Wednesday, January 26, 2011

Why Spend Your Own Money When Somebody Else Will Pay?

A hospital employee approached me the other day and asked politely if I would sign a prescription for him. I've worked with him for years and know him to be a decent honest guy who wouldn't abuse this courtesy. I looked at the prescription form that he had already filled out which only required my signature and medical license number on the bottom to complete. When I looked at the medication he had written, I was surprised. It was for a very common over the counter pain medicine. It wasn't the usual antibiotics or prescription strength pain meds or muscle relaxants that most people ask for.

I looked at him and asked, "Why do you need a prescription for this? Can't you just buy this at the pharmacy or supermarket? It shouldn't cost much more than $5." His reply says a lot about the state of the health insurance industry in America today. He said he needed a documented prescription filled out by a doctor so that his health insurance policy will pay for it. Otherwise he will have to pay out of pocket for the medication.

Now I can't really blame the guy for working the system. Isn't that what all smart consumers are supposed to do, milk the process for every last penny? If his insurance policy will pay for his drugs, even generic OTC meds, why should he pay for it himself? Does it matter that such behavior eventually drives up the cost of health insurance premiums for everybody? If Joe next door is doing it, why should Bob have to pay higher premiums without getting his fair share? Though it makes as little sense as your auto insurance policy paying for your gas, patients in America will be damned if they have to pay out of pocket one single cent more than necessary for their healthcare. If the government is demanding that insurance companies cover mental health services, obstetric services, physical therapy and chiropractic services, and every other global desire that few will actually use, further driving up insurance costs, why shouldn't I take advantage of it to the fullest extent possible?

Yeah I signed his prescription. Though I shook my head at the absurdity of these arcane rules set up by the insurance companies, who am I to deny my friend his right to his cut of our country's $2.5 TRILLION health care industry?

Prescribing For Friends

It's inevitable. As a doctor, you'll be sitting there minding your own business when a hospital staff, friend, or family will sheepishly approach you and ask, "Do you mind if you fill out a prescription for me?" It's always an awkward moment for me. Since I have a medical license number, I can easily make a prescription without much fuss. But should I?

Now I would never fill a prescription for any narcotics, something that would immediately send up a red flag to the DEA and the state medical board. However people have asked me to prescribe drugs as diverse as antibiotics, NSAIDs, and antireflux medications. Should I be doing this? Hard to say. The meds I have prescribed are pretty benign. And the requester is usually somebody I already know and not just some stranger walking into the hospital. Still, I feel a twinge of guilt every time I put my signature down on a prescription pad for somebody who isn't a formal patient. But if I don't, I feel guilty for turning down a seemingly simple and innocuous request from a family or acquaintance. How can I refuse somebody who maybe coming to me with an ear infection and asking for some antibiotics? Isn't that an act of compassion? Is my trepidation of writing a prescription due to real concerns about the possible side effects the antibiotics may cause or is it just fear of the possible consequences from the medicolegal system? Should I just flat out refuse everybody a prescription request and risk their ire and disappointment? There doesn't appear to be any good answers for this common dilemma.

Tuesday, January 25, 2011

MOCA For Everybody

Seems like I'm not the only one who has concerns about the ability of aging doctors to do their jobs. I recently posted about older colleagues who have difficulty intubating patients, the cornerstone of anesthesiologists' responsibilities. Today the New York Times has a lengthy article about senior doctors who are not mentally or physically fit to treat patients safely.

The article talks about old surgeons who are incapable of operating or internists who are too confused to manage their patients but refuse to retire. It mentions that there are no protocol for forcing a doctor to stop working. While airline pilots have to take a competency test every six months after the age of 40 and mandatory retirement at 65, no such rules apply to doctors. One medical group was concerned enough about the abilities of one of their colleagues that they requested he retire. Only they didn't have the guts to tell him directly so they held a retirement party for him as a hint. The trouble was the colleague ignored their farewells and kept right on working. It took the intervention of an outside consultant to step in and gently but directly confront the doctor about his need to retire.

The general population probably doesn't realize that older doctors probably haven't cracked open a journal or textbook in years. Thanks to their peers at their respective medical boards, the older generation of doctors have all been grandfathered into lifetime board certificates while we younger generation are forced to recertify periodically, every ten years for anesthesiologists. It's ironic that the ones with the most current medical information has to retake a test every ten years while those who haven't been to school in decades can just coast until they wish to stop working. Sure the senior doctors have to take some CME courses to maintain their state medical licenses. But most people don't know that the state medical boards don't care what CME you're taking. You could be an anesthesiologist and take a CME course in Hawaii on skin psoriasis and it would still count towards the license requirements.

The article is correct in that doctors protect their own and are reluctant to force a colleague, and friend, out.  The physicians who are the heads of their medical groups are also from the older generation, most likely having worked with their impaired colleagues for decades. They can have trouble firing one of their friends, and possibly seeing their own professional mortality in the process. I could tell horror stories about the complications caused by anesthesiologists who should have retired ten years ago but which are glossed over by management whereas a younger anesthesiologist with similar complications are raked over the coals or fired.

The solution to this problem is to take retirement out of the hands of the physicians. Since doctors seem incapable of policing themselves, they need an objective unemotional method for weeding out the bad apples. A psychological analysis for mental competency may be too subjective. An arbitrary retirement age will discriminate against doctors who are still highly productive. But if all doctors are required to take periodic board recertifications to prove their abilities, that would take the agony of forcing a doctor to retire out of the hands of their friends. Are you listening American Board of Anesthesiology? MOCA recertification for every single anesthesiologist, regardless of when they finished residency, would help ensure that every anesthesiologist in this country is competent to safely administer anesthesia to patients and gently ease the incompetent ones out. This idea should be one more to consider since we consider ourselves "Leaders In Patient Safety."

Sunday, January 23, 2011

When Flying Was Fun

As some of you history buffs may know, Eastern was a major airline in the United States during the 1960's and 70's. Their stronghold was the eastern United States and the Caribbean. It was a highly regarded airline company at the time, right up there with TWA and Pan Am. They all eventually met the same fate after the airline industry deregulation; Eastern went bankrupt in 1989.

I was cleaning out my desk drawer in preparation for moving to our new house when I came across this little bit of nostalgia. I've had this Eastern pin for almost forty years now. It has survived several cross country moves, multiple job transfers, and family celebrations and tragedies. Looking at it and holding it in my hands instantly brought back a flood of memories of a more tranquil time not so long ago.

I must have gotten this lapel pin when I was still in elementary school. It was probably during our family vacation to Disney World in the mid 1970's. Back then it was actually fun to fly in an airplane, at least for a kid. Though all the smoking inside the cabin wasn't such a great deal, the cabin crew tried their best to keep a child entertained. There were the free sodas, snacks, and actual meals served during a flight. The flight attendants passed out pins to the kids. If you asked, she (they were all women then) would also give you a deck of cards with the airline's logo on it. Something that would be inconceivable today (thank you Osama bin Laden) the pilots would sometimes step out of the cockpit and invite a lucky few to go to the front to see how they fly the planes. If we were sitting near the front, we could look up the aisle and peer into that little room with its hundreds of round gauges, levers, and flashing lights. Oh flying was a blast.

Nowadays I avoid flying like a bad emergency C-section. Between the cattle herding, baggage check in fees, and TSA strip searches, flying on planes is more hassle than hilarity. That's one reason we went on a long road trip over Thanksgiving instead of flying. Maybe I'm just getting old, over the hill. But it seems like life in America was better back in the day.

Saturday, January 22, 2011

So You Think You Want To Move To Los Angeles

This is for all the graduating medical students and residents. You think you would like to start your career in Los Angeles, CA. You're thinking about the sun, the surf, the Hollywood stars you'll bump into at the local Starbucks. Sure it sounds great to be sipping frappuccino in January when it's 75 degrees outside. Or maybe you want to drive two hours into the local mountains for a little snowboarding action. Yes you can do it all if you live in L.A.

But there is always trouble in paradise. As any Angeleno will tell you, L.A. is not for the timid or faint of heart. If you move here you have to take the good with a lot of bad. Besides the traffic, congestion, high taxes, and air pollution, this past week illustrated some of the chaos that's inherent in living in a county of over ten million people.

Last Tuesday, a 17 year old kid brought a gun in his backpack to school in the suburb of Gardena. When he set the backpack down too hard, the gun discharged and struck two students, one in the neck, the other in the head. Luckily both will survive. This guy may not be the brightest kid in class. He brought a gun to school. Strike one. After the gun went off, he ran away into another classroom to hide, as if nobody would be able to identify him in the school. Strike two. Then it was discovered that he is on probation for assault. Strike three. Not a great start for a young life. The school was locked down for hours as police tried to search for any possible accomplices.

The next day, on the other side of the county in affluent Woodland Hills, a school police officer noticed a man conducting some suspicious activity just off the school grounds. When he approached the man, the guy shot him in the chest. Luckily the officer was wearing a bulletproof vest and survived. Again a school was locked down while police searched for the assailant. This time they were not successful.

Then the following day, a pedestrian was walking across the street in the suburb of Hawthorne and got run over by a car. The driver of the car did not stop. The body was then run over by another car which also did not stop. When a witness tried to help the victim, she too was run over by a third car. This time the driver did stop. But the crowd that had gathered at the scene starting attacking the third driver and stole his cell phone. He escaped and sped away. When he came back later to give a report to the police at the scene, he identified one of the people in the mob who beat him and the police were able to make an arrest.

So there you have it, life in Los Angeles. If you don't mind having your children in danger of getting shot in school or having the crap beaten out of you if you attempt to help somebody, this is the city for you.

Friday, January 21, 2011

Goodbye Thiopental. We'll Miss You, Not

Hospira Corp., the last remaining manufacturer of sodium pentothal, has decided to stop making the barbiturate. The company had hoped to start up production of the drug at its manufacturing plant in Italy this year. The Italian government had other ideas. Knowing the drug's reputation as a means for executing convicts in prison, their legislature decreed that no drugs made in their country can be used for executions. Hospira decided it was not worth the fight to persist in making the drug so has decided to hang it up permanently.

I for one am not the least bit sentimental about the passing of pentothal. It says something about a drug's reputation where its only viable market is for people who are about to die. But I certainly have a lot of memories of using pentothal. In the late 1990's, when propofol was already in wide circulation in hospitals around the country, our residency program director said propofol was too expensive to be used in our department. Instead we all had to use pentothal for induction. In some ways it was equal to or superior to propofol. Pentothal was just as effective in putting patients to sleep. Plus it seemed to have less cardiovascular instability in sick patients.

But its problems were legion.  The drug came as a powder form. The box it came with included a large syringe of saline that you had to mix by hand every morning. Pentothal was also caustic in tissue. If your IV accidentally infiltrated while injecting pentothal, it would cause extreme pain to the patient. Finally pentothal and rocuronium could not coexist in the same IV line. If you were in a rush to start a rapid sequence induction and pushed roc immediately after pentothal, a hard precipitate would form in the IV and you would have to change the line completely or start a new IV. This usually occurred at the worst possible moments, like putting a trauma patient to sleep.

So goodbye pentothal. You've had your run for a good long time. But somebody better has come along. Propofol is the new love of anesthesiologists' hearts and we won't be looking back to rekindle a bad relationship. As for all the prisons looking for an alternative for putting their inmates to death humanely, I say that a humane execution is an oxymoron. If your going to kill somebody in the name of justice, any method that's quick and effective will suffice. Think about it, they are not going to come back and complain about it. And it's better treatment than the convicts gave to their victims.

Thursday, January 20, 2011

When Anesthesiologists Get Bored

Top Ten things anesthesiologists do when they get bored in the operating room.

1. Peer over the ether screen and pretend to be interested in this tedious ten hour muscle flap case.

2. Change the music playlist from Billy Joel's greatest hits, to hair bands of the 80's.

3. Nosh on the power bar you had hoped to save for later as an afternoon snack.

4. Red Bull anyone?

5. Finish some CME work that needs to be sent out next week or you won't be able to renew your medical license.

6. Play Angry Birds on the evil iPhone with the mute button on.

7. Stare at Apple's stock chart in disbelief and flagellate yourself for not buying it two years ago when it was $85.

8. Update your Facebook page, leave comments on your friends' latest children/pets pictures, and wonder why your life is so much less interesting than theirs.

9. Think about your last sexual conquest.

10. None of the above. Keep your eyes and ears focused on the patient and the monitors. Vigilance is an anesthesiologist's professional duty to the patient.

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?