Sunday, April 29, 2012

Thinning The Herd

You could call it Darwinism by EMR. In my ongoing reports on our hospital's conversion to all electronic medical records, I've mentioned some of the difficulties of adjusting to this 21st century reality. There has been much frustration and hair pulling by all as the seemingly mundane tasks of writing notes and orders on a paper chart are transformed into time-consuming chore that a few months out still require handholding by a team of software support people who roam our hallways.

Now comes word from our Chief of Staff that several doctors have had enough of this. In a recent email, he noted that a couple of dozen doctors have resigned or downgraded their status with the hospital. The ones who remain have either chosen to do consulting work only, thereby eliminating the hassle of entering computerized orders, or retired to "Emeritus" status, which pretty much is the same as resigning while still maintaining a link to the medical center (free parking in the doctor's parking lot and free breakfast with free newspapers in the lounge).

Most of the physicians who resigned were ones who were close to retiring anyways. They had few patients in the hospital and didn't have very active practices. The EMR was just the final straw for these guys, most of whom went to medical school in the 1960's and 1970's. Many didn't know how to type, much less use a computer mouse. It must have been infinitely aggravating for them to try to enter an order for "Accucheck" to measure a patient's glucose level and have the computer reject the order because it could not identify it. The doctor would have to know that the order is actually listed under "Glucometer". Grrr. It's a wonder more doctors haven't resigned by now because of this craziness.

How are the older anesthesiologists holding up in our group? I've mentioned in the past about how rusty some of my colleagues are in performing some basic anesthesia skills. But so far they are all using the EMR quite well. Maybe it's because we have so many support people hovering around the preop and postop areas to assist them. Perhaps it's because anesthesiologists have very simple documentation requirements. Most of our paperwork is easily converted to templates that are quickly filled out with a few clicks of the mouse. So our department has been spared the angst suffered by our internist and surgical colleagues during these trying times. We'll have to see what happens when our operating rooms finally converts to electronic anesthesia records, which is promised in a couple of years. The thinning of the herd will continue unabated.

Friday, April 27, 2012

Loving The Keystone State

Anesthesiologists are the top earners in the state of Pennsylvania. That is according to citybizlist. Using data from the Census Bureau, they calculated that anesthesiologists made an average of $248,380 or $119 per hour. That is just above second place OB/GYN who made $243,530 or $117 per hour. The rest of the top five are dentists, physicians, and surgeons. So in Pennsylvania anesthesiologists are paid better than the average greedy, unscrupulous, one percenter CEO, who came in at number six with $176,440.

Congratulations to the anesthesiologists of Pennsylvania. You're one of the reasons why anesthesiology is one of the best jobs in America. You'll have to give us your negotiating tips with your insurance companies.

Monday, April 23, 2012

Who Are The Uninsured?

There was an enlightening article in the Los Angeles Times over the weekend. It discussed the plight of visual effects artists in Hollywood, the guys and gals who make the computer generated graphics you see in movies like "Titanic 3D" and just about every modern movie you can think of. Apparently there is a lot of job dissatisfaction in the field. They are unhappy with their long working hours and lack of company subsidized health care insurance. Now they are attempting to unionize their work force.

The workers, oops I mean artists, are frequently forced to work on very tight schedules. Their gigs may last weeks at a time while working fifteen hour days to make sure a movie is finished in time for its release. The jobs may be exhausting, but they are paid $1,000 per day. The newspaper discussed one artist, who didn't want his name released because of fear of reprisals. He is a forty year old guy who had been working seventeen hours a day for 75 days straight on the movie "National Treasure: Book of Secrets." He was so exhausted from his work that he crashed his car while going home from a particularly long day. Shortly after the job, he developed chest pains and went to the emergency room where he was eventually diagnosed with having a heart attack. He didn't have any health insurance so now he is stuck with a $100,000 medical bill.

Hmm. First of all, I'm not even going to mention the whining these artists are doing about their work hours. Fifteen hour days for weeks at a time but getting paid $1,000 a day? Most medical residents would kill for that kind of compensation considering their working conditions are similar but they don't make nearly $1,000 a day. More like $800 a week. Heck, most doctors don't make $1,000 a day. So right away I lost pretty much all sympathy for these people.

Then to read that this one guy made $75,000 in two and a half months but still didn't have any health insurance had me bringing out my tiny violin to play him my saddest song. Seriously? He is easily pulling in over $100,000 a year but still didn't buy health insurance? He wants to unionize because he wants somebody else to pay for his insurance because he is still cheap to buy it himself? Since I am classified as a private contractor by the government, I've had to buy my own health insurance ever since I finished residency. I've never complained about it because that is the price of doing business. I've never once thought that somebody should be responsible for my own well being.

This brings up the question of how many people in the United States don't have health insurance. I've read numbers as high as fifty million people have no coverage. But who are these people who don't have insurance? Are they all some poor destitute or even middle class families with children who can't afford it? Let's break down those numbers. The Census Bureau has noted that nearly ten million of those people are probably illegal immigrants. A study by Blue Cross/Blue Shield showed that about fourteen million people are eligible for some sort of government help like Medicaid or SCHIP if they are ever sick and find themselves in the emergency room. They just haven't bothered to sign up for these government insurance programs yet. Millions more people are uninsured but only for a few months of the year as they may be between jobs. Then there are the millions of people like the sad sack in the newspaper who make plenty of money to buy their own health coverage but choose not to because they think they are young and invincible. Overall, Blue Cross/Blue Shield calculated that only about eight million people in the U.S. are actually long term uninsured but want insurance. Also remember that lack of health insurance doesn't mean lack of health care in this country. Thanks to EMTALA, anybody can walk into the emergency room and get health care, whether they can pay for it or not.

So it's obvious that many people are uninsured not because they can't afford it. They would just prefer that other people pay for it. Everybody wants a company to pay for their health insurance because according to tax laws it is classified as tax free income. Who wouldn't want tax free income? Ultimately I think the only legitimate way to get everybody insured in this country will be to have a single payer system where everybody pays a TAX to have the government insure them. Just call it a tax and get it over with. Stop playing games with "mandates" and "obligations". Start talking about TAXES to get everybody used to the term and discuss the benefits of insuring everybody in the richest country in the world. The people will understand. Until then there will always be haves and have nots in health insurance.

Friday, April 20, 2012

Missing My Anesthesia Cheat Sheet

We are a few months into our new electronic medical records and I have to say I have grown to like it very much. It does make work a lot easier for me. Everything is just a few clicks away, if you know where to look. Preop orders? One click to pull up the prefilled order form and one click to sign it. Done. History and physical? One click to get the template. One click to fill in past medical history. One click for past surgical history. Click, click, click. Sign. Done. It really is a time saver, at least for anesthesiologists.

However one I thing I do miss is having the actual paper H+P in front of me during a case. As a byproduct of all the convenience of clicking in a patient's history, I tend to forget details about the patient. I'm the kind of person who remembers things better if I write it down first. Now I don't ever actually write anything down and it gets kind of tough to recall what I just pasted into my electronic assessment.

For instance, the surgeon may ask what antibiotics the patient is receiving. Nowadays I really don't have a clue. I have to log into the computer, open the patient's file, and look for the patient's medications list. What allergies does the patient have and what are the reactions. Again, log in, look up the patient, and check the allergies list. How tall is the patient? Same routine. Same delay. Same tedium.

During the paper and pen analog era of physician records, all that would be in front of me on my handwritten H+P. That information would  be no more than a few seconds away from me, a quick glance at my quickly scribbled note. Now that is obsolete, never to return again. I can't help feel that some intimacy is lost between a patient and his physician when the doctor can't even remember his height and weight. But at least we are getting more efficient at dehumanizing our patients.

Thursday, April 19, 2012

The Day The Anesthesiologists Stood Still

Anesthesiology is great. Anesthesiology is wonderful. Anesthesiology is considered one of the best jobs in America. But working in anesthesiology is not all peaches and cream. Like any other job, there are issues with salary, peer relations, the bosses, working environment, the bosses, fairness, and, did I mention, the bosses.

In an attempt at projecting empathy, our department sent out anonymous computer surveys to every anesthesiologist that asked how much we liked working here and how the department could be improved. Everybody received almost daily emails encouraging us to complete the survey as the results would be shared with the hospital administration to gauge the health of the anesthesiology department. Many people were excited by having their voices heard instead all the secretive grumblings that normally take place in the anesthesia lounge/break room/call room. The promise of anonymity was especially conducive to airing out all their grievances about the group and having the possibility of the hospital administration itself understand some of the unhappiness and resentment that some colleagues felt working here. Some of the unhappiest people were almost giddy when they typed in page after page of their issues with the group. At last, somebody would do something about this place.

After the survey was completed, we didn't hear anything about it for a few weeks. We began to wonder if anybody had even bothered to look. Then one day, a memorandum came down saying there will be a staff meeting for all anesthesiologists to discuss the results. Attendance was required. Oh goody, we all thought. We can finally see how everybody in the group feels about this place and what our bosses were going to do about it.

Late in the afternoon, after most of the cases in the OR were finished, we dutifully assembled in one of the conference rooms. Sure enough, sitting in the room were members of the hospital administration. But also present were our bosses, including the Chief of Anesthesia and the Godfather. After they deemed that enough people had entered, they started a slide show presentation of the survey results. In general, the questionnaire showed that people enjoyed working at our hospital. We also liked most of our peers. Where the marks plummeted was in the perception of transparency and fairness with our bosses.

This last item brought some consternation with the administrators. They certainly didn't want a dysfunctional anesthesiology department seething with resentment towards their leaders. They then opened the floor to comments and asked us to verbalize why we didn't particularly appreciate our superiors. You could have heard crickets at that point. The initial ANONYMOUS survey was now being aired in front of the whole group while our bigwigs were sitting right there.

Well, nobody was a fool. After all, we all finished medical school. After a few uncomfortable minutes, when not a word was uttered, somebody finally spoke up. That person changed the subject completely and said she wished we had better relations with some of our surgical colleagues. Our chief was visibly relieved. The administrators made some platitudes about how anesthesia and surgery should try to get along with each other. When no more brave souls volunteered any information, the meeting was adjourned and our dear leaders walked out of the room with their administrator buddies with their heads held high.

As you can see, and the anonymous survey proves, there are no morale issues with our department. No sir. None at all. We are just one big happy anesthesia family.

Monday, April 16, 2012

I've Got My Sexy On


We're all familiar with that sensation. The slightly scratchy throat. The dysphagia that can make it easier to drool than to swallow your own saliva. And THE VOICE, that sexy baritone quality that makes you think you can be a voice character for the next Lion King. Ya, I have THE VOICE. And it also means I am in the early stages of a mild flu that has been going around here lately.

Unfortunately the sexy voice disappears all too quickly. That is replaced by the not so sexy rhinorrhea and persistent hacking cough that can make it torture to work in the operating room. There are few things more disgusting than mucus running down your nose under your mask and you're too busy to get a tissue to clear it. Assuming you can find a box of Kleenex in the OR to begin with. And don't get me started on the nastiness of sneezing into a mask. It often occurs during a period when I don't have the chance to run out the OR to get a fresh mask. Therefore I have to live with rebreathing the viruses and mucus that are splattered all over the inside of my contaminated one.

People may ask why I don't just take time off when I have a cold. Well for several reasons. Most anesthesia groups are pretty tightly staffed. There is not much slack in manning OR's. It's not like another anesthesiologist can do two rooms simultaneously to make up for my absence. Somebody may have to work after a grueling call night to make sure all the rooms are properly staffed if one person calls in sick. Taking time off also burdens others when it comes to the call schedule. There are few things more annoying to your colleagues than somebody who is supposed to be on call who phones in sick. That means another person will have to take call for him and the favor is rarely returned, especially if you're the kind of person who rarely gets sick or who has the fortitude to work through the night with a fever of 102. Lastly, for purely selfish reasons, I don't take time off when I'm ill because I don't get paid if I'm sick. Our group doesn't offer paid sick leave. If I'm not here doing cases, my financial situation deteriorates a few weeks down the road when my reimbursements suffer.

So here I am, with a sexy scratchy voice and the onset of a flu. Hopefully it will be relatively short-lived this time. But just in case, I better head on down to Costco and get a giant bag of Halls cough drops.

Thursday, April 5, 2012

Robot Anesthesia

You knew this was going to happen eventually. Somebody has invented a machine that can intubate a patient with an accuracy that is just as good, or even better, than a human anesthesiologist. This month's Anesthesiology News reports on a study out of McGill University in Montreal that details this system. Dr. Thomas Hemmerling uses a Kepler Intubation System to accomplish this trick.

The operator of the machine sits in a "cockpit" and manipulates the robot remotely. Using a mannequin, they were able to achieve an intubation success rate of 100%. The time to intubation dropped from 51 seconds down to 41 seconds over the course of thirty attempts. Using live patients, the team was able to successfully intubate their patients 91% of the time. The lone failure was due to fogging of the camera lens, which of course might happen with living subjects. The goal of the project is to eventually have the robot intubate patients autonomously without an operator controlling it.

Is this the end of anesthesiologists as we know it? Here is a robot that can potentially intubate a patient without human intervention. We've previously seen machines that can dose the proper amount of anesthetic better than humans can. We already have anesthesia machines that automatically chart a patient's vital signs in the operating room. Therefore, a nurse starts the IV in preop. A robot intubates the patient. Another mechanical contraption monitors the patient, anesthetizes the patient to just the right level of sedation, and charts its actions. Presumably it wouldn't take that much more expertise to program a robot to know when to extubate a patient. Then an OR transporter, human for now, can move the patient to recovery. Are we reduced to just watching machines watching patients? Well, somebody still has to read the sports pages to the surgeon while he's operating.

Tuesday, April 3, 2012

Anesthesiologists Give Better Colonoscopies

A recent JAMA article has ignited another storm of controversy over the use of anesthesiologists in routine colonoscopies. They found that the use of anesthesiologists in the GI suite has increased over the past few years, from 14% in 2003 to 30% in 2009, most of which go to "low risk" patients. The authors speculated that the reasons for this include quicker turnaround of cases with the use of propofol, patient preference, and most cynically, financial gain by the physicians.  Skeptical Scalpel wrote in KevinMD that a likely reason for an expanding role of anesthesiologists in GI is because of medicolegal reasons, or cover your ass. If there is a complication with the sedation, such as an aspiration or cardiac arrest, it is more convenient for the gastroenterologist to blame somebody else if there is another MD in the room. It's harder to pin the blame on the nurse giving the Versed that he himself ordered given to the patient.

I'd say we have all forgotten another benefit of having anesthesiologists give the sedation for an endoscopy. Last year I mentioned a paper was presented at Digestive Disease Week, the largest GI conference in the country, that concluded colonoscopies were more effective if an anesthesiologist was giving propofol. More polyps were found when we were in charge of monitoring the patient. This only makes sense as the GI docs can concentrate their efforts on the actual scoping of the patient instead of worrying about the patient's vital signs, assuming they actually do pay attention. At the end of the day, isn't detecting more polyps the goal of giving routine colonoscopies to prevent colon cancer? In the long run, the use of anesthesiologists in GI will save insurance companies millions of dollars in preventable cancer treatments. But of course it is hard to put a number on a supposed future savings when these companies only count their quarterly profits.

So get the word out. We are not going to win the battle on patient safety when it comes to anesthesiologist monitored endoscopies. But if continue to spread the word that disease detection is greater with us present, then that will hit the skeptics where it counts, in their pocket books.

Monday, April 2, 2012

Medicine Without Charts

Our hospital has been using electronic medical records for over a month now and in general most people have adapted well to it. Still it is shocking to open a patient's plastic binder and find almost nothing is inside that can be considered a chart. Sure all the progress notes now are legible since everything has to be typed in. There is less chance of an order mix up because there are all sorts of electronic nanny barriers that prevent you from giving something like penicillin if the patient gets anaphylactic reactions to penicillin.

But that doesn't mean all is hunky dory. Maybe it is just our particular system, but I find it harder to find the information I want these days. Before, I could scan through a chart to find the note I'm looking for. I can skip through the pages of social worker and nutritionist notes to find the ones written by the cardiologist or the nephrologist, since those are labeled at the top of their notes "Cardiology" or "Renal". Now when I click on the Notes section in the EMR, I get pages of notes that have been written into the computer by everybody who has been taking care of the patient, including nurses, respiratory therapy, and other ancillary services. While I can focus down to just physician notes, they are not labeled by the type of physician, just their names. Therefore, unless I know the specialties of all the doctors in the hospital, it is very hard to find the pulmonologist's note or the ID doctor's note. All I have a bunch of doctors' names.

That's what I miss since moving to an EMR, the ability to quickly scan through a chart to find the information I need. Most doctors know that daily progress notes in general don't have much new information so they can be quickly skipped to the ones that truly hold new relevant details. With the new system, it is impossible to do this. I have to click on every single progress note and hope something important is written on it. In fact I've missed important information on a patient because in preop I don't have the time to open every progress note on a patient that may have been in the hospital a month or longer. The surgical procedure note that details the patient's recent abdominal surgery may be three pages down on the list of physician notes. The cardiologist's interpretation of a patient's echocardiogram may be lost in the vast trove of information that doesn't distinguish between what's important and what's filler.

We're all still learning the system so I'm hopeful that these frustrations will eventually be ironed out. The amount of customization available to a doctor is mind boggling so there must be a way to get to the things I need without so much fuss. At least I'm keeping my fingers crossed and hoping for the best. In the meantime I still have to do the maddening pattern of clicking open each freaking progress note one by one and hope there is more information there than the patient's morning vital signs.

Sunday, April 1, 2012

Shades Of Grey

By now we are all too familiar with the sordid details of Dr.(?) Conrad Murray and his unscrupulous treatment of Michael Jackson. We all know how he gave the anesthetic propofol for treatment of insomnia in a private bedroom with no monitoring equipment, no supplementary oxygen, and no presence of the doctor himself when the late singer needed him most when he went into respiratory and cardiac arrest. We anesthesiologists loudly and sanctimoniously proclaimed that propofol should never, NEVER, EVER be given in a private home.

Now comes the story of Dr. Robert Markman. Dr. Markman is a retired anesthesiologist who just had his medical license suspended by the California Medical Board for giving his daughter propofol in a converted bedroom in her house. The Northridge, CA physician was charged by the Board with giving his daughter propofol 500 times over the last five years. She had been suffering from debilitating pelvic pain for seventeen years that had not been able to be controlled by other doctors. As a last resort, he started giving her propofol every three days which he claimed gave her the best pain relief she ever had.

Unlike Dr. Murray, Dr. Markman kept detailed records of his daughter's medical treatments. In fact he gave the Medical Board over 1200 pages of records to prove he was legitimately treating his daughter/patient. Presumably as an anesthesiologist he also had all the usual ASA mandated monitoring equipment in her bedroom while giving her the anesthetic.

So now we have a dilemma. Is the use of propofol ever appropriate outside a hospital or surgery center setting? If somebody's bedroom is equipped with oxygen, monitoring equipment, and personnel trained in giving an anesthetic, can it be legitimately used for giving sedation? Can a room be used for sedation or surgery only if it is inspected and certified by a government agency or can anyone set up a cubicle somewhere with all the necessary equipment and personnel and start giving propofol? With Dr. Murray, the answer was crystal clear. In Dr. Markman's case, the answer is a lot murkier.