Bigger Is Better, Even In Anesthesia

This is a cautionary for all anesthesia practices and residents evaluating anesthesia groups to join after graduation. Olean General Hospital in New York has just informed its anesthesia providers, Southern Tier Anesthesiologists, that it has decided to go with a different group for their anesthesia needs. Bye bye. And don't let the door hit you on the way out.

What's particularly galling is that STA had no conflicts with the hospital prior to them seeking proposals from others. STA members asked directly if there were any issues with their work and the hospital denied any work or personality conflicts. Ultimately the work contract was awarded to another anesthesia group out of Buffalo who were willing to work for less money.

STA had been OGH's exclusive anesthesia providers for 24 years. And OGH has been the exclusive hospital to STA for the last fifteen. Unfortunately they may just have been too small to compete with groups that are much larger and have economies of scale. STA only has six anesthesiologists and two CRNA's. Meanwhile, hospitals and insurance companies are merging at a furious pace. OGH is part of a much larger hospital group, Kaleida Health. When large corporations start running hospitals, loyalty takes a back seat to the bottom line.

For the anesthesiologists in STA, the future looks bleak. It's unclear if they will be absorbed by the Buffalo group if they are willing to work for less money. Otherwise, there are no other hospitals within an hour drive and the physicians will have to move away to find other jobs.

While it may be desirable to work in quaint small towns with Mayberry quality lifestyles, medicine isn't practiced like the 1950's anymore. Corporate medicine is creeping into even the smallest medical practices. I've had personal friends who thought they found the perfect anesthesia jobs after residency. Then one day, they show up for work and find out their hospital has negotiated with a different anesthesia group willing to work for less money. They were suddenly unemployed. Devastating.

In order to compete, doctors will need to team up or get run out of town by companies with billions of dollars in revenue and no compunction to fire staff at will if it helps their stock holders. I wish all the luck to the members of Southern Tier Anesthesiologists in their careers and hope they land somewhere that will provide a more stable job environment for themselves and their families.

The Fallacy Of The Universal Time Out

Scott Baker, MD

Is it possible to legislate away human error? It would appear not. Despite the best intentions of hundreds of bureaucratic agencies and thousands of rules governing every conceivable aspect of medical practice, plain old human error still rears its ugly head to make sensational news headlines about the latest grievous injury to a patient.

Last week, an Iowa woman sued her surgeon, Dr. Scott Baker of Sioux Falls, SD for removing the wrong body part. In 2016, Dena Knapp of Iowa was supposed to have an adrenal mass removed by Dr. Baker. Instead, the surgeon was notified by the pathology department afterwards that he had removed a kidney, not the adrenal. To make matters worse, Ms. Knapp states that the surgeon lied to her about the mistake and claimed he did not get all of the mass and needed a second operation, never informing her that he had accidentally removed a healthy kidney. She went to the Mayo Clinic for her second operation. Now she claims that her one remaining kidney is starting to fail and she is suffering from severe mental distress and pain.

Can you see the difference between the adrenals and the kidney?

This incident has so many open questions. It also points out the fallacy of imposing more and more rules on people in order to prevent human error. First of all, let's agree that the surgeon made a huge error in judgement when he somehow mistook a kidney for the adrenals and took the wrong one out, even if they are right next to each other. However, I'm curious about what the rest of the surgical team  was doing when the error took place? As part of the Universal Protocol required by the Joint Commission, every member of the team in the operating room had to confirm the correct patient, surgical procedure, and site of the procedure prior to the start of the operation.

So that begets the question, where was the rest of the OR staff when the kidney was being removed? Did the nurse or the surgical tech, who would have been right there to document the specimen being removed from the patient, not notice that they were being handed a kidney and not an adrenal? Was the surgeon's assistant not confident enough to tell Dr. Baker that he was resecting the wrong organ?

For that matter, what about the anesthesiologist in the case? We are an integral part of the surgical team and consider ourselves leaders in patient safety. That includes being an active participant in the Universal Time Out. Did the anesthesiologist not notice that the surgeon had removed the kidney by accident? Was anything said to the surgeon by anybody in the OR when the nephrectomy was taking place? So many unanswered questions that I'm sure will be aired out in court very soon.

This is just the latest medical malpractice case to make headlines since the practice of Universal Protocol was conceived in 2004. No matter how many rules are enacted, the best protection for the patient is one of the simplest--stay vigilant.

Don't Google Check Your Attending

Now is the season when medical students all over the country start doing away rotations in their desired fields hoping to gain experience and come away with a favorable letter of recommendation for their residency applications. We are currently trying to accommodate dozens of students each month who come and go through our hospital who are undergoing this ritual.

In general, most of the students are great to work with. They are eager to learn and still in awe of some of the amazing work we do in anesthesia. Many have little experience in our specialty other than what they see on TV or over the drapes during their surgery rotations. It's a pleasure to have them around.

But that doesn't mean that they are all easy to work with. We love it when they ask great smart questions about what they are seeing in the operating rooms. However I recently had one student who loved asking questions but then would quickly look up Google on his smartphone to double check the answer I gave him. This was beyond annoying.

If you just want to learn from Google, why bother going to a far away rotation to questions everything somebody is trying to teach? Sure maybe my own fragile ego may have something to do with my insecurity when I'm up against an omniscient presence like Google. But I don't like being told while I'm teaching that my MAC number for Sevoflurane was just a fraction of a decimal point different from that almighty search engine. I find it rude when I'm questioned about every nugget of wisdom I'm trying to impart on our future anesthesiologists while I'm in the process of doing so. It got to the point where I stopped teaching that particular student anything. Instead we just sat there and talked about his personal life and interests, which frankly he seemed far more receptive to than anesthesia.

Every anesthesia attending I discussed this situation with agreed that the student should be more tactful in how they question their instructors. Don't Google check your attending unless you're invited by them to look something up together as a shared learning experience. If you question something that was said, you can always look it up later and perhaps ask another attending about the discrepancy in information. But to constantly berate your teacher with the internet will quickly shut down the conversation and leave you poorer for it. And that's not why students spend thousands of dollars and months of their lives to gain experience to be smart physicians.

The Genius of Sting

I have been a fan of Sting since his Police days in the 1980's. Well, mostly early Sting music anyways. His later solo career works just became too mellow for me. So while driving home from work the other day, I was listening to the oldies station (God when did my favorite music migrate to the oldies station?) when they started playing Sting's "If I Ever Lose My Faith In You". I've heard it hundreds of times before but not recently. Then I suddenly caught these lyrics in the second verse.

Some would say I was a lost man in a lost world.

You could say I lost my faith in the people on TV.

You could say I'd lost my belief in politicians.

They all seemed like game show hosts to me.

What?! This song was released back in 1993. Yet the lyrics are so prescient of our current times and politics. In four simple lines he so perfectly encapsulates the present day controversies regarding fake news, Russian collusion, lost emails, special counsels, qualifications for higher office, etc.

Sting, wherever you are, you are truly a genius.

Jahi McMath Has Died. Again.

The family of Jahi McMath released news that their daughter has passed away. If you don't remember who Jahi was, she was the adolescent who suffered anoxic brain death after complications from a tonsillectomy and uvulectomy for sleep apnea in 2013. She suffered her second death last week after complications from an abdominal surgery.

Multiple doctors declared the child brain dead five years ago yet the family refused to accept the diagnosis. Even though there was no blood flow to the brain, the family pointed to such findings as twitching of the fingers and toes. Most doctors would say those are spinal reflexes that has nothing to do with brain activity but they found a sympathetic judge who kept the child on a ventilator in the hospital until they found another facility in New Jersey willing to take this "patient".

This case had huge implications for the anesthesia community. For years afterwards, the ASA's CME material repeatedly emphasized the active ingredients in the metabolism of narcotics and how to be extra careful sedating obese young patients in recovery. In all the years before the McMath case, they never discussed this issue once. 

Thanks to the Jahi McMath media circus, at least there was tremendous educational opportunity for physicians. She did not die twice in vain.

The Anesthesiologist Who Attacked Senator Rand Paul Is Sentenced

Remember the bizarre story last year when Senator Rand Paul of Kentucky was attacked by his next door neighbor? The neighbor was an anesthesiologist by the name of Rene Boucher. The incident left the senator with multiple broken ribs and lung contusion. Now it has come to a conclusion.

Dr. Boucher pleaded guilty to the assault and has been sentenced to 30 days in jail. He will also pay a $10,000 fine and serve 100 hours of community service. This sentence seems light to me considering that he pummeled the senator when his back was turned and was unprovoked. His lawyers had requested a 21 month sentence.

During the court hearing, we find out that Senator Paul was not as seemingly innocent as first appears. It seems that the two neighbors did indeed have a longstanding dispute over lawn maintenance. Senator Paul dumped a bunch of grass and tree clippings right on the property line between the two. This was no ordinary pile of leaves. This was a 10 foot by 5 foot stack that sat there for a few weeks.

When Dr. Boucher complained, the senator did nothing about it. Eventually the doctor brought in a dumpster and had it hauled away himself. Then Senator Paul did the same thing again. Then again the anesthesiologist had a dumpster come remove it. This repeats itself several more times. At one point Dr. Boucher even set the pile of grass on fire, burning himself in the process. He asked for the homeowners association to do something about this but they were not responsive.

The last straw came when Senator Paul, who sounds like a big asshole, blew grass clippings over into his neighbor's house. That's when the doctor turned rogue and blind sided the senator. Sounds like Rand Paul was the neighbor from hell. Wonder how he is taking care of his lawn this year?

What Cars Do Doctors Drive?

Surprise! What your doctor likely drives.

When I picture for you the image of a doctor driving carefree along the sunny California coast or along the boulevards of Beverly Hills, what kind of car do you see in your mind? A Porsche Carrera GTS? A Bentley Continental GT? Maybe even a Ferrari 488 GTB? Well, the latest Medscape Physician Lifestyle and Happiness report has the answer for that.

In a survey of over 15,000 doctors, some of the questions were related to the wheels they own. If you thought that physicians usually drive some exotic European import to work, you'd be mostly wrong. According to the responses, the most popular make of cars among doctors is a Toyota, with 21%. The second most common car driven by doctors is a Honda with 16%. As you can see, many doctors are quite practical and frugal in the types of vehicles they own.

But then you get to the next three: BMW, Lexus, and Mercedes. Now these are the more stereotypical cars that one would expect physicians who make six figures are more likely to possess. However each of these brands holds less than ten percent market share among doctors. The rest of the top ten are Ford, Subaru, Chevrolet, Acura, and Audi.

No longer your typical doctor's car. Sad.

What are the least favorite cars among physicians? Bringing up the bottom are Lincoln, Kia, and Cadillac, each with about 1% ownership with doctors. Then they are followed by Dodge and Volvo. I find it sad that storied nameplates like Lincoln and Cadillac, once the epitome of wealth and success, are now irrelevant among the monied set.

Even though nearly all physicians make six figure incomes, does the medical specialty influence the type of cars they drive? I mean, any doctor could theoretically afford a Mercedes if they wanted one. In reality the specialty you practice does make a difference. Toyota is owned  by more primary medical doctors than specialists 23% to 20%. Honda also has more PMD's in their corner 18% to 16%.

But once you look at the luxury imports, the reverse happens. Far more specialists than PMD's own BMW, 11% to 6%. Same with Lexus 9%-7% and Mercedes 9%-7%. Is it more evidence that PMD's don't make enough money in this country compared to the specialists? Is it an indictment of our healthcare system that prizes costly interventions over preventive care? You be the judge.

It would have been interesting if the survey broke down the types of cars owned by the age of the physician. The report notes that over 50% of the respondents are under the age of 50. In fact, nearly one fifth of the respondents say they are in the 28-34 year old age bracket. That's extremely young, practically fresh out of residency. They will be the ones most likely to still be driving the old Honda and Toyota they had in college while they are trying to set up a practice and pay off student loans.

So next time you see a Mercedes GT-R roaring down the street, know that it is unlikely to be driven by a physician. The driver is more likely to be a Wall Street titan or business mogul than a doctor. We sacrificed years of our lives to go through medical school. Practicality and delayed gratification are in our blood. It would be uncharacteristic for doctors to blow their money on such exotic rides. Unless you're a plastic surgeon in Beverly Hills.

The Lonely Lives Of Anesthesiologists

Medscape has just released its latest clickbait physician survey. This time it's the 2018 Lifestyle and Happiness report. Who wouldn't want to click on a link with that title? While we'd like to think that doctors are all living lives filled with milk and honey, doctors do in fact possess varying degrees of contentment.

According to this poll of over 15,000 doctors, exactly half say they are extremely or very happy outside of work. Only ten percent claim they are extremely or very unhappy in their personal lives.

Who are these happy doctors? The top four are in Allergy and Immunology, Dermatology, Emergency Medicine, and Ophthalmology. Notice these are the fields where doctors may have more free time away from the hospital than most. About sixty percent of these doctors claim to be very happy.

The most unhappy doctors work in Cardiology, Public Health, Oncology, and Infectious Disease. Here, less than half are happy outside of work. The nature of their work, dealing with sick cancer and heart patients, probably contribute to their ennui. Anesthesiologists wind up in the middle of the pack, with 50% stating they are happy outside work. This is about the same as previous surveys.

When asked if they are introverted or extroverted, a large plurality said they are a little bit of both. The most introverted physicians are in Public Health, Pathology, Rheumatology, and Public Health. The most extroverted doctors are pretty predictable: General Surgery, Urology, OB/GYN, and Gastroenterology. In general, doctors who go into a procedural field tend to be more gregarious in my experience. Interestingly anesthesiologists are neither the most introverted or extroverted. We're just vanilla.

Maybe that explains why anesthesiologists have so few friends. When asked how many close friends they have, the doctors mostly answered between 1 to 3 friends or 4 to 6 friends. But when broken down by physicians with three or fewer close friends, anesthesiologists ranked near the top. The top four most lonely doctors are Pathology, Critical Care, Radiology, and Anesthesiology. This tends to feed into the perception that pathologists, radiologists, and anesthesiologists are more socially awkward than their more outgoing colleagues like the surgeons.

Perhaps we need to shed some of our fuddy duddy image and live it up a little. While we like to be perceived as the doctors who most care about patient safety, maybe we should also be the doctors who care about where the next kegger is going to take place. With the best paying job in America, we should try to be the life of the party for once.

Anesthesia Books In The News

This doesn't happen very often, but it occurred twice recently--reviews of anesthesia books. The first one was in the Wall Street Journal. "Anesthesia, The Gift of Oblivion and the Mystery of Consciousness" by Kate Cole-Adams seems to linger on the issue of intraop awareness. The author relates horror stories of patients who are wide awake during surgery and can feel everything.

As if that's not bad enough, Ms. Cole-Adams writes about subconscious awareness during surgery. These patients don't remember anything when they wake up from anesthesia but under hypnosis, they are able to recount words spoken by the OR staff while they are anesthetized.

Though the review was published two weeks ago, it just recently prompted a response from James Grant, MD, president of the ASA. You can read it in the published comments at the bottom of the article and also here on the ASA website. Naturally he defends anesthesiologists as diligent physicians who are looking after the patients' best interests and that any surgical recall is extremely rare, occurring in about one in ten thousand cases.

The New York Times also reviewed the same book from Ms. Cole-Adams but it also reviewed a second book, "Counting Backwards, A Doctor's Notes on Anesthesia," by Henry Jay Przbylo. This review was written by a neurosurgeon/author and is much more sympathetic to anesthesiologists than the WSJ article.

Dr. Przbylo is an anesthesiologist and he relates the history of anesthesia and how it has evolved. He uses the standard analogy of anesthesia as being similar to flying in an airplane. Most of the time the flight is uncomplicated and routine. Occasionally it can be harrowing and rarely fatal. But there is nothing the patient/flyer can do about it except lean back and enjoy the ride.

There you have it. Two books about anesthesia, one more sensational while the other one probably more educational and enlightening. Start off your new year right by reading two books about your profession instead of binge watching another season of "Game of Thrones." You'll feel better equipped to answer questions from your patients when they confront you about the fears of anesthesia.

Anesthesiology Still The Best Paying Job In America

This is beginning to sound like a broken record. The latest statistics from CNBC show that anesthesiologists have the best paying job in America. We have an average salary of $269,600 according to the U.S. Bureau of Labor Statistics.

As a matter of fact, the top eleven best paid jobs are all in healthcare. The number two job is surgery with a salary of $252,910 followed by OB/GYN with a pay of $234,310. The top nonmedical career field is petroleum engineer, with a salary of $147,030. Lawyers, a career once associated with steady high income, clocks in at sixteen, with a mean salary of $139,880.

Despite these great numbers, they all appear suspect. The physician salaries seem low compared to Medscape's annual compensation survey that showed anesthesiologists last year made on average $364,000. Lawyers' mean salary may be only $140,000 but they have a much greater variation in their compensation compared to doctors. Many earn much less than $100,000 while some make well over $1 million. The data also don't look at the medical subspecialties that earn much more than mere anesthesiologists, such as neurosurgery, gastroenterology, or interventional cardiology, many of whom earn well over half a million dollars per year.

So for all you naysayers who claim the best days of medicine are in the past, there's still hope for continued good times in the medical field. As the old saying goes, while past performance may not predict future results, it's still a good starting point to have.

Are Young Doctors Better?

In this Sunday's New York Times op-ed, Dr. Haider Warraich, a cardiovascular medicine fellow at Duke University, makes a fairly convincing argument that young physicians are better doctors than their older colleagues.

He cites research that shows patients treated by younger doctors have a lower mortality. They are less likely to overprescribe medications and order unnecessary tests. Young physicians are also not as likely to be brought before their state medical boards for disciplinary action.

Why is that? Older doctors are more set in their ways. They may not be as familiar with the newest medications or the latest protocols to treat a medical condition. Their skills may not be up to date with the latest techniques. And let's face it, we've all seen the curmudgeonly doctor who refuses to change his ways no matter how archaic their thinking may be.

The older doctors benefit from their ability to maintain their board certification for a lifetime. While new doctors have to pay exorbitant fees and spend countless hours to keep their ability to practice medicine, older physicians can continue to use information they learned in training decades earlier to muddle through their careers and nobody will call them out on it.

Due to this leniency a large number are continuing to work past the usual retirement age. About twenty percent of doctors are currently over 65 years old. That is expected to rise to a third in only three years. Personally in our anesthesia group, we have many partners who have elected to work part time instead of retiring, thus limiting the ability of the group to hire new younger doctors to freshen the blood in the organization.

Yet it is the young doctors who will be looked upon with suspicion from their patients. When patients and their families remark on how youthful their doctor looks, that is not a compliment. They are questioning in an oblique way the qualifications and experience of the physician that is sitting in front of them. Unfortunately there isn't a simple way to allay their fears short of bleaching one's hair white. The smart patients will welcome the enthusiasm and knowledge that a younger doctor brings to the table because sometimes experience isn't the best teacher. It's the training, not the wrinkles.

Anesthesia Resident Commits Suicide

It's so sad when you read about events like this. Wayne Hendrix, MD, an anesthesiology resident at the Medical College of Wisconsin committed suicide the last week of 2017. The 43 year old doctor charged into Froedtert Hospital in Milwaukee brandishing a gun. He then hid himself in one of the operating rooms and gave himself a lethal injection of fentanyl. When the SWAT team entered the room, they found him already down.

Dr. Hendrix had previously been diagnosed with depression. He was divorced with two small children who resided with the ex wife. Reports say he had also just broken up with a girlfriend. His family said he also had an alcohol addiction and attempted suicide in 2016. This was a troubled soul who was unable to overcome all his demons.

To most of us it's unfathomable why somebody so young and full of potential would end their lives at such a tender age. They seemingly have their whole lives ahead of them and the possibilities are endless. Yet either because of mental illness, substance abuse, or myriad other reasons, they just couldn't make it past one more day.

Anesthesiologists have long had a reputation for being the group of physicians most likely to suffer from drug addiction. Male anesthesiologist may have the highest suicide risks among all doctors. Dr. Hendrix had previously been diagnosed with depression with a difficult personal life. I hope anybody reading this will recognize the cries for help either within themselves or in their acquaintances and seek the medical attention they need before they become another terrible statistic.

When The Vagina Is A No Go Zone

This post has nothing to do with anesthesia. But I find the subject matter eye opening and highly amusing. Dr. Jen Gunter, a Canadian OB/GYN and blogger, wrote about seven trendy vaginal inserts that happened in 2017 and why they should horrify any physician and any sane person in general.

Some of these are promoted by celebrities, such as jade eggs which were endorsed by the actress Gwyneth Paltrow. I've never even heard of jade eggs for the vagina until I read the blog. Others trends were popularized by the internet, such as inserting a peeled cucumber into the vagina to make it smell fresh. Or applying glitter to the vagina to make it...shiny?

So please do yourself a favor and consult your physician if you're thinking of putting something in your vag-vag that may not be, how should I say this, approved by a medical professional. You may save yourself or significant other a whole lot of trouble in the future.

Texas Anesthesia Group Pleads Guilty To Fraud

So sad when I read about anesthesiologists who wind up on the wrong side of the law, either out of stupidity or greed. Limbic Partners, LLC, an Irving, TX medical management group started by three anesthesiologists, pleaded guilty to defrauding insurance companies. 

The founding physician partners, Herbert Brown, Brian Rudman, and Maulik Parikh, were accused by the government of billing insurance companies for millions of dollars for anesthesia services that were not performed. The cases in question took place from 2011 to 2013.

The company would send bills for work done by a CRNA when that person was already working at a different facility at the same time. Or an anesthesiologist with the company would take care of a patient but the doctor was not in the insurance company's network. They would just tell the billing company to insert a different doctor's name who was in the network. Not terribly slick. 

The attorney general's office accepted the plea and Limbic Partners will pay $933,251 in restitution. They've also paid back over $133,000 to the insurance companies that they defrauded. However, like the massive bank fraud that nearly collapsed the U.S. economy in 2008, none of the leadership of the company are being held accountable. Isn't American capitalism great?

The Big Kahuna Of Physician Investment Advisors

As a doctor, if you've done any research at all into financial management, you almost surely will have come across The White Coat Investor. Started by James Dahle MD, FACEP, an emergency physician, WCI has morphed into a financial advisory empire. It's been featured in mainstream press, has published advise books, conducts speaking tours, and holds extensive forums on the site for its readers to argue about money and taxes. They even offer scholarships for graduate students.

The web site is vast. There are hundreds of posts and thousands of forum threads to read. Most of the posts are no longer written by Dr. Dahle but by guest contributors. If you have any questions about money I'm sure there is at least one post that covers that topic. You could lose yourself on that site for days trying to read everything they have.

He is very candid about his success. Each year he posts the latest financial results of his business. In his January 2017 article, he notes how quickly the site has grown in readership and monetary success. His income from the blog would make even an orthopedic surgeon blush. He is so successful that when he temporarily lost his physician job (look it up), he was quite happy about possibly taking a year off from the drudgery of working in medicine. Now that is real financial independence.

I hope you have a chance to read through all these investment blogs that I've mentioned this week. You'll quickly realize that you are far from being alone as a doctor who dreams about escaping the tedium of medical practice to live a fulfilling life outside of medicine. There are plenty of people willing to offer advice on how to pull that off. Let's see if you can make 2018 the year you actually take the steps necessary to realize your life goals and financial dreams.

A Stingray Attack Looks More Painful Than I Ever Imagined

Southern California has had a tremendous increase in the number of stingray attacks along our beaches recently. Specifically in Huntington Beach, there have been over 300 injuries in the last week alone. If you think getting stung by a stingray is like getting attacked by a bee, take a look at this picture.

Ouch!

That barb sticking out of this poor victims foot looks extremely painful. It is much larger than I ever thought a stingray barb would be. It looks like a giant rusty nail impaling itself in the foot. Luckily, stingray attacks are rarely fatal. Of course that doesn't mean there haven't been deaths attributed to stingrays.

The treatment for stingray injuries involves only removing the barb and washing the site with hot water. Maybe take some antibiotics to prevent infection. And next time don't walk too lively into the shallow waters of our beaches. Shuffle your foot in the sand to warn the stingrays to move. Or you may wind up with an organic spear to take home with you as a souvenir.

Physician On FIRE

To start the new year, I've decided to bone up on my financial knowledgebase and wealth management. I've already written about Passive Income MD. It offered me some of the best tax advice I've come across for calculating my potential new tax liabilities with the tax reform law that was recently passed by Congress.

Now I'm going to give a shout out to another financial blog for physicians. It is called Physician on FIRE. It's written by an anesthesiologist and is all about working towards early retirement. FIRE stands for Financial Independence, Retire Early. The author claims he achieved financial independence at the age of 39 years old, only nine years after starting his career.

His bio is rather interesting. He started out working in a small hospital as the only anesthesiologist on staff. His dreams of a stable long term career were shattered soon after when the hospital closed for financial reasons. He then went through a series of locum tenens jobs before landing at another permanent job position. Thinking he needed to have more financial stability he started thinking about becoming financially independent which eventually led to his blog.

While quickly perusing his site, it seems to emphasize long term investing in stocks and real estate with a healthy dose of prudent spending. His family appears to live modestly which allow them to keep expenses down and let them live well within their means. That in essence is the recipe for long term monetary success. So check it out if you want to see why you are living paycheck to paycheck despite earning a six figure income. Your goal in 2018 should be getting away from that precarious position and start enjoying your work, not just working for that next check.

Tomorrow, we'll talk about one of the granddaddies of investment websites for physicians. This doctor has truly achieved financial freedom using nothing but the written word and thousands of followers.

Death Of A Blog

I have a bad habit of not pruning my blog for dead links and outdated information often enough. I've occasionally received information from my readers notifying me about links that no longer work or videos that are not able to be loaded anymore. Yesterday while adding a couple of new blogs to the My Blog List on the right side of my home page, I noticed that one of my favorite anesthesia blogs has died.

Anesthesia Goes To Hollywood was a terrific site started by an anesthesiologist in Texas. Its purpose was to document the ridiculous scenes created by Hollywood in TV and film of how anesthesiologists, and medical professionals in general, work on screen as opposed to real life. I marveled at how he was able to watch so many TV shows and movies while working full time.

I first linked to his site in 2013. Alas, the blog did not last long. While I was cleaning house, I noticed that his last entry was made three years ago, about 2014 or 2015. As a matter of fact, the awesome HollywoodAnesthesia.com URL no longer belongs to him. Damn I didn't realize that that domain name was up for grabs because I had mentioned how surprising nobody in LA had snatched it up for themselves.

The brief snippet of his last entry mentioned something about preserving memories but I couldn't get the whole story. Since the URL is gone, his blog has essentially disappeared from the internet. Granted I hadn't been keeping up with his blog in awhile which is why I didn't know it had ended three years ago. Since I rarely watch broadcast TV and have never watched a single episode of Grey's Anatomy or ER, the blog's subject matter didn't really appeal to me. But I thought it was a great concept to write about the medical misconceptions in Hollywood from a real anesthesiologist's point of view.

So Dr. AGTH, if you're still out there reading anesthesia blogs and you happen to come across this page, please drop me a note to let me know why you decided to stop writing. Was it the time pressure to watch so many shows all the time to maintain your blog while working full time? Was it the banality of those shows that bored you to death so you could not bear to watch anymore? Have you moved on and started another blog? I'm curious to know and also use it as a learning experience as a blog writer.

As my readers know, there have been many times where I've felt really burned out and stopped writing new entries, sometimes for months at a time. It may be that I had severe writer's block and just couldn't put another word down. Sometimes there just doesn't seem to be anything worthwhile to write about that I haven't already covered in the past. Frequently I wonder how many people actually read my blog. Am I writing this to entertain and enlighten the ten people on the planet who follow me? Am I writing this blog to earn enough Adsense dollars from Google to buy a couple of movie tickets each year? Those are the issues that sometimes stymie my writing process and brings this blog to a screeching halt. Eventually I'll come across a subject so interesting that I feel many anesthesiologists will be interested in reading and start writing again. That usually gets the ball rolling and my creative juices stirring again. But the death of a blog is always just an indifferent shoulder shrug away.

The Best Pass Through Corporate Tax Law Explanation I've Read

The recently passed tax reform law is confusing to say the least. Rather than minimizing the reporting requirements to a single postcard as many Republicans claimed they were after, the new law maintains seven tax brackets and myriads of new and expired tax deductions.

Some of the most befuddling new rules are the deductions for pass through companies such as subchapter S or C corporations. What made it even more difficult to understand was that initially its new lower deductions didn't apply to service professionals like physicians, attorneys, accountants, or essentially anybody running a service business. The favorable tax treatments only apply to manufacturers. Luckily that unfair treatment seemed to have changed somewhat after the House and Senate reconciled the differences in their bills. Now professionals also get a low corporate deduction, but only up to a point.

I spent many days searching through the internet trying to find a simple explanation for how tax reform will affect S corporation professionals like myself. I believe I've found it. It's written by Passive Income MD and it gives great examples of how different income levels are treated differently by the tax laws.

Conveniently for me, PIMD uses a hypothetical situation that is very similar to mine: married couple with children, lives in a high tax state like California, uses an S corporation with about half salary and half distribution, and a fairly large mortgage (this is coastal California after all). Just scroll down through the article to see how the taxes change for incomes ranging from $400,000 to $700,000.

The good news is that for the average anesthesiologist income as reported by Medscape, we should do very well with tax reform. After accounting for all the deductions, we should wind up in a lower tax bracket and have more take home pocket money.

For higher paid specialties like orthopedic surgery or interventional cardiology, the picture doesn't look so rosy. The pass through deduction of 20% starts phasing out at $315,000 adjusted gross income and is completely gone by $415,000. Essentially fifty cents of every dollar earned over $415,000 will be paid to the government in taxes.

The only relief from high tax payments will be to maximize my 401K contributions each year and thank my lucky stars that I purchased a nice expensive home in Los Angeles with large mortgage interest payments that have been grandfathered into the new law. Other than that many of my old deductions like my high state, local, and property taxes will only get a minuscule $10,000 in deductions from now on.

Thank you Passive Income MD for this easy to understand explanation of the tax reform law and how it will affect high income professionals like us physicians. I'm going to put a link to his site on my home page since I believe his informative articles will be of great interest to my readers.