Wednesday, October 21, 2009

The Congress that can say no

Well it eventually had to happen. After a decade of relentless spending by the federal government, Congress has finally decided that an unfunded mandate for a lobbying group was too much and they voted it down. When the music stopped, the group that was left without a chair was...doctors. This afternoon, Congress didn't approve an AMA supported bill, S1776, that would have prevented a 21% cut to Medicare reimbursements for next year and abolished the SGR system that has driven down physicians' incomes every year. Though it was a bad bill, just the thought that physicians, of all the special interest groups, would come out on the losing end is galling.

The Republicans in the Senate decided that they are the party of smaller government and fiscal discipline after all. This despite the trillions of dollars spent in the last ten years for two wars and the new Medicare drug entitlement program. They unanimously voted against S1776. They just couldn't stand the thought of spending another $250 billion over ten years ($25 billion per year out of a $2 trillion federal budget) for doctors unless some way was found to pay for it.

The Democrats came to the conclusion that enough was enough. They had to draw the line somewhere on federal spending. This after spending trillions in the last year on bailouts for: banks, insurance companies, brokerages, auto companies, auto suppliers, car dealers, home builders, unions, etc. The Blue Dog Democrats decided to live up to their reputations as "conservative" Democrats and said no to more spending without limits.

I wouldn't be too concerned about the welfare of doctors though. We won't get our Medicare reimbursements cut; Congress will issue their annual "doc fix" to make sure we continue to subsist off the crumbs of the federal budget while a more permanent solution is found. The reason they will do this is not because they are afraid of angry doctors and the AMA, which has proven itself to be a paper tiger. No, it will be because they are afraid of all the elderly voters and the AARP, who will be up in arms if they have trouble finding a physician to take care of them. Doctors, the biggest losers so far during this health care debate.

The AMA is not your friend

In an eye opening editorial in the Wall Street Journal today, they dissect how the AMA is selling out the medical profession, particularly by AMA president J. James Rohack. The daily emails I get from the AMA on how I should support their efforts to pass health care reform fail to mention many of the punitive clauses that will hurt doctors in the long run.

The AMA has maintained that their primary goal is to do away with the SGR, sustainable growth rate, that punishes doctors every year by potentially lowering Medicare reimbursements. But the current bill that moves the SGR fix off the health care reform bills only delays SGR cuts for ten years. In fact, some in Congress would lock in current Medicare rates for the next ten years. Can you imagine how that would devastate physicians' inflation adjusted incomes? Health care inflation is usually twice as high as the consumer price index so the cuts in incomes would be far greater than the general population.

There is also no longer a demand for some sort of tort reform even though it is high on virtually every doctors' priority list. Don't even mention Obama's laughable $25 million for pilot projects to "study" tort reform in states. This is the kind of bill the AMA wants doctors to write to their Congressmen about in support? As I've mentioned before, the AMA has only a minority of physicians in the country amongst its membership. It hardly speaks for physicians as a whole. Yet it promotes itself to Congress as the voice of doctors everywhere. Its advocacy of these flawed reform bills will be a detriment to all physicians.

Tuesday, October 20, 2009

My pet peeve

When my surgeon finally walked into preop holding this morning for the first case, thirty minutes late, the first thing he said to me was how he wanted his anesthetic performed. That automatically raised my ire and soured my mood for the rest of the case. When he started injecting local anesthesia into the nose for the septoplasty case, rivulets of blood started streaming down the patient's face. He then turned to me, asked me what anesthetic I was using, and asked me to use a different one since I was causing his patient to bleed excessively. Then I thought this guy doesn't know what the f*** he's doing. I've seen hundreds of nasal injections for septoplasty and not once has another surgeon blamed it on the anesthesia.

That is just one thing I can't stand to hear and immediately lowers my attitude toward the surgeon. I don't understand why surgeons don't get it that they are not anesthesiologists. I am not their CRNA, there to be directed by an MD on how to do my job. Do I ever tell the surgeon where to make the incision? Or what sutures to use? Or which rod to insert? They would just as soon kick me out of the room for demanding that they follow my instructions.

I try to stay professional by acknowledging their "request" and will try to fulfill it if it is not detrimental to the patient. But some surgeons will repeatedly look over the drapes to check on the vital signs or ask if the patient is "completely paralyzed." Some have even asked what muscle relaxant I was using, as if they knew the difference. Then it just gets annoying and I blow them off with a dismissive "uh huh." But I'm passive in that way. I know some anesthesiologists who wouldn't blink an eye at talking back directly, setting up a confrontational atmosphere in the OR. We even have anesthesiologists in our group who are known to have such anger issues that nobody dares mess with them. Bravo I say. If I only had the guts myself. But in the end, the case finishes soon enough and the surgeon never knows my true feelings about his professional conduct. And we each go our separate ways.

Saturday, October 17, 2009

My iphone, seduced by the dark side

Sorry I haven't posted in quite some time. I'm being initiated into a cult. I consider its insidiousness right up there with Scientology and the Theory of Global Warming. Of course I'm talking about my new Apple iphone (or iPhone?). I couldn't stand it anymore. I watched day after day as legions of residents and attendings stand like zombies in the hospital hallways and elevators, flicking their fingers over that seductive glass surface, completely oblivious to the patient gurney about to run over them. At meetings, everybody is furtively glancing down at their iphones, trying to be inconspicuous in their contempt of the speaker and his topic at hand. It all reminds me, ironically of Apples infamous 1984 commercial. Except this time the face of the Supreme Leader on the screen is Steve Jobs and as yet there is no pretty blond lady to smash the spell the Leader is casting over his lemmings.

I tried to console myself by stating the obvious; there are millions of dollars worth of computer monitors all over the hospital. All I need out of my cell phone is a phone. I don't need no freaking internet browser, music player, compass, GPS navigator, gazillions of apps, etc. in my pocket. Why do I need to pay a mandatory extra $30/month for a data plan and even more money for simple text messaging? Why doesn't an unlimited data plan cover texting also? But my cell phone was over two years old and starting to do funny things, like rebooting itself in the middle of a conversation. Plus my wife freaked when she found out her phone had above average radiation emission and wanted a new phone. So my decision came down to two phones, get a Blackberry with its higher learning curve and radiation exposure or succumb to the dark side.

To the dark side did I befall.

So far, it has been...okay. When I downloaded itunes (iTunes?) for the first time, it promptly reconfigured my entire music collection from WMA to AAC, which believe it or not took about 20 hours. I had to tell everybody in the house not to touch the computer during that time, just in case somebody forgets and accidentally turns it off. What can I say, I have a huge music collection on my computer. So now I have two sets of files for each song on my hard drive. The iphone has an annoying safety feature where I have to type in a Passcode to unlock the phone so I can make a simple phone call. It's nice in case my phone ever gets stolen but downright dangerous when I'm trying to call somebody while driving in rush hour traffic. Remember the iphone has no keyboard so my finger is just kind of hovering over where I think the keys should be to type my password while trying to maneuver in urban traffic. My final criticism that I'll bring up here, though by no means the last criticism of the iphone, is that the apps are WAY overrated. There is an entire category devoted to the medical field but the anesthesia subcategory is woeful. There are a few anesthesia handbooks for downloading. But rather than flicking through my phone, wasting battery life, it would be much easier for me to carry a copy of an anesthesia handbook for referral. As far as games are concerned, who has time for games? Certainly not at work. And I've got plenty on my plate at home to have time for games.

So that's what I've been doing with all my free time in the last week. The exercise program has taken a temporary break for now (but also because I came down with a cold but that's another blog entry for later). I've got the iphone functionally just about where I want it. My wife's days and nights of being an iphone widow is almost over. And I can start blogging again about the crucial health care reform votes that are coming up along with how they are going to continue to screw the medical and anesthesia professions.

Sunday, October 11, 2009

Another lawyer's wallet biopsy

I had previously posted a case where an attorney decided to drop a high profile case because the defendent apparently could not afford his legal fees. In today's news there apparently is another lawyer that felt his time and money is more important then protecting a client facing murder charges.

The defendent is Andrew Thomas Gallo, a 22 year old driver accused of DUI and running into another car killing Los Angeles Angels pitcher Nick Adenhart along with two other people and seriously injuring a fourth person. According to the paper,

"The Orange County Public Defender got the headline-making case earlier this month after private attorney Randall T. Longwith bowed out when he could not get court funding to hire additional investigators and medical experts."

Again I ask, why is it illegal for physicians to turn away patients facing life and death situations if they cannot pay yet lawyers are allowed to turn away clients facing murder charges apparently because the government will not pay his expected legal fees? Is it any wonder hospitals all over the country are closing their emergency rooms, if not the whole building, because their indigent patient expenses are not being adequately compensated by the government?

Friday, October 9, 2009

Nobel blinded by The One

This blog normally doesn't delve into politics ouside of medicine, but this morning's announcement that President Obama has been awarded the Nobel Peace Prize is quite shocking. It puts to rest the idea that the Nobel Committee judges without prejudice and awards based on merit. This is a president who has been in office only nine months and two years ago was a little known senator from Illinois. He has been very good at talking about wanting peace but his accomplishments so far are pretty thin. Now I don't blame him for that since, again, he has been in office for only nine months. His policies for the Mideast, Iraq, and Afghanistan pretty much mirror President Bush's policies. Iran is still developing nuclear weapons. Hamas still presides over Gaza and terrorizing Israeli border towns. So far his one main foreign policy difference from the previous administration has been the withdrawal of defense missiles from Eastern Europe, to the delight of autocratic Russia and fanatical Iran.

If you look at a list of prior Peace Prize winners, there are some pretty dubious choices. In 2007 Al Gore won for promoting the doctrine of global warming. In 1994 Yasser Arafat won for promoting "peace" with Israel. Henry Kissinger and Le Duc Tho won in 1973 for attempting to bring peace to Vietnam with the Vietnam Peace Accord. Several deserving public figures have been denied the prize, including Mahatma Gandhi, Pope John Paul II, and Corazon Aquino, who brought down a dictatorship in the Philippines with the nonviolent People Power movement.

Is President Obama as deserving of the Nobel Peace Prize as Dr. Martin Luther King, Jr.? Or Mother Teresa? Or Desmund Tutu? Or Aung San Suu Kyi? When Lech Walesa, the leader of the Solidarity movement in Poland and a Peace Prize laureate, was told of Obama's win, he seemed confused, "Who? What? So fast? Well, there hasn’t been any contribution to peace yet. He’s proposing things, he’s initiating things, but he is yet to deliver." I'm sure even Obama will say there are other candidates more deserving of this award than he. But the Nobel Committee apparently has awarded him the prize based on his potential for promoting peace, not for actually accomplishing it. So while Obama's poll numbers are falling in the U.S., he can still dazzle those who don't have to live under his spendthrift socialist policies.

Thursday, October 8, 2009

A Doctor's Sacrifice

I admit that I'm a newbie to this whole social networking phenomenon. I skipped the whole MySpace fad but couldn't resist signing up for FaceBook. I heard so much about people catching up with long lost friends on FB, and for the most part that is true. I've reconnected with friends from decades ago that I thought I'd never hear from again. It's fun to see how our lives have all taken different unexpected turns. In general, everybody's gotten a little heavier and a little balder (at least the men).

What struck me though was how different my physician friends are from my high school friends, specifically how we doctors delay our lives until much later to further our education and careers. Nearly all my medical school classmates have very young children like mine. We are all in our early forties but very few have children older than ten. Meanwhile, many of my high school friends have children that have graduated from high school and are now starting college. They have albums full of pictures of prom nights, high school field trips, first dates, first cars, first sports trophies. I'm still changing diapers at two in the morning and watching Elmo on Sesame Street.

By the time my youngest one finishes college and (if I'm lucky) graduate or professional school, I'll be eligible for Social Security. If they follow the same path as me, I won't see any grandchildren for another thirty years. My old high school friends by then will be posting pictures of their great grandchildren. Why do we do this to ourselves? Is it for prestige? Is it for the money? The way the political climate is blowing, we'll have neither in the near future. Can we really say we have more satisfaction treating sick patients rather than starting a loving family of our own? These are all points to consider if my children ask me whether they should follow my footsteps and go into medicine.

Tuesday, October 6, 2009

Make mine monkey ass red

This one is just too funny. From Autoweek, a report on Toyota's new concept sports car.

“Sports cars have to be red, but we wanted a new red,” chief engineer Tetsuya Tada said. “So we came up with shoujyouhi red, the traditional red color of a Japanese monkey's” backside.

Somehow I don't see Americans ordering their sports cars in the shade of a monkey's butt.

Monday, October 5, 2009

The hospitalist will be happy*

An op-ed in the Wall Street Journal details how the health care reform bills will punish medical specialists will helping the primary care doctors. It is widely believed that primary care physicians in this country are grossly underpaid relative to their specialist colleagues. Thus very few medical students, 5%, report wanting to go into primary care. But if everybody gets health insurance, there will be an acute shortage of doctors to take care of all these new patients. So the reform bills will increase reimbursements for primary docs.

But the pool of money is static. Thus reimbursement will be a zero sum game. If primary doctors get more money, somebody else will get less, much less. The article details some of the proposals, highlighting cardiology and oncology specialties. In 2010, cardiology will receive 11% less money while oncology will get 19% less. Echocardiogram reimbursements will fall 42% and cardiac catheterizations will drop 24%.

I shudder to think how much less anesthesia will receive. We already get less from Medicare than nearly all specialties. On average anesthesiologist are reimbursed only 33% of private health insurance payments versus 80% for other medical fields. Maybe anesthesiologists can reclassify themselves as the internists of the operating room, which we are. Then we can convince Congress to reimburse us better.

*With all due respect to A Happy Hospitalist.

Thursday, October 1, 2009

This is a healthy Michael Jackson?

From the Associated Press:

"The [autopsy] report says Jackson's arms were covered with punctures, his face and neck were scarred and he had tattooed eyebrows and lips. But overall he was a fairly healthy 50-year-old."

Arms covered with puncture marks with neck and facial scarring (from previous surgeries?) don't sound that health to me, regardless of age. Yuck.