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...

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.

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.

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.

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.

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.

Children's Books And Childhood Obesity

Childhood obesity is a huge problem in this country and increasingly around the world. The number of children who are considered obese has doubled in the last 30 years and quadrupled for adolescents. Eighteen percent of preteens in 2012 are obese. Over one fifth of adolescents in this country are obese. Globally, the number of children under 5 years old who are obese is a staggering 42 million. In a good news is bad news way, there are now more obese people in the world than people who are starving.

First Lady Michelle Obama's mission in the White House has been to educate people on the dangers of childhood obesity. She has been active in teaching children and their parents how to eat properly and exercise to maintain good health. However, even though she has been very proactive in this area, she is fighting a losing battle as the rate of obesity keeps climbing. Though the cause of childhood obesity is multifactorial, there is possibly one that has been promulgated as being healthy when in fact it may teach children the wrong lessons.

I have three children. Between them I've read hundreds of children's books. While reading to kids is good for them, the messages the books popularize is not always the healthiest. Any parent knows what I'm talking about. Kids' books almost always convey rewards with eating sweets and other unhealthy foods.

In children's stories, when the characters come back from school, what do they do? They head to the kitchen to grab some cookies and milk. When they win a baseball game? They go celebrate with pizza and ice cream. What do children do when they go visit grandma's house? They learn to bake cakes and pies. How do children interact in each other's homes? They share a milkshake and laugh over a plate of cookies. Even the kids in the Harry Potter stories get excited when they can leave Hogwarts to go on their field trips into town so they can visit the local candy shop.

You never read about children chatting while eating a bowl of grapes. They don't share each other's secrets while munching on celery sticks. Healthy eating just isn't a part of children's literature. When they are, the books are very preachy and written specifically to educate children about diet and exercise. In other words, no fun books.

Mrs. Obama and every parent and doctor have a nearly impossible task. Reading to children is important for intellectual growth. But doing so also indoctrinates them into believing that every activity should come with a sugar laden junk food treat. Sometimes I wonder if we can bend the First Amendment rights to freedom of the press so that there are fewer books about eating cookies and more books about the joys of quinoa.

The NFL Schedule Only Looks Easy

Fascinating reading from the LA Times. This is a subject I never really even thought about and always took for granted. What does it take to draw up the National Football League's game schedule each year? It has to accommodate 32 teams, 256 games, 17 weeks, multiple times zones, five different broadcast networks, and 26,000 rules such as stadium availability.

The answer? Two hundred fifty-five computers spread out around the world running 24/7 for months each year. This year all those computers came up with 43,399 different combinations of game schedules. The NFL eventually settled on #43,066 for the upcoming season. Goes to show that, just like anesthesia, making something look easy really demands a lot of behind-the-scenes hard work.

The Most Addictive Drugs In The World

This sounds like a trivia game you can play with your anesthesia friends after a few rounds of mojitos. What are the most addictive drugs in the world? The answer of course is dependent on who is answering the question. But a group of researchers in the U.K. attempted to rank addictive substances based on their ability to cause physical harm, social harm, and dependence. These five are considered to be the worst offenders.

1. Heroin--Using heroin causes the brain to increase its dopamine release, its reward center, up to 200% greater than baseline. It is also extremely dangerous with a very narrow therapeutic window. Its lethal dose is only five times greater than its recreational dose. Over half a million people in the United States used heroin in 2012 and the number is still rising, especially among the millenial generation. Over 156,000 tried heroin for the first time in 2012, far higher than the 90,000 in 2006.

2. Cocaine--The brain's ability to turn off the dopamine reward center is impeded, thus causing dopamine levels to rise to three times greater than normal. Cocaine is considered so addictive that one fifth of people who ever tried it will become dependent. About 20 million people in the world use cocaine creating a market worth $75 billion per year.

3. Nicotine--How addictive is nicotine? Over two-thirds of people who ever tried smoking will become lifelong smokers. Nicotine causes dopamine levels in the brain to increase 25-40%. Over one billion people in the world smoke and by the year 2030, eight million people worldwide will die from smoking related illnesses annually.

4. Barbiturates--Also known as "downers". These drugs were prescribed for treating anxiety but at low doses can lead to euphoria. Though highly addictive, they are not as prevalent anymore due to easy access of other drugs.

5. Alcohol--Over one fifth of people who ever drank alcohol will become alcoholics. Alcohol bumps up the brain's dopamine level from 40-360%. And the more you drink, the higher the dopamine level. That's part of the reason why binge drinking is so popular. Over two billion people in the world drink alcohol and three million will die from alcohol related illnesses.

What, propofol didn't make it on this list? I've never tried four of the five substances that are on this list so I guess I'm good. My personal addiction is sour cream flavored potato chips. Mmm. Sour cream and chives Lay's potato chips. Pardon me while I go binge on a bag.

Healthcare Only A Bureaucrat Can Love

Government agencies and insurance companies love numbers. They hire armies of statisticians and accountants to pore over the millions of numbers generated by the healthcare industry. They then focus on the specific measures that they feel will help them save money. These become the core quality metrics that are used to judge a physician's competence and compensate accordingly. What initially started as guidelines to improve patient care have become bludgeons to force physicians to practice medicine as bureaucrats see fit.

Whereas in the past a physician's reimbursement might be rewarded with a bonus for following quality metrics, the new payment models punish doctors if they don't follow these rules. Therefore in order to make sure they comply with all these rules, doctors now have to spend an inordinate amount of time and money to document their compliance. In an article published in Health Affairs, researchers calculate that it costs the healthcare system $15.4 billion just to make sure they are following the quality metrics. They estimate that each physician spends fifteen hours per week documenting their activities just for the payers' benefits. This works out to about $40,000 per year per physician of wasted productivity doing nothing but charting into a computer for some faceless agent to decide whether the doctor will be given his proper reimbursement. 

The winners in all this? Certainly not the patients who are unlikely to receive medical care that is substantially improved compared to before this mess. Nor is it the doctors who have become just another arm of the true overlords of the medical industry, the health insurance companies. The payers have become the judge and jury in how healthcare is delivered in this country. They can and will change how these quality measures are supposed to work to their own financial benefit. 

Another winner? If you're looking for a job in a high growth field, perhaps consider going into medical transcription. With all the new computer charting that needs to be done to be in compliance with these rules, medical transcribers are projected to grow from a current number of 15,000 to 100,000 by the year 2020 according to the American College of Medical Scribe Specialists.

How Much Money Should Anesthesiologists Make?

Medscape recently released its Physician Compensation report for 2016. Anesthesiologists' salaries were about the same as last year, $360,000, showing almost no annual growth. Now $360,000 sounds like a lot of money, and it is. But apparently that's not enough for some people.

As part of the Medscape survey, they also asked physicians how much more money they feel they deserved to be fairly compensated. Surprisingly, the highest paying specialties felt they were the least fairly paid. Orthopedic surgeons, already the physicians with the highest incomes of $443,000 per year, felt they were underpaid by $156,000. On the other hand, anesthesiologists were much more humble in their appreciation of their income, generally wanting "only" $44,000 more to feel they are well paid.

But that doesn't mean everybody feels even that is enough. Medscape did a separate email poll and asked the same question. The results were separated out by different levels of extra income instead of lumping them together as an average. As you can imagine, some people felt they deserved a LOT more money than what they are making.

The email survey asked what factors determined how anesthesiologists decided fair compensation. Not surprisingly, the number of hours they worked had the greatest influence in their satisfaction with their salaries. Other influences included how rushed they felt doing their work and the amount of administrative tasks they have to complete. Don't think professionals like doctors aren't immune from petty envy as ten percent judged their salaries based on how much money their peers make.

So how much more should anesthesiologists make to be satisfied with their incomes? Only 16% of anesthesiologists who answered the survey felt their income was fair. But one third thought they should make at least $50,000 more per year. Another 30% said they need an extra $100,000.

That's a lot of wishful thinking. I hope this information doesn't leak out to the general public. When the average income in the United States is a little over $50,000, saying one needs another $100,000 over the average anesthesia salary of $360,000 to be happy sounds very greedy and shallow. Maybe the people who checked off the >$100,000 box are older physicians who still long for the halcyon days where patients followed doctors' orders and physicians could afford to drive exotic cars. Or perhaps the respondents were younger physicians with overwhelming student loans that need to be paid back. The survey doesn't say. But whatever the case, seems like no matter how much money one makes, it will never be enough. Until physicians are satisfied by living within their means, no amount of complaining about poor insurance reimbursements or difficult patients will make them any happier with their lot in life.

What Happens If Doctors Could Bill By The Heartbeat?

The New York Times had an article about an innovative new way computer companies are able to monetize their vast networks of cloud servers. Amazon, Google, and Microsoft are charging their corporate users just fractions of a penny every time the servers are accessed. For instance, Amazon Web Services gives free access to their servers for the first one million times a company uses A.W.S.'s computer code. After that it charges for every one million lines of code processed at two-millionths of a penny per code. With the lightning fast processor chips that web servers possess, a million lines of code may only mean a fraction of a second that the server is being used.

However, when added all up, these cloud companies are raking in billions of dollars every year. A.W.S. has become quite the Wall Street darling and is the main reason stock analysts recommend owning Amazon stock. A.W.S. was started only in 2006 and reached $10 billion in revenue in ten years. Next year it is forecast to make $17 billion.

Contrast these meteoric and innovate businesses with our dowdy healthcare industry. In medicine, we are beholden to third party payers who dictate how we are to run our businesses and how much they are willing to pay us for doing it. Silicon Valley is run by an almost purely capitalistic ideology of making money with the most creative ways possible while medicine is more akin to Soviet era decrees issued from faceless and brutal bureaucrats.

What could happen if true capitalist animal spirits were unleashed in the healthcare industry? What if hospitals billed patients for every heartbeat they experienced? Or every breath they were given or taken? Would doctors try to keep their patients alive longer if there was a profit motive? Sounds ludicrous? Yes it does. But does charging two-millionths of a cent for every computer code that was accessed more bizarre until some really smart people realized you can make billions of dollars doing it?

But of course medicine can never be run as a real free market enterprise. Why? Because healthcare alone, not food, not housing, not clothing or transportation, is considered so essential that is is almost a human right like the air we breathe. Therefore it is considered gauche, even amoral to even think about making money off of its users.

Look at all the handwringing about doctors who want to improve their patient relations by switching to concierge medicine. "Oh no! Only rich people will get access to decent healthcare!" No we can't have that. Medicine has to be 100% egalitarian unlike the cars we drive or the food we eat. In medicine, every single patient deserves their Rolls Royce and filet mignon. Nobody is allowed to have medicine that is any "better" than anybody else's. They all have to be treated special. When that happens, then nobody is treated special anymore.

Where Is The Personal Responsibility In Healthcare?

How is medicine different from other businesses? And let's face reality--medicine is a business. It's an enterprise that costs $3 TRILLION per year in the U.S., consuming 17.5% of our GDP. Yet it is also a field where its customers are under no obligation to pay for any of its services if they can't or don't want to.

Take for instance this article in the LA Times about people who live on minimum wage. There are plenty of profiles of people whose housing and transportation costs make up a large majority of their monthly income. Therefore they have to prioritize their needs with what's leftover from their paychecks, and healthcare seems to fall to the bottom of the list.

Carolyn Allen works as a custodian at Atlanta's Hartsfeld-Jackson International Airport. She makes close to minimum wage of $7.70 per hour. Yes life on income that low is tough. "I budget and budget, and I still really can't buy no food," she bemoans. Her rent takes up half of her $1,000 monthly income. Transportation takes another 10%. She has a $100 bill from the hospital for an emergency room visit that she hasn't paid in months. Yet this person, who just claimed she doesn't have enough money for food, pays $86 per month for her cellphone.

Wait. What? She has money to throw away for expensive cellphone plans but denies being able to pay for services staffed by professionals 24 hours per day willing to treat anybody no questions asked? Granted a cellphone these days is practically indispensable as a tool for work and social interactions. But if she really needs to save money there are plenty of cheap plans that cost far less than what she's paying now. Bottom line is she prioritizes her cellphone over her hospital bill because she already got the medical services she wanted but her cellphone company would cut her off after 30 days of nonpayment. How's that for running a business into the ground?

This just crystallizes doctors' cynicism toward sob stories about people who want free this and free that because, oh my god, they might have to pay for it themselves. Doctor's visits? If they have to pay the $20 copay then they might not make their annual visit and develop terrible chronic diseases costing the system more money. Birth control? Must be given gratis because heavens forbid they might get pregnant because they couldn't spend $1 out of pocket for a condom. Subsidized health insurance? People better pay more taxes because otherwise they would just run to the emergency room costing society more money. Sounds like we're spending trillions of dollars on healthcare each year due more to coercion than charity.

Society has become obligated for the individual because now there is no accountability for a person's irresponsibility. Enforcing personal responsibility is viewed as cruel and uncaring. Therefore the only answer that is proffered is to throw more money at the problem so everybody gets more free stuff. No sane or solvent business can be run like this for long. But then again medicine has become an enterprise that is too big to fail. The government will just have to keep taxing and spending until ultimately people eventually run out of money.

More Bloopers From The ASA Monitor

Still can't find pictures of real doctors, ASA?

Oh ASA. What are we going to do with you? You publish an award winning publication like the ASA Monitor, which just won the Bronze Award for Monthly Newsletter or Communication in the 2015 Association TRENDS All Media Contest, yet you continue to insult the intelligence of your anesthesiologist readers with god awful pictures of fake doctors and phony patients.

I know somebody over at ASA HQ is listening to my criticisms because they have usually been corrected shortly afterwards. When I pointed out how terribly unbelievably fictitious the cover photo of the then ASA Newsletter in May, 2015 was, the ASA soon after declared that they would start using more pictures of real doctors and not rely so much on stock photos. In January of 2015, when the ASA unveiled a new website that featured only female anesthesiologists on its homepage, I quickly pointed out how sexist that was and how excluding men doesn't make the organization more inclusive. The homepage was changed within 48 hours.

Don't get me wrong. I think the ASA Monitor is an important publication for the ASA to produce. I read it from cover to cover every month when it arrives in my mailbox. But because I consider it to be so relevant, I feel that we the readers should do our best to call upon its shortcomings to make it better.

Which is why I am calling out this picture that is printed on page 29 of the April 2016 issue. Included in the article titled "Interdisciplinary Teamwork and Bureaucracy Flattening: The Keys to Optimal Perioperative Care", the picture doesn't really have anything to do with the article. But that's not why I find this photo confounding. As a newsletter for anesthesiologists, I would think that the ASA editors would try harder to find pictures that didn't have so many flaws in it that could be noticed by even CA-1 anesthesia residents. You can actually see a much clearer image of this picture on the ASA's website if you're an ASA member.

1. There is not a single drop of blood anywhere during this "operation." It's not on the surgeon's gloves, the drapes, his instruments, or on his gown.

2. If there is no blood on the field, why is his assistant holding the suction in the surgical site? And that is the tiniest suction tubing attached to the suction catheter. I can just imagine the surgeon hollering at the circulating nurse seconds after the picture was taken, "Nurse, we need more suction!"

3. The IV reservoir is either completely full or completely empty. There is no fluid level seen within. No anesthesiologist would ever flush an IV line that way.

4. Worse, the IV line actually dangles on the wrong side of the ether screen. The surgeon's left elbow is brushing up against the IV. He will have to step back and replace his now contaminated surgical gown. How fast can a surgeon scream, "Get me another anesthesiologist!"?

5. On the patient's monitor behind the anesthesiologist, we see that the patient's heart rate is 68 and blood pressure is 116/71. The blue waveform that normally represent the pulse ox doesn't seem to synchronize with the ECG. The pulse ox appears to show a rate at least twice as fast as the ECG.

5. This is probably the biggest sin. The elbow on the anesthesia circuit is capped. There is no catheter in place to monitor the patient's end tidal CO2. This goes against the ASA's own guidelines about basic patient monitoring under sedation.

6. The anesthesiologist is standing. We all know that if a patient is as stable is this patient's monitor implies, we'd all be sitting down doing our Sudoku.

I don't mean to embarrass the ASA or the editors of the Monitor. Don't hate me because I point out the flaws in your publications. I only do it because I care. As your mother probably told you when you were growing up, "You can do better next time."

Another Doctor Unknowingly Gets Recorded By Patient and Indignation Ensues

I hope this doesn't become a trend. Ethel Easter, a patient at Lyndon B. Johnson Hospital in Houston surreptitiously recorded her doctors while she was undergoing a hiatal hernia repair. She complained to her surgeon during a consultation visit about her severe abdominal pain caused by the hernia. When he dismissed her symptoms and scheduled her operation months later, she became suspicious of his demeanor and decided to record his conversations during the procedure. In preop, she went to the restroom to change into her gown and placed a tiny audio recorder into her ponytail. What she heard astonished her.

The surgeon can be heard on the recording complaining about her attitude. "She's a handful," he said. "She had some choice words for us in the clinic when we didn't book her case in two weeks." Later on, one voice is heard laughing about her navel, "Did you see her belly button?" The anesthesiologist was heard to ask cryptically, "Do you want me to touch her?" The surgeon replied, "I can touch her." Then another person said, "That's a Bill Cosby suggestion."

For Ms. Easter, she was even more disturbed by a cellphone conversation the surgeon made during an operation and that he dismissed her penicillin allergy. She claims penicillin gives her a rash. When the surgeon ordered a test dose of Ancef anyway, she developed pruritus and rashes postop that required an emergency room visit. She says she still has trouble breathing normally.

Ms. Easter sent the recording to the hospital administrator. She hasn't decided whether to file a lawsuit against the doctors. For now she says she just wants an apology. She claims that she is doing this, "For all the workers and the doctors: Don't do this. Just treat people the way they would like their mother, their sister, their wives to be treated."

Yes there is great truth to her statement. It is easy for physicians to forget that our patients are more than just another name on the medical record. They are somebody's husbands, wives, mothers, fathers, sisters, brothers, sons, daughters. We should treat every patient with the same dignity we would treat our own relatives. That should go without saying. Otherwise more patients may feel the need to secretly record their doctors to protect themselves from any possible shenanigans while they are incapacitated. With the miniaturization of electronics these days, it is all too easy to slip a tiny device into the hair and cover it up with an OR hair net. Or leave a recording device on in one's personal belongings which are taken into the room with the patient.

Do the right thing by the patient and you'll never have to say sorry for what you do.

Anesthesiology-EM Residency. For Doctors Who Can't Make Up Their Minds

Okay this is rather unexpected. The American Board of Anesthesiology and the American Board of Emergency Medicine have announced a joint Anesthesiology-EM residency program. It's not April Fool's Day anymore, right? The new training program will last anywhere from 5-6 years depending on if the resident goes through a complete four year EM residency. So the ABA is saying that a resident really needs only two years of training to become an anesthesiologist but needs four to be an emergency physician? According to the ABA secretary Dr. James P. Rathmell, M.D., the new training program, "addresses a demand from residents interested in both emergency medicine and anesthesiology." The ABA and ABEM are currently accepting applications from residency programs who want to start up this new hybrid.

I didn't even know there was a huge demand from medical students who just absolutely can't make up their minds and want to do both anesthesiology and EM. This isn't like a Med-Peds program where the training is similar to Family Medicine minus the OB/GYN portion. I would think that an anesthesiology-cardiology or anesthesiology-pulmonary-critical care combined program would be a more natural fit.

When I was trying to decide what I wanted to do after medical school, EM was clearly near the top of my list of career choices, as it is for many med students. However I had good reasons for not choosing EM and to me those circumstances makes this combined residency all the more puzzling.

First of all, the work of anesthesiologists and EM couldn't be any more different. Anesthesiologists are responsible for studiously managing one patient at a time, carrying them through a difficult operation successfully with minimal complications. EM docs are frequently involved with a dozen or more patients simultaneously. Within minutes to hours, they have to decide whether a patient is safe for discharge or need to be admitted for higher levels of care. How does one juggle these two completely different mentalities in patient care?

I would think that an EM physician will be completely bored with sitting in the operating room. If one is used to the adrenaline rush of seeing multiple patients and being at the ready for whatever comes through the door, how are they going to feel being inside a small confined area of a cold OR watching one monitor on the same patient for hours at a time? Likewise if an anesthesiologist is used to the cerebral pace of managing patients during surgery, the move to the emergency room will come as a huge shock to their mental and physical capacities. Not that EM is harder than anesthesiology--it's just different.

When will this Anes-EM physician find time to use both of their board certificates? I suppose since most EM doctors work three days a week, they can use the other days to work in the operating rooms. But most EM docs I know treasure their days off. They can go on long weekends at least twice a month or string together a whole bunch of off days to take weeklong vacations without ever having to lose any shifts. Or many of them moonlight elsewhere to make even more money. I can't imagine they are eager to head to the operating rooms after several days of frenzied 12 hour shifts.

The only upside I see for an Anes-EM doctor is that this will alleviate one of my main concerns about going into EM. Because being in the ER is so stressful and carries a high risk of burnout, EM is not a field that one can grow old into. Now with an anesthesiology board certificate as backup, one can switch careers anytime they want without needing further training. I don't see a possibility that an anesthesiologist will become so weary of being in the OR's that they will want to switch into EM. Somebody like that should probably have done an EM residency instead of a combined program.

Despite all these reasons, I predict that an Anes-EM program will be in high demand. I see many medical students who love both fields but have a hard time deciding which one to make as a career. I just can't imagine how one juggles the different work styles of these two very different disciplines. But if they don't mind doing an extra two years of residency training, now they don't have to fear about going into the wrong field.

How Does Anesthesia Work

This is a quick and surprisingly informative primer on how anesthesia works. Created by Dr. Steven Zheng, this cute animated video is a must see for any patient, and even medical students going through an anesthesiology rotation.

My favorite part is the illustration of an anesthesiologist mixing up drugs from a flask into a beaker like we are conducting chemistry experiments in the operating rooms every day. I only wish I was that smart. Some days I can barely get my electronic medical record to record properly.

What Happens To Doctors When The Government Stops Playing Nice

As medical students prepare to exit the comfortable familiarity of medical school and start their residency training, they may have heard all the horror stories that are about to befall them in just a few months. Lack of sleep, difficult patient care environments, and no personal time. But at least our residents don't have to face what our colleagues across the pond are having to endure, a protest against their very own government.

The medical residents in England, or junior doctors as they are called, are about to start a nationwide strike over the government's new employment contracts that are being offered. Actually, offered is too mild a word. More like coerced. The much vaunted National Health Service said they made their final best offer back in February which was then promptly rejected by the British Medical Association.

How bad is the contract? Junior doctors in England are similar to the residents here in the States. They are in training from three to nine years depending on their specialty. Their base salary starts around £23,000, or about $32,500. This can rise to over £30,000 if the resident works more nights and weekends, or what the British euphemistically call "unsociable hours". This is where the new government contract really stings.

The NHS's proposal will increase the base pay for regular hours, but decrease the amount paid for unsociable hours. Their hope is that decreasing the salaries of the doctors who work on the weekends will allow more money for more of them to work during those periods. This way more patient care can be accomplished 24/7 and patients don't have to wait for the following Monday to get their treatment. There is also the belief that patient care suffers during the weekend, with a 10-15% increased mortality compared to a weekday. By having more staff available during the weekend, some of this may be mitigated.

As you can imagine, this hasn't go over well with the BMA and the junior doctors. They counter that weekend patients tend to be sicker to begin with. There is no evidence that having more physicians available on weekends will change the statistics. Plus it is an insult to anybody who has to work unsociable hours to have to take a similar pay as somebody who works normal business hours on weekdays. So more nights and weekend shifts with less compensation? No dice, says the BMA. Therefore the strike is on.

As usual, the government is shaming the doctors, portraying them as heartless for even caring about money. They say that 5,000 operations have to be postponed because of the protest. A total of 24,500 procedures have been postponed as this is the fourth strike since the contract impasse. The BMA counters that instead of cutting the salaries of the junior doctors who have to work weekends, the government should just cough up the money to pay more people to work those dreaded hours. But since the NHS is already constantly running a deficit, that is unlikely to occur.

This is what happens when there is a single payer system and the government controls every aspect of healthcare. There is a monopoly on the payer side of the business and little to no recourse for anybody who is dependent on it to negotiate a reasonable agreement. Beware what you ask for during this election year.

To Infinity, And Beyond

From the GomerBlog. Why stop the pain scale at ten? You know those chronic pain patients who are taking multiple narcotics every 3-4 hours at home while wearing multiple fentanyl patches? They are sitting in preop screaming in pain even though not a single sharp object has touched their skin yet? You ask them what their pain scale is on a scale of 1-10 and they reply 15?

The Joint Commission has proposed expanding the Wong-Baker pain scale to inifinite. That way patients will know that their doctors will take them seriously when they complain their pain is 25 out of 10 and they need their preop Dilaudid NOW.

It's a sad statement about the opioid epidemic in the U.S. when this satire unfortunately rings all too true.

California Supreme Court Wants To Kill Workers

The California Supreme Court rules that workers have the right to demand a chair to sit on while on the job.

Sitting increases the risk of dying early. According to the World Health Organization, sedentary lifestyles are the fourth leading cause of mortality globally, causing 3.2 million deaths per year. Sitting can substantially increase the risk of developing obesity and Type 2 diabetes. But what if somebody is only standing in one spot for a prolonged period of time. Is that also considered sedentary? On the contrary, standing, even if not actively moving around, shows a decline in mortality rates.

So thank you California Supreme Court for causing more California workers to potentially develop chronic illnesses leading to higher death rates. Just goes to show what happens when you let a bunch of lawyers determine healthcare rules.

CRNA Equivalency Is All A Sham

The Holy Grail for the ASA would be to find a study that definitively showed that physician anesthesiologists give better patient care than CRNA's. Yet after all these years, just like the Grail itself, that research has been quite elusive. Many studies have shown little difference in patient outcome between physician anesthesiologists and CRNA's. Maybe we've developed monitoring technology to the point where virtually anybody can anesthetize a patient with little risk of harm. Or perhaps studies comparing CRNA's and physician anesthesiologists haven't included enough patient numbers to produce a sufficient and unequivocal result.

Now there is another possibility for why we can't seem to prove that we are better than the nurses many of us are supervising--fraud. A new study published in Anesthesia & Analgesia by Amr Abouleish, M.D., M.B.A. from the University of Texas Medical Branch, Galveston, has found that determining who is administering anesthesia is more complicated than expected. Researchers frequently use billing codes to determine who is administering the anesthetic to the patient. The billing codes can use the QX modifier to show that a physician anesthesiologist is giving a high level of care, or the QZ modifier to show that a CRNA is being supervised by an anesthesiologist, another physician, or performing unsupervised work. Thus it is impossible to determine with a QZ modifier who is caring for the patient, the nurse practicing solo or being supervised. Yet prior studies used the QZ code to represent cases where the patient was supposed being cared for by CRNA's unsupervised. The infamous Health Affairs paper was one of those that found no differences in the care given by physician anesthesiologists or CRNA's. It relied on the QZ code as a marker for CRNA's working alone.

Now the Texas researchers have shown that the use of the QZ modifier to determine solo CRNA activity may be inaccurate and possibly fraudulent. Abouleish's team evaluated over 9,000 patient records and found 538 hospitals where 100% of anesthesia claims used the QZ code. Yet 47.5% of those hospitals have physician anesthesiologists on the staff. How could the CRNA's claim to be doing 100% of the anesthesia when nearly half of the hospitals have anesthesiologists present? Was there no time when the CRNA's consulted with a physician anesthesiologist or been supervised by one even for very difficult cases? Therefore reliance on the billing code alone is insufficient to determine who is responsible for anesthetizing the patient.

Perhaps the only way to find cases where the CRNA is working unsupervised is to develop another billing modifier just for that situation. Maybe the ASA can use some of their political clout in Washington to make this happen. Otherwise the assistance that physician anesthesiologists give to the nurses in difficult cases goes unrecognized and makes them look better than they should.

By the way, Dr. Abouleish's study was sponsored by the ASA.

The Best And Worst States To Be A Physician

Many of us decide where we want to practice medicine based on subjective factors like family, climate, or familiarity with a region. Now WalletHub has compiled a list of the best states to be a doctor. It is based on more objective categories like physicians per capita, punitive medical boards, and cost of malpractice insurance.

The top five states to be a doctor? They are Mississippi, Iowa, Minnesota, North Dakota, and Idaho. The bottom five are District of Columbia, New York, Rhode Island, Maryland, and Connecticut. Some surprising facts found in the survey--Missouri is one of the most competitive states to be a doctor with physicians per capita just behind New York and D.C. Wyoming has the most punitive state medical board in the country. If you're afraid of getting sued, North Dakota has the lowest malpractice award payout of all the states.

Go check out the survey for more fascinating details.

Sage Advice From Former Residents

As the academic year slowly and inexorably winds down, I see our medical students start becoming more nervous about what lies ahead for them. There is the natural fear of the unknown as they are all too aware that what they've just accomplished in medical school is nowhere near the experience they will encounter in residency.

Perhaps they can take some solace from the words of former residents who have just gone through the wringer. The AMA Wire has posted comments from graduating residents and what advice they can give to the incoming interns. Though it was published almost one year ago, I think it is worth rereading.

Though it may be cold comfort, millions of physicians have gone through the same rigorous process you are about to start and nearly all have come through relatively unscathed. Just remember the shit really hits the fan AFTER you finish residency. Then you'll wish you could go back to the warm comforts of being a perpetual trainee with no responsibilities for your actions.

How Much Money Do Anesthesiologists Make In 2016?

It's that time of year again. Medscape has released its survey of physician salaries for 2016. Full disclosure--I participated in the poll when it was sent out. Over 19,000 physicians filled out the poll and about 6% of the responses were from anesthesiologists. So how much money did anesthesiologists report making this year? Drumroll please.

The annual compensation reported by anesthesiologists was $360,000. This was about even with last year's number of $358,000. This tiny increase came in at the low end among all doctors. Internal Medicine and Rheumatology each registered a 12% increase in salary compared to last year. Only Pulmonary and Allergy/Immunology actually reported drops in salaries. Anesthesiologists came in seventh in a list comparing physician incomes. We trail Orthopedics, Cardiology, Dermatology, Gastroenterology, Radiology, and Urology. Seventh isn't bad, but it seems like others are doing better.

Anesthesiologists who work in the North Central region of the country, the Dakotas down to Kansas and Missouri, made the most money, averaging $413,000. The geographic area with the worst compensation was the Mid-Atlantic region, from the Carolinas up to Pennsylvania. The anesthesiologists there reported incomes of about $342,000.

Male anesthesiologists, as always, made more money than female anesthesiologists, $372,000 to $317,000. Don't start screaming "DISCRIMINATION!" based on this persistent difference in salaries. There are lots of reasons why female doctors make less than their male colleagues. Self employed male anesthesiologists reported incomes averaging $413,000. Self employed female anesthesiologists earned $357,000. We've had several female partners leave our group recently for employed positions because they want the more predictable hours of being an employee. Female employed anesthesiologists reported to the survey incomes of only $307,000. If you don't put in the time, you're not going to get the dime.

Are anesthesiologists satisfied with their income? Yes, according to 55% of the respondents. That is 6th on the list of all doctors. Dermatology topped the list with 66% rate of satisfaction. This was followed by Pathology, Emergency Medicine, Psychiatry, and Radiology. Looks like Radiology is still holding its own despite all the doom and gloom about the specialty being outsourced and saturated. Surprisingly Urology was at the bottom of the satisfaction rating despite their high incomes and supposed country club hours.

About 54% of anesthesiologists are satisfied with their careers. This is midpack on the list of all physicians. Once again Dermatology was at the head of the class with 65% reported being satisfied. No wonder Derm is one of the hardest residencies to get.

Bottom line? Anesthesiologists are just treading water while other specialties appear to be surging ahead. Though most anesthesiologists report being satisfied with their careers, I wonder how long that good feeling will last when they see their medical colleagues in the doctor's lounge moving ahead in compensation. There's a lot more to see in the Medscape survey.

I Like Big Butts And I Cannot Lie

This is a picture of a blimp of the future. Its form, however, leaves little to the imagination. It is almost too easy to make up a caption to describe this image. But let's give it a try.

1. Oh. My. God. Becky. Look at her butt. It is so big.

2. Dear, does this make my butt look big?

3. Somebody finally made a pair of pants big enough for Kim Kardashian's behind.

4. Honey, can you find my G-Spot now?

5. The blimp designer must have been a Sisqo fan.