Monday, December 11, 2017

Medical School Is For Chumps

This story makes you realize your parents are so 20th century when they advised you on going to medical school. A 6 year old boy makes an estimated $11 million from his YouTube videos. That's right. Eleven freaking million dollars. What does he do on these videos? Nothing more than toy and children's food reviews. He has ten million subscribers to his channel and has been successfully doing this for only two years. That's less time than it takes to finish med school.

So next time you finish that 36 hour shift and drag yourself home to finish more charting, remember that the future belongs to bitcoin and YouTube advertising revenue. Old fashioned hard work and education are for suckers.

Many Doctors Could Face A 100% Marginal Tax Rate

This is a truly terrifying finding in the Senate tax reform bill. Though this is only the Senate version and the final tax bill after reconciliation with the House plan could turn out to be very different, it's worth reading the fine print now.

According to analysis of the Senate bill, small business owners and people who make good money but are not the super rich could be on the hook for a marginal tax rate of greater than 100% on their income. What does that mean? It means that for every dollar you make over a certain tax threshold, you will owe more than one dollar to the government. That is literally the definition of a confiscatory tax rate.

How does something like that happen? It's rather complex and I haven't quite wrapped my head around it yet. That's why I have a CPA doing my taxes. First you have to be in a business that uses a pass through structure, like an S corporation, the way many small companies and physicians have their corporations set up. The special 23% rate for these corporations currently in the Senate bill slowly phases out after reaching an income of $624,000. Thus the corporation will face the full force of the top personal income tax bracket of 39%. Then if you live in a high tax state like the blue states on both coasts, the deduction for state and local taxes are going to be eliminated. Here in California the top tax bracket is 13.3%. After that various tax credits like the $2000 per child tax credits also phase out for high income earners. And don't forget to add the payroll tax such as Medicare. Voila. Pretty soon the most productive members of our profession are getting hit with taxes close to or greater than 100%.

While the majority of physicians don't make more than $625,000 per year, thousands of them do. The Senate bill is similar to the House version, which is biased against doctors with its refusal to grant a pass through tax cut for physicians. The House-Senate Joint Committee will be meeting this week to bring the two separate bills into agreement. They're hoping the final bill will be signed by President Trump before Christmas. It may be a very unmerry Christmas for many MDs this year.
I want pay more taxes.

Saturday, December 9, 2017

The Meandering Path To Anesthesiology

When I wrote about why I chose anesthesiology as a career a few years ago, I received a few criticisms from readers complaining that I didn't actually choose anesthesiology. Instead I had settled on the field after eliminating all the other possibilities. Did I really become an anesthesiologist because I liked it or was it because I didn't like anything else?

In this month's issue of the ASA Monitor, the editor, Dr. N. Martin Giesecke writes about how he became an anesthesiologist (membership required). His path to his career epiphany was very similar to mine. However he had a little head start down that path since his father was also an anesthesiologist. Yet as a medical student he experienced different medical fields that made him think about other possibilities but ultimately led him to his current profession.

Dr. Giesecke related his admiration for pediatrics. However he didn't have the stomach for taking care of so many small helpless patients. Then he did a rotation in surgery, his first choice in medical school. Though he contemplated going into plastic surgery, the environment he encountered was off putting. He was disgusted by the hostile work environment and mental and physical abuse of the trainees, students and residents alike. That story sounds very familiar.

As part of his surgery rotation, he also did a few weeks in anesthesiology. That's when he realized how awful the surgeons are to their underlings and to each other. Anesthesiology by comparison was pleasant and collegial yet still academic and patient oriented. It was easy to make a decision at that point.

So as you can see, there is not one track to becoming an anesthesiologist. Everybody has a different story on how they made their career choice. Very few people actually decide from day one they're going to become anesthesiologists and not alter their plans. And that's okay. It's like serial dating. You Tinder a few specialties and finally settle on the right one for you.

Friday, December 8, 2017

The Mystery Of Anesthesia

Modern medicine has allowed the humane treatment of patients for over a century now. Yet we still know very little about how it works inside the body. Just recently there was a new proposal on the mechanisms for propofol's remarkable ability to induce sleep. Now there is a new theory on how the volatile anesthetics work to induce anesthesia.

Anesthesiology News details a new study on the mysterious mechanism of gas anesthesia in the body. Though volatile anesthetics have been in use for over 150 years, we know very little about how it actually works. The current theory is that the molecules of gas become absorbed by the bilipid cell membrane of neurons which alters its ability to propagate electrical signals, thus inducing sleep. Now this new paper puts a question mark to that long standing premise.

Published in the Proceedings of the National Academy of Sciences, Dr. Karl Herold, chair of anesthesiology at New York Presbyterian/Weill Cornell Medicine, discovered that it may actually be cell membrane proteins such as ion channels altered by anesthesia that inhibit cell function instead of changes in the bilipid cell membrane. The researchers developed an artificial cell membrane with ion channels in place. Any change in the membrane would alter the flow of ions through the channels. When they immersed the model with therapeutic levels of volatile anesthetics, they discovered that there was not enough reshaping of the bilipid layer to cause inhibition of cell depolarization and signal propagation. Only at super therapeutic levels of anesthesia did they find a change in the cell membrane. Thus they theorize that it is unlikely that cell membrane changes are the source of anesthesia's effects on the human brain.

Though this study did not pinpoint an exact location for the mechanism of action of anesthetics, it at least disproved an old theory, which will allow researchers to move forward to find the real reason why we anesthesiologists can put patients to sleep, and perhaps someday develop even better anesthetics.

Is Anesthesiology Better Served By Having More Women?

The University of Wisconsin, Madison's Department of Anesthesiology has one of the most storied programs in American medical history. They were pioneers in the field during its infancy and invented practices that were eventually adopted by anesthesiologists all over the country and the world. Yet it is being brought low by accusations of bias against women.

The Wisconsin State Journal details the problems in the department that were brought up during a "climate review" after Dr. Robert Pearce, the former department chair, resigned last July. The report noted multiple grievances among the female staff. They described the atmosphere within the department as a "good-old boy network."

The male staff significantly outnumber the women who mostly work part time. The women felt belittled when the men told them they are less committed to their profession because they take more time off to take care of family. Many of the female anesthesiologists who work at the American Family Children's Hospital felt insulted when their workplace was described as "the crying hospital" or "candyland." Female residents were told not to "rock the boat." CRNA's felt they were not valued in the department.

Oy! These are a lot of complaints that really don't seem justified in this male blogger's point of view. First of all, so what if the men outnumber the women by two to one? Must every single job have an equal distribution of the sexes to make it free from discrimination and bias? The truth is one can be harassed whether one is in the majority or minority in a group. Plenty of men have felt they were treated unfairly in their jobs by their male colleagues or superiors.

Let's face the facts here about women who work part time yet expect the same respect at work as men. Yes it's admirable that they want to go home and take care of our children so that we can continue to work hard for the family. But don't expect to get equal pay or get invited to departmental committees if one has to leave by 3:00 PM every day to pick up the kids. It wouldn't be fair to the men who toil away 12 hours a day at their jobs. No disrespect but you can't expect to get the same appreciation from your colleagues if you're only working half the time as others. In fact many of the female anesthesiologists in our department want to work part time. Some even leave our group to work at other hospitals that allow even greater time flexibility. That is no stigma against their dedication to their jobs when they are at work.

The other complaints just seem silly. Calling a children's hospital a crying hospital or candyland doesn't sound insulting, it sounds appropriately descriptive. Describing it as such doesn't demean the people who work there. Stop being so sensitive. Female residents shouldn't rock the boat? Why would you want to? As a resident all I wanted to do was finish my training and get the hell out so I can start my practice. Why would I want to make my life more difficult than it already was as a resident? CRNA's who don't feel valued by the doctors in the department? If they want to feel valued then they need to go get a medical degree.

The department is rectifying the situation by appointing a new female interim chair, Dr. Aimee Becker. While I'm sure Dr. Becker is a fantastic anesthesiologist, I can't help but feel that this was a very political choice to deflect the uproar over the report. When can we get past the sexual politics and just hire the best people for the job without counting how many X chromosomes are in one's DNA?

Thursday, December 7, 2017

Seeing A Permanent Solar Eclipse

This past summer I got to witness one of the great natural wonders of the world, a total eclipse of the sun. It was one of those events that I have dreamed about my entire life. Though my view wasn't perfect due to heavy cloud cover that rolled in over our Midwestern location just as the eclipse took place, we got just enough clearing to see the corona. And to me that was a win. I will never forget the phenomenon and I hope my young son, who I brought along with me, will too.

Now there is an unfortunate woman in New York who may being seeing the solar eclipse forever, not just in her mind's eye, but permanently in her vision. An article in JAMA Ophthalmology written by solar retinopathy specialist Avnish Deobhakta (there really is such a sub subspecialty in ophtho?!), details the cautionary tale of this patient who was too eager to watch the eclipse without first getting the proper equipment.

The patient is a young woman in her 20's who decided she wanted to watch the eclipse at the last second. She stared at the blinding sun for about six seconds before she had to turn away. Then she decided to borrow a stranger's regular sunglasses and continued to stare at the partial eclipse for another 15-20 seconds. Within hours she was having visual difficulties.

When ophthalmologists examined her eyes with a special instrument that can see individual retinal cells, they found a perfectly shaped burn that corresponded to the partial eclipse she witnessed, including the crescent cutout made by the moon partially obstructing the sun. Six weeks later, she still has a hole in her vision where the retinal cells remain damaged.

Again this shows that one should pay heed to doctors' warnings. Physicians for weeks cautioned people to wear eclipse glasses or they could suffer permanent eye damage. Apparently some people just didn't get the message.

Wisconsin Anesthesiologist Retires After Inappropriate Behavior

Think physicians are all well educated and unlikely to conduct obviously inappropriate behavior in the operating room? Not a chance. This blog has documented several cases of anesthesiologists behaving badly in the OR, including here and here. I'm not even going to talk about the deranged anesthesiologist who attacked Senator Rand Paul a few weeks ago. In this atmosphere of heightened awareness of sexual harassment and unacceptable conduct, every person should know by now that witnesses are more willing than ever to report any actions that they deem improper.

However this didn't stop a University of Wisconsin anesthesiologist from being forced to resign for his conduct. Dr. Mark Schroeder, a senior anesthesiologist at UW, was reported by the staff for frequently positioning himself where he isn't supposed to be. A staff member since 1984, it was reported by nurses and other staff that he "likes to be at the 'bottom of the bed' and 'see parts of a patient that he does not need to see.'"

Dr. Schroeder was reprimanded by the hospital for "inappropriate interactions with employees and patients." When his case was brought to the Wisconsin Medical Examining Board, he offered to turn in his medical license and retire.

What an ignominious ending to a long career. The Wisconsin State Journal doesn't mention whether he stood at the foot of the bed only for female patients or male or both. But regardless, anybody who has ever worked in the operating room knows that anesthesiologists rarely make a trip below the shoulder. Other than for putting in arterial lines or a regional block, we rarely venture past the waistline of patients. So if this doctor was regularly wandering his way down there while all the patient's monitors are up at the head of the bed, people know immediately this is not normal behavior. In light of all the sexual accusations that populate headlines daily, any suspicious activity can be construed as deviant. So keep that ether screen up and stay on your side of the blood-brain barrier if you want to maintain your good reputation with the staff.

Wednesday, December 6, 2017

My Patients Have A Good Excuse For Being Late Today

This is what it's like to live in Los Angeles today. A major wildfire broke out early this morning next to the always busy 405 freeway, snarling traffic all over the Westside. It's unfortunate location was made worse by the fact it occurred at a particularly narrow portion of the freeway with steep cliffs on either side and no way to get off. Therefore the road was closed for miles before and after the fire. 

Since this is in the popular and tony Westside, many of our patients and hospital staff live in the area. Consequently doctors are late for their procedures, patients are cancelling cases because they're evacuating their homes, and generally the traffic in this entire area has come to a standstill. Isn't LA grand?

The Most Amazing Library I've Ever Seen

Ok, there are some pretty impressive libraries in the world. The Library of Congress and the New York Public Library are definitely iconic. But this new library in China is almost out of this world futuristic. The Tianjin Binhai library east of Beijing has a unique architecture that needs to be seen in pictures to be appreciated.

The undulating walls can hold 1.2 million books. Right now the shelves are not nearly that full. Many of the "books" on the walls are just images placed there on aluminum plates until real books are eventually stacked there. Still, it is a very awe inspiring design. Maybe if my alma mater can show me something like this when they ask me for donations I would give more money to their library fund.

Tuesday, December 5, 2017

Young Doctors Get More Patient Complaints

We could probably have deduced this one from experience. In a study published in JAMA Ophthalmology, researchers at Vanderbilt University have found that young physicians are much more likely to get complaints from patients than their older colleagues.

The retrospective paper looked at the experiences of 1342 ophthalmologists who practiced at Vanderbilt affiliated medical facilities. The ophthalmologists were grouped in cohorts of ten years of age, from 31-40 years old up to greater than 70 years old. Their records were reviewed from January 1, 2002 to December 31, 2015. The median age of the doctors was 47 years old.

The results showed that the two youngest cohorts were statistically more likely to hear complaints from their patients. The youngest group were 2.36 times more likely to get a complaint while the next youngest cohort had 1.73 times higher risk relative to their older physicians. The younger doctors also had patients who complained more quickly about their problems than the older ones.

The researchers conclude that their findings are consistent with the medical malpractice environment where physicians with less than 10 years of practice are more likely to get sued than their older partners. Their malpractice insurance cost the most until it tapers off when they hit their mid career years. The physicians halfway through their careers may feel social, professional, and family pressure to work harder and see more patients. This leads to greater risk of getting patient complaints. The late career physicians are the ones who survived the burnout and legal difficulties of their earlier years. These doctors have demonstrated the skills and composure to to survive in the medical field and thus should have the fewest patient complaints and lowest malpractice liability.

So for all you medical students and residents out there who see nothing but bleakness and despair for the foreseeable future. Yes it does get better, eventually. You'll just have to survive the first 20-30 years of medical practice then you're golden. Don't you feel better now?

A $500 Million Golden Parachute

The general public often complains that doctors make too much money. But we know who are actually raking in the dough in medicine. And they usually don't take care of any actual patients. A report in the Wall Street Journal discloses that the chief executive of health insurance company Aetna may walk away with $500 million if his company gets bought by pharmacy company CVS.

The money will come in the form of stock options and personal stock holdings. CEO Mark Bertolini will receive $85 million in exit pay for selling the company. If the deal settles for the reported $207 per share, he will also get $230 million in stock options and his Aetna stake would be worth another $190 million.

Think about that for a minute or ten. While doctors are getting vilified for earning a decent living after decades of education and toil, insurance executives are being given nine figure incomes and bonuses for maximizing shareholder profits by denying insurance coverage to patients and reducing reimbursements for physicians. If healthcare reform is to succeed in this country, the insurance company gatekeepers need to be removed so that all those billions of profits will be properly distributed to the patients and their caretakers. It's immoral that insurance companies stand in the way of doctors properly treating their patients while they keep most of the healthcare industry profits.

Monday, December 4, 2017

Remember When Masturbation Was Considered Shameful?

Why are so many men masturbating in front of unwilling participants? The act of masturbation used to be considered shameful. It has been used to great comic effect in movies and TV, in everything from "American Pie" to "Seinfeld." Who wouldn't want to be the master of his domain?

But now it seems that a remarkably large number of well to do men have been forcing their self love onto others as a form of harassment and abuse. Every day another high powered man is accused of or confesses to touching themselves in full view of reluctant colleagues. The latest ones to be charged with this act include the great music maestro James Levine and California Assemblyman Matt Dababneh. This follows the infamous actions of Louis C.K. and the man now synonymous with sexual harassment, Harvey Weinstein.

I know that doctors have been trying for years to reeducate people to make masturbation a less shameful act. It is a natural activity that should not cause embarrassment of its practitioners, which is virtually everybody. However, after all these revelations, I'm inclined to side with our less enlightened ancestors and punish people who can't keep their hands off themselves in front of others. Can you imagine if the victim was allowed to flog the perpetrator for their abusive acts as in the olden days? It would put a real quick end to all these disgusting displays of power and toxic masculinity. Keep it in your pants or take them out only when you have a consenting partner present. Nobody else cares to see how little you respect yourself or others.