Wednesday, May 17, 2017

Patients With Older Doctors More Likely To Die

A study out of the BMJ has concluded that patients who are treated by older physicians have higher thirty day mortality than younger doctors. Dr. Yusuke Tsugawa and others from the Harvard T.J. Chan School of Public Health evaluated 736,537 patients records in the U.S. that were managed by 18,854 different hospitalists. They found that while the thirty day readmission rates were the same, patients whose doctors were greater than sixty years old had an 11% higher thirty mortality than ones who were less than forty. This works out to one extra death for every 77 patients that were treated by older doctors.

When broken down by age categories, doctors aged less than forty had a 30 day mortality of 10.8%. Those between 40 and 49 were 11.1%. From 50 to 59 were 11.3%. And doctors 60 years or older had a mortality rate of 12.1%. However, when the researchers stratified by patient volume, doctors who took care of the highest number of patients, greater than two hundred per year, did not show any difference in mortality between age groups. They speculate that by treating larger numbers of patients, older doctors are more likely to keep up to date on best medical practices and current knowledge base.

This study adds more evidence to the hypocrisy that medical boards thrust upon their younger doctors to pay for expensive Maintenance of Certification programs. Other articles have also pointed out that it is the older doctors who are most at need to recertify for their boards regularly since many haven't cracked open a textbook in decades. Yet they were given lifetime board certification while their younger colleagues are the ones who have to spend countless hours and thousands of dollars to keep theirs. Reads like a medical version of Wacky Wednesday.

If the name of the author of this study sounds familiar to you, that's because this is the same team that published the controversial paper last year that claimed female physicians are better doctors than men. Therefore for patients to have the best outcomes they should only be treated by doctors who are young, female, and attractive. Okay I added the attractive part but it makes sense if it will bring along more male patients, who are notorious for not seeking routine medical check ups, in to see their doctors. All you male premed students might as well forget about applying to medical school. You'll just wind up killing more patients than your female classmates.

Tuesday, May 16, 2017

Deportation Could Have Saved Boston Anesthesiologists

The shocking and grisly murder of two Boston anesthesiologists might never have happened if the murderer had been properly deported. Bampumim Teixeira was shot by police in the penthouse apartment of Drs. Richard Field and Lina Bolanos after he had slashed their throats and attempted to steal a bagful of jewelry. Now reports have surfaced that Teixeira should never have even been in this country if not for the benevolence of defense lawyers and courtroom judges.

Mr. Teixeira had two prior convictions before the murders. He was convicted twice of robbing the same bank, once in 2014 and another time in 2016. Even though he is a green card holder, this would have made him eligible for deportation back to his native Cape Verde. However, the first conviction was placed as "guilty filed." Essentially it meant he received a warning from the judge that further criminal activity could lead to his deportation. And that's it. He was free to go. That was not enough to notify immigration to start deportation proceedings.

Then after his second bank robbery, he was convicted of larceny and given a jail sentence of 364 days. This is important because he would have been reported to ICE for a major felony only if he went to jail for at least one year. So thanks to the judge's leniency, Mr. Teixeira once again eluded deportation.

Think about how outrageous this whole chain of events is. How many people have attempted bank robbery even once in their lifetimes, much less two. Yet this man who has already proven he would not be a good law abiding American citizen was allowed to stay in this country to later commit even more heinous crimes. Is it any wonder there are so many Donald Trump supporters in this country?

Tuesday, May 9, 2017

Jerry Seinfeld Contributes To Medical Journal

There's a reason most of those medical magazines in the doctors' lounge are described as throwaway journals. Their standards for publication are suspect at best. John McCool, senior editor of Precision Scientific Editing set out to prove how vacuous the contents of those journals are.

Being a big fan of the TV show Seinfeld, he submitted a case report based on one of the show's episodes. It is the one where Jerry is caught urinating in a parking garage. Jerry tells the security guard that he suffers from uromycitisis, a condition where he needs to urinate as soon as a feels the urge or otherwise he will die.

Mr. McCool created a paper based on uromycitisis, including false references, and submitted it to a journal called Urology & Nephrology Open Access Journal. The author doubted that such a blatantly imaginary medical condition would pass peer review and get published. After all, any person on the magazine's editorial board who has watched Seinfeld would catch on. Even a simple Google search of uromycitisis would instantly expose the paper as a fraud.

But lo and behold, the journal wrote back to Mr. McCool and said his article will be published after a few revisions. In return, they asked him for $799. He refused to send any money but the journal published his paper anyway on March 31.
After all the notoriety, the link to the article has been removed from the website. But surprisingly it is still on their home page table of contents. Next time you're bored and perusing all the journals in the lounge, be extra skeptical of the "research" that are being presented. Their credibility may be less than meets the eye.

Monday, May 8, 2017

MOCA 2.0 Scoring Explained

A couple of years ago, physicians around the country were up in arms over the strong arm tactics of their medical boards coercing them to pay for ever pricier exams in order to maintain their board certifications. These monopolistic, non elected board members used their positions of power to enrich themselves and their organizations at the expense of doctors, since many would not be allowed to practice their craft without the precious certificates.

The American Board of Anesthesiology too felt the pressure to reform the process. In response, they developed MOCA 2.0. One of the biggest advances of MOCA 2.0 is the elimination of the once a decade recertification exam. Instead of studying furiously like taking your first written boards, the ABA replaced it with an annual 120 question MOCA Minute. Each quarter, the anesthesiologist is supposed to answer 30 questions to track their progress in maintaining their knowledge base.

This makes recertification a lot less intimidating than taking another do or die exam every ten years. However there were always questions about how the MOCA Minutes were being scored. If you take one exam, it's easy to decide where you fit on the curve and whether you've passed or failed. But how do they score mini exams every quarter over ten years? How do they know if you've been reading your journals and reviewing your texts? Well the ABA has a website for that, and it isn't pretty.

As you can imagine, trying to decide if somebody is maintaining their anesthesia knowledge every three months is quite convoluted. They use something called the Measurement Decision Theory to calculate if you're smart enough to maintain your board certification. It looks something like this:
Got that? It looks like something out of your biostatistics class that you slept through in medical school. Basically the MDT starts out with the premise that the physician has a 97% chance of keeping his certificate, since that was the average passing rate prior to MOCA 2.0. Now each MOCA Minute question has a difficulty value assigned to it. How this is determined is not mentioned. The ABA then compares the chance of answering the question correctly from doctors who passed the recertification in the past versus doctors who didn't. Then it passes through several more calculations to come up with the likelihood that you would pass board recertification. In their example, the physician has a 98.6% chance of passing versus 1.4% chance of failing. So the doctor gets to practice another ten years.

So if you're one of those slackers in medical school who graduated by the skin of your teeth, how low a score can you get and still satisfy the ABA requirements for maintaining your knowledge base? First of all it's not that hard. Here is my score so far:

Remember that the higher the score the more likely you'll pass the former recertification exam. Mine so far is 1.0 so basically I have a 100% chance at being successfully recertified. And believe me, I am no anesthesia savant. But I do a competent job and have been in practice for nearly 15 years. The minimum score that the ABA will tolerate for meeting their standards is an MDT score of just 0.1. That's right. You can have a 90% chance of failing and still be within the ABA's guidelines for maintaining recertification.

Basically our professional careers and livelihoods are now governed by game theory. Whether this is an improvement over the previous one-exam-to-rule-them-all has yet to be determined. In the meantime, download the app and do your quarterly mini tests in the comfort of the operating room during one of those interminable multi hour cases. You'll be finished with your ABA obligations sooner than it takes for the surgical intern to close that skin incision.

Sunday, May 7, 2017

Unspeakable Tragedy In Boston

Two anesthesiologists were brutally murdered in Boston last Friday. Dr. Richard Field was a pain medicine specialist. He was an instructor at Harvard Medical School and director of anesthesia for plastic surgery at Brigham and Women's Hospital. Dr. Lina Bolanos was a pediatric anesthesiologist at Massachusetts Eye and Ear and also an instructor at Harvard Medical School. They were engaged to be married.

The police were called to their penthouse apartment in Boston Friday night after Dr. Field texted a friend for help. When the police arrived at the residence, the suspect, Bampumin Teixeira, fired a gun at them. The police shot back and injured him. He is currently being treated at Tufts. The officers found the victims with their hands tied up and throats slit. A note was found that indicated the shooter knew the doctors but the content has not been made public yet.

Mr. Teixeira was recently released from prison in April after spending nine months in jail for two counts of attempted bank robbery. His ex girlfriend said he told her he was born in Guinea-Bissau but was raised by his aunt in Cape Verde. She described him "charming" and a "gentleman". No motive has been announced for this horrible act of violence.

In my opinion, I hope that when Mr. Teixeira has surgery for his gunshot wounds at Tufts, the anesthesiologists there "accidentally" forget to give him any inhalational agents or narcotics. He deserves nothing better. RIP Drs. Field and Bolanos.

Saturday, May 6, 2017

Everything You've Always Wanted To Know About Anesthesiologists

Becker's ASC Review has compiled 22 facts about anesthesiologists. Okay so it's not quite everything but 22 is still a pretty good summary. While most of the information relate to income, I find #19 quite alarming, "Over the last three years, 49 percent of hospitals sought to change their current anesthesia provider, and 25 percent did change their anesthesia providers." Twenty five percent? Wow that's a really high number of turnovers in the anesthesia department.

The three main reasons cited were: the hospital subsidy levels (the hospitals wanted cheaper anesthesia service), adequate service level (hospitals wanted the anesthesiologists to take more calls than what the doctors were willing to give), and issues with group leadership (the hospital CEO and the anesthesia chief were not in sympatico).

So at any given time half the hospitals in the country are shopping around for a different (cheaper) anesthesia group to staff their operating rooms. That shows how tenuous the career of an anesthesiologist can be. Unless there is a very strong relationship between the hospital and the anesthesia chiefs, like they attend each other's children's bar mitzvahs, the hospital will always try to cut costs wherever they can. And anesthesiologists are considered one of the leeches that drain the hospital's profits, like radiology and pathology.

Probably the best way from being one of the statistics of laid off anesthesiologists is to join a very large anesthesia group or even national anesthesia service provider. The power of large numbers makes it more difficult for a hospital to replace their anesthesiologists with a cheaper group. Or join an academic or government hospital where the anesthesiologists are employees of the facility. The money is less but the job security is better. In these perilous political times for physicians that maybe the most important factor of all.

Do Gastroenterologists Make Only $50 Per Hour?


We recently had visiting medical students rotate through our hospital. As their final exit projects, they made presentations about what fields they find interesting and are thinking about entering. One student assembled a beautiful poster board of his favorite medical specialty. He chose gastroenterology.

Among all the detailed descriptions of the duties of GI docs, there was this one little panel down near the bottom. As you can see, he stated that they make roughly $200,000-$400,000 per year. Sounds a little low but okay. But then there was the kicker. This salary comes out to roughly $50 per hour. What?

All the gastroenterologists who saw this were aghast. Could that be right? Were they making only $50 per hour? After multiple decades of education and training, hundreds of thousands of dollars in student loan debt, tens of thousands of dollars in malpractice insurance payments each year, countless hours of lost sleep and family time, were they earning just $50 each hour? How can GI docs, always ranked near the top of physicians with the highest compensation, be making so little?

When they did a quick back of the envelope calculation, they were dismayed to realize he was right, up to a point. First of all, let's assume that the student meant that $50 is after tax income. The alternative is just too horrible to contemplate. Therefore, the doctor is making roughly $100/hr before taxes in a high tax state like here in California. Thus the gastroenterologist who makes $200,000 each year is putting in roughly 2,000 hours per year. This is the same number of hours as Joe Schmoe who works 9 to 5, 40 hours per week, 50 weeks per year.

But we know that doctors don't work 9 to 5 jobs. They are at the hospital by 6:00 or 7:00 AM, rounding and doing procedures, going to their offices and seeing patients, and may not get home until twelve or thirteen hours later. And don't forget about calls and weekends and middle of the night phone calls from nurses. According to Medscape's physician survey, gastroenterologists typically spend 30-55 hours each week seeing patients. Then there is the paperwork and office administration. More than half in the poll said they spent more then ten hours each week dealing with this headache.

So now we're up to around 60 hours per week of work. Calculate that into the $200,000 with 50 weeks of work each year and we're down to $67 per hour PRE tax income. After tax that comes to less than $40 per hour. How depressing is that?

But GI doctors don't make that little amount right? Aren't they more likely to make the upper range of incomes listed on the poster? When I asked our gastroenterologists, I was surprised that it is quite common to make $200,000 per year, or LESS in GI. Mostly this affects the doctors that are working in academia. Among high profile medical institutions, the compensation granted to GI doctors is typically less than $200k. The prestige of being named an Associate Professor of Gastroenterology at High Falutin Medical Center allows these hospitals to pay their physicians much less than the private world. In return, they can list on their C.V.'s their academic prowess and hopefully get more lucrative job offers and speaking fees in the future.

But if one wants to bust their balls or ovaries in private practice, they can certainly make $400k or more. They're just gonna have to rack up their hours and make sure they are at the beck and call of the emergency department and the hospitalists. They will be expected to come to the hospital and scope a patient at any time, 24/7. If they start refusing cases because the hours are inconvenient, then the consults dry up and so do their incomes.

Makes one wonder why they didn't choose other jobs that pay $100 per hour. But then again, nobody goes into medicine for the money, right?

Friday, May 5, 2017

Proof CRNA's Don't Care About Patient Access To Anesthesia

This will finally put to rest the lie that CRNA's want to practice independently without supervision from physician anesthesiologists for altruistic reasons. They say nurse anesthetists should be able to work without anesthesiologists watching over their shoulders because they can increase the availability of anesthesia care since there are not enough anesthesiologists for all the cases that need to be done. It doesn't matter that studies have shown that states who opt out of physician supervision do not have more anesthesia cases than non opt out states.

Now we have this tweet from Juan Quintana, the immediate past president of the AANA. After the Department of Veteran Affairs denied CRNA's the right to practice without physician anesthesiologists in VA hospitals, he tweeted, "stick to your guns. In the meantime we will keep taking MDA jobs." For good measure he added a laughing so hard he's crying emoji.

Does this sound like he wants to give patients more access to expert anesthesia care? How can taking jobs from physician anesthesiologists lead to greater anesthesia access? All the propaganda from the AANA about CRNA's giving patients and surgeons more anesthesia choices have just been shown by their own society president to be a bunch of baloney. Their blatant bald faced lying would make even Hillary Clinton blush.

So next time you hear anything out of the AANA pushing their agenda for independent practice without physician anesthesiologist supervision, know that it is all fake news. Their real agenda is to prevent as many anesthesiologists as possible from observing and correcting their errors.