Thursday, February 26, 2015

ASA Loves All Nurses, Except CRNA's

The American Society of Anesthesiologists sent out a crowing email yesterday announcing a new bill introduced in the Senate by Mark Kirk, Republican Senator from Illinois. S. 297 would allow most nurses in the VA to practice independently of physicians. These independent nurses include: Nurse Midwives, Clinical Nurse Specialists for mental health, and Nurse Practitioners.

Notably absent from this list of nursing professionals are, of course, CRNA's. The email proudly states, "The ASA is pleased that S. 297 appropriately excludes nurse anesthetists. The legislation reflects a growing Congressional consensus that the surgical/anesthesia setting is a high-risk health care environment requiring physician involvement in care."

Naturally the AANA is not taking any of this lying down. They also sent out their own press release, "Please help stop this damaging course of action by contacting your U.S. Senators today. We have reason to believe that the ASA is now behind S. 297 as a political maneuver to halt further Veterans Health Administration action." Gee I wonder how they figured out that the ASA was behind this bill?

I'm not sure what the ASA's strategy for this legislation is. In my opinion, by endorsing a bill to allow other nurses like NP's to have independent practice taking care of our nations veterans, it weakens their argument that CRNA's are not able to perform their duties without physician oversight. If the ASA thinks NP's and Midwives are good enough to see patients on their own, how can they make a distinction with CRNA's? And how thrilled are the Internists and OB/GYN's with Congress allowing nurses to compete with their practices? Did the ASA just make enemies with these two large physician organizations?

Of course this battle is far from over. This is only one bill that has yet to make its way through the entire Legislative branch and hopefully avoid the President's veto pen. There is still a long ways to go before any of these new rules become reality.

Wednesday, February 25, 2015

It's Pediatric Anesthesia's Turn Under The Gun

Uh oh. Is anything in medicine really safe for patients? Michael Jackson exposed the dangers of propofol to a public who were previously complacent, if not ignorant, of anesthetics. Then last week we were all exposed to the panic from drug resistant bacteria that may find safe harbor inside sophisticated GI endoscopic equipment. Now the New York Times has printed an article pointing to the dangers of anesthesia to childhood brain development.

The paper talks about two types of research that points to potential pediatric brain injury under anesthesia. Animal studies have shown that anesthesia can kill brain cells and impair learning in young monkeys and other mammals. Human studies of children who have undergone surgical procedures have shown that multiple exposure to anesthesia can cause learning difficulties in the future. However single exposure to anesthesia hasn't been found to be a detriment to brain development.

These ambiguous results have resulted in pediatric anesthesiologists trying to awkwardly explain the risks of anesthesia to concerned parents. Says Dr. Randall Flick, director of the Mayo Clinic Children's Center and a pediatric anesthesiologist, "On the one hand, we don't want to overstate the risk, because we don't know what the risk is, if there is a risk. On the other hand, we want to make people aware of the risk because we feel we have a duty to do so."

Boy that's an awkward conversation to have with a concerned parent. We want to warn parents about potential brain damaging risks of anesthesia on children, but we don't really know if that risk really exists. Do you think most parents, when they hear an explanation like that, will believe there is no risk? Or will they most likely assume that the doctor is not telling the whole truth about the dangers of anesthesia? My feeling is that many parents will automatically assume the worst and start stressing about the surgery even more than they already do.

What gets lost in the conversation is that almost all children have surgery because they have a medical necessity. They're not like adults who can decide to have an unnecessary surgical procedure like plastic surgery just because they want it. No surgeon will operate on small children unless there is a sound medical reason to do so. Also most children will not have multiple operations at that age. Common operations like hernias and appendectomies are one and done. The children who have multiple operations like spine and cardiac cases probably already have a predilection towards other abnormalities that can lead to a higher incidence of learning difficulties in the future.

The Society for Pediatric Anesthesia recognized the confusion about the safety of anesthetics given to children over two years ago and released a statement that was endorsed by both the American Academy of Pediatrics and the Food and Drug Administration. It encourages anesthesiologists to, "Discuss with parents and other caretakers the risks and benefits of procedures requiring anesthetics or sedatives, as well as the known health risks of not treating certain conditions." Also, "it must be recognized that current anesthetics and sedatives are necessary for infants and children who require surgery or other painful and stressful procedures."

That in essence is the bottom line. Children almost always receive anesthesia only when they need it. We don't administer anesthesia just because we enjoy watching children fall asleep and getting paid for it. Anesthesia is risky in even the healthiest adults, more so with children. Anesthesia is a necessity for surgery and is one of the miracles that makes modern medicine possible. Parents can talk to the anesthesiologist about the risks of anesthesia to children but the only alternative is no anesthesia or sedation for a frightened child in an extremely stressful and potentially painful event.

Tuesday, February 24, 2015

Anesthesia Has Become A Zero Sum Game

Anesthesiologists are under siege. Compensation is being attacked by payers from the insurance industry and federal government. CRNA's are rapidly encroaching on the livelihood of anesthesiologists. Why do you think the American Society of Anesthesiologists is trying so hard to promote the term "physician anesthesiologist"? If there were plenty of anesthesia jobs around, we wouldn't care about the nurses scrapping for our throwaway cases. But there aren't an infinite amount of jobs available. It has become a zero sum game where somebody who has a job is keeping somebody else unemployed. It's eat or be eaten.

In order to enlarge the trough from which we're all feeding, the ASA is attempting the popularize the concept of the Perioperative Surgical Home. In a nutshell, it's designed to keep anesthesiologists involved with patient care, from the moment a case is scheduled, through the preoperative workup and operation, then guide the patient to a successful postop and discharge with a thirty day followup. This new role has been coined the tongue-twister "perioperativist". It is modeled after the concept of the Patient Centered Medical Home advocated by Obamacare where the internist takes charge of a patient who is admitted for a medical issue, guiding the care and the consultations that the patient may require while in the hospital.

Some studies, conducted by anesthesiologists of course, have hinted at improved cost savings when surgical patients are taken under the anesthesiologists' wings. The PSH program at the University of California, Irvine Medical Center reduced the cost of a total knee replacement from a nationwide average of $16,267 to UCI's $9,952. Much of the cost savings was derived from being able to discharge the patient three days postop versus the national average of four days. The UCI PSH also had fewer readmissions after discharge.

Oschner Hospital also started a PSH program. Last year, their length of stay after a total hip dropped from 3.5 days in 2013 to 2.1 days in 2014. This allowed the hospital to admit additional patients, giving it an extra income of $201,931.

However, we already have doctors who see surgical patients before and after their procedures. They are called hospitalists. Surgeons have been relying on them for years to optimize their patients prior to surgery. There have been calls for anesthesiologists and hospitalists to work together and complement each other's abilities for the good of the patient. That's sounds just a wee pollyannish to me. Let's face it, the payers are not going to give more money just because there are now TWO doctors taking care of the patient perioperatively. Ultimately the same check that is being issued for one procedure will have to be shared between more interests. Right now, the medical team, usually chosen by the surgeon, makes sure a patient is ready for surgery. Are they going to abdicate their traditional roles and give up that lucrative consult just because a new doctor waltzes in with some less than impartial studies about cost savings? I find that highly unlikely.

I would expect that the hospitalists are going to come out with some studies of their own showing how they are the better perioperativists for a patient. They will find some way to show that anesthesiologists really aren't qualified to take care of all the medical issues a patient has without seeking multiple consults for specialists. Then they will trumpet their findings to the feds and the insurance industry so that they will maintain their position as the real perioperativists. If the ASA thought fighting the AANA was hard, wait until they have to duke it out with other physicians.

Monday, February 23, 2015

Anesthesia Causes Global Warming. Research Grant Bait Or PC Think?

According to their mission statement, the Anesthesia Patient Safety Foundation's goal is to, "improve continually the safety of patients during anesthesia care by encouraging and conducting safety research and education." It certainly is a lofty and worthwhile principle to live by. To further that endeavor, the APSF's last newsletter announced a large grant totaling $450,000 to three researchers for projects to improve patient safety.

While I'm not going to argue the merits of the research that the grant recipients are conducting, since I'm sure they've all been vigorously vetted by an experienced and selective committee, one of the projects rubs me as too much politically correct thinking. In fact I can't help feeling that the grant proposal was written to specifically warm the souls of the typical liberal academic mentality that pervades the ivory towers in order to receive the big bucks.

Dr. Jodi Sherman of the Yale School of Medicine is one of the three receivers of the APSF grant. She starts with the premise that, "The large global warming impacts of inhaled anesthetics, particularly compared to intravenous propofol, are established." Wait. What? Inhaled anesthetics have a LARGE impact on global warming? And it's been clearly and scientifically established? Compared to all the pollution coming out of the millions of cars traveling around Los Angeles, the massive emissions from giant factory smokestacks in China, the clearcutting and burning of the Amazon rain forest, my volatile anesthetics is causing a LARGE impact on climate change? Did anybody notify the United Nations about this climate disaster emanating from our operating rooms?

Unfortunately this line of thinking is starting to pervade the anesthesia membership at large. It all started with a paper by Dr. Susan Ryan from U.C. San Francisco in 2010 titled, "Global warming potential of inhaled anesthetics: application to clinical use." In the highly speculative article, she compared anesthesia to the amount of pollution from driving a car a certain number of miles. When you multiply the number of cases being performed each day by the number of operating rooms working, this adds up to a potentially catastrophic impact on global warming.

Bull, I say. And one of the best rebuttals I've read is this paper from Dr. George Mychaskiw, an anesthesiologist from University of Central Florida School of Medicine in Orlando. He starts out with a great quote, "There are three kinds of lies: lies, damned lies, and statistics." By his calculations if the total amount of CO2 generated in the world each year is equivalent to the area of the state of Kansas, 82,282 square miles, the amount of pollutants caused by desflurane, the anesthetic most often implicated in global warming, would be equivalent to 300 square feet. If the total CO2 produced annually is equal to the Empire State Building, desflurane's contribution would be only 0.3 millimeters tall.

Does that sound like anesthesia is making a deleterious impact on global warming? Dr. Sherman's research is going to go much further to demonstrate the harmful effects of anesthesia on the global community. She is going to delve into how regional anesthesia, sedation, general inhaled anesthesia, general IV anesthesia, and all their different combinations and permutations will cause the demise of mankind as we know it. PLUS she is going to track how all the various equipment anesthesiologists use to administer these different forms of anesthesia are going to drown all of us in an uncontrollable mountain of refuse. That's a highly ambitious project with a grant of only $150,000. But personally, as soon as I read the first sentence of her research proposal, which is based on a bogus PC mindset, I would have given her $0.

Sunday, February 22, 2015

I Am Stunned By How Magical iPads Really Are.

I love my iPad. Apple describes them as magical devices. I didn't realize how magical they are until this magician demonstrated his skills with the device on the Ellen show. Amazing.

Heartbreak For A Ferrari Owner

Many people, including doctors, aspire to owning a Ferrari. Most of us guys have had Ferrari posters up on the walls of our childhood bedrooms, an aspirational image to goad us to work harder so that eventually, hopefully, we will some day make enough money to buy one. If not, that poster of a Porsche 930 Turbo with the whale tail next to it would make a nice consolation prize.

As an adult who has the privilege of driving into the doctors' parking lot every day, I have seen several physicians who actually made their fantasies come true and purchased, or leased, Ferrari's. The owners are usually the more flamboyant plastic surgeons or neurosurgeons. I can't help but think life is very good for them. But now a writer at Jalopnik has chronicled the heartache of actually owning a Ferrari.

The writer is Doug DeMuro. He chronicles his year of owning the Ferrari and why he eventually had to let it go. He had purchased a used 2004 Ferrari 360 Modeno but over the ensuing year, he encountered various unexpected issues. Filling up the car at the gas station always involved receiving attention like he was a Hollywood celebrity. People wanted to take pictures of the car both inside and outside. He got peppered with predictable questions about how much it cost, how fast does it go, and what kind of mileage does it get. It was fun for a while but it got old fast.

Taking the Ferrari out also required careful advanced planning. He couldn't go anywhere that had large speed bumps that could scrape the bottom of the car. That would be true in our own parking lot. He couldn't park it on the side of the street lest it got damaged intentionally or accidentally. He had to make sure there was no steep entrance or exit out of a parking structure or it would damage the front of the car.

Eventually the Ferrari was only good for driving a couple of hours a month, during good weather and he had the time to take it out into open country roads with no traffic around. He got 5,000 miles out of his vehicle that year, which is pretty good when most Ferrari owners get around 2,000 miles per year.

As one of his friends astutely noted, "It's a Point A to Point A car. In other words: this isn't a car you use to go somewhere. It's a car you take out of the house, and drive around for a while, before you return it to your house. You don't go to the mall in it. You don't take it to dinner. You can't pick up anything large, and you can't transport more than one person. It's not a vehicle you use. It's a toy to be played with."

So for all you doctors out there who fantasize about purchasing a Ferrari, this article explains why you shouldn't. If you absolutely must scratch that midlife crisis itch, just rent one from a luxury car rental agency for a weekend. It will be a lot cheaper and you won't have as many regrets as real Ferrari owners. This truly is a toy that one buys with discretionary income after everything else has been funded, like your home's mortgage, children's college education fund, and all the other necessities of life. Until then, don't buy a Ferrari.

Medical Education Is Changing. But Is It For The Better?

American medical doctors have been considered the best physicians in the world for over a century now. People come from all over the world seeking a medical education in this country because it is universally accepted as the most highly developed. Yet the Wall Street Journal recently wrote about how medical schools are changing their academics to graduate doctors who are more in tuned with the current fiscal and political climate. My question though is if this will produce better doctors.

At Hofstra North Shore-LIJ School of Medicine, freshman med students spend their first eight weeks being trained to become EMT's. They will supposedly become more proficient at dealing with fast moving, life or death situations. There are so many things wrong with this. I know plenty of fast thinking physicians, including surgeons, emergency physicians, and internists who make critical decisions without having gone through EMT training. I think EMT's have an essential role in the healthcare system. I did one night of ride-along with an EMT during my ER rotation and it was kind of cool and fun. But with so much information med students have to cram in with only four years to do it, it seems such a waste of time and resources for these students to be taking eight weeks off their harried lives to do what requires mainly a high school education to complete. If I am paying $50,000 per year to attend medical school, I would feel really screwed having to spend one sixth of that for EMT school, which costs far less.

At NYU Medical School, students are required to look up every charge that a patient receives during his care at the hospital. This is supposed to help them understand why healthcare costs so much in this country. Says Marc Triola, NYU's associate dean for educational informatics, "This isn't a textbook exercise. This is real life and students love it." The problem is that doctors actually have almost zero responsibility for how much hospitals charge their patients. That is negotiated between the hospital and the insurance companies. How can med students learning about ridiculous $11,000 colonoscopies make them better doctors? It just takes more time away from actually seeing and taking care of patients.

Even the MCAT has changed to this more politically correct medical training. The new test starting in April last two hours longer than the old one--six and a half hours long. Holy crap. Who can take a test for nearly seven hours without their brains melting? And the test now includes subjects like behavioral and social sciences. Thus you get questions like which choice "is most consistent with the sociological paradigm of symbolic interactionism?" What the hell did I just type? What kind of weird ass question is that for future doctors? Will patients prefer to go see a physician who answered that question correctly?

Schools don't even want their future graduates to memorize as much data anymore. We used to cram for nights on end to make sure we didn't look stupid during morning rounds when we got picked on by the attending. Now, says NYU's Dr. Triola, "The fund of medical knowledge is now growing and changing too fast for humans to keep up with, and the facts you memorize today might not be relevant five years from now." Instead they are interested in making sure their student display "information seeking behavior." In other words, do the students know how to use Google. You know what? If doctors know how to use Google to look up medical problems, their patients surely do too. Who needs physicians if everybody is googling the same information? And what happens when the physician has to make split second life and death decisions? Between their EMT training and lack of internalized medical knowledge, the doctors will have to make a blind choice without the crutch of the internet. Is that a doctor you want to treat your family?

This is just one more way that American medicine is losing its way and becoming more irrelevant. No good can come out of this when medical schools are more worried about teaching their students the costs of medicine instead of how to treat their patients. If memorizing medical information that has accumulated over centuries of intense research is considered too burdensome and old school for students, then surely we are not graduating students who are worthy of being called medical doctors.

Saturday, February 21, 2015

Healthcare Driven By Media Hysterics

Our endoscopy suite right now is in complete turmoil. If you haven't heard the news yet because you've been on a 48 hour call shift, UCLA Medical Center released a bombshell of a press release yesterday. They've had two people die and five other people infected with the highly resistant bacteria CRE or carbapenem resistent enterobacteriaceae. The patients came into contact with the bacteria after undergoing ERCP with contaminated duodenoscopes. Up to 180 other people who had the procedure performed from October 3, 2014 to January 28, 2015 are being asked for follow up at the hospital to determine if they too have been contaminated.

When the news broke late Wednesday afternoon, our own hospital went into crisis mode. The following morning, swarms of epidemiologists and microbiologists invaded the GI department. Every scope was taken down from their storage racks and cultured. Multiple meetings involving the highest levels of the hospital administration were quickly convened to deal with the hundreds of calls from worried patients and the news media, even though our hospital has never had any known transmission of CRE through a GI procedure. Patients are cancelling cases out of doubt and fear. When they do come, they are demanding full accounting of how our facility cleans the scopes, as if they had any clue which scope washing techniques works the best.

Olympus, the maker of the duodenoscopes, is already facing lawsuits from infected, and potentially infected, patients. Funny how there were no suits before this became big news. But as soon as the cameras start rolling, lawyers just suddenly pop out of nowhere, each seeking face time on TV to express their outrage at the manufacturer for making a "defective" product.

The Food and Drug Administration is also circling the wagons. People now accuse the FDA of knowingly approving a medical device that could potentially transmit harmful pathogens between patients. They may be fast tracking new cleaning protocols for duodenoscopes, which will probably involve outsourcing the cleaning using expensive gas sterilization with ethylene-oxide, a known carcinogen.

Though the UCLA deaths and infections are terrible events, I can't help but wonder why this has suddenly become front page, network news material. Gastroenterologists, the FDA, and the scope makers have known about this potential flaw in the design ever since it was approved for use. This is not new news. The only reason the duodenoscope continues to be supported by the government is because there is no real alternative for these patients who need an ERCP performed for acute cholangitis, pancreatic cancer, or a host of other pancreato-biliary diseases. But as soon as the four letters U-C-L-A becomes involved, then the entire weight of the masses comes crashing down on all the affected institutions.

As an example of the persecution being heaped on UCLA just for having those famous initials, there was an even more severe outbreak of CRE last year that nobody outside that local area and GI doctors know about. The highly esteemed Virginia Mason Medical Center in Seattle had eleven patients die after contracting CRE from infected duodenoscopes. That certainly did not make any front page headlines anywhere. Even earlier than that, the University of Pittsburgh Medical Center also suffered a rash of CRE infections that were traced to ERCP's. In that instance nobody died.

But now, just because UCLA is the targeted institution, a whole new way of taking care of a medical device will probably be instituted across the entire nation. This is going to cost the hospitals, and eventually the consumers, millions of dollars to prevent a few infections out of half a million ERCPs performed every year in this country. Healthcare consumers in the U.S. are demanding absolute protections with minimal costs. They are going to realize eventually that you just cannot have it both ways.

Thursday, February 19, 2015

Howard University Replaces CRNA's With Anesthesiologists. Why That Is A Bad Sign.

The American Society of Anesthesiologists trumpeted this news all over social media yesterday. Howard University Hospital has fired eight CRNA's and replaced them with anesthesiologists. The ASA contends the facility has realized that anesthesiologists provide superior levels of care to patients as the reason for the staffing change.

But if you look at the hospital's press release, it says nothing about the poor quality of care by CRNA's at their facility as the reason for the change. It clearly states that the hospital has been in financial distress and is seeking ways to save money. It has hired an outside corporation, Paladin Healthcare Capital, to outsource its daily operations. According to the newspaper article, "The changes at Howard are a result of the ongoing effort to turn around its finances."

So the fact is that Howard didn't hire anesthesiologists to give their patients superior care. They were brought in to save money. If they cost more than the CRNA's, they probably would not have been hired due to the hospital's poor financial situation.

Think about that for a minute. The anesthesiologists were hired because they are cheaper to use than the nurses. How can that be when anesthesiologists are supposedly making six figure salaries and rank in the upper echelons among physician salaries? The answer is that CRNA's also make six figure salaries, particularly in expensive areas like Washington, D.C. In addition, the CRNA's would be considered full time employees. Full time employees have the added costs associated with full time work, like health insurance, malpractice insurance, union negotiated break times, paid time off, fixed daily schedules, and pension plans. These are all very expensive, and rising, costs that the hospital has to bear.

On the other hand, the anesthesiologists are likely to be considered independent contractors who pay for their own benefits. The anesthesiologists will have to work for every dollar they earn and be responsible for all their own financial risks, freeing the hospital from these expenses. You think the anesthesiologists will demand a morning break, lunch break, and afternoon break during the work day? Only if they want to see a lower salary and ire from the OR director. They are hired to work, not take fifteen minutes off for a bathroom break. You have to leave by 3:00 PM in the middle of a case because you don't want to miss your zumba class? You want to come back to work tomorrow?

This is indeed sobering news for anesthesiologists. No matter how much the ASA is trying to spin this as a win for us, it actually implies that hospitals value our work no greater than the CRNA's. In the future, anesthesiologists may have to get used to receiving the equivalent incomes of nurses if they want to be gainfully employed.

Sunday, February 15, 2015

Change MOCA. Sign The Petition

A reader of this blog has sent me an email asking me to publicize a petition to demand that the American Board of Anesthesiologists change the current cumbersome rules for maintaining our board certificates. Dr. Thomas Gallen, M.D., M.P.H., is a cardiothoracic anesthesiologist in Indiana. Here is his email to me, which he gave me permission to reprint:

MOCA costs a minimum of $5,000 over 10 years and countless hours of your time in travel and activities of [at best] questionable educational benefit. I/We am/are not opposed to CME nor even to the possibility of mandatory tests but the current system is burdensome and bloated.

We are reaching an age in medicine when the cost-value of everything we do is questioned and I suggest that logic be applied to MOCA as well. Other boards are beginning to question their "practice performance and improvement" components among other components and I ask you now to support me in asking the American Board of Anesthesiology to do the same.

Please read and sign the following petition. This is unlikely to be a final accepted solution but rather a demonstration of Anesthesiologist opposition to our governing Board's decision to monetize the business of certification against our best interests. You are highly encouraged to pass this petition on to your friends, to every Anesthesiologist you know and ask them to do the same. You have the utmost gratitude of my self and the colleagues who have already signed and those who follow you.

You can like and share on Facebook here:

Thank you for your consideration.

Most sincerely,
Thomas Gallen M.D., M.P.H.

Longtime readers know that I have been a persistent critic of the maintenance of certification process for years. If you use the search bar on this page and look up MOCA, you will see the numerous posts I've made criticizing the ABA for this cumbersome and expensive coercion. In fact, I wrote so many posts about MOCA that some readers complained I had nothing better to write about so I put this subject to rest.

But now I see that I merely jumped the gun. Before, the majority of practicing anesthesiologists were rewarded lifetime board certificates so they didn't give a damn about their younger and more vulnerable colleagues who had to pay dearly to take yearly CME courses and fly long distances for tedious simulation and written exams. But the ABMS made a crucial decision recently that significantly widened their base of enemies. The physicians who hold lifetime certification now have a qualifier attached to their certificates. Unless they are also enrolled in this extortion, their certificates will read, "Certified, not participating in MOC."

Clever little bit of legalese, right? The doctor is still considered board certified but unless he starts paying into this unproven program, everybody, especially the lawyers, will be able to see that he hasn't maintained the proper continuing medical education as suggested by the medical board. The doctor's medical judgement just became that much easier for a malpractice lawyer to annihilate.

So please go to the petition website and sign it. I don't know how much of an effect this will have at the ABA, especially since there are literally millions of dollars at stake for the organization. But if the ABIM can start noticing the dissatisfaction with their MOC and begin a new conversation of implementing changes, it doesn't hurt for thousands of anesthesiologists to do the same to the ABA.

Wednesday, February 11, 2015

How Much Does Obama Hate Doctors? Let Me Count The Ways.

We knew President Obama hates doctors. Frankly he dislikes anybody who works really hard for his money and becomes successful at it. Unfortunately for the country, he is in a position of power to redistribute income as he sees fit. This is especially bad news for physicians, as his new Medicare funding proposals demonstrate.

In his latest budget plans, he wants to decrease Medicare spending by nearly $400 billion over the next ten years. How does he plan on finding such enormous savings? Hold on to your wallets because this gets really scary.

The president wants to decrease the amount of money Medicare pays to teaching hospitals and the doctors that work and educate there. He will reduce the amount of money Medicare reimburses these teaching hospitals for noncollectable debt, like care for the poor or homeless, which in most tertiary care facilities is a significant percent of the population.

He also proposes keeping physician reimbursements static, with no adjustments for inflation. In other words, physician payments will shrink in real terms from their already low Medicare rates. This is projected to save $100 billion over ten years.

President Obama also want to cut the amount of money Medicare pays towards residency training programs. This idea would save $16 billion over the next decade. Cutting residency training is particularly ironic since Obamacare is supposed to bring in millions more patients into the healthcare system. There are already too few primary care doctors willing to see the Medicare patients we already have. How can reducing the number of physicians being trained help Obamacare succeed if there are not enough doctors to allow patients to be seen in a timely manner?

The list goes on and on. Again it emphasizes income redistribution, taxing more well off seniors with higher copays and paying less to drug companies for medicines given to low income patients. This Medicare plan is like a slow stranglehold on the healthcare system and physicians. The whole enterprise dies a slow death until the only survivors left are low cost providers like nurse practitioners. That's fine if the president thinks it's normal for people to go to the drug store to get their routine check up.

Hopefully Congress will give this plan the respect it deserves and a truly serious reform for the teetering Medicare and Medicaid plans will emerge. In the meantime, we can see how clearly why doctors will never be able to trust the actions of this president. Just keep telling yourself "Two more years. Two more years."

Tuesday, February 10, 2015

One Distinction Anesthesiologists Would Rather Not Have.

I came across this article from Becker's Hospital Review. Titled "Compensation growth among physician specialties," I thought this looked promising. I could use a little good cheer after reluctantly predicting the end of anesthesiology as we know it.

The article concerns a physician survey conducted by SullivanCotter and Associates. They are a consulting firm specializing in physician compensation. There is no information on the number of physicians who participated in the survey or any other demographic data so take it for what it's worth.

The information initially looked promising. In general, nearly every specialty saw its reimbursements rise from 2013 to 2014. Great. I'll just look down this chart to see how well anesthesiologists fared. Okay. Urology. Up 7%. Good. Next. Gastroenterology. Up 6%. This shows promise. According to the Medscape Physician Compensation Survey, anesthesiologists usually rank right up there with GI in earnings so we couldn't be that bad. So I keep looking down the long comprehensive chart. And keep looking. And looking.

Pediatrics, up 5%. Hospitalist, up 4%. Family Medicine, up 3%. Where is this going? Did they forget to survey anesthesiologists? Just when I was starting to think that anesthesiologists were not included in their compensation poll, I arrive at the rock bottom of the chart. And guess who resides down there. Anesthesiologists, DOWN 2%.

WTH. Granted the median compensation is still pretty good at $368,510. But we were the only medical field to show a decrease in earnings year over year. Our services aren't even valued enough to maintain our previous year's income, which would actually be a decrease when inflation is taken into account.

Is this another sign that the anespocolypse is upon us? One year's worth of data doesn't make a trend. We'll have to wait another year or two to discover if it's time to start moonlighting in a profession where there is real pricing power and you don't have to take sh** from anyone--nursing.

Monday, February 9, 2015

Blame Anesthesia

I love this flow chart from the Gomer Blog. Having come from the surgery side of the ether screen, I'll let you in on a little secret--this protocol is what they teach surgery residents at their M&M conferences. That's how surgeons can become instant pricks as soon as they start private practice.

How Hard Is It To Match Into Anesthesiology? The Surprising Answer.

FiveThirtyEight has a very informative article about how the whole Match process came about. It gives an historical perspective of the horrors experienced by medical students and hospital residency programs prior to the institution of the Match. Some students would take the first offer that was proposed, whether they really wanted to go there or not, in fear of not receiving a residency position later on. Others would drop their commitment to a program when a better offer came around, leaving programs in a lurch. The Match has done a pretty good job of bringing order to this chaos.

The history of the Match started with algorithms developed using game theory. That's right, the future doctors of America have their whole professional lives dependent on how games are played. Developed by American mathematicians Lloyd Shapley and David Gale, the algorithms were first used to describe how to match up men and women for marriage. Since then, the program has been able to successfully match nearly 95% of medical students with a residency spot, with nearly 80% able to get one of their top three choices.

Now ideally every single student would be able to receive the residency of his or her choice. But of course it doesn't happen that way. Some residencies are much more competitive than others, resulting in a low match number for students. Meanwhile the less popular specialties go begging for applicants. They have no choice but to accept nearly everybody who shows even a hint of interest in going there. Therefore students who wanted to go into the undesirable programs were almost guaranteed to get in. The National Residency Matching Program has produced a tidy little graph detailing how competitive each specialty has in attracting medical students.

Last year, the NRMP showed that Plastic Surgery and ENT were some of the hardest fields to enter. Only about three-fourths of 4th year US medical students successfully matched into those programs. The numbers were even more abysmal for other students, like foreign medical graduates. They were able to get into those spots less than half the time.

By contrast, the least competitive programs had match rates of nearly 100%. For 2014, the surprising wallflower was Diagnostic Radiology. It was nearly impossible for future radiologists to not get into a radiology training program last year. Even FMG's had almost a 75% likelihood of matching into radiology.

While predictably Pathology and Internal Medicine were shunned by many medical students, look who rounded out the top five in the most unwanted residencies--Anesthesiology. It was actually easier to match into anesthesia than, horrors!, Family Medicine. This was especially true for FMG's, who had about a 75% chance of getting into anesthesia compared to 50% for Family Medicine.

Of course this shouldn't come as a surprise to anybody who's been paying attention. Demand for anesthesiologists have been falling for some time now. The number of practicing anesthesiologists have increased at twice the rate of the general population growth for the last decade. Meanwhile the anesthesia residency program directors keep cranking out more new graduates every year. According to the NRMP, the number of PGY-1 spots in Anesthesiology has increased from 797 in 2010 to 1,049 last year.

The writing may be on the wall for the future of anesthesiologists. It is rapidly becoming a saturated medical specialty with too many providers scrambling for too few good jobs. Factor in the competition from non physicians, the anesthesia job market is on the verge of crashing under its own weight. Good luck to all the medical students on Match Day who want to go into Anesthesiology.