Wednesday, September 5, 2012

My Life Is Not Worth $25,000 (Unless It's Other People's Money).

How much money would you pay if somebody possessed a magic potion that could save your life, or at least prevent crippling pain and injury? One million dollars? Ten million dollars? For one scorpion bite victim, she has decided she won't even pay $25,000.

Marcie Edwards, an Arizona resident, was stung by a scorpion at home. She went to her local hospital, Chandler Regional Medical Center, for treatment. The doctor told her they had an anti-venom that can treat the sting. She claims the physician never told her how much the medicine would cost her. That is probably believable since how many of us ever tell our patients how much their treatments cost? As it turned out, the medication cost $40,000 each for two doses. Later, Ms. Edwards received a bill from the hospital for $83,000. Her insurance company paid $57,000. Now the hospital is asking her to pay the balance of $25,000. She has so far refused.

So the hospital saved this woman's life but she feels that they have received enough compensation and shouldn't pay anything out of her own pockets. Is it unfair for the facility to ask for that much money from a victim of a potentially deadly incident? Well, how much money does it cost to maintain a state of the art medical facility in the middle of the desert, staffed with top notch physicians and nurses, fully stocked with the latest medicines and medical equipment? Ms. Edwards was lucky she got stung in Arizona where modern medicine is just a car hop away. What would have happened if the same thing occurred to her in the Sahara desert? How much money do you think she would have given to be taken to the closest hospital? But now that she is treated and well, she decides that she will not pay anything to her saviors. Is it any wonder hospitals all over are losing money hand over fist? Twenty-five thousand dollars here, twenty-five thousand dollars there, pretty soon it adds up to real money, and real debt.

Tuesday, August 28, 2012

Medicine Is A Lose-Lose Profession

What is a doctor to do? The environment feels increasingly hostile towards doctors and how they practice their art. The other day, the New York Times took doctors to task for overtreating patients. They trot out multiple anecdotes of patients and families who found doctors who were overmedicating their patients, performing unnecessary medical procedures, or requesting blood draws that didn't alter the course of treatment. One nonmedical genius chastised his father's two physicians for prescribing medications that caused him to display signs of dementia. Said the son, "All the medical professionals seeing him along the way, the hospital, two nursing homes and nobody thought of this." Yes sir you are smarter than the average medical doctor who has 20+ years of education.

By contrast, last month the New York Times publicly chastised and humiliated doctors for missing the sepsis the led to the death of a young Rory Staunton. Rory's family is friends with a NYT journalist so his story got special treatment. In the extremely one sided account, the reporter named names and pointed fingers at doctors for supposedly overlooking clear cut evidence of septic shock. The doctors obviously couldn't defend themselves due to potential malpractice suits that might be filed by the family. However, much of the "evidence" has been refuted by others. So before there is even an inquiry by any court or medical board hearing, the Grey Lady has already pronounced these physicians guilty as charged.

Is it any wonder that half of all doctors suffer from some degree of job burnout? Physicians have to put up with more Monday morning quarterbacking than even NFL quarterbacks. It's so easy to state after the fact that a doctor should have done something else besides what was prescribed. The internet has not made this job any easier as people bring a list of possible diagnoses to the doctor's office or ER and ask the physician to refute each possibility one by one. But if you order tests to do so, you're are wasting healthcare dollars. If you miss one of the diagnosis, you are incompetent or burned out and should have your license revoked. Makes me want to go work for Wall Street where one can lose billions of dollars on a trade and still receive bailout money from the government to keep working.

Monday, August 27, 2012

The Marked Man

The New York Times' Pauline Chen recently wrote about the bullying in medical training. She described a study out of the UCLA School of Medicine where medical students complained about being verbally abused, slapped, and racially taunted. The researchers expressed dismay at their findings despite all attempts at elevating medical education. I'm quite surprised too. Most medical students I know are quite coddled, if not spoiled, during their clerkships. If they don't finish seeing their patients before rounds, no worries; the intern is supposed to do it anyway. If they're bored with an operation, they can easily make up an excuse about a meeting that they must attend to. And heaven forbid if they should have to stay after 5:00 PM or work weekends. There are all sorts of rules for protecting medical students from the real rigors of being a resident and attending.

In reality, the real bullying and abuse occurs at the residency level. If these medical students are complaining about their treatments now, wait until they hit residency. Then they'll understand what physical and verbal abuse really means. Though I've previously addressed the abuse I took as a surgical resident, I think I can point to one particular incident that marked the beginning of the end for my unsuccessful surgery training.

It was coming towards the end of my surgical internship. By then I'd become pretty comfortable with the work and had been praised by many nurses and staff for my work ethic. One weekend night while on call, I was paged by a nurse to come evaluate a patient's foot. The patient had just had a vascular bypass during the day and now the nurse was having difficulty finding a pulse. I went to see the patient though I was only cross covering for the vascular service and didn't know the patient that well. Sure enough, the foot felt cold and I too couldn't find a pulse. I quickly notified the second year resident about the findings. She agreed and said she'd take care of it. This was around 2:00 AM so I went to bed after that, exhausted as usual. The next morning, I told the vascular intern about what happened overnight. We rounded on our own patients then I went home to be with my family who had flown in from out of town during one of my rare weekends off.

We were out for most of the day. When I came back, my answering machine was blinking furiously at me. I pushed the button to hear who had called me. Out came the angriest message from the vascular chief resident. It was laced with all sorts of expletives and threats. He kept yelling I was such a screw up and how I almost allowed his patient to die and how I was a complete moron. That's the sanitized version. Unfortunately the machine was sitting in the living room where my whole family heard the message. I must have turned pale as a ghost since they all asked anxiously if I was okay. I quickly tried to contact my chief and the vascular chief but nobody called me back.

By the next day, I got the whole story on that patient. The patient's graft had clotted off and he nearly lost his leg. All the blame was being pinned on me as I was the intern on call. I thought this was extremely unfair as I had notified my resident about it, and even documented it in the chart. But what I didn't understand was that the second year resident had already notified the program that she was quitting surgery and starting radiology residency in a couple of months. So she got a pass while I as a categorical surgery intern was supposed to be more responsible than a second year surgery dropout.

That week's M&M Conference was a total nightmare. My case was supposed to be the highlight of the hour. Though the entire surgery program was supposed to be there, the second year resident, who would have been my backup, decided she wasn't going to attend M&M since she was leaving soon enough. So I was left to try to defend my decisions in front of the entire staff. Needless to say, it did not go well. One after another it was "What were you thinking?" or "Why didn't you?" or "Didn't you know?" The humiliation didn't ever seem to end.

But what was worse was that I was now a marked man. In residency there are always the golden or chosen residents and the marked residents. The golden residents could sever a carotid and everything would be forgiven. The unfortunate targeted residents could get a skin dehiscence and he'd be raked over the coals for why the wound got infected, why he chose that particular suture, why he didn't treat it earlier. I had seen this happen to other surgery residents and it was always painful to watch them getting flagellated up in the front of the room every week while the golden residents were always given a pass for much more egregious errors in treatment. I though this was extremely unfair but that was how the system functioned. Now I was one of the marked men. As if surgery residency wasn't hard enough as it is, now everything was ten times worse, with every decision second guessed and analyzed. Every complication was amplified and torn apart on a weekly basis.

I believe that night was truly the end of my surgery training. Once you are marked for failure by the staff, there is very little that one can do to change their minds. As an anesthesiology attending, I have seen that this preconceived notion about who are good residents still exist with surgeons. So if these medical students are already complaining about their abuses in medical school, they ain't seen nothing yet.

Sunday, August 26, 2012

The Preop Huddle. Management's Stupidest Idea Yet.

It's the bane of the operating room. The first case of the morning rarely starts exactly on time. Though the schedule may say 7:00 AM, frequently the patient doesn't get into the room until 7:15 or later. This sets up a cascade of delays as the second case in the room gets delayed, which further puts back the start time of the third case, etc... Of course by then the incriminating surgeon who didn't show up at 7:00 is long gone. He couldn't give a rat's behind about how he has caused much anxiety and headache for the operating room staff as we hustle to catch up with the clock and have to deal with irate patients wondering why they aren't going in on time.

In their infinite wisdom, the O.R. managers have decided to correct this situation by instituting what they call the preop huddle. They have decided that before the first case of the day, at 6:45 AM, all parties will congregate at the patient's bedside to assure a prompt start to the day. Who originated this brilliant idea for holding a meeting first thing in the morning? It was the surgeons. Because so many of them were being delayed later in the day, they complained to their chief, who naturally thought the fault lies with anesthesia and nursing. It couldn't possibly be one of their own colleagues who was causing all this mischief. So the surgical staff developed this huddle to make sure there would be no more "anesthesia delays".

This is so wrong on so many levels. First of all, 6:45 AM is probably the worst time to be holding a meeting of the minds. It is at that precise moment when everybody is getting the patient ready for surgery. I'm busy interviewing the patient, starting an IV, writing my electronic preop note, getting my narcotics, checking my anesthesia machine, and on and on. The last thing I have time for is stopping everything so I can stand next to the patient for a roll call.

The same situation goes for nursing. The preop nurses are trying to make sense of the chaos in preop holding as multiple patients have to be admitted at the same time. The room is noisy and hectic as dozens of surgeons, anesthesiologists, residents, medical students, and family members are wandering in and out of the room . The nurses are trying to get their patients ready for surgery in this environment and don't appreciate having to drop everything to hold a meeting. Plus the nurses work on a clock. They are always there in the morning because their shifts start way before 7:00 AM. They are not the culprits for OR delays.

The real source of the scheduling issues, if you haven't figured it out by now, are the surgeons. They saunter in at their leisure, expect everything to be ready for them, then wonder why the patient isn't in the room already. Nobody will be screaming for another surgeon if they are five minutes late showing up. What makes the OR managers think the huddle system will change this habit? If the surgeons can't be bothered to show up on time for a 7:00 AM case, what's going to make them appear magically for a 6:45 AM huddle? This new system is both befuddling and incredibly irritating.

Sunday, August 5, 2012

Hip Hop O.R.

Thump! Thump! Thump! Thump!

The operating room was rocking. People could hardly hear what each other were saying. The young new surgeon was blasting his favorite playlist through the O.R. speakers, which unfortunately for me was mounted on top of my anesthesia cart. He is a good surgeon with a great personality. Everybody likes working with him. But his taste in music runs towards, what's a charitable way of describing it, urban. When he first started working here he received a few complaints from the staff about his music. Now everybody's cool with it, as long as you don't mind the lyrics or the volume.

Tonight I'm f***** you! Tonight I'm f***** you! Tonight I'm f***** you!

Since the speakers are placed on my cart, I have the unlucky privilege of sitting closest to the noise, I mean, music. It's like sitting in the front row of a hip hop concert. Worse than that. It's like sitting directly in front of the speakers in front row of a hip hop concert. The booming bass sends 128 beats per minute vibrations clear through my body. While the volume may be tolerable for everybody else, they are all at least ten feet away. My eardrums are melting being only a couple of feet from the source.

Sticks and stones may break my bones but chains and whips excite me!

The first time we worked together he asked me to play some music during the case. I asked him what kind of music he liked. He replied he liked anything. Since I didn't know him well, I put on my most generic, least offensive playlist consisting of classic rock with a few country and western thrown in. This list will satisfy 95% of the surgeons here. He, lamentably, wasn't one of them. He quickly nixed it and brought out his own. I'm not sure where he was trained but it was obvious they didn't mind rap since he had no qualms about playing music which loudly trumpeted misogyny and male chauvinism. He raised some eyebrows at first but he eventually won us over with his humor, knowledge, and efficiency.

Everywhere you turn I'm going to make you wet!

Thank goodness for his speed. I can't stand much more of this. Now I know what it's like to sit in those lowriders I come across all over Los Angeles. When the case is finished, the surgeon quickly leaves, taking his music with him. At last, peace and quiet. Now I can put on something that is relatively more calming. Metallica anyone?

Thursday, August 2, 2012

How To Get Into An Anesthesiology Residency

To all the medical student readers out there, here is the news you've been waiting for. A common question that I've been asked is what does it take to get into an anesthesiology residency. Well, there were no easy answers as it was purely speculative. However we now have concrete peer reviewed results to help with that inquiry. The current issue of Anesthesiology has published an article on the characteristics of applicants who successfully matched into an anesthesiology residency. The authors used the Electronic Residency Application Service to obtain their data. Since applications are made electronically and each applicant can apply to any or all anesthesiology residencies in this country, they were able to look only at applicants to Northwestern University's program in 2010 and 2011 to get a broad sampling. This gave them data on 1,976 applicants which corresponded to 58% of all anesthesiology applications at that time. That year, only about 66% of applicants were rewarded with a spot in a program in this country.

So who are the successful applicants? First of all, and not surprisingly, graduates of American medical schools are more likely to find a position than international graduates. The authors speculate that since it has been shown that international students have more problems with lower USMLE scores, language barriers, and higher failure rates on the ABA board certification, they are less likely to be chosen to enter a training program.

Another major, and one of the strongest, determinant of a successful match is a high USMLE 2 score, at least 210. The ratio of successfully matched applicants with a score of greater than 210 vs those with less than 210 was 1,076 vs. 86. So you can see that 210 seems to be a threshold for program directors. Score less than 210 on your USMLE and your chances of getting into a program shrinks significantly. While a higher test score does not equate to stronger clinical performance, the high achievers usually do better on in-service exams which leads to a higher likelihood of program accreditation. The authors think this makes directors more likely to choose better test takers regardless of their clinical abilities.

There's also a bias toward choosing female candidates for a slot. Perhaps since there are fewer female applicants, 36% of the applicants, they have a higher probability of getting chosen as programs try to show they don't discriminate against women. Also if you're older than 28, you'll have a harder time getting into anesthesiology. They theorize that since older students usually score lower on the USMLE, this makes them less desirable to programs looking for high achievers.

One surprising finding in this paper was that being well published bears no relationship whatsoever with successfully matching into an anesthesiology residency. Applicants who've done postgraduate work like getting a Ph.D. and working in a research lab are not anymore likely to get a spot than one who hasn't. As a matter of fact, the study found that the average number of publications made by those who made the cut was exactly ZERO. That's right. Despite what you may have been told about getting into a competitive residency, the quantity of papers published has absolutely nothing to do with the likelihood of getting in.

What do the residency program directors themselves consider the most important factors in residency applicants? They rated the residency interview as the most significant criteria when evaluating applicants. Excellent interpersonal skills and professionalism are highly prized by the gatekeepers. Next come grades and class ranking followed by USMLE scores. What is the least important element when looking for new residents? At the bottom of the list is interest in research and academic career. Surprising isn't it?

So there you go. If you are young, female, with excellent USMLE scores and graduated from an American medical school, you're golden. If you're older, male, finished at an international school and are interested in academic research, you may be out of luck. But you may still get in if you remember to bring your most vivacious personality and brightest smile to the interview.

William Morton's First Patient

If you're a fan of anesthesia history like me, you need to get yourself the August 2012 issue of Anesthesiology. There is a fascinating account of William Morton, the dentist who first demonstrated the efficacy of ether anesthesia which later became known as Ether Day, and his first documented anesthetized patient, a man by the name of Ebenezer Frost.

First of all, the authors debunk the idea that Dr. Morton was some sort of gifted professional with a fascination for scientific discoveries. They wrote of his troubles with the law as an embezzler and malcontent. He traveled all over the country as he swindled multiple business partners. He eventually settled in Massachusetts and married his wife mainly for her family's wealth. Through circumstances of association Morton came upon the identification of ether as a potent anesthetic. Now he just needed a subject to prove its effectiveness.

Ebenezer Frost was a baker who later became a professor of music. He showed up late on Sept 30, 1846 at Morton's front door complaining of a severe toothache. Morton quickly realized this was the moment he had been waiting for. He brought the patient inside and got his consent for the tooth extraction. Morton then poured ether into a handkerchief which Frost inhaled. Frost was quickly unconscious and Morton pulled out the diseased tooth. When Frost awoke, after Morton poured a glass of water on his face, he didn't even realize that the procedure was already finished. Sound familiar? Morton then had Frost sign an affidavit that he had his tooth pulled while under anesthesia.

Morton wanted to popularize the application of ether anesthesia in the hopes of receiving royalties. This eventually led to the public demonstration at Massachusetts General Hospital on October 16, 1846 which has become immortalized as Ether Day. While the patient on Ether Day was Gilbert Abbott, the first documented anesthetized patient was Ebenezer Frost. Great story.

Monday, July 30, 2012

Losing The Art Of Anesthesia

Recently I was doing some minor cases at the ambulatory center. One of the cases required that the patient be intubated for general anesthesia. When I told the OR staff about my anesthetic plan, the circulator kindly asked me if I wanted the video laryngoscope. I looked at him quizzically. "Why would I need to use video? The patient has a perfectly normal airway." He replied that many of my colleagues now use the video laryngoscope exclusively to intubate all their patients. Really? I was quite surprised by that information. Have anesthesiologists become so dependent on technology that something as basic as intubation skills have degenerated to the point we need electronic assistance to do the job?

For decades we anesthesiologists have been using advances in computers and monitoring to exponentially improve patient safety. I can't imagine doing anesthesia today without the automated sphygmomanometer, real time pulse ox readings, and capnography. Thankfully, the days of looking at a patient's skin color to determine adequate oxygenation are long gone. But has the use of video laryngoscopy made us lose confidence in this fundamental anesthesia skill? I've seen some anesthesia residents who don't even want to learn how to use a regular laryngoscope. All they want is the video scope, as if every facility they'll ever work in will automatically have one sitting in the corner for their convenience.

Another gadget that has almost reached ubiquity in the operating room is the ultrasound. I was preparing to perform an interscalene block for a shoulder case. Our anesthesia tech asked me if he should go get the SonoSite for the procedure. Again, I was surprised by the question. I don't do regional blocks that often but I felt confident enough in my abilities to do it with traditional anatomic landmarks and the nerve stimulator for guidance. The case went off without a hitch. However some of my colleagues who have had extra regional training almost always use the ultrasound to do their blocks. Am I missing the boat by continuing my ludditian (ludditic?) behavior?

Other procedures that I've been asked if I needed ultrasound guidance include central line placement and even an arterial line placement. The fear of a pneumothorax complication with central lines is so great now that our hospital mandates the use of ultrasound when placing the line. While I can see how the use of the ultrasound will increase the accuracy and safety of line placements, I don't want what I saw happen to one of my attendings happen to me.

During residency, we had an attending who was trained in central line placement only with ultrasound guidance. One day our machine broke and he had to teach the residents how to do the procedure without one. He didn't know how to use the classic technique of inserting the needle at the apex of the sternocleidomastoid muscle while pointing towards the ipsilateral nipple. Instead he kept pointing the needle perpendicular to the neck as if he was still using an ultrasound. Needless to say his technique didn't work. He stabbed the carotid artery a couple of times and we had to cancel the operation, much to the patient's and surgeon's chagrin. Since that traumatic experience, I have vowed not to tie my skills to the availability of an electronic crutch. It may be a losing battle but I think it is something we should all be practicing.

Sure it's more fun to play with the latest electronic gadgets. Who wants to learn the multiplication table from flash cards when it's so much more fun to do the same thing on an iPad? But we should never allow ourselves to forget how to perform fundamental anesthesia skills simply because it's more entertaining to watch yourself doing it on a little screen.

Saturday, July 28, 2012

Great British Contributions To The World: The Industrial Revolution, The Beatles, and...Socialized Medicine?

If you were part of the estimated one billion people who watched the opening ceremony of the 2012 Olympics in London you were treated to a spectacle of great British contributions to society. Multiple Beatles tunes were played. J.K Rowling of Harry Potter fame was there reading "Peter Pan." Her Royal Highness, The Queen was accompanied to Olympic Stadium by Bond, James Bond. Yes the Brits are rightfully proud of their achievements.

In the midst of this pageantry, they also rolled out, literally, another one of their grandest accomplishments: hundreds of hospital beds representing their National Health Service (NHS). Many of the dancers on the stadium floor were actual NHS employees. With taxation covering the cost of "free" health care, over two thirds of the British are happy with their socialized medicine. This is an astonishing high satisfaction rate despite the well publicized list of shortfalls in the program. There are the denials of care (death panels) for the extremely old and extremely young patients. State of the art drugs are slow to be approved by NHS committees. A waiting time of 18 weeks until treatment is considered acceptable by this authority.  But the Brits, or at least their aristocratic elites, seem to be able to see past all that and grandly flaunt this bureaucratic nightmare to the world.

If so many British citizens love their "free" universal health care, might it not work here in America? We American doctors frequently criticize socialized medicine for their limits on health care choices and long wait times. However, one perk of being a physician in the NHS is that you can't be sued for medical malpractice. The NHS indemnifies all its employees, including doctors and nurses. If a patient wants redress for malpractice, they have to sue the NHS itself, a giant government program with millions of pounds to defend itself. As a matter of fact, in response to rising legal costs, the government wants to make it even more difficult for its citizens to sue the NHS. It is cutting funding of monetary aid that help the poor find legal representation.

So would American doctors be willing to work under socialized medicine if they cannot be sued? If the responsibility of defending frivolous medical malpractice cases was pushed to the government, will that be enough to get the support of the AMA and other physician groups? I have a hunch that there would be a large number of physicians who would support socialized medicine if they were immune from medical malpractice. However with the strong lobbying of trial lawyers here, we would probably get the worst of both worlds: socialized medicine and unlimited uncapped medical litigation. So I'm not holding my breath on us imitating the NHS in the near future.