Sunday, August 16, 2020

What Would Steve Jobs Think About Reaction To Coronavirus?

One of the things about living through a pandemic is that you have a lot more time to do leisurely activity since schools, summer camps, and vacation spots are all closed. Therefore I tried to catch up on some reading. One of the books I read is the biography "Steve Jobs" by Walter Isaacson. It is a fascinating story about the complex history of Jobs and his eccentric personality. I can relate to much of the book as I remember reading about a lot of it as they happened 30-40 years ago. 

I came across a passage that I thought is so meaningful for our current coronavirus afflicted times. Isaacson describes how Jobs was a firm believer in people meeting each other to talk and exchange ideas. When he designed the headquarters for Pixar, he made sure that the structure would naturally lead people to congregate in a central atrium. He even went so far as to initially design only two bathrooms in the entire building so people would have to gather in one area. Wrote Isaacson, 

Despite being a denizen of the digital world, or maybe because he knew all too well its isolating potential, Jobs was a strong believer in face-to-face meetings. "There's a temptation in our networked age to think that ideas can be developed by email and iChat," he said. "That's crazy. Creativity comes from spontaneous meetings, from random discussions."

What would Jobs think about the work from home and online education trends in the country? Many companies, especially the high tech industry in Jobs' own Silicon Valley, have told their employees to work remotely. Likewise, teachers are now refusing to resume classes in school and are staging sickouts. While millions of people are still working or have returned to work, teachers feel they are not essential workers and demand to stay home. This despite the fact the parents and students across the country feel online learning is inferior to real classroom involvement. What's worse, college students have to continue paying exorbitant tuition and fees even though classrooms are closed.

As the panic surrounding Covid 19 continues, are we teaching a generation of workers and students that they should run away from adversity, even if they are the generation least likely to get sick from the disease? Are the students being taught to cower in fear of the unknown instead of striving to conquer what ails society by going to school and returning to work? Steve Jobs, one of the great geniuses of the last half century, would probably have scoffed at this remote learning and work trend. As millions of people at hospitals around the country continue to work daily, despite a hospital being a natural aggregator of sick Covid patients, I can't help feeling that this reluctance to return to pre-Covid normalcy will be with us for a very long time.

Friday, August 14, 2020

Pandemic Paradise

Lot more gridlock now.

I hate to say it because it sounds so callous, but this coronavirus pandemic has made living in Los Angeles so pleasant. Yes I know thousands of people have died and millions of people have lost their jobs. But there are many millions more people who are still working, and that includes most healthcare workers. 

The situation isn't so dire as it was a few months back. At that time, we didn't really know what we were dealing with. Images from Italy and New York portrayed apocalyptic images of doctors and nurses overwhelmed with the sick and dying. But frankly, they were the exception, not the rule. In fact, hospitals and surgery centers across the country lost billions of dollars because they sat empty as patients were too afraid to seek medical care and operating rooms went dark. 

No traffic! Love it.
I wrote about how deserted the freeways were here in the city. As the stay at home orders forced businesses to close and millions of people were laid off, LA looked like a scene from the Twilight Zone. There was no traffic any time of day or night. I could zip down the 405 freeway at 5:00 PM going 80 mph. It was amazing.

Now things have improved. Restaurants have started opening up. I see packed tables socially distanced apart appearing along sidewalks and parking lots as people enjoy their meals al fresco. The hospital and surgery centers are busier than ever as the backlog of cases are slowly getting whittled down. Traffic has even picked back up. At the worst moments in the spring, my commute time was less than half the usual time. Now my commute is back up to about seventy-five percent of my previous time. I actually have to avoid the 405 now during peak rush hour and take local streets again, like a true Angeleno. It's still a vast improvement from the previous gridlock though.

I hope the economy picks back up quickly for everybody so we can continue to live our American prosperity. But for those of us who are working harder than ever, this time is indeed a blessing as getting around town is easier than ever. Now if only more places, like museums, movie theaters, and shopping malls, opened up, I will have somewhere to go during this golden era of LA freeway driving.

Thursday, August 13, 2020

Boston Murderer Gets Life Sentences For Killing Two Anesthesiologists

With all the overwhelming news about the coronavirus and the presidential election, I overlooked a very important story a few months ago. Remember that horrifying double murder of two anesthesiologists in Boston in 2017? Drs. Lina Bolanos and Richard Field, an engaged couple working at Harvard Medical School, came home from work and were confronted by an intruder. They were bound and their throats slashed. The murder, Bampumin Teixeira, used to work in the building as a concierge and had access to the premises. He committed two murders for a simple robbery.

Well justice has been rendered. In December of last year, he was found guilty of the murders and received two consecutive life sentences with no possibility of parole. This doesn't even count the sentences for his other crimes including armed robbery, kidnapping, and home invasion. 

Mr. Teixeira exhibited erratic behavior throughout the trial, including threatening the prosecutor and shouting in the courtroom. He had to be dragged out and watched the proceedings on TV from a separate room. He showed no remorse when he learned of his sentence.

RIP good doctors.

Tuesday, August 11, 2020

How To Improve Your Hospital's National Ranking

US News & World Report recently released its latest rankings of the nation's hospitals. Eagerly awaited each year, it is a source of pride and free publicity for numerous hospitals. A high position in the survey is frequently cited in radio, print, television, and online advertisements, sometimes literally the day after its publication.

Naturally hospital administrators are eager to figure out how to improve their rankings in the survey. This is even more true if there is a rival hospital in town. Wouldn't USC's Keck Hospital love to leapfrog UCLA's Ronald Reagan Medical Center in the LA hospital market. 

While looking through the list, it seems to me that there is an easy and effective way to get one’s hospital into a better position. The US News survey is subdivided into seventeen subspecialties. These include Cancer, Rehab, Orthopedics, and others. Ten of those are surgical subspecialties like Urology, Orthopedics, Neurosurgery, and GI Surgery. So obviously the best way to improve the hospital score is to improve the surgical rankings. And what can the surgery departments do to improve their positions? Hire a good anesthesiology department of course.

Think about what a good anesthesiologist can bring to the hospital. Anesthesiologists can improve patient satisfaction by treating patients effectively for postop pain and nausea. Anesthesiologists can help decrease the infection rate of cases. Through the concept of the perioperative surgical home, anesthesiologists can increase the flow through of the patient through the hospital, allowing the patient to recover more quickly and saving the hospital money at the same time.

To all the hospital administrators who are reading this post. Find the best anesthesiology group you can afford. The increase in productivity and morale in the operating rooms and the surgical units will more than pay for itself as anesthesiologists use our professional training to improve perioperative care and drive efficiency and satisfaction among your patients. Increased US News hospital ranking is just icing on the cake.

Saturday, August 8, 2020

White Doctors More Likely To Suffer Burnout

Here is one white privilege that is rather unexpected. Researchers at Stanford University have found that white physicians suffer a higher rate of burnout than other races. In a survey of 4,424 doctors, they calculated that white doctors have a burnout rate of 44.7%. This compares with burnouts of 41.7% in Asians, 38.5% Black, and 37.4% Hispanic.

Traditionally, primary care doctors have higher burnout than specialists and minority doctors tend to practice in primary care. However the researchers speculate that white doctors have different expectations of their careers compared to others. Many white physicians come from a multigenerational family of doctors so they may fondly remember the experiences of being a doctor from decades ago. By comparison, minority doctors are more likely to be first or second generation. Therefore the current medical environment doesn't feel so different.

Perhaps burnout is really a matter of expectations. If you feel lucky to be practicing medicine because you're the first one in your family to go to medical school, you'll be less likely to complain about your difficult job than someone who attends a family reunion where all the doctor family members gather to gripe about the government, insurance companies, patients, etc. It's all about perspective.

Tuesday, August 4, 2020

Did Medical Racism Kill Rep. John Lewis?

I'm just going to be a little provocative here today. Last week, Democratic Georgia Congressman and Civil Rights icon John Lewis was laid to rest after a brief battle with stage 4 pancreatic cancer. He announced his diagnosis back in December 2019. At the time, he was girding for a fight with the disease, stating, "While I am clear-eyed about the prognosis, doctors have told me that recent medical advances have made this type of cancer treatable in many cases, that treatment options are no longer as debilitating as they once were, and that I have a fighting chance." Unfortunately his fight came to an end July 17, 2020.

Contrast that with two other very famous people who coincidentally were also diagnosed with stage 4 pancreatic cancer recently: Alex Trebek, the game show host, and former Democratic Nevada Senator Harry Reid. Trebek was diagnosed in February 2019 while Reid was diagnosed in May 2018.

Trebek has been very vocal about his treatments. He's been chronicling his chemotherapy with the public routinely, recently announcing his one year anniversary of his diagnosis. He said last September he was not doing so well. He had lost 12 pounds and his CA-19 numbers were still elevated. So he started an experimental immunotherapy treatment on a compassionate use case. Remarkably it worked well. His CA-19 numbers went from 3,500 before the treatments to under 100 now. 

Sen. Reid was also doing poorly with his cancer in 2019. Surgery and chemo had failed to halt the progression of the disease. He then got in touch with billionaire physician Patrick Soon-Shiong and got enrolled in the same treatment program as Trebek. Now, two years after his diagnosis, Reid is cancer free.

So what is this miracle drug that is eliminating stage 4 pancreatic cancer? They are using a medication called Abraxane that in combination with other treatments like interleukin-15 and natural killer cells form a "triangle offense" to eliminate metastatic pancreatic, breast, or lung cancers. The regimen is so new it is still undergoing phase 2 trials in the U.S.

This raises the question of whether Rep. Lewis was offered the same treatment protocol. He was the last of the three to be diagnosed with pancreatic cancer yet he is the first to succumb to it. Both Trebek and Reid appeared to respond quickly to Abraxane, within months. Was Lewis given the same opportunity? It's couldn't be about money. I'm sure Rep. Lewis, a congressman for decades, is well off financially. It also couldn't be about VIP's getting different treatments compared to ordinary people as Lewis is as VIP as it gets. Was his cancer stage much worse than the other two such that it was meaningless to offer him this miracle cure? Is it a coincidence that the two survivors are white men while the black man died from his disease?

Due to privacy concerns we will probably never know the answers to these questions. But it seems to add to the confounding statistics that Black men die at a higher rate than white men for the same diseases, even if they are socioeconomically equal.

Sunday, August 2, 2020

Which Specialties Will Make You Rich?

Most people think that all doctors are rich, right? One definition of rich is somebody who makes more money than you. If that is the case, then nearly all doctors are richer than the average American. But to really understand how well off somebody is, you need to look at their net worth. A high income doesn't mean anything if it is frittered away and there is nothing left to show for it. A Charles Schwab Modern Wealth Survey reported that most people considered a net worth of $2.3 million as a definition of being wealthy. That is a considerably higher bar to hurdle than just merely have a high income.

For most physicians, that is a difficult, though not impossible goal to achieve. Obviously if you're just starting out, $2.3 million in net worth sounds like a pipe dream. But as your career flourishes, the goal gets closer and closer within your grasp. And certain specialties have an innate advantage in achieving high a net worth.

While the average person thinks $2.3 million defines the wealthy, physicians have a different point of view. Most doctors would probably be happier with $5 million in net worth. Can't show up at the country club driving a Mercedes when your colleagues roll in with their Bentleys and Aston Martins. So here are the ten specialties that have the most doctors who have a net worth of over $5 million courtesy of Medscape.

1. Orthopedics, 19%
2. Plastic Surgery, 16%
3. Gastroenterology, 16%
4. Cardiology, 15%
5. Oncology, 15%
6. Dermatology, 15%
7. Otolaryngology, 14%
8. Urology, 14%
9. Radiology, 13%
10. Ophthalmology, 13%
*11. Anesthesiology, 12%

Medscape Physician Compensation Survey 2020
Medscape Physician Compensation Survey 2020

Naturally most of the fields in this list are also the same ones who have the highest incomes. But making a lot of money doesn't guarantee that you'll end up with a high net worth. If you spend all your money on fancy cars, bad investments, and multiple wives and children, you can still end up a pauper despite making a six figure income. I know doctors who are working well into their 60s and 70s because of poor life choices over the years.

While this list looks impressive, fifty percent of all physicians have net worth of under $1 million. Since there are no ages associated with these statistics, it's probably safe to say that most of the doctors under 50 years don't have a net worth of $5 million. In fact, in some fields like pediatrics and family medicine, over 40% have net worth of under $500 thousand.

So all you millenial physicians just starting your careers, keep saving into those tax deferred accounts and other wealth building plans. Five million dollars may seem impossible to attain at your current situation, but keep plugging away. Compound interest and six figure incomes will work to your advantage in the future.

* I just had to add anesthesiology to the list to show how close we are to the top ten of wealth generating specialties.

Saturday, August 1, 2020

How To Find The Perfect Anesthesia Job

There's a really good article in this month's ASA Monitor that describes the choices one has to make to find a job in anesthesia that is both satisfying and rewarding. Some of the suggestions are obvious but others may make you think about what aspects of a job are acceptable to you personally.

Their first suggestions is to decide where you want to live. Most people wind up working where they did their training. It's pretty obvious since that's the job market you know and the professional network you've developed. Since the location of your residency match frequently is based on where you want to live, this just makes sense. But don't forget that many people have to take their spouse's concerns into consideration too. Maybe the spouse wants to move back closer to their family and not where they've been stuck in training all these years.

Next you have to consider if you want to be involved in research, educational training, or neither. When I finished residency, I knew I didn't want to do any research or teach residents. I went straight to the private practice model. But now that I've had years of experience, I have started getting move involved in working with residents and even done some simple research projects. Luckily I am able to do that without changing job locations. So keep an open mind as your preferences may evolve over time.

Do you want to do your own cases or supervise others? I absolutely wanted to do my own cases when I first started out. As a new residency graduate, I didn't feel comfortable supervising CRNA's. I didn't have enough self confidence to tell other people how to give anesthesia. And some of them probably wouldn't pay any attention to me anyway as they can claim many more years of experience compared to me. But now that I've been working for nearly two decades, I'm more open to supervising others. I know many anesthesiologist who love to supervise CRNA's. They feel perfectly comfortable lounging in the break rooms while the nurses work in the OR.

What kinds of cases do you want to do? Do you want to do a bunch of knee scopes and hernia operations all day or do you want to go hardcore and work at a Level 1 trauma center and deal with whatever medical catastrophe rolls in through the ER? 

Here's literally the big money question--how do you want to be paid? Do you want to receive a salary or do you want a fee for service model? A set salary is preferred by many as it usually involves a more predictable work environment, either at an academic or government institution. You also get the benefits and perks associated with these locations. However if you're looking to make a lot of money, fee for service is where it's at. Your daily schedule is more unpredictable, as it's impossible to know ahead of time how many cases the surgeons are going to book, but this is where the you can make far more income.

Then finally, make sure you have a good feeling for how the other anesthesiologists feel about working there. Though it may be difficult to get an objective opinion of the job during your interview, it never hurts to ask them what their opinion is. Do the partners steal cases from each other after they've performed a wallet biopsy? Do the new guys take all the holiday and weekend calls? How long have they been working there? Is there a revolving door of anesthesiologists? These are important factors to think about when interviewing to see if a new job will fit your personality and lifestyle.

So there is a lot to think about when deciding what is your perfect anesthesia job. Answering these questions will narrow your choices considerably and make it easier to decide. And remember, sometimes things don't work out and you realize your choice was not the correct one. That's okay. You're still a physician anesthesiologist and you can take your skills anywhere you want. Nobody is forcing you to work at a place that doesn't fit your needs. Good luck.

Friday, July 31, 2020

What Anesthesiologists Hate

Recently there was a Twitter post by an emergency medicine physician who asked what it is that each medical specialty hates the most. This quickly went viral as doctors started piling on. That got me thinking. What do anesthesiologists hate the most? Well it didn’t take long before I had a fairly long list. Not surprisingly many of them relate to surgeons. But I dislike many things I have to deal with every day that can ruin my usual sunny disposition. Here are some of the items I came up with, in no particular order.

1. Surgeons who tell me how to do my job. I’ve written before that this is one of my biggest pet peeves. I don’t even like telling other anesthesiologists how to give anesthesia. What makes a surgeon think he can tell me how to do something he has no training or competence in?

2. Surgeons who lie. If you’re going to be late, then just own up to it. Don’t tell the OR you’ll be here in five minutes or you’re just parking your car then show up 45 minutes later. We can handle the truth. Stop acting like a lying three year old. 

3. Being called anesthesia. We have names. Surgeons get the courtesy of being called Dr. So and So. Why can’t the staff extend the professional courtesy to us too? If you don’t remember our names you can always ask or just address us as Doctor, which we are.

4. Taking calls. This is probably something all doctors hate. That’s why we’ve had colleagues who leave our group to work at surgery centers where there are no night calls, even if there is less job stability and you’re working at the whim of the surgeon.

5. Morbidly obese patients. If I had to choose between a patient who is 97 years old or a patient who is 500 pounds, I’d choose the 97 year old each time. A morbidly obese patient just makes everything more difficult and dangerous. It’s not just the airway that is problematic. Blood pressure and ECG monitors don’t work as well. IV access can be nearly impossible. Moving the patient becomes a massive team effort. There is potential for greater injury to the staff and the patient. Morbid obesity is the bane of healthcare and this nation.

6. ASA 4 or greater. Another reason why anesthesiologists flee to the surgery centers. Nobody wants to deal with an ASA 4 patient who comes to the OR in septic shock with a heart rate of 125 and hemoglobin of 7 with a single 22 gauge IV in one hand. And when you flush it, it blows. 

7. Patients who tell me where to start their IV’s. Most of the time it is helpful when patients tell me where they’ve had the most success in getting IV’s placed. But if all I see is one single vein that looks like it might not blow up after I poke it, don’t tell me that spot hurts and you always tell people not to start the IV there. You’d rather I poke you five times trying to find a vein then a single stick in one that is most readily accessible?

8. Colleagues who leave a mess of the anesthesia workspace. I can feel my frustration rising when I come in to work in the morning and the anesthesiologist from the previous night has left a complete mess on the anesthesia cart and anesthesia machine. Half filled syringes lie everywhere. Used drug vials are scattered on every surface. The cleaning crew are taught not to touch any anesthesia equipment so the mess stays until somebody decides to throw everything out. Please clean up after yourselves people when you leave the room. Show some courtesy to your fellow anesthesiologist.

9. Doctors who think we’re “just” anesthesia as if we’re not real physicians. It’s amazing how prevalent this attitude is. I’ve questioned specialists about their consultation note on a patient and they talk down to me like I have no business asking them since I’m “just” anesthesia. Like I have no clue about cardiac or pulmonary or renal physiology. 

10. Getting rushed by the OR. Why is it the anesthesiologist is called to come see a patient in preop ASAP but the surgeon can walk in 30 minutes late for a case and nobody dares utter a peep? Even the patient, who is complaining loudly to everybody within earshot about how his case is delayed will greet his surgeon with all smiles. This inequality in treatment always astonishes and frustrates me. 

This is just a quick list I jotted down. It is by no means comprehensive. There are a lot more if I wanted to bore you with the details. But suffice it to say the one redeeming factor that makes this job worthwhile is because anesthesiology is one of the best jobs in the country.

Wednesday, July 29, 2020

Has Anesthesiology Become One Of The Hardest Residencies To Get Into?

Here are some interesting statistics about the recent Match Day results from the latest issue of the ASA Monitor. This year, there were 1,884 anesthesiology positions available for the Match. This includes both CA1 and CA2 spots. By the end of Match Day, 1,873 positions were taken. Only eleven spots remained unfilled. That turns out to be a 99.4% match rate for anesthesiology. This compares similarly to other highly competitive residencies like orthopedics and ENT which also had a 99.4% match rate success. This is even more impressive when one considers that the number of anesthesiology residency positions has been increasing every year, from 1,590 spots in 2016 to 1,788 in 2018 and this year's 1,884, an increase of 18.5% in four years.

These kinds of statistics wouldn't seem possible for those of us who were around to remember the disastrous match rates for anesthesiology back in the 1990s. At that time, false analysis of the manpower needed for anesthesia jobs declared that there was going to be an excess of anesthesiologists and not enough jobs available. This caused medical students to avoid anesthesiology like the plague, or the coronavirus in contemporaneous terms. The number of students matching into anesthesiology went from 1,025 in 1992 to a bottom of 324 in 1996. That's not a misprint. Back then anesthesia residency programs couldn't give away their spots. It's taken a long slow road to improve to the current state of exclusivity for anesthesia again.

So what accounts for this recent surge in popularity of anesthesiology? Perhaps the warnings about a catastrophic oversupply of anesthesiologists and subsequent collapse of their incomes have finally been buried. Anesthesiologists consistently are in the top ten of income earners as measured by various surveys of physicians. Maybe it's the so called lifestyle that most young people prefer these days. The days of living at the hospital 18 hours a day no longer appeals to the newest generation of physicians, or anyone else for that matter. Or could it be that ambitious young doctors have realized that anesthesiology isn't just about intubating patients and passing gas. It encompasses the whole physiologic complexity of human disease, from cardiothoracic to neuro to OB to pain and regional medicine. Anesthesiology is no less challenging than any other medical or surgical fields.

Whatever the case, there doesn't appear to be any slowdown in the interest in anesthesiology or the number of positions being offered each year for Match Day. One day perhaps when our fellow medical students find out we matched into anesthesiology, they'll think we got in because we are really smart, not because we did it for the lifestyle and money.

Tuesday, July 28, 2020

What Do You Get When Anesthesia Residents Party? A Coronavirus Outbreak

More news of anesthesiologists behaving badly. However this is more out of hubris than greed. The University of Florida Health system in Gainesville reported that 18 members of their anesthesiology department came down with the coronavirus after attending a private party. The afflicted include fourteen junior residents, two senior residents, a fellow, and an administrative employee (attending?).

The occasion for the party is vague. Some described it as a farewell party for graduating residents while others say it was a welcoming party for the new residents. It was probably a little of both. What is known is that there were up to 30 members of the department at this party. Afterwards the chairman of the anesthesiology department, Timothy Morey, MD notified the hospital on July 10th that members of the department had come down with Covid.

The hospital had kept a lid on this news until the university's own news organization, Fresh Take Florida, published it this week. It never notified the public or the government out this outbreak. Dr. Morey said all the sickened members were kept home in self quarantine. Because of privacy reasons they will not reveal who attended this party or who got infected.

This goes to show that in a free society it is getting increasingly more difficult to keep people from socializing over a long period of time. Unless we are willing to take drastic measures like China where they literally welded people's doors shut so they can't go out, we will hear more stories of social gatherings and virus outbreaks. Even people who are at the center of this pandemic and have all the information available to them will not be immune to the innate human need to gather and celebrate.

Beverly Hills Anesthesiologist Charged With Multi-Million Dollar Insurance Fraud

It breaks my heart every time I read and write about anesthesiologists who have gone astray. But unfortunately it is a fact of life that some people lose their moral bearings as they pursue their shallow materialistic desires through depraved and unethical actions.

Well known Beverly Hills anesthesiologist, Randy Rosen, MD, has been charged with a massive insurance fraud scheme. He and his girlfriend are accused of billing insurance companies $676 million for unnecessary procedures and receiving $52 million in payments. Their bail, originally set at $52 million, has since been reduced to $16 million.

The doctor would pay "body brokers" a few hundred dollars to bring in drug addicts to his clinic for outpatient procedures where he'd implant a device that's supposed to help ease their addiction symptoms. The procedure takes just a few minutes and he would charge insurance companies thousands of dollars. According to a text message from Rosen (I hesitate to give him the title Dr.), "The procedure takes me less than 5 minutes. So on an hourly that would be about 120k. Lol." He would also bill insurance companies for radiologic studies that never took place or send his patients to his girlfriend's laboratory for blood tests and getting kickbacks. 

There are real world consequences from this couple's greed. At lease one patient died when he didn't get the proper addiction treatment he needed, instead relying on the naltrexone implant that Rosen performed. That patient's insurance was billed $59,000.

In the meantime, the couple were living it up, remodeling a mansion high in the hills of Brentwood and buying exotic cars and jewelry. If Rosen is found guilty of his charges, he faces 88 years in prison. Let's hope somebody with such a lost moral compass never practices medicine ever again.

Monday, July 27, 2020

The Richest Doctors In The World

Do you think doctors make a lot of money? They can but not by practicing medicine. Forbes list of billionaires in the world includes six physicians and none of them practice clinical medicine.

1. Thomas Frist, MD. Founder of HCA Healthcare, the largest hospital company in America. Net worth: $11.6 billion

2. Patrick Soon-Shiong, MD. Inventor of Abraxane. $6.7 billion

3. Phillip Frost, MD. Inventor of Opko Health. $2.4 billion

4. Gary Michelson, MD. Retired spine surgeon and inventor. $1.7 billion

5. James Leininger, MD. Founder of Kinetic Concepts. $1.5 billion

6. George Yancopoulos, MD. Chief Medical Scientific of Regeneron. $1.4 billion

The lesson here is that if you think you can make it rich seeing a bunch of Medicare and Medicaid patients, you are in the wrong field.

Sunday, July 26, 2020

Anesthesiologists Make Excellent Incomes, Until Coronavirus Happened

Normally when Medscape releases its annual Physician Compensation Survey, I can't wait to announce the results to all of you. Every year, the numbers just keep going up. Last year's survey, which encompasses survey results on income in 2018, showed anesthesiologists made $392,000. When the 2020 survey results were published back in April, the self reported compensation for anesthesiologists were even better, reaching $398,000.

Unfortunately, that data is now completely obsolete. Medscape conducted the survey prior to February 10. And we all know what happened after that. The coronavirus decimated much of the world economy and medicine was not spared. Over half of medical practices reported a decrease in their revenues and sixty percent said their patient volumes have softened. News of practices closing and staff laid off, some permanently, are widespread. 

At our own hospital, surgical volume dropped off a cliff in April and May during the worst of the first wave of the pandemic. We were running a bare bones operation as all elective surgeries were cancelled. Like the rest of the country, we were left on our own to figure out how to adequately test our patients for Covid, how to secure adequate supplies of PPE, and how to staff the operating rooms safely. Everybody in our group applied for the government's Paycheck Protection Program loan just to carry ourselves over during the worst of the crisis. 

Now the situation may have turned a corner. All those elective cases that were postponed have been put back on the operating schedule. We are facing a huge demand for OR time as old cases compete for new cases to get done. Overhanging all this activity is the threat that the government could shut down the economy at any time on a whim and Covid cases continue to increase in the aftermath of all those rioters and protesters. 

We won't get a complete picture of how the coronavirus has affected physician compensation until we've navigated all these lockdowns and feast or famine patient interactions. Medscape Physician Compensation 2021 will make for very illuminating reading.

Saturday, July 25, 2020

Your Inner Neanderthal May Be Causing You Pain

Are you the type of person who is sensitive to pain? Do you reach for the Percocet at the first sign of a headache? Perhaps it's not your fault that you are more acutely aware of pain than others. It maybe because of a Neanderthal gene you inherited eons ago.

Scientists who examined these ancient genes found a variant that alters an ion channel in nerve cells. This causes the channel to initiate pain perception more readily than those who don't have the gene. The Neanderthal genes are more commonly found in people of European and Central and South American descent.

So next time you tell your doctor that you need a refill of Norco along with a prescription of Dilaudid for breakthrough pain, tell her that it's not your fault. It's your Neanderthal genes making you sick.

Friday, July 24, 2020

Best of Both Worlds

Imagine a job where you get to practice medicine but don't have to go through medical school. Then while treating your patients you are not legally responsible for your actions if something goes wrong. On top of that you make more money than many actual physicians? What kind of dream job is this? A certified nurse anesthetist, of course.

Working as a CRNA just got a whole lot sweeter after a court in North Carolina declared that they are not responsible for their actions because they are really just a "nurse" who can't be held liable for what they do. This involves a tragic case of a three year old child who suffered a cardiac arrest and anoxic brain injury after the CRNA and physician anesthesiologist induced her with sevoflurane for a cardiac ablation. 

The anesthesiologist was able to settle the case out of court but the hospital and the CRNA went to trial. At the trial the judge found the CRNA not liable because of a 1932 ruling by the North Carolina Supreme Court that said nurses are not responsible for their actions. As the judge wrote, "The Court reasoned that nurses 'are not supposed to be experts in the technique of diagnosis or the mechanics of treatment.'" Therefore the current appeals court could not rule against the precedent set by the NC Supreme Court, even if it occurred nearly 80 years ago.

So now CRNA's, at least in North Carolina, have the best of both worlds. They can claim they are just as skilled and intelligent as physician anesthesiologists. Yet when the s*** hits the fan, they can also claim they cannot be held liable because the courts said nurses are not experts in diagnosis or treatment.

Seriously who would want to be a physician anesthesiologist when CRNA's have the best job in the world

Wednesday, July 22, 2020

The Best Non-Political Reasons To Wear A Face Mask

It's pretty common sense to wear a face mask to keep from breathing in anything that might be harmful. It's been practiced for hundreds of years. Unfortunately that act of self protection has turned into a political battle. It's become a litmus test of a person's adherence or rebellion towards authority.

While that battle rages, I think wearing a mask is great. But it has nothing to do with my political affiliation or opinion of the effectiveness of the country's battle against Covid. There are lots of terrific practical reasons why I think we should all wear face masks, even after we conquer this terrible episode of human history. Here are my personal observations after wearing a face mask daily for the last four months.

1. You never have to trim your nose hair. No more lectures from the Queer Eye For The Straight Guy team about how important it is to trim your nose hair. Just let it grow until you can braid it. Nobody will ever know.

2. You don't have to worry about food getting lodged in your teeth. You know how you worry whether there is a small piece of salad stuck in your teeth after lunch? No problem anymore if you're wearing a mask.

3. Bad Breath. This applies to both you and the patient. That breakfast of onion bagels with sour cream and chives cream cheese spread followed by a cup of strong Starbucks? The only one who can smell your breath is you.

4. Don't you hate it when a giant zit starts growing on your nose? Face mask it and you won't feel like your pimply fifteen year old self all over again.

5. Make elevators safe again. Everybody's experienced that fearful feeling when somebody in the elevator rudely coughs or sneezes. You try to hold your breath the instant it happens but inevitably you breathe in that person's respiratory droplets and viruses. If everyone is wearing a mask, there no worry of catching something contagious because you were too lazy to walk up one floor to get to work.

6. I don't want to make my frown upside down. Some people like myself just have natural frowny faces. It's a chore to always remind myself to turn up the corners of my mouth so patients don't think I'm mad at them. Now I can just draw a smile on the outside of my mask and look like I'm smiling ALL THE TIME. Whoopee!

7. My dentist can kiss my ass. With my mouth covered all the time, why should I spend thousands of dollars on teeth whitening and dental care? I can let my teeth rot to the core and nobody would notice. The mask would also cover up all the bad breath (see #3).

8. Shaving accidents. The world no longer has to know all the shaving nicks and cuts on my face because I'm too cheap to get a new blade. 

9. That cheesy mustache. Feel like growing a handlebar mustache like your great uncle who performed in a barbershop quartet but are worried about the ridicule? Wear a mask and go for it.

10. Nothing wrong with tongue or lip piercings. Express your inner emo. Now you too can get your perioral body parts that are covered by a mask pierced to your heart's content and still look prim and professional. 

As you can see there are tons of good reasons to wearing a face mask that are applicable even after we get over the pandemic. Masks--they aren't just for surgeons anymore. 

Tuesday, June 2, 2020

Where Are The Medical Scolds?

Remember a few weeks ago during this interminable pandemic? People were starting to chaff under the restrictive stay at home orders and social distancing guidelines. Mass demonstrations against these government edicts began to pop up all around the country as people clamored to get back to work and restore their livelihoods.

Instead of supporting their fellow citizens who were on the verge of financial ruin through no fault of their own, a bunch of healthcare workers stood in the streets in their possibly coronavirus infected scrubs to act as human barriers against the protesters. They looked like they were emulating the tank man at the Tiananmen Square uprising in China.

One physician made an indignant plea on YouTube after visiting her local Target store. She was appalled at all the customers who weren't wearing their masks and accused them of being immoral. She freaked out that this was endangering the lives of medical workers by not practicing the proper social distancing and wearing protective coverings.

The press lionized these medical professionals for standing up to the so called ignorance of the selfish population who only wanted to live their own lives free from bureaucratic interference. These were the new social justice warriors who needed to be paid attention to during these difficult quarantined times.

Now flash forward to this past week. There are massive demonstrations throughout the country in the aftermath of the George Floyd death under the knee of a police officer in Minneapolis. Thousands of people are marching shoulder to shoulder through the streets. Some are wearing masks though I suspect it's not for health reasons.

Yet where are the medical scolds to come out and defy these massive crowds? Where is the righteous indignation that all these people dare to endanger themselves and the healthcare workers by deliberately allowing themselves to get exposed to the coronavirus? Where's the outrage at this defiance of the medical establishment? 

Could it be that the earlier stand of the physicians against protesters was more about their political views than the health of the population? Now when thousands of marchers are congregating over a police killing, there is nary a concern for virus transmissions. The politicians who before were threatening to arrest people for walking outside with their families are suddenly encouraging the masses to express their impassioned views even if they are blocking the streets and disrupting businesses. There is no mention of extending the lockdowns as the Michigan governor had threatened last month after peaceful protestors surrounded her capital building.

So color me skeptical about this whole pandemic quarantine. Countries like Sweden, Japan, and Taiwan demonstrated that lockdowns are not necessary to combat the coronavirus. This financially catastrophic episode in America appears more and more politically motivated than healthcare driven. The country followed the orders of epidemiologists like Dr. Anthony Fauci, believing that their physician oaths to first do no harm guided their recommendations. After 40 million people suddenly found themselves in the unemployment line and politicians have decided it's acceptable for thousands of people to gather together after all, we wonder if this was the biggest political con job on the American public ever perpetrated. 

Monday, March 23, 2020


The coronavirus pandemic continues unabated through much of the world. Despair is starting to weigh on society as millions of people have lost their jobs and our freedom of movement has been curtailed by the government with no recourse for dissent. Through this natural disaster, a morbid theme has emerged for the Corvid-19 virus--Boomer Remover.

Used mostly by the young, boomer remover shows their disdain for the elderly and who they think is the source for much of their misery. While they are trying to carry on and party like the young are wont to do, they are being forcefully suppressed by their supposedly more educated and worldly elders. They have been thrust into the worst US economy in at least a generation, and maybe as bad as the Great Depression of the 1930's just as they are graduating from school and starting their families and careers.

However, it is the baby boomer generation that is feeling the brunt of the Corvid-19 chaos. First of all, the disease is much deadlier among the elderly than the young. The death rate for those under 50 years old is less than one percent. After that, the rate increases exponentially until after the age of 80 where the death rate is almost fifteen percent. That's why the college kids feel like they can party on Miami beaches with little consequence for their own health while the country watches in horror.

Then the government guidelines ask that those over 60 years old should stay home since they are the ones most likely to suffer severe illness from the virus when they get infected. This has caused many of them to miss precious work just when they are getting set to retire. In our practice, our older partners have voluntarily stopped working for the last two weeks. I don't know how much longer that can last as they are making zero income sitting at home.

The stock market crash has also disproportionately affected the baby boomers. The financial crash of 2008 forced many in our group to work past their expected retirement age. This caused our partnership to become too top heavy as the older anesthesiologists refused to retire, making it difficult to hire younger partners. After eleven years of a bull market, we finally had an exodus of retirements in the last two years. Wouldn't you know it, the market crashed again. Who knows when people can feel whole enough again in their retirement accounts to contemplate hanging up the shingles.

So the younger generation may feel that they are the ones bearing the brunt of this economic collapse because of government mandates beyond their control. But the term #BoomerRemover may be more accurate than they realize. The increased mortality associated with the disease and the financial difficulties that will crush their retirement savings may cause a calamity for the boomers that are yet to be calculated.

The Unhealthy Dependency Of Anesthesiologists

I've mentioned in the past about the anesthesia profession as being highly dependent upon the well being of their surgeons. Though the ASA would hate me for saying it, anesthesiologists have almost a parasitic relationship with the doctors on the other side of the blood brain barrier. The surgeon is the doctor who brings the patient, and the money, to the facility. The anesthesiologist is the doctor who feeds off this relationship. Sure the surgeon wouldn't be able to do his case well with a bad anesthesiologist, but there are a lot more anethesia providers around than there are surgeons with lots of well paying patients.

The Covid-19 pandemic has brought this dependency into stark relief. With hospitals everywhere overwhelmed by the number of Covid-19 patients being admitted, all elective and many nonemergent surgeries have been cancelled across the country. Unless the patient has cancer or is in imminent death without surgery, the cases are being rescheduled for a later time. The tricky part is nobody knows when a better time can be found as the end to the pandemic is nowhere in sight.

Subsequently anesthesiologists are hurting financially everywhere. The Boise Anesthesia Physician Associates just laid of 53 of their CRNA's for lack of work. The anesthesiologists themselves are not drawing a salary so their employees can work another month before they are let go. Then after that who knows? Their banker would not extend a line of credit without the doctors using their personal assets like their homes for collateral. Their hospital still needs anesthesia providers for critical care and intubating expertise but they need far fewer of those than the number who used to work in the OR.

In my facility, the operating schedule has dropped by well over fifty percent in the last week. The suddenness of this change has been breathtaking. Just two weeks ago people were planning their summer vacations and watching their stock portfolios hitting record highs. Now we're all talking about how to reuse our N95 masks and calculating how we'll ever pay for our kids' college education, much less thinking about our decimated retirement funds.

This has truly been a black swan event. Whereas the 9/11 terrorist attack and the 2008 financial meltdown also brought the stock market to its knees, there was very little change in the need for surgeries. In 2008 many of the plastic surgery offices were hurt as the high end Beverly Hills clientele lost money in real estate and had to cut back on their cosmetic surgeries. But they were a small minority of the operating schedule overall.

This time it's different. When all elective surgeries are cancelled, there really is no escape course for the anesthesiologist, or surgeon. Many of the ambulatory surgery centers in town have been closed by government mandate since they're not considered essential businesses. Nobody is allowed to go outside anyway as we're all supposed to be sheltering in place at home. The worse part is that nobody knows when all this will end. It could start improving in a month or two. Or maybe it won't get better for six months or more.

Currently we have far more anesthesiologists than necessary for the number of cases we have each day. They're talking about rotating on off days so that everybody has at least a little bit of work. It's a level of financial uncertainty that is rarely experienced by well paid physicians. The coronavirus may ultimately remake the American healthcare system as we know it.

Sunday, March 22, 2020

We Are Now Living The Green New Deal

No traffic in Los Angeles!
Thanks to the panic of Covid-19, we are now living in the world of the Green New Deal. You remember what that was, right. That was when the country, and the world, was free and prosperous enough to contemplate what the climate will be like a decade in the future. Thanks to far left liberal politicians like New York Congresswoman Alexandria Ocasio Cortez, the predictions were that the world will end in a decade unless drastic action was taken to prevent climate change.

They proposed the elimination of all use of fossil fuels. Everything would have to be powered by electricity obtained from clean renewable energy sources like wind or solar, but not nuclear. There would be no more airplanes, automobiles driven by fossil fuels, and boats. Homes and businesses would not be allowed to turn the lights on unless the electricity came from clean energy. And even cows were demonized for emitting too much methane into the atmosphere.

The GND was rightly mocked for being impractical and unrealistic, a fantasy of the privileged elite who don't have to drive to work every day to earn their paychecks. They idolized their beliefs to the point of declaring a teenager who espoused those views to become Person of the Year by Time magazine despite having no formal education in environmental science.

Now we know what living in a GND world is like. Through (overly?) draconian actions taken by the government to prevent the spread of the coronavirus, the American economy has ground to a halt. Practically all air travel has stopped as people are told to hunker down. All cruise ships have cancelled their trips. Millions of people have lost their jobs because all nonessential businesses are told to close until further notice to prevent gatherings of crowds. Millions of children and college kids are out of school with no clear idea when they will return to finish the school year, if at all.

The consequences of these actions have been terrifying. Billions of dollars have been lost in the economy as people are confronted with no income. The stock market is crashing by astonishing amounts almost every day. The federal government is looking at spending trillions of dollars to prop up the economy and it may still not be enough. People are panic buying and hoarding food and survival supplies. There are long lines to purchase guns as people think civilized society is hanging by a thread.

The only bright side for me personally is that my commute to work has been cut in half. A traffic map I took in the middle of the afternoon on a weekday showed virtually no traffic jams anywhere in LA County. Normally there would be red lines through all the freeways. Now they're all green. Los Angeles really is glorious when it's easy to get around. The skies are wonderfully blue. It's easy to see the distant snow on top of Mt. Baldy. The air feels crisp and clear. The only problem is that there is nowhere to go despite so little traffic as everything is closed.

For all those who talked a few months ago about the urgency of implementing the Green New Deal, be careful what you wish for. It's easy to advocate for those policies when you know there is little likelihood of their implementation. This current crisis is just a taste of the chaos that will happen to society if those ideas ever come to pass.

Thursday, March 12, 2020

A World Without Vaccines

Okay all you anti vaxxers out there. This is what the world looks like if man had never invented vaccines. Not pretty is it? You refused to immunize your children against deadly plagues like measles and polio. You go on internet tirades and troll anybody who expresses the necessity of giving children their vaccinations. You cheer on quacks and celebrities who preach their uninformed opinions about the potential complications of vaccines.

Now the world is faced with a pandemic from the coronavirus. How many of you still think the whole vaccine business is a profit making scheme cooked up by the pharmaceutical industry with the tacit approval of a government influenced by highly paid lobbyists? If we had a Covid-19 vaccine tomorrow, would you rush to get it for yourself and your family? Or would you stand by your principles and refuse to accept it, hoping for herd immunity to keep your loved ones from getting sick?

It's tough to stand by your medical convictions when it seems the whole world around you is one step from calamitous chaos and civilization is hanging by a very fragile thread. But for you anti vaxxers out there, rebelling against the miracle of modern medicine should be par for the course, right? We'll let you stay in the back of the line when the coronavirus vaccine is invented so that you won't betray your core beliefs.

Sunday, March 8, 2020

The Road Not Taken

To do anything truly worth doing, I must not stand back shivering and thinking of the cold and danger, but jump in with gusto and scramble through as well as I can.
                                                                                         Og Mandino

I let a virus defeat me. The Los Angeles Marathon was today and I wasn't there. Now I'm overwhelmed with regret.

Against all medical and governmental advice, the organizers of the LA Marathon, along with the city government, proceeded with the race today. They set up some precautionary steps to make everybody feel safer. The organizers banned participants from six especially affected countries like China and South Korea. They put out more hand sanitizers along the route. And they advised runners and roadside viewers to stay at least six feet away from each other. As if it's possible to corral 27,000 runners into a small starting gate and maintain six feet of distance between each other.

Social media lit up with outrage that the event was still happening. Dozens of conferences, concerts, and other large public gatherings have been cancelled. Yet out of sheer greed, or hubris, the city allowed the marathon to continue. They did however tell runners who aren't feeling well not to come. What a laugh.

The statistics would support the city's decision. Roughly 80% of people infected with coronavirus will get very mild flu-like symptoms, or none at all. The mortality rate is about 1-3% so far. In general, marathon runners are on the more healthy side of the overall population spectrum and unlikely to come down with severe symptoms. So I was actually ready to go ahead and check off another bucket list item today.

Then the hammer came down. My wife was adamantly opposed to me running this race. She called the mayor's office and California governor's office to try to get them to cancel the event. There were online petitions to convince the organizers to stop this from spreading what is already described as a worldwide pandemic. She threatened to kick me out of the house for at least two weeks if I ran.

Finally I had to relent. The negative consequences of running this marathon outweighed the positives. What if I did catch the coronavirus? Even though runners from the six most affected countries were banned, the participants come from all 50 states and dozens of other countries. There's no way the race could guarantee a disease free environment.

If I ran, I could potentially be spreading the disease to my own family before I showed any symptoms. The kids would then spread it to their schools before anybody realized they were infected. I would be out of a job for at least a couple of weeks, jeopardizing our financial situation if even one runner out of 27,000 turned out to be positive for Covid-19.

So I sat out the race. I didn't set my alarm clock to get up at 4:00 AM. I rolled out of bed well after the sun came up, like my usual Sunday morning. But now I'm consumed with what could have been. The weather outside is gorgeous, perfect for running. There was a light rain last night so the air is clean and crisp. The temperature is neither too hot or too cold. There are fluffy clouds floating over the city, providing brief respites of shadow for the runners under the unrelenting Southern California sun. In other words, perfect running weather.

For now I've lost my motivation to keep running. Next year seems so far away and I'm not sure I can keep up my desire for running a marathon that long. I don't even feel like maintaining my strict diet for now. Sure there are other marathons throughout the year. But this is the LA Marathon, my hometown event and one of the premier marathons in the country.

So you'll forgive me if I wallow in my own self pity for awhile and gorge on a pint or two of chocolate chip cookie dough ice cream. Nothing feels worse than self defeat.

Friday, March 6, 2020

Plastic Surgeon Required To Use Anesthesiologist

Dr. Geoffrey Kim
Here's a followup to the tragic story of an outpatient plastic surgery case gone horribly wrong. Emmelyn Nguyen is an 18 year old girl who was having breast augmentation in a Denver surgical facility by Dr. Geoffrey Kim. After induction of anesthesia, the surgeon and his CRNA somehow were not monitoring Ms. Nguyen closely. She suffered cardiac arrest and was revived but now has permanent anoxic brain injury. She now requires 24/7 monitoring and support.

Dr. Kim initially had his medical license suspended. But now with a settlement with the Colorado Medical Board, he can resume his practice immediately but will have his license on probation for three years. He will also need to undergo more medical education and work with a board certified anesthesiologist.

Enough said.

Saturday, February 29, 2020

A More Holistic Approach To Finding Good Residents Or Just More Political Correctness

The recent news that the USMLE Step 1 will no longer issue a numerical score has stunned the medical community, especially all the medical students who have yet to take the test. The test takers will now only receive a pass/fail instead of the all important number that's used by residency programs everywhere to screen for acceptable candidates.

Why did the NBME, which administers the test, make this change? Their explanation is that they are trying to de-emphasize the importance of the Step 1 score so the students can concentrate on their clinical clerkships without being distracted by studying for the exam. Apparently some students are so anxious about the Step 1 that their clinical work suffered while they crammed for the test.

However there are some pretty notable flaws to this switch to pass/fail. The most obvious one is that now the emphasis will be on Step 2, since that still retains the numerical score. This comes at the even more crucial senior year when students are trying to juggle residency applications, impress their residency programs with their clinical excellence, and studying for Step 2 with its all too crucial score. I can't imagine that this change will make the students feel any less nervous about their prospects.

Then there is the conundrum residency directors now have in trying to winnow the number of applicants to their programs. Many subspecialty residencies, particularly the highly competitive ones like orthopedics, ENT, dermatology, use the Step 1 score as the first cutoff for choosing which applicants to ask for interviews. There's the absolute minimum score below which a program will not request an interview. Then there is the upper score where students will definitely be asked to come. Everybody else is in a gray zone. Because of this change to pass/fail, all applicants are now effectively in the gray area. Now admission directors will have to use soft evidence of an applicant's excellence, like research conducted or letters of recommendation.

If you've heard something similar to this before, that's because the move away from ranking students based on a number has been prominent in college undergraduate acceptance for years. There is a growing movement among colleges to do away with SAT and ACT exam scores. The University of California recently but just narrowly decided to keep these tests as part of their application requirements.

The reason colleges are removing test scores is because they have a high correlation with a student's socioeconomic status, not necessarily their ability to succeed in college. Students from high income families go to better high schools with more resources like AP classes to help them sail through the SAT. They also have more opportunities to take exam prep courses to give them a leg up on kids who can't afford those after school classes. Now many colleges emphasize a "holistic" approach to accepting high school students to college. They give students extra credit for coming from disadvantaged backgrounds and poor family situations.

However this creates its own complications. Look at the recent lawsuit against Harvard University. It's student admissions office was accused of discriminating against Asian Americans. Many of them had perfect SAT or ACT exam scores yet were denied acceptance to the school. Harvard's holistic approach to finding undergrads seemed to gloss over their high achieving test scores and instead punished them for a far more subjective "personal rating". They were considered less sociable and creative than their non-Asian American applicants.

Will this be the future of residency programs? While a large percentage of medical students are minorities, will the still mostly white residency directors judge the students on their race and perceived advantages in becoming doctors? Seems like this is just another lawsuit waiting to happen as some people are denied entrance to the most competitive programs and questions linger about why somebody got chosen over others since there are really no objective criteria anymore.

Friday, February 28, 2020

Panic At The Costco

Just how bad are people freaking out over the coronavirus? Here's a picture of the bottled water section at our local Costco. Normally there is a mountain of plastic bottles here. On this day, there were almost none.

It wasn't just water that people are starting to hoard. In our supermarket, an entire row of vinegar was nearly empty. Usually the giant one gallon jugs of vinegar are left languishing at the bottom of the store shelf as who needs a whole gallon of vinegar at one time. Now they are all gone.

I'd like to think that my neighbors are all well educated and level headed. But the steady bombardment of news about the coronavirus is starting to sow anxiety and trepidation into people who usually don't give into their worst primal fears of survival.

Never mind that so far less than 3,000 people around the world have died from Covid-19. Most of those are in countries with suboptimal healthcare systems and afflicted mainly the elderly and frail. By comparison, the U.S. had over 40 MILLION people with the flu and over 40,000 deaths just from this past flu season alone. Yet we have to spend millions of dollars in public service announcements to get people to take their flu shots.

So as the stock market keeps crashing lower every day (BUYING OPPORTUNITY!) and meetings around the world get cancelled, let's try to keep this virus outbreak in perspective. The most common symptoms for people who are healthy are just mild flu-like illness. This is not the end of the world like some Hollywood science fiction movie. We will all get through this just fine. After all, we still have ten more years to go of living on this earth before we all succumb to climate change.

Tuesday, February 18, 2020

Is Gastroenterology The Best Medical Field?

Cha Ching!
Is gastroenterology the best field in medicine? Gastroenterologists enjoy some of the highest incomes among physicians. Some 18 million colonoscopies are done each year in the US, making it the most commonly performed procedure in the country. GI is estimated to bring in almost $3 million in revenue per physician in 2019, double what it made only three years ago. By some calculations, gastroenterology is responsible for $1 TRILLION in medical expenditures each year.

With eye opening numbers like these, it's no wonder that the smart money is starting to pour into gastroenterology. Private equity investors are buying up GI practices to get in on this hot action. The investors are cutting expenses by consolidating office and equipment expenses. They are also able to negotiate better insurance reimbursements by forming larger groups.

GI is relatively easy to make money through buyouts. Many gastroenterologists practice in ambulatory surgery centers that are usually already highly profitable. Purchasing multiple ASC's gives them higher purchasing power and a more efficient backoffice. They are making their businesses even more profitable by bringing inhouse other expenses like pathology and anesthesia services. Why pay another physician a fee when you can pay them a set salary?

So is GI the best field in medicine? From a financial standpoint, it sure looks like a winner. The fees generated from endoscopic procedures would make any general surgeon hopping mad with envy. GI doctors can do dozens of procedures per day in each ASC, generating tens of thousands of dollars in revenue. Surgeons by comparison may only do two or three operations on a good day. As endoscopy gets more advanced, GI doctors are also slowly encroaching on the general surgeons' bread and butter of treating bowel diseases, with the advantage of not making any painful incisions. It looks like GI is ready to take over the medical world. The smartest people in the financial world certainly believe that.

Monday, February 17, 2020

"The Gig's Up". San Diego Anesthesiologist Caught Literally With His Pants Down.

Bradley Glenn Hay, MD

Anesthesiologists have long had a reputation for being the physicians who are most likely to have a drug addiction. One third of all medical residents who are treated for an addiction are anesthesiology residents, even though they make up less than five percent of all residents. Eighty percent of anesthesiology residencies reported having at least one resident with substance abuse problems. Almost twenty percent of anesthesia residencies have reported at least one fatal overdose in a ten year period. As you can see, drug addiction weighs disproportionately heavily on anesthesiologists and the profession.

So it's extremely disheartening to find an anesthesiologist in the news due to his substance abuse. Bradley Glenn Hay, MD, an anesthesiologist at the UC San Diego hospital system is being sued for causing patient harm while being under the influence of drugs. In his deposition, which you can read here, Dr. Hay states that he has been addicted almost throughout his residency and professional career. He started out as a heavy drinker in college, drinking a twelve pack of beer three to five times per week. He then moved on to heavy liquor like vodka and tequila. He would go to class or on rounds either drunk or with a hangover. He had been involved in two traffic accidents from DUI. Both times he underwent diversion treatments without much success.

Once he started anesthesia residency at UCSD, he started abusing narcotics. His drug of choice was usually fentanyl. He would check out far more narcotics than most anesthesiologists would use for a case. He would then give himself most if not all the drugs, causing his patients to wake up from surgery with extreme pain. Frequently he would "waste" leftover narcotics in a syringe with a witness when he had actually replaced the syringe with saline, giving himself the drugs he needed for himself. He would even talk his CRNA into falsifying the anesthesia records to make it look like they gave all the narcotics that were checked out.

Then in January 2017, he went to the staff restroom and shot up with some sufentanil, a narcotic far more potent than fentanyl. He almost immediately collapsed. The staff found him lying face down in a pool of vomit, with his pants down by his ankles. When he was revived, he saw all the staff standing around him and realized what happened. "Well I'm caught. The gig's up," he confessed.

He and the hospital are now being sued by former patients for causing bodily harm. Two lawsuits have claimed that while Dr. Hay was under the influence, his patients had received inadequate amounts of anesthesia. They claim to suffer awareness of their surgeries while experience excruciating pain but were too weak to let their predicaments be known. UCSD is being sued for essentially covering up Dr. Hay's addiction from his patients, nearly 800 over a two year period.

This is just a horrible tragedy all around. Hundreds of patients at UCSD may have suffered unbelievable horror movie scenarios while having surgery. The surgeons involved may have lost the faith of their patients. The hospital will spend millions of dollars in legal fees and fines for allowing this anesthesiologist to practice in their facilities. And Dr. Hay may never work as an anesthesiologist again. He has already lost his California medical license and his ABA board certification. I hope he finally gets the successful drug treatment he should have received prior to his overdose.

Monday, January 20, 2020

Social Justice Anesthesia

Et tu Anesthesiology? Recently, medicine has come under fire for promoting ideas that are more akin to social justice ideology than medical facts. In a widely reported op-ed in the Wall Street Journal last year, Dr. Stanley Goldfarb, former associate dean of the University of Pennsylvania School of Medicine bemoaned the intrusion of topics like climate change and gun control into the already overburdened medical education system. This leaves less time for students to learn about actual disease processes and caring for the patients that are sitting in front of them.

Now the journal Anesthesiology has published a social justice article of its own. In the January 2020 issue, a paper by Angela Jerath, MD, et al, titled "Socialeconomic Status and Days Alive Out Of Hospital After Elective Noncardiac Surgery," the authors attribute  the environment that the patients come from for varying rates of successful care. Naturally those who live in the lowest quintile of median neighborhood household income had higher rates of postoperative complications and 30 day mortality. Sounds like something straight out of the Democratic party agenda.

I fail to see how this article has anything to do with anesthesiology. It reads more like something that should be published in Health Affairs. What am I supposed to do with this information? Am I supposed to accept that my poorer patients will have higher rates of complications and mortality? Am I supposed to lobby my Congressional representative to give everybody a basic universal income to lift them up to a different quintile of economic status? If Anesthesiology begins to pivot more to these social justice articles instead of publishing more information about how I can improve the anesthesia I administer to my patients, I'm going to find less need to read the journal.