Thursday, March 31, 2016

It's A Wonder More Anesthesiologists Aren't Drug Addicts

The New York Times last week wrote that fentanyl is now the go to drug for former heroin addicts. Fifty times more powerful than heroin, fentanyl works faster and is cheaper to acquire on the streets. Last year in New Hampshire, fentanyl was attributed to 158 deaths while heroin only 32. A drug dealer can easily obtain fentanyl from his wholesaler and make $35,000 per week.

As the epidemic of drug addictions continues to spread around the country, to me it is a testament to the willpower and resolve of anesthesiologists that not more of us aren't addicts. Let's face it, anesthesiologists alone are the only physicians who routinely draw up and administer medications to patients without the aid of another person. All other doctors write orders for drugs which must be retrieved from the pharmacy and given to the patient by another party. We anesthesiologists have nearly unfettered access to highly addictive substances like fentanyl, methadone, ketamine, and yes propofol. Nobody bats an eye when we order up a narcotic and charts its use with nary any oversight. Whether we actually gave it to the patient is knowable only to the anesthesiologist.

Even the use of the Pyxis machine to dispense drugs is dependent on the trustworthiness of the anesthesiologist. When I need to document the return of any unused narcotic to the machine, I need to have another person witness my half used syringe as the drug I claim to be returning, usually a nurse in the recovery room. However, it is only a syringe of clear liquid with a label on top. It could be a syringe of sterile water that I labeled as fentanyl or dilaudid and the nurse would never know. They are trusting me as the physician to tell the truth about the drugs I am wasting. If an anesthesiologist is truly a drug addict, it would be all too easy to save the actual leftover narcotic for themselves and waste the fake syringe.

So instead of mischaracterizing anesthesiologists as junkies who got a medical degree, one should admire our fortitude to resist the enormous temptations that accompany our job every day. Though an unfortunate number of us do succumb to an addiction, the vast majority handle these dangerous substances with expert care and professionalism. Sadly, too many Americans are not able to do the same.

Wednesday, March 30, 2016

Doctor's Day Vs. Nurses Week

Happy Doctor's Day everybody. Doctor's Day has been celebrated since 1933 as a day to acknowledge the contributions of physicians to the healthcare system. This morning, when we walked into the hospital, we were given red carnation boutonnieres to carry around as if we were getting ready to go to a wedding. The flowers weren't terribly practical though since we're not supposed to bring them into the OR's and some patients on the wards are not supposed to have flowers in their rooms. The hospital also provided a nice tray of high calorie carbs for breakfast, which was promptly snarfed up by everybody else since the doctors were too busy seeing patients to go to the lounge to eat.

These small gestures of are appreciation are nice, but they pale in comparison to what the hospital does for National Nurses Week. The hospital is so desperate to keep our nurses happy that the festivities last for an entire five days. One day there is free breakfast. Another day is free lunch. A rolling ice cream cart loaded with Dove ice cream bars circulates throughout the medical facility as nurses dash after it to get their free dessert. They hold a lunchtime gala where nurses can pick up free T-shirts, pens, notepads, and other tchotchkes emblazoned with the hospital's insignia just so that they know they are wanted and needed. Frankly, there is no comparison between the level of gratitude shown to nurses and the token actions given to doctors that come across as afterthoughts.

I can't really blame the hospital for this disparate treatment of physicians and nurses. The American Nurses Association is already touting National Nurses Week on its home page. And it's not even until May. Meanwhile on Doctor's Day, our trusted advocates over at the AMA doesn't mention it at all. Doing a search on their website today doesn't bring up any links pertaining to Doctor's Day. If our own national organization doesn't care about the one day celebrating the contributions of physicians, why should anybody else?

Tuesday, March 29, 2016

Single Payer Healthcare Is Almost At Hand

Take a good look at the above chart. It's a breakdown of the different entities who purchase insurance in the United States. It clearly shows that privately purchased insurance now covers just a small portion of the country's population. Health insurance received from private employers are available to about 117 million Americans, or only 36% of the total population. Nearly everybody else in the country receives their insurance from the government.

The federal government is responsible for everybody who gets their insurance through Tricare (military health insurance), Medicare, Medicaid, or Obamacare. The private individual market for health insurance has pretty much disappeared thanks to the Affordable Care Act. The ACA has been responsible for slowly pushing people off their previous insurance plans and into the arms of the feds. This is contrary to what President Obama promised during the debate over passage of the ACA and what I personally had to endure.

Because of the massive presence of the government in the health insurance business already, some people think that a Bernie Sanders proposal for a single payer Medicare for all system may not be that far fetched. According to a study from the City University of New York School of Public Health, the American government in all its entities currently paid around 64.3% of all healthcare spending. That number is set to rise to 67.1% by 2024. The American system will then be very similar to the Canadian single payer program where their government paid for 71% of all healthcare expenditures.

By doing away with the taxpayer funded subsidies granted to private companies for providing health insurance to their employees, hundreds of billions of dollars could be returned to the government to provide insurance for universal coverage. At this point, the Bernie dreamers will realize their vision at last.

So whether you like it or not, universal health coverage is almost at hand. The ACA has effectively squeezed the private insurance market to the point where it is not economically feasible for more and more individuals and companies. Government run health insurance will very shortly be the law of the land without Congressional debates about its merits. Physicians better stop moaning about the low reimbursements provided by the government programs and learn to live within their means.

Friday, March 25, 2016

Futility Of Eliminating Human Errors In Medicine

Is it possible to eliminate human error in medical care? Is it a sign of mental illness to even think it can be done with absolutely 100% certainty? News out of New Haven, CT demonstrates another horrific error in patient mismanagement. At the Yale New Haven Hospital, a patient had the wrong rib removed from her body. She had a precancerous lesion in her 8th rib but the surgeon resected the 7th rib instead. This despite the fact that the proper rib was previously identified with coils and dye. One has to wonder why mistakes like this still happen when there is a room full of medical professionals who perform a time out prior to incision to make sure the correct patient and procedure is being done, radiographic images available at the touch of a button to correctly identify the side and location of the lesion, and the specimen that was removed with no evidence of the markings that were supposedly in place.

Yet hospital and government administrators continue to add ever more rules to healthcare to try to reach a utopian level of patient safety. Our blood bank requires two blood samples from a patient for a simple type and cross. These samples have to be drawn at least ten minutes apart which means the patient has to be stuck with a needle twice. Years ago only one specimen was necessary. I'm sure somebody received the wrong blood type which resulted in this decree.

Another example of this quixotic pursuit of healthcare perfection is in our heparin dispensation. A few years ago at a local LA hospital, a Hollywood celebrity's twin babies received a massive overdose of heparin. Consequently new rules were established for nurses who dispense heparin to their patients at our facility. It now requires two nurses to read the heparin label before one of them can draw it up and give it to the patient. Obviously having only one nurse carefully read a drug's label before giving it to the patient is not good enough to prevent medication errors.

The latest order to come from the C-Suite regards attempts to eradicate wrong sided surgeries. Previously a surgeon could just make a mark on the patient's correct side. Any mark will do, like an "X". Then the bosses decided that wasn't good enough and the surgeons had to write "Yes". That still wasn't adequate so the surgeons were told they had to initial their mark, because I guess they didn't want just anyone to write "Yes" on the patient. Apparently that still wasn't good enough to defeat wrong sided operations. The latest order is that besides all the previous rules for marking a patient, the surgeon has to write "No" on the side that isn't being operated on. What?

To me that was the most absurd plan yet. Is there any proof that any of these actions have lessened, much less eliminated, wrong sided procedures? Yes medical errors cause a huge amount of unnecessary suffering. But try as the administrators might, they need to realize that humans make errors. We have human patients being ministered by human care givers covering thousands of cases per year. No matter how many rules are devised to prevent mistakes, it will still happen. Before long, your loved ones coming out of an operation will be covered in more ink than you'll see at a Hell's Angels national meeting. Adding more decrees to the already extensive preoperative preparation is unlikely to significantly make a dent in the number of errors that are made. But at least the hospital can say they are doing everything imaginable they can to eliminate it.

Thursday, March 24, 2016

IV Line Infection Is Anesthesia's Fault Too

A new study in Anesthesiology has shown that anesthesiologists may be a significant source for IV line infection in the surgical patient. The paper's authors evaluated 303 cases that were performed by 25 anesthesiologists in New Zealand. They attached a microfilter into the IV line leading to the patient. At the end of each case, the authors collected the filters and all the syringes that were used during the case. What they found was sobering.

The authors were able to culture bacteria from over 6% of the IV filters they received. The cultures grew different Staph and Corynebacterium species, among others. They were also able to grow bacteria from the residual drugs in 2.4% of the used syringes from the operating room.The bacteria were similar to the ones inside the IV filters.

Though these percentages may seem small, remember that IV line infections in patients is supposed to be one of those never events in a hospital. So even a 2% incidence of bacteria inside the IV is a big problem. It is particularly alarming since the anesthesiologists involved in the study were aware that their aseptic techniques were being scrutinized and bacteria were still isolated from the syringe samples. However, the study concedes that it is not able to correlate the clinical relevancy of these bacterial cultures to actual patient infections.

The journal's editorial suggests that one way to reduce this contamination is to have prefilled syringes of the drugs anesthesiologists are most likely to use. This eliminates the handling of half empty vials of drugs that may have been sitting inside dirty anesthesia cart drawers. Though we despise the practice, the meticulous wiping of the rubber stoppers on top of drug bottles and IV ports for at least 15 seconds according to CMS guidelines may also decrease the likelihood of bacterial transmission.

As part of anesthesia's goals of patient safety first, these small actions on our parts may be a relatively easy and effective way to lessen the number of hospital acquired infections.

Wednesday, March 23, 2016

I Chose The Wrong Specialty. Now What?

Though Match Day happened less than a week ago, it's never too early to consider the unthinkable, that perhaps one matched into the wrong field. It happens more often than you think. According to the AAMC, up to 30% of residents don't finish in the same specialty they started in. Long time readers of mine will recall all the drama I went through when I made the move from General Surgery to Anesthesiology.

Now an article in Medscape by resident physician Rosalyn Plotzker, MD gives advice for residents who feel they have hit a dead end in their residency and that it's time to move on. She accurately describes the initial feeling of doubt about one's career choice and how it slowly ripples and mutates into an all consuming conviction that one cannot imagine practicing in it for the rest of their lives. She then gives good suggestions on how to decide if one is just hoping the grass is greener over in the other department or whether one is just going through a bad day at work and where to go from there.

Good reading.

Anesthesiologists Not Working As Hard As They Think They Are

I thought I was working hard. Between coming to the hospital in the predawn hours to get cases started to going home well past dusk as the LA traffic is already thinning, I barely have time to grab a few bites for lunch and take a pee break. I'm not even counting my call days where this treadmill runs 24 hours straight. But apparently I'm not actually working that much.

According to a new study presented at the 2016 ASA Practice Management Meeting, anesthesiologists like to gripe and moan about how hard they're working. However when their work hours are objectively measured, they are actually not as productive as they thought. At the University of Pittsburgh Physicians anesthesia group, 39 anesthesiologists self rated the number of hours they thought they worked. This was then compared to their billing data and a 10 hour work shift 5 days per week over two calendar quarters.

The discrepancy between reality and perception was embarrassingly large. The anesthesiologists perceived that they worked an average of 12.9 hours per shift. In fact, they averaged only 7.5 hours. This worked out to a difference of over 5,000 hours, enough to cover five full time anesthesiologists. Some of the reasons for this may be due to memory bias or something called the Von Restorff effect. That's when people remember the longest or worst shift experience and extrapolates that to all shifts. Based on the results of this study, the author says his group has already made changes to how their organization manages their doctors.

I'd sure hate to be an anesthesiologist working in that group. It sounds like they are going to whip those anesthesiologists at the University of Pittsburgh even harder to get the productivity numbers the bean counters want. In my opinion, anesthesiologists have very little control of the number of hours they work. Unless they are employed by the medical facility, they are at the mercy of the OR schedule which is outside their control. I've had days where I've had to sit for three hours between cases, not being able to bill one dime, because no surgeons wanted to book a case between 9:00 AM and 12:00 PM. Should that lack of productivity be held against me? I've also had times where I've busted my ass off for hours taking care of highly intense cases like a multiple gunshot wound or ruptured AAA and I didn't want to pick up another case after that and elected to go home. Does that make me a slacker and undesirable physician?

The ASA should know better than to publicize a study like this. As an advocate for anesthesiologists, they should be more sympathetic to the plight of their members instead of airing reports that is fodder for all the hospital administrators and insurance payors.

Tuesday, March 22, 2016

Anesthesia Dreams

From the current issue of Anesthesiology, a poem titled "V.I.P. Patient" by Todd Lasher, MD.
Membership required. If you don't have one, you can go to a medical library to look up a copy. If you can't find one, here are the last four stanzas that you can't read for free on the website:

Recheck my syringes
Recheck my I.V.

Patient still moving
People screaming at me

Awake and still thrashing
Whatever I do

Bolt upright as always
I'm awake too

I've had dreams like this too.

A Hard Day's Night

There are all sorts of worker protection now in place for medical residents. Residency program directors have to abide by very stringent work hour rules and allowable number of calls. That's great progress for resident well being but what happens when these coddled physicians finish training and go out into the real world?

As somebody in private practice, I work hours that would make most residents blanch in disbelief. Multiple calls in one week? Check. Multiple 16 hour work days back to back? Check. Five hours of sleep per night for a week at a time? You betcha.

In Anesthesiology News, there is a study on how sleep deprivation can affect an anesthesiologist's temperament. Not surprisingly, it isn't very pleasant. Twenty-one pediatric anesthesiologists at the Nationwide Children's Hospital in Columbus, OH participated in the survey. They were asked to rate their moods on several criteria at 7:00 AM on a non call day and again at 7:00 AM after a 17 hour call shift. As you can imagine, being post call SUCKS.

When post call, the anesthesiologists were more likely to experience significantly more anger and fatigue and have much less vigor. They also showed increased tension, depression, and confusion though not to a statistically significant extent. These changes did not seem related to age as all age groups were affected.

Now this is based on the perceptions after a 17 hours call shift. Most of us do 24 hour call shift as private attendings. Our anesthesia group tries to give us the day off after a call. Sometimes though that is just not possible due to staff shortages so like good soldiers we trudge on for another 8-10 hour day shift. That is when I usually get into trouble with the hospital staff as I get quite snippy and impatient with people. It doesn't even matter if it was a busy call night or not. The same feeling of fatigue happens either way because a good night's sleep just isn't possible when one expects to get called for a case at any minute. Then that's when I get hauled to the Chairman's office for a little one on one intervention. After some dressing down, I'm sent back out into the trenches, ready to take on my next 24 hour shift.

Friday, March 18, 2016

Is Anesthesiology At The End Of The ROAD?

For nearly two decades, anesthesiology was considered one of the elite fields that medical students aspire to. Along with the other ROAD specialties (radiology, ophthalmology, and dermatology), anesthesiology was associated with intellectual stimulation, good income, and a humane lifestyle. But the specialty may be peaking, or even already peaked and heading back down to the ignominy of the 1990's.

Click to enlarge
Match Day 2016 results were released today to thousands of innocent and hopeful medical students this morning. For nearly everybody, there was news worth cheering. However the results for the anesthesiology match was less than sensational. Sure the anesthesia residency programs can tout that over 95% of their spots were filled this year. But as the NRMP chart shows,  that leaves the highest number of vacancies unfilled in the past five years.

Worse, the number of PGY1 positions being offered are increasing even though the number of U.S. seniors applying to anesthesiology has not, staying roughly in the mid 700's. This year, there were 1,127 PGY1 spots offered. Back in 2012, there were only 919, a 22.6% increase. Consequently the percentage of positions being filled by U.S. seniors has dropped to only 68.7%. This compares to a fill rate by U.S. educated seniors of 78.9% in 2012.

How bad is 68%? That's a number that feels more at home with the primary care fields which offer thousands more residency jobs than anesthesiology. Pediatrics has 2,689 positions and 68% filled by U.S. seniors. Internal Medicine has 7,024 jobs and 46.9% acceptances. Family Medicine has 3,238 and 45.3%. Meanwhile more desirable fields like Emergency Medicine managed to fill 78.4% of their spots with U.S. seniors. Orthopedic Surgery, 90.7%. Even General Surgery (categorical), supposedly a field nobody wants to enter because of the terrible lifestyle, filled 76.4% of their positions.

What about the other ROAD specialties? As usual, Dermatology was able to offer 100% of their jobs to U.S. seniors. Ophthalmology, though not in the official NRMP match, usually matches around 90%. Unfortunately for Radiology, it is also suffering the same kind of loss of prestige, with 61.6% of its PGY1 jobs going to U.S. students.

Is there any hope for anesthesiology? First we have to stop increasing the number of residency positions offered. We want the best and brightest medical students to go into the field, not try to fill residency positions out of a sense of desperation. Besides, many people already feel the anesthesia market is saturated and all the graduates have to do an extra year of fellowship just to find a job. Next, the ASA needs to find a future direction for the field besides the Perioperative Surgical Home. Yes the leadership feels that is the most compelling vision for the specialty. But frankly I didn't sign up for this gig to become an internist and compete with the hospitalists for a job. Finally, we need to make anesthesiology exciting again. This field has made some of the greatest contributions to the advancement of medicine. Why does anesthesiology feel like it's stuck in a rut? Why aren't there any smart companies developing exciting new technology to improve patient safety and monitoring? Why is the most talked about anesthesia tech in the past five years related to how to remove anesthesiologists from the procedure room? Why does the anesthesiology match every year feel more and more like a sinking ship and nobody wants to be stuck as the last one out?

How To Piss Off An Emergency Medicine Resident

I love this post from the GomerBlog. Many of them apply to anesthesia residents too.

Thursday, March 17, 2016

The Fallacy of Opting Out of Physician Led Anesthesia Care

One of the canards of the AANA's relentless pursuit of independent practice for CRNA's is that physician anesthesiologists just don't want to work in rural or low reimbursement settings. This limits the access of residents to crucial anesthesia services. If nurse anesthetists are allowed to work without physician supervision, according to their conceit, this would open up the wonderful world of anesthesia to all these disadvantaged people.

Now a new study has shown how much of a red herring this theory truly is. In a paper in Anesthesia and Analgesia, researchers from Stanford School of Medicine compared the rates of anesthesia use in Medicare patients from the 17 states who opted out of physician supervision to the other states who have not. They stratified the opt out states by the year they began the policy. The results should surprise nobody outside the AANA.

In the states that have opted out since 2001, anesthesia utilization increased 16% compared to 32% for non opt out states. For the states that have had no supervision since 2002, anesthesia use went up 18% compared to 26% for physician led anesthesia care. The trend is the same up to the most recent state that opted out in 2009, California. Only here was there a slight increase in anesthesia utilization for non supervised anesthesia use, 5% vs. 4%. The difference is so slight as to be almost meaningless.

As one can see, just because nurse anesthetists can practice independently doesn't mean more people will have access to anesthesia services. The issue is much more complicated than this one dimensional argument. But it is an easy way to fool legislatures and governors into thinking three year nursing school trained personnel are the equivalent of minimum eight year post graduate trained physician anesthesiologists.

By the way, the study was sponsored by the American Society of Anesthesiologists, if that makes any difference to you.

Wednesday, March 16, 2016

Bigger Is Better Even In Medicine

A study out of the University of California has demonstrated that people think more highly of men who are taller and more physically fit. When shown pictures of men and women who were very buff, volunteers invariably stated that the more fit men had better leadership qualities and were smarter too. This perception only applied towards men, however. Physically fit women did not get the same perception of leadership.

You would think that this is a pretty primal way of interpreting somebody's leadership quality. Well educated physicians with over two decades of formal education wouldn't fall into this primitive trap of following the biggest male like a pack of wolves. Well you would be wrong. Even though we usually impart leadership in medicine on the usual cerebral traits such as intellectual curiosity, productive research, and clinical acumen, size doesn't hurt either.

I'll always remember one story that has been told in our department for years. One of our taller colleagues had just finished inducing his patient for surgery and sat down to start his paperwork. In walks the surgeon. He was relatively new to the hospital but he had already gained a reputation for arrogance and obnoxiousness.

He then stands over the anesthesiologist complaining about something or another, making a complete jerk of himself. Having none of that nonsense, my colleague then slowly straightens his legs and stands up, all six foot eight inches. He towers over the surgeon and asks, "Do you have a problem?" The surgeons gets real quiet and doesn't say anything else. The rest of the case he is as polite as he could be to the anesthesiologist. Needless to say he never worked with that anesthesiologist again.

Maybe Dr. Lundy was right. We anesthesiologists should all hit the gym and wear muscle shirts since surgeons rarely respect our intellectual superiority and frequently judge us by their primal instinct of following the biggest leader.

Tuesday, March 15, 2016

Sedasys is DEAD!

In one of the greatest victories for patients and physician anesthesiologists so far this year, Johnson and Johnson has announced that it is no longer selling the Sedasys system for automated propofol sedation. The machine never lived up to the company's sales expectations. Its elimination is part of J&J's corporate restructuring that will cost company 3,000 jobs.

Anesthesia is not just about pushing drugs. Sedating patients is more than filling up a large syringe of medication and waiting for the procedurist to tell us when to put patients to sleep. Physician anesthesiologists have been at the forefront of patient safety for a century and no machine is going to be replace our vigilance in keeping patients safe during a procedure.

The physicians who were hoping to benefit the most from Sedasys, the gastroenterologists, should get down on their knees and thank the powers above that they will no longer have the machine to play around with. It was only just a matter of time before one of them got into serious airway trouble using a drug most of them are unfamiliar with. And physician anesthesiologists may not always be around to save their ass.

I have always been skeptical of the potential monetary savings from Sedasys. The risks a patient faces when being given a powerful anesthetic by an uncaring, unfeeling box of circuit boards does not justify the minuscule cost savings hoped for by its advocates. The GI doctors who were pushing for the approval of Sedasys the hardest from the FDA will now just have to go back and learn to play nice with the physician anesthesiologists who are making sure their patients survive their procedures in relative safety and comfort.

Monday, March 14, 2016

In Which States Do Anesthesiologists Make The Most Money?

It must be good to be an Ohioan. Not only do they get to decide the U.S. presidential election every four years, they also pay their anesthesiologists the most money. According to, the top five highest paying states for anesthesiologists are Ohio ($228,800), Connecticut ($227,380), Arizona ($226,020), Florida ($223,390), and Tennessee ($222,800). Anesthesiologists in Florida and Tennessee also have the benefit of paying no state income tax. The five lowest paying states are Oklahoma ($169,700), Mississippi ($161,010), South Dakota ($153,240), Nebraska ($151,810), and though not a state but counted in the survey, Puerto Rico ($110,470). These numbers are probably contract salaries medical facilities are offering the recruiting company so they are a little suspect. They are certainly lower than other anesthesiologist salary surveys.

The website also states that the top five states for anesthesiology job growth are in New Mexico, New York, Puerto Rico, Texas, and Florida. The worst states for anesthesia job recruiting were Hawaii, Oklahoma, Oregon, Maryland, and Ohio.

Again these are the numbers that a recruiting company is seeing in the job market. I'm sure a well connected anesthesiologist can find a much more lucrative offer in his/her local area so take these numbers with a grain of salt.

Sunday, March 13, 2016

Where Anesthesia Residents Go After Graduation

The American Society of Anesthesiologists conducts a survey of CA-3's every year about where they are headed after residency. As the academic year starts winding down, it might be helpful to look back to see what last year's graduating class had planned for their post-residency career.

The ASA sent a survey to all CA-3's it had on their email list. Out of 1,481 residents in its membership list, it had 1,391 email addresses on file. After they sent out the poll in May 2015, it received responses from only 192 residents or 14%. That is admittedly a very small sample but still the best data that is available.

Geographically, the respondents were pretty spread out, with about a third of them from the Northeast, a little less from the South, a fifth from the Midwest, and the rest from the West. About two-thirds of the responses were from men.

When the survey was sent out, 97% had confirmed job offers. More than 55% of the residents joined anesthesia groups with partnership tracks while 20% joined groups with no partnership track, 18% are becoming employees of health care organizations, and the rest joined anesthesia staffing companies. The mean starting salary was over $289,000 which was virtually unchanged from 2014. But if you want to make more money, then head West with a reported mean salary of almost $315,000.

How do residents decide where they want to work? The most common answer was Geography. This was followed by Schedule Flexibility, Job Description, Monetary Compensation, and Call Requirements. Considering all the major changes in the healthcare system right now, Stability of the Hospital System surprisingly ranked last.

Those seeking academic careers were more likely to have come from the Northeast, probably since there is a higher concentration of research oriented programs there. In general most CA-3's applied to 4-9 different practices with about twenty percent applying to more then ten. Over 80% received up to three job offers with the rest getting more acceptances.

Overall 44% said they were heading for fellowship training. The most popular fellowships, in descending order, are Pediatrics, Cardiothoracic, Critical Care, and Regional. When asked why they were doing fellowships, the most common answers were because they were interested in the field and wanted to learn more about it, and because they felt it would make them more desirable in the job market.

Some of the wise comments from the CA-3's last year that just went through the job market wringer:

  • "Fellowship not necessary in this market."
  • "Okay, but certainly not flourishing."
  • "Very difficult job market; practice models are mostly employment with very few partnership tracks available; management companies seem to be taking over."
  • "I took a lot less money to supervise fewer CRNA's."
  • "Tighter than most years but improving. National anesthesia companies providing much worse benefits and lifestyle than any other groups." 
  • "Get involved in your state society to network. Do your residency in a region you'd like to work. Don't be a complainer or a lazy resident. Work hard and be a team player."

That last advice, if followed, will probably give you greater job satisfaction and security than all the fellowship training in the world. Good luck to the class of 2016.

Friday, March 11, 2016

Anal Sex Questions Answered

Okay, so this has absolutely nothing to do with anesthesiology but it brought a smile to my face when I read it. The American Journal of Gastroenterology published a study on the practice of anal sex. And I bet you didn't realize anal intercourse needed a scientific inquiry.

So what's the lowdown on going to Brokeback Mountain? Well, out of over 4,000 people in this retrospective study (I guess you can't really do a prospective study on this subject), 37% of women and 5% of men have had their brown eye poked. White people are more likely to perform it than blacks. And if you have only a high school degree, you are more likely to ride along the Hershey highway than if you have a college degree or did not graduate high school.

And one last thing. In this case, smaller is definitely better. Unless you'd like to wear Depends after dancing the chocolate cha-cha. Have a nice weekend.

Tuesday, March 8, 2016

Sacrificing Physician Morale To Save Medicare Pennies

Here's another example of why doctors are always getting screwed when lawmakers without any skin in the game make up rules about healthcare. Medicare has decided that in order to save costs from all the expensive drugs that physicians prescribe, they are going to cut the reimbursement for administrating the medications.

Under Medicare Part B, doctors get a fee of 6% of the cost of the drug that they give to a patient in the office or other medical facility. So if a $100 drug is given to a patient, the physician will get a fee of six whole dollars from the government along with the $100 cost of the drug. If the drug costs $1,000, the doctor gets $60 plus the cost of the medication. Sounds pretty skimpy to me already when one considers that the $6 fee has to cover all the risks of administering that $100 drug.

With the new proposal, Medicare wants to increase reimbursements if the doctor prescribes a cheaper drug and cut the fee if a more expensive drug is used. Now the new rules state that doctors will only get 2.5% of the cost of the drug while earning an additional flat rate of $16.80. So now a doctor who administers a $100 drug will receive $19.30 while a $1,000 drug will only net $41.80.

Think about the numbers for a minute. The government saves $18.20 on a $1,000 drug, or 1.7% ((1060-1042)/1060). But for the physician, his reimbursement just got cut by 30% ((60-42)/60). In the meantime, the pharmaceutical company still gets to sell its drug at $1,000. Where is the outrage? Where were our so called advocates in the AMA when these plans were being devised? The drugs companies can continue making billions of dollars and their CEO's raking in hundreds of millions while physician livelihoods are getting chopped by double digits. While government employees are striking over inadequate pay raises, doctors quietly submit to working harder for less pay because we're afraid of tarnishing our image.

I predict that this latest experiment in healthcare authoritarianism will fail miserably. It doesn't make sense when one considers the usual capitalist market forces. If a doctor is getting less money for prescribing an expensive drug, is he likely to switch to a cheaper drug that will reimburse him even fewer dollars? No. A rational person would prescribe even more of the expensive medication to make up for lost income. Using the above as an example, even though the reimbursement for giving the cheaper drug has gone up, it still doesn't make up for the higher fee the doctor gets from giving the expensive drug. So now the doctor has every incentive to give more patients the expensive drug to compensate for lower reimbursements.

The real cost drivers of this scenario, the drug companies and the patients who insist on having expensive drugs so that they feel they are getting their money's worth, get off scot free. But no American lawmaker would dare vote for a British style government rationing system. And they can't resist all the money the pharmaceutical lobbyists throw at them. That leaves doctors out of the loop and holding the bag.

Sunday, March 6, 2016

Macho Macho Anesthesiologists

The latest issue of the ASA Monitor has a great picture of one of the pioneering giants of anesthesiology, John S. Lundy, MD. As you can see in the undated photo from an article in the Monitor, Dr. Lundy is demonstrating to a group of physicians how to intubate a patient. However I was most struck by what the doctors were wearing in the operating room. These guys were all donning scrubs that wouldn't look out of place at your local Gold's Gym.

What's with all the sleeveless tops? Though a couple of the guys in the picture have the guns to dress the part, most of them look like they need to go do some biceps curls for a few weeks before they expose their flabby arms to the world.

Maybe once again Dr. Lundy was ahead of his time. With all the controversies about long sleeve clothing causing patient contaminations, he was miles ahead of the rest of us in preventing bacterial contamination that plague medical facilities around the world today. Or perhaps he just liked showing off his bazookas.

One last thing, can anybody tell me what is that thing that is hanging off the IV bottle on Dr. Lundy's right side? Part of it overlies his right arm. It looks like it maybe some sort of syringe that is hooked up to the IV but I can't tell for sure.

Saturday, March 5, 2016

My First MOCA Minute

The American Board of Anesthesiology has been surprisingly progressive in their reforms of the anesthesia Maintenance of Certification (MOCA) process. Ahead of other medical specialties, the ABA has done away with the nonsensical Part 3 Simulation exam and the much feared and despised recertification exam at the end of each certification period.

Instead the ABA has instituted a new program called MOCA 2.0. Instead of a once a decade pass/fail exam that could potentially ruin one's career, the ABA started the MOCA Minute. It's an annual series of 120 computerized questions that one takes at home that after ten years is equivalent to the previous recertification test. It's essentially open book without all the intimidation and expense of the previous exam. Only thirty questions can be answered each quarter to prevent people from doing it all at the end of the year. After doing my first MOCA Minute, my verdict is that I like it.

It is very easy to register for MOCA 2.0. Basically they want your credit card information. Then each quarter the ABA will send you reminders to take the MOCA Minute. I received a couple of emails from them before I got around to taking the test. The questions are pretty easy. There is a gimmicky countdown clock that ticks down 60 seconds as soon as each question pops up. I don't know the purpose of this timer since just reading the questions and the multiple choices takes longer than one minute. There is no penalty for taking as long as necessary to answer a question. After you answer it, it will instantly tell you if you answered correctly and give a brief explanation of the answer. Again there is no penalty for answering wrong. It took about one hour to go through all thirty questions and explanations. It gets easier as you go along since several questions and topics repeat themselves. Thus the percent of correct answers go up the more questions that are taken.

This process is a much more relevant way for anesthesiologists to maintain their medical knowledge and certification. It does away with the intimidation and expense of the previous recertification. Is it perfect? I think there are a couple of areas that could be improved upon. First get rid of that 60 second timer. It is not relevant at all to the exam. I think it is only there because of the name MOCA Minute. The MOCA Minute ideally should count towards one's CME requirements. Right now I still need to purchase CME tests for the CME requirements for recertification and state medical licensure. If I'm already spending time reading and learning, why doesn't the MOCA Minute count towards my CME requirements? It isn't just about the money, is it? Finally please get ride of Part 4 of MOCA 2.0. It's purpose is nebulous and just adds more tedium to the already onerous recertification process.

Thank you ABA for listening and acting on the concerns of your members. Your proactive approach to the maelstrom that is angering physicians nationwide should be emulated by the other medical boards.

Thursday, March 3, 2016

The Perilous Journey From Anesthesia Resident To Attending.

It's almost that time of year again, when CA3's are ready to take wing and depart the comfortable confines of residency and start their professional careers. It is a period of great excitement and anxiety. This is when cocky senior residents suddenly realize they are finally on their own and have no attending backup for the inevitable screwup that will occur.

In the annual report of the California Society of Anesthesiologists, Dr. Adam Djurdjulov has a nice essay titled "Easing the Transition from Residency to Private Practice". He gives a few pearls about the action plan all CA3's should follow before they finish their residencies. Use all the resources that are still at your disposal before going out on your own. Even though oral boards still seem so far away, now is probably the best time to start practicing for the exam. And don't be the locker slammer of the anesthesiology department. It shows you have little respect for your departmental colleagues or your profession.

As I see the CA3's make their anesthetic plans for each patient and competently carry them out, I always admire their confidence and enthusiasm. But there is so much more to practicing anesthesiology than being able to regurgitate a book chapter in Miller. I hope they all use their remaining time in training to ask lots of questions and really explore the profession with their attendings.

Wednesday, March 2, 2016

How Wonderful Is The Anesthesia Lifestyle?

We often hear about how great the anesthesiology lifestyle is. After all, it is one of the ROAD specialties that are so highly coveted by medical students. But does reality match perception? How do anesthesiologists actually feel about their work/life balance? The 2016 Medscape Lifestyle survey provides some clues.

Medscape polled over 15,000 physicians on their feelings of burnout and bias for this survey. It doesn't say how many of those were anesthesiologists. If anesthesiologists truly had the fantastic lives that people imagine, you would think that we would all love to come to work every day, make our six figure incomes, and drive home in our German luxury cars to happy spouses and children in our mini mansions in the suburbs without a care in the world. But the survey says otherwise. Exactly 50% of those surveyed said they felt burnout at work. Burnout is defined as lack of enthusiasm for work, feelings of cynicism, and low sense of personal accomplishment. That sounds like a lot of people for a job that is supposedly heaven on earth. In fact, anesthesiologists are right in the middle of the pack amongst all physicians, with Critical Care, Urology, and Emergency Medicine having the highest rates of burnout and Endocrinology, Ophthalmology, and Psychiatry the least. I'm surprised that urologists feel that miserable since it's considered one of the more humane subspecialties of surgery.

Why do anesthesiologists have such a high rate of burnout? The top reasons given are: too many bureaucratic tasks, spending too many hours at work, feeling like a cog in a wheel, impact of Obamacare, increasing computerization at work, income not high enough, difficult colleagues to work with, difficult patients, and maintenance of certification requirements. This can be broken down to lack of autonomy at work, with surgeons and administrators telling us how to do our jobs all the time. We also have no control over the types of patients we see since we're not the ones who bring them into the hospital. We have no control over reimbursements. And we don't get paid enough for all this aggravation. So yes, anesthesiologists are simply just cogs in a wheel.

Only 32% of anesthesiologists polled said they were happy at work. That number sounds low but is actually more than the average physician. Dermatologists, ophthalmologists, and psychiatrists not surprisingly had the highest happiness ratings. Rheumatology, Critical Care, and Internal Medicine ranked the least happy at work.

There's a lot more information in the Medscape survey that you should check out, including which gender is happier at work and the surprisingly high number of physicians who use marijuana.