Wednesday, September 22, 2021

Doctors Are Not As Essential As They Think They Are

Remember at the height of the pandemic last year when people were hanging outside their windows applauding healthcare workers for their selfless sacrifices to treat Covid patients? That was quite an ego boost and seemed to signal that people finally realized how essential doctors and other medical workers are to the well being of a nation and the world. But now, when it's time to match the rhetoric of appreciation with cold hard cash, all the applause is silenced.

The federal government is on schedule to cut Medicare reimbursements to doctors close to ten percent next year. The complicated formula for this involves the expiration of bonus hero pay of 3.75% enacted last year. Then there is another 5.75% cut to meet budget neutrality rules that were put into law back in 2011. Altogether, that plus other scheduled pay cuts add up to a nearly 10% reduction in Medicare reimbursement next year. This is happening even though doctors are already making less than plumbers. (Many readers have pointed out that Medicare actually pays doctors around $80-90 per hours rather than $45 that I wrote previously. Well, $90 per hour after years of higher education and hundreds of thousands of dollars in student loans still stinks. After you take out taxes, it's closer to $45 than you think).

How pernicious are these annual drip drop reductions in physician pay? Since 2007, GI doctors have seen their Medicare reimbursements drop 6%. Cardiac surgeons are down 8%. And cardiologists are lower by 22%. What other professional field has seen their pay actually go down over the last 15 years? 

Meanwhile, the cost of running a medical business keep rising. Staffing salaries are higher. Utilities are higher. Insurance is higher. Taxes are higher. Yet doctors are expected to pay all that with less income coming in. 

You want to know who the government considers the real essential workers? All you have to do is follow the money. The Biden administration announced they are increasing federal workers' pay over two percent next year. That may not sound like much but it's still better than the cuts doctors are facing. On top of that, the federal workers also get a brand new paid holiday to enjoy their new money, Juneteenth. Could you imagine the uproar if the government unilaterally cut their workers' pay ten percent and they had no say in its implementation? The entire federal government would shut down within 24 hours as they all go on strike and stay home.

Yet doctors continue to act as martyrs and just accept the reductions in reimbursements year after year. This makes it necessary for them to run faster than ever just to stay in place. Or more commonly, most doctors now don't run independent practices anymore. Many have gladly sacrificed their independence by working for large medical corporations. Independent doctors just don't have the resources and time to be fighting behemoth entities like insurance companies and the government. 

You would think the five trillion dollar budget supplement that Congress is haggling over could include more money to treat the country's population. Unfortunately clean energy and immigration reform for illegal aliens seem to take precedence over caring for sick people in America. They do it because they know they can and we doctors won't put up much of a fight just as we have not done so for the last fifty years.

Saturday, September 18, 2021

Nimbex Is Dead. Long Live Sugammadex

I've been a lifelong fan of cisatracurium (Nimbex). It has been my neuromuscular blocker of choice ever since residency. Why do I love it so much? Let me count the ways.

I've found that Nimbex is very predictable in its metabolism. I've been burned badly before when I used another agent like rocuronium on a patient with renal insufficiency and the patient had incomplete reversal at the end of the case that necessitated reintubation. Not good for the patient or your reputation as an anesthesiologist.

Thanks to its Hoffman elimination, I don't have to worry about a patient's kidney or liver function. The drug just metabolizes at a very steady and predictable manner. This is particularly important when a patient may have an unknown issue with their renal or hepatic functions and suddenly you're wondering why the patient isn't waking up. Nimbex is also very easy to reverse. Neostigmine easily takes care of the drug and the patient emerges quickly. 

Sure you can't use Nimbex for rapid sequence induction but that's okay. Most cases don't require RSI anyway. Due to Nimbex's property of predictable reversal, I've stuck with it long after many of my colleagues switched to roc. But now that's all changed thanks to the miracle of sugammadex.

Sugammadex (Bridion) is a drug invented specifically to reverse the paralysis induced by rocuronium. But it also works with other aminosteroid compounds like vecuronium. I feel it has revolutionized NMB reversal the way propofol transformed the induction of anesthesia.

First of all, Bridion works very fast. I'm always amazed by how quickly a patient starts moving after it is given, even if there is still a fair amount of inhalational agents on board.

Rocuronium no longer needs to be carefully titrated in order for it to be reversible at the end of the case. This is especially relevant in procedures that finish rapidly like in ENT. Those cases always present the conundrum of the need for deep paralysis followed by a quick emergence. There's no greater predicament for the anesthesiologist than staring down at a patient with zero muscle twitches and an impatient surgeon wanting to get his next case started ASAP. Prior to sugammadex there was no way to reverse a deeply paralyzed patient effectively.

One can give roc to anybody with sugammadex. Before, I was always leery of using Bridion in dialysis patients because there was always a small chance that the reversal agent would wear off before the body has cleared the NMB. I have yet to see that happen. It's just as easy to wake up a patient with renal failure as a patient with normal kidney functions.

With all these advantages, rocuronium and sugammadex have become the combo of choice in our department. Nimbex use has practically disappeared. Bridion is in such high demand that our pharmacy is complaining about the high cost of the drug. Whereas one 200 mg vial of sugammadex costs about $100, one vial of neostigmine costs $10, and that can be used with multiple patients. Our sugammadex costs are now disrupting our pharmacy's budget because people are using it so often. In addition, the anesthesiologists frequently use more than one vial per patient as some are now becoming too lazy to titrate their NMBs properly.

Are there costs that are saved because we use so much sugammadex? One has to consider the cost benefit analysis for a weak patient in PACU that requires reintubation. What are the costs of prolonged OR use because the patient took a longer time than anticipated to wake up? What is the cost of the psychological trauma in a patient who is gasping for breath because he is too weak to breathe? Or the patient who is too weak to protect his own airway when extubated too early and she aspirates, requiring hospitalization for pneumonia? All these should be taken into consideration when calculating the cost of using sugammadex.

Are there downsides to sugammadex? I've already mentioned the exorbitant price of the drug. That hopefully will come down in a few years when the drug goes off patent and generics flood the market.

Worse than that though is that I think sugammadex makes anesthesiologists lazy and they lose an essential skill. It's a real art to titrate paralytic agents properly so it can be reversed quickly at the end of a case. It's not something that can be taught in a book since each patient is unique in their ability to metabolize NMBs and every surgical case is different. With sugammadex, it doesn't matter at all. This is particularly detrimental to the anesthesia residents. It is just as easy to wake up a patient with zero twitches as one with four twitches. There is no learning there. Just give more sugammadex! But they didn't learn anything about the art of controlling anesthesia.

This is all part of the long standing trend of making anesthesia ever faster and easier to use. From halothane to desflurane. Pentathol to propofol. Pancuronium to rocuronium. If we're not careful, anesthesia could become too easy to administer. There are plenty of people who would love to get anesthesiologists out of their procedure rooms. From gastroenterologists to cardiologists, having one less physician in the room would be a dream come true. If anybody ever makes reversal agent for propofol, anesthesiologists would soon be unemployed.

Thursday, September 16, 2021

How Much Do CRNAs Make And Why I'm Totally Jealous

US Bureau of Labor Statistics

The U.S. Bureau of Labor Statistics has released the numbers for the average salaries of CRNAs. You better sit down for this. They are quite astonishing. Remember when nurse anesthetists first broke into six figure incomes and everybody thought that was amazing? Well now they are doing much much better. According to the federal government, the average CRNA income was $189,190. However many CRNAs are doing even better than that. The nurses in Oregon are doing the best, with annual incomes of $236,540. As a matter of fact, CRNAs from eleven states earn over $200,000 per year. 

Why should I be jealous of this when the average income for anesthesiologists is twice as much? Medscape's annual physician compensation survey this year showed that anesthesiologists reported earning over $370,000 per year. I shouldn't be upset that somebody makes half my income, right?

Remember that CRNAs also have work schedules that resemble any other nurses in the hospital. They have a set schedule during the day that are practically inviolable. If they have a 12 hour shift, by golly they are only working 12 hours that day. We've had an instance where the case reached a critical period and because it happened right at the end of their shift, the anesthetist simply walked away from the patient and boogied their way to the parking lot. The anesthesiologist was the one who stayed behind to finish the case and make sure the patient was satisfactorily taken to the recovery room.

The anesthetists also have guaranteed morning and afternoon breaks along with a luxurious lunch break. We've had CRNAs literally quit because they didn't get their required lunch break one day. I've had days where I'm lucky to get a two minute run to the bathroom between cases. Getting a daily 30 minute lunch break is the stuff of fevered dreams.

CRNAs also don't work as many hours. Like other nurses, they work three days a week. Ours also don't take any calls or work any weekends. So with all that free time they can work at other locations and double their salaries if they so choose.

I've been told by CRNAs that not all of them have such schedules. Many of them work in remote or dangerous places unlike anesthesiologists who prefer to congregate in nicer locations. Some also take calls and work long unpredictable hours like anesthesiologists. But I suspect those work conditions are fairly uncommon and they always have the option of moving to a different job with all the perks.

So yes I'm jealous of the CRNAs. I know many anesthesiologists who would gladly take half their incomes for a work schedule that includes guaranteed breaks, guaranteed hours, three day work weeks, no calls or weekends, and the most important thing, little liability for any incident. I would say that's a fair trade. Wouldn't you agree?

Sunday, September 5, 2021

Medicare Pays Anesthesiologists Less Than Plumbers

American doctors may be among the highest paid physicians in the world, but that wouldn't include anesthesiologist who receive their patient reimbursements through government healthcare. 

In an interview in Becker's ASC Review, Dr. Scott Harper, Assistant Professor of the Department of Anesthesiology and Perioperative Medicine at the University of Alabama Birmingham, noted that Medicare pays anesthesiologists the equivalent of $45 an hour for their services. That's less than what your local plumber charges you to come in and look at your clogged toilet.

With new federal laws prohibiting doctors from balance billing, which is charging patients for the balance of a medical bill not fully paid for by insurance, the problem is only getting worse. Insurance companies have no incentive to reimburse doctors fairly because they don't have to deal with irate customers who have to pay out of pocket anymore. Now these companies are canceling contracts and lowering thier reimbursement rates, getting closer to Medicare rates.

Anesthesiologists already have to put with Medicare payments that are only about one third of private insurance reimbursements. Medicaid, which is government insurance for the poor and indigent, pays even less. The wide expansion of stingy Medicaid is how the Affordable Care Act aka Obamacare is able to insure millions more people, on the backs of doctors and hospitals. 

If the private insurance payments keep going lower, anesthesia private practice will be a thing of the past. We will all become hospital employees like emergency medicine or pathologists. Only hospitals will have the leverage to negotiate fair contracts with these behemoth insurance corporations. Individual anesthesiologists will not be able to sustain a viable business model with payments that rival the plumbing profession because plumbers don't have to pay back six figure student loans and five figure malpractice insurance premiums as part of their business expenses. 

Sunday, August 29, 2021

Are American Doctors Overpaid?

Here we go again--another article that compares physician incomes around the world. It's not surprising that they almost always show American doctors are paid more than any other country's, seeming to confirm the belief that the US healthcare system is too expensive because of greedy doctors. However, there is a big caveat in any of these international physician income comparisons. We will get to that. This time, the income survey comes to us courtesy of Medscape. 

Medscape International Physician Compensation Survey

Medscape's study, in a survey of thousands of doctors around the world, once again shows American doctors are paid much more than anybody else, with an average income of $316,000. This is almost twice as much as second place Germany ($183,000) and United Kingdom ($138,000). Mexican physicians earned the least in this survey, averaging only $12,000.

American primary care doctors made about the same as their German counterparts, $242,000 to $200,000. But that is still twice as much as the UK, $122,000. Our specialists made far more than anywhere else, with male specialists earning $376,000. Meanwhile the German specialists made $194,000 and the UK specialists earned $155,000. It's plain that the Europeans place more of an emphasis on compensating their primary care doctors rather than their specialists like we do here.

Since American doctors make the most money, it goes to reason that our net worth is far higher than anyone else's. American physicians' net worths average $1,742,000. The UK doctors' net worths average only a third of Americans, $657,000. Germans are even lower, $441,000.

What are the debts that physicians have to carry? As expected, doctors around the world have mortgage payments to make and car loans to pay off. No surprise there. What is unfortunately not covered in the survey are the expenses that American doctors are faced with and makes our system uniquely expensive and burdensome.

American doctors carry a huge amount of student loan debt when they graduate from medical school. That expense is carried through the three to seven year residency and fellowship programs when there is not enough income to pay back the loan. Therefore doctors here are burdened with a giant fiscal deficit when they first begin their practices. Perhaps this important aspect of American medical economics is not asked of our international counterparts because their doctors are usually trained for free or with just nominal fees. 

International physicians also don't have to worry as much about medical malpractice lawsuits. American doctors face annual five to six figure malpractice insurance expenses that our global compatriots don't even have to think about. 

Yes American doctors make more money than anywhere else in the world. But we also have the highest education debts and the highest insurance expenses. You subtract these payments and our incomes aren't so disparate after all.

Wednesday, August 25, 2021

Past President Of The Kansas Society Of Anesthesiologists Indicted For Fraud

Scott T. Roethle, MD
This is totally effing unbelievable. Dr. Scott T. Roethle, MD, an anesthesiologist residing in the state of Kansas, has been indicted by a federal grand jury for healthcare fraud. What makes this case so difficult to fathom is that Dr. Roethle is a past president of the Kansas Society of Anesthesiologists. He has also served as a delegate to the ASA and an executive director of the Kansas City Medical Society. In addition, he appears to be involved in multiple start up companies according to his bio

According to the indictment, Dr. Roethle was charged with receiving kickbacks worth $674,000 for writing prescriptions for patients he never saw or documented. He would charge $30 per prescription. His orders were usually for orthopedic devices or lab tests that the patients said they never asked for. This fraud carried on from 2017 to 2020. Medicare says they lost $26 million for these phony prescriptions. He has medical licenses in 22 states and thus could write prescriptions for patients all over the country. 

I'd like to think that there is more than one Scott T. Roethle who is an anesthesiologist in Kansas. I would love to be proven wrong and chalk this up as a mistaken identity. But Google only found one Scott Roethle, MD and the ASA's own membership directory showed only a single anesthesiologist in the whole country by this name. In a physician review website, Dr. Scott Roethle is listed as having ten disciplinary actions taken against him by different medical boards across the country. How do doctors continue to find hospitals who will hire them when they've got so much baggage? 

Dr. Roethle, good luck with your court case. I hope they throw you in the slammer and take away your medical license forever for besmirching the reputations of anesthesiologists everywhere. Was your life really worth a measly $30 per prescription or $674,000 over four years? Any decent anesthesiologist can make much more than that working an honest job.

Thursday, May 6, 2021

Awake While Under The Knife

This is a surgical patient's worst nightmare. Frankly it's also an anesthesiologist's worst nightmare too. In July 2020, Matthew Caswell underwent a hernia operation at Progress West Hospital in O'Fallon, Missouri. Unfortunately he was awake for at least thirteen minutes during the operation. The anesthesia team had paralyzed him then forgot to turn on a volatile agent to induce amnesia.

Mr. Caswell said he knew something was off when he could feel his skin being cleaned with the cold prepping agent. Expecting that his anesthesia would kick in any moment, next thing he felt was the knife cutting his skin. He was paralyzed and could not inform the anesthesia team that he was awake. His heart rate jumped from 70 to 115. Meanwhile his blood pressure shot up from 113/73 to 158/113. He could feel three trocars inserted through his abdominal wall and his abdomen being insufflated for the operation.

According to the lawsuit, the anesthesia team at this point should have noticed that something was wrong. Yet no further anesthesia was given for thirteen minutes. In the meantime he could hear and feel everything that was going on in the operating room. Mr. Caswell said he was so scared he thought he was having a heart attack.

The anesthesia records later showed a "Significant Event Note." It said that "review of the anesthetic record demonstrates a delay in initiating inhalational anesthetic after induction of anesthesia." Mr. Caswell and his mother were "immediately informed regarding the delay in initiating the inhaled anesthetic agent until after the start of the surgical procedure." It goes on to say that the hospital provided emotional support immediately after the surgery and they would offer psychological counseling for free. His mother took a video of Matthew immediately after the operation and it's clear he has been traumatized by the entire ordeal.

Mr. Caswell is suing Washington University along with the anesthesiologist, Brian Weber, MD, JD, and Kathleen O'Leary, CRNA. (Though the first page of the complaint says Dr. Weber's first name is Brian, the subsequent pages of the complaint call him Bruce. I can't explain the discrepancy.) I can't think of much defense they can mount against this tragedy. Better just write a big fat check right now. Lucky for them the plaintiff is suing each defendent for only $25,000 each. 

This is going to be an unfortunate black mark on this young anesthesiologist's career. It's the kind of incident that can easily derail a promising new physician and make him question everything he's learned during training. Though not as traumatized as the patient, Dr. Weber is likely to feel enormous guilt for a very long time.

There are various methods to prevent surgical recall. Some have advocated using a BIS monitor to track a patient's level of consciousness. Other's show that making sure enough inhalational agents in the patient will prevent recall just as well as the BIS. Giving the patient midazolam preoperatively can help ensure amnesia in case not enough gas has been given to the patient.

Perhaps the most important thing the anesthesiologist can do is to always be vigilant. Be constantly aware of what is happening to the patient. Just because an operation is likely to be routine and uneventful is not an excuse to stop monitoring the patient scrupulously. If the anesthesia team in this case had been more attentive to the stresses manifested by Mr. Caswell's tortured surgery, maybe they wouldn't have waited thirteen whole minutes before finally giving him his anesthesia.

Wednesday, May 5, 2021

Anesthesiologists Need Space Too


Looks about right for an anesthesia work space.

Anesthesiologists are frequently an afterthought when it comes to designing operating rooms. I've worked in operating rooms so small there was literally just enough space for the patient gurney to get wheeled in and no room to walk around it once the patient was inside. I've worked in rooms that were literally former janitorial storage rooms. I vividly remember administering anesthesia in rooms so tiny that when you went to relieve the anesthesiologist inside, that person had to get out first before you could squeeze yourself into the space. There was just enough room for the anesthesiologist to stand in place, never mind a space for a chair.

A dream space for the anesthesiologist.

All that discomfort and disrespect for the anesthesiologist may be changing. The New York Times has written about a revolution in operating room design. The article follows the OR remodels taking place at the Medical University of South Carolina. Led by Dr. Scott T. Reeves, the chair of the department of anesthesia and perioperative services at the hospital, they are making OR's that are bigger and far more accommodating for all the staff. They even take into account how to future proof the new rooms, deciding where to place bulky equipment like X-rays and robotic surgery that are used with increasing frequency during operations.

This is a far more professional way to design the operating rooms than what I've witnessed in the past. I remember when we were opening a new wing of the hospital and the anesthesia department had its first chance to see how the operating rooms would look. We had absolutely no input into the space during the design phase. They never asked for nor received any input from the anesthesiology department. Needless to say, the placement of the anesthesia equipment was suboptimal, almost dangerously so. 

Upon review of the blueprints, we noted that the rooms were drawn with plenty of space around the operating table for the surgeon. However, the anesthesia machines and carts were not drawn to a realistic scale and were squeezed into the corners of the rooms. Our anesthesia machines were easily twice the width and depth of the models that were used in the blueprints. To this day, we still have problems with placing the machines in the proper locations to ensure patient safety. But the surgeons have plenty of space to do their work though. 

I'm glad hospitals like MUSC, Stanford, and Loma Linda are not forgetting the needs of all the staff in the operating rooms. Surgeons may think they walk on water in the OR, but without consideration for all the other professionals in the OR, they and their patients would sink pretty quickly.

Monday, April 26, 2021

ASA Gets Sued For Scientific Article

Pacira BioSciences, the maker of Exparel, a liposomal bupivacaine, has sued the American Society of Anesthesiologists and writers in the journal Anesthesiology for economic damages. They are seeking a retraction of the articles. The articles involved in the lawsuit appeared in the February 2021 issue.

According to Pacira, the papers in question disputed their assertion that liposomal bupivacaine is superior to plain bupivacaine. The articles exposed possible biases in research that originally led the company to tout the superiority of Exparel over bupivacaine. Previous papers claimed that Exparel achieved increased analgesia 24 hours after injection. However further study of the data showed that it did not meet the relevant threshold to make this statement.

Other biases leading the FDA to approve Exparel include the company submitting studies comparing the superior action of the drug to placebo. This is an easy thing to prove as it most likely will be better than injecting saline into the body. However when the company conducted research comparing Exparel to other local anesthetics like ropivacaine or nonliposomal bupivacaine, it failed to show increased effectiveness.

Why would a company sue the ASA over studies questioning its drugs? As always, just follow the money. When Exparel was approved by the FDA, sales at the company increased double digits annually, reaching over $400 million in 2019. One dose of Exparel costs $334 compared to only $3 for regular bupivacaine. Yes Exparel costs over 100x more than nonliposomal bupivacaine. To promote this costly drug, the company over the last decade has spent over $25 million to 27,000 physicians for speaking fees and nonaccredited educational events ie/fancy dinners at the local steakhouse and free gifts and rounds of golf.

In the lawsuit, Pacira claims it, "has suffered and will continue to suffer significant pecuniary harm as both existing and potential customers who have seen the disparaging articles, have either canceled contracts with Exparel, declined to purchase Exparel, or are considering removing Exparel from hospital formularies."

I want to congratulate the ASA for publishing some hard hitting articles that will help patient care and improve healthcare economics. However I also remember that there were some MOCA Minute questions in the past that stated liposomal bupivacaine is superior. I hope the writers of MOCA Minute go back and review these questions in light of the new research. ASA, keep up the good work to keep us anesthesiologists well informed and patients safe.

Tuesday, April 20, 2021

Tesla Crash Kills Anesthesiologist

A Tesla that was supposedly on Autopilot crashed into a tree near Houston on April 16, killing both passengers. It's been revealed that one of the passengers is William Varner, MD, an anesthesiologist who worked at Memorial Hermann Hospital in Texas. Now there is some controversy regarding this tragic accident.

Initially, it was reported that the crash occurred when two men were trying out the Autopilot feature in the Tesla. When the police investigated the incident, they reported that nobody was in the driver's seat. One was in the front passenger seat and one was in the backseat. They said they were almost 100% sure of their findings.

The crash was so intense that it took the firefighters over four hours and 32,000 gallons of water to put it out. It was complicated by the nature of the flame, which was an electrical fire, not the usual gasoline fire that firefighters are more used to. The fire was so stubborn that the firemen had to call Tesla for advise on how to extinguish it. By the time the fire burned out, the vehicle was just a metal carcass, almost unrecognizable. 

When news of the accident came out, Tesla's stock price dropped immediately when the stock market opened. Elon Musk, CEO of Tesla, then quickly came to the rescue of his company.

He claims that the Tesla in the accident didn't have its Autopilot featured turned on prior to the crash. In addition, that car didn't purchase the complete Full Self Driving features that costs an extra $10,000. Therefore it's not the cars fault that it crashed into the tree. Somehow two people were in the car and nobody was in the driver's seat when it was moving but the Autopilot wasn't on. Not sure how to square these claims and counterclaims.

When I first read this story a few days ago, I thought it was just another case of good ole boys doing stupid things late at night after having too many drinks. Now that we know one of the victims is a respected anesthesiologist, it makes me question the entire assertion about the police findings. Guess we'll hear more when the investigation continues. 

RIP Dr. Varner.

Sunday, April 18, 2021

CRNA's Take Over America

The American Society of Anesthesiologists' worst nightmare is now at hand. Due to clever promotion from the American Association of Nurse Anesthetists, the vast majority of patients in the U.S. can be sedated by CRNA's without any physician supervision. According to the AANA, there are now 42 states that do not require the CRNA's to take direction from any doctor.

The ASA thought they were doing well holding the opt-out of supervision states to just 17. Covid changed that calculus almost overnight. By pushing the narrative that critical care physicians are in short supply due to the pandemic, the AANA was able to convince a panic stricken federal government to drop the requirement for physician supervision during this health emergency. Unless a state specifically keeps the opt-in regulations, in essence the federal government has allowed all states to drop requirements for physician supervision.

This is just a temporary situation, right? Once we have herd immunity and everybody has gotten the vaccine, we can go back to the way we were, amiright? Uh huh. So far, government officials like Dr. Anthony Fauci don't seem to be in any hurry to declare the pandemic under control. Instead there are new variants popping up seemingly each week that require people to keep wearing their masks and consider getting annual booster shots to tame the virus. Though economies are starting to open up, control of the virus appears to be still a long ways off.

The longer the government and payers taste the elixir of CRNA billing, the more they are going to stay with the opt-out model. As our own group has experienced, CRNA's make anesthesia billing more viable as payers relentlessly pursue cost cutting measures. CRNA's can do 90% of the work anesthesiologists can do at half the price. Payers don't care about the anesthesia complications that arise from unsupervised nurses. That is the risk they are willing to take when confronted with the stark economic advantages of opting out. 

For a long time the ASA has had its finger in the dike lobbying to prevent more states from removing physician supervision. Unfortunately for the organization, and all patients and anesthesiologists, there probably won't be a happy ending to this story. The covid tsunami has swamped that wall and the last barrier to removing physician supervision has probably been breached.

Wednesday, April 14, 2021

Pandemic Takes Its Toll On Doctors' Incomes

There's no getting around the fact that the pandemic was devastating to the economic well being of nearly every industry last year. Healthcare was no exception. Between the loss of revenue from cancelled appointments and procedures to the increased expenses of paying for personal protective equipment and scarce hand sanitizer, many people in medicine saw their incomes slashed or evaporated.

Medscape has just released its 2021 edition of its annual Physician Compensation Report. It was drawn from a poll taken from October 2020 to February 2021. It therefore captures all the income made from 2020 and reflects on the continuing difficulty physicians were having during the severe winter surge in coronavirus cases.

The bottom line is that many physicians saw their incomes drop but hardship was not spread evenly. Anesthesiologists took a big hit with a five percent reduction in income compared to the year before. The average salary is now $378,000. However other fields like plastic surgery and oncology saw big jumps in income. So overall, physician income last year was about flat from the year before.

The average income numbers masked some really painful situations for doctors. Ninety-two percent of doctors said covid caused their incomes to decline, mainly due to loss of hours, patients, or even their jobs. In fact, 13% in the survey said they went for a period with no income at all, with the average length of time about three months. That is a scary prospect for people like doctors who have high expenses to meet like student loan debt and office overhead to maintain.

The top three reasons doctors said their incomes dropped were: reduction in hours, no annual pay raise, and reduced staff hours. However 45% said the pandemic didn't affect their salaries at all. If their incomes dropped, about 40% predict it will return to prepandemic levels within twelve months so at least the affects were only temporary.

Unfortunately for my group, our incomes are not likely to ever return to the salad days prior to covid. We dissolved our anesthesia group due to multiple economic weaknesses that became glaringly obvious during the pandemic. As Medscape's survey shows, employed physicians make a lot less than self-employed, an average of $52,000 less.

So our group's plight last year was not unique, even if it was still extremely painful to live through. We, like many other doctors across the nation, and the world, were hammered by the coronavirus both professionally and economically. So far we have made major adjustments and forged ahead to a totally different business model. We can only hope the coronavirus has been contained well enough for now so that we can get some back from what was lost for the last year and hope this truly is a once in a century medical phenomenon.

Tuesday, April 13, 2021

The Medical Boards' Money Machines

The maintenance of certification (MOC) run by the various medical boards is one of the most despised activities that physicians have to endure. The various tests and continuing medical education materials cost thousands of dollars in order for a physician to keep his board certification and stay gainfully employed. The kicker is that there is no evidence that any of these activities actually improve a physician's clinical acumen. As proof, look at the doctors who have lifetime certifications and never have to take any of this crap. These older physicians who grandfathered into these certificates should be the ones who need CME's, not the newly graduated doctors who still freshly retain their recent training. Yet these older doctors will vehemently deny they are any less qualified to see patients than their younger colleagues.

Many doctors have long suspected that the existence of MOC's is just a money making scheme perpetuated by the medical boards. Now Medscape has done a deep dive into the tax returns of the American Board of Emergency Medicine and it shows how lucrative running a monopoly institution can be. 

According to the ABEM's 2018 tax return, the organization reported $19 million in revenue and has $38 million in reserves at its disposal. It also reported $16 million in expenses with a profit margin of 11.2%.  How does this small medical organization with only 41 employees make millions of dollars? 

The ABEM states its major revenue maker are the tests it administers to physicians. New certification costs $4.7 million to administer and brings in $5.4 million. Fair enough. Continuing certification, on the other hand, only costs $1.6 million but hands the ABEM $7.3 million each year. Even Microsoft's profit margins aren't that good.

For comparison, the article looked at the American Board of Radiology. Their revenue numbers are similar to the ABEM so it can be assumed their expenses should be too. The ABR reported initial certification brings $4 million while the continuing certification makes $10 million.

What does the ABEM do with all this money? They lavish their directors with paid vacations to exotic locales, even including their families in on the largess. The company retreats are in lavish settings like Hawaii and Park City, Utah. They fly first class and get virtually unlimited meal expenses. The directors also make mid six figure incomes that dwarf the average salaries of the doctors who they are supposed to represent.

These numbers are only going to go up as more physicians graduate and need board certification and MOC while older physicians who don't make any money for the boards retire. In the years ahead the boards can only look forward to an ever increasing revenue stream, even before they raise prices for their monopoly services. 

Is it any wonder that there is such resentment of the medical boards? Their monopoly status, sanctioned by the government, insurance companies, and hospitals, makes them virtually unaccountable to the doctors who have to pay for their services to keep their jobs. The only beneficiaries of MOC are the boards themselves, not physicians or patients.

Friday, April 9, 2021

Best Anesthesiology Residencies

US News & World Reports has released its annual rankings of medical schools in the country. The list is split between medical schools that primarily focus on primary care and schools that are more research oriented. The research oriented schools are no surprise. They comprise the usual suspects of top universities in the country: Harvard, NYU, Duke, Columbia, Stanford.

The survey also lists the top specialty fields at each school. I'm assuming this means the residencies that are located at the schools. It is based "solely on ratings by medical school deans and senior faculty from the list of schools surveyed." In other words it's a popularity contest. They rank several residencies including internal medicine, radiology, surgery, and anesthesiology.

So let's cut to the chase. Which anesthesiology residency did these medical school faculty think is the best in the country? No surprise here, they closely mirror the top research medical schools. The top ten from one to ten are: Johns Hopkins, Harvard, UC San Francisco, Duke, Penn, Michigan, Columbia, Stanford, NYU, and UCLA. These are almost all the same schools as the top research schools in the list.

What about the best surgery programs? You would think that having a great surgery residency is almost a prerequisite for having a great anesthesiology residency since the two professions work so closely together. Once again, the list closely matches the best research schools. They are: Johns Hopkins, Duke, Harvard, Michigan, UCSF, Penn, Stanford, Columbia, UCLA, and Washington University.

Since these rankings are based on their presumed reputation from faculty members, there is an inherent bias towards well known schools like the Ivies and East and West coast schools. Just remember that, like going to college, it's not the name of the school that you graduate from that matters. It's what you do with your education afterwards that will determine your success in this world. If you graduate from virtually any anesthesiology residency you will be considered to have gone into one of the best jobs in medicine.

Wednesday, April 7, 2021

CRNA's Take Over Wisconsin Hospital

No anesthesiologists work here.

This is the type of news that makes anesthesiologists' blood run cold. Watertown Regional Medical Center in Wisconsin has removed all their anesthesiologists and replaced them with CRNA's. Wisconsin is one of the states that allows CRNA's to work without physician supervision. Therefore they can practice independently without even a surgeon supervising them. How does this cost cutting move by the hospital make the surgeons feel? In a decidedly indifferent comment, Adam Dachman, DO, a surgeon at Watertown, said, "It's a misconception that physicians are required to administer anesthesia." Ouch. Thanks for standing up for physician brotherhood.

This attitude is what I was afraid of when I said the anesthesia care team model will be the end of physician anesthesiologists. With the ACT model, anesthesiologists' roles become more like physician assistants. We're outside the operating rooms, dealing with preop history taking, starting IV's, making sure the patients are ready for their surgeries. Meanwhile, the CRNA's are the ones that are administering the anesthesia. They are the ones the surgeons will interact with 90% of the time. Our interactions with surgeons diminish to the point where they feel the CRNA's are doing all the work and no physician anesthesiologist is needed. This makes the hospital administration's decision to save money by firing all the anesthesiologists that much easier and less controversial with the staff.

The federal government is helping the demise of physician anesthesiologists by allowing the nurses to practice nationwide without supervision. Under the guise of increasing medical access during a pandemic, the CMS is letting CRNA's work independently so physician anesthesiologists can use their critical care skills to treat the maximum number of patients. This provision is supposed to sunset in June as the pandemic eases across the country. Not surprisingly, the AANA has something to say about that. They are talking with the nurse friendly Biden Administration about extending the opt out provision to the end of the year and possibly beyond. 

The coronavirus has been a seismic shift in how medicine is practiced. For anesthesiologists, it may be the final push out the OR doors that we have always feared. 

Sunday, April 4, 2021

Things That Don't Belong In A Human Orifice

The orifices of the human body usually proceed in a one way direction. It either goes in or out. It can be very painful if one violates this law of nature. Anyone who has ever had a Foley catheter inserted or undergone a colonoscopy will attest to that. This hilarious Buzzfeed article lists some grotesque, gag inducing, so unlikely it-must-be-true-stories told by medical personnel of their encounters in the emergency room with foreign objects inserted into different holes of the body. It made me remember one of the most unbelievable and vivid sights I had ever experienced in the ER.

It was early morning and the ambulance dropped off a young man in excruciating agony. He didn't want to talk about it until after we pulled the curtains around his gurney. Once we did that, he pulled back the bedsheet and there was the most enormous, angry looking penis that I had ever seen. It was not enormous in any kind of enviable way. This was not just any ordinary case of priapism either. At the base of his penis was a very tight, very small metal penis ring. It was preventing the blood in his erection from draining back into his body. The penis was purplish in color as arterial blood was not able to enter the organ. It was becoming ischemic. If this was not corrected soon, he could lose his penis. This was a medical emergency.

The urologist on call was notified. When he came down, the man complained that it felt like there was something inside his urethra too. The urologist then ordered an X-ray of the man's groin. What was on the X-ray was even more astonishing. In the film, one could see various objects lodged inside his urethra. There were several fishing weights, paper clips, and even the spring from a retractable pen. Smartphones weren't invented at that time so I couldn't take pictures of that film but I'll never forget it.

Apparently what happened was the man was drinking heavily and doing drugs during his sexual encounter. He then passed out. While he was unconscious, his partner starting doing these masochistic acts on him and left. He finally woke up from the pain and called 9-1-1 since he couldn't drive himself to the hospital.

The urologist carried a small ring cutter for just this purpose. I guess this wasn't his first rodeo. Unfortunately, the penis ring was so tight and the tissue around it so swollen that he couldn't get the ring cutter around it to snap it off, no matter how much lubrication he put on the cutter. It was also excruciatingly painful for anybody to touch the patient's penis, even with sedation.

Ultimately the patient had to go to surgery to remove the penis ring and all the objects inside his urethra. I never found out how the man faired afterwards. I'm sure the surgeon was able to save his penis and urinary function but that is one lesson the man hopefully will never forget. Ask any physician and they will all tell you their stories of patients with some foreign objects inserted into a body cavities. 

For anybody who wants to explore their sexual fantasies by inserting objects into various orifices. Please. Be very careful. Or we'll be seeing you in the ER eventually.

Friday, April 2, 2021

Microaggression In Anesthesiology? Try Macroaggression.


An article published in JAMA Surgery recently listed the level of microaggression present in a group of surgeons and anesthesiologists at Southern California Permanente Medical Group in Irvine, CA. Out of 588 respondents to a survey, a large majority expressed some level of microaggression in their workplace.

The results were measured with different ratings scales. There is the Maslach Burnout Inventory (MBI), the Racial Microaggression Scale (RMAS), and the Sexist Microaggression Experience and Stress Scale (Sexist MESS). I didn't even know that somebody had invented actual legitimate ratings to measure microaggression.

Of 259 female physicians who responded to the survey, 245 of them reported feeling microaggression at work. That's a vast 94%. The most common microaggressive act was "environmental invalidation" or seeing and hearing degrading images about women. This was reported in 86% of female respondents. The next most common microaggression, experienced by 74% of females, was "leaving gender at the door" or having to overcompensate for being female or hiding their emotions and femininity at work. So women feel they are the victims of microaggression if they are not allowed to display their feminine side at work yet are slighted if you complement their looks. Got it.

Among racial minorities, the most common microaggression was not having a role model of the same race at work, which happened to 67% of respondents. This feeling was more prevalent among female physicians (74%), underrepresented minorities (90%), and South Asian physicans (70%). The second most common racial microaggression reported at 51% was feeling like being treated as a foreigner or 'not a true American'. This was most commonly reported by females (58%), Asian (57%), South Asian (60%), and Middle Eastern (54%).

Wow people get their feelings hurt really easily these days. You don't like it when you have to check your gender at the door? Your ego is bruised when the chairman of your department is not the same ethnicity as yourself? Give me a break. How about trying some real macroaggression, the kind of mano a mano conflicts that can happen between an anesthesiologist and the surgeon. Next time you feel like you're depressed because the surgeon told a dirty joke, read about a real life fistfight between the anesthesiologist and surgeon in the operating room while the patient is asleep. That's when men were men and... oops did I step over the line and present too much microaggression for my readers? I guess I better sign up for my hospital's Anger Management class to check my microaggression.

Wednesday, March 31, 2021

Anesthesiology Is An Elite Residency

It doesn't get much more competitive than this. Match Day 2021 has come and gone and anesthesiology has once again shown itself to be an elite residency. Out of 1,893 PGY1 and PGY2 positions available in the NRMP Match for anesthesiology, there were only three unfilled spots. That's a match rate of 99.8%. This is an improvement from 99.4% last year.

How difficult is it to match in anesthesiology? Let's compare it to other programs that are considered extremely competitive. Dermatology had six unfilled spots in the match. Emergency Medicine had fourteen unfilled positions. Radiology, part of the previously exclusive ROAD programs, had eleven.

This news is even better (or worse if you're applying for an anesthesiology residency) when you consider that the number of residency positions has been increasing every year. This year, there were 1,460 PGY1 spots available in the match. That compares with 1,370 last year and only 1,202 in 2017. 

The reason there are so few unfilled positions is that anesthesiology is becoming more popular with medical school students. This year, 5.6% of US MD seniors went into anesthesiology. That compares with 5.2% last year and only 4.6% in 2017. Despite the fact that there are more anesthesiology residency programs offering more positions than ever before, there doesn't appear to be any oversupply of residency spots yet.

The anesthesia residents aren't having any trouble finding a job either when they graduate. The job market right now for anesthesiologists is hotter than ever. From our own personal experience, we can't hire anesthesiologists fast enough, even as we're hiring CRNA's at the same time.

So congratulations to all the medical students who matched into anesthesiology. You have accomplished one of the most difficult tasks in med school. You're on your way to becoming one of the most highly sought after physicians in the medical field. You're not going to regret it.

Saturday, March 27, 2021

My Tumultuous 2020


This is the conclusion of my series on my tumultuous 2020. While I was very lucky and didn't suffer any personal loss from the covid pandemic, the year was nevertheless one of the most unpredictable and contentious in my career.

When 2020 first started, I thought I was going to to have another routine banner year. The operating rooms were full. We were working hard, but getting paid handsomely. I had just run my first half marathon. The Wuhan virus was a disturbance in a faraway land that didn't seem to have any significance on this side of the Pacific. It was so inconsequential that Los Angeles proceeded with their marathon in early March. Then just a few days later, everything stopped.

Our incomes dropped over fifty percent over the next six weeks. The operating rooms practically shut down as images from Italy and New York haunted every doctor on the planet. We learned how to wear N95 masks and don and doff PPE's. Different treatments for covid came and went each week with no clear understanding if any of it worked. We all took out PPP loans from the government to keep from going bankrupt. The stock market had its fastest drop into a bear market in history. It was a darkness that we didn't know when or if it would let up.

Then spring brought a bit of a respite. The state governor allowed hospitals to start accepting elective cases again. Our operating rooms slowly began gearing up to do elective surgeries. But before long there came another surge. This time instead of shutting down the OR's, the administration took a more measured approach by limiting, not eliminating cases. As long as the hospital census was not overwhelmed with covid patients the OR's could continue to run. 

Our anesthesia group could see this was going to be problematic for an indefinite amount of time. We couldn't let a disease dictate the economic well being of the group or the group's partners. It was time to change economic models. The group that I joined almost two decades ago was shockingly disappearing. We were going to get taken over and become employees, no longer the master of our destinies. My dreams of coming to work every day and working the same way for thirty years until I retire had been upended by a virus. Medicine's relentless march towards consolidation of physicians' groups and hospital systems was being abetted by a disease.

It took months of departmental meetings and contentious zoom chats but almost all of us signed on the dotted line and overnight became hospital employees. There were pros and cons to the new job, but the biggest adjustment was the introduction of CRNA's to the department. I think our anesthesiologists needed more education on the new system than the CRNA's. They had worked elsewhere with an anesthesia care team model while we had never had one. This is still an ongoing process within the group as we all adjust and try to make the system as efficient and profitable for the hospital as possible. 

If any of you had wondered why I hadn't posted for several months, it's because of all these changes going on in my life. It was very stressful and caused me physical symptoms like weight gain and flareups of my eczema. We are still adjusting to the ACT model but we don't have a choice anymore. We no longer decide our own careers. It's dictated to us and we have to make it work or leave. This is my first taste of corporate medicine and it's a bitter pill to swallow.

Friday, March 26, 2021

How CRNAs Could Eventually Supplant Physician Anesthesiologists


After working with CRNA's for several months, what is the main problem that I think is going to affect our group? So far, it's not the quality of their work. They're all competent in the OR and some are actually very good, dare I say even better than a few anesthesiologists we have in the department. We haven't had any issues with bad attitudes or incompetence. The problem with having CRNA's in the department is not that there is anything wrong with the nurses per se. It's the way the system is set up so that it diminishes the role of the anesthesiologist. What do I mean by that?

When supervising CRNA's, the anesthesiologist becomes more like a perioperative physician's assistant than a physician. We examine the patients in preop. We make sure the IV's are in place. We go over the findings with the CRNA and implement an anesthesia plan that we don't actually carry out. It's the nurse in the room that is giving the anesthesia. What goes on during the surgery is almost completely unseen by the anesthesiologist who is busy running a perioperative service outside. 

When we talk about an anesthesia care team model, it's usually defined as a team led by a physician anesthesiologist supervising a CRNA. We can call it supervision, but once the patient is inside the operating room, the supervision pretty much stops and the CRNA can do pretty much they please while the physician "leader" is outside keeping the operating schedule flowing smoothly and efficiently. The anesthesia part of the job is very much diminished in the ACT model. At the end of the day, I'm exhausted from running around the OR suites without ever actually intubating or sedating a single patient.

I'm afraid this will lead to more severe problems in the future. Since the physician anesthesiologist is outside running a perioperative service, the surgeons may eventually equate the CRNA that they see in the room as the default anesthesia provider. They're the ones doing the cases and chatting up the surgeons, developing a strong professional rapport. 

While we've had a long history inside our hospital and have strong standing relationships with the surgery department, this won't always be the case as younger anesthesiologists and surgeons start working here. I have nearly two decades of service in our hospital so most of the surgeons know me well. But that is not always going to be true with the younger staff. The new surgeons may only see the CRNA sitting in the room even though the anesthesiologist is theoretically the supervisor in this team model. The new anesthesiologist may never develop a strong relationship with the surgeons. When was the last time you saw a surgeon have a long extended conversation in preop or PACU. They're barely there for five minutes to talk with the patient then they're gone. All the long meaningful conversations take place in the OR, which our younger staff will less of a have a chance to participate in.

Thus the influence of CRNA's will continue to grow in the hospital. It's not because they are any more qualified or more skillful than physician anesthesiologists to give sedation. It is the insidious way that the ACT model pushes the anesthesiologist outside the OR, diminishing their role as the leader in the anesthesia team. Our highly trained abilities to resolving split second complications in the OR will go unappreciated as the surgeons only see the nurses working and appreciating their anesthetic skills, not ours.

Thursday, March 25, 2021

Fear Of The Unknown CRNA

When the anesthesia leadership first announced that we were taking on CRNA's as part of the hospital's deal to rescue the group, they were met with anger and disbelief. "How could they do this to us?" "I'm not spending all day babysitting a bunch of nurses and putting out fires all over the OR's that they will create." "We are doomed and this is just the first crack in the door for the CRNA's to eventually move in and kick us out." The anguish was epic. It felt like a betrayal of the physician anesthesiologist brotherhood that we had fought for so many decades to sustain.

Once cooler heads prevailed, it was clear we were behind the times in developing the anesthesia care team model. There were few large groups of anesthesiologists who didn't use CRNA's. The economic advantages were pretty compelling if one looked at it with a cold unemotional eye. We were also desperately short staffed and it was difficult to hire enough anesthesiologists in the short and long terms to fulfill our hospital's service contract. 

Mainly it was fear of the unknown that caused all this trepidation. Our hospital had never used CRNA's before. Our group has been around for three decades and many of us had never worked with them. Some of the partners who transferred from other groups relayed horror stories they encountered while working with the nurses. Ultimately, none of the excuses we came up with could defer the inevitable. Dollar signs trumped irrational fearmongering. 

We have now been working alongside CRNA's for several months. So far most of them have been excellent. It helped that the first few we hired were real superstars. They each had many years of experience and could be trusted to do the right thing when left alone in the OR. They instilled a lot of confidence from the group and tamped down any murmurings about the qualifications of CRNA's.

Of course, like any group of people, there will always be a few who are not up to snuff. We haven't had anyone yet that I would call bad. However, we've had several who came to us straight out of CRNA training. They are as green as Kermit the Frog's back. Those we put on a shorter leash, more so than new anesthesia residency graduates. 

Speaking of residents, since most of us had not worked with CRNA's in the past, it was a really delicate situation trying to figure out exactly how much independence to give them. We know how to supervise anesthesia residents. We know their education levels and can adjust the oversight based on which year residency they're in. For CRNA's, it was more of a gray area. Yes they are certified and have the proper credentials. But it was hard for us in the beginning not to want to sit in the room with them during the entire case to see if they really know what they're doing. We were told that was too intrusive and we can't treat them like residents. So we just had to learn to trust their judgement and let them do their jobs that they were hired to do. That took a little getting used to.

Another fear of hiring CRNA's that so far has not yet materialized is getting the nurse with an attitude. You know what I'm talking about. These are usually found in public medical facilities like county hospitals or the VA. They are the CRNA's who cop an attitude when we try discussing the anesthetic plan with them. They have an almost militant attitude where they are trying to prove that they are the equal of physician anesthesiologists and constantly trying to put physicians down. These are not team member nurses that would work well in an ACT model. Luckily we haven't hired anybody like that and we're keeping our fingers crossed on not getting one.

So far any adverse events involving our new CRNA's have been few and far between. Of course we don't have too many nurses right now and we're keeping a rather close eye on each one of them. Eventually we'll have to let them have a little more independence. When that happens, I can see how our physician anesthesiology group could become jeopardized by the presence of having CRNA's around. I'll get to that dire prediction next.

Tuesday, March 23, 2021

The Anachronism Of An All Physician Anesthesiologist Practice


The all physician anesthesiologist group


Prior to becoming hospital employees, our anesthesia group had been fiercely proud of our all physician anesthesiologist makeup. Our group had served our hospital well in this fashion for three decades. Before that, the hospital also had never hired any CRNA's. But that was then. Medical economics has transformed tremendously in the past several decades. It was probably a long time coming but the covid pandemic pushed us into an anesthesia care team (ACT) model and there is no turning back.

First of all, let's set aside the question of equivalency between physician anesthesiologists and CRNA's. That is a contentious discussion that has been well covered in this blog and anesthesia posts all over the internet. Let's just talk about the nitty gritty, the dollars and cents aspect of using CRNA's. While our group was researching the pros and cons of the hospital takeover offer, we discovered that we were one of the last large all physician groups still in existence. Almost every other large anesthesia group had switched to an ACT years, or decades ago. We were an anachronism, a dinosaur. We were the equivalent of an Al Bundy, sitting around thinking about how good we had it years ago and wondering why we don't have it as good as the next door neighbor driving a Mercedes.

If one looks strictly at economic factors, then hands down the use of CRNA's makes perfect sense. You can hire two or three nurses for one anesthesiologist. If the medical facility is expanding rapidly like ours, then it quickly becomes cost prohibitive to hire more anesthesiologists every time new OR's come on line and need to be serviced. The current shortage of anesthesiologists makes this a buyer's market. With the lack of benefits in our old business model, we were having a terrible time trying to get new recruits to consider joining our group. This made our service agreement with the hospital difficult to fulfill as we were frequently short of enough people to cover all the OR's. We were in danger of losing our hospital contract if we couldn't live up to our obligations.

A second impetus for the hospital to switch to a care team model is the ever decreasing anesthesia reimbursements from insurance companies and the government. Every hospital would love to have an all physician anesthesiologist group staffing the operating rooms. Unfortunately the entities paying the bills don't see it that way. They are looking for the least expensive method to achieve the same quality results. While we were desperately holding onto our physician anesthesiologist model, others have figured out that having a physician led ACT was almost as good for a lot less money.

When we saw the overwhelming odds that our anesthesia group was not going to survive through the pandemic and beyond, it almost wasn't a choice anymore. We had a hospital that was willing to keep our group intact and offer us extremely generous benefits we never had before. The only thing in return that they asked for was that we incorporat CRNA's into our practice. We would have committed professional suicide if we turned down their terms due to misplaced pride. The first CRNA joined our group one month after we signed on the dotted line.

Monday, March 22, 2021

There Is No Perfect Job

When we switched from an independent contractor to an employee job model, a huge weight was lifted off our shoulders. The constant threat of insurance and Medicare reimbursement cuts no longer fell directly on the group. The fluctuating caseloads in the OR during a pandemic made less of an impact on our individual incomes. We thought we had found the formula for the perfect job.

Going in, we weren't just wearing rose-colored glasses. We knew that employed physicians typically made less money than fee for service. This is borne out every year in Medscape's physician compensation survey. But the picture is more complicated than a simple graph.

As independent contractors, we worked as much or as little as we wanted. Some people who wanted a large income could slave away every night and weekend to make a ton of money, far higher than the average anesthesiologist's income in the survey. Others desired more free time and worked less, making much less than the survey average. But those were the choices each individual made for themselves. Now that is no longer an option.

The hospital is paying each of us for a contractually determined number of working hours per day. The ability to leave early because you feel like going outside to absorb some of that bright California sunshine is not permissible. If you finish your OR lineup early, they'll find other cases for you to do until you've fulfilled your work hours for the day. You can't just walk out and refuse to do more work. You're an employee now with expectations of how an employee needs to behave in a workplace. If there really is no other cases in the OR pending, then you can be dismissed early, but that is a rarity.

The flip side is that somebody who wants to work longer hours to make more money also can't do that. After you've filled your quota of hours for the day, they almost push you out the door so they don't have to pay overtime. Therefore your income ceiling is much lower than before. Everybody's income in the department has narrowed closer to parity.

This loss of individual choice was very difficult to adjust to and I've yet to fully come to grips with it myself. When doctors say they don't want to lose their independence, this is what they mean. Suddenly people are telling you when and how you can work.

I've also noticed a new psychology at work that I never experienced before when I was working for myself. I was often amused before about how nurses frequently say they only have another so many hours or minutes to go before the end of their shift. I thought to myself how nice it was that there is a definite end to their workday. After we switched over, I started behaving the same way. When they want to add another case to my room late in the afternoon, I no longer get riled up about it. I just look at the clock to see how close to finishing I am and thank my lucky stars I'm not the one who will be stuck doing this five hour spine case the rest of the night.  

Those aren't even the biggest changes we've experienced since becoming hospital employees. The more predictable daily hours and generous benefits are wonderful. However there's a price for all this largess; the hospital expects something in return for taking us in and providing these benefits.

Suddenly hiring a large number of anesthesiologists added a huge chunk of money to their payroll expenses. In order for it to work out economically, the hospital decided that they wanted to move to an anesthesia care team model. In other words, we now work with CRNA's. And that, my MD/DO anesthesia friends, has been an eye opener.

Sunday, March 21, 2021

From 1099 To W-2 in 2020

Overnight, we morphed from independent contractors to hospital employees as the hospital took over our anesthesiology department. I won't go over again all the details about why our group made the switch, but it was done out of necessity due to the pandemic and the reality of a different set of expectations among younger physicians.

This change brought on many immediate improvements. No longer was there an obligation to work late into the night if the room was running long. If you weren't on call, they almost hustled you out of the OR by 5:00 PM lest the hospital had to pay overtime. Working weekends brought extra pay. The set work hours was a revelation for those of us who had only known unpredictability and exhaustion. My wife even remarked that sometimes it felt like I was only working part time when I kept coming home before the children went to bed. 

Besides having a set number of hours per day, we also finally achieved a contractually determined number of vacation and sick days. As independent contractors, we could theoretically determine our own work hours and take as many vacation days as we wanted. But if we did that, we won't make any money and it's no fun losing your house because you wanted to take a month long vacation to explore the world. Now we have paid vacation days and the mental relief of not worrying about paying our bills while taking time off.

Perhaps the most important benefit we received was health insurance. As independent contractors, we had to buy our own health insurance. This flexibility is nice if you're single with no family obligations. But most of us had to worry about family coverage and Covered California, our state's version of Obamacare, was raising its premiums every year while increasing the deductibles and copay. This took a giant chunk out of our monthly incomes. It became my second largest personal expense, after the mortgage on my house. The deductibles for a family reached over $20,000. We weren't even buying the gold plan, but the least expensive plan we could find that included our family doctors in the network. This was essentially a catastrophic health insurance plan which we avoided using as much as possible. We paid almost everything out of pocket as we never got close to using up all the deductible in one year. Now we have much better health insurance from the hospital. It also eliminated a giant hangup to recruiting new physicians as most young people expect to receive their health insurance from work.

The headaches of running a medical corporation also disappeared. No longer did we have to pay the expenses of a large back office operation. The hospital now was in charge of all the billings and collections. No longer were our incomes held hostage by how successful our collections process was. That was the hospital's responsibility to collect the money, not ours. We got paid based on our hospital contract, not how much reimbursement we could achieve.

Having the heft of a hospital behind us also did wonders for insurance company negotiations. Tales are rife of insurance companies unilaterally cancelling their contracts with anesthesia groups, or cutting previously agreed to reimbursement rates. A hospital will have more leverage negotiating with insurance companies than a little single specialty medical group could.

The advantages of becoming hospital employees became evident when California experienced its surge of coronavirus cases last winter. We again had to reduce the OR schedule as the hospital was trying to preserve as much ICU and regular hospital beds as possible. Unlike the first surge though, our incomes didn't change. The hospital continued to pay us as if we were working full time even though many of us were given paid time off for lack of cases. We anesthesiologists were no longer beholden to the surgeons and their operating schedule.

But I shouldn't make it sound like it's all been wine and roses since we became employees. There have also been deep grumblings within the department about some of the changes the hospital has made to our practice. That will be the next installment of this journey.

Saturday, March 20, 2021

Fee For Service Is Over

The Covid pandemic destroyed countless lives and businesses. Our anesthesia group was unfortunately one of its victims. After almost 30 years of independent practice, we decided that the way we conducted business was no longer tenable. It has been a long time coming but Covid gave our group a final shove into the dustbin of history.

The group was an all physician anesthesiologist endeavor. When times were good, they were very good. It was an old fashioned fee for service practice. Some of us who wanted to make more money could work harder and longer than those who didn't want as much income. Some people made money to buy fancy cars and real estate while others earned just enough to satisfy their vacation splurges. Covid put into sharp relief the shortcomings of this model.

When the economy was put into mandatory lockdown by the government, suddenly the economics didn't work anymore. No work meant no money. Most of us were really hurt economically when our incomes dropped well over 50% last spring. Almost all of us applied for the PPP loans, which we qualified for since we were considered independent contractors. Unfortunately the loans were only a temporary bandaid since we can't live on government loans for long. Luckily the lockdowns started to lift just when the PPP loan money was running out. 

Meanwhile the doctors and nurses who were employed by the hospital didn't see any cuts in their incomes, even though they too were working less (other than the pulmonary, ED, ICU, and other so called frontline workers of the pandemic). When the second surge started to hit and our surgical volume waned again, we knew that our anesthesia group needed substantial help. 

In reality, our fee for service model was terribly outdated and could not survive for much longer. There were lots of problems with a business model that had been stagnant for decades. The most pressing issue was the difficulty we had in recruiting. We had survived by hiring people who really wanted to live in Southern California. That was the number one draw. Though the cost of living was exorbitant, some people were willing to take that economic hit to live here. Over the years, as the taxes and housing costs kept rising, fewer people were willing to make that sacrifice. 

The fee for service model also did not appeal to a new generation of anesthesiologists. Yes you can make fist loads of money if you work hard enough. But younger doctors were more interested in a better work-life balance. They were willing to make less if they could be guaranteed set work hours and regular time off to spend at home with their families. We just couldn't do that with our practice. People were expected to stay until all the cases in their room were finished. It was very difficult to plan any family events as there was no way to know even 24 hours ahead what time you might be able to go home. That was a gigantic turnoff to many young doctors.

Then there was the rising cost of doing business. Our back office was taking a substantial portion of the group's income. There was staff to hire, offices to rent, computers systems that needed constant updating as insurance companies and government bureaucrats kept changing how and what kind of paperwork they needed before we could get reimbursement. It was a constant battle to keep expenses down.

I'm not sure who approached who first, but when the hospital saw the difficulties we were having, they proposed to absorb our group into their system. They valued our expertise as we were active in a substantial portion of medical care. Everything from labor and delivery, surgery, critical care, chronic pain, and many other areas of patient management involved our anesthesia training and the hospital was grateful for it. Therefore they couldn't afford for our anesthesia group to suddenly disintegrate and leave them with an unstable and unpredictable anesthesiology department. I can't say it was a buyout as none of us got a buyout offer. Instead, we became employees of the hospital.