this screen?

Doctors have always been at the forefront of public health. We have strongly advocated for smoking cessation, low fat and low salt diets, and increased exercise. That's why we should also be more vocal about the scourge of distracted driving, and in this case, the fiendishly addictive nature of the smartphone app Waze.

For those who are unfamiliar with Waze, it is a navigation app that acts as a traffic monitor. Users of the program enter the condition of the traffic they are currently driving in which allows others to see how bad the road congestion is, thereby allowing them to bypass to a less congested path. This information is critical in densely trafficked cities like Los Angeles. Since users can also input various road hazards like police speed traps, it also allows scofflaws to avoid run ins with the law.

It is this active participation of its users that makes Waze dangerous to drivers. Users, myself included, are constantly looking at the phone to look for traffic congestion up ahead and away from the immediate surroundings. But to report the traffic conditions to Waze, the user must also enter the information, thus taking their eyes off the road. No matter how quickly they can press the simple icons in Waze to input the data, it is still taking their minds away from driving.

Waze compounds this problem by enticing its users to become even more diverted. Drivers get points for putting in road information. It becomes a game to see who can add more points to their total. Waze even offers little virtual candy points for consistent users. The more data they enter, the more points they get, and the more distracted driving is involved.

Since it is now a social media world, Waze also allows one to chat with other Waze users on the road. Now how can somebody drive properly if they are constantly seeking chat buddies nearby?

I know Waze tries to mitigate this problem by allowing the use of voice commands. But it has been shown that the imprecise nature of voice commands in noisy cars cause drivers to take their eyes off the road due to frustration with the system.

Many cities and states have banned the practice of texting and driving because it can be even more dangerous than drunken driving. With the increasing use of safety features like antilock brakes and airbags, automobile fatality rates have been trending down for years. Driving apps like Waze may cause an unfortunate reversal in this pattern. I personally vow to minimize the amount of time I spend on Waze, just as soon as I get my 25 candy points up ahead.

People Care More About White Teeth Than Their Grandparents

I received this junk mail in my mailbox the other day. It is an ad for a local dentistry office promoting some of its services. As you can see, dentists do a lot more these days besides root canals and teeth cleaning. What caught my eye is the only price listed on the whole sheet--$399 for one hour of teeth whitening. Wow, that seems like a lot of money for one hour of work. My teeth better look like the freaking surface of Hoth after they're done for that price.

Then I got to thinking about how much my services are worth. Do people value anesthesia as much as they do white teeth? To find out, I downloaded Medicare's physician payment worksheet, this one is for 2012. The worksheet has a list of all the procedures that were billed to Medicare and what the program actually paid out to physicians. Private insurance pay more to doctors than the government's Medicare program. However since each insurance company pays each doctor differently depending how their rates are negotiated, looking at Medicare data provides a more uniform look at how much money physicians are getting for performing certain services.

The results are quite sobering. Out of the thousands of payments Medicare made to anesthesiologists that year, only a little over 500 cases received more than $400. You may bill the feds $6,390 for giving anesthesia for a CABG on pump, but they will only reimburse you $376. Think you're going to get $4,384 for anesthesia on a carotid endarterectomy? Think again. Medicare thinks your time and malpractice risks are worth only $371.69. The list goes on and on. Spinal cord surgery? You: $3,498. Medicare: $357.40. Knee Arthroplasty? You: $3,991. Medicare: $349.82.

There are regional differences in how much Medicare compensates. But the prices between what anesthesiologists are asking for and what the program will pay just seem so out of sync that one has to wonder who determines these numbers to begin with? Are they merely pulled out of thin air? Magical thinking on the part of physicians? Perhaps doctors deliberately set their prices into the stratosphere in the hopes that private insurance will actually pay that much money. But how many anesthesiologists will hit the jackpot and actually receive the reimbursement that they asked for, like the $1,320 for a ten minute colonoscopy?

As the country's population continues to get older, more and more patients will be on Medicare. Don't forget the millions of people who are enrolled under Obamacare's expanded Medicaid program, which pays much less than even Medicare. Add in the stagnant physician wages that has been written into law under the AMA sponsored SGR fix, it's easy to see why doctors are pessimistic about the future of medicine in the U.S. Is it any wonder that the U.S. News and World Report recently ranked dentistry as the best health care job in the country over nurses and physicians? When people are willing to pay $399 out of their own pockets for white teeth but quibble over a $20 copay for life saving medicines, than you know it is time to get out of Dodge.

What Do CRNA's Really Want?

Recently, a bill came up in the California legislature to allow the use of anesthesiologist assistants to practice in this state. Never heard of AA's? Anesthesiologist assistants have a Master of Science in Anesthesia degree and are licensed to work under the direct supervision of an anesthesiologist. They are currently allowed to work in 17 states and the District of Columbia. An AA graduates from training with a minimum of 2,000 hours of clinical work. There are currently about 1,700 AA's working in the country.

The California bill, AB 890, is sponsored by Democratic Assemblyman Sebastian Ridley-Thomas and the California Society of Anesthesiologists. Why does California, or any state, need AA's? To allow greater access to health care, of course. According to Dr. Paul Yost, president of the CSA, "So many more patients are entering the health system and more baby boomers will be needing care."

So who would oppose granting patients increased access to medical care? Ironically, it's CRNA's. Even though their political mantra has always been that CRNA's are needed because there are not enough anesthesiologists available for all the cases that need to be performed, they are angrily opposing the passage of AB 890. There is even an AA opposition letter that is circulating on the web that is very much a rough draft at the moment.

Why would CRNA's be against having more healthcare providers available to take care of patients? Just follow the money. AA's can do everything that CRNA's do, except they are under the supervision of an anesthesiologist. AA's don't have privileges to work independently and they have no desire to do so. They know they are not doctors and would rather have an MD take the responsibility of making critical decisions in patient care. They are here to help the anesthesiologist, not supplant them.

CRNA's, on the other hand, wish to act and be treated like physicians. They want to work without anesthesiologists looking over their shoulders, even though their level of training is far below what most anesthesiologists would consider adequate for independent practice. If AA's are allowed to work in the biggest state in the country, they will severely hinder the expansionist agenda of CRNA's. If anesthesiologist assistants can work the same cases as CRNA's, but with the built in safety net of an experienced anesthesiologist present, why wouldn't you want to hire more AA's? This is where the nurse anesthetists are going to have to show their true colors. Who are they really advocates for, patients or CRNA's?

What Is Wrong With This Picture?

Let's play a game of "What is wrong with this picture?" You know that game that is usually found in children's magazines where it asks the reader to identify all the things that could not possibly be correct in a drawing or photograph? The subject of our game is the cover of the latest issue of the ASA Newsletter, shown below.

First we have to make a couple of assumptions about this image. Since this is in the ASA Newsletter, we are going to assume that the person examining the patient is in fact a physician and an anesthesiologist. Who else could it be? A CRNA? A second assumption is that the patient is in an operating room or ICU environment, based on all the different pumps that can be seen in the background. Plus that's where you will find anesthesiologists working most of the time. So look at the picture really carefully and I'll give you the answers below.

1. Anesthesiologists don't wear a shirt and tie to examine patients. About 99% of the time we wear operating room scrubs because it is impossible to change in and out of street clothes between each case.

2. The doctor is touching the patient and her bed with his bare hands. Instant Joint Commission violation.

3. Anesthesiologists rarely use stethoscopes.

4. Maybe because of #3, this anesthesiologist obviously doesn't know how to use his stethoscope since he is listening to the patient over her hospital gown.

5. His hair is too perfectly coiffed to be a hard working anesthesiologist. Most anesthesiologists' hair are flattened from being tucked inside a surgical cap. Plus there is no telltale ring around the forehead where the cap rubs up against the scalp.

6. The patient looks much too healthy to be a typical hospital patient. Check out her alert, come hither eyes and pinkish flush of her cheeks. Not the usual ICU or OR gomer.

7. The monitor is not even on. How can the patient be in the ICU or OR with the monitors off?

8. There isn't a spaghetti tangle of wires draped all over the patient's torso from a properly monitored patient.

Did you get all that? Let me know if you spot any other inconsistencies with this badly staged picture of an anesthesiologist and his patient. One thing the cover does get accurately though--pretty young girls are always giving anesthesiologists that cute lovey-dovey stare while we examine them. NOT.

From Horndog Doc To ISIS Propagandist

The popular image of the foreign members of the terrorist group ISIS is that of the disgruntled poorly educated westerner who is unattached to any family or significant others. Some have half jokingly suggested that if these young men would just find some girlfriends then they wouldn't have the desire to go off to the Middle East desert to wreak havoc.

Maybe that doesn't accurately describe all the ISIS anarchists. Say hello to Dr. Tareq Kamleh. Dr. Kamleh is an Australian pediatrician who trained at the Royal Adelaide Hospital before deciding that terrorism is the life for him. Funny thing though is that prior to seeking a life of depravity, Dr. Kamleh was voted the most sexually promiscuous intern at his hospital during training. For that, he received the Golden Speculum award in 2011.

The Australian Medical Association and the South Australian Salaried Medical Officers Association both consider the Golden Speculum a bit juvenile but not worthy of condemnation. Say Dr. David Pope, former president of the SASMOA, "It's purely done for their own entertainment...it's not a matter for the association. It is a matter for the medical students themselves."

After finishing his residency, Dr. Kamleh first worked at the Adelaide Women and Children's Hospital. As recently as late 2014, he was found working in Perth. He left Australia for Malaysia in March of this year. He then he popped up in an ISIS propaganda video extolling the virtues of the organization. He is seen handling neonates and urging more people to become jihadists. He has also changed his name to Abu Yusuf.

It is illegal under Australian law to join a terrorist organization. Though the Australian Medical Board has so far declined to deregister Dr. Kamleh as a physician, if he ever returns home he could face 25 years in prison.

Fifty Shades Of Red

Dr. Edwin Perez

Oh wow. I don't even know how to begin this one. I saw this come across my Twitter feed today and it totally blew my mind. Dr. Edwin Perez, an anesthesiologist from Newark NJ, is seen participating in a sadomasochism party involving blood letting.

At an event called the Cirque de Plasir in Manhattan, Dr. Perez, acting as the dominant, is witnessed using what looks like an arterial line catheter to extract blood from his submissive and then spraying the fluid onto a white art canvas.

Dr. Perez tells the reporter that he and his partners don't do blood play only at S&M parties. They also perform the act in their private homes. He says everything is done under mutual consent and the girls even hang their bloody art work in their rooms.

Of course his professional life and private activities are totally separate. He compares his S&M participation to professional wrestling, "Like the WWE...kids don't try this at home. I just want to be treated like every other extreme performer. It just turns out that I have a day job." He says these parties always have "dungeon monitors" to make sure everybody is comfortable submitting to the different forms of masochistic play that are being administered.

When asked, the New Jersey Board of Medical Examiners say that what Dr. Perez does in his private life is not punishable, no matter how unsavory. Unless there is a specific work place complaint, he is free to do as he wishes outside the hospital.

Is it a coincidence that Dr. Perez is listed also as a pain physician? He certainly chose the right medical field to enter. With his extracurricular activities, if I wanted somebody to draw my ABG, he would probably be the first one I'd ask for.

Anesthesiologist Running For U.S. President? Sure. Why Not.

Dr. Marc Feldman

You may not realize it, but there is an anesthesiologist who is officially running for the office of the U.S. Presidency in 2016. His name is Marc Allan Feldman. He is running as a member of the Libertarian party.

From his official bio, Dr. Feldman completed his undergraduate education at Northwestern University, majoring in Philosophy. (Who says a philosophy degree is worthless?) He received his medical degree from Johns Hopkins School of Medicine and his Master's in Health Finance and Management from Johns Hopkins School of Public Health. He is currently practicing anesthesia at the Cleveland Clinic.

While Dr. Feldman's run will be considered the longest of long shots in the upcoming election, that doesn't mean anesthesiologists can't win an elected government office. The most famous anesthesiologist to win an election is of course Andy Harris, the only anesthesiologist serving in Congress. Dr. Harris has now won a couple of terms, winning his last election in Maryland by a landslide. He looks set to be feted at every anesthesiology conference for the rest of his life.

On a smaller scale, the newest mayor of posh Beverly Hills is Dr. Julian Gold. He is the Co-Chairman of the Department of Anesthesiology at nearby Cedars-Sinai Medical Center.

But those appear to be the exceptions that prove the rule. More frequent outcomes are like Dr. Vanila Singh, a Stanford faculty anesthesiologist who ran for Congress as a Republican in a heavily liberal Democratic Silicon Valley. Needless to say she didn't win but at least she had the courage to try when most other conservatives in the state gave that district up by default.

So good luck to you Dr. Feldman. Many physicians probably have the same fiscally conservative/socially liberal philosophy as you. But unfortunately in this country where a two party political system has been in charge of elections for over a century, the chance of hailing a President Feldman is slim. Besides, if you won we wouldn't know how to address you--Mr. President? Dr. President? Hey Anesthesia?