Sunday, December 25, 2016

Flaunting It

Somebody must have been very good this year. Or at least had a very good year. I saw this insane vehicle parked in the doctor's parking lot. It is a Lamborghini Aventador. It comes with a V12 engine with 700 HP and goes 0-60 mph in 2.9 seconds. And it has a base price of $400,000. Who drives this as a daily commuter car? I guess if you've got it, might as well flaunt it. Here's hoping I will get on Santa's nice list next year too.

Friday, December 23, 2016

Easy Way To Treat Gonorrhea

You know the uproar over those drug trials that involved $100,000 medications to treat an illness? Makes you wonder if medical scientists cared about the economic plight of the man on the street. Once in awhile, however, researchers will actually conduct a study that is truly useful for the average Joe and can significantly improve his daily life.

For instance, a study out of Australia has demonstrated the efficacy of using an over the counter mouthwash to treat oral gonorrhea. The researchers took oral swabs of gonorrhea positive men and had them rinse and gargle Listerine Cool Mint or saline for one minutes. Afterwards, 84% of the men in the placebo group remained positive for gonorrhea while only 52% of the group who used Listerine were positive.

This goes to show that academicians really do care about the little guy. Now we want to know if dipping any other body part into mouthwash will have the same effect. This could potentially be a cost effective way to treat millions of people without causing drug resistance. Or maybe people should wear condoms and stop hooking up with strangers so much.

Wednesday, December 21, 2016

Men Should Not Go Into Medicine

Men, you should not be doctors. If you're a male medical student, start thinking about changing course and go work for SnapChat instead. If you're already a practicing male physician, consider early retirement and start taking Bob Ross art classes. Your patients will thank you. Your hospital administrator will thank you. Your country will thank you. That is because a new paper published in JAMA Internal Medicine has shown that female physicians demonstrate statistically better outcomes than men.

The study out of the Harvard School of Public Health examined 1.5 million Medicare patients from 2011-2014. They found that the patients treated by female internists had lower mortality rates, 11.07% vs 11.49%. Their 30 day readmission rates were also lower, 15.02% vs 15.57%. If male internists had the same mortality rates for their patients as women, 32,000 lives would be saved in this country each year.

How to explain this discrepancy in outcomes? There are a few clues. The female doctors in the study, out of a total of 58,344 physicians examined, tended to be younger, 42.8 years old vs 47.8 years for men.They are more likely to have trained in osteopathic medicine and to have taken care of fewer patients.

But studies have also shown that male and female doctors conduct their practices differently. According to Dr. Ashish Jha, one of the coauthors of the study, "There is data out there that women practice evidence-based medicine, and they tend to stick more closely to clinical guidelines."

There you go. We men are like bulls in a china shop, running amok through the hospital corridors, cavalierly treating our patients based on nothing but a whim. Meanwhile our cerebral female colleagues follow the edicts from the ivory towers up high, following every new algorithm and wisdom they deign to pass down to us ignorant medical masses. The female doctors will even work for less money, earning on average $51,000 less per year than men. We male doctors should just do all our patients a favor and quit right now.

But of course we need to take these results with a large grain of salt. If male doctors truly produced worse outcomes for their patients, I would think that would have become readily apparent. Hospital administrators and state medical boards would long ago have disciplined doctors for not producing similar results, otherwise known as community standards, as their female colleagues.

The income disparity between male and female doctors is also a red herring. Like a widely quoted statistic where women make only 80¢ for every $1 that men make for similar work, there are multiple studies to disprove that. Otherwise industry would only hire women if they can truly do the exact same work with the same productivity for less money. Why bother hiring men?

Therefore this is just another shoddy medical study that is trying too hard to be politically correct to impress the liberal media and government organizations. What would be truly impressive would be a study that showed the productivity gains by hiring more male physicians over women. But that would probably never pass the scrutiny of the academic editors who control the medical journals.

Tuesday, December 20, 2016

Doctors For Trump

Let's get this straight. Not everybody who voted for Donald Trump for president is an uneducated disgruntled white male unemployed factory worker, as the liberal press would like to have you believe. Hundreds of thousands of doctors also voted for him. You can hardly call them uneducated.

For many physicians, their votes had nothing to do with Russian hacking of the Democratic National Committee or the FBI investigation of Hillary Clinton's careless handling of classified emails. No, the disastrous prospects of continuing Obamacare was probably one of their top priorities in sending Republicans into all federal branches of power.

We already know that President Obama lied when he promised that the PPACA would allow people to keep their insurance policies and doctors if they want it. His statements about Obamacare lowering healthcare costs have also proven to be false. The whole package was passed by hoodwinking Congress and the voting public. Now, insurance premiums have gone through the roof. My family's personal health insurance costs will increase almost 25% this year. If we switched to a cheaper plan we would lose our family doctor. Yet we consider ourselves lucky. Millions of people across the country will only have one insurance company to choose from thanks to the crippling costs mandated by the law.

Despite these drawbacks, I've been reading a lot of anger and frustration in medical forums like KevinMD about the potential demise of Obamacare as we know it. They predict doom and gloom for patients and medicine in general if Republicans dare repeal it.

Funny thing is, most of these prognostications were written by medical residents or faculty physicians in academic settings. These are hardly the unbiased views of what's really going on in the healthcare business. In fact, they are completely shielded from the real world of medicine.

They're not out there fighting for every penny from the insurance companies for proper reimbursements. These academics aren't dealing with losing long term patients because they are no longer part of the ever tighter insurance networks. As part of an academic institution, these big hospitals are usually included in almost all health plans. And if they did lose a few patients to insurance changes, how much did they really care?

How can medical residents be complaining about the demise of Obamacare when they haven't experienced how hard it is to make one honest nickel running a medical business? Have them come back in a few years when they've had the opportunity to implement all of Obama's expensive mandates like electronic medical records or alternative payment models.

So forgive me if I ignore all the whining and kvetching about an unfair Electoral College bypassing the will of the people. Millions of voters, thousands of doctors among them, voted for Donald Trump. Nobody said we had to vote against our own self interest in order to be good compassionate physicians. In fact, patients may find their doctors to be happier and more friendly once many of these Obama era rules are banished.

Monday, December 19, 2016

NAFTA For Doctors

Okay, this is one of the crazier ideas I've read in awhile. Dean Baker, co-director of the Center for Economic and Policy Research, laments in the LA Times that doctors make too much money. He bemoans that the North American Free Trade Agreement has decimated the ranks of blue collar and factory workers here in the U.S. because the treaty allowed corporations to use cheap labor outside the country to lower their costs. In a fit of inspiration, Mr. Baker asks why we can't do the same thing to doctors. Why can't we allow cheap foreign medical graduates to flood the American landscape to lower healthcare costs?

As the writer sees it, there are several good reasons to promote this plan. It's unfair to discriminate against perfectly well trained doctors from foreign countries to practice here. If it wasn't for the protectionist practices of our medical organizations, these fine young doctors would be here already taking care of the unmet needs of millions of patients. Why must the only way to practice medicine here is through an American residency program?

Then there is the awful amount of money physicians make in the U.S. We make twice as much money as other doctors in First World countries. The way to lower our incomes and promote income equality is to bring in competition. A two for one special. Anybody who argues otherwise is not a true believer of fair trade practices. These discriminatory policies cost the country $100 billion in higher labor costs. Imagine the savings if foreign doctors were allowed to see patients for a fraction of what American doctors charge.

He believes that the only downside to his plan is that this would cause a severe brain drain to other countries. All their smart doctors will clamor to our shores to set up shop, causing their native countries to lose healthcare access. His solution to this problem? Taxes of course. He would tax the incomes of these foreign doctors and return the money to their home countries so they can train even more doctors, who of course will want to come here to work too.

I don't even know where to begin to comment about this asinine idea. It hits all the liberal ideologies about taxes, income inequality, protectionism, and racial discrimination. All I can say to Mr. Baker is that there are plenty of doctors just south of the border that he can go see. Let him put his money where his mouth is and take his family's health needs to Tijuana or Ciudad Juarez. He will then be doing his part improving the healthcare system of this country by decreasing its burden by one family and improving the livelihoods of the Mexican doctors and nurses. Somehow, like most limousine liberals, I doubt he will follow his own prescription.

Sunday, December 18, 2016

Surgery Residents Are Abandoning Ship

A new study published in JAMA Surgery finds that almost 20% of general surgery residents quit their programs. The article reviewed 22 studies of general surgery residencies involving over 19,000 residents. They found that a quarter of female surgery residents leave versus about 15% of men. Of all the people who pull out, almost half of them leave after their intern year. Another 28% give up after their second year.

Where do these young doctors go after dropping out? Only a fifth of them choose a different general surgery program. The rest switched to a different specialty, the most popular being, surprise!, anesthesiology.

The most popular reason given for abandoning surgery residency is lifestyle issues. This was followed by the desire to go into a different specialty. Other excuses mentioned included financial hardship, poor performance or dismissal, and family needs.

The lead author of the study suggested that the solution is to expose medical students to an even longer surgery rotation. He thinks another six to eight weeks of surgery experience would help students realize if they are fit for general surgery. In a back handed slap at all the residents who leave for a more humane field, he stated that "Not everybody can be a commander or a Navy SEAL." Ouch.

Long time readers of this blog know that I too started my training in general surgery. Unlike most of the residents in this study though, I was too stubborn to quit after my first two years. I toiled on for four years before finally deciding that life is too short to live so unhappily. Now I think that was the best decision I ever made in my life. You don't appreciate how wonder anesthesiology is until you've been through the hell of general surgery and lived to tell about it.

Thursday, December 15, 2016

Anesthesia Is Bad For Developing Brains

One of the most common questions I get asked is about the effects of anesthesia on pregnancy and childhood development. Now the Food and Drug Administration has published some precautions they want the public to be aware of if they are getting anesthesia.

The FDA has issued a warning about repeated exposure to anesthetics in developing brains. Children under the age of 3 years and pregnant women in their third trimester should be more judicious in receiving anesthesia. According to animal models, a single anesthetic is unlikely to cause any problems but repeat surgeries, especially if they're over three hours long, can adversely affect brain growth. Warnings about these potential complications will now be required on the drug labels of general anesthetics and sedatives.

The AMA Is A Political Whore

Before the recent presidential election, most doctors suspected that the American Medical Association is nothing more than a political lobbyist group pretending to act on behalf of physicians. In reality, they care more about money and politics than the welfare of doctors who they claim they represent. That is why only about 15% of physicians in this country still belong to the AMA. Now after the election, our suspicions have been confirmed.

Back during President Obama's first term in office, the AMA gave a crucial endorsement of the PPACA, aka Obamacare. A letter written by AMA President, Dr. Jeremy Lazarus, to the Wall Street Journal stated, "While the law is not perfect, the AMA, the nation's largest physician organization, supported it because it makes necessary improvements to our health care system." This nod of support from an organization claiming to represent the doctors of the country gave the politicians an alibi to vote for legislation that they knew to be seriously flawed. Even up to last year, a study published in JAMA by authors affiliated with the federal government, praised the effectiveness of the health law.

Meanwhile, a survey of 20,000 physicians found a different reality. Almost half of the doctors described Obamacare as a failure. Only a quarter considered it a success. Fully two thirds of doctors in the survey did not accept health insurance that were offered on the Obamacare insurance exchange markets. This highlights the flaws of the system, namely people had more access to insurance, but less access to actual healthcare.

Since the election of Donald Trump, the AMA has displayed a sudden shameless change of heart about its endorsement of Obamacare. When Trump nominated Tom Price, a Congressman from Georgia and orthopedic surgeon by trade, for the position of the Secretary of Health and Human Services, the liberals were sent into fits of outrage. Why? Mr. Price has pretty much devoted his government career into devising ways to repeal Obamacare. The only reason he hasn't been more successful was because of Senate Democrats and President Obama. Now he and the Republicans are in a strong position to fulfill their vision.

So what does the AMA say when confronted by a person whose goal is to dismantle their major legislative accomplishment of the past decade? They heartily endorse Mr. Price for head of the HHS! What kind of logic is this? How can the AMA very publicly and loudly support a law that is despised by thousands of doctors yet quickly turn around and encourage the confirmation of the man who vows to destroy the same law?

The answer obviously is that the AMA has no moral or guiding principles other than political expediency and money grubbing. The AMA is like the prostitute who will sleep with the client with the most money. They don't care what acts they have to do to gain favor just as long as they are able to bring in more cash into the organization. If that means screwing their own membership, then so be it. Most doctors know that the AMA survives mainly as a legacy group with very little real support from the medical community. Nowadays doctors are more likely to be involved with their own state and national specialty societies than be in the AMA. But the AMA will continue to use its name recognition and historic relevance to push its own greedy survivalist agenda in Congress instead of acting on behalf of the doctors they falsely claim to represent. President-elect Trump just revealed that the American Medical Association is nothing but a government slut.

Wednesday, December 14, 2016

I Should Have Been A CRNA

Why didn't I go to nursing school and become a CRNA? After Medscape released its latest salary survey of advanced practice nurses, including CRNA's, that question should hang heavily over any student contemplating a medical career. The survey was completed by over 3,000 APRN's but only 290 were CRNA's so the sample size is very small. But the information that was revealed is still illuminating.

In 2015, CRNA's made an average salary of $176,000. That is up over three percent from last year. That is an income that would not be out of place for a primary care doctor. By contrast anesthesiologists' salaries, though at a much higher level, have remained static year over year, at around $360,000. But it's not just CRNA's that make good money. Other APRN's are also doing quite well. Nurse midwives and nurse practitioners both make over $100,000.

Besides the money, CRNA's also receive generous benefits. According to Medscape, 91% of APRN's receive paid time off. Three fourths get an education allowance and liability coverage. Many are reimbursed for society membership dues and paid family leave.

Going through nursing school and APRN training is much more affordable than medical school. The average medical school debt upon graduation is over $150,000. Some owe a lot more than that. In many parts of the country that is enough to buy a decent house. By contrast, nursing students are in debt for about $30,000 upon graduation. Consequently, only about a third of APRN's still have student loans outstanding.

Finally, what is the best reason to become a CRNA instead of an anesthesiologist? The total lack of accountability. Even though the AANA is fighting hard to allow their members to practice independently without the supervision of physicians, I suspect that many of them secretly prefer being directed by an MD. If any anesthesia complications arise, they can easily point their accusatory fingers at the anesthesiologist and say they are simply following orders from the physician. They are not held responsible far any adversities in care.

So to sum it all up, CRNA's make a very decent salary, with lower student loan debt, receive better benefits, and are not responsible for their actions. Sounds like a pretty decent living to me.

Tuesday, December 13, 2016

Safe Anesthesia At The VA Assured

Safety first. Safety always. The VA system has made its final ruling on the use of CRNA's in the operating room. They wisely sided with having physician anesthesiologists continue to lead the operating team in safely administering anesthetics to our nation's veterans. Thanks to over 200,000 comments submitted to the VA advocating for anesthesiologists in the OR, there will be no CRNA's practicing independently at the VA hospitals endangering our patriots with their inferior anesthesia training. By contrast only a little over 9,000 letters were sent recommending that nurses alone can take care of our veterans.

But the fight is not over yet. There is still a 30 day comment period after publication of this final ruling for people to express their satisfaction, or lack thereof, with this judgement. The AANA is desperately asking an all hands on deck offensive to use this last opportunity to voice their displeasure. They are hysterically calling this, "a slap in the face to veterans who will continue to endure dangerously long wait times for anesthesia." They are even singling out one individual for their lost cause, "the undersecretary of the VA--whose personal bias, politics, and favoritism may have undone years of work by the agency he oversees and subverted the best outcome for veterans." Bitter much? This guy should be promoted to the head of the Department of Veterans Administration by the Trump administration ASAP. He at least knows common sense and is not distracted by all the hype and falsehoods promoted by the AANA.

So thank you undersecretary of the VA and the VA department. This one act alone will help President-elect Trump fulfill his promise to our veterans that they will receive the best medical care that the country can offer. This is YUGE!

Friday, December 9, 2016

Medicine In A Time Of Hate

Pranay Sinha, a third year medicine resident at Yale, shared his experience with racial hatred post presidential election. He thought he would be lauded for going above and beyond the call of duty taking care of an older white patient. Instead he was shouted down and fired by the patient. This sets Dr. Sinha into all sorts of mental turmoil.

Was he being singled out because he is a foreign medical graduate? Was it racial intolerance, since he never saw the patient treat white doctors the same way? Is it acceptable for doctors to be angry at their patients? When patients are sick and vulnerable, are they responsible for their words and actions? Should he develop thicker skin or should doctors demand respect from their patients the way we show respect to them? Has the presidential election emboldened people to drop their facade of tolerance and revealed their true colors?

As physicians, it's hard to get angry at patients without coming off as uncaring and impatient. I've had patients swing at me with their fists, spat on, scratched at, verbally abused, or generally not following orders. Yet I attribute them to the patients' general circumstances. They're in an unfamiliar environment, practically naked, most likely hungry and cold, with needles stuck in them or getting stuck every single day. I try not to judge them based on their aggressions. But many days it requires the patience of Job to make it through the day. And frequently, when I see the patient again later on they have usually forgotten about any slights that have been thrown my way and we can resume a normal relationship. But it is a challenge every doctor has to master to have a successful career, no matter their color or ethnicity.

Wednesday, July 13, 2016

Cage Fight At The VA

There is a cage fight going on at the Veterans Affairs hospital near you. It involves the VA's recent proposal to allow advanced practice nurses (APRN's) to practice to the "full extent of their education, training, and certification without the clinical supervision of physicians, regardless of individual state regulations." The ASA is having none of this.

This is the number one battle right now for the ASA. It's importance to the society and specialty is bigger than Obamacare, bigger than MACRA. Though NP's could potentially supplant physicians in other specialties like internal medicine, anesthesiology is uniquely susceptible to being replaced by nurses in clinical practice.

Medscape has lined up the president of the ASA, Daniel J. Cole, M.D. and the president of the AANA, Juan Quintana, DNP, MHS, CRNA, to go mano a mano to breakdown this controversy. Reading the interviews tells me that the two sides will never come to terms with each other. It's war. It's a fight to the death. Both sides are talking past each other, reciting their respective journal statistics without acknowledging the merits of the other. This will not end until one combatant is down on the mat, bleeding profusely out of every orifice, barely conscious. Then victory will be declared until the next president of the U.S. is elected, fresh lobbyists are hired, and new members of Congress are bribed. Then the fight will be renewed once again.

While the entire article is worth reading, I could barely get past the terrible picture of Dr. Cole in the article. Here's a screenshot.

Why is the man purple? He looks like he got some terrible spray tan going on where they loaded the nozzles with blueberry juice instead of tanning pigment. Or maybe he just came back from a blueberry pie eating contest where the contestants aren't allowed to use their hands. Regardless this horrible picture is very distracting and unfortunately lowers the quality of Dr. Cole's arguments. Looks count.

By comparison, Mr. Quintana's skin tone is more appropriate in his picture.

Not to sound too paranoid, but I think there is some conspiracy going on in the graphic design studio at Medscape to make the anesthesiologists' side less credible. Step it up Medscape. There is no place in your supposedly nonpartisan news coverage for this kind of blatant favoritism.

Tuesday, July 12, 2016

The Hypocrisy Of Natural Childbirth

I love this editorial in the New York Times. Titled "Get the Epidural," the author Jessi Klein explores why some women think it is better and more natural for deliveries to be performed without the comfort of an epidural anesthetic.

Says Ms. Klein, "But how often do people really want women to be or do anything 'natural'? It seems to me the answer is almost never. In fact, almost everything natural about women is considered pretty horrific. Hairy legs and armpits? Please shave, you furry beast. Do you have hips and cellulite? Please go hide in the very back of your shoe closet and turn the lights off and stay there until someone tells you to come out. (No one will tell you to come out.) It's interesting that no one cares very much about women doing anything 'naturally' until it involves their being in excruciating pain. No one ever asks a man if he's having a 'natural root canal.' No one ever asks if a man is having a 'natural vasectomy.'"

There it is. Not only do women have to undergo unnecessary pain during labor for the questionable benefits of "natural" delivery, it is also a highly sexist attitude to condescend women who do choose to have an epidural. So get the epidural. You and your newborn baby will enjoy their birth day more.

Monday, July 11, 2016

Pokemon Go For Doctors

The worldwide craze of the new game app Pokemon Go has people wandering all over the streets looking for Pokemon characters. Some are getting into trouble by running into signs or even getting robbed. Wouldn't it be wonderful if we could harness that kind of intensity from medical students so they devote their energy into improving their medical skills? How about planting Pokemon characters into different body surfaces and orifices to motivate students to examine their patients more thoroughly? Here are a few suggestions.

Yes sir. With a treasure hunt like this for students to explore, they will all become expert clinicians in no time.

Monday, June 6, 2016

Finding The Anesthesiologist In The Bathroom

This is another sad story about how addiction ruins careers, reputations, and lives. Carlisle, PA anesthesiologist Gregory Theodore was found to have overdosed on Demerol while working at Carlisle Regional Medical Center.

His surgeon was trying to find him when wasn't answering his page. He went to the bathroom and could hear the beeper going off behind a stall door. When he managed to get the door open, he found the anesthesiologist unconscious on the seat with a syringe in his lap. When awakened, Dr. Theodore claimed he didn't feel well and had given himself some Zofran. However when he was sent down to the ER, he told the emergency physician that he had been taking Demerol for several years.

He is being charged by the Attorney General with administration of a controlled substance, acquiring a controlled substance, refusal to keep records of controlled substance, theft by unlawful taking, and possession of drugs with intent to manufacture or deliver. Dr. Theodore, your life is now totally f****d up. I hope you get the treatments you need, and a very good lawyer, to turn your life around. His formal arraignment is scheduled for July 21st.

As thousands of medical students graduate shortly and start their residencies, remember that no amount of stress is worth starting an addiction for. It may make you feel better for a very short period of time, but eventually it will completely devastate your life.

Sunday, June 5, 2016

The Purple Patch

When King of Pop Michael Jackson died from propofol abuse, the drug became forever known colloquially as the "Michael Jackson drug". Now the devastating news that Prince has died from an overdose of fentanyl may bring notoriety to that pharmaceutical. Will fentanyl forever be linked to the singer's death? Can we expect to hear people call a fentanyl patch the Purple Patch?

Or maybe a fentanyl lozange a Purple Pop?

It's probably making the marketing department of these drugs start singing "Let's Go Crazy."

Wednesday, June 1, 2016

The Stress Of Running Late

"Oh dear! Oh dear! I shall be too late!"
From Alice In Wonderland

The stress of driving through LA rush hour when you're running late. There is nothing you can do except crank up the radio to your favorite chill music and accept your fate.

Tuesday, May 24, 2016

California Wants Its Money Back From Radiologists

Imagine when you were a teenager and you mowed your lawn to earn your allowance every week. Then suddenly your parents announce that they think they've been paying you too much and will withhold a portion of your money until the overpayments have been returned. How would you feel? Would you continue to mow the lawn or go on strike? What if you can't go on strike and have to keep mowing that lawn with the reduced payments?

That is exactly the predicament facing California radiologists now. Back in 2010, California was facing an historic state budget deficit, mainly due to its own fiscal incompetence. To help balance the budget, the legislature enacted cuts to Medi-Cal payments to doctors, the state's Medicaid program. The law said that no radiology services could exceed 80% of Medicare's already measly reimbursements.

Unfortunately the Department of Health Care Services did not get around to implementing the new rule until July 20, 2015. Now the DHCS wants to claw back money from radiologists to right this oversight. It wants the radiologists to return the excess money they've been receiving since October 2012.

Normally when the government says they've overpaid you, they want the whole amount returned in one big lump payment. But since they feel for the little guy and understand that would probably bankrupt most of the radiologists in the state, the DHCS has decided that they would reimburse the doctors 20% less than what they should be receiving until the money has been returned whole to the state.

The irony is that now the state is swimming in a budget surplus. Every special interest group is hungrily eyeing that extra money for themselves. Yet they are taking back money from doctors for services fairly rendered years ago. And the radiologists have no say in this travesty. Goes to show that when you sleep with snakes, you're gonna get bit.

Saturday, May 21, 2016

Tank For The Memories

One of the really cool things about living in a major city like Los Angeles is that you can get experiences that are unavailable anywhere else. Today, the very last space shuttle external fuel tank is being moved from a barge in Marina Del Ray to its final resting place at the California Science Center. I took the opportunity to drive down to Inglewood to take a few pictures. Memories of past American space program glories almost brought tears to my eyes.

Once at the museum, it will be rejoined with one of four existing space shuttles in the country, the Endeavor. Eventually, the display will look like this for kids too young to know what the space shuttle looked like.

This will be the only place in the whole world where one can see the entire space shuttle launch configuration intact. Gosh it's good to live in LA.

Saturday, May 14, 2016

Cheating Your Way Into Anesthesia Residency

You would think that anybody who enters medical school would hold the highest ethical standards. Their integrity should be above reproach. After all, they are making life and death decisions about their patients every single day. Nobody wants a shady doctor with questionable credentials. But alas that is not always the case.

In the February issue of A&A Case Reports, researchers at West Virginia University Anesthesiology Residency Program evaluated the personal statements of all their residency applicants after the 2014 Match for signs of plagiarism. What they found was discouraging.

They used plagiarism scanner software to look through 472 applications to their program. These were split between 228 U.S. applicants and 244 international applicants. Five were eliminated for technical reasons. The plagiarism program pulled out 82 out of 467 personal statements for possible plagiarism. These were then reviewed by the three authors of the study. At least two of the three had to agree that the statement was plagiarized from another source.

After the human review, the authors concluded that nine American applicants (4%) had plagiarized their statements while 33 international applicants (14%) had some plagiarized material. Overall 9% of the personal statements had unoriginal passages. Two of the U.S. and 17 of the international applicants contained more than 10% plagiarized content. One student's personal statement had more than 58% plagiarized material. The most common source for plagiarizing passages were from, a collection site of personal statements.

Sadly, some people either don't care about honesty and personal integrity or they don't think they are smart enough to get into residency without cheating. You have to wonder how these people got through college and medical school in the first place. For international students, they may think their English is not good enough to get them into an American residency so they hope to sneak in by copying other people's material. But with the advent of scanning software, students will hopefully realize that a bland but honest personal statement is much more acceptable than a stellar one written by somebody else. Nobody should ever have to question the trustworthiness of their doctor.

Friday, May 13, 2016

When To Call For An Orthopedic Consult

Remember how we belittled orthopedic surgeons in the hilarious Orthopedics Vs. Anesthesia video? It was a perfect encapsulation of the stereotype about the big dumb orthopedic surgeon vs. the intellectual anesthesiologist. Now the orthopods have returned the favor. In a GomerBlog post, the "College of Orthopedic Surgery" sets out guidelines to hospitalists and emergency physicians about when it is appropriate to call for an orthopedic consultation.

It mentions with obvious glee that orthopedic surgeons are probably a lot smarter than the people who are calling for the consults. Since it is such a competitive match, they most likely have higher USMLE Step 1 scores than anybody else.

The list asks that somebody review the X-ray first before calling in a consult. Don't just order it and call the surgeon before looking at it. And try to remember the name of the bone that is broken. "Tibula" is not an actual bone. If the radiologist reads the film as "Unremarkable study" then don't call the orthopod. If the patient has a diabetic foot ulcer or foot celllulitis, call podiatry. That is not an orthopedic problem.

There are more funny guidelines in the post to help us clueless non-orthopods figure what is an orthopedic injury.

I'm Tired Of Reading About Physician Burnout

You drag it around like a ball and chain
You wallow in the guilt; you wallow in the pain
You wave it like a flag, you wear it like a crown
Got your mind in the gutter, bringin' everybody down
Complain about the present and blame it on the past
I'd like to find your inner child and kick its little ass.

Get over it
Get over it
All this bitchin' and moanin' and pitchin' a fit
Get over it, get over it.

"Get Over It" by The Eagles

Sometimes it feels like the phrase "physician burnout" is the most important medical topic among doctors. It seems to appear at least five times a day in KevinMD. Medscape has an annual survey just for this subject. The current issue of the ASA Monitor has an article devoted to anesthesiologist burnout. According to a Mayo Clinic study, anesthesiology is one of the unlucky seven medical fields with both a high burnout rate and low work/life balance. The other specialties with this dubious record include radiology, internal medicine, orthopedic surgery, family medicine, urology, and neurology. Though to anesthesia's credit, we are just barely on the burnout and work/life imbalance quadrant of the graph. Does that mean anesthesiologists are almost but not quite happy with their chosen lifestyle?

Personally I'm burned out from reading about physician burnout. As I mentioned years ago, doctors can whine and complain about how hard it is to practice medicine, but frankly nobody else gives a damn. Why should they? Even the lowest paid physician is doing better than most of the rest of the country. Unemployment among doctors is virtually nil. A medical degree still carries with it respect and admiration from most people. Doctors have the privilege and responsibility to query their patients' personal lives in ways that the CIA or the FBI can only dream about.

Yet physician misery seems to becoming more ubiquitous. I don't think it's a mere coincidence that this talk about job dissatisfaction has arisen shortly after the change in resident work hours. Whereas before one was supposed to lament about missing half the cases when they're on every other night call, now the residents expect to have nap times during the day and weekends off. Is it any wonder that when they finish their training and start working in the real world that they become overwhelmed? Suddenly having the day off post call is not automatically granted anymore. Patients don't care if you've been up all night. You're the responsible physician and they will call you to take care of them even if you only got two hours of rest the night before. The ability to learn from hardship has been removed by the benevolent but misguided government bureaucrats.

Now the poor dears don't know what to do but gripe about how difficult their professional careers turned out to be. As the Skeptical Scalpel points out, all this grumbling may be infecting others who before may not have given a second thought about workplace difficulties but now find it socially acceptable to cry like a child who doesn't get his way.

So you know what all you complainers? Your patients, your hospital staff, and your physician colleagues don't owe you a damn thing to make your life better. Just pack up your sad sack and take it back to your momma's house where somebody may actually care. If you don't find satisfaction with your hard earned career choice, then find solace outside of work such as your family, your church, your hobbies, your exercise routine. Take a vacation. Go on a sabbatical. Do some volunteer work in an underprivileged neighborhood to come face to face with what real hardship looks like. Don't bring me down to your level because you don't know how to deal with stress. Being a doctor has always been stressful. Nothing has changed but the embarrassing complaining.

Thursday, May 12, 2016

If Only They Had Listened To The Anesthesiologist

A settlement has been reached in the medical malpractice case involving the death of comedienne Joan Rivers. If you recall, Ms. Rivers died in 2014 while undergoing an endoscopy to evaluate her hoarse voice. The circumstances were pretty murky but somewhere along the line, Ms. Rivers' personal ENT doctor was allowed to evaluate her larynx during the procedure even though the surgeon had no privileges to operate at the Yorkville Endoscopy Center and there was no consent for it to be performed. Presumably during the laryngoscopy and possible cord biopsy, Ms. Rivers suffered laryngospasm, causing her to become hypoxic and go into cardiac arrest. Her heart was revived but she never regained consciousness. Life support was removed by her daughter one week later.

The terms of the settlement were not disclosed though supposedly the monetary compensation is quite substantial. However, more details about the events of that day have been released. Apparently, Dr. Renuka Bankulla, the anesthesiologist in the room, rightfully feared that she would face a malpractice suit after her patient's death so she wrote a lengthy five page note about what happened in the procedure. This proved to be invaluable for Ms. Rivers' lawyers during the case.

According to Dr. Bankulla, the doctors in the procedure room were so enamored of Ms. Rivers' celebrity status that they violated normal protocols of conduct, including taking pictures of the patient while she lay on the operating room table and allowing a surgeon to do a procedure who had no privileges at the facility.

The anesthesiologist documented that she told the surgeon the patient's vocal cords were swollen and they might close off. Dr. Lawrence Cohen, the gastroenterologist in the procedure, replied, "You're such a curious cat." and ignored her warning. He called his anesthesiologist "paranoid" and allowed the ENT surgeon, Dr. Gwen Korovin, to proceed with the laryngoscopy.

Sure enough, Ms. Rivers' cords snapped shut, closing off her airway. When Dr. Bankulla asked for help in performing an emergency cricothyrotomy, Dr. Korovin had already hustled herself out of the building, leaving the anesthesiologist and her colleagues by themselves to try to reestablish an airway. When they finally did, it was too late to save Ms. Rivers' life.

One has to wonder what might have been if Dr. Bankulla had been more forceful in her warning about Ms. Rivers' precarious airway status and stood up for her patient to prevent the laryngoscopy from proceeding. Was she intimidated by Drs. Cohen and Korovin? Was she in awe of Ms. Rivers and let her better judgement slip? We may never know.

The lesson here to all surgeons is that they need to listen to their anesthesiologist. If the anesthesiologist suspects trouble, it is time to back away from the procedure. Our only responsibility is the safety of the patient. Nothing else in the procedure room matters.

How To Be A Star On Your Anesthesia Rotation

Another academic year is almost done and the number of medical students rotating through their anesthesia rotations has slowed to a trickle. As we wind down towards graduation, this is a good time to reflect on the qualities of what I thought made certain students really shine during their brief visits to this side of the ether screen.

Many of our students weren't even going into anesthesiology. It was usually part of their surgery rotation and they wanted a little taste of what anesthesiology is all about. This year it seemed like most were either going into emergency medicine or internal medicine. One thing they all had in common though was that they thought an anesthesia rotation was an exercise in learning how to intubate. When asked what they hoped to get out of this rotation, that was probably the most frequently mentioned objective.

Let me just say right off the bat that intubation skills is probably one of the least important reasons to rotate through anesthesia. One doesn't go through four years of medical school and four more years of anesthesia residency to learn how to intubate. It is a simple mechanical motion that anesthesia residents pick up in their first month. It is like taking driver's ed and only wanting to learn how to start the car. Intubating a patient is just a simple process in the middle of all the analytical thinking that is required for a successful surgery.

Instead, students who are going to do an anesthesia rotation will do themselves a huge favor and study a critical care book. Anesthesiology is essentially critical care outside the ICU. While I am in general pretty lenient about students who don't know the answers to my pimp questions, I have colleagues who will absolutely shut down the student if they can't answer seemingly simple questions about patient care. They will leave the student just standing there alone as an observer and not bother doing any more teaching. I don't expect fourth year students to know anything about anesthesia. That is something I may teach them if we have time but I will absolutely hammer them if they don't know simple patient physiology and pharmacology.

For instance, I had one student, just weeks away from graduating from a top ranked medical school, who couldn't tell me the normal values for an arterial blood gas on room air. After I gave myself the biggest eye roll, I almost questioned my own teaching skills. Am I asking too much of fourth year medical students? Was this something I would have known when I was a student? Then after discussing with other attendings, I decided that the questions was not unreasonable. Students who are about to get their M.D. should know what normal blood gas values are since that stuff was taught in physiology class back in the second year. There is no reason to not remember it just because they have already taken their physiology tests and passed the class.

Likewise many students don't know what a normal A-a gradient is or, even harder for them, how to calculate it. The ability to draw for me the oxygen-hemoglobin dissociation curve also eludes quite a few of them. These are not anesthesia questions that I use to stump students. This is basic knowledge that I feel every doctor should have a firm grasp of when they start their residencies regardless of their field.

And please know critical care pharmacology. When I ask students what drugs they would give to treat intraoperative hypotension, it always amazes me that so many of them say either dopamine or dobutamine. However not many know the mechanism of action of those drugs or indications for using them. If I gently remind them about other drugs like phenylephrine or norepinephrine, again I get a blank stare when they're quizzed about how they work.

This is essential information that all doctors should possess, not just anesthesiologists. If they know the answers to these questions, then I might move on to more anesthesia specific questions like the mechanism of action of volatile agents or the molecular structure of succinylcholine and why it's a depolarizing instead of nondepolarizing muscle relaxant. But if they're list of IV antihypertensives starts and ends at metoprolol, then I know they did not come prepared to learn on their anesthesia rotation.

So for anybody who is going to do an anesthesia rotation, forget about how many patients you're going to intubate. That is one of the least important things you will learn. You will gain an understanding of how to take care of critically ill patients who are on the verge of dying every minute they are under the knife and how anesthesiologists are there to keep that outcome from happening. Get yourself a condensed pocketbook on critical care and get a headstart on your colleagues who didn't bother to do a little homework before starting the rotation. We may actually move past the simple student questions and actually start learning anesthesia at a more advanced level.

One last thing. Please, PLEASE, don't whip out your smartphone and start searching Up-To-Date or Wikipedia if I ask a question you don't know. That just annoys the heck out of me and again shows me the student is unprepared to become a doctor, much less an anesthesiologist.

Wednesday, May 11, 2016

Anesthesia Salaries Around The World

How much money do anesthesiologists make outside the United States? A site called Salary Voice has the answer. At least for English speaking countries. Just for reference, Medscape's Physician Compensation report for 2016 says that anesthesiologists in the U.S. earned about $360,000 in their latest survey. We ranked number seven among all physicians behind highly paid (overpaid?) fields like dermatology and gastroenterology.

According to Salary Voice, anesthesiologists in the U.K. can expect after one year of service to make £199,828 or about $289,000. After ten years, British anesthesiologists will probably make in excess of £234,265 or $338,000.

In Canada, anesthesiologists' salaries range from 95,094 CAD to 171,258 CAD or $74,000 to $133,000. Australian anesthesiologists earn between AUD$100,000 to AUD$197,527 or $74,000 to $145,000.

Seems like being an anesthesiologist in the U.K. is the way to go. Their salaries are similar to American anesthesiologists without having to deal with all the medical malpractice liabilities that pervasively overhangs everything we do. Plus you get to speak with the impeccably proper and respected British accent.

Monday, May 9, 2016

The Sexual Desirability Of Doctors

Tinder, the dating/hook up app, has put together the jobs that most often resulted in its users swiping right, or showing their interest in a person's profile. You might suppose that people in highly paid positions would generate the most interest. You would be wrong.

For men, the number one most attractive job to its users was airline pilots. This was followed by Founder/Entrepreneur, Firefighters, Doctors, and TV/Radio Personality. If you look at the list of interesting men, you'll see that there is more interest in men in uniform than highly paid professionals like doctors and lawyers. The old adage that women love men in uniform certainly applies to the Tinder universe.

What qualities in women do men want to get to know more about? Sorry lady doctors, but men just aren't that into you. Whether female physicians intimidate men with their higher income or superior intellect it's hard to say. But physicians don't even make the top 15 professions that male Tinder users want to date. Instead men are interested in women who make moderate incomes or show a modicum of physical fitness like personal trainers or models.

So if you thought becoming a doctor will help you attract a mate, you'd be wrong. Unless you are Patrick Dempsey or George Clooney, having an MD in your name won't help you as much as the ability to look good in a uniform.

Saturday, May 7, 2016

Obamacare Is Killing The CRNA Market

The CRNA jobs market is under attack and not from our anemic medical societies like the ASA or the AMA. No, the culprit is none other than the AANA endorsed Patient Protection and Affordable Care Act, otherwise known as Obamacare. Due to the system's intense pressure to reduce costs, hospitals are having to outsource more of their labor to reduce expenditures and save money. Who knew, apparently not even the AANA, that CRNA's could be outsourced like some third rate janitorial service.

Crain's Detroit Business chronicled the termination of 66 CRNA's at two hospitals in southeast Michigan. When the hospitals, owned by St. John Providence Health System, offered the nurses a new contract, it was soundly rejected by 66 of the 74 CRNA's. Those 66 lost their jobs on January 1.

CRNA's in the Detroit area earn a median salary of $168,000. It can range from $154,000 to $182,000. This high rate of compensation is affecting how hospitals view their CRNA staffing. Says Ricardo Borrego, M.D., president of Dearborn based Anesthesia Surgical Associates, "Hospitals that employ CRNA's now view them as an expense they can't control. They are outsourcing them so they don't have to deal with the revenue side to pay them."

Imagine that. An employee who makes well over six figures who is so inflexible they refuse to work more than forty hours per week, overtime, or weekends is a source of expense irritant for their employer. It's no wonder hospitals prefer to outsource their CRNA needs to third party employers, many of them run by anesthesiologists. They are freed from the staffing issues and expenses of employing clock watching nurses. No more payroll taxes, workers comp, paid vacation time, or health benefits to deal with. Just write one check to an anesthesia staffing company and, boom, CRNA's show up at the front door. What hospital CEO wouldn't prefer that?

By contrast, employing anesthesiologists on staff who take calls, work nights and weekends, and can handle any train wreck coming in the ER without supervision is looking like a better deal all the time. Yes superficially we cost more. But anesthesiologists are worth more. It's not just about the bottom line. Anesthesiologists will keep working until their case is finished, not demand that they be relieved at the end of their shift. Our expertise makes us full partners in patient care in the operating rooms, not just another employee taking orders from the surgeons. Hospitals are beginning to see this logic, and it's in no small part due to the cost cutting enforced by Obamacare.

Friday, May 6, 2016

Celebrating Nurses Week

It is good to be a nurse. As Nurses Week winds down, I want to show you how much our hospital LOVES our nurses. Compared to the pathetic tray of bagels the facility offered physicians for Doctor's Day, this is what the nurses got for lunch, just today.

Nothing like an all you can eat taco bar as a term of endearment. And this was only in one unit in the hospital. All the other units got similar lunch buffets. Oh yes, our hospital just adores our nurses. If you feed the ones you love, then we absolutely revere our RN's. This is what our nurses got yesterday.

We just love to keep our nurses fat and happy. Apparently it must be much harder to retain or acquire new nurses than it is to keep doctors placated. Besides these two examples, another day they received a full English breakfast buffet with all the cholesterol and salt the hospital cafeteria could possibly unload on our nursing staff. The nurses also received free tote bags and other swag with the hospital's logo on it just so they will remember who is treating them so royally.

Why become a doctor and get taken for granted when one can become an RN in half the time and one third the cost and actually get some appreciation at work?
Our sad Doctor's Day bagels.

Thursday, May 5, 2016

What BIS Monitor Is Really Good For

This is a brilliant idea from the Gomer Blog. You know those times when you just can't stay awake during a case? It's 2:00 in the afternoon and you're in a plastic surgery case that just won't seem to end. Well, instead of plastering the BIS monitor on your patient, how about pasting one on your own forehead. That way if you start falling asleep the circulating nurse will notice right away and wake you up. No more dumb excuses like you're just resting your eyes. I'm sure the BIS should have marketed this idea to hospital administrators and lawyers first. They would have sold a lot more of these devices.

Wednesday, May 4, 2016

How Does Anesthesia Work?

Anesthesia has been used for surgical procedures for well over a century now. Yet for a subject as important and ubiquitous as anesthesia, we have surprisingly very little knowledge about how it works.

Gizmodo has a nifty article that rounds up some of the theories about how we lose consciousness with anesthesia. It involves ideas as esoteric as microtubules in cellular cytoskeletons and our inability to accurately measure levels of consciousness. In fact we don't even know precisely what it means to be conscious or unconscious in a measurable fashion.

This will become more important in the future as our ability to develop artificial intelligence advances. Studies involving anesthesia could eventually pave the way forward for a future controlled by Skynet or Agent Smith. Isn't anesthesiology more exciting than mundane fields like cardiology or orthopedic surgery?

Tuesday, May 3, 2016

Free Healthcare But Not Free Water

The poor people of Detroit are getting their water turned off. This week, Detroit's Water and Sewage Department will begin shutting off water to 20,000 residents who have been delinquent on their water bills. Even though the average bill is only $75, thousands of people are months behind in their payments.

What I find ironic is that the government is allowed to turn off water to its citizens when they haven't paid for it. Water! Isn't that one of the most essential necessities of any living creature? Yet people who don't pay for it can have it removed by their own representative government. Meanwhile hospitals and doctors are forced to treat patients regardless of their ability to pay thanks to EMTALA. While hospitals around the country are declaring bankruptcy because of all their unreimbursed free healthcare, the government is free to turn off a service that is even more important than access to a doctor--the free flow of water.

How much would the healthcare industry improve if we had the same flexibility as our elected leaders? We would no longer have to watch patients Snapchatting on their smartphones in the waiting room while declaring themselves too destitute to pay for an emergency room visit. Improved financial results can lift healthcare for everybody. But by mandating that anybody should receive treatment regardless of ability to pay, then obviously only losers will pay for it.

The government should just declare that free access to water is an essential universal right and give it away for free. Then they will finally understand the economic strains that bedevil healthcare providers. But it's easier to force the pain onto somebody else than onto themselves.

Monday, May 2, 2016

Why Do Hospitals Change Anesthesia Groups?

From Enhance Healthcare Consulting
In a survey of hospital administrators conducted by Enhance Healthcare Consulting, 49% of all hospitals have sought to change their anesthesia providers over the last three years. Eventually one quarter of them did just that. To me that sounds like an astonishing large number of hospitals who are not satisfied with their anesthesia services.

What are the reasons hospitals want to change anesthesia groups? Forty percent wanted to change their subsidy level to the anesthesiologists. In other words they wanted cheaper anesthesia. Thirty-four percent said the anesthesia group was not providing adequate coverage. That is usually the case when an anesthesia group is unable or unwilling to provide services that the hospital and its staff requested. The survey also found that 26% of the respondents claim they are changing anesthesia providers because of problems with the anesthesia leadership. This is why political acumen is so important for any anesthesia group hoping to have a long term future with their hospital. If the group's chair does not get along with the hospital, then no matter how well the group performs, the door is already open for them to get kicked out.

So what happened after the hospitals hired new anesthesia groups? Surprisingly, the new hires didn't always provide any cost savings. Twenty-eight percent reported an increase in subsidies for anesthesia services while only 32% resulted in savings. This is probably the result of the hospital kicking out the old anesthesia group not to save money but because of inadequate services or poor relationships with the anesthesia leadership.

The takeaway message here? A shockingly large number of hospitals are always on the lookout to replace their anesthesia providers. This means many anesthesiologists only have a very tenuous hold on steady employment. Therefore it behooves anesthesiologists to play nice with the hospital staff and not act like some spoiled prima donnas when asked to pick up another case at the end of the day or cover a weekend call. The hospital administration is constantly on the lookout for reasons to change anesthesia groups if it will help their bottom line.

Friday, April 29, 2016

The Seven Deadliest Emergency Surgeries

This is rather surprising news. In a study published in JAMA Surgery, researchers from Brigham & Women's Hospital in Boston have concluded that just seven types of operations account for eighty percent of all complications and deaths from emergency surgeries.

The researchers collected data of 421,476 patients from 2008-2011 who underwent emergent operations. They found that the following procedures accounted for the vast majority of all morbidity and mortality from emergency surgeries: partial colectomy, small bowel resection, cholecystectomy, operative management of peptic ulcer disease, lysis of adhesions, appendectomy, and exploratory laparotomy.

To me it's interesting that other emergency cases like ruptured abdominal aortic aneurysm, ischemic leg, ectopic pregnancy, D+C, subdural hematoma, trauma, open fractures, and many others did not get on the list. I guess their numbers are much smaller than the GI cases and thus didn't make it into the top seven.

I can understand why partial colectomies and small bowel resections would be in the top seven. Seems like almost every night I'm on call there is some octogenarian patient who comes in with perforated diverticulitis or small bowel obstruction who needs a repair. The patient's systolic blood pressure is in the low 90's while the heart rate is in the 110's and the surgeon's yelling "Go, go, go!" Of course the complication rates would be high.

But who would have thought that appendectomies would contribute to the overall morbidity and mortality of emergency operations? They are considered so benign that they are used as training procedures for surgical interns. Lap choles are also fairly gentle operations that rarely get complicated. Though I suppose if one is going to do an emergency lap chole the gall bladder is probably pretty socked in making the operation more difficult. I guess since they are done so frequently, hundreds of thousands are performed every year, that it is inevitable they would make the list even if there are rarely any complications.

So next time you are called to do an emergency appendectomy at 3:30 in the morning, just remember that it is considered one of the top seven procedures with the most deaths and complications. Doesn't that make your loss of sleep feel more worthwhile?

ASA Internships Available

Want to work for the American Society of Anesthesiologists? The ASA is looking for summer interns who are willing to toil for them for the princely sum of $15 per hour. You can choose to intern either at their headquarters in Schaumburg, IL or in their more cosmopolitan political offices in Washington, D.C. Hurry before this lucrative offer expires in 3,2,1...

Tuesday, April 26, 2016

To Pee Or Not To Pee, That Is The Anesthesiologist's Question

How many times per day is it normal for somebody to urinate? Don't tell me that you've never thought about it. CNN reached out to Neil Grafstein, M.D., assistant professor of urology at Mount Sinai Hospital in New York for the answer. According to Dr. Grafstein, a person usually pees about four to seven times per day. (There are also some nice pictures of exotic loos around the world, including one at an 18,000 foot elevation in Nepal in the article.) But of course there are large individual variations.

We anesthesiologists have learned to hold in our bladders for extended periods of time. Some days, either because I'm doing a very long case or the schedule is so tightly packed I have no chance to run to the bathroom between cases, I may only go to the bathroom once or twice during a twelve hour day. Days like that pose a dilemma. Should I drink fluids to keep myself hydrated or refrain from drinking so I don't distend my bladder?

That is not as superficial as it sounds. I know many of my partners who developed kidney stones because throughout their careers they didn't drink enough fluids. Almost to a man, they all say it is the worst pain they've ever experienced in their lives. I certainly don't want to have to suffer through that kind of agony for the sake of my job. But bouncing around in the OR with my legs crossed because my bladder feels like it's about to burst isn't very pleasant either. In case you're wondering, this is what happens when you do your own cases and not supervising CRNA's. Full control of a case includes controlling your own urinary urges.

So on days where I know my opportunities for toilet relief will be limited, I try to minimize the liquids I consume. It's not that hard anyways since hospitals are getting stricter all the time about consuming foods in the operating rooms. Then at the end of the day, after I've relieved my minimal dark brown urine into the toilet, I grab an extra large Trenta sized Starbucks drink to rehydrate and encourage urination. Kidney function saved for one more day.

The Most Hypochondriac Patient In The World

I was reading an article in the New York Times about the latest research into peanut allergies. It states how doctors now encourage patients to expose themselves to small amounts of allergens to prevent severe allergic reactions. As I always do, I looked over at the comments section. I do this mainly for my own entertainment as some of the hysterics expressed in these anonymous remarks are frequently quite funny.

But this one really took the prize for blowing me away by its sheer paranoia. Written by commentator2357 from the Bay Area, they wrote that, "I have a kind of allergy cancer that is like a peanut sensitivity, and which causes continual anaphylaxis triggered by mild heat, cold, exercise, stress, scents, foods, and many other things."

My goodness. How does that person manage to survive 24 hours? They get anaphylaxis to heat and cold? They can stop breathing in the middle of zumba because of an anaphylactic reaction to exercise? While I'm sure they truly believe they are that sensitive to their environment, I question the doctor who enables this type of behavior and belief.

We've all seen patients who tell you about their bizarre "allergies" but are in fact just known side effects. I've lost track of the number of patients who told me they are allergic to epinephrine because it made them tachycardic. How many times have patients told you they're allergic to narcotics because it causes constipation and itching. Then somebody somewhere dutifully lists that in the patient's EMR under the allergy section where it will reside for all eternity.

None of these patients would hold such thoughts if their doctors at some point educated them on what is a real allergy and what is just a side effect or maybe even mere coincidence. That would save so many other doctors from doing an eye roll when they meet them in the hospital. Having such a large number of allergies in one patient also harms the patient as maybe the best treatment for them is not available because someone years ago said they were allergic to it without any real concept of what a true allergy is.

I feel sorry for commentator2357. The blame for her hypochondriasis really belongs to her doctor who encourages this type of conduct. Physicians who enable these problematic patients just makes the rest of our lives that much more miserable in an already challenging work environment.

Sunday, April 24, 2016

MOC Tyranny Coming To An End?

Has the American Board of Medical Specialties finally overplayed its hand? There may finally be some movement to remove the shackles of the Maintenance of Certification programs that have bedeviled physicians. On April 12th, Oklahoma became the first "Right to Care" state by banning the use of MOC as a prerequisite for a doctor to practice medicine in the state. According to SB1148, "Nothing in the Allopathic Medical and Surgical Licensure and Supervision Act shall be construed as to require a physician to secure a Maintenance of Certification (MOC) as a condition of licensure, reimbursement, employment, or admitting privileges at a hospital in this state."

So there you have it. Oklahoma has legislated that no doctors can be denied their right to pursue their profession just because they don't have a piece of paper saying they paid thousands of dollars to take exams that are barely relevant to their jobs. No insurance companies can deny reimbursements to physicians who have not put up the extortion money to their medical societies to take meaningless simulations and tests. No physician needs to live in fear of losing their medical license just because they refuse to bow down to the overlords at the ABMS and put up with their greedy nonsensical plans.

This train doesn't seem to be stopping. Kentucky's SB17 is also on board with abolishing the requirement to participate in MOC to work as a doctor. "The (medical) board shall not require any form of specialty medical board certification or any maintenance of certification to practice medicine in Kentucky." It further states that "The board's regular requirements, including continuing medical education, shall suffice to demonstrate professional competency." Boom. Kentucky's bill forbids their medical board from requiring MOC as a prerequisite for obtaining and keeping a medical license. Though I question their wording where it sounds like one doesn't even need a specialty certification, like a certification from the American Board of Anesthesiology to practice anesthesia in the state. Unless I'm misreading the statement, it would seem that any doctor can practice any form of medicine there without needing board certification.

Other states are also seeing the light. Missouri's legislature is currently debating a bill similar to Kentucky's. Michigan is working on a law the specifically prohibits hospitals from denying admitting privileges and insurance companies from refusing reimbursements to doctors who don't participate in MOC.

The ABMS and all their minions in the other specialty boards thought they could push doctors around when they first required ten year recertifications. But then their megalomania could not be stopped as they required an ever increasing number of expensive and pointless hurdles to cross for doctors to keep their jobs. The final straw was when they requested that previously lifelong certificate holders should participate in MOC or their certificates would be diminished in the eyes of the ABMS. We may finally be witnessing some sanity returning to the medical licensure and certification process. Keep pushing your state medical societies to advocate for similar laws in your state. This was passed with bipartisan support, actually unanimously, in Oklahoma. There is no reason it can't work in other state legislatures. Hope all states eventually follow Oklahoma's lead before my next recertification exam.

Saturday, April 23, 2016

It's Not What You Make But What You Keep

While it is important that one makes sufficient income, what is more pertinent is how much of it you keep. It doesn't make much difference if you make millions of dollars per year but wind up spending it all. Medscape already gave us an exhaustive survey of physician income for 2016. Now it answers the question about how much of that money doctors actually manage to save. Medscape defines net worth as total assets (bank accounts, home equity, investments) minus liabilities (mortgage, car loans, student loans, credit card balances).

Medscape's Net Worth 2016 report in general reveals good news for anesthesiologists. They already stated that anesthesiologists' salaries increased ever so slightly to $360,000 per year. Likewise, our net worth also gained. As compared to 2015, our average net worth went up from $2.68 million to $2.74 million. Granted that's a very small difference in this self reported survey but at least the numbers are heading in the right direction. In addition, almost all the different medical specialties reported an increase in their net worths so the anesthesiology numbers aren't an anomaly.

The older one gets, the higher their net worth reaches. While 55% of physicians over 70 years of age reported net worth of over $2 million, only 9% of those 40-44 years old are that wealthy. I'm proud to report that my net worth is above average for my age group though much of that is due to the overheated California housing market.

What are the major liabilities that physicians face? Not surprisingly, the primary residence mortgage is the greatest drag on net worth. This is followed by car loans, children's college tuition, medical school debt, and car lease payments.

Doctors in general are pretty frugal. Ten percent reported that they live within their means and have little debt. Another 60% said that they live well below their means and people would be surprised about how much money they have. Only 26% said they live beyond their means and have credit card balances. I don't think anybody in Los Angeles would be surprised by how much money doctors make as many here have no problems with conspicuous consumption.

So doctors, heal thyself. Stop complaining about cuts in reimbursements while you're still paying off your college and Porsche loans. Live within your means then you won't be beholden to insurance claims adjusters. You'll be surprised how much more you enjoy being a doctor when that happens.

Friday, April 22, 2016

Good Day At Work

What makes for the ending of a good day at work?

I had no complications in the OR and everybody was discharged healthy and happy.

I checked off every required box in the EMR to satisfy my PQRS requirements.

I can thank the heavens that I don't work with angry CRNA's with inferiority complexes.

For one more day I don't have to think about MICRA, MACRA, or MOCA.

I'm good at what I do and can make good money doing it.

As a physician I have good job security.

I work with a group of dedicated, caring professionals who look out for each other's well being to make every workday productive and pleasurable.

I have a loving wife who is going out tonight with the kids and said I can stay out with my buddies for drinks and dinner.

So tonight we're heading to the uber hip Koreatown neighborhood in Los Angeles for Korean BBQ, soju, and beer.

Grilled meats and alcohol. Yes it has been a very good day.

Monday, April 18, 2016

The Most Dangerous States To Be A Patient

Medical error is the third leading cause of death in the United States. Every year 400,000 people die due to a medical mistake. But not all states are equally to blame for this epidemic. Some states have a higher prevalence of errors leading to major complications or death than others. Bay Alarm Medical compiled a ten year list of medical malpractice cases from the National Practitioner Data Bank. These are the Top 10 states with the highest incidence of medical errors leading to death or major injury. The numbers are the cases of malpractice suits from death or major injury per 100,000 state residents.

1. Pennsylvania (64.26 cases/100,000 residents)
2. New Jersey (60.78)
3. Louisiana (55.85)
4. New York (55.32)
5. District of Columbia (48.86)
6. Kansas (42.94)
7. New Mexico (42.44)
8. Florida (41.36)
9. Massachusetts (39.46)
10. West Virginia (37.40)

These are the ten states with the highest incidence of medical malpractice for death or major injury. What about overall malpractice suits? Which states are patients most likely to encounter incompetent physicians leading to medical errors? Or you can phrase it in a different way and ask which states are doctors most likely to be sued?

1. New York (116.23 cases/100,000 residents)
2. New Jersey (94.95)
3. Pennsylvania (92.23)
4. District of Columbia (91.57)
5. Louisiana (89.09)
6. West Virginia (70.97)
7. Kansas (68.35)
8. Montana (66.30)
9. Rhode Island (65.55)
10. Michigan (55.04)

On the flip side, what are the Top 10 states where patients are least likely to file a medical malpractice claim?

1. Alabama (17.99 cases/100,000 residents)
2. Wisconsin (18.73)
3. Minnesota (19.57)
4. North Carolina (24.42)
5. Virginia (28.62)
6. Hawaii (28.62)
7. Arkansas (29.18)
8. Idaho (29.92)
9. Georgia (35.92)
10. Tennessee (36.10)

One final set of statistics. Out of 596,000 malpractice suits filed from 2004-2014, 45% were claims against nurse practitioners, 31% against physicians. The rest of the top five medical practitioners who got sued were dentists, physical therapists, and technicians/assistants.