Monday, March 28, 2011

Public Transit In L.A. Not For Most Private Citizens

Don't know about the rest of you, but gas prices here in California have been skyrocketing. The local stations are now selling regular gasoline for over $4.00 per gallon and premium gasoline for over $4.25. Darn you Mideast unrest and Chinese economic boom. So you would think that people would be stampeding toward their closest bus or train station to ride the public transit, right? Well, not so fast.

I calculated the time it would take for me to use public transportation to travel from my house to my hospital. A nifty little free website called Google Transit calculates your bus route from your home to your destination based on actual bus routes in your city it possesses in its records. I live about 25 miles from my work. Some of you may blanch at that commute. But here in L.A. it's par for the course. In fact I know some people who drive over 50 miles each way to get to the hospital every day. Why do we do this? First of all out in the suburbs we get a lot more for the money compared to central L.A.: more housing, more land, more parks. It is just a better quality of life. The second important reason is the public school system is much better. The only doctors I know who live close to my hospital are either older doctors who bought their houses decades ago when housing was still reasonable and doctors' salaries were multiples of what they earn today, or they have kids who attend expensive private schools while living in small, congested bungalows. Not exactly the kind of situation that would make your parents proud they raised a doctor.

How long would it take for me to take public transportation to get to work? I entered my home and my hospital addresses in Google Transit. I thought maybe, just maybe, if the public transit was reasonable I might try it just once. I entered my arrival time at the hospital as 6:30 AM, which is reasonable for my 7:00 AM O.R. start time. In less than a second, the program had an answer for me: one hour and 58 minutes! Are you kidding me? First of all, it instructed me to walk to the closest bus station from my home, 28 minutes away. Then I had to ride two separate bus lines, each one with over thirty stops each. Finally the last stop still left me short of the hospital by about two blocks. Yikes. Therefore to get to my work on time, I would have to leave the house by 4:30 AM, walk in total darkness for half an hour, then endure over sixty bus stops along the way before I have to schlep the last half mile to work. Thanks but no thanks.

Los Angeles has never been a subway or busing city like Washington or Manhattan. All the work are located where people can't afford to live and all the housing are where companies don't want to locate. This is why my next car is going to be a hybrid. Now if I can just ask the government to give me a raise by increasing our reimbursement rate...

Saturday, March 26, 2011

Bleeding Heart Cake

From the Hannibal Lechter department of baking, here is a bleeding heart cake in all its oozing, hemorrhaging glory. It was being sold by Lily Vanili for a good cause (pediatric cancer). It is unfortunately sold out. Maybe if you call her and begged hard enough she will bake some more. If not, she helpfully provides the recipe. It would be perfect for your next cardiac anesthesia Halloween party or Tea Party gathering. Now go eat your heart out--sorry I couldn't resist

Friday, March 25, 2011

Want To Know Why Anesthesiology Is Such A Popular Field? Try $5,000 Per Hour

L.A. Times columnist David Lazarus recently wrote about an outlandish hospital bill from one of our local premier hospitals, Cedars-Sinai Medical Center. One of his readers sent him her hospital bill after she had a laparoscopic assisted hysterectomy at the facility. She was in the hospital for about four hours, with probably only two of those hours actually in the operating room. Her charge from the hospital came to over $65,000.  Granted the hospital she went to was Cedars, on par with some of the best hospitals in the country like Brigham and Women's or Mayo. Still $65,000 seems excessive. For comparison, a study in 2007 at Thomas Jefferson University Hospital in Philadelphia showed the total hospital charges for a hysterectomy there average $5,707.

Now this was the upfront fee. Through her insurance company the charges were cut by 50% while the patient herself only had to pay $800 as her deductible. She herself has no quibbles about either the hospital or the insurance company. She just wanted the world to know about the dystopian world of medical billing in the America.

The interesting aspect about this article that fascinated me was the breakdown of the hospital charges. For a four hour stay, she was billed over $35,000 for the operating room, $13,000 for OR supplies, and get this, over $10,000 for anesthesia services. Ten thousand dollars for a case that may have required two hours of operating time. Even if the anesthesia bill was reduced by half like the rest of the hospital charges, the anesthesiologist made $5,000, or $2,500 per hour. Not bad for two hours of work on what sounds like a healthy patient. A few more cases like that and this anesthesiologist will be able to make his house and Porsche Panamera payments with only one day of work. Of course most anesthesiologists don't get the money they bill. Only people without insurance actually face the full charges and those are the patients least likely to pay any of their medical bills. And after deducting expenses like insurance and office overhead the take home pay is much much less than this. But still the amount on this lady's hospital bill is breathtaking.

Anesthesiology IS the ROAD to success. Congratulations to all those medical students who recently matched into an anesthesiology residency. You're well on your way to being the envy of the operating room.

Dream Dashed

My fantasy of buying the perfect Porsche has been dashed. At the Geneva Auto Show last year, Porsche displayed the 918 Spyder Hybrid. It is a Porsche with 500 HP that also gets 78 miles per gallon. I described it as a "dream". I certainly wasn't living in this reality. I unrealistically hoped the car would be affordable even for a physician. Now the reality has struck me with a giant two by four on both cheeks, and all cheeks.

At this year's Geneva Auto Show, the company has announced the price for this environmentally conscious Porsche--$845,000.  As a bonus, Porsche will allow the buyer to purchase a special limited edition Porsche 911 Turbo S for the exclusive price of $170,000. Who can pass up such a deal? Despite the public's perception that all doctors,especially anesthesiologists, are fat cats, I don't know of too many physicians who have the discretionary income to afford this car. In fact, the only medical people who can buy cars like this are hospital administrators and their ilk. Surely the CEO of New York Presbyterian Hospital, 2007 salary of  $9.8 million, can purchase this car. If he is reading this, let me just say that donating a car shows generosity of heart, even if it is given to little ole me. I'm just saying.

Thursday, March 24, 2011

Please Call Me Z

An interesting commentary appeared in the Wall Street Journal the other day. The author wrote about the difficult experience of calling her previous superiors by their first names as a rite into adulthood. Reading the article brought back awkward memories for me too. Medicine is a very hierarchical profession, almost equivalent to being in the military service. Not to disparage anybody, but at the bottom of the pyramid are the interns (medical students are actually held in higher esteem because attendings want the students to like their particular field and encourage them more so than interns who are already captive). One step up is the resident followed by the senior resident, and depending on your specialty, the Chief resident, Fellow, and finally the Attending. Everybody has his place in this business. Attendings are always addressed as Dr. So and So. The residents relax and talk shop with other residents. The interns are too busy (at least in the old days) to fraternize with anybody except their own.

The awkward moment comes immediately after completing the residency. You're suddenly a full time attending of your own. The instructor you have always addressed as Dr. So and So can now be called by his first name. But for me it felt extremely uncomfortable to do that. Some other residents who were bolder or had social interactions with their attendings outside of work or were more blatant brown-nosers seemed to transition through this quite easily. For me, I literally had to spit out the first names of my new colleagues. I had to remind myself every time not to call them Dr. So and So and talk to them as an equal, which was expected. It was a difficult transition. I even had to learn to call the Chief of my department by his first name. After of 20+ years of education, where I've always called a superior by a title, now there are no more titles. I am the Man. Now if I can just convince my wife and kids to treat me as the Man, not as their Workhorse.

New "Tourists" In Los Angeles

One of the bedrock industries in L.A. is international tourism. We have folks from all over the world here visiting Hollywood, Disneyland, Venice Beach, etc... Now we learn there is a new tourism industry that has sprung up. It is called "birthing tourism". Some entrepreneurs in the San Gabriel Valley suburb of L.A., which is predominantly Asian, have set up private residences for women from Asia to give birth so the child can be automatic American citizens.

In this particular case, people in this quiet part of town were wondering why there were suddenly so many pregnant women in their neighborhood. When the police raided the nice looking townhouse, they saw ten women sitting around having dinner while seven newborns were laying in bassinets, being taken care of by a nurse. The police fined Dwight Chang, the property manager, $800. They could only fault him for remodeling the townhouse without the proper permits. After all, giving birth in a private residence isn't illegal, even for the purpose of delivering an anchor baby. Capitalism at its best--find a need and fill it. And make a profit out of it if possible.

Saturday, March 19, 2011

How You Know Your Wife Loves You

Here on the West Coast, we are dealing with radiation fallout from the stricken nuclear power plants in Japan. There has been a run on iodide pills and face masks. At least we haven't reached the level of panic where people are stockpiling iodinated table salt like they are doing in China. Some outdoor activities have been curtailed because of parents' concerns about exposing their children to falling radioactive particles.

My dear wife has gotten caught up in this hysteria. Though the amount of radioactivity from Japan has been officially described as minuscule, she has decided to stock up on emergency supplies in case the family can't go out due to more radioactive contamination or a major earthquake. And guess what she bought to prepare the family for the apocalypse?  Just my favorite snack of all time--a big giant box of Cheez-Its. And the funny thing is that is the ONLY food item she got. No canned items. No dried goods. Oh, she did get extra bottled water. You have to wash down the Cheez-Its with something. That my friends is true love.

Thursday, March 17, 2011

Surgeon's Pet

I was on call when I was asked to go do a routine case. At least on paper it sounded routine. Upon further inspection the patient was quite sick and warranted further medical workup. Though I will give anesthesia to virtually anybody, I had to balk at this case. I strongly expressed to the surgeon, whom I rarely ever work with, that the patient needs more workup in order to undergo a safe anesthetic. The surgeon was not amused. He was outraged that I was holding up the case when he and the patient's primary care team had already discussed and agreed to the procedure. I calmly reiterated my cautionary stance with this patient. He then told me he will find an anesthesiologist who will do the case and hung up the phone. Later I found out the surgeon found an anesthesiologist he works with frequently. That anesthesiologist, despite obvious contraindications for surgery, proceeded with the case and the patient did well.

What does this episode illustrate? Is anesthesia so safe nowadays that it can be given to anybody at anytime with little consequence? No. In my mind, it tells me that some anesthesiologists will do cases for "their" surgeons despite our duty to be the patients' advocates. I think it's part of human nature. Probably all anesthesiologists have at some point done a case for their favorite surgeon when it was against their better judgement and certainly not what they would do if the case was an oral board question. It's like the good friend you have known for years who suddenly wants to borrow money from you to start a small business. Against your better instinct you do it anyway, hoping and praying everything turns out well and nobody (especially you) gets hurt in the end.

While surgeons love the loyalty of their pet anesthesiologist, guess what happens when the turd hits the fan. The pet is suddenly left out in the cold, at the mercy of the lawyers and insurance companies that come looking for the criminal doctor who messed up the patient. What will the good buddy surgeon say when the attorneys come knocking at his door? He will point the finger straight at the anesthesiologist. "He said it was okay to do the case," will be his deposition.

It took me a few years of practice to understand this relationship with surgeons. Life is too short to be worrying about what the surgeon thinks of your anesthesia skills. No amount of money is worth the heartache and guilt when the patient crashes on the OR table, or worse, in the Recovery Room. Like a good friend who has your back, a good surgeon will never pressure his anesthesiologist to do a case against his will. If there is any arguing with the surgeon, it is probably best to resign yourself from the case and have him call for his pet, I mean, anesthesiologist. Hopefully, if they have any integrity at all, they too will deem the case not acceptable to take to the OR and the surgeon will finally realize we are all looking out for the welfare of the patient.

Tuesday, March 15, 2011

Who's Next?

2/27/10 Bio-Bio, Chile. Magnitude 8.8

9/4/10 Christchurch, New Zealand. Magnitude 7.1

2/22/11 Christchurch, New Zealand. Magnitude 6.3

3/11/11 Sendai, Japan. Magnitude 9.0

Anybody notices a pattern here? Three corners of the Pacific Ocean have been struck by severe and deadly earthquakes in the last year. Guess which corner is long overdue for a major one of its own?

Monday, March 14, 2011

Not So Evil Anymore

Many of you read have read my rants against my evil iPhone. In my mind, the iPhone was a method by which the messiah Steve Jobs ensnared his victims into the world of Appleology. All the technology geeks out there who bemoaned the monopolistic practices of Microsoft suddenly couldn't get enough of the tightly controlled ecosystem that is the iPhone and iTunes. The Jesus Phone appeared to be a device by which the weak minded go trapped into its cult. I shuddered at what I was getting myself into. Would I soon be brainwashed by this technologic orthodoxy and start knocking on strangers' doors to convert the heathens to this new religion?

But now I've changed my mind. The iPhone isn't merely a really bad cell phone with a great ability to waste away your day playing Angry Birds. (Full disclosure. I did download that game, but only the free versions. I'm not about to give more money to the high priest.) But I've discovered apps that can actually save me money. I found an app that can download books for free. Now these books are only in the public domain, ie/ before 1923. But that covers a lot of territory. So if you ever wanted to revisit your Western Literature class in high school, this is the perfect program. I've read books by Lewis Carroll, Arthur Conan Doyle, and Edgar Allen Poe since I've downloaded this program. I never have to buy another paperback anymore if I want to catch up on my literary classics. At about $10 per paperback, my savings are really adding up. Anna Karenina or Romeo and Juliet anyone?

I've also found the iPhone to be the best babysitter. You see it everywhere you go. At restaurants, children no longer take part in conversations at the table. They're all staring down at their iPhone/iPods playing games or texting each other. I've converted my DVD's into the iPhone format. Now the kids can watch Cars, Toy Story 3, and any other of their favorite DVD's at home and watch it outside when I need some peace and quiet. I normally wouldn't condone this sort of activity but sometimes we all need just a few minutes of respite from the whining and complaints that accompany small children when they go out..

So here's another paean to the Almighty Mr. Jobs. My iPhone still gets awful reception at my home. But its other uses makes it completely indispensible. Goodness I hate you for that.