The Best States To Practice Medicine.

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

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

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

Los Angeles Is A Terrible Place To Start A Medical Practice

People hear all the time the horrors of commuting in LA. But unless you actually live here, you don't really understand the tediousness and frustration of driving in stop and go traffic for miles at a times. I recently left work at the hospital a little after 5:00 PM. I knew the commute would be a long one but on this particular day I was even more exasperated than usual. As you can see by my odometer, after driving for over half an hour, I had covered a distance of only three miles. Only twenty more miles to get home.

Why don't I live closer to my workplace? Because a doctor's income is barely sufficient to purchase a house big enough to raise a young family on the Westside of LA. Almost all our staff who have small children live just as far away from the hospital as me in order to have access to good public schools and park space. We are experiencing an exodus of young anesthesiologists in our staff who either want to move away to afford a better lifestyle or their spouses refuse to consider the sacrifices they would need to make in order to live here. So unless ninety degree temperatures in the middle of February is your first priority in finding a place to work, LA is a terrible city for doctors to practice, especially if you're just starting out your career.

Is California The Worst Place To Practice Medicine?

Becker's Hospital Review and Becker's ASC Review has released their annual list of the 100 best places to work in healthcare. The article doesn't elaborate on what their methodology is for selecting these places. Nevertheless, the list is filled with the who's who of medical practices in this country.

Naturally, medical giants like the Mayo Clinic and the Cleveland Clinic made the list. Other great hospitals that made the cut include Memorial Sloan-Kettering and New York-Presbyterian in New York, Massachusetts General Hospital in Boston, Baylor in Dallas, and Duke University in North Carolina. No surprises there. These are some of the most famous hospitals in the world.

After going through the list, I was struck by how few California hospitals are on this survey. The largest California facility that is on the roster is Scripps in San Diego. While it is a very large medical corporation, it is hardly a household name across the country. Then there are a few smaller hospitals in San Diego County, and a couple of small surgery centers in Orange County and Beverly Hills. That's it. This is not exactly a vote of confidence in California hospitals.

The biggest names in this state are not mentioned. What happened to the medical centers in Northern California like Stanford or UC San Francisco? What became of the behemoths here in Southern California like UCLA, Cedars-Sinai, and USC? Then of course there is the biggest hospital corporation in the state, Kaiser Permanente. None of these places were chosen to be in the 100 best places to work.

Could it be that the negatives of working in California are starting to overshadow the advantages of having a Mediterranean climate and sandy beaches? There is of course, the low income made by doctors here relative to other regions in the country. Then there is the country's highest marginal income tax rate, approved by the envious masses to  redistribute the earnings of those who work the hardest to be successful. Let's not forget the outrageous real estate prices in the neighborhoods most doctors would want to live in. Even if you can afford to live in a nice neighborhood, our leftist governor wants to take our tax money for education and redistribute it to poor performing schools over the good schools, thereby depriving the kids who are most likely to succeed the support they need. Even this dry temperate weather is not all it's cracked up to be.

So think twice before deciding on working here in California. It may look nice on TV and the movies, but it sure can be a lot easier elsewhere. But if you do come here, we will welcome you with open arms. After all, we need you to work so that I can take fewer calls.

How Many Anesthesiologists Work In California?

Here are some fun facts from the latest issue of the Medical Board of California newsletter.

Other than the primary care fields (Family Practice, General Practice, Internal Medicine, OB/GYN, and Pediatrics), what are the top three specialties to hold active licenses to practice in California?

1. Psychiatry (8,556)
2. Anesthesiology (7,657)
3. Radiology (6,695)

Of the 128,071 physicians who are licensed to practice in California, what are the percentages of the top three specialties?

Psychiatry (7%)
Anesthesiology (6%)
Radiology (5%)

In the top three specialties, what percentage self report holding board certification?

Psychiatry (62%)
Anesthesiology (64%)
Radiology (73%)

So let me get this straight. Over a third of anesthesiologists in California are not board certified? What the hell am I doing spending hundreds of hours and thousands of dollars maintaining my board certification when thousands of anesthesiologists are practicing without one? You mean one can be a good anesthesiologist without a phony piece of paper from some pompous and self important organization?  Screw you ABA!

"Housecall" From Hell

The body of an internist in Bakersfield, CA was found stuck in the chimney of her boyfriend's house. Dr. Jacquelyn Kotarac was reported missing by her office two days prior to her death.  She had attempted to forcibly get into her boyfriend's house with a shovel.  When that failed she climbed a ladder to the roof and slid herself down the chimney.  In the meantime her BF escaped from the house.

A house sitter smelled a foul odor a couple of days later. She noticed fluids dripping down from the chimney (Ewww. One reason I didn't go into Pathology). When they shined a flashlight up into the chimney they discovered Dr. Kotarac's feet wedged inside. Took firefighters five hours to dismantle the chimney and remove her body. Now her ex is stuck with repairing a broken chimney and depressed housing value. Thanks a lot doc. Just goes to show doctors are imperfect (occasionally frighteningly crazy) humans after all.

California Doctors

The Medical Board of California's end of the year newsletter has a table listing reasons doctors were disciplined by the Board. The most common reason cited was Negligence, resulting in 21 licenses revoked or surrendered. But the most common outcome for Negligence was either Probation or Public Reprimand. Other unfortunate excuses for disciplinary action by the Board includes Inappropriate Prescribing, with eleven licenses revoked or surrendered, Sexual Misconduct with four, Mental illness with six, and Self-Use of Drugs or Alcohol with nineteen.

The quarterly newsletter also lists the physicians who have been disciplined within the past three months by name and the cause of the action. For the sake of privacy and brevity I won't list the names here but you can read them for yourself as this is public information. Just follow the link above. Most of the causes for Board intervention are vague, like "gross negligence" or "repeated negligence." But there are some real eye-openers.

There were several cases of driving under the influence of alcohol. One doctor received a "Misdemeanor conviction for dusturbing the peace" and got a Letter of Reprimand. Another doctor was disciplined for "failing to meet the standard of care when inadvertently inserting a PEG tube into a patient who was not scheduled to receive one." That's another Letter of Reprimand. Another doctor received the LOR when he "Committed unprofessional conduct and made false representations by sending an e-mail to 4 individuals containing negative and untrue statements about 2 physicians while pretending to be the spouse of a patient." Would love to hear the backstory on that one. One doctor surrendered his medical license when he pretended to be a board-certified physician. Several lost their licenses for insurance or Medicare fraud.

Then there are the really disturbing ones. One doctor received a three year probation for a "Misdemeanor conviction for attempted unlawful sexual intercourse with a minor more than 3 years younger than himself." Doesn't say if the minor was his patient, just that he's a pedophile. Another doctor received probation for "performing physical examinations on 3 female medical students that made them uncomfortable." A Letter of Reprimand was issued to one doctor who "Committed unprofessional conduct by inadvertently touching the breast of a female patient during an axillary examination; failing to explain what was being examined and why; failing to document the performance of the examination; and making an inappropriate comment to the patient." Hmm. I thought all doctors by now have figured out that when examining the female anatomy, there should be a female nurse in the room. And finally, a physician received a 2 year probation for being "Convicted of assault with a deadly weapon." Could be anything from a syringe of potassium to a hit and run with his car. Doesn't say.

There's a lot more in the newsletter that I won't get into, for lack of time and space. But it shows that doctors are all to human. The public may like to put physicians on pedestals but we are just like everybody else, with all the frailties and insecurities of other people. The lessons for doctors to learn include: document everything, don't drink and drive, make sure the proper consent is in the chart, have a female nurse in the room for a female patient, and don't have sex with a minor. That should keep you from about 90% of disciplinary actions by the Medical Board of California.

Statistics on California Doctors

The Medical Board of California publishes a newsletter every quarter. For their end of the year issue, they print some interesting statistics about physicians in California. For instance, did you know there are 99,900 licensed physicians in California, with another 27,536 doctors who hold California licenses but don't live in the state? The county with the most licensed doctors is, you might guess, Los Angeles County with 27,556. The county with the next highest number of doctors is San Diego County with 9,428. The counties with the least number of doctors is Sierra County, with ZERO doctors, and Alpine County with 1 doctor.

There were 6,437 complaints against physicians received by the Board. Of those 5,303 wer closed by the Complaint Unit. Four hundred fifty cases were referred to the Attorney General and twenty-seven were referred for criminal action. The Board received a total of 811 malpractice reports against physicians. There is another list of malpractice settlements broken down by specialty. The field with the most number of malpractice settlements per physician was Neurosurgery, with 16 settlements for 541 neurosurgeons in the state, or 2.95%. The field with the next highest number of settlements per physician was Vascular Surgery, with six settlements among 228 vascular surgeons or 2.63%. The top five fields with the most malpractice settlements per physician were Neurosurgery, Vascular Surgery, Plastic Surgery, Orthopedic Surgery (do you see a pattern here?), and Neonatalogy/Perinatal Medicine.

The field with the least number of malpractice settlements reported was Oncology, with one case among 1,965 oncologists or 0.0509%. The next lowest was Neurology, with one case reported in 1,516 neurologists or 0.0659%. The five fields with the lowest reported malpractice settlements per physician were Oncology, Neurology, Physical Medicine/Rehabilitation, Psychiatry, and Pulmonology.

The fields that traditionally were thought to have a lot of malpractice complaints did surprisingly well. Emergency Medicine had the seventh most number of malpractice settlements per physician. General Surgery came in at number eight, and Obstetrics was in the top ten at number nine. Anesthesiology performed in the middle of the pack, ranking number fifteen, with 27 malpractice settlements among 4,781 anesthesiologists or 0.564%. All the research into providing safe and effective anesthesia has paid off well for us anesthesiologists.

Tomorrow, some more interesting reading from the Medical Board of California.