Wednesday, May 29, 2013

Can Oral Sex Be Considered Sound Medical Advice?

J. Peter Zegarra, M.D.
This story has been making the rounds for a couple of weeks. However, to me it is so amusing and ludicrous that I can't help writing about it. A Sacramento surgeon has been reprimanded by the California Medical Board for giving bad medical advice. Dr. J. Peter Zegarra had advised a patient to get an EGD. The patient said she was hesitant to get the procedure done. She complained that she has a very strong gag reflex and would have difficulty getting through it. In response, Dr. Zegarra, in front of the patient's husband, told the patient to perform oral sex twice a week to suppress her reflex. Let's just say the patient was not amused.

She brought the matter to the Medical Board. They too failed to see the humor in all this. Says Cassandra Hockenson of the Board, "This constituted unprofessional conduct, and so this is a message that probably wasn't appropriate."

This incident raises a few questions. It makes me wonder about the doctor's relationship with the patient and her family. Had they known each other for a long time and that's why he felt he could openly suggest oral sex to her and her husband? I can't imagine giving a patient advice like this after meeting with them for fifteen minutes. But if she had been his patient for years, maybe he felt less inhibited about saying something as politically incorrect as this. What was the husband's reaction? Did he laugh out loud when the suggestion was made knowing that it was just a joke? Or did he jump with glee thinking about how he would help his wife follow her doctor's orders? What was the patient's reaction when he first suggested fellatio as a medical aid? Did she run out of the office in tears at the horribly inappropriate words she got from her doctor? Did she attempt it at home and didn't like it so she referred the matter to the Medical Board as revenge? Or did she also initially saw this as a bad attempt at humor then later on decided it was wrong enough to bring the doctor's name to the attention of the Board?

I guess we'll never know the answer to all these questions. However, I do have one suggestion for Dr. Zegarra next time a patient complains about a strong gag reflex. Viscous lidocaine. Simple. Just ask an anesthesiologist and he would have saved your hide and good name and prevented this whole shameful episode.

Monday, May 27, 2013

The Dirty Secret Of Biometric ID's

Our hospital recently installed new Pyxis drug dispensing machines. These babies did away with the usual password for accessing the medications and instead required a biometric ID, aka fingerprint scan, to get in. It seemed like a much safer and more secure method than a password that could be easily stolen by someone looking over your shoulder while you log in.

Unfortunately the device has proved trickier than anticipated to use. The first time I tried to enter the system, it asked to scan my fingertip four times in a row to get a record. Try as I might, I just could not get it to scan properly four times. No matter how hard I pushed down on the glowing red window, it just wouldn't accept my print. It took me several days and a few different machines to finally get all four prints scanned properly.

The problems were just beginning. The Pyxis seemed to accept my fingerprint erratically. Sometimes I could get in on the first try. Other times I would pound the red window in frustration as it kept blinking and asked me to try again. This was especially bad in the mornings when I'm trying to get my drugs to get the first case of the day going. No matter how I positioned my finger or how hard I pushed down, the darned thing just wouldn't cooperate.

Then one day, one of the nurses noticed my frustrations with the Pyxis. She kindly suggested that what worked for her was to place a small dab of Purell on her finger to get it wet. Sure enough, there was a small bottle of Purell sitting right on top of the machine. I put a small drop on my fingertip and, voila, the machine picked up my print right away. I was elated. I was no longer subject to the tyranny of the blinking red light.

But the Purell wasn't entirely a panacea. Some machines didn't have a little bottle of Purell sitting on it. That meant I had to walk over to a nearby wall that had a bottle attached and put a drop on my finger then walk back to the Pyxis, usually losing my place in line, and start all over again. The machines that did have Purell on it became very messy. There would be dribs and drabs of Purell all over the top and the keyboard. It was very unsightly.

Then I had an eureka moment. I noticed that if I washed my hands immediately before I tried to use the Pyxis, the red light of pain would not register. Apparently, the computer requires a certain amount of sheen or reflection off the skin to record a fingerprint. So where could I conveniently get some liquid to wet my finger without hunting down a Purell bottle or walk to a sink to moisten it and bring it dripping back? Hmm. Can you guess? That's right, I stuck my finger into my mouth and gave it a quick lick. Desperate times call for desperate measures.

Furtively, while watching to make sure nobody was looking, I did just that and smashed my finger onto the pad. Bam. It worked right away. I got my drugs then quickly found an alcohol pad to wipe down the machine. So now I know the reason for the difficulty in accessing the Pyxis. But I didn't want to lick my finger every time I needed to check out drugs. That was just too gross to contemplate.

Then I tried a different tactic. I just need something to make my fingerprint shiny for the red light to bounce off so the machine can analyze it. Instead of using saliva, how about a bit of grease? I just washed my hair so I couldn't use that. But I figured if I rubbed my forehead with my finger, I can get just enough skin oil to allow the Pyxis to work. Plus it's not as unsanitary as using my saliva. It can't be any worse than shaking somebody's sweaty palms now, can it? Sure enough, the greasy forehead trick worked just as well.

So next time you confront a biometric ID, you'll know the secret to logging in quickly and accurately. Just make sure you wash your hands afterwards unless you want somebody's DNA stuck on your finger.

Tuesday, May 21, 2013

Anesthesiologists Prefer The Natural Look

Why do women think they need to come for surgery looking like this?
One thing I've never understood is why women feel the need to get all made up before coming for surgery. They come to preop with heavy powder plastered all over their faces. Overly abundant mascara and eyelash extenders obscure their eyes. Fingernails are painted with black or dark red polish, looking like they're ready for a night out on the town. Who do they think they are going to impress?

When I see a girl come for surgery with a ton of makeup on, all I can think of is what a mess this will become by the time I'm finished. First of all, that dark fingernail polish? It is a total pain in the ass. Half the time my pulse ox monitor can't pick up the patient's arterial flow and I'm left with readings that normally would suggest incompatibility with life. I then have to scrounge for fingernail polish remover and wipe away the polish to properly monitor my patient.

That ruby red lipstick that looks so cute when you go out clubbing? That stuff gets smeared all over my equipment. It spreads onto my gloves, my face mask, my laryngoscope, and inevitably onto those teeth that their dentist just charged a bundle for whitening. By the end of the operation, that lipstick looks like it was applied by a five year old in a moving car.

And those eyes. Why must women put on false eyelashes and mascara before surgery? When I tape the eyes during surgery to prevent corneal abrasions, the makeup and eyelashes become adherent to the tape. It's not a pretty sight when I pull the tape off afterwards.

So for all the women who are about to undergo anesthesia, please don't put on any makeup the morning of the operation. You're not going to find Mr. Right while you're being prepped for surgery. Plus we promise we will provide great care even if you don't look like Kim Kardashian.
What makeup looks like after surgery.

Friday, May 17, 2013

Suspended From School And Hoping To Become A Doctor

The Los Angeles Unified School District made national headlines this week when it banned the practice of suspending kids from school for "willful defiance." The district felt that sending children home from school for acting out was detrimental to their education and discriminatory to minorities.

The use of willful defiance was criticized by students such as one Damien Valentine, a sophomore in high school and profiled in a recent LA Times article. Mr. Valentine, 16 years old, has been suspended from school multiple times since he was in 7th grade. He said he was suspended for talking in class and not switching chairs when the teacher asked him to do so. Says Mr. Valentine, "Getting suspended doesn't solve anything. It just ruins the rest of your day and keeps you behind." The young man says he likes chemistry and hopes to be a doctor one day.

He says he wished his teachers had spent more time talking with him and helped him control his ill temper. Now he is joining a program in the school district that attempts to mediate the difficult relationships of teachers and students. When students misbehave, instead of kicking them out of class, the teacher and students write letters to each other explaining their actions and how the animosity should be resolved. Says one of the proponents of this new compassionate teaching, "Instead of punishing students, we're going to engage them."

Excuse me if I don't buy into this new touchy feely form of discipline, if you can even call it discipline. When I was little and I acted out in school, the teacher did engage us, with a forced march to the principal's office where the big wooden paddle was just waiting to be taken down from behind his desk. If he didn't do it, I was sure that the note that was sent to my parents would lead to the same actions at home. There was none of this "but the teacher was unfair and doesn't understand me" business.

So Damien Valentine thinks he can get into medical school despite multiple suspensions on his academic record? His denial of his own culpability is beyond belief. He hasn't yet realized that his own actions lead to his suspensions, which most surely ruins his day and all future days. And responsible adults who should know better are abetting his delusions by letting him think it is the teacher's fault that he is getting kicked out of school. If this is the pool of students from which future physicians will be selected, the malpractice lawyers are going to have a field day.

Tuesday, May 14, 2013

Anesthesia Illustrated

Okay this is pretty cool stuff. Anesthesia Illustrated is a project of the Stanford University Anesthesia Informatics and Media Lab. The website broadcasts all the lectures that were recorded over the course of the three year anesthesia residency at the university. This is amazing work and it's all free, for now.

The videos cover a broad spectrum of topics. While many of them seem to be about obstetrics anesthesia, they range from the very basic, like how to properly induce anesthesia, to the complicated, like pediatric cardiac anesthesia.

This is almost like getting a Stanford anesthesia residency education for free. Between these webcasts and simulations as learning tools, young doctors in training may never have to talk to or touch a real live human being before they start their practices. 

Saturday, May 11, 2013

Porsche-Physician Social Mixer. For Shame LACMA.

I recently received this flyer from the L.A. County Medical Association. It is an invitation for an upcoming networking mixer sponsored by LACMA to be held at the Beverly Hills Porsche dealer. My readers know that I am a huge fan of Porsche cars. However I felt that this event is a bit inappropriate and broadcasts the wrong statement about the real purpose of LACMA and its members.

To me, it seemed to imply that the regular educational conferences held by LACMA was not interesting enough for more members to attend. Isn't that where doctors should be doing their networking? Is this an indictment on the quality of the speakers they invite to their usual meetings? What does Porsche think they will get out of this? Don't tell me that the dealer will rent out space to a bunch of doctors out of their appreciation for medical education. They are hoping to snag a few sales from some of the assembled MD's. Is this any different from drug companies sponsoring "educational dinners" at a fancy restaurant?

Holding a gathering at a Porsche dealer also sends a bad message. When we are fighting tooth and nail to keep our reimbursements stable, much less keeping pace with medical inflation, what kind of image does that send to Congress, insurance companies, and the public about physician incomes? LACMA should know that image, especially with Hollywood in its backyard, is everything. While doctors complain about how Obamacare will devastate physician salaries, they are holding a car and wine party in Beverly Hills.

Now I'm not saying that LACMA should have a mixer at the local Kia dealer. But perhaps it would have been more suitable to hold a meeting in a less conspicuous and blatantly consumerist location. And doctors shouldn't be lured into attending just so they can be surrounded by cars that cost as much as houses in much of the country. LACMA should continue their business of physician advocacy and educational fare without creating a potential publicity boondoggle.

Wednesday, May 8, 2013

Why I Make A Lot Of Money

There is an interesting study that has been published by the online recruiting site TheLadders. After analyzing the names of their six million members, they have found that people with shorter names make more money. They don't give an explanation for this finding. Maybe it is all just a publicity stunt. But it is still worth a look.

According to the firm, the highest paid male names all have five letters or less: Tom, Rob, Dale, Doug, and Wayne. The top five female names also tend to be shorter though there is less of a correlation: Lynn, Melissa, Cathy, Dana, and Christine. In fact, when they analyzed the numbers, they found that for each letter that a name is lengthened, the person makes $3,600 less per year.

TheLadders also found that people who use shorter nicknames make more money than the corresponding longer names. Bills make more money than Williams. Debbies make more money than Deborahs. Philips earn more than Phillips. Again no reasons are given for this.

This must be the reason why I make a lot of money. Other than the fact that I am an anesthesiologist, I have an extremely short first name. Are you ready to find out what it is? My first name is spelled--D-r. But you can call me Z, which is even shorter and more portentous of future fortune. A website that I had never heard of before wouldn't lead me wrong, would it?

MOCA Is A Sham. Let The Lawsuits Begin.

Somebody has finally recognized the hypocrisy of the entire maintenance of certification process in medicine and is doing something about it. The Association of American Physicians and Surgeons has filed a federal lawsuit against the American Board of Medical Specialties for restraining trade and restricting patient access to doctors. The AAPS is using the case of a New Jersey physician who has taken care of thousands of patients over the years. But because he has not spent the time and money to get his board certification renewed, he is now barred from practicing at his hospital. This certainly sounds like a bureaucratic reason for preventing a doctor from seeing his patients. Nobody has disputed this physician's ability to treat patients. He only lacks a flimsy piece of paper that will cost him thousands of dollars in ransom payments to his medical board.

The entire MOC has been suspicious from the start. It begins with the arbitrary date whereby some physicians who were certified before that date get a lifetime certificate to practice while others, through no fault of their own, who finished residency after that date need to spend thousands of hours and dollars to recertify every ten years. This despite studies that have shown that older doctors are much more likely to get sued for malpractice than younger ones.

There has never been any studies to prove that doctors who have been recertified are better than those who have not. This is proven by the shifting requirements necessary to achieve recertification. A couple of years ago, the American Board of Anesthesiology changed the rules so that a portion of the CME hours needed to recertify has to be obtained from material sold only by the American Society of Anesthesiology. The ABA couldn't possibly be thinking about all the money that will come in when thousands of anesthesiologists have to purchase study material from them, could they?

Then this year the ABA changed the rules again, lowering the CME hours required to recertify, from 350 to 250. Why did they do this? They claim this will allow anesthesiologists to complete their MOC along the same standards as the other specialties in the ABMS. But this only goes to prove that the extra money and hours I spent to recertify last time was for naught. It did not make me a better physician. This is just some arbitrary number that somebody at the ABMS made up to force doctors to spend money on CME materials sold by the medical boards.

Is it any wonder people are fed up with the MOC rules? If continuing one's medical education is important for some doctors to maintain their competency, then it should be important for all doctors. Otherwise the ABMS and the ABA should abolish this shameful moneymaking scheme and refund our money. I wish the AAPS the best of luck in their case.

Tuesday, May 7, 2013

Sedasys Is Here. Who Will Be Affected The Most?

The Food and Drug Administration has finally approved the use of Sedasys in the GI endoscopy suite. Sedasys is a computer operated propofol infusion device that automates patient sedation while he is getting an endoscopy. The device monitors six parameters including heart rate, blood pressure, pulse ox, respiratory rate, end tidal CO2, and patient responsiveness to deliver a sedating dose of anesthetic. It is approved only for ASA 1 or 2 patients undergoing EGD's or colonoscopies.

The battle for the approval of the Sedasys system has been going on for years, with Johnson & Johnson and gastroenterologists pitted against anesthesiologists. The ASA won a small victory last year when the FDA initially rejected Sedasys. However, in an unprecedented move, the FDA reconsidered the rejection and now has given the go ahead for the device.

Do you think that there is no way a computer program could function as well as a human anesthesiologist? You better think again. Before you get too cocky, there are several studies that have shown that computers can administer sedation as well as or even better than an anesthesiologist. They are also less likely to oversedate the patients too.

As with any new disruptive technology, there are bound to be winners and losers once all the dust is settled. Who are the likely losers if this equipment becomes widely available? Could it possibly hurt CRNA's? Since it is approved only for sedating healthy patients, most GI docs probably wouldn't use an anesthesiologist anyway in such situations. However, they might use CRNA's instead. The low cost CRNA's suddenly find themselves squeezed between the even cheaper Sedasys for healthy patients and the more expensive but higher expertise of anesthesiologists for sick patients. Uh oh.

What about gastroenterologists? They may think that they can finally rid themselves of the dead weight of anesthesia providers and keep all the money to themselves. However, FDA approval is contingent on having a trained anesthesia provider available immediately for possible airway emergencies. Even that may not be fast enough if nobody is watching the patient except some computer program which is almost always reactive instead of proactive. GI docs may see their malpractice insurance rise as a result of this increased responsibility.

How does the patient fare through all this? I shudder at the possible short cuts endoscopy units might consider once there is no anesthesiologist around to remind them about proper patient safety. We already know that GI docs have a much lower criteria for monitoring patients than anesthesiologists. I also wonder how reactive Sedasys is. Anybody who has ever administered GI anesthesia knows that patients can be maximally stimulated by the endoscope one second then completely relaxed the next once the scope goes past a particularly difficult passage. As an anesthesiologist I've seen far too many instances where the GI doc is yelling at the anesthesiologist to give more sedation because the patient is moving. By the time the extra bolus of propofol has reached the patient's bloodstream the scope has worked through its loop. Now the patient is relaxed but oversedated and his airway is obstructed. Will Sedasys recognize these temporary events and hold back or will it keep pumping propofol into the patient only to overdose when the crisis passes? If the machine does dribble less anesthetic to the patient to prevent oversedation, will that just create more anxiety for the patient?

Anesthesiologists may not be the winners here but I don't think we'll be too badly hurt either. Our expertise will stand out since we will still be called upon to do the difficult cases. Our mastery of the airway will also be evident when we are inevitably called to the endoscopy unit to provide emergency airway support. While there will be some anesthesiologists who may lose their cushy ambulatory surgery center endoscopy jobs, most anesthesiologists don't give anesthesia only for endoscopies. Most ASC's provide orthopedic, urologic, and other procedures that will still need an anesthesiologist present. So I don't see a huge disruption to anesthesiologists either. With a projected shortage of anesthesiologists in the future, our craft should be better utilized on patients who truly require the full gamut of our training. Technology is inevitable. We better get ourselves used to providing a higher level of medical treatment and let the bottom fall out where they may.

Saturday, May 4, 2013

More Data On Salary Of Anesthesiologists. It Gets Even Better.

I recently reviewed the salary of anesthesiologists based on a survey conducted by Medscape. In that tally, anesthesiologists on average earned $337,000 in 2012. Not shabby at all. Now comes another list detailing anesthesiologists' incomes, this time from the physician staffing service Jackson & Coker.

J & C's results are based on the salaries of the 24,521 anesthesiologists in the company's database. If an anesthesiologist was to work for J & C, he would make approximately $456,000 per year.  This income is based on a salary of $380,065 plus benefits that total $76,013. I imagine the benefits include health and malpractice insurance, vacation time, possible retirement benefits, etc. This was something the Medscape survey left out. And if you think anesthesiologists are overpaid, the average anesthesiologist working for Jackson & Coker brought in revenues of $1,307,066 last year. So the compensation is pretty miserly considering how much money the anesthesiologist is bringing in to the hospital.

All the data continue to point out the success of anesthesiology as a profession. Different surveys may show slightly different numbers, but they all conclude that the field is still extremely well compensated and a major reason why medical students still flock to our specialty.