Wednesday, January 19, 2011

Work, Slave!

There is an interesting legal case from California that has just been accepted by the U.S. Supreme Court for a hearing. As most people know, California has a horrendous budgetary problem; we have run out of money. The state budget currently has a $25 billion deficit. To help resolve this, the state government has made major cutbacks to nearly all programs, including Medi-Cal, the state's Medicaid program. Our new governor, Moonbeam Brown, has proposed another 10% cut to the program, or over $700 million. A group of doctors, including the California Medical Association, sued the state, saying state cutbacks will deny poor people access to health care, which is contrary to the mission of the federal Medicaid program. The state says the doctors do not have a right to bring legal action. They claim doctors have NO RIGHT to a particular reimbursement from the state. So far the doctors have won in the lower courts. However California is appealing on the basis of state sovereignty. They say federal courts are interfering with a state's individual right to set its own budget. The Obama administration has directed the U.S. to respect the lower courts' rulings and stay out of the debate.

This highlights the terrible dilemma doctors have in this country. Obamacare is inching ever closer to reality. Along with it will be a flood of over 30 million new patients who will get Medicare level health insurance. Doctors are expected to treat all these new patients but according to the state they will not be allowed to challenge the reimbursements they receive for the care. Instead the money, if it comes, will be set by fiat in legislative chambers filled with lawyers and insurance lobbyists. So let's see, we'll have more patients to treat, with possibly lower reimbursements, with no recourse for protesting the meager payments, while our business overhead like staffing, insurance, rent, and supplies continues to rise. Doesn't sound like a good business opportunity to me. I hear Government, I mean General, Motors is hiring again.

Tuesday, January 18, 2011

Doctors Are Afraid Of Pretty Women

Forget what you may have seen on Gray's Anatomy. Male doctors are in fact scared to death of pretty female patients. I've noted this reality many times. Whenever there is a young good looking female patient in the procedure room, suddenly it is mandatory to have a female staff member also present. It doesn't matter if the patient says she's comfortable with having an all male staff inside, the procedurist will insist on having a female nurse or tech in the room at the same time for nothing more than a figurehead.

I understand this is all to prevent possible future litigation (thank you malpractice lawyers for increasing staffing costs), but this same wariness doesn't seem to apply to older women. Somewhere after the age of forty, female patients suddenly don't instill the fear of sexual harassment lawsuits anymore. We can bring a middle aged or elderly woman into the room and there is nary a consideration for having a female staffer present. It appears that doctors are not afraid of older women bringing a lawsuit against them. Is this age discrimination? Do physicians not find older women attractive enough to harass? Or do doctors think juries are unlikely to believe they would harass an older woman?

One last observation. I've never noticed a female doctor feel the need to have a male figure in the room if there is a male patient and an all female staff, which is not as uncommon as you might think. There are plenty of female procedurists and anesthesiologists these days along with still plentiful female nurses. I guess sexual harassment only works one way.

Friday, January 14, 2011

Why It's Better To Be A Doctor Than A Lawyer

In a word, jobs. According to a scathing article in the New York Times, the vast majority of law school students graduate with virtually no job prospects befitting a lawyer. Only the top graduates from the highly elite law schools will be hired for the advertised average salary of a first year lawyer of $160,000. Most everybody else will take temp jobs proofreading legal documents that pay $20 per hour with no benefits. Or they take menial jobs not in the legal field. Or move back in with mom and dad. All this after accumulating hundreds of thousands of dollars in student loan debt with little immediate prospect for repayment.

How did this happen to this once proud profession? The article lays the blame on the American Bar Association and U.S. News and World Report. College students scrutinize U.S. News for its ranking of law schools every year and notice that most of them say over 90% of their graduates are employed nine months after graduation. In these times of economic turmoil this sounds like going into law is a sure ticket to employment. What the readers don't recognize is that being employed is not the same as being a lawyer. If somebody is working at a McDonald's drive through window nine months after law school, they are considered gainfully employed. There is also a certain bias in this statistic. The information is strictly voluntary from the former students. Therefore those not employed at that time are less likely to report back to the school for the survey. Who allowed this charade to happen? None other than the ABA. U.S. News is simply following the statistical methodology as established by the ABA and they don't feel the need to change it unless the ABA makes the first move.

This is not a sudden revelation. There are multiple blogs established by unemployed lawyers complaining about this deceit. So why not close down a few dozen law schools to tighten up the supply of lawyers and boost employment? After all, doesn't the ABA grant accreditation to open up law schools? As it turns out, it is much easier to open a school than to close one down. The ABA says there are antitrust issues to closing schools. After all, whose to say which school deserves to remain open and which ones should close. While everybody recognizes that Harvard Law School should stay, what about a small school like McGeorge School of Law at the University of the Pacific, also ABA accredited? Therefore the ABA is throwing its hands up at the whole issue.

By comparison, there truly is a shortage of doctors in the country, now and into the foreseeable future. According to the Association of American Medical Colleges, there will likely be a deficit of 150,000 physicians in the next fifteen years. The shortage extends to anesthesiologists too, with an estimated deficit of 12,500 by the year 2020 according to the RAND Corp. If there is such an obvious need for more doctors, why doesn't the laws of supply and demand step in to fix this? Simple. Medicine in this country doesn't follow market principles. The federal government controls how many doctors are trained by decreeing how much money they will give to support medical schools and residencies. Right now there is talk of opening more medical schools to train a new army of primary care doctors in preparation for the onslaught of Baby Boomers hitting the retirement age. But Medicare has not allocated more money to open residency positions for all these doctors to continue their training after graduation.

Isn't it ironic that the government knows full well we need more doctors but won't supply the money for them? Yet this institution of lawyers, along with the ABA, can do nothing to stop the oversupply of law school graduates flooding the economy, wreaking havoc in its wake and causing untold suffering to thousands of bright young legal minds. Is it any wonder we have legions of lawyers trying to chase down every possible class action lawsuit, car accident victim, and frivolous malpractice case?

Thursday, January 13, 2011

Down The Rabbit Hole

Most people consider hospitals to be places of sanctuary. By definition, a person should expect to be admitted into a hospital with an illness and be discharged later at least as well as, if not better than, before. That is the entire function of a building which houses a large population of healthcare workers and a sizable collection of multimillion dollar medical equipment. But we doctors know better. We have seen too many cases where patients innocently arrive with an innocuous problem and don't leave quite the same way, if they are able to leave at all.

I remember a sad case in preop. While perusing through the patient's massive ICU chart, family members tried to fill me in on everything that happened to her during this admission. The patient was admitted over three months prior with a simple diabetic foot infection. Actually more like a toe infection according to them. What was supposed to be an admission lasting a few days for IV antibiotics turned into a nightmare of multiple vascular surgeries, renal failure requiring hemodialysis, massive decubitus ulcers, respiratory distress necessitating a tracheostomy, altered mental status, constant IV sedation, isolation precautions for hospital acquired infections, and on and on. The family members understandably were bewildered by how quickly the patient had deteriorated to practically a stranger they no longer recognized.

"How could this happen? Will she ever be the same again?" they asked me in vain. I tried to be empathetic and reassuring. I explained that once the human body starts healing it can be amazing how well it returns to its previous state. Maybe this one last operation will start her on the road to a healthy recovery. I knew that was something they needed to hear but deep down I recognized that this would be a very long and arduous course for the patient. With all the medications, infections, organ damage, and prolonged sedation, the odds are against her for a complete recovery. She will most likely be discharged one day, maybe even back to her own house. But she will probably never be the same again, physically or mentally. There will always be a scar left behind from the side effects of modern medicine. With an encouraging smile, I asked them to keep their hopes up and pray for a good outcome. We then wheeled the patient into the operating room.

Friday, January 7, 2011

Irresponsible Hollywood

Is that title redundant? With all the stories coming out of Hollywood involving months-old marriages dissolving into "amicable" divorces, drug overdoses, and revolving door rehab visitations, does anything involving Tinseltown surprise anyone? Living in Southern California I thought I was pretty immune to the tastelessness of what passes for pop culture here. Then all these posters advertising a new movie started popping up  town and my respect for Hollywood dropped to a new low.

It's bad enough that it shows a half dressed young couple either about to get into bed or are just finishing up a tryst and getting ready to leave. But the tag line on the billboards reads, in six foot tall letters, "Can sex friends stay best friends?" Attempt at humor and intrigue I presume. But how do I explain to my young daughter when she sees these billboards from her car seat and asks, "Daddy, what are sex friends?" Hmmm. There is nothing I can say at the spur of the moment that can answer that question without getting into the details of the birds and the bees, which I am not prepared to give at that moment, or the next ten years. So I ignore the question and turn up the volume on the DVD player. Then the ubiquitous poster reappears a few blocks down the road and she asks, "Can my best friend Rachel also be a sex friend?" "No honey. Don't look outside anymore. Just watch your movie." is all I could come up with. I fast forward the DVD to her favorite part where Cinderella is about to put on her glass slipper.

However she has zeroed in on my discomfiture and can't let go. She repeats herself, "Daddy, what are sex friends?" Sigh. Now I have two options. One is to be straightforward and give her the unvarnished truth about sex. The other possibility is to dumb it down and use euphemisms like "when two people fall in love..." Being a physician, I recite the driest and most clinical explanation of sex that's appropriate for a primary schooler. "Honey, sex is when a man and a woman get together when they want to make babies. They are usually best friends when they make babies." I suck in my breath and hold it for what feels like an eternity, waiting for another equally uncomfortable follow up question. But she says nothing. She seems satisfied with that unemotional, dispassionate answer. She goes back to her TV and squeals with delight when Cinderella marries Prince Charming and rides off in the horse drawn carriage. Whew. Now I only have ten more years to think of a proper explanation for sex friends.

Wednesday, January 5, 2011

I Want That!

For gearheads and electronics junkies like myself, the Consumer Electronics Show currently going on in Las Vegas is like a second Christmas. It's a nonstop display of all my aspirational purchases for this new year. So far I haven't been terribly impressed with all the new 4G Android smartphones (more speed, bigger screen, same old horrible cell phone reception) or tablet computers (Yawn. Hard to make a rectangular piece of glass interesting).

But this picture really caught my eye. It's a 17 inch display screen in the new electric Tesla S sedan coming out in 2012. The size of the screen is just outrageous. It is powered by an Nvidia 8-core processor capable of generating HD quality video. The same processor also powers the 12 inch screen that will display the virtual instrument panel.  Notice with the portrait arrangement it would be a perfect shape for surfing the web. How about watching HD video on the top half while still having access to HVAC virtual controls below that? This is awesome. I want that!

The Cardiologist Who Did Not Know CPR

As the evidentiary hearing for Dr. Conrad Murray in the Michael Jackson case continues, we are hearing more sordid details about what happened in the minutes after the singer died. We are learning that the doctor delayed calling 911 after discovering the unresponsive body in the bedroom. According to phone records, Dr. Murray did not call 911 for anywhere from 9 to 21 minutes after he stopped talking on his cell phone while Mr. Jackson lay dying in bed from propofol induced apnea.

Dr. Murray then called the security guards to the room and asked them how to perform CPR! I guess he hasn't gone to an ACLS class in quite some time. The guards just looked at each other with incredulity. He then attempted to perform CPR by, as one guard described it, using only one hand while using the other hand to balance himself on the soft bed. Meanwhile the children were standing in the doorway of the bedroom watching the whole episode. He then lied to Mr. Jackson's kids by saying he had a allergic reaction to the medicines, asking them for a list of Michael's allergies, which surprisingly they were able to recite to him.

Before the paramedics arrived, he ordered the guards to clean up all the bottles of drugs laying around the bedroom and in particular some special "cream" that he said Michael would not want the world to know about. Once the paramedics came, he continued his story about a drug allergy causing Michael's unresponsiveness without ever mentioning that he was given propofol.  He went with the ambulance to UCLA but did not stick around long enough for the emergency doctors to question him about Michael's medical history. He did not reappear for two days until he had a chance to speak with his lawyer. Ugly, ugly, ugly.

The defense attorneys are now saying that maybe Michael killed himself. There are reports that two syringes of propofol were found next to the bed. One was given by Dr. Murray and the other one supposedly has an unidentified fingerprint on it. They theorize that perhaps Michael woke up while Dr. Murray was gabbing on the phone in another room and injected himself with the propofol in the other syringe. It's always so much easier to blame the dead who can't defend themselves. This does not excuse Dr. Murray from negligence in pushing an anesthetic that should not have been given outside a medical facility in the first place then promptly walking away while his patient was unmonitored. Then this "doctor" didn't even know how to perform life saving resuscitation on his own patient. Did he think he was just going to collect $150,000 a month from Mr. Jackson by doing nothing except pushing propofol every day into the singer's veins? This needless death gets more tragic with every shred of evidence presented.

Messy Anesthesia Cart

There are few things more annoying to me than walking into the operating room and finding somebody's mess all over my anesthesia cart. I feel it's the equivalent of going into the restroom and finding somebody had soiled the toilet seat and didn't bother to clean it up. Or sitting down at a restaurant and finding food bits still stuck to the utensils. Yuck.

Look at what some thoughtless anesthesiologist left on my cart the other day after he finished his case. There's a half used syringe of propofol, a half dozen used needles scattered haphazardly around the cart top, multiple bottles of used drugs, and a heating pad for God knows what body part he was trying to relieve his aches and pains. Disgusting. This is not as bad as other hospitals I've worked in. I'll always remember one place where I found syringes of unused narcotics and benzos still sitting unattended on the cart. You talk about a drug addict's paradise.

Our OR cleaning crew have been told specifically to never touch anything on the anesthesia carts. Therefore it's up to the anesthesiologist ALONE to clean up his own mess. So if you're an anesthesiologist reading this, please clean up after yourself. I know you can do it. You managed to go through college, medical school, and residency so you must have some level of personal responsibility. You wouldn't leave this kind of mess for your spouse to clean up at home so why would you disrespect your colleagues by leaving this repulsive, and dangerous, trash heap on the anesthesia equipment? Clean it up. Don't make me call your mother.

Tuesday, January 4, 2011

Wanted: BC/BE Anesthesiologist. Intubation Skills Optional

What is the most important function of an anesthesiologist? Is it the ability to start an IV? How about the capacity to push a syringe of propofol? I would guess that to most people, including most doctors and nurses, an anesthesiologist is the physician who is the professional who is most proficient at intubating a patient. So is an anesthesiologist really an anesthesiologist if they are not capable of this simple but vital task?

At our surgery center, we mostly perform cases under MAC. They usually involve endoscopies or simple nips and tucks that do not require general anesthesia or intubating patients. Anesthesiologists may not intubate a patient for months at a time.  As a consequence, some of the veteran anesthesiologists here have intubating skills that are best described as rusty. They actually find it easier to use a fiberoptic scope to place an endotracheal tube than to use a regular laryngoscope.

Now don't get me wrong. Their preop skills are superb. They've had years of experience dealing with severe medical issues like morbid obesity, critical aortic stenosis, or severe coronary artery disease and how that might affect their anesthesia. But if during the course of the procedure the patient suddenly requires an emergent intubation these anesthesiologists are stumped. I've personally had to rush into the room to assist a colleague when they've lost the airway. Usually the laryngeal view is a Grade 1 or 2. In other words, an easy intubation for any anesthesia resident. They thank me profusely and I tell them it's no big deal.

Does that make them any less an anesthesiologist? Does the physical skill of intubation trump the analytical skill of evaluating and minimizing a patient's anesthesia risks? Should all anesthesiologists have to demonstrate the capability to intubate a patient safely while under duress every couple of years as part of their CME? Would you want a doctor like this to administer your anesthesia?

Monday, January 3, 2011

Dear Dr. Harris

Dear Dr. Harris,

As the newly elected representative from Maryland and the first anesthesiologist to serve in Congress, we in the anesthesiology community are rightfully proud of your already historic political career. If anything, you prove to the naysayers (surgeons) that anesthesiologists have more intelligence and drive than just passing gas and reading the stock charts on 

However you've already had an inauspicious start to your budding political aspirations. Your actions at the Congressional freshmen orientation have caused doctors around the country, and particularly the anesthesiologists who supported your campaign financially, to cringe with embarrassment. According to Politico, you complained at the meeting that it was outrageous that healthcare benefits for new members of Congress don't kick in until a month after swearing in. This smacks of extreme arrogance and cluelessness in how many Americans receive their health benefits, if they have any at all.  Do you not have any health insurance from your previous job that can carry you over until February? Could you not buy COBRA insurance to cover you for the one to two months you are between jobs on your way to taxpayer funded health insurance nirvana? This is the same single payer system that many people in this country feel we should all be allowed to access in the first place instead of the insurance industry monstrosity that currently exists.

How are you going to explain to your constituents your opposition to Obamacare with its mandate that insurance companies have to insure people whenever they ask for it regardless of preexisting medical conditions when you yourself seek the same benefits? Do you realize you just personified to the general public their suspicions that doctors and politicians are not "regular people" but live in a different caste system, far removed from their daily troubles and concerns? How do you explain to all the anesthesiologists who supported you financially to the tune of $250,000 this shameful lack of public relations savvy for somebody who won a national political office?

Don't get me wrong Dr. Andy Harris. We anesthesiologists still hold extremely high hopes for your political endeavors. We know you will do the right thing by helping anesthesiologists correct Medicare's subpar payments to anesthesiologists and achieving the holy grail of doctors in this country, the abolition of the Sustainable Growth Rate formula that is in fact a Unsustainable Diminishing Rate to physicians. We are going to follow your career more closely than other Congressman because, well, you are one of us. Besides the people of your district, you also represent what all of us wish we could do, make a difference to society and create a better nation as a result. Now that you've learned your lessons in the perils of national political office, go out there and make us proud.