A Devious Lawyer Can Be A Doctor's Best Friend

We all know that lawyers can be lying, cheating scumbags that destroy all that is good in the world. (Obviously just being hyperbolic here.) Here is the story of a lawyer in Orange County, California that helped a physician get out of a malpractice suit by basically lying to the jury.

The patient, Enrique Garcia Sanchez, was admitted into South Coast Global Medical Center in Santa Ana, CA in 2017 with alcoholic pancreatitis. He was unable to eat for over a month. His gastroenterologist, Dr. Essam Quiraishi elected to put in a PEG tube to facilitate his nutritional intake. He unfortunately perforated the colon while doing the procedure. This mistake was not caught until Mr. Sanchez developed peritonitis and died from septic shock at the University of California, Irvine Medical Center a month later. The family sued Dr. Quiraishi for $10 million.

This is where Dr. Quiraishi's lawyer comes in. His name is Robert L. McKenna III, a founding partner at Kjar, McKenna & Stockalper. He was able to convince the jury that Mr. Sanchez died from catastrophic pancreatitis, not septic shock despite the coroner's death certificate stating the death was due to sepsis and peritonitis from a colon perforation. Mr. McKenna also blamed the hospital staff for not notifying Dr. Quiraishi about the X-ray findings in a timely manner. Not to leave any stone unturned, he also blamed the plaintiff's lawyers for "extortion" of the doctor and being part of a "personal-injury industrial complex." Mr. McKenna sowed enough doubt into the jury that they found the physician innocent of malpractice in a unanimous vote.

Normally this would be the end of another malpractice suit that happens every day across the country. But what makes this extraordinary is that Mr. McKenna was caught on video celebrating his legal victory at his office and it was posted on the internet. It was quickly taken down later but not before other people saw it and reposted it all over the web. 

#LosAngeles lawyer bragging about his client negligently killing the plaintiff in a #medicalmalpractice case....absolutely reprehensible #tortreform #personalinjury pic.twitter.com/qzOVmk3VPd

— torthub (@TheTorthub) May 18, 2022

In the video, Mr. McKenna is seen at an office party discussing the case and how he deceived the jury into accepting his alternative facts. He described the case as "a guy that was probably negligently killed, but we kind of made it look like other people did it. And we actually had a death certificate that said he died the very way the plaintiff said he died and we had to say, 'No, you really shouldn't believe what the death certificate says, or the coroner from the Orange County coroner's office.'" He said it was the fastest defense verdict he had ever gotten and even had a colleague ring a victory bell in the office.

Naturally the internet mob is now calling for Mr. McKenna to be disbarred. His manipulation of the jury personifies the qualities that people expect and hate about lawyers. However, others have stated that lawyers lie all the time to juries to get their clients free from charges like murder, assault, and other felonies because that is their job. Mr. McKenna is just very good at it. His only mistake was getting filmed bragging about his legal abilities and belittling the jury. 

As a physician, I certainly would want somebody like Mr. McKenna on my side, no matter what he has to do to get me off the hook. This story also illustrates that most people want to believe that doctors are doing the best they can to help people. Almost 90% of medical malpractice cases are found for the defendant even when the evidence is strong for conviction. So should Mr. McKenna be brought before the Bar or should he be lauded for his success? This is a tough one legally and ethically.

Anesthesiology Compensation In 2022

Medscape has released its annual Physician Compensation Report for 2022. The report polled over 13,000 doctors about their salaries and other details about their work. It looks like the pandemic induced reduction in physicians' incomes are over. For the first time in Medscape's survey history, all medical specialties saw increases in compensation during the past year. ENT topped the list with a 13% increase in average annual income.

Anesthesiologists fared well, as usual. This year, anesthesiologists reported an average income of $405,000. That is up significantly from last year when they disclosed an average of $378,000. That is a seven percent improvement over 2021 which was down five percent from 2020 due to Covid shutdowns.

Since 2015, physician salaries have increased an average of 29%. By comparison, inflation in the U.S. over the last five years has been 14.7%. Anesthesiologists didn't fare as well. In 2015, Medscape said anesthesiologists made an average of $358,000. So In the past seven years, anesthesiologists salaries have flatlined, not even keeping up with inflation. Perhaps that's why our specialty doesn't rank in the top ten anymore of the highest paid physicians. And the ASA wants to keep opening more anesthesia residency spots at the same time.

The top five states with the highest physician incomes are: Kentucky, Tennessee, Alabama, Missouri, and Oregon. If you think you would never live in a rural state even if they have very low cost of living and high salaries, then you're stuck in a bicoastal elitist mentality. Though these states may seem rural, they have very cosmopolitan urban centers too, such as Nashville, Louisville, and St. Louis. Alabama even has nice beaches also. So if you're looking for the biggest bang for your buck, don't overlook this list. 

There's a lot more information in Medscape's survey than what I have listed here, including one nice aspect of working in anesthesiology that tops all other specialties. Check it out.

"Ailee Was Massively Poisoned By The Anesthesiologists"

Ailee Jong, from SF Chronicle

In a 9,200 word article in the San Francisco Chronicle (behind a paywall or free if you have Apple News), the newspaper details the tragic death of two year old Ailee Jong at John Muir Medical Center in Walnut Creek, CA. 

In 2019, Ailee started complaining of abdominal pain. Her parents, Tom and Truc-Co Jong quickly took her to a hospital emergency room. The CT scan results were devastating. The little girl had a 12 cm hepatoblastoma in her liver and probable lung mets. 

When they heard the diagnosis, the parents quickly searched for the best possible care for their daughter. Since they live near San Francisco, they naturally gravitated toward Stanford University and University of California, San Francisco. As they looked through the list of doctors that could treat their daughter, they noticed one pediatric oncologist who was affiliated with Stanford Children's Health and also worked at John Muir Health in Walnut Creek, which is only 15 miles from their house in Danville. This would make commuting to the hospital easier than driving 40 miles to Stanford. 

But little did the Jongs know that John Muir had little experience taking care of complex pediatric liver disease. Their pediatric ICU had only been in operation for about a decade and they'd never had a liver resection like Ailee's before. According to Tom Jong, "They did say, in these words: 'We can treat her. She can be cured.'"

When Dr. Alicia Kalamas, medical director of perioperative medicine and an anesthesiologist, found out about this upcoming hepatectomy, she immediately questioned whether the hospital was capable of successfully doing the operation on such a small child. However, Dr. Jeffrey Poage, medical director of pediatric surgical services and a pediatric anesthesiologist, countered that the surgeons were up to the task. When Dr. Kalamas brought her concerns to Dr. Thomas Greely, the vice president of clinical affairs at JMH, she was told that Stanford physicians who had been consulted about the case had assured them the small hospital could handle the operation. She brought the case to Dr. Moussa Yazbeck, the chief of staff at JMH who did not question the procedure. Dr. Kalamas's contract was not renewed in 2021.

Dr. Poage was originally supposed to be Ailee's anesthesiologist for the procedure. Less than a week before the operation, he reported a scheduling conflict and two other anesthesiologists were brought in: Drs. Wayne Lee and Romerson Dimla. Dr. Lee finished his fellowship in pediatric anesthesiology at Johns Hopkins in 2017 while Dr. Dimla completed his fellowship at Children's Hospital of Los Angeles in 2019.

On November 12, 2019, Ailee entered the operating room at 7:30 am. By 9:30 am, the anesthesiologists documented that the estimated blood loss was 345 ml, significant for a 24 pound patient with a total blood volume of 800 ml. They noted that they had already transfused four units (1,261 mL) of PRBC and one unit (222 mL) of FFP. 

Ailee's body temperature started to drop, going below 95 F. With all the blood products her potassium level went from 4 in preop to 5.6. At 12:10 pm, she went into severe bradycardia then asystole. They were able to resuscitate Ailee by 12:30 pm. Echocardiogram showed no PE or air embolism. Instead of stopping the surgery, the surgeons continued with the resection.

The anesthesiologists noticed blood emanating from the endotracheal tube, mouth and nose of the patient. Labs at 12:32 pm showed Ailee's potassium had jumped to 8.2, a critically high level. Then 15 minutes later, she had another cardiac arrest. An operating room nurse desperately searched for help and found Dr. Poage, the medical director of pediatric surgical services and "begged him to come to the OR." He threw his anesthesia colleagues under the bus and refused to get involved. 

The surgeons continued with the operation despite the second arrest. She was now bleeding profusedly everywhere and the anesthesiologists kept pumping more PRBC and FFP. By now, the anesthesiologists stopped documenting the amount of blood products they were giving. Ailee's heart stopped again. Several times during the resuscitation, the ETT fell out, requiring the anesthesiologists to reintubate her while chest compressions were taking place.

When the surgical team finally realized the operation was futile, they went to the waiting room to inform the Jongs and asked for permission to stop the resuscitation. The parents refused and demanded to see the little girl in the operating room. They were informed that that was against policy but relented. 

When they walked into the OR, they noticed a stack of bloody towels on the floor three feet high and a nurse doing chest compressions. The room smelled of blood. They said Ailee was unrecognizable. Her head was massively swollen and blood was seeping out of her eyes, ears, nose, and mouth. After almost five hours of CPR, she was declared dead at 5:12 pm. 

The lawsuit the Jongs are bringing against the hospital complained that the anesthesiologists did not transfuse an adequate amount of FFP to allow her body to clot properly, leading to the massive hemorrhage. They also said that too much PRBC was given, leading to the critical hyperkalemia. The lawsuit claimed that "By 12:32 p.m., Alee was massively poisoned by the anesthesiologists."

This story illustrates that there is more to an operation than just the surgeon. It takes an entire ecosystem to successfully perform surgery. John Muir Health was not candid with the Jongs when they assured them that the hospital could do the hepatectomy despite internal warning flags raised by staff. The anesthesiologists, who only recently completed in their pediatric anesthesia fellowships, probably had not done such a complicated case since they finished training. The Jongs were wowed by the hospital's decor and amenities but were not given relevant information about the experience of the hospital and its staff in doing pediatric liver resections. Just a sad case for all involved.

An Anesthesiologist's Perspective On The Oscars Slap

Jerome Adams, MD, ASA member and former US Surgeon General, gives his views about the infamous slapping of Chris Rock by Will Smith at the Academy Awards last night. He uses the incident to highlight the need for mental health maintenance in all people, even the rich and famous. But he also points out that nobody should make fun of another person's medical condition, especially if the condition can't be hidden from view. 

What I first considered a clearcut case of unprovoked physical assault witnessed by millions of people has turned into a much more nuanced debate about mental health, personal privacy, and sensitivity to health issues. I guess that's why I'm not a deep thinker like Dr. Adams.

Terror In The MRI

RaDonda Vaught, former nurse at Vanderbilt University Medical Center, has been found guilty of negligent homicide in the death of Charlene Murphey, a 75 year old patient under her care. Back in 2017, Ms. Murphy was admitted to the hospital for a stroke. The patient was supposed to get an MRI scan and was anxious, which is not uncommon in patients undergoing an MRI. Ms. Vaught, as her nurse, went to the drug cabinet to fetch some versed, an anxiolytic. Instead, she took out vecuronium, a paralytic agent. She injected the muscle relaxant into Ms. Murphey, how much is unknown, and left the patient to get scanned. By the time the scan was completed and Ms. Vaught returned, her patient was braindead.

As an anesthesiologist, this drug mixup is very perplexing. Versed comes in liquid form. Vecuronium, on the other hand, comes in a powder. It has to be dissolved in a liquid before it can be administered to a patient. How the two drugs got mixed up is incomprehensible. As an ICU nurse, Ms. Vaught surely has given versed in the past to her patients. She may also have given vecuronium to intubated patients to help them ventilate more easily. She should be familiar with both drugs. The two are nothing alike. This mistake isn't even like the heparin debacle a few years ago in Los Angeles, where the children of Hollywood celebrities were overdosed due to a high concentration solution being injected instead of the standard concentration. Versed and vecuronium are packaged completely differently and don't look ANYTHING alike. 

The responses from the medical community have been predictably defensive and disappointing. Some tried to blame the drug dispensing machine, which got the first few letters of the medications mixed up and gave her the wrong one. The American Nurses Association issued a statement lamenting that, "The nursing profession is extremely short-staffed, strained, and feeling immense pressure. This ruling will have a long-lasting negative impact on the profession." Excuse me? The ANA is worried that there won't be enough nurses because of the criminal actions of one of their own? You know what? Right now there are real shortages of police officers all over the country. Should we have let Derek Chauvin go free because finding him guilty might cause other officers to quit? 

Let me picture for you the gruesome ending of Ms. Charlene Murphey that fully justifies Ms. Vaught's verdict. Imagine you're going to get an MRI done. The test usually takes at least 30 minutes, frequently longer. You're stuck inside this long narrow tube with barely any room to move your body. There are loud strange noises reverberating in the machine throughout the entire procedure. Not surprisingly, many patients ask for a sedative to make them feel a little more relaxed during the exam. 

Ms. Murphey asked her nurse for something to calm her down. Ms. Vaught decided to get versed, which is a fairly standard sedative for this procedure. Inexplicably, she grabbed vecuronium instead. Without ever reading the label on the drug vial, she dissolves it in a solution and injects the drug into Ms. Vaught. 

The patient, fully trusting of her nurse, then goes into the scanner. Vecuronium is not a fast acting paralytic agent. It can take a few minutes for it to fully kick in. By then, her nurse would have been out of the room so they can proceed with the scan. When the patient realizes something is amiss and she is having great difficulty breathing, it's too late. There is nobody around. The only people nearby are the staff in the control room where they can see the patient at all times. But all they can tell is that Ms. Murphey was laying there quietly, not disrupting their scan. 

The patient obviously was not being monitored or else the staff would have noticed her vital signs kick into overdrive as the body realizes it can't breathe. There was no monitoring to detect when here oxygen saturating started drifting lower. The patient, fully conscious because she has been paralyzed without any sedation at all, is locked in and has zero ability to communicate. As her brain screams for help, her body is helpless to escape this situation. Finally, after several minutes of agony, Ms. Murphey would have gone into cardiac arrest and brain death from the lack of oxygen, with a room full of people just on the other side of a large window unwittingly watching her die.

This is the worst nightmare for anesthesiologists, to have a patient awake under the knife. But at least we're still providing ventilation so the patient isn't suffocating. Ms. Murphey was left all alone to die because her trusted nurse didn't do something as basic and routine as read the drug label before she killed her. 

ICE or BEV With Your Blizzard?

Just a quick introduction. I don't own a Tesla or any electric vehicles but I found this information very educational as we head off into our battery powered future.

Remember that blizzard in Virginia on January 4 that made national headlines? The state highway system came to a complete stop, trapping travelers on the road for nearly 24 hours. A truck driver tweeted that a Tesla driver knocked on his cab window and asked him for a blanket to keep his kids warm. He wondered what would happen when the Tesla ran out of juice. Would that poor family freeze to death as they waited futilely for a rescue?

That tweet became major news. A Washington Post op-ed (paywall) worried about what will happen when the country's transportation goes completely battery electric vehicles (BEV) only. Electric cars are much more difficult to get off the road when they run out of power compared to internal combustion engine (ICE) powered autos. You just need to add a couple of gallons of fuel into the tank and the car is good to go. 

The good folks at Car and Driver decided to run a little experiment with this scenario. They took a 2019 Tesla Model 3 Long Range and idled it next to a 2022 Hyundai Sonata N to see which car would last longer. The average outside temperature during this test was 15F though it got as low as 9F. They set both cars' climate controls to 65F.

Well guess what--the Tesla could last nearly as long as the Hyundai in this demonstration. The Tesla has the advantage of Camp Mode which turns off every part of the car except for climate control when the car is in park. The Hyundai's engine idled at full power the entire time. The Tesla started out with 98% charge on the battery and ran for 37 hours straight, leaving about 17% charge or 50 miles remaining. In theory, it could have continued for a total of 45.1 hours. The Hyundai's engine was stopped after 24 hours but they calculated it would have gone a total of 51.8 hours with its 16 gallon gas tank.

US Dept. of Energy

The Tesla was able to achieve this because BEV's have more efficient motors. The Model 3 used up 1.6 kWh per hour while the Hyundai burned through 10.6 kWh per hour. Another reason BEV's are safer in unexpected emergencies is because electric vehicles are more likely to have a full "tank" every time they go on the road since most owners charge their cars at home overnight. Meanwhile, ICE owners don't usually fill up their cars until well under half-tank. Good luck trying to find a gas station when there is an emergency evacuation order. 

So next time you snicker at the BEV driver and their worries about range anxiety, just remember that they are more likely to have a full tank in their car than what you're currently driving. In fact, when was the last time you even saw a BEV stranded on the side of the road because they ran out of juice? In Los Angeles, cars are stranded on the sides of the freeways every day because they ran out of gas.

By the way, that truck driver later tweeted that the Tesla family did just fine when the Virginia highway finally opened up. They still had 18% charge on their Tesla when they finally made it off the road to the nearest Supercharger station. I'd be more worried about trying to find a bathroom in a blizzard than getting stuck long enough for an electric car to lose all of its battery power while trying to stay warm. 

Anesthesiologist Who Killed Surgeon Goes To Jail

Just a follow up from a story from back in 2017. Dr. Stephen Kyosung Kim was charged with murder when his patient, Dr. Mark Greenspan, a 71 year old orthopedic surgeon, died after surgery. Blood and urine drug tests showed Dr. Kim had Demerol and Fentanyl in his system at the time of the incident.

Dr. Kim admitted that he had stolen Demerol 50 mg from the Rodeo Drive Plastic Surgery Center in Beverly Hills that morning. He administered a general anesthetic to Dr. Greenspan even though they had discussed using regional anesthesia. Dr. Kim then left the operating room to give himself Demerol and Toradol. He subsequently fell down and hit his head but came back to the OR to finish the case. While in recovery, Dr. Kim overdosed Dr. Greenspan with Demerol and the patient became apneic and went into cardiac arrest. Dr. Kim tried multiple times to intubate Dr. Greenspan but was not successful and the surgeon died. 

The anesthesiologist admitted to the prosecutors that he had a drug addiction and had taken narcotics over 150 times while at work. His medical license was subsequently revoked. After four years, Dr. Kim pleaded guilty on December 2021 to manslaughter and was immediately taken to jail. It is expected that he will return to court in December 2023 and be sentenced to two years of jail time which he will have already served. 

This tragic case once again illustrates the unfortunate link between anesthesiology and drug addiction. It's well known that anesthesiologists have one of the highest incidents of addiction in medicine. I have unfortunately covered multiple incidents of drug addiction among anesthesiologists, including here and here. Eighty percent of US anesthesiology residencies have had at least one drug impaired resident. Almost a fifth of all residencies have experienced the death of a resident due to drug overdose. Male anesthesiologists are considered the highest risk for drug addiction and suicide among all physicians. A deadly combination of high stress work and easy access to narcotics makes drug addiction an ever-present risk of working in the field. If you suspect an anesthesia colleague may have an addiction problem, say something. It may save his, and his patients', lives.

Doctors Are Vassals Of The State

If there is any doubt that doctors do not have autonomy in their workplace, recent court decisions regarding vaccine mandates have proven it. A couple of weeks ago, The Supreme Court ruled that the Biden Administration's vaccine mandate for all employers with more than 100 employees was unconstitutional. Congress never authorized this action and the executive branch doesn't have that authority no matter how the administration contorted the laws. Then last week a US District Court in Texas found that vaccine mandates for federal employees were also unconstitutional, again citing overreach of the administration in their use of federal laws. 

So does anybody in the US need to get the vaccine? Large employers cannot force their employees to take the coronavirus vaccine. Federal employees also cannot be required to accept the vaccine. Small employers have not had any federal mandates for their employees to receive it or get fired. The only federal mandate for vaccines that was accepted by the Supreme Court was for doctors, nurses, and all medical industry who accept Medicare and Medicaid reimbursements. Yup, it's all about the money.

The reason the Centers for Medicare and Medicaid Services was able to force healthcare workers to get jabs despite deep concerns among large groups of the population, including doctors and nurses, is that there is a clause in the Medicare laws that states the government can do whatever it takes to make sure the programs function smoothly. Therefore it gives the Secretary of Health and Human Services broad authority to make sure they run uninterrupted, which in this case means healthcare workers who accept money from CMS do not get sick from Covid and they do not transmit the virus to their patients.

I am not a vaccine skeptic. I got my first shot the first week that it was available at our hospital. I have since been boosted. I just find it frustrating that even though physicians are some of the most highly educated people in the country, we are under the boot of the federal government with little recourse for dissent. 

Besides vaccine mandates, other government rules keep doctors on a very short leash. EMTALA laws tell us who we can and cannot treat (spoiler: we have to treat everybody). HIPAA laws decide what we're allowed say. Through the Joint Commission, they dictate what we can wear, where we can eat, how we dispose of trash, and essentially all functions of a healthcare facility. Doctors are threatened with loss of their livelihoods if they exercise their freedom of speech to talk about their skepticism of the consensus. Our incomes are based on the whims of the federal government where they threaten to cut reimbursements every year. Medicare reductions of 1-2% are considered a win for the healthcare community even though inflation is soaring all around us. 

Do physicians have any constitutional rights left? When physicians first got into bed with the federal government, many were anxious about cozying up with such a large entity. We were assured it would be just a small program, costing only a few billion dollars each year. Besides, shouldn't doctors just suck it up so the elderly and destitute can receive their rights to decent healthcare? Half a century later, as the programs expand their eligibilities and the demographics of the population has changed, Medicare and Medicaid enrollment are now over 100 million people. 

The medical community essentially cannot function without government money. With so little leverage, is it any wonder the Congress can so easily talk about cutting medical reimbursements each year and face almost no backlash? We are required to follow rules that would have a private employer facing an ACLU lawsuit within five minutes. If we're going to ride the bull, we're going to have to expect to get gored.

Doctors Should Make Passive Income A Priority

Doctors are always complaining about being overworked and underpaid. They dream of accomplishing the gospel of FIRE, financial independence/retire early. Yet few physicians are able to execute that plan because it calls for massive financial deprivation (saving 50% or more of your income) and social hardships (no fancy cars or vacations to pay off debt). All this to retire by the age of 50 and worry whether your portfolio will last the next 40 years. 

Yet you regularly read news of people who are able to parlay their smarts and sweat equity into substantial passive income. There are the two children from Dallas, 14 and 9, who are now making $30,000 per month mining cryptocurrency. Ishaan Thakur and his younger sister Aanya started by converting their gaming computer to mine ether after watching YouTube videos. The first day they made $3. Just like that they made money from thin air. Satisfied with their results, they added more processors and made $1000 their first month. As they made more crypto income they kept adding more processors. In four months they were making $36,000 per month! Their only expense is paying utilities to a data center which is about $3000 per month. These kids are doing the ultimate FIRE and could retire before they finish high school.

Then there is this story of an ex-pastor and his wife who are now living comfortably on their rental income generated from 30 properties. They started with nothing and were able to accomplish this feat in two years. (Business Insider subscription required.) The young couple were living paycheck to paycheck in Denver when their daughter had a medical emergency. They realized how little safety net they had. So they started watching house flipping shows on HGTV and read real estate investment books. They sold their house in pricey Denver and bought a house in St. Louis, saving hundreds of thousands of dollars. The family began with one house where they did all their own rehab to save money. Before long they were renting out the property, earning a small income. With that cash flow they kept buying more houses, fixing them up, and renting them out. Within two months they were renting out three properties making $1000 per month. Now less than two years later they have thirty properties and live comfortably on their rental income.

It seems like doctors should be able to generate this level of passive income easily with our high levels of education and large salaries to start. These people did not go to school as long as us and basically started out with nothing but their smarts and hard work. Why can't doctors routinely do the same thing?

Is it because with our high salaries it takes a lot of passive income to move the needle and so many doctors don't think it's a worthwhile endeavor? If you're making $4000 per month and generate an extra $1000 per month renting houses, you've substantially increased your earnings. However if you're earning $40,000 per month as a doctor, making another $1000 per month doesn't seem worth the trouble.

Or maybe it's because we're too busy to think about starting a second income stream. When you're working sixty hours per week, the last thing you want to worry about is going to a rental to fix a leaky toilet after getting off work at 7:00 PM. If you hire somebody to do all the repairs then that destroys your cash flow and you wind up losing money on that property. So perhaps doctors would rather spend their off hours resting at home than running off to fix a tenant's complaints.

Maybe our education narrows our mental focus. All those years of medical school blinds us to business opportunities when they present themselves because we're concentrating so much on running a medical practice. Any thought about earning extra money invariably is medically related, such as becoming an expert witness for malpractice cases or getting honorariums giving talks for pharmaceutical companies. We should broaden our scope and look beyond the medical industrial complex. With our ample incomes, why can't doctors also buy a bunch of crypto miners and start generating crypto money? If two children can do it, surely physicians with over a decade of higher education can too. 

Next time, before buying that new Mercedes to replace the three year old Mercedes, maybe think about keeping the old car and use that money for creating a meaningful change in your life. Plenty of people are able to create wealth for themselves with far less education and cash flow. Perhaps we should get on this gravy train too.

Anti-Vax UCLA Anesthesiologist Removed From Hospital

UCLA anesthesiologist Christopher B. Rake, MD was escorted out of UCLA Medical Center for refusing to take the Covid vaccine. He filmed himself as he was led out of the building.  As he's leaving, he says to the camera, "This is what happens when you stand up for freedom. This is the price you have to pay sometimes. I'm willing to lose everything, my job, paycheck, freedom, even my life. United we stand, divided we fall." The hospital has placed him on unpaid administrative leave, which is just fancy words for getting fired. 

Dr. Rake, NOT an ASA member, graduated from Tufts University School of Medicine in 2004 and completed his residency at UCLA. He has been a prominent spokesman for the anti-vax movement in Southern California. He was filmed in Santa Monica at a rally against the vaccine and talking about Q-Anon. He is so adamant against the vaccine mandate that he hasn't even tried to use a medical or religious exemption. 

One one hand, he can be admired for standing up so strongly for his principles. He's willing to lose his reputation and livelihood for something he truly believes in. For most of us, it is far easier to just give in to these mandates and take the shot. It's not that different from the flu vaccine that all healthcare workers in LA County are required to get each year. Get the shot or get fired. 

However, I wonder what Dr. Rake thinks about all the other rules we willingly follow to improve our lives and those of others. What about childhood vaccinations for measles, mumps, rubella, tetanus, etc.? How about seatbelt laws? Rules against driving while under the influence? Airport security inspections? All these things are personally uncomfortable or restrictive. Yet we tolerate them because we know they help the greater good.

Good luck to Dr. Rake finding another anesthesia job. He will probably have to move out of California since we have some of the strictest rules against anti-vaxxers in the country. However, hospitals all over the country are requiring their healthcare workers to get vaccinated so it won't be an easy job search. 

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.

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.

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.

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.

Your research as a private individual is better than professionals @WSJ!

Data logs recovered so far show Autopilot was not enabled & this car did not purchase FSD.

Moreover, standard Autopilot would require lane lines to turn on, which this street did not have.

— Elon Musk (@elonmusk) April 19, 2021

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.

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.

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.

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.

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.

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.

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.