Saturday, April 5, 2014

House Of GAWD (Giving Anesthesia While Distracted)

This cautionary tale should be a shot across the bow for any anesthesia resident or attending surfing and posting on the web during the middle of a case. It involves Dr. Christopher Spillers, an anesthesiologist practicing in Medical City Hospital in Dallas. Dr. Spillers is accused of neglecting his patient during a routine AV node ablation. His inattentiveness to his charge supposedly caused him to miss his patient's hypoxia for 15-20 minutes leading to her eventual death.

When the cardiologist in the procedure, Dr. Robert Rinkenberger, gave his deposition for the inevitable medical malpractice case, he specifically focused the blame at the anesthesiologist. Dr. Rinkenberger said whenever he looked over at Dr. Spillers, he seemed to be distracted by his cell phone or pad. When asked by the lawyer if the anesthesiologist was watching the patient, the cardiologist replied, "No." Ouch. Dr. Rinkenberger complained about the anesthesiologists he's seen working in his cath lab, "You know, we see this sort of thing with these procedures. I mean, they're long procedures. We see this kind of thing, and usually I--it's not--doesn't seem to be a problem especially with relatively short cases. What can I say? I mean it happens."

As Dr. Spillers took his turn giving his deposition under oath, he initially claimed he always paid complete attention to his patients in the operating room. Unfortunately for him, his initial flat out denial of surfing the net while working in the OR was all too easy for the attorneys to shoot down. He started backpedaling by claiming he only looked on the web to check patient information, email, or schedules.

That's when the lawyers started bringing out the embarrassing evidence. He was asked specifically if he ever posted on Facebook while giving anesthesia. He again denied doing so without qualification. When asked if posting on social media would be an unsafe practice, he replied, "It wouldn't be recommended." Well, why not? In his best oral boards answer, he said, "Because you're supposed to be monitoring the patient. You wouldn't want to be spending time in extraneous activities that were not related to patient care. Is it possible to do so safely? Yes, because we have ways of monitoring the patient. But I don't do that." When asked again whether he ever posted on Facebook while doing a case, he again answered with single syllable certainty, "No."

At this point, they presented their most damning evidence--his own Facebook page. It has since been erased of nearly all posts but at that time was chock full of easy fodder for the attorneys. Dr. Spillers was asked to read what he posted on one Christmas Day, "Just sitting here--sitting here watching the tube on Christmas morning. Ho ho ho." It was accompanied by a picture of an anesthesia monitor with vital signs on it. He conceded that the monitor was attached to his patient at the time he took the picture but denied the patient's privacy was compromised because there are no identifying names or numbers in the picture. He claimed he may have posted the picture after the case was finished, not while doing the case. However when the attorney pointed out that the caption under the picture was written in a present tense, he had to admit that it was placed while he was doing the case. Now he has painted himself into a corner because initially he said he never posted on social media while anesthetizing a patient. Now he has admitted doing so in the past, even some with derogatory comments about his patients.  Check and mate.

I don't know what happened to Dr. Spillers since then. I do know that on his now sparsely posted Facebook page he identifies himself as having "worked" at Tx-An Anesthesia, the name of his anesthesia group. His case is scheduled to go to trial in September.

In this age of electronic media, nearly everything we do can be traced back to us. Electronic medical records keep track of nearly every keystroke we enter. Hospital computers monitor every website we surf to. Personal cell phones and tablets maintain logs of each phone number and web page we use. While those can be considered private information, a smart lawyer can easily get a subpoena for the phone company to release that data.

So don't become another occupant in the House of GAWD. While some long cases may present a challenge to the anesthesiologist to simply stay alert, posting on social media during a case for entertainment is never a good idea. Medicolegally it is impossible to justify and it goes against every anesthesia doctrine about patient safety.

Friday, April 4, 2014

Too Many Anesthesiologists? Let's Take A Look At The Numbers.

The latest issue of the ASA Newsletter has some very interesting statistics about the trend in the supply of anesthesiologists over the last decade. The figures were compiled from physician workforce data compiled by the trusty AMA. Not counting research and academically oriented anesthesiologists, the study showed that as of 2012 there were 45,357 practicing anesthesiologists in this country. They constitute 5.8% of all doctors for that year.

This number has been steadily climbing in the last ten years. Taking 2003 as a baseline, the U.S. population has increased 8.21% in that period. By contrast, the number of anesthesiologists have increased by 16.2%, or nearly double the rate of population growth. The anesthesiologist growth rate also eclipsed the growth rate of physicians in general, which rose 13.4%. Growth in a few specific medical fields include primary care (6.6%), gastroenterologists (20.2%), and surgeons (4.7%).

Where are all these anesthesiologists congregating? During that time, the District of Columbia, Vermont, and Connecticut have shown a >20% increase in anesthesiologists per population ratio (ApPR). Most of the states fall between 0-20% ApPR increase. Where are the anesthesiologists hanging up their shingles? Delaware, Nevada, New Mexico, Alaska, Iowa, Montana, West Virginia, and Idaho all registered lower ApPR. The study does not try to understand why D.C, VT, and CT showed such large increases. Maybe they started from a low baseline of anesthesiologists. Though with D.C. and CT, I find that to be hard to believe. We also don't know why those eight states showed a decrease in per capita anesthesiologists. Bad economies? Poor reimbursements? Who knows?

How many CRNA's are out there competing for anesthesia jobs? The study authors used Medicare claims data to deduce how many CRNA's filed claims compared to doctors. From 2009 to 2012, Medicare showed that the number of CRNA's had increased by 14.7% compared to only 4.4% for physicians. From 2001 to 2011, the number of graduating CRNA's each year increased from 1,159 to 2,447. They estimate that between 2003 to 2012, the number of nurse anesthetists practicing in the country increased by 50-75%, or at least triple the rate of growth of anesthesiologists.

How are all these anesthesia providers going to find work? We better hope there are a lot more GI docs and surgeons in the future. The authors note that the number of cases performed by these two specialties significantly determined the number of anesthesiologists working in a given state. Surprisingly, the change in a state's population had no significant impact on the number of practicing anesthesiologists. They are unable to answer questions such as how work hour changes and inroads made by nurse anesthetists and anesthesia assistants will affect the need for future anesthesiologists. They also couldn't predict whether we are currently at an equilibrium with the supply of anesthesiologists and the work available.

There you go. This is the most current data for the demographics of anesthesiologists. It gives us some numbers but it really can't tell what we really want to know. Do we already have too many anesthesiologists or are we still working off a shortage from the doldrums two decades ago? Regardless, we better hope the gastroenterologists and surgeons stay busy for awhile.

Wednesday, April 2, 2014

Tales Of The Hungry Surgeons

Here is one surgeon who should have taken advice from this blog. A cardiac surgeon in Fresno, CA has been accused of leaving a patient's chest open so that he could go out to lunch. Dr. Pervaiz Chaudhry left the closure of the sternum to his physician assistant after a heart operation. Unfortunately the patient suffered a bleeding complication after he walked out of the operating room. When the OR manager asked him to return, he threatened to pull his business from the hospital. By the time he finally came back the patient suffered a cardiac arrest and is now in a persistent vegetative state.

I remember that I had a similar incident once a while back though without such a severe sequela. The hospital had just hired a young hot shot microvascular surgeon, which we were sorely lacking. One evening, right around dinner time, this surgeon was in the middle of reattaching a partially severed limb when he said he needed a break. We all thought, ok, nothing wrong with that. Surgeons sometimes need to go to the bathroom or get a cup of coffee during a long case. He left the OR while we waited for him to come back. And waited. And waited. When he didn't return after 30 minutes, we paged him and called his cell phone. No answer. We overhead paged him. No answer. Now going on 45 minutes, we called the Chief of Plastic Surgery and the operating room director. The Chief promptly rushed to the OR and starting scrubbing in, grumbling the whole time about these new young surgeons.

Then wouldn't you know it, the young surgeon wandered back to the room. When asked by his boss where he'd been, he said he was down in the cafeteria eating dinner. Why didn't he answer his calls? He didn't like to be disturbed while eating. He wondered what all the commotion was about. This was par for the course where he did his fellowship training. The two surgeons then finished the case together. However, the new surgeon's reputation in the OR had been established. He was gone from our hospital within six months.

Both of these hungry surgeons should have followed my advice on what to eat in the operating room. We all understand that during a long case a surgeon can get hungry and thirsty. And we're cool with them going to the break room for a little refreshment or even getting sips of juice through a straw in the operating theater itself. But as a rule we would prefer the surgeon stay on the OR floor rather than meandering all the way to the hospital cafeteria for grubs. And we definitely frown on them leaving the building while the patient is still under anesthesia. These actions are usually construed as abandonment of the patient and highly discouraged.

That's why as an anesthesiologist being ignored in the operating room can have its privileges. We can discreetly munch on our power bars behind our anesthesia machines without anyone raising a stink. Just leave the double-double animal style outside the OR for when we have time to eat a proper meal.

Tuesday, April 1, 2014

Who Is The Biggest April Fool? My Vote Is On The AMA.

Last week, Congress pulled a fast one on the AMA and decided not to vote on permanently repealing the SGR formula for determining Medicare reimbursement to doctors. Instead, they resorted to their old standby and approved another doc fix for the next twelve months. It replaces a 24% cut to payments for doctors as called for by the SGR with a 0.5% increase.

Who is the biggest loser in this debacle? Besides the doctors who will get a pay increase that again lags behind medical and consumer inflation, I believe it is the reputation of the AMA. It has once again shown itself to be an ineffective organization at promoting the best interests of physicians.

The stars couldn't have been aligned any more perfectly for the AMA to finally get one of its most cherished pet projects passed by the government. Both the House and the Senate were on board for the SGR repeal. They had each passed a version of the bill and only needed to reconcile the two so that it can be voted on by both houses and sent to the president to sign into law. The medical organization sent out massive amounts of email urging doctors to call their representatives to vote for SGR repeal. This despite many doctors' misgivings about accepting a measly 0.5% increase in reimbursements for five years followed by a punishing pay freeze for the next five. The AMA put the full brunt of its PR behind the campaign to finally push this legislation across the finish line, legitimizing its claim as an advocate of doctors' interests.

In the end, it fell short, again. The AMA's lack of clout was fully demonstrated with this failure. The king was once again exposed as the little, shriveled, naked body of an organization it has become, a mere shadow of its former self. When will the leaders of the AMA come down from their academic ivory towers and start listening to the interests of actual physicians? Did they think that doctors want laws passed that will shrivel their pocketbooks? After all the money that was spent by the AMA to get this bill passed, in the end they had to settle for the usual 0.5% increase.  They might as well have saved their money and had a big St. Patrick's Day party over in their Chicago headquarters. The outcome would have been the same and at least they would have gotten some good green beer.

Until the AMA starts taking seriously the issues that doctors confront every day, like the denial of payments by insurance companies and the need for medical malpractice reform it will continue to lack the legitimacy to call itself the torchbearer for this country's physicians.

Monday, March 31, 2014

The ASA Could Use A Little Liposuction.

If anybody wanted to know why the American Society of Anesthesiologists needs an enormous new headquarters building, part of the answer was revealed by the former ASA president himself. In the March issue of the ASA Newsletter, John Zerwas, MD, the immediate former president of the group wrote a piece praising the number of anesthesiologists who volunteer to work with the ASA. Titled "ASA Exceptionalism," Dr. Zerwas gives a heartfelt thanks to all the people who help run the organization. He writes that there are 100 committees in the ASA with over 1,500 anesthesiologists working in these groups.

While having a lot of people willing to volunteer for the ASA appears nice, to me that sounds like a lot of committees for our field. I can't even think of 100 issues that needs to be urgently addressed by the organization. I think perhaps ten topics are truly affecting anesthesiologists and maybe if I try really hard a total of 20-25 concerns that rise to the level of a national problem. I'll even give them a list of big topics I think they should be most involved with:

1. CRNA's and the states that are opting out of physician supervision.
2. The VA's proposal to allow CRNA's to practice independently.
3. Medicare's low reimbursement for anesthesia services.
4. Medical malpractice reform.
5. Persistent drug shortages.
6. Insurance denial of payments for GI anesthesia.
7. Attracting bright medical students to choose anesthesiology.
8. The abuse of the Company Model for anesthesia services.
9. Publicizing the patient safety advances made by anesthesiologists to the media.
10. Improving the swag handed out at the ASA annual meeting to increase turnout.

Okay so this sounds pretty simple but it was the best I could do at the spur of the moment. I'm sure there are a few more legitimate matters that should be addressed by the ASA. But ninety more? I doubt it. After awhile, committees create their own problems to justify their existence. Then they need to increase their annual budgets to prove they are working on grander issues than their original intent. Like Congress, once a committee is set up, it is rarely phased out.

So instead of praising the large number of people who work at the ASA, how about the leadership downsize a bit and concentrate on a few core issues that affect us plebes down here in the trenches. I think they would find that the membership will be more responsive to real problems than to a committee that investigates romantic relationships in the operating room (warning: gross out kissing pictured if you follow the link).

Sunday, March 30, 2014

Is Anesthesiology Losing Its Cachet?

Another Match Day has come and gone. We are finally getting some details on the results of Match Day of 2014. The NRMP crowed about the increasing number of U.S. medical school graduates matching into primary care. They highlighted in their press release that more than 3,000 seniors had decided to go into Internal Medicine. Never mind that most of these folks will probably move on to a more lucrative subspecialty once their residency is completed.

Despite this laudatory statistic, less than half, 48.5% to be specific, of all Internal Medicine spots were filled by U.S. graduates, the rest presumably taken mostly by foreign medical graduates. The same dismal numbers are found in Family Medicine (45%), Psychiatry (51.8%), and Prelim General Surgery (38.1%). If the match rate is an indication of the popularity of a field, then subspecialties like Dermatology, Neurology, Orthopedic Surgery, and Neurosurgery are still the most desired by U.S. medical students, each with nearly 100% fill rate. Overall, 61.5% of all PGY 1 spots were filled by U.S. graduates.

How did anesthesiology do? At least we can say we did better than average. For 2014, 71.9% PGY 1 spots were filled by U.S. seniors. It was the ninth most popular field ranked by the students, falling just behind OB/GYN. But if you look at the trend over the last few years, the numbers are starting to look troubling.

The 71.9% is the smallest percentage filled since at least 2010, the last year published in the NRMP press release. This follows a drop last year to 74.8% from 78.9% in 2012. In 2011, 79.8% of all PGY 1 spots were taken by U.S. seniors. Is it because we are now reaching a saturation point in the number of anesthesia residencies being offered? This year 1,049 positions were offered, with 754 successfully filled with American students. In 2010, just 797 spots were available which were taken by 626 lucky seniors. So the number of positions has expanded dramatically while the take rate has grown to a lesser degree.

Other fields that are highly sought after have kept the number of residency positions level or even decreased despite the clamoring for spots. Dermatology went from 31 in 2010 to just 20 this year, making it even more desirable like a rare commodity. Neurosurgery went from 191 five years ago to 206 today, a barely perceptible increase of 7.9%. Orthopedics stayed fairly stable from 656 to 695, or 5.9%. What did anesthesiology department heads do? They increased the number of positions available by 31.6% in five years. That rate of growth is clearly not sustainable and will take time to absorb.

Perhaps all the talk about the encroachment of CRNA's into the profession is scaring away potential anesthesia candidates? That sounds like a pretty defeatist attitude for the next generation of anesthesiologists. But a quick glance through the Student Doctor Network will quickly demonstrate the anxiety facing medical students who are thinking about going into anesthesiology.

I get emails routinely from nervous medical students asking me for my prognosis on the future of anesthesiology. All I can tell them is that statistically there is still a shortage of anesthesiologists in this country, particularly away from large cities and the coasts. Will CRNA's overrun our field with their cheap labor? Not if we're smart and organized like them and contribute to PAC's like the ASAPAC to help get our voices heard in the halls of Congress. What is our leadership at the ASA doing to prevent an exodus of bright medical graduates from going into something else? I don't know but they better get their heads out of their butts and start doing something more constructive besides building a new headquarters for their bloated bureaucracy.

Saturday, March 29, 2014

Feeding The Fantasy

Remember that sad and sordid story a few months ago about Jahi McMath? She was the 13 year old girl who died from an anoxic brain injury after surgery to treat her sleep apnea. She was pronounced brain dead by multiple pediatric neurologists last December. However a sympathetic judge sided with the family who believed she will one day wake up from the catastrophic surgical complication. The judge allowed the the family to keep the body on a ventilator and let them move her to an undisclosed location.

Apparently this fantasy has not played itself out yet. Yesterday, Jahi's mother, Nailah Winkfield, told a local TV station that Jahi was "still sleeping." Says Ms. Winkfield, "She is blossoming into a teenager before my eyes." Never mind that the poor girl's brain is now a protein mush while her internal organs slowly and inevitably shut down. The only thing keeping her heart pumping is the ventilator that is forcing air into the lungs.

What is really disturbing to me is that Ms. Winkfield was actually being "honored" for her delusional attempts to save Jahi by the Terri Schiavo Life & Hope Network in Philadelphia. They wanted to praise the family for "protecting the dignity of a loved one against overwhelming odds." Says Bobby Schindler, Terri's younger brother, "Jahi's family persevered through extreme pressure from doctors, media, and public opinion to enable their child a chance to be properly cared for."

Is there any worse way to dishonor the memories of Terri Schiavo? I guess the people who run this network don't recognize the difference between persistent vegetative state and brain death. When somebody is in a persistent vegetative state, which is what Terri was in, their brain is still alive. It's just in a coma but can have a very slim chance of waking up. Brain death means dead.

You would think that after her family struggled through years of heartbreak and legal fighting to keep her alive, they would understand the difference between brain death and persistent vegetative state. Apparently they didn't learn anything despite years of legal arguments about the medical definitions of life, death, and PVS. To equate Jahi's condition, and her family's fantasies, to Terri's medical state is the ultimate affront to her memory and cause.

Friday, March 28, 2014

Nothing Says We Love You Like Sugar And Fried Dough

This Sunday, March 30th, is Doctor's Day. Since it falls on a weekend this year, our hospital decided to show its appreciation for us by sending two big boxes of doughnuts and pastries to the nursing break room. Obviously they couldn't put them into the operating rooms where the doctors could actually get to them. Luckily for me I had a late start today and was present when the gifts were brought in.

Needless to say, by the time the anesthesiologists and surgeons, you know, the hard working DOCTORS, got out of their rooms after completing the first cases of the day, most of the goodies were gone. Well, I suppose it's the thought that counts.

Monday, March 24, 2014

City Workers Get Pay Raises While Doctors Settle For A Pay Freeze. What Is Wrong With This Picture?

I've been getting bombarded with emails from the AMA urging me to contact my Congressman to pass a bill to eliminate the SGR once and for all. This will finally get rid of the annual games Congress plays with physician incomes in which the SGR formula calls for draconian cuts in Medicare reimbursement only to be rescued by the legislature at the last minute.

Unfortunately, the fix to the doc fix may be worse than if nothing is done. At least when we had the doc fix, Congress usually slips in about a 1% raise in reimbursements each time. With the new bill, reimbursements will rise 0.5% every year for five years followed by a pay freeze for the next five. With medical inflation easily running at least 4-5x that number, it's easy to see how doctors' incomes will be drastically curtailed in ten years on an inflation adjusted basis.

So the AMA wants me to call my representatives in Washington to support a bill that will cut my income over the next decade? I didn't know Chicago already allowed medical marijuana to be used at the AMA's headquarters. Is it any wonder that only a quarter of the nation's physicians belong to the AMA? With friends like this, we might as well buddy up to the trial lawyers who have the real power in Washington.

What about my own society, the ASA? Well, true to their gutless selves, they are taking no stand on this issue. They are taking no action to prevent my income from being reduced by half over the next decade. Thanks for nothing. I guess they are too busy over there in Schaumburg erecting their new headquarters with my annual membership fee.

In the meantime my local city union workers are getting a six percent raise in their salaries this year. If the laws of supply and demand were truly in effect, it should be the doctors who are getting the raises as there is a constant harping about the severe shortage of physicians in this country. The city workers, who we all have seen barely lifting a finger to help anybody, should be the ones getting right sized. This again shows how powerless physicians are in creating their own destinies. We are at the mercy of representatives who pay far more attention to lawyers and city unions than the people who will be taking care of their mothers in the hospital.

Sunday, March 23, 2014

KevinMD Headlines That Make Me Want To Go Ugh.

I love the KevinMD blog. It gathers up medical opinions from all over the web and makes it easy for me to read different points of view from fields like IM, Emergency Medicine, Surgery, etc. But sometimes the headlines it present are so saccharine and self important that it makes my skin crawl and my eyes roll. The following is just a brief list of blog posts on KevinMD that were written in the past few months that made me throw up a little in my mouth.

Be Emotionally Intimate With Your Patients.

People Die Without Love.

Sympathy Is The Missing Art In Medicine.

Compassion Is What Connects Us All.

Through Our Patients We Find Ourselves.

My Cancer Shows How Our World Is Ruled By Love.

Seriously, these are actual titles on KevinMD. Now this is no way a commentary on the contents of these posts. In fact, with names like these, I usually don't bother reading the articles. I don't need a lecture on how my cynicism is keeping me from connecting to my patients. I also didn't bother to link the titles to the actual posts in the blog. I figure if headlines like this float your boat you can figure out how to find the articles yourself.

So if you haven't done so already, head on over to KevinMD to read some very good op ed pieces on the state of today's healthcare system. Just make sure you have an emesis basin handy in case you feel that nasty reflux creeping up your esophagus as you peruse some of the blog posts.