Can You Be Too Old To Practice Medicine? There's An Answer For That.

Isn't this easier than paper charting?

New Hampshire physician Anna Konopka, MD  has had her state medical license revoked. After practicing for 55 years, the 84 year old doctor says she is not able to maintain electronic medical records as required by the medical board. She still writes out by hand her patient charts and keep them in file cabinets. Even her typewriter is broken. The state requires that doctors use a prescription drug monitoring program on patients to cut down on opioid abuse and deaths.

However Dr. Konopka says she doesn't have any problems with writing out pain prescriptions by hand to her patients who need pain relief, "Bureaucrats who don't know medicine--they are getting this kind of idea that they can handle this type of pain without narcotics. I prescribe a small amount of OxyContin and they are doing beautifully."

She adamantly refuses to be drawn into the electronic age, "Even if I knew how to use the electronic system, I would be unwilling. I cannot compromise the patient's health or life for a system. I refuse to."

On the other hand the medical board says they are revoking her medical license because of poor medical judgement. A young girl with asthma came to see her with tachycardia. The state maintains she did not perform any follow up tests or refer her to a specialist. Her reaction was, "I'm not sending sending my patients to this doctor and this doctor. I treat everything. I have enough experience and can treat any disease."

So who is telling the truth? Is the state taking away Dr. Konopka's license because as she believes she can't or won't start using electronic medical records? Or is her medical judgement so poor that she is a danger to her patients? There's an easy way to answer that. Why not have her take a Maintenance of Certification exam to see if she is still retaining a minimal level of competency to treat patients? After all, isn't that what the ABMS designed the MOC to do, ensure physicians have a certain level of knowledge so that they're not a danger to their patients?

Oh but wait, Dr. Konopka has probably had her board certification grandfathered in. She has not taken a medical exam in fifty years. The ABMS in their infinite wisdom say that the young and most recently trained physicians are subject to their extortion while the older doctors who haven't cracked a medical text in decades get a pass. This again shows the inadequacy of the entire MOC process and how it is just a revenue raising means for the medical boards to sustain their lavish expenses. Any wonder most doctors think the MOC is the biggest scam in medicine?

Racist Nurse Says White Boys Should Be Thrown To The Wolves

Racism much? A nurse at Indiana University Health Methodist Hospital was found tweeting extremely offensive and racist remarks. The recently hired nurse, Taiyesha Baker, was posting under the account "Night Nurse." She wrote, "Every white woman raises a detriment to society when they raise a son. Someone with the HIGHEST propensity to be a terrorist, rapist, racist, killer, and domestic violence all star. Historically every son you had should be sacrificed to the wolves Bitch." Needless to say the nurse was fired from her job shortly after her tweet was discovered.

Funny how somebody with such extreme racist thoughts can categorize an entire demographic as being racist even though they may only be innocent children. I could say this is the pot calling the kettle black but I don't want to be accused of racism and get sacrificed to the wolves.

Are Doctors Paid Too Much?

This is the perennial question that comes up every time there's a discussion about healthcare costs in the U.S. People look at the statistics of physician income and can't help but verbalize their envy by asking if they are being paid too much money for their work. It's nearly impossible to answer this question as a doctor without sounding defensive.

Therefore, at your next holiday party some wise guy brings up this subject to your face, point them to this article in Forbes magazine. It is written by a retired pediatrician from Georgia and gives a wide ranging, fact based argument for why American doctors make as much as we do.

It goes through everything from the high debt load carried by American medical students, which aren't shared by many of our foreign trained doctors who get their medical education free, to the huge expenses of running a medical practice starting with the litigious nature of our society. It also brings up a couple of points that you may not have thought about before.

Talking heads often complain that the U.S. has the highest per capita costs for healthcare in the world. The writer's retort is, so what? The U.S. is the richest country in the world. We have the highest expenditures of everything from national defense to leisure activity to charity giving. Should we cut back on all those other costs to match other countries?

They also note that American doctors are drawn from the best and brightest students our school system has to offer. These students could literally choose anything else to become yet they decided they wanted to go heavily into debt to help other people while facing the peril of a malpractice lawsuit with every single customer (patient) they encounter. These kids could have gone into a field that pays even more money with less risk of being dragged into court such as a Wall Street trading desk. Instead they chose the longer and harder road of becoming doctors. Wall Street applicants aren't as likely to make it into medical school even if they wanted to.

The article finishes with a quote from the legendary Chicago columnist Mike Royko, "Let us talk about medical care and one of the biggest problems we have. That problem is you, my fellow Americans." If it wasn't for all the bad habits carried on by Americans, there wouldn't be so much need for expensive healthcare to keep us alive.

So don't argue with your detractors with raised voices and poor me hardship stories. There are plenty of cold hard facts to refute the ignorance of critics who only look at doctors as the source of the high costs of American medicine rather than looking into a mirror.

Bitcoin Envy Hits The Nurses' Break Room

By now you've probably heard about bitcoin and its road to instant riches. The cryptocurrency has risen from practically nothing a couple of years ago to over $9000 per coin today. Its value has increased nearly 900% this year alone. I won't go into detail about what bitcoin is or how it was invented by one man out of practically thin air. You can read about its origins here. Needless to say I'm kind of an old fart and have not jumped on the bitcoin bandwagon which is probably just as well as that train left the station months ago. I'm perfectly satisfied with the unfashionable way of wealth accumulation such as real estate and stocks.

But that doesn't mean that plenty of other people aren't willing to jump on for that heady ride. Today in the nurses' break room, I saw plenty of envious eyes as one young tech savvy nurse held court. He was extolling the virtues of his bitcoin investment made a few months ago when it was less than $2000. He was throwing out terms like Mt. Gox and ethereum as the other nurses hung on his every word. He was already talking about cashing out and retiring on his newfound bitcoin wealth.

I could see the sad resignation in the other nurses as they realized they had missed the investment of a lifetime. They all talked dreamily about how wonderful it would be if they could retire right now. How smart that young nurse was to invest in something that could allow him to stop working at such a tender age. Soon somebody piped up and said, "It's not too late!" Sure it is currently about $10,000. But who's to say that it won't double again in the next few months.

As their breaks finished, they headed back to work, shoulders slumped, as they had to face the reality that they missed their chance at stupendous bitcoin riches. They'll just have to retire the old fashioned way, with hard work and diligent savings. As the religious writer Nathan Whitley says, "The pain of regret is far worse than the pain of discipline."

Good News--American Students Just Don't Give A F**k

Remember all the angst that were expressed when American high school students did poorly on standardized tests compared to their international peers? There was much debate about the quality of our educational system, our culture that prized jocks while demeaning nerds, and our high income inequality that lead to underperformance in economically disadvantaged students. Now another study seems to show that maybe it's the American students themselves who are responsible for their low test scores. They just don't give a damn.

In a paper released by the National Bureau of Economic Research, scientists conducted a study comparing two groups of 10th graders in Massachusetts against similar high school students in Shanghai, China taking the same standardized tests. In a twist, half the students in each country were given a financial incentive to do well. One group of American students were told they would receive $1 for every correct answer while the control group got no money for taking the exam. The Chinese students were given the same deal.

And guess what, the American students who were given money did better than their classmates who received no money. However the Chinese students didn't show any improvement when money was offered. What did the scientists conclude? American students are raised like true capitalists. They are incentivized by cold hard cash. If in the previous international testing the Americans had achieved the same results as the paid students, the U.S. standing would have risen from 36th to 19th. Not top ten but still a huge jump. Americans just don't seem to care when taking a test that has no personal consequences.

By contrast, the Chinese students seemed to have had the test taking mentality drilled into them from early on. In a culture where a single test in high school can determine one's fate for the rest of their lives, testing is an all consuming event and takes precedence over every other daily activity. So yeah you can say that testing is very important to Chinese students. Not so much for American students.

So perhaps we shouldn't be so defeatist when we look at our education system relative to other countries. Our students are pretty smart. They're not going to give their best effort without some sort of reward for doing so. They're not test taking robots that other nations have trained their children to become. They just need to be bribed to do their very best, just like the rest of us. USA! USA!

The Day Everybody Is A Full Stomach

NPO after MN is not going to help after this meal.

Let's not even pretend that on the day after Thanksgiving people can truly achieve an empty stomach before surgery. Unless the patient had a bowel prep for colon surgery or skipped Thanksgiving dinner completely, there is no way the stomach can have emptied in time by first case of the morning.

Our family changed our holiday meal tradition this year by having a big lunch at a restaurant instead of a homemade dinner. It really is a nice alternative as it frees up the rest of the day to watch football, play outdoors when there is hardly anybody outside which is a rare event in a big city like Los Angeles, or prepare for shopping. Plus the house is not a total disaster afterwards. After over 18 hours since our meal, my stomach still feels full and I have a persistent heartburn that just won't quit.

Now imagine your patient who decided to eat their Thanksgiving dinner and then followed the preop instructions by staying NPO after midnight. With all the meats and fats in the food, there is no way that their stomachs will not still have food inside. If the patient is having a general anesthetic with intubation then it shouldn't be a problem as long as they're done under rapid sequence induction. But for cases where the airway is not protected, such as interventional radiology or cath lab, then I'd be concerned about a high potential for a full stomach.

This raises the question of why surgeons would schedule cases for the day after Thanksgiving. And why would patients want to have surgery on this day? Unless it's an emergency, there doesn't seem to be a good reason to skip a holiday tradition to have an elective operation. It can always wait until next week so patients and their families can enjoy their time together over a long weekend. Why would anybody want to schedule a spine or even a major vascular case for today?

I suppose everybody has different priorities. Some patients just want to get better sooner instead of agonizing over their operations over a holiday weekend while some surgeons need the extra cash for their holiday shopping. Whatever the reason the operating rooms are full today as if this is just another usual Friday. Except on this day most of the patients will have food retained in their stomachs so be careful out there.

Thanksgiving In Los Angeles

We achieved record high heat this Thanksgiving day. Temperature was in the 90's all throughout LA. I'm glad we decided to eat out rather than slaving away in a hot kitchen. Doesn't feel like late fall weather but that's just the price we have to pay for living in Southern California. Yes it's just another day of sun.

On This Thanksgiving, Let's Be Thankful For...Anesthesia

We often take modern medicine for granted. People just assume that if they get sick they can go to their nearest hospital and expect to be treated and released within a reasonable amount of time. We forget how primitive medicine has been for most of human history.

Anesthesia is frequently not even the main concern of patients when they come for surgery. They have zillions of questions for the surgeons but the only thing they want to know from the anesthesiologist is if they will be completely asleep for the procedure. If it wasn't for Michael Jackson's notorious death from propofol, most people would have no inkling of what anesthesia is.

However, there is a reason that anesthesia was voted the most important advancement in the history of medicine by the readers of the New England Journal of Medicine, which means just about every significant physician in the world. We forget how agonizing, harrowing, horrifying, horrific, was the suffering of patients who had been through surgery. People would prefer to die than to go under the knife.

Anesthesiology News has a story of the written accounts of people who had to suffer through surgery without anesthesia (membership required). Reading them will give one the chills and make you thank your preferred deity that you live in an age where anesthesia is readily available.

George Wilson, a chemistry lecturer at the Royal College of Surgeons in Edinburgh, Scotland had to undergo a Syme foot amputation in 1843 by Dr. Syme himself. He described the agony as, "Suffering so great as I underwent cannot be expressed in words, and thus fortunately cannot be recalled. The particular pangs are now forgotten, but the black whirlwind of emotion, the horror of great darkness, and the sense of desertion by God and man, bordering close on despair...I can never forget..."

The great evolutionist Charles Darwin attended medical school at the University of Edinburgh in 1825. He was present at two surgeries, including one of a child. But he was too traumatized by the experience and had to leave before they were finished. He said he was "haunted" by the experience for a long time.

Michael Furnell, who trained at London's St. Bartholomew Hospital in 1846 described the case of a young girl who suffered severe burn injuries resulting in contractures of her neck, making it difficult for her to eat. After she consented to surgery, she was tied down to the operating table, "but before many minutes of the operation had elapsed, her cries and entreaties to be untied and allowed to remain as she was were the most frightful that can be imagined. As the operation, which was necessarily a lengthy and slow one, proceeded, her cries became more terrible; first one then another student fainted."

These and other first person tales would probably deter most students today from going into medicine if they had to witness them in person. The suffering that patients had to endure for the slimmest chance of survival is unimaginable in today's world. So as we give thanks this holiday season for all we have, let's not forget the advancement that has allowed medicine to move beyond the Victorian age, the modern miracle of anesthesia.

iPhone X Face ID Doesn't Work In The Operating Room

Well this is one way to discourage anesthesiologists from looking at their smartphones all the time. As you probably already know, the new iPhone X dispenses with the old reliable home button with its fingerprint sensor and instead uses Face ID. Now instead of using your trusty fingertips to conveniently unlock your phone, the phone recognizes your face to unlock itself. Apple claims it is orders of magnitude more secure than the old Touch ID.

After using my iPhone X for a few days, I find that Face ID is usually reliable and incredibly fast when it works. However there are two locations where the technology has difficulty functioning properly. They are also unfortunately two areas that I use my phone pretty regularly. One is in my car. The dashboard mount on my car has to be pointed exactly at my face for the phone to unlock. Even then it doesn't always work. Since the phone is in the center of the dash and slightly below eye level, and not directly in front of my face which would obviously be a driving hazard, it regularly doesn't recognize me. I wind up having to pick up the phone to type in the passcode since it is difficult to type in a string of characters on a glass screen in a moving car that is off to the side of your visual field. The worse alternative is if I awkwardly hold the phone directly in front of my face to unlock it while driving which is illegal here in California. Apple is making a criminal of me while I'm using their product.

The second more serious issue is in the operating room. This really should come as no surprise but it is still incredibly annoying. When you wear a mask in the OR, your brand new, very expensive, iPhone X doesn't recognize you at all. I can't really blame the phone for not being able to tell who I am under the mask while wearing a surgical cap. Sometimes even I have trouble recognizing people when they're wearing masks. Every time I punch in my passcode to unlock my iPhone I wish the X had the ability to unlock with either Face ID or Touch ID. How difficult would it have been to put in a fingerprint sensor somewhere on the phone like what Samsung Galaxy S8 has?

So now when I have the phone sitting flat on the anesthesia machine writing desk, I have to pick it up to either type a passcode or look into the Face ID if I'm not wearing a mask for a procedure. This is much more cumbersome than just pressing my finger on the home button with my old phone to instantly check messages and notifications.

Every new technology comes with adjustments and growing pains. The Face ID advancement seemed like a panacea for convenience and security. Unfortunately it will take some getting used to as I have to readjust my routine just to unlock my phone.

The Hopelessly Ambiguous ASA Classification

I've ranted before about how ineffective the ASA classifications can be to evaluate patient morbidity. The American Society of Anesthesiologists is well aware of how ambiguous the different levels of the system can be to categorize patients. They have even published examples of patients in each level to help physicians understand how to organize different scenarios. Despite that, there is still much confusion among physicians, even anesthesiologists who should know this system better than anyone else.

A wonderfully illuminating study was published in "Anesthesia & Analgesia" that looked at how different patients would be categorized by physicians. Just in case you don't know what the different ASA scores are, there are six levels, ranging from one in a perfectly healthy patient to a six, who is considered brain dead. You may want to read the link to the ASA first if you don't understand it.

In the study, 235 anesthesiologists and 101 trauma surgeons were queried about eight different scenarios. They are:

1. Previously healthy patient with hemorrhagic shock.
2. Morbid obesity with non life-threatening injury
3. Brain dead organ procurement
4. Massive trauma
5. Healthy elderly patient with minor injury
6. Hemorrhagic shock in a Jehovah's witness who refuses blood transfusion
7. Previously stable patient with septic shock
8. Intracranial hemorrhage with mass effect

In none of the eight stories was there a consensus where everybody agreed on a single ASA score. In fact, #3, which might obviously belong to ASA 6 was classified by physicians from ASA 1 all the way to ASA 6.

One of the problems is that there is no clear instructions from the ASA about whether the ASA classes relate to the preinjury condition of the patient or postinjury. They found that 72% of the physicians think the ASA scores refers to postinjury status of the patient while 27% think it is preinjury. Over three quarters of anesthesiologists use the ASA scores to indicate postinjury status while 62% of surgeons did. Therefore it is conceivable that a perfectly healthy young person who suffers a brain death injury, an ideal organ donor, could be classified as ASA 1. But for the smattering of respondents who called #4 or #8 an ASA 6, they really need to go back and review the definition of brain death.

At least the anesthesiologists were more in agreement in how to use the ASA scores. They were more in consensus than the trauma surgeons or the combined anesthesiologists and surgeons. However that didn't prevent one anesthesiologist from scoring #8, an obvious life threatening condition, as ASA 1.

So it looks like the ASA has a lot more work to do to educate physicians, and the members of the society, how to properly use the ASA classification. However, attempts at education may be futile since getting anesthesiologists to agree on anything is like herding cats.

Green Potatoes And Other Dangerous Foods

Just in time for Thanksgiving. Medscape has published a list of the eleven most dangerous foods to eat. Naturally some are pretty exotic like the puffer fish that you might find at high end sushi restaurants. Who hasn't heard stories about the poor soul who ate an improperly cleaned puffer fish and developed muscle paralysis and died. That is the whole thrill and reason for eating it, the ability to cheat death.

But you may not have heard that more common foods found in nearly every American pantry can also cause devastating illnesses and death. The homely nutmeg contains myristicin, a toxin that can cause hallucinations and seizures with as little as one nut. Apparently some teens use it as a readily found mind altering drug to induce "nutmeg psychosis."

Remember when you were a kid and you opened a bag of potato chips? There always seemed to be a few chips that had a greenish discoloration to them. You worried whether they were okay to eat or if they were poisonous. You wound up eating them anyway but now we know potatoes that have turned green can be dangerous. Green potatoes contain high levels of glycoalkaloids. Consuming too much can lead to vomiting, diarrhea, and even death with as little as 3-6 mg/kg of body weight.

So peruse through the list if you don't want to accidentally poison your families and guests during Thanksgiving. And I'd be careful about serving any tropical fruit salad.

How Homophobia Affects Anal Hygiene

Please use properly and frequently.

Okay, I didn't know this was an issue until I read this article in BuzzFeed. Apparently some men are ignorant or intolerant of proper anal hygiene. The piece has excerpts of social media posts describing the horror of people who have encountered partners who don't quite know how to clean themselves after defecation.

One recently married woman complained that she noticed brown stains on his white underwear. She also found poop stains on their bedsheets after intercourse. When she complained to her newlywed husband about it, his angry reply to her was, "a real man doesn't go in between his cheeks or spread them open for anything. Men do not spread there (sic) cheeks to wipe or clean...nothing goes between them." Makes me want to take a shower with Purell after reading that. There are a lot more anecdotes like that, including one woman's solution using a tampon pad.

Moms, and dads, please educate your boys on the proper way to wipe themselves after going #2. And men, it is not a sign of homosexual tendencies to clean yourselves between the butt cheeks and even at the anal surface when going to the bathroom. Remember the old adage about wearing clean underwear before going out? Well it doesn't matter much if your butt is covered with old poop so wipe those butts.

CRNAs Hijack State Licensure

The audacity of advanced practice nurses, which include CRNAs, knows no bounds. And in this case, no state borders. The National Council of State Boards of Nursing has developed a blueprint they are trying to advance in state legislatures to allow APRNs to practice in a state without actually being officially licensed to work there.

The NCSBN is advocating legislation called an APRN Compact. If a state approves the Compact, then an APRN who is licensed in another state which also is in the compact will automatically be allowed to work there. It also allows the APRN to write prescriptions for controlled and non-controlled substances in any state within the Compact. The Compact specifically says if a state in the Compact allows APRNs to work independently without physician supervision, then all states in the Compact will do the same, even if the state had not previously given this privilege to nurses.

I don't understand why any state would get sucked into this hoodwink. Why would a state allow somebody to practice there without a formal licensing review? Physicians certainly don't have that ability, and we have thousands of hours more training and undergo far more rigorous reviews before being licensed to practice. It seems like a recipe for disaster if a nurse can leave a state under a cloud for poor performance and instantly start working in another state since nobody at the state level would have reviewed their records.

Currently the APRN Compact has been approved in three states: Idaho, Wyoming, and North Dakota. It will start taking effect once ten states have approved it. The ASA is urging the AMA and other medical societies to counter this confiscation of government oversight and physician led patient care.

Which Doctors Are Most Likely To Get Sued?

Medscape has released its report on medical malpractice in 2017. The survey was taken from over 4000 physicians who responded to their poll. The results show that the top five specialties most likely to be sued are Surgery, OB/GYN, ENT, Urology, and Orthopedics. Over 85% of surgeons and OB have been involved in litigation. Anesthesiology, formerly one of the most notorious specialties for getting sued, drops in at a humble tenth place with 61% having been sued.

Of course the more often one is getting charged, the higher the malpractice insurance premiums will rise. Unfortunately for general surgeons in New York City, their premiums are over $141,000 per year. OB is even great, with almost $200,000 of their hard earned money going to insurance companies. That is an astounding amount of work that's required by the doctor just to pay insurance companies.

Luckily most doctors aren't sued that often. Almost half have faced less than five lawsuits in their careers. An unlucky 2%, have faced ten or more. Maybe those doctors shouldn't be in medical practice at all.

The most common reason a suit was brought against them was failure to diagnose or delay of diagnosis. This occurred about one third of the time. The next most common complaints that lead to litigation are complications from treatment or surgery, poor outcome, failure to treat, then wrongful death. Everything else only occurred in single digits.

A vast majority of the doctors, almost 90%, felt that the lawsuits were not justified. Almost half didn't think the inciting incident warranted a malpractice complaint. They were completely caught off guard when they were filed with the legal paperwork.

It's not just the mental stress that causes physicians to despise trial lawyers and their pesky lawsuits. It takes a huge toll on the time that could be used to see patients or be with families. While many doctors spent 10-20 hours preparing for a case, one third spent over 40 hours to get ready to face the court. A plurality of 39% said they spent 1-2 years involved in one case while an unlucky 10% took over five years to resolve their cases. That's years of their lives they will never get back.

And most of that time was spent for naught. The doctors only lost 2% of their cases, either with a guilty finding or they settled out of court. And when they lost or settled, about one third had to pay out $100,000 in damages. Another third reached $500,000.  Though we often hear about blockbuster malpractice lawsuits that were lost for millions of dollars, only a very small minority of verdicts reached seven figures.

This survey has tons of other data to go over. If you're a doctor who is concerned about medical malpractice, and every doctor should be, it is well worth reading through the entire poll.

Maybe He Can Be A CRNA

The Wall Street Journal has a great article about how quickly one can learn to do things if you're totally dedicated to a single task. Max Deutsch, a 24 year old college grad from San Francisco decided he would set up a series of goals for himself for one year. He would dedicate one month to complete each of them before moving on to the next one. The idea was to make each job so outlandish that he would most likely fail. Surprisingly he has been successful at each item he has tackled. He has taught himself fluent Hebrew, standing backflips, and memorizing a shuffled deck of cards, all in one month each. His college roommate said Max is the fastest learner he has ever met.

His greatest challenge was to defeat a chess app simulation of chess grandmaster Magnus Carlsen. To his surprise, a WSJ reporter relayed this story to Mr. Carlsen who agreed to play Max in person. You'll have to read the rest of the article to see how he prepared himself for this incredible meeting and the surprising result. Heck, if this guy studied anesthesiology for one month, he could probably qualify to be a CRNA.

The Hardest Part Of Being An Anesthesiologist, Part 2

In the first part of this series, I opined on how the anesthesiologist is not in fact the patient's savior in Preop Holding, unlike what another blogger may have written. There are much harder and more frustrating aspects to anesthesiology than holding a patient's hand. Here, in no particular order, are what I think are some of the more difficult characteristics of this job to get used to.

1. Early morning work hours. If you're a night owl like me, this is a tough transition that your body never really gets used to. Getting up at 5:00 AM to get ready to go to work is not a natural activity for most people. Even now, on weekends I allow my natural circadian rhythm to get me to bed by 1:00 AM and wake up around 8:00 AM. So weekdays are a struggle to get myself into bed early enough to get a good night's sleep. Of course I know some colleagues who are natural early risers and get up at 4:00 AM to go for a brisk morning run before work. I hate them.

2. Unpredictable work schedule. If you're looking for a 9 to 5 job, anesthesiology is not for you. Sure you can find some locations like at academic centers where you do more predictable shift work and are more likely to go home at a set time. But in academia you have other activities to keep you working long hours like giving lectures and attending endless faculty meetings. Most anesthesiologists in private practice have to do the cases the surgeons are booking for that day. One day your work may be done by 1:00 PM. Another day it could be 8:00 PM. And there is no way to tell more than 24 hours ahead of time what kind of day you'll have. You wind up missing a lot of dinners and occasionally surprising your kids when you are able to pick them up from school. It's just that kind of job.

3. You're not in charge. Surgeons bring in the patients who bring the money to the medical facility. They have all the leverage to run the OR as they see fit. You can't dictate when to start the day or when it should end. You don't get to tell people what kind of case you want to do today; you do whatever is offered. Calling in sick is a huge burden because it's not like they have a spare anesthesiologist just sitting around to pick up the work. So if you're an assertive person who doesn't like being told what to do, this isn't the field for you.

4. You feel more dispensable than you would like. You earned your medical degree like every other doctor. You spent years getting trained and board certified to practice anesthesiology. Yet once in practice you'll often get the feeling you're opinion is not taken seriously. A common lament is that if you try to cancel a case, the surgeon will simply ask for another anesthesiologist. It's as if all your years of medical training to provide the safest patient care means nothing. Unfortunately, some of your colleagues will betray you and agree to do it, making you feel small and stupid. Yes you probably did the best thing for the patient but the patient probably did fine during the case. The same can't be said for your reputation in the OR afterwards. You've now become the anesthesiologist that likes to cancel cases.

5. High stress levels especially when on call. Anesthesiology is a high stress career to begin with. Patients can unpredictably crumple within seconds and you have to know how to deal with it. When you're on call, it is ten times worse. The difference is that elective cases are usually on healthier patients and you've had time to evaluate the cases hours beforehand. When you're on call, it can be anything that rolls through the OR doors. It could be procedures as diverse as a five year old with post tonsillectomy bleed to a ninety year old with a fractured hip. A crash C-section on a drug addicted mother to twenty something year old gangbanger with multiple gun shot wounds to the chest and abdomen. While the surgeon only operates on the part of the body he is trained to work with, the anesthesiologist has to be a master at everything. Talk about high stress.

6. You have to act cheerful all the time. The surgeon and the patient get to be grumpy. But nobody likes a dour anesthesiologist. You can't have mood swings and yell at the OR staff like surgeons can get away with. You're supposed to have a calming pleasant personality that's just borderline dull so that everybody in the room feels reassured. A loud angry anesthesiologist will not last in his job for very long. Same can't be said about surgeons.

7. There is very little patient rapport. As I previously mentioned anesthesiologists are the staff with the least amount of time to spend with the patient. The patient loves their surgeon and that's why they're having a procedure with him. The nurses usually have more time to talk with the patient in preop and establish a relationship. You're lucky to get in three questions in preop before people start pacing impatiently to get the case started. That's why around Christmas time the surgeons and nursing staff get all the gifts from patients and the anesthesiologist (who the patient rarely recalls) get to watch other people open them.

8. And finally anesthesia is a very isolating job. If you're used to the team approach in medicine as a resident, you'll quickly discover that anesthesia is a one man show. While internists and surgeons run around in packs, the anesthesiologist walks alone into the operating room and goes home alone. We have no idea what is going on in the OR next door to us. All our cases finish at different times so it's almost impossible to get colleagues together after work to hang out. So if you feel lost without your posse around, anesthesia is not the job for you.

Now don't get me wrong. I love my job as an anesthesiologist. In fact, anesthesiology is considered one of the best jobs in America. However, anyone contemplating going into this field should go in with eyes wide open and understand that it, like any other medical field, has its advantages and disadvantages. Despite this list, for me the rewards of anesthesiology far outweigh the negatives.

The Hardest Part Of Being An Anesthesiologist, Part 1

When I saw the headline in KevinMD, "For an anesthesiologist, this is the hardest part of medicine," I thought, great. Somebody is finally voicing their frustrations with the the practice of anesthesiology. I figured maybe I can learn something from this person's career difficulties and how they overcame it. What I got from the article was not what I expected.

The article is what JK Rowling might describe in the UK as treacly or here in the US as cringy. Its saccharine depiction of the author's encounters with patients in preop made me roll my eyes until my extraocular muscles felt like they might rip off my eyeballs. Dr. Sasha Shillcutt, a cardiac anesthesiologist, describes that when she shakes hands with her patients, they are so scared that frequently they won't let go. She portrays herself as the patients' and their families' medical hero because, well, the surgeon and the preop nurses are just too busy running around to really listen to their concerns. It's the anesthesiologist to the rescue since nobody else in the entire OR suite has the time or the humanity to sympathize with the abject fear the patients are silently experiencing.

I'm sorry but I don't have the same experience. Yes the author can write whatever she wants on her blog, but let me inject some reality into this situation. It's usually the anesthesiologist who is running around like crazy before surgery. Especially for cardiac cases, we arrive in the OR at an ungodly early hour to check our machines, draw up drugs, mix bags of more drugs, and do fifty other things to get ready for surgery. Then we rush to Preop Holding to do a quickie five minute evaluation with the patient and start the IV. We are the member of the OR team that has the least rapport with the patient and their family. The surgeon will presumable have already had a decent relationship with them when he saw them in his office and explained the procedure to them. The preop nurse has had about thirty minutes of undivided attention to sit there and discuss with the patient their history and other concerns. We are the ones who rush in, say a quick hello, and quickly rattle off the anesthetic plan, which for most patients means they will be sleeping during the case. That's usually as specific as patients want to know about anesthesia.

So, no. The hardest part of anesthesiology is not comforting a scared preop patient by shaking their hand. I'll tell you what are really the hardest parts of anesthesiology in the next article.

Sexual Harassment And CPR

Researchers from the University of Pennsylvania have discovered that women are less likely to receive cardiopulmonary resuscitation from a bystander than men. The study, presented at the American Heart Association conference in Anaheim, CA, looked at over 20,000 cases of people receiving CPR following cardiac arrest.

They found that only 39% of women received CPR when they arrested versus 45% of men. The men were also 23% more likely to survive than the women, likely because they were more likely to get the maneuver done. The researchers speculate that people are too embarrassed to put their hands on a woman's chest to initiate CPR. Even though the proper placement of the hands is on the sternum between the breasts, many people would be hesitant to do that on a stranger, even if they are dying in front of their eyes. Virtually all training videos and mannequins show a male torso being given CPR. There are almost no female torsos shown. If the American Heart Association is too prudish to demonstrate CPR on women, is it any wonder the general public would feel the same?

In this era of rampant reports of sexual harassment, when women seem to be coming out of the woodworks decades after a potential encounter to finger blame on a male perpetrator, who can blame them for the reluctance. The question becomes will you watch a woman die in front of you because you are afraid of a potential legal suit if she lives or will you do the right thing and save a life? I think the answer is pretty obvious.

#CanadaWAITS For Single Payer Healthcare

This is for all those people who just love the idea of single payer healthcare. They believe having the government take over a country's medical system is the right thing to do because, well, healthcare is a human right and thus should be free. Well, let's just go back to kindergarten and relearn the concept that nothing is free in this world. Not even your parents'or your government's love.

A new hashtag was created called #CanadaWAITS by a Canadian author, André Picard. He wanted to hear how Canadians fared with their government run healthcare. And did he get an earful. His twitter page is filled with hundreds of people's stories who waited months, even years to be seen and treated by doctors.

Total time from referral to OR: 2.5 years in which every step patient takes is in excruciating pain; rationing of ORs means #CanadaWAITS https://t.co/XeXRvky91k

— Deepa Soni, MD (@drdeepasoni) November 4, 2017

In the meantime, over in the UK, where they are so proud of their single payer system that they featured it in the opening ceremonies of the 2012 London Olympics, the government is starting to play its inevitable role as rationer in chief. The National Health Service has decided that patients who are obese or actively smoking cannot have elective surgery unless the patient fixes these defects in their personality. Granted this will take place in only one small district. However, the district is expected to save £68 million. And if you're the government who is paying everybody's medical bills, you're going to try to find savings anywhere you can, even denying healthcare for people who are less desirable because of their social habits.

So next time you attend a Bernie Sanders rally, just remember that single payer healthcare sounds great on paper. But you totally lose control of your medical care to some faceless bureaucrat who couldn't care less if you don't get timely care as long as it saves them money.

The Best States To Practice Medicine.

Physicians Practice has compiled a list of the top five best states to practice medicine (requires membership to read the whole report). The results are surprising, to say the least. They are:

1. Mississippi
2. Texas
3. Alaska
4. California
5. Arkansas

They made their list based on the cost of living, the tax climate, physician density, and the Medicare Geographic Cost Index. Based on these criteria, it's astounding that California isn't at the bottom of the 50 states for desirability. We have some of the highest cost of living anywhere. We have the highest state income tax in the nation. Along the coast where people want to live, it seems like half the kids in good schools have physicians as parents so the competition for patients can be intense if you're just starting out. And the Medicare reimbursement really isn't high enough to compensate for the high costs of everything else in the state. But if you can afford it, and you don't mind having a lower standard of living considering your sizable income, California is a beautiful place to live.

Joint Commission Sued For Opioid Crisis.

This couldn't have happened to a nicer group of bureaucrats. The state of West Virginia, which has the highest rate of drug overdoses in the country, is suing The Joint Commission for instigating the opioid epidemic plaguing the nation.

The lawsuit is based on the TJC's recommendations in the early 2000's to aggressively treat a patient's pain symptoms. Since the TJC has the power to shut down a medical facility if it didn't follow their recommendations, their suggestions were essentially blackmailing physicians to do what they wanted. They urged doctors to make sure patients were "free from pain." They pushed the so called "fifth vital sign" which had the consequence of making doctors prescribe narcotics far more frequently than otherwise.

However, few people knew that the TJC's pain recommendations were based on studies that were sponsored by drug companies such as Purdue Pharma, maker of OxyContin, and Janssen Pharmaceuticals, maker of Duragesic.

I'm glad somebody is finally calling out The Joint Commission's power over healthcare with little accountability. I've bemoaned the senseless rules they have imposed on our hospital in the past that have no relationship to any legitimate study on patient safety. If they are going to make up rules that affect the practice of medicine and patient care, they better be able to stand by them in the court of law. Otherwise, the government needs to look into the TJC's monopoly power to hand out hospital accreditations without any official oversight. This is truly an organization that has run amok terrorizing medical facilities with no recourse for the hospitals who may disagree with its demands.

CRNAs Are Smarter With Money

We doctors think we're so smart, with our years of medical training and our precious hard earned degrees hanging on our office walls. But economically, it makes little sense anymore to go into medicine and hope to get rich. While the income is certainly in the top 1% in the country, the six figure debts that are incurred severely hinders physicians' ability to get ahead.

By contrast, CRNA's have it all figured out. PayScale, the compensation tracking company, has declared that a CRNA degree is the most lucrative master's degree in America. With a two year degree, a CRNA can earn anywhere from $143,000 to $165,000. The second most lucrative master's degree is for telecommunications engineer with a median of $141,000. The reported CRNA salary is comparable to Medscape's APRN Compensation Report where survey respondents average $182,000. If they get a PhD, they will make even more money.

The nurses who get CRNA degrees have a work history prior to getting their master's. That is one of the prerequisites of getting into the program. Therefore they have some savings cushion when they go to school to get their degree. Since the program is only two years long, CRNA's usually come out with close to $100,000 in student debt.

By contrast, most medical students go straight from an expensive undergraduate program to an even more expensive medical program, with zero income to show for all that training.  Even after medical school, their incomes are a pittance for years as they go through residency and fellowships, frequently shouldering hundreds of thousands of dollars in student loans.

As physician compensation continues to be pressured downward and the cost of the training rises inexorably, the economic rationale for becoming a doctor makes less sense. It truly becomes a calling, like going into ministry, to get a medical degree. Maybe it is the CRNA's that are really doing it for the money.

Anesthesiologist Who Treated Texas Shooting Patients

The New Yorker has an interview with Dr. Maxim Eckmann, an anesthesiologist who was on call at University Hospital in San Antonio when the victims of the church massacre started coming in. It's professionals like Dr. Eckmann who keep calm and collected when seconds count and lives are saved. Thank you for being there when your patients needed you the most.

How To Prescribe Medical Marijuana

Algorithm for prescribing marijuana.

Did you miss your cannabis pharmacology lecture in medical school? Were you too busy following your Facebook friends when your attending described how to prescribe marijuana during morning rounds? If you did and you have no idea how to get in on the lucrative medical marijuana business, the Medical Board of California has good news for you.

The Board, along with coauthor Governor Jerry Brown, has published a short, concise pamphlet on how to prescribe medical marijuana. It is only six pages long, not counting the diagram at the end. Why are they publishing information about a drug that they clearly state in the pamphlet is "an illegal substance under federal law"? Because California voters approved way back in 1996  Proposition 215, which made it legal for people to acquire marijuana for medicinal purposes. It's taken 21 years for the Medical Board to finally establish instructions for physicians "who choose to recommend cannabis for medical purposes to their patients, as part of their regular practice of medicine, that they will not be subject to investigation or disciplinary action by the Board if they arrive at the decision to make this recommendation in accordance with accepted standards of medical responsibility." In other words, it's another way for California to thumb its nose at the feds, like so much else it's been doing since the presidential election last year. If a doctor gets in trouble with the federal Drug Enforcement Agency for prescribing marijuana, he can point to the publication from the Medical Board to prove that he was following strict guidelines made by the state. So there. Nah Nah.

Of course the instructions don't actually tell you how to specifically write for a marijuana prescription. The reason is that marijuana has no proven medical purposes. It's almost all anecdotal as there are no controlled studies for how weed might help patients. As it states, "At this time, there is a lack of evidence for the efficacy of cannabis in treating certain medical conditions" such as patients with cancer, AIDS, anorexia or chronic pain.

The purity of the leaves the patients eventually buy are lacking. It's not like a regular pharmaceutical that has undergone years of clinical trials to arrive at the precise dosage necessary to treat a specific medical condition with minimal side effects. One sample of pot will almost certainly contain a different amount of active ingredient from another sample even if they're both from the same plant. So how can the Medical Board possibly instruct physicians on how to prescribe marijuana?

Instead most of the guideline just goes through the usual patient-physician interaction that you learned when you first started your clinical rotations in medical school. Things like how to document the patient's health, how to make an informed decision on choosing marijuana, discussing alternative therapies. Yada yada yada. When a patient goes to a doctor looking for a marijuana prescription, I don't think they are the least bit interested in discussing alternative therapies.

Regardless of how effective these guidelines are, the sclerotic Medical Board has already missed the boat when the state's voters agreed to allowing recreational marijuana use last year. Starting in January, any adult can purchase pot without a prescription. The state is already anticipating billions of dollars of new taxes. Doctors can then get out of the business of cash for prescriptions that has become a source of shady income for some.

Sen. Paul Assailant Pleads Not Guilty.

Next door neighbors in their gated mansions in Bowling Green. 

Retired anesthesiologist Rene Boucher pleaded not guilty in court today for attacking his next door neighbor Sen. Rand Paul. Dr. Boucher was charged with fourth degree assault which carries a possible one year jail sentence.

However the charges may be upgraded to a felony due to the severity of the injuries. Sen. Paul revealed that he actually has SIX rib injuries and hemothorax around his lung. That was some tackle. The FBI is also investigating since this was an attack on a federal public official.

Too bad the senator and the anesthesiologist are not on speaking terms anymore. Since Boucher is a pain specialist, he could have given him a few intercostal blocks to ease his pain. But I don't think Sen. Paul will be inviting his neighbor over for beer and basketball games anytime soon.

Medical Emojis

Emojis are awesome. I love how they can graphically replace a long string of words with one single image. With the new animojis on the iPhone X, they are going to be even more fun to use than ever. Medical related emojis aren't that well represented. However there are some that could stand for different medical fields. Here are a few examples:

Surgery

Internal Medicine

Pediatrics

Gastroenterology

Pathology

Anesthesiology

Ha ha. Just kidding.

LOL

This Is The Dumbest Way To Conduct Residency Interviews.

I'm not sure why I never noticed before, but I finally realized that my fourth year medical students were paying hardly any attention in the operating room. Instead they were glancing at their smartphones incessantly every few minutes. I thought maybe these millenials just can't stop checking their Instagrams even at work. But then one of them told me up front that he will be on his phone to check his emails for any residency interviews that might be offered and will be distracted the entire time.

Why? Don't they just send out a letter informing you that you were accepted for an interview? He just kind of rolled his eyes and looked sympathetically at me like I was his senile grandfather. He explained that these days, residency programs will send out mass email to everybody they find acceptable for interviews. However there are not nearly enough spots in the program for everybody they invite. Therefore only the first few people who answer the emails will get the interview. He had several friends who missed out on interviews at coveted programs because they were busy and didn't reply to their emails within 30 minutes of receiving them.

I was astounded by this revelation. Just to confirm that the first student wasn't pulling my leg, I asked another student in a separate room and who didn't know the first one, if this was true. She said yes. During these program interview months they are constantly checking their emails. But how do you know when to look? She said it depends on where the residency is located. If they are on the East Coast, the acceptance email may arrive on the West Coast at 5:00 AM Pacific time. Conversely for those on the East, the West Coast programs may send out their emails when it's 8:00 or 9:00 PM Eastern time. Essentially they are locked to their smartphones from the time they get up until nearly bedtime.

I don't know when or how this started and I'm not sure why it's done this way, but I have to say the way medical residencies send out invitations for residency interviews is one of the stupidest ways I can think of to find future physicians. When did finding our best and brightest doctors turn into a radio call in contest where the first ten callers get tickets to the Bruno Mars concert?

It just doesn't seem fair that after years of hard exhausting work, these kids may miss their number one choice for a residency because they were actually paying attention at the hospital. Some of our students have travelled thousands of miles and spent thousands of dollars to come for their externships. It's really not right they waste all those resources checking their email accounts when they should be trying to impress us to get into a residency. 

I'm really surprised the ACGME allows this conduct to occur. They should be looking after the medical students' best interests. The students gain nothing during the important autumn months of their fourth years if they're worried they may miss the most pivotal interview of their lives because they put the phone down to go to the bathroom. How can the residency programs care so little about the crucial fourth year medical education? They are just being too lazy to conduct a proper vetting of the applicants who they really think will do well at their programs. Maybe they should go back to snail mail like back in my youth. Our medical students are getting no favors with this "Survivor" method of choosing their careers. The future of medicine deserves better than this.

My Experience With Propofol Frenzy

The Mayo Clinic Proceedings recently had an informative article on a condition called propofol frenzy. This is a state where propofol has an unintentional effect of causing increased agitation rather than the expected sedation. I wish this article had arrived a few months earlier because I was flummoxed by a patient with the exact same problems.

I had a female patient describe to me how she always goes into "seizures" after getting propofol for endoscopic procedures. I was skeptical of her description and explained to her that propofol actually attenuates seizures and is used to break seizure activity. I should also mention that she says she's allergic to benzodiazepines. Her old anesthesia record didn't document any complications from previous sedations so I assured her I would use as little propofol as possible to get through her procedure.

The endoscopy proceeded without incident and was quickly completed. Postop, she was extremely lethargic, much more than would be expected from a small brief interaction with propofol. After about 20 minutes she started to thrash her head. Then she began trying to get out of bed and then falling hard back onto the mattress. It took four people to hold her down and keep her from injuring herself. The entire time she was not aware enough to answer questions. When we brought her husband in, he said that is pretty much what happens every time.

Finally after about one hour she started to calm down and became responsive to commands. After two hours she was calm but felt too groggy to go home. We finally decided to admit her because of her symptoms. The admitting team even ordered a Neurology consult to rule out seizures. Of course they found nothing.

The Mayo article notes there is no known cause why propofol causes a paradoxic reaction in some people. Maybe it deactivates GABA receptors in some whereas propofol normally activates GABA. But nobody knows for sure. It's not related to the quantity of propofol given. The seizure like activity is not attenuated by adding more drugs like benzos or narcotics.

The only recommendations are to anticipate the symptoms if a patient tells you they get seizures with propofol and to avoid propofol if possible. Perhaps attempt sedation with dexmedetomidine, benzodiazepines, or narcotics if propofol frenzy is a possibility. And always listen to your patients.

Senator Rand Paul Attacked By Anesthesiologist Over Landscaping?

Here's a quick follow up to the bizarre incident last week in Kentucky. Senator Dr. Rand Paul was out mowing his yard when his neighbor, retired anesthesiologist Dr. Rene Boucher, assaulted him without provocation. The senator was wearing sound cancelling ear protectors at the time and did not see or hear his attacker coming. In the melee, Sen. Paul suffered five rib fractures, pulmonary contusions, and facial lacerations.

What is so strange about this is that the two have been neighbors for years. They both practiced at the same hospital in the past. However the two have not spoken to each other in years. Though they had very different political leanings, other neighbors discount the idea that political ideology played a role in the fracas. According to Jim Skaggs, the developer of the community and who lives nearby, "They just couldn't get along. I think it had very little to do with Democrat or Republican politics. I think it was a neighbor-to-neighbor thing. They just both had strong opinions, and a little different ones about what property rights mean." In other words, "Stay off my lawn!"

Dr. Boucher is currently being charged with fourth degree assault, a misdemeanor. Based on the severity of the senator's injuries, the prosecuting attorney may upgrade that to a felony. Somehow I think there is still more to this story than what is being discussed so stay tuned.

Another Experimental Cocktail To Die For

Here we go again. State prisons all around the country have been having increasing difficulty achieving their public duties to execute convicted felons. Drug companies have made it a policy not to sell their pharmaceuticals for executions because, well, they were not approved by the FDA for that purpose. In the meantime, the court systems have halted executions when they believed the prisoners would suffer any kind of pain during the process. In desperation, prison systems have been experimenting with different cocktails of drugs to carry out their deathly functions.

We saw recently how Florida became the first state to use etomidate as part of their drug cocktail for executions. Propofol has been getting more difficult to attain as drug companies and pharmacies demand that their wares not be sold to the penal system. Now Nevada is trying another novel drug: cisatracurium. The state will be trying a new potion consisting of fentanyl, diazepam, and cisatracurium on Scott Raymond Dozier. Mr. Dozier was convicted of two separate murders. He is schedule to be executed November 14.

Naturally there are all sorts of objections to this, besides the general disagreement with capital punishment. The state's Chief Medical Officer, Dr. John DiMuro was an anesthesiologist. However he resigned a week ago and his replacement is a psychiatrist. Some fear that a psychiatrist would not know how to administer these drugs. The state assured that there would be trained medical personnel at the time of injection.

The ACLU also objects that cisatricurium would paralyze the prisoner but not actually kill him, causing him to die of slow painful asphyxiation. This actually makes some sense. None of the drugs being used would be considered fast acting. With this combination, the prisoner would die from oxygen deprivation, which is very slow. This is unlike the previous drug cocktail of pentathol, succinylcholine, and potassium. Those drugs are all rapid acting and lead to amnesia and cardiac arrest quickly. So if not enough benzos are given, and this can be tricky since many of these prisoners have histories of drug abuse that require larger than normal pharmaceuticals to work properly, the condemned may awaken before the cisatricurium has stopped his breathing long enough for the heart to fail. They would have to administer massive doses to be sure the drugs take effect quickly.

Naturally this debate will continue since they are trying to execute somebody using chemicals that were developed to help life, not end it. If they truly wanted to end Mr. Dozier's life quickly, history has cleverly invented all sorts of contraptions to do just that. However, we Americans are just too squeamish to consider using them as part of our "sophisticated" modern society.

Anesthesiologist Attacks Senator And It Has Nothing To Do With Obamacare

Here is the poster boy for the Anti-Trump Derangement Syndrome. Senator Rand Paul of Kentucky was severely injured over the weekend by his next door neighbor. Apparently the good senator was just minding his own business and mowing his yard when he was unexpectedly tackled by physician Dr. Rene Albert Boucher. Sen. Paul suffered five broken ribs (!) and cuts to his face.

As it turns out, Dr. Boucher is a retired anesthesiologist who is affiliated with The Medical Center at Bowling Green. He is a pain medicine specialist and graduated from the Des Moines University College of Osteopathic Medicine. He has been practicing medicine since 1982. His claim to fame is that he invented something called the Therm-a-Vest, a rice filled vest that is heated up in the microwave than worn around the thorax to relieve back pain. It was marketed on QVC but never took off. The doctor retired in 2015. The ASA will be happy to hear that he doesn't appear to be a member of the society.

The deranged physician is a registered Democrat and his Facebook pages are filled with anti Trump and liberal rantings. If he was smart, he would have realized Sen. Paul, an ophthalmologist, is one of the senators that's inhibiting the more conservative members from carrying out the Trump agenda. But there is no reasoning with stupid.

Republicans Give Doctors The Middle Finger

So all you doctors who voted for Republicans in the last election thought you were going to get a big ole tax break thanks to the GOP's control of all branches of the federal government. Candidate Trump and all the Republican Congressmen claimed they were going to enact massive tax reform to give the middle class YUGE tax relief if they got elected. Well guess, what, they won and we doctors lost.

The Republicans in the House of Representatives released their tax reform bill last week and it sure likes they are giving doctors and other professionals the middle finger. It has to do with pass through corporations that many professionals like doctors, lawyers, and architects use. It's a legal way of lowering taxes by separating out the business taxes from the personal taxes. Its more famous users include former Senator John Edwards and former Congressmen Newt Gingrich. By declaring an extremely lower personal income relative to their total income from their businesses, they were able to save thousands of dollars from their payroll taxes.

The Republicans have decided that businesses who use pass through corporations should get a lower tax rate just like the large corporations that will receive a substantial tax cut. In this case, the pass through tax rate will be lowered to 25% from the owner's personal rate, which is usually in the upper brackets of the tax system.

However this new lower rate does not apply to a few select professions. Why? According to Rep. Chris Collins of New York, a Republican, "If you earn your income as a doctor, a lawyer, an architect, you're not getting anything. But you're not supposed to get anything--that's how you earn your income. It was intended to lower the rate for manufacturing companies making widgets and employing other people."

And you wonder why doctors are always getting screwed by the federal government? This Congressman said physicians are essentially just leeches on the government and the country. We only take money and don't contribute anything to society. Never mind that doctors have a huge influence on how trillions of dollars are spent in healthcare. All those millions of people who work in this industry, from the office clerk, to nursing staff, to hospital administrators, medical device manufacturers, and insurance companies, are dependent on doctors. If physicians decide not to use their services, they would be facing the unemployment line tomorrow.

But no, Congress thinks doctors don't deserve a tax break because we don't make any widgets. This is one more nail in the coffin of doctors in private practice. More doctors will start realizing that being an employee of a large medical corporation is the future of medicine. Taking less income is surely more appealing than wrestling with the indignities heaped upon us by our own government every day.

Animoji Karaoke

My Animoji Karaoke on the iPhone X inspired by @harrymccracken . @animojikaraoke #AnimojiKaraoke #animoji #OneDirection #iPhoneX pic.twitter.com/Nc4E1vgvIh

— CarParazziKid15 (@CarParazziKid15) November 4, 2017

I have wasted far too much time this weekend watching the latest internet sensation, animoji karaoki. Thanks to the iPhone X and its face detection technology, people have discovered more uses for the front camera than just unlocking the phone and taking selfies. Even though the phone was just released to the public three days ago, there are already lots of amusing karaoke clips on Twitter and YouTube. My kids and I can't stop watching them and you probably will get a few good chuckles too.

Ok, so to celebrate the arrival of iPhone X, here’s some Animoji Karaoke inspired by @harrymccracken 🎤🦊🐶🐔🐵 pic.twitter.com/wmJAZRoJfk

— Eoin Hughes (@_ehughes_) November 3, 2017