Thursday, November 6, 2014

Celebrity Doctors And Their Celebrity Patients

The New York Times has a lengthy puff piece on the ENT surgeon who was present during Joan Rivers' final and fatal procedure, Gwen Korovin, M.D. Dr. Korovin graduated from Cornell then went to SUNY Syracuse for medical school. Upon graduation she did her residency in Manhattan's Lenox Hill Hospital. There, she was mentored by Dr. William Gould, an ENT physician with many celebrity patients. When Dr. Gould retired, Dr. Korovin assumed his practice, retaining many of his famous clients.

Dr. Korovin was highly recommended among the rich and famous. She appeared to have treated everyone on Broadway for throat and sinus ailments. They all loved her. And she loved them back. She was glamorous in her own right, dressing in chic outfits that rivaled her patients and attending their red carpet premiers. Like a good concierge physician, she apparently could be reached at all times day or night by her patients. She received their loyalty when she confronted show producers and demanded they let the stars rest their voices instead going on. So much for the old show business ethos, "The show must go on."

The writer, who admits he has been Dr. Korovin's patient, name drops the doctor's patients throughout the article. Stars like Cher, Bruce Springsteen, Elvis Costello, Ariana Grande, and many others are mentioned. I wonder if all these people that are named gave the author permission to mention them as being patients of Dr. Korovin. If not, this is a huge HIPAA violation.

Perhaps it was these ongoing relationships with VIP patients that ultimately led to her downfall. She may have been just a bit too cocky as she breezed into Yorkville Endoscopy that fateful day last August to treat her good friend Ms. Rivers. She was so sure of her status that she couldn't even bother identifying herself to the staff at the surgery center, some of whom assumed she was the patient's makeup artist.

The coroner's report ultimately stated that Ms. Rivers died from an anoxic brain injury from a propofol sedation that was "a predictable complication of medical therapy." A doctor who has no credentials for working at a surgery center can just waltz in without any identification is a complication of medical therapy? When a doctor can perform a procedure that the patient may not have consented to is a complication of medical therapy? When a surgeon is so confident of her relationship with her patient that she can commit the atrocious act of taking a selfie with her phone while the patient is asleep under anesthesia is a complication of medical therapy? An ENT surgeon who is actually present in the operating room when a patient suffers laryngospasm but incredibly is unable to establish an emergency airway is a complication of medical therapy? Wow. Who paid off the coroner's office in New York?

Whether the doctor will be sued by Ms. Rivers' daughter for medical malpractice is still to be determined. But that is the life of a VIP doctor. Your mistakes are just as outsized as your patients.

Doctor, There Is A Hair In My Anesthetic

Ewww. A human hair was found stuck in the stopper of a Hospira produced bottle of local anesthetic. The company has voluntarily recalled the drug, which is a single dose, preservative free 1% lidocaine. They were distributed from May 2014 to June 2014 with an expiration date of April 1, 2016. The lot numbers are NDC 0409-4279-02, Lot 40-316-DK.

Says the FDA, "[if] the particulate breaks and pieces are able to pass through the intravenous catheter, injected particulate material may result in local inflammation, phlebitis and/or low-level allergic response to the particulate or microembolic effects." Gee no kidding.

Your Tax Dollars At Work--Free Anesthesia For Screening Colonoscopies.

The Centers For Medicare & Medicaid Services (CMS) finalized its physician fee schedule for 2015 and there was good news for anybody receiving Medicare. The government has decreed that Medicare recipients will not have to pay a dime for anesthesia services while getting a colonoscopy. No deductibles or copays will be charged. You can walk in with nothing but your Medicare card and receive free anesthesia.

You can thank the ASA for this freebie. Due to their vociferous lobbying, they urged the CMS to classify anesthesia services for colonoscopies as an essential benefit. In their strongly worded letter to the department, "Medicare should pay the anesthesia provider for the service; payment should not be conditioned on the presence or other specified diseases, conditions, or other diseases." Who could turn down a mandate like that?

So thank you, oh great ASA for providing us with more taxpayer money. I am curious though why your letter to the CMS uses the term "anesthesia provider" instead of "physician anesthesiologist" like you use for all your public statements. Don't tell me my membership dues are being used for you to lobby for the CRNA's to get their government handouts too.

Wednesday, November 5, 2014

Where Do CRNA's Make More Money Than Anesthesiologists?

In my last post I looked at the Rasmussen College's web tool for comparing the buying power of an anesthesiologist's income across different states. However, since the data is based on the government's Bureau of Labor Statistics, the site can also be used to compare the income of other jobs. Let's just randomly pick one now okay? How about...CRNA's.

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You might think that the incomes of CRNA's and anesthesiologists would roughly parallel each other in each state. But this is clearly not the case. If we search under CRNA, it's easy to see how the rank of income levels is far different from physicians.

Whereas anesthesiologists' incomes for California, New York, and Illinois are clustered close to the bottom of the country according to the BLS, CRNA's working in those states rank much higher. In fact, California CRNA's make it into the top ten in the country in income for their profession.

If you then rank the incomes based on buying power, again the big blue states fall down the list due to their higher taxes and cost of living.

But if you look at the top of the rankings, Nevada and Wisconsin show substantial income and buying power. The average CRNA salary of $221,000 in Nevada translates to an equivalent of $225,000 when adjusted for cost of living. In Wisconsin, a $200,000 salary becomes $215,000 due to its extremely low cost of living.

How substantial is a cost of living adjusted salary of $215,000? In fact it is greater than the average adjusted income of anesthesiologists living in CT, IL, MD, DC, NJ, MA, CA, NY, and MS. These expensive (not counting Mississippi) coastal states pay their anesthesiologists less than CRNA's who reside in cheaper states like WI and NV. In addition, CRNA's in Nevada make competitive incomes, within $10,000, of anesthesiologists in these other states: MN, VT, WA, VA, DE, NH, CO, AK.

With all the extra liability and reimbursement issues that anesthesiologists face, it makes one wonder why we didn't just become nurse anesthetists. It's pretty clear from the government's own statistics that the income disparity hardly justifies the extra responsibilities of having an M.D. appended to the back of our names.

Where Should Anesthesiologists Live?

Where is the perfect place for anesthesiologists to practice? If all you care about is money, there is a new salary comparison tool to guide you. Using data from the federal government's Bureau of Labor Statistics, Rasmussen College has developed a website to compare the buying power of your salary across all fifty states.

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I made a screen shot of the Rasmussen result for anesthesiologists. First a couple of quirks. The salaries for anesthesiologists that the BLS uses seem to be a lot lower than the Medscape survey of physician salaries released earlier this year. Medscape reported that anesthesiologists made on average $338,000 last year, while the BLS seem to list anesthesiologists as making only in the mid to low $200's. Because Medscape's survey is based on doctors self reporting their own incomes, there may be a bit of a bias towards high income earners being more eager to participate.

It's surprising that anesthesiologists in the big coastal states of New York and California make among the lowest incomes in the country, ranking only 47 and 48, respectively. Illinois, another big population state, did even worse coming in at 49 while the poorest state in the union, Mississippi, unsurprisingly offered the least amount of money for anesthesia services. In the graph I also highlighted the other populous states of Florida and Texas.

The interesting picture appears when these numbers take cost of living into account. The high tax and high cost states of CA and NY stay stuck at the bottom. IL, due to its lower cost of living, rises slightly in the rankings. TX rises due to its low tax environment while FL drops because of its higher cost of living compared to TX. The high income low tax states like Kansas increase their buying power even more. Is it any wonder doctors tend to skew conservative and Republican? While money is nice though, the Midwestern states don't get to celebrate Christmas like we do out here on the left coast.

Proposition 46 Fails In California! Because Doctors Don't Need No Stinking Oversight.

Hallelujah! The bitterly despised Proposition 46 here in California failed at the polls by a 2-1 margin yesterday. It would have raised the medical malpractice cap for pain and suffering here in the state from $250,000, which has been in effect since 1976, to $1.1 million, which is what the inflation adjusted number would have been. If malpractice lawyers can't make a viable business case from six figure payouts for representing their suffering clients, then they probably don't really care that much about these "victims" and really should go into a different legal field. Many doctors have to make a living with far less reimbursements than that.

Another provision of Prop 46 would have subjected physicians to random drug tests and testing after patient complications. This is patently silly. While drug testing maybe required for professional athletes, airline pilots, bus drivers, and other people, obviously citizens held in as high esteem as doctors would never abuse drugs and alcohol, do we?

So hats off to all the medical societies who spent our annual dues to protect us from urinating into a little cup. I'm glad our money has been put to good use, instead of spending it on hosting another luxurious conference in Hawaii.

Monday, November 3, 2014

Songs To Drive Your Surgeon Crazy

You know that tune you hear on the radio as you're driving in to work that you just can't get out of your head all day? Now somebody has conducted a survey to discover which songs are the catchiest of all time. The Museum of Science and Industry in Manchester, UK asked 12,000 visitors to its website to listen to snippets of the top 1,000 songs over the past seventy years. The participants were then asked how quickly they could identify a song.

Since this survey was done in the UK, it doesn't seem all that surprising that the Spice Girls' "Wannabe" came out on top, able to be identified in about 2.29 seconds. Second place went to Lou Bega's "Mambo No. 5" which was recognized in 2.48 seconds. Third was Survivor's "Eye of the Tiger" in 2.62 seconds. Go here to see the list of the top 20 catchiest songs in the survey.

Most of the survey participants must have been relatively young. I'm not sure many surgeons, especially the ones over 50, would be identify Hanson's "MMMbop" in 2.89 seconds. And I'm sure he would have you turn off your iPod if you tried. There are a couple of Elton John and Elvis Presley songs in the list that the more mature surgeons may be able to identify. But otherwise it looks like mainly the Gen Xers and above took part in the survey.

Frankly I don't think any of these songs are all that catchy. In my opinion, the tune that will stick to your brain and never let go was from the 1957 movie "The Bridge On The River Kwai." I dare you to play the video clip below. You'll be whistling the song until you want to tear your hair out.

Anesthesia Is Safer Than Ever.

Some great news was reported out of the ASA conference in New Orleans. Out of over three million anesthesia cases examined  between 2010 and 2013, which is about a quarter of all anesthesia procedures performed in the country, researchers found that anesthesia complications decreased from 11.8% to 4.8%. The risk of dying dropped to a tiny 0.03%

Forget the fears of having surgery on weekends or evening hours, at least as far as anesthesia risk is concerned. They found no evidence that anesthesia complications were any higher during a hospital's off hours than normal business hours.

Patients over fifty had the highest rate of adverse events. The most common minor complication was post operative nausea and vomiting, 35.53%. The most common major complication was medication error.

This is the kind of data that we anesthesiologists should be trumpeting every day to refute all the scary stories about anesthesia and anesthesiologists that pervade popular media. With the incredible strides our profession is making in patient safety, this information will make it even tougher for the ASA to prove that anesthesiologists provide a safer anesthetic than CRNA's. But at least they aren't declaring war on the nurses this year. Peace.

Is The Growth Of Epidural Steroid Injections A Consequence Of Too Many Pain Doctors?

The November issue of Anesthesiology has a devastating indictment of the common practice of epidural steroid injections for back pain. In a study out of Johns Hopkins, 59 patients with cervical radiculopathy received pain medicine plus physical therapy, 55 patients had epidural steroid injections, and 55 had a combination therapy.

One month after the beginning of the treatments, arm pain was no different between all three groups, suggesting a lack of effect. However, when measured three months out, the combination group appeared to show significant improvement, 56.9% compared to conservative treatment, 26.8%, and epidural injections alone, 36.7%.

In an editorial in the same issue, Dr. James Rathmell, a director for the American Board of Anesthesiology and is involved in the certification for Pain Medicine, notes that epidural steroid injections should never be the first line of treatment for neck and back pain. They should always be part of a combined therapy involving physical therapy, pharmaceuticals, and injections. The patient must also understand that epidural injections don't treat the underlying cause of the pain to begin with. It only potentially speeds up the recovery that would otherwise have taken place with conservative measures. While speeding up recovery sounds good, one must balance that with the potential complications of infection, wet tap, and potentially permanent nerve damage and death when receiving a needle in the back.

It is easy to see how the rise of Pain Medicine as a desirable subspecialty for anesthesiologists has led to an explosive growth in the use of epidural injections. In an accompanying graph, the number of physicians boarded in Pain Medicine has grown steadily every year, reaching about 5,000 in 2012.

At the same time, the number of injections performed have exploded, particularly for lumbar injections. Talk about a growth business, the quantity of lumbar and transforaminal injections have reached one million per year over the last decade. While not as parabolic, cervical injections have also inexorably risen.

Is this another case of too many doctors looking for a lucrative source of income? As we all know by now, insurance companies pay physicians much more for performing procedures than to sit and talk to their patients. If pain doctors followed best guidelines and simply prescribed drugs while coordinating with physical therapists and forgoing procedures, how would that undermine their plump incomes? They would be reduced to, shudder...internists. And NOBODY wants to be one of those nowadays.

Sunday, November 2, 2014

Anesthesia And Eye Injuries. The Latest Statistics

The current issue of the ASA Newsletter has an analysis from the Anesthesia Closed Claims Project database on the problem with eye injuries in anesthesia. The authors of the study focused on the years 1990-2012 in which there were 184 anesthesia claims during eye surgery.

The most common event during eye surgery that led to a malpractice lawsuit was needle injury to the globe in association with a regional block, which occurred in 29% of the claims. Fortunately, the claims rate for needle trauma have been decreasing due to the more widespread use of topical anesthesia, dropping from 37% in the 1990s to 19% in the last decade. Death during eye surgery was the second largest complaint, comprising 27% of claims. Other injuries, including difficult intubation, myocardial infarct, and poor ventilation, have held steady.

Eye surgery claims were more likely to lead to malpractice payments to plaintiffs, 68% compared to 54% for all other surgical anesthesia claims. The average payout was $205,000.

The most common eye injury when regional block is excluded was optic nerve injury which occurred in 38% of claims. Most of these injuries were related to spinal surgery. When it does occur, the effects are devastating, and it reflects in the claims payouts. It has risen from $129,400 twenty years ago to $429,000 recently. Due to this explosive rise in eye injury claims, the ASA issued a Practice Advisory for Perioperative Visual Loss Associated with Spine Surgery in 2006.

By contrast corneal abrasions have decreased in occurrence to only 18% of eye injury claims. Half of the claims resulted in payments to the plaintiff. The median payment was $12,000.

Go to the ASA Newsletter website for a lot more statistical information on this dreaded anesthesia complication.