Thursday, September 5, 2013

When The Shoe Is On The Other Foot

I received an urgent missive in my email from a colleague the other day. She wanted to warn all the anesthesiologists about the impending calamity about to befall doctors. It appears that there is a movement afoot that may require all physicians to periodically retake examinations to maintain their board certificates. The horror! She mass emailed this to the entire department not realizing that many of her younger partners already have to do this. I find her anxiety and panic quite amusing and not without a touch of schadenfreude.

For over a decade there have been two classes of physicians: those who received a lifetime board certificate after residency and those who have a temporary time limited certificate. Through no fault of our own, maybe our parents', many of us were born too late to receive medical training that allowed us to receive the lifetime certificates before they were phased out. Instead we have to pass through an onerous ten year cycle of CME courses, peer reviews, and simulation exams to continue to practice medicine. All these tests cost thousands of dollars, a burden not carried by the older doctors. How this discrimination passed the equal protection clause of the U.S. Constitution is beyond me.

Now the shoe is on the other foot. All the lame rationalizations that the medial societies have forwarded for requiring periodic recertification exams have come back to haunt them. After all the proselytizing about physicians keeping up with current medical knowledge and protecting patient health, the politicians have taken notice and decided that maybe it is a good idea to have a Maintenance of Certification (MOC) process for all doctors. In fact they think it is such a great idea that several states have attempted to tie MOC to state medical licensure.

To no ones' surprise, suddenly doctors around the country are saying that MOC is not really necessary to treat patients well after all. They have been practicing medicine for decades and not once have they felt the need to recertify and update their knowledge base. Besides, lawyers don't have to retake their bar exams every ten years. Why should doctors have to take tests every decade to keep practicing?

The irony here is beyond belief. Suddenly what's good for one group of doctors doesn't apply when all doctors come under the same scrutiny. Change Board Recertification is a website dedicated to bringing about an end to the MOC process. All the excuses for abolishing MOC are here: that MOC hasn't been proven to improve patient care, that it is just a bunch of busy work that wastes a doctor's time and money, and that MOC is actually a method for the different medical societies to enrich themselves with fees from CME courses and mandatory exams. Yes we've heard all of this before. But somehow, the excuses take on more legitimacy when the rules are being applied to all.

If we can't get rid of MOC in its entirety, I wouldn't mind the state legislatures passing laws requiring ALL doctors go through the process. If the older doctors really felt that MOC is a positive experience for doctors and patients, then they should all do it. Unless of course it really is a sham and now they have to admit it or suck it up and starting writing checks every year to attend CME classes to keep their practices. I guess those lifetime guarantees on those certificates are about as good as the the one that came with my set of Ginzu knives I ordered from the late night infomercial.

Wednesday, September 4, 2013

Stupid Anesthesia Tricks

From the "WTF was the anesthesiologist thinking?" department. An anesthesiologist decorated a patient's face with colored stickers while the patient was asleep. He then had a nurse's aide take a picture with his cell phone. The photo may or may not have then been posted online depending on who was asked.

In October 2011, Dr. Patrick Yang, an anesthesiologist at Torrance Memorial Medical Center was giving sedation to Veronica Valdez, an employee of the hospital, for a hand procedure. Before the patient woke up, he placed black mustache stickers and yellow tear drop stickers on her face and had Patricia Gomez, the aide, take a picture. Later, when the patient was awake the aide showed her the photo.

As you can imagine, Ms. Valdez was none too pleased. She filed a civil lawsuit for breach of privacy and emotional distress. Ms. Gomez claims she deleted the picture right after showing it to Ms. Valdez. Several people have testified in court that they saw the picture on the internet. Ms. Valdez resigned from the hospital after working there 13 years because she felt completely humiliated. Dr. Yang was suspended from his practice for two weeks but is still currently working there. Ms. Gomez was also suspended briefly before returning to work. The lawsuit is still ongoing.

While the gross violation of patient privacy is bad enough, I bet that Dr. Yang felt comfortable taking this picture because he knew Ms. Valdez well. He would know better than to do this stupid act on a total stranger he had just met in preop for ten minutes before surgery. Both people had been working at the hospital for over a decade. Whenever a hospital employee has surgery, he or she usually chooses the surgeon and anesthesiologist they know best and arrange to have the procedure done by them. As an anesthesiologist, whenever I am asked by a hospital employee to personally administer to them the anesthetic, I feel extremely honored and gratified and feel tremendous pressure to do my best job possible. So besides being a breach of privacy, this also most likely led to a loss of friendship and respect between Ms. Valdez and Dr. Yang.

As a doctor you live and die by your reputation. That really is the only thing patients know about you. They could care less that you were AOA president or served as secretary of the state medical society. If they hear good things about your work, they will choose you. Nothing in your C.V. will matter more than what people say about your competence on the job. What a shame two hospital careers have been marred by this imbecilic action.

Just as an aside, where was the surgeon when all this was happening?

Tuesday, September 3, 2013

Why We Hate Government Run Healthcare

Do you know why doctors despise Obamacare? Not because it will provide health insurance to more people in the country, which we can all get behind. Not because of potentially disastrously low reimbursements, which I'm sure we will all work around eventually. Actually it is because of the hassle of complying with the byzantine rules the government has formulated to receive the money in the first place that draws the greatest ire.

Take for instance this urgent email I received from the ASA. The organization is asking for all anesthesiologists to respond ASAP to changes being considered by Medicare for how anesthesiologists should be reimbursed. I'll reprint it below for you to understand what I'm talking about.

Many ASA members use the “claims-based” method of reporting PQRS measures since it permits successful reporting when there are fewer than three measures applicable to an eligible professional (EP). At present, the Centers for Medicare and Medicaid Services (CMS) has criteria in place for physician anesthesiologists to successfully report quality measures; however, the proposed rule for the 2014 Medicare Physician Fee Schedule seeks to alter the criteria in a way that will place physician anesthesiologists at a great disadvantage.
CMS is moving toward elimination of the claims-based reporting mechanism and is seeking comment as to whether that mechanism should be eliminated in 2017. Some of the actions described in the proposed rule would sharply curtail claims-based reporting even sooner. Specifically, of the more than 40 proposed new measures CMS intends to add to the 2014 PQRS, none allow reporting via claims.
Additionally, CMS proposes to increase the required number of measures that must be reported from the current three (3) measures to nine (9). These nine measures must cover at least three of the National Quality Strategy (NQS) domains: Patient and Family Engagement; Patient Safety; Care Coordination; Population and Public Health; Efficient Use of Healthcare Resources; and Clinical Processes/Effectiveness.
Currently, there are a maximum of three measures applicable to most physician anesthesiologists. They all are within a single domain. Accordingly, if Medicare’s proposed rule is finalized, anesthesiologists will be unable to satisfactorily meet reporting requirements.
This change would have a significant impact on anesthesiologist’s practice because 2014 is the performance period for your 2014 PQRS incentive and for the 2016 PQRS penalty adjustment.

See what I'm saying? Does anybody outside of political action committees and government lobbyists even know what that means? Just for your information, PQRS isn't a teaching moment on an episode of Sesame Street. It stands for, wait while I look it up, Physician Quality Report System. Click on the link if you want your mind melted by more alphabet soup of arcane government red tape.

The older doctors lament the days when they could just turn in their bills to insurance companies or Medicare and a check would arrive a few weeks later, no questions asked. But unfortunately, through a combination of greed, fraud, and fiscal austerity, the era of blank checks are over. Now we younger doctors are the ones to face the consequences as payers seek ever more creative ways to save money by not paying doctors. Is it any wonder doctors prefer to sell their practices and work for giant healthcare organizations as paid employees? You need to have an army of lawyers to understand all the new rules that are being created under modern healthcare. No independent doctor can afford that can of overhead to stay in compliance and get paid. Welcome to the future.

Monday, September 2, 2013

Scariest CBC I've Ever Seen

This is the scariest CBC result I have ever seen. I didn't think it was even possible for somebody to be alive with a hemoglobin that low. Usually they would have succumbed to the lack of oxygen carrying capacity in the blood before this.

The labs were from a patient who came in with GI bleed. Before you say that the blood sample was drawn from a vein above an IV site, which can dilute the blood and give you dramatically low readings, the patient was transfused three units of PRBC and his hemoglobin almost reached 6. Still less than half of a normal hemoglobin level but at least somewhat above fingernail biting, sphinter releasing stage. So this result is true.

I'm frequently amazed by how much redundant functional capacity our bodies contain to overcome adverse events. Anemia, renal insufficiency, liver failure. The list goes on and on. We are endowed with so much more than what we need to survive it's a wonder anybody ever gets sick or dies. Virtually all our organs have to have reductions of at least 50% before we start feeling the consequences. People do well with only one kidney or one lung. You need to remove at least two thirds of the small bowel to suffer malabsorption. And you can live very well, if uncomfortably, with no colon at all. You need to lose about half of your cardiac output before you start getting symptoms of failure. And you can definitely survive without any brain function, though by then you're not really considered "human" anymore and are considered brain dead.

So whatever your beliefs, thank your maker for how resilient the human body is. We wouldn't have the capacity to destroy our planet if it wasn't for our ability to survive through virtually any adversity.

Sunday, September 1, 2013

Anesthesiologists Do Well By Doing Good

Anesthesiologists seem to have the best of both worlds. We contribute significantly to the welfare of humanity while at the same time we are paid very well for that privilege. That at least is the findings from a survey conducted by  The site asked respondents if they felt their jobs made the world a better place. They then correlated the answers with income data. The information was then compiled into a list of the top 25 most meaningful jobs that pay well.

Our profession came out near the top at number three. Eighty-eight percent of anesthesiologists felt that they made the world a better place. That's not surprising considering that our job is to alleviate pain and suffering. Who wouldn't consider that making the world better? At the same time the average salary of anesthesiologists is $283,600. Not a bad chunk of change for improving people's lives.

As a matter of fact the top five on's list are all physicians. Number one is neurosurgery, with an average salary of $381,500 and a positive survey response of 97%. The second place profession is cardiothoracic surgery, with a salary of $353,900 and a response of 91%. Rounding out the top five are dermatology, because who doesn't appreciate a more beautiful complexion, and OB/GYN, because we all love healthy newborn babies.

So consider this another feather in the cap for anesthesiology. While it's admirable to volunteer to help the world's poor like Mother Teresa or the Peace Corps, that's just not realistic for most of us who have families to support. Like them, anesthesiologists also contribute to the general welfare of society but with the added incentive of a substantial income. In addition, of the top three, anesthesiology has the shortest residency training period and the best lifestyle. Is it any wonder anesthesiology is one of the best jobs in America?

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.