Friday, August 30, 2013

We Treat Zoo Animals Better Than People

Sad news out of New York City today. Gus, the celebrity polar bear at the Central Park Zoo, was euthanized yesterday. Zookeepers had noticed that his appetite was not as healthy as it used to be. When zoo veterinarians went to examine him, instead of a bad tooth that they had expected, they discovered that he had inoperable thyroid cancer. Rather than allowing him to suffer, they decided that Gus should have a dignified death before he suffered from his terminal illness.

What a refreshing attitude. We can learn so much from how Gus was allowed to exit this Earth while still relatively healthy and in comfort. Instead of watching an old dying bear suffer from treatments that would only prolong his misery, the zoo did the right thing and allowed him to die gracefully so that we can still reminisce about what a wonderful bear he was and how much happiness he brought to the world.

Why can't we do the same with our fellow human beings? All too often patients with end stage disease are almost forced to linger on through their misery. Various tubes are inserted into nearly every single external orifice of the body. If that isn't enough, we iatrogenically create new ones. I've seen countless patients who are demented, emaciated, contracted, and end stage with no hope of ever recovering a meaningful existence get brought to the hospital for a gastrostomy tube placement. Why? Is it really more humane to force feed this moribund person than to allow him to pass away peacefully with a morphine drip?

Our ICU's are filled with patients who only exist because of machines. They have mechanical support for their respiratory, kidney, and cardiac functions. Their blood pressures are supported by multiple chemical agents. The hematologic functions are boosted by frequent transfusions. When the body tries to take its natural course into oblivion, we hurriedly rush them off to the CT scanner or the operating room, hoping desperately to maintain a pulse on an otherwise inanimate lump of carbon tissue.

We should all consider the legacy of Gus the polar bear and what he can teach us about humanity. Our last memories of our loved ones should be of the times when they brought vibrancy and joy to our lives. We shouldn't have to hold out desperately for a miracle treatment that may prolong life by an extra two months according to some drug company sponsored study. When we make medical decisions based on the uneducated wants of family members and fear of lawsuits, we aren't serving the most important person on our service, the patient.

Wednesday, August 28, 2013

We Love MOCA Simulation Exams. As If We Had A Choice

In 2010, the American Board of Anesthesiologists made yet another change in how anesthesiologists get recertified ten years after getting their initial board certification. After conducting a survey of ASA members in 2006, they claim that greater than 80% of respondents felt a simulation component to MOCA would enhance their skills as anesthesiologists and are interested in trying it out. Thus the simulation portion was instituted.

In the MOCA simulation, the anesthesiologist travels to one of 34 centers around the country that conducts the test. He or she is placed in a team of four to six other test takers. Then scenarios similar to the oral board exams are conducted with each anesthesiologist taking turns being the team leader. Afterwards, each member is supposed to identify three improvements he can make in his practice because of the simulations and submit the plan to the ABA. A few weeks later the ABA will contact the physician to see how his practice has changed because of the simulation. That's it. There is no pass/fail or grading curve.

According to the ABA, follow up surveys of simulation participants showed that 95% would recommend the course to their colleagues while 98% thought it helped them improve their practice. Those are pretty impressive numbers. Almost too impressive if you ask me. I can't think of anything else in American society where 98% of us agree on one thing. Those numbers sound like election results coming out of North Korea or Cuba.

I wonder how honestly the survey participants answered the poll questions. The fact is that anesthesiologists like myself who hold time limited board certificates are completely beholden to the ABA and its policies on MOCA to keep our board certificates and our practices. How many people are going to say on an ABA survey that they thought the simulation was a total waste of time and money. And we're talking big money. These tests cost thousands of dollars and that doesn't even include money for lost wages and travel expenses. Any anesthesiologist who remembers studying for the oral board exam will also recoil with horror the amount of time spent studying for it and the extreme anxiety that comes with preparing for it. After suffering through all that, are survey participants likely to say it was so not worth the effort or will they try to attempt to make the best of the situation by stating that it was a truly glorious and absorbing experience?

Of course the elephant in the room is that only some anesthesiologists are required to go through this hassle to keep their jobs. According to the ABA and ASA, "Physicians are being asked by local, state, and federal agencies to do more to maintain their licensure and medical staff credentials in order to demonstrate their commitment to lifelong learning. Our patients deserve physicians who can deliver the most appropriate evidence-based care and document the quality of their practice." Okay, I'll buy that . We should all commit ourselves to lifelong learning to ensure quality care for our patients. Agree 100%. Then why is it that anybody who got board certified before the year 2000 have a lifetime certificate that never needs to be renewed? They can coast through their entire career with only what they learned in residency two, three, or even four decades ago. If anything, it is the older generation of anesthesiologists who are in most need of simulation exams so they know the most current anesthetic techniques. They shouldn't be hiding behind their yellowing and fading certificates and proclaim board recertification is good for all doctors and patients, except themselves. The ABA should stop this hypocrisy and either admit that MOCA is a sham or make it universal for the good of our patients.

Tuesday, August 27, 2013

Sometimes I Wish I Can Stop Learning New Things

Twerking. That is a term that I had never heard of before last weekend but it must be the hottest buzzword in the news today. After Miley Cyrus's scandalous dance routines at the MTV Video Music Awards program last Sunday, that's all anybody is talking about. Even normally staid reporters at respectable publications are talking about twerking. When did non entertainment reporters suddenly get so hip?

The Urban Dictionary defines twerking as, "When a woman slams her bottom on a man's pelvic area while dancing." In my youthful days, it was known as dirty dancing or grinding. But somehow the act appears far more outrageous today. When Patrick Swayze and Jennifer Grey were gyrating their hips in "Dirty Dancing" in 1987, it didn't feel like you needed to take a shower after watching the movie.

Perhaps I'm just getting old. When Madonna sang "Like A Virgin" at the VMA's in 1984 in a white wedding dress and rolled around the floor moaning, I thought it was entertaining but hardly earth shattering. But I was merely a teenager then. However its shock value to adults in the audience has transcended time and is now mentioned as one of the signature events in the history of the VMA's.

Somehow I feel that my world would have been better off if I had never heard of twerking. It scares me to think how much more debased our culture will become in the future. If this is what it takes to get grab attention these days, I shudder to think what my children will be subjected to when they become teenagers themselves. If teens consider sexting to be just another form of communcation, are we surprised by what we saw on TV over the weekend? How soon will it be before MTV moves the VMA's into the late night hours so that can show full on coitus on TV to attract attention?

Does The ASA's New Headquarters Signal Peak Anesthesia?

There is a well known theory that when record setting skyscrapers are built, it is a signal that a major economic downturn is about to begin. This has been true throughout the history of skyscrapers. The Empire State Building was finished in 1931, near the onset of the Great Depression of the 1930's. The original World Trade Centers were built as the U.S. was entering into the severe economic malaise of the 1970's. The tallest building in the world, the Burj Khalifa in Dubai, was completed just as the Great Recession of this century took hold. It is thought that the reason skyscrapers and bad economies coincide is because skyscrapers are designed during times of great economic optimism and expansion. By the time it is finally completed years down the road, the economy has usually started on its inevitable down cycle. Thus these giant monuments of human ingenuity open just when it seems most foolhardy to build one.

I was thinking about this when I read my latest copy of the ASA Newsletter. Inside is a large spread reporting glowingly on the ASA's brand new headquarters being constructed in the suburbs of Chicago. There are pictures of smiling people holding shovels and gorgeous architectural renderings of the new building. The 70,000 square foot building will better house ASA's employees, which have doubled in number since 2007. This is all in the name of adding "value to its 50,000 members."

Well how nice for the big honchos at the ASA to get new offices. Is that why my annual membership fee is now over $600 per year? While they are admiring their views from their new corner offices, they also keep raising the cost of the CME's they offer. The ACE program that I use to maintain my CME's and MOCA has risen in price over 50% in the last two years. Why does the ASA need to double its number of employees in the past five years? Membership in the ASA has not doubled in that period. I don't feel any better served by my society by having a larger overhead.

The number of anesthesiologists reached its recent nadir in the mid 1990's when high malpractice premiums and low job availability scared medical students away from the field. Opinions changed when more surgeries began to be moved to surgery centers, necessitating more anesthesiologists. Medical malpractice was also helped by payout caps legislated by multiple states. Since then anesthesiology has become one of the hottest fields in medicine.

But now we may be reaching a peak in the number of anesthesiologists in this country. The ASA is fighting tooth and nail to prevent more states from opting out of physician supervision of CRNA's. Alas it is not having much success as 17 states have already taken that step while others are increasing the scope of practice of the nurses. The lucrative field of anesthesiology is starting to feel mighty crowded. With the advent of Obamacare in two months, more anesthesiologists may start contemplating retirement to avoid having to wrestle a new government bureaucracy to get reimbursed for their services. So there is a real danger that the number of anesthesiologists in practice may start to decline.

We shouldn't be shocked by all this. The number of physicians who train in different specialties are cyclical, just like the economy. Anesthesiologists may currently be peaking. Meanwhile, general surgeons could be hitting a bottom. In the 1990's a good categorical surgery residency was a tough get. Now surgery residencies have trouble filling their spots without hiring foreign medical graduates. Primary care appears to be starting its ascent after years of neglect by the government and insurance companies. So don't be surprised if anesthesiology starts to wane again as a specialty. It wouldn't be the first time. But at least the ASA officers will have new offices in which to cry into their Starbucks.

Monday, August 26, 2013

Everybody Has A Price

You may not realize it, but the Michael Jackson trial is still ongoing. While the country has seen the George Zimmerman trial come and go, the Jackson family's $40 billion wrongful death trial against his concert promoter AEG has steadily marched onward. I normally would not bother with this sad specter of celebrity self destruction, but some news came out of the courtroom last week that I thought was worth mentioning.

As it turns out, Mr. Jackson's personal physician, Dr. Conrad Murray, realized that he was not qualified to give his client the propofol he craved to help him overcome his insomnia and drug dependency. In 2009, he contacted Dr. David Adams, a "roving anesthesiologist" who had given Michael propofol on four separate occasions for dental work. Dr. Murray asked Dr. Adams if he wanted to join Michael on his world tour. Dr. Adams naively and amusingly testified that he didn't initially understand the question since he could neither sing nor dance. When it was explained to him that Michael needed an IV to help him sleep, he finally started getting the picture. He was asked how much money it would take for him to close his practice and follow Michael on his concert tour to treat his insomnia. After taking a short time to consider, he came up with a number: $100,000 per month for three years. When he relayed his demand to the Jackson camp, his calls were never returned. Dr. Murray was then signed up for $150,000 to work as both the personal physician and anesthetist; probably the worst bargain he ever made.

We can all see how unethical it was for Drs. Murray and Adams to even consider treating Michael with propofol. But when faced with offers of unbelievable riches, who can blame them? I've never had anybody proposition me with a blank check for administering anesthesia. I would like to think that I would refuse the money if the task was not medically sound, but who knows. There is always another human need or want that could be easily sated with just a few more dollars in the checking account. When we all took our Hippocratic Oath after graduating medical school, nowhere did it mention that we should stay away from celebrities wishing to toss money at us to do whatever they want.

Medical Care Is Expensive, But Not Because Of The Doctor

The New York Times has published its latest article in its quest to understand why medical care is so expensive in the U.S. Previous articles remarked on how expensive colonoscopies and child birth are compared to the rest of the world. This time, the offender is the humble IV solution.

The writer followed cases of food poisoning that occurred in upstate New York in 2012. She noted that hospitals were charging hundreds of dollars just for intravenous fluids in these severely dehydrated patients. While IV solution can be made for less than one dollar per liter, hospitals were billing hundreds for "IV therapy." In particular, a Chinese-American grandmother and her granddaughter were charged $4,000 and billed for $1,400 for their hours of treatment in the emergency room even though they were on Medicaid and should not have received a bill. The author noted that IV fluids for the grandmother cost $787 while the granddaughter's IV fluids cost $393, suggesting the IV solutions cost hundreds of dollars if you assume the labor cost of inserting the IV were equal between the two.

Clearly somebody is making a huge amount of profit from IV fluids. Middlemen that act as distributors for the manufacturers are implicated, as well as hospital profit margins. Unfortunately due to confidentiality agreements there is no way to know for sure who is making off with all the loot. One thing that clearly stood out for me was how little money the doctor is actually making for taking care of sick patients. Medicaid eventually reimbursed the hospital $119 out of $2,168 for the grandmother's portion of the medical bill. It paid the doctor who treated her life threatening illness in the emergency room a paltry $66.50. You read that right. For treating a patient who could have died if not properly tended to, the doctor will get less than $60 per hour from Medicaid.

Do you know how little that is? My children's piano classes cost more than that. The dishwasher repair man who came over for 30 minutes just to tell me that my old dishwasher was dead and I'd need to buy a new one charged $130 for the visit. But for the privilege of slogging through college and medical school, racking up hundreds of thousands of dollars in debt, then working as a slave/resident for several more years only to be paid less than $60 per hour as a doctor is beyond insulting.

Pundits complain that doctors make too much money. The government's formula for calculating SGR projects a further cut to physician payments of 25% next year. Yet how demoralizing it is to make so little as a doctor, with all the hardships that one puts up with, not just for himself but for his entire family, and people still criticize doctors for being "greedy." That level of reimbursement isn't even enough to repay student loan debt much less maintain a practice.

Thanks to Obamacare, payments like this could be the norm very soon. Millions of people are about to be enrolled in the system that is set to pay doctors at Medicaid rates. Even if the government wants to be generous and raise reimbursements 73% to make it equal with Medicare rates, that fix is only good for ONE year according to government legislation. Obamacare has no funding plans for maintaining physician reimbursements at that level after 2014. I think in legalese that is called bait and switch. And doctors got baited really good.

Monday, August 5, 2013

Is Being A Virgin A Social Pariah?

I've been seeing billboards of this new movie popping up all over town. While I haven't seen its trailer or heard anything about it, I am more concerned about the message it sends regarding sexual attitudes in this country. The movie poster appears to suggest that the family in the movie is a bunch of social pariahs you wouldn't want living next door to you--a father figure who may be a drug dealer, a mom who may be a night club stripper, a daughter whose antisocial behavior has turned her into a runaway (check out her I-don't-give-a-f*** facial expression). But the last member of the family is an innocent looking boy who has a big black arrow labeled "virgin" pointing straight at his head. Really? Is being a virgin in America nowadays the equivalent of a neighborhood drug dealer?

Has Hollywood's portrayal of virginity reached such scorn that it is almost unacceptable for a male to remain a virgin? In the "40 Year Old Virgin", the main character had remained a virgin because of several sexual misadventures in his past. But he was perfectly satisfied with his current social situation, even if it is nerdy to the extreme. However his buddies just knew that nobody can be right if they haven't had any sex, even if it is only with a one night stand. Spoiler ahead. Once he does lose his virginity, he does a little happy dance to a Bollywood style musical. So losing it will solve all of life's problems and make you a complete man?

Hollywood's cultural influence doesn't just affect immature and vulnerable teenagers. A few weeks ago there was a Craigslist help wanted ad from a mom in Philadelphia who wanted to hire a girl to help her son lose his virginity before he leaves for college (Harvard just in case you think the kid is some low life loser). She goes into great detail about how handsome and fit her son is but is just too shy to approach girls to lose his cherry. The mom even offers to pay off any prospective candidate's debts if she is successful in this scheme. How creepy and sickening is that?

Perhaps if we had a more conservative attitude towards sex in this country, we wouldn't be having so many problems with teenage pregnancies. If teen boys are conditioned in this country to start their sexual activities early, guess who they are going to jump on. That's right, teen girls Maybe if we didn't associate virgins with a social misfits, we wouldn't have to give every girl an HPV vaccine to prevent cervical cancer down the road. If virginity was not a dirty word, maybe we wouldn't have millions of new cases of STD's every year.

I know I sound like a prude, somebody who is still living in the 1950's. But this blatant movie poster just drew out my moral outrage. There are many problems in our country. Keeping one's virginity is not one of them. Losing it the wrong way just for the sake of getting rid of it to fit into societal expectations is. How refreshing and original would it be to poke fun at sexually promiscuous movie characters instead of holding them up as an ideal. Sometimes doctors can only treat the consequences of bad choices. We all need to do our parts to help promote a healthier population.

Wednesday, July 31, 2013

Ways To Improve The Operating Room Environment

A recent post in Becker's ASC Review discussed strategies for improving communications and work environment in the operating room. Using ideas as outlined by a colorectal surgeon, it lists five methods that he felt should be implemented. The plans include using a preop huddle to make sure everybody in the OR is on the same page and taking the team approach during surgery because, you know, the anesthesiologist might be too intimidated by the superior surgeon to speak up.

Blah blah blah. What do you expect in an article that uses a surgeon as its source? They should have asked an anesthesiologist who will give the true low down on how to improve the atmosphere in the OR. This advice is directed to all the surgeons out there. You may think you're perfect, but there is always room for improvement.

1. Show up on time. Stop feeding us B.S. about how you weren't paged when the patient was ready to leave preop. If the schedule says 7:00 AM start, be here at 6:55 AM. Not 7:01, 7:05, or 7:15. We're not your mother who has to remind you that you'll be late for school if you don't get up soon. If you're not sure if the case will start on time, CALL. We'll tell you if we're running late. Don't make us chase you around on your cell phone, pager, and office numbers, none of which you will answer. And please man up about your tardiness. Don't feed us baloney that your secretary didn't tell you what time your case is supposed to start. It's your schedule and you're responsible for checking it before going to bed each night. I do. Why can't you?

2. During an operation, don't ask me to answer your pager or cell phone. That's not my job. I'm too busy making sure your patient doesn't die on the OR table. Frankly, it's nobody else's job in the room either. The nurse is as busy as me keeping the case going smoothly. If you have a resident, use him to answer your calls. Or your PA or  NP. My medical degree was not obtained with a rotation in answering phone calls.

3. Be quick about it. We know the difference between being meticulous and dawdling. We understand the former but won't put up with the latter. Even though I get paid more for longer cases I don't want to face the angry surgeon who is waiting to follow you in the room. He'll yell at the OR staff but will rarely confront the surgeon who is the major offender for why his case is starting an hour late.

4. Don't drag me into a faux emergency operation. It's not an emergency if the only reason the patient needs to go into the operating room stat is so you will make your dinner date that evening.

5. Stop acting juvenile. While this encompasses the previously listed suggestions such as showing up on time and not lying to get your case into the room, it also includes things like not throwing a temper tantrum if you can't get exactly what you want. Don't complain that your procedure card falsely listed a 3-0 Vicryl suture when you always use a 4-0 Vicryl suture when the OR has been using the same card for you for the last ten years. Stop throwing a hissy fit because your headlight isn't shining as brightly as you think it should be. Deal with it. Grow up!

6. Don't tell me how to do my anesthesia. If there is one thing that really, REALLY annoys me, it is a surgeon who emperiously tells me what kind of anesthesia to give. I have my own plans and I'll be happy to discuss them with you but you better remember I have the last word on this subject. As a corollary, don't tell your office patient beforehand what kind of anesthesia she will receive during an operation. You may think that the morbidly obese patient with severe obstructive sleep apnea and pulmonary hypertension only needs a MAC sedation for a case but I may completely disagree for the patient's own safety. I don't want to have to fight with the patient in preop to get her to agree with my plan for her anesthesia. If a patient asks, just tell her she will meet with the anesthesiologist before surgery to talk about it. That's all you need to say.

7. Don't cancel cases without telling anybody about it. Few things are more frustrating than preparing for a case and the patient never shows up because it had already been cancelled by you and you never told the surgery scheduler. It is a waste of my time and a wasted opportunity to use precious operating hours for legitimate cases. One simple phone call. That's all we ask.

8. Stop harassing me if I need to take a little break between cases. Don't page me incessantly if I need to take ten minutes to take a crap in the bathroom. If I need to get a cup of water, don't have the OR call my cell phone every thirty seconds to ask where I went. I cannot and refuse to be leashed to my anesthesia machine all day like a dog on the sidewalk. You get a nice break between cases while the rest of us are hustling to get your next case ready. It's only humane if we are shown a little consideration too.

These are some of my rules for improving the relationship between the anesthesiologist and surgeon. If you follow this guideline, we will get along just fine.

Tuesday, July 30, 2013

How To Prevent Childhood Obesity. Stop Reading To Your Children

My wife and I try to maintain a healthy diet for our kids. We rarely ever eat at fast food restaurants unless it is a special occasion. We don't keep bags of junk food in the pantry, tempting little hands to snack between meals. Consumption of candies and chocolates are strictly monitored. Therefore it is quite dismaying for us when we read children's books to them each night before they go to bed.

Any parent who reads to their kids knows what I'm talking about. Books for young readers are filled with depictions of children eating sweets. When kids come home from school, what do the stay at home moms do? They bring them a plate of freshly baked cookies and a glass of milk. When the children go to a friend's house, they are more likely to sit around drinking punch and eating cupcakes than they are going outside to toss a football. One version of "Wheel On The Bus" has all the bus riders ending up at a picnic, with the table loaded with cakes, cookies, punch, and ice cream.

Even Harry Potter is not immune. He and his pals are forever tempted by sweet desserts like chocolate frogs, treacles, and pumpkin juice (vomit flavored jelly beans don't count). Their favorite store to visit when they are allowed out of Hogwarts is a candy shop. I don't remember reading the Hogwarts's banquet table, with its endless supply of food, having ever served a crisp green salad or a slice of whole grain toast.

Consequently, at every activity where children are present, somebody always brings bags of empty calories for them to eat. After soccer practice, a parent may supply silver pouches of sugary fruit punch. After Sunday school, a teacher will hand out bite size candy bars or M&M's. The sweet temptations bombarding our children are ubiquitous.

Maybe the stories of the Brothers Grimm got the right idea. When Hansel and Gretel started chowing down on the witch's house made of candy, the sweets served as a bait to lure them in. The shingles made of chocolates and windows of spun sugar were not there to signal a party was awaiting them inside. The writers knew the treachery of junk food on children's health, even over two hundred years ago.

I implore modern children's books authors to do the same. Stop writing books showing how much fun it is to pig out on ice cream and cake. All these books give a false impression that unless kids are eating sugar, they are not having a good time. Cookies and cakes have a place in the diet, but not at every play date or after every meal. Nobody really needs that slice of apple pie after dinner when a fresh apple or a bowl of strawberries can be just as good. If we can alter the mindset of our youngsters, hopefully this will be a small step towards fighting the obesity epidemic in this country. I think I'll read to my kids "The Hunger Games" from now on.

Thursday, July 25, 2013

Why It's Better To Be A Doctor Than A Rock Star

Remember the days when you were in high school and you were spending your nights and weekends at home cramming for the SAT's? Meanwhile the cool kids were living it up playing in garage bands and getting all the girls. Then you got into a prestigious university and medical school through hard work and diligence. In the meantime your former rock band classmates were playing gigs as cover bands at the local bars and getting phone numbers and underwear from the floozies in the front row. Was all that stress and intensity worth it?

You bet your Top 1% income bracket it is! While we all envy the riches and lifestyle of megabands like U2 or Aerosmith, they represent the absolute cream of the crop of rock bands. Reaching that peak is like winning the lottery. Probably 99.9999% of all groups will never amount to more than a weekend part time bar mitzvah band. Even if an act makes it big, it is extremely unlikely it will have the longevity like The Rolling Stones with their 50th anniversary tour. Most will be a one hit wonder, if they're lucky.

Take for instance, the 1980's new wave band A Flock Of Seagulls. I bet you didn't know they were still playing did you? I know I didn't. I thought that hairtastic group flew off into the sunset when Nirvana arrived on the scene and pretty much took over rock. But lo and behold, they are still around and making news. Unfortunately it is not news that will land you in the Rock and Roll Hall of Fame. The band, whose lead singer's do was so iconic it was even parodied in an episode of "Friends", had just played a gig in Bellflower, CA last weekend. They went back to their Comfort Inn luxury suites afterwards to crash when their equipment van was stolen overnight. They lost $70,000 worth of instruments, clothes, and even the band's demo for a new album.

A Flock Of Seagulls
Not to make light of other people's misfortunes, but I find it rather sad that there are so many musical acts out there still playing for dollars and faded glory as nothing more than a cover band of their former selves. Their rock star dreams have devolved into a zombie like existence as they drive in their rented vans from one small town to the next. Now I have nothing against Bellflower, a middle to lower class suburb of Los Angeles. But playing there certainly doesn't have the glamor of headlining the Staples Center.

In the end, all your hopes and dreams have come true. You worked your ass off your whole life and now you're in medical school or a practicing physician, ready to cash in on some the rewards you have coming to you. Those garage band kids, on the other hand, can only show up at the next school reunion and thumb wistfully through the yearbook, reminiscing about how they were once awesome but now have nothing to show but a beer belly gut and a receding hairline. The girls won't be screaming for them anymore. All eyes will be on you, the responsible hardworking high achiever of your class. Rock On!