Wednesday, December 31, 2014

The Decline Of Medical Neologism

Medicine has always been good at inventing new terms to describe the human condition. Traditionally the words were based on Greek and Latin roots. That's why we get words like "hypokalemia" that can still stump new medical students, National Spelling Bee contestants, and electronic medical record software engineers alike.

Later on, the French made their contributions to the medical dictionary with lyrical terms all their own. Phrases such as peau d'orange (to describe the orange peel looking skin of advanced breast cancer) and cri-du-chat (the crying cat sound a child makes when he or she suffers from chromosome 5p- syndrome) flummoxed our less savoir faire young doctors. However, they do make the speaker seem more sophisticated and worldly if he can easily slip French words into a medical conversation.

American medicine has been in ascendency for the last couple of centuries. Therefore it is appropriate that American English words (not equivalent to British English) would make its way into a doctor's dialogue. Unfortunately we have not been quite as creative at inventing new elegant sounding phrases like the French.

For instance, we have descriptions like "cobblestone" to characterize the look of the intestinal mucosa of a patient suffering from inflammatory bowel disease. Or we get a contribution from the uniquely American melting pot with a term like "schmutz" to represent nonspecific debris on the body. Descriptively accurate? Yes. But decidedly pedestrian.

All of which leads me to a head turning note I saw on a patient in our hospital computer. It would seem that despite millenia of development of medical terminology, some young doctors feel they have to come up with new words to truly chronicle the plight of their modern patients. Thus the appearance of the phrase "stably-sick".

Now some purists would say that doctors should never refer to patients as stable. Stables are where one beds down horses for the night. But since it has been universally used to refer to patients who are neither deteriorating nor improving, I'm not going to quibble with it. But then this doctor can't quite bring himself to say the patient is stable. The patient is also very ill as illustrated by the need for IV pressors to maintain blood pressure. So is the patient progressing or sinking? Hmm. Let's think about this for a minutes. Since we can't make up our minds, let's just mash two words together and broadcast to every doctor and nurse who reads this note that despite our years of medical training we are too indecisive to truly understand this patient's medical condition.

Maybe medical schools should include a semester of French as part of the curriculum. That way if these new doctors are going to start making up words and putting them into legal documents, they can at least sound educated, not like graduates from the generation that gave us "twerking".

Tuesday, December 2, 2014

"Studies Show We Are Just As Good As You." Anesthesiologist Vs. CRNA



It's a rare gloomy and rainy day here in Los Angeles. The patients are all running late because of the horrendous traffic that paralyzes the city every time a few raindrops slicken the roads. So I thought this is a good opportunity to have a few laughs while at work, especially if it is at somebody else's expense. Enjoy.

Monday, December 1, 2014

Evolution Of The Anesthesiologist

I saw this chart on the Facebook page of a British anesthesiologist (anaesthetist if you're speaking the Queen's tongue).There is only one thing wrong with this picture. Can you guess? There were no cavemen in 2,000 B.C. Everything else is about right.

Which Institution Is The First In The Country To Embrace Sedasys?

Though the Food and Drug Administration approved the use of Sedasys in 2013, it has taken a year for the first hospital to accept its use in a clinical setting. Sedasys is a computerized system that administers propofol autonomously without the presence of an anesthesiologist in the room. It was mired in regulatory limbo for years before the FDA, in extraordinary fashion, reversed its own earlier ruling and allowed it to go into the market, thus realizing most GI doctors' propofol fantasies.

The first medical center to embrace Sedasys has turned up in...Seattle, Virginia Mason to be exact. Otto Lin, M.D., the Director of Quality Improvements at Virginia Mason and also a gastroenterologist, proudly states that, "It really allows us to use propofol, which we believe is superior to midazolam and fentanyl, in outpatients without having the added cost of having the anesthesiologist administer the drug."

Quite frankly, unless the anesthesiologists at Virginia Mason are employed by the hospital, Dr. Lin and the other GI's who work there may have trouble finding any anesthesiologist to back them up when, not if, an airway emergency occurs. Any anesthesiologist knows that once he steps into that procedure room, or even if he is within earshot of the impending disaster behind that closed door, the liability for the airway catastrophe instantly shifts to the anesthesiologist and away from the GI doc. Do they expect anesthesiologists to rush into an unknown and unstable situation at any time and just perform an airway resuscitation on a complete stranger out of the charitable goodness of our hearts?

Anesthesia reimbursement for endoscopies have been steadily eroding anyway. Sedasys was approved by the FDA only for ASA 1 or 2 patients. Insurance companies have increasingly denied anesthesia payments for MAC administered to these relatively healthy patients. Therefore it probably isn't going to have a major effect on most anesthesiologists' incomes. Any anesthesiologist whose livelihood depends on giving anesthetics exclusively to ASA 1 or 2 endoscopy patients every single day probably isn't living up to the potential of his hard earned board certification and should probably move on to something more professionally fulfilling in his life.

So let's see what happens now that Sedasys has been unleashed out into the wild. Will the cost savings really justify its exclusion of the potentially life saving presence of a second physician in the room? Will gastroenterologists accept full responsibility for a patient's airway calamity or will they still attempt to push the job to any anesthesiologist that just happens to be walking past the endoscopy suite? Only time, and a few unfortunate complications and possibly deaths, will answer that question.

Sunday, November 30, 2014

Why Surgeons Can't Seem To Show Up On Time

We have been trying to understand the reasons why so many of our cases start late. Cases not starting on time is probably one of the chief complaints of surgeons, anesthesiologists, and patients. If we can solve this thorny issue, half the battles in the place would be taken care of.

Our surgery center has been focusing on the first case of the day since if the first case is delayed then the entire lineup in that room will also likely be late the rest of the day. Therefore, for the last year we have been keeping track of the reasons for the first case not getting into the procedure room on schedule.

After compiling the data, it will come as a surprise to virtually nobody that surgeons are one of the chief causes for delayed starts. The nurses have to clock in by a certain time so they are rarely late. The anesthesiologists have to get there early to set up their rooms. Consequently it is almost always the surgeons who are the source of the bottleneck.

We then wrote some gentle email reminders to the worst offenders to ask them to please show up on time so the whole day isn't ruined by their tardiness. Did we get any mea culpa's from these medical professionals? Were there any acts of contrition and promises to be more responsible in the future? Maybe in your wildest propofol dreams. Here are some examples of the responses we received from these doctors.

"We are not motivated to get there on time b/c it never runs on time.  My 7AM case started on Monday at 7:45 b/c my patient was held up in registration.  Why should I go out of my way to get there on time just to sit await and await."

This is clearly circular logic at its best, or worst. So this surgeon will routinely show up late for cases because his patients are not being properly instructed by his office to show up early so the voluminous paperwork can be completed in a timely manner. Even if the patient did get all the preop work finished on time, the surgeon likely won't be there anyway because in his mind the patient has probably been delayed by the system. So why should he be held accountable for the whole day running late?

"I, not being an IT person, takes me a very long time to get the attestation to get the H&P and all the requirements which I feel have no relevance to patient care and probably other doctors feel the same."

Meanwhile this surgeon is blaming our computer system for causing the cases to be delayed. Never mind that we have been using the system for over a year and almost all the other surgeons have long ago figured out how it works. He goes on to complain about the relevancy of the EMR to patient care which actually has nothing to do with the problem at hand. It's just another form of deflection and not taking responsibility for causing the main source of irritation to his fellow surgeons and their patients.

This is the kind of mentality anesthesiologists have to deal with every single day. We have to work with unreliable and immature egomaniacs who think nothing of meting out the blame to everybody but themselves. It's a wonder that these people ever graduated from elementary school.

Thursday, November 20, 2014

The Most Meaningful Job In Medicine Is...Not Anesthesiology

The website Payscale.com released an interactive chart on the most meaningful jobs in the country. They define meaningful as "Does your job make the world a better place?" Not surprisingly, Clergy came in as the most meaningful occupation one can attain. A full 97% of clergy reported that their work is meaningful, with 88% saying they have high job satisfaction. On the other hand, fast food cooks came in last, with only 22% saying they have a meaningful job and 45% reporting a high satisfaction.

While it's important to have a job that makes the world a better place like Clergy, maybe some of us prefer to have a high income AND a meaningful job--have our cake and eat it too. For that, you need to get your butt into medical school. Healthcare workers report the highest income and the highest meaningful numbers according to Payscale. On their chart, all the little yellow circles that are far to the right on the meaningful scale and trail up towards the top of the income scale are all healthcare providers. They include OB/GYN, Internal Medicine, Psychiatry, and Family Practice.

And ranked at the very top for medical workers are surgeons. Surgeons reported having the highest median income of all doctors. They arrive at a median income of $299,600 by including the salaries of high paying surgical fields like neurosurgery and orthopedics. About 94% of surgeons say their jobs are meaningful and 82% have a high job satisfaction. However, 79% say their jobs also come with high stress levels.

How do anesthesiologists compare on this chart? We come in at a very respectable number two. The reported median income is $291,300. Ninety-one percent of anesthesiologists say their jobs make the world a better place. Seventy-eight percent say they are highly satisfied with their jobs. Like surgeons, 79% of anesthesiologists report having a high level of stress at work.

So if you want to be poor and change the world, get yourself to theology school. If you want to be poor and inconsequential, apply to your local burger joint. If you want to be rich but unfulfilled, get yourself into law school (40% meaningful). If you want to have it all, be a doctor. But your mother already knew that didn't she when she made you apply to med school.

Sunday, November 16, 2014

When The Surgeon Asks For Cash...And Puts It In His Pockets

Here is some pretty contemptible news out of Torrance, CA. A young woman is suing her surgeon because he said her operation at a local hospital was not covered by insurance but if he paid her in cash he would do it at a surgery center that he co-owns. Sounds pretty shady, right?

Liza Lumanlan-Domingo had a fetal demise and needed to have the fetus removed. She is a nurse at Torrance Memorial Medical Center and asked for one of the staff surgeons, Dr. Steven Rosenberg, to do the procedure. Incredibly, Dr. Rosenberg told her that her insurance would not cover her surgery at her own hospital but he could do it at Pacific Coast Surgical Center, a facility in which he is part owner. Liza and her husband met Dr. Rosenberg at the surgery center at 7:00 AM on a Sunday and gave him $800 in cash which he puts into his pocket with no receipt returned.

She had her surgery the next day but started to bleed profusely. The surgeon asked her husband to run to the hospital pharmacy to buy $160 worth of medications that the outpatient facility did not carry. Eventually she needed to be transported by ambulance to Torrance Memorial for treatment where she stayed in the ICU for three days. Only later were they informed that her insurance would have covered her procedure at the hospital.

We hear these kinds of self-serving stories all the time. As more surgeons start building their own outpatient surgery centers, they siphon off the best patients from the very hospitals that they work in. Patients who have good health insurance or can afford cash are quickly whisked off to a posh aromatherapy infused ambulatory center while the Medicare/Medicaid/Uninsured patients are herded to the local hospital. Hospitals start losing money because of poor reimbursements while their staff physicians drive into the doctors parking lots in their Mercedes and Bentleys.

Should the couple have called the insurance company to question the denial of payments for treatment at the hospital that she works at? Perhaps. But maybe they were so emotionally distraught and they felt they had a surgeon whom they thought they could trust that they didn't want to go through the red tape of dealing with the insurance company. They just wanted to expedite the surgery for a quick closure.

One day, when all doctors in this country become government employees, these terrible stories of how avarice infected one of the most respected professions will serve as cautionary tales. We'll look back and wonder how we let the critical need for healthcare become a profit center that made a very few people very, very rich.

Friday, November 14, 2014

News Flash--Expanding Medicaid Enrollment Costs More Money

This story is both comic and tragic. State governments are now realizing that expanding the number of patients eligible for Medicaid is straining their budgets and the healthcare system. Hello! Obamacare allowed the states to expand their Medicaid eligibility rules to cover more people. Twenty seven states have done so. Now Medicaid covers 68 million people in this country while Medicare covers 53 million. In ten years it is projected Medicaid will be used by 93 million citizens. The Wall Street Journal has an article detailing the outcome of expanding Medicaid in New Mexico, the state with the highest proportion of Medicaid patients in the country.

Who will see all these patients? The primary care physicians who are expected to be the gatekeepers are already straining to keep up. Many have capped the number of Medicaid patients they will see in their practice. Dr. Holly Abernethy, a family practitioner in New Mexico, has to keep her Medicaid patients to less than 13% of her practice. Otherwise she will have to work a lot longer to keep her office from closing. As it is, she is making $150,000 per year.

In the meantime patients still need to be seen so they are gravitating to healthcare providers like nurse practioners. Jodi Padgett, an NP in New Mexico, has seen an influx of new Obamacare patients on Medicaid. She will accept up to 40% of her patients being on government insurance. She will be paid the same amount of money seeing a patient from Medicaid as Dr. Abernethy, about $80. Her income this year will be $130,000, almost the same as a medical doctor. But she too will eventually have to turn patients away to keep her business from bankruptcy.

Patients finally turn to the emergency room for their care when they run out of options. At a San Juan Regional Medical Center, ER usage is up about 9%. However, Obamacare cut back compensation to hospitals for uncompensated care, reasoning that more patients will have health insurance. This has decreased the government funding from $12 million to only $2 million. As a result, the local government has had to trim other programs like the local park and raise taxes.

The first hints of the consequences of Obamacare are now starting to trickle in. So far it doesn't look good. More patients have insurance but access to medical doctors may be limited. They may have to settle for being seen by nurse practitioners or physicians assistants. Hospitals are getting flooded by poorly paying patients while their funding gets chopped. Local governments have to raise taxes to make up for the lost revenue. And this is while the federal government is paying for 100% of the extra Medicaid expenses. What will happen in two years when the states will have to start paying for a portion of the Obamacare bill?

It's no wonder nearly half the states' governors have opted out of expanding Medicaid despite the federal government's enticement of 100% reimbursement. The crap is starting to hit the fan. Let these other states get splattered first with the excrement and see how they clean it up.

Thursday, November 13, 2014

When Male Chauvinism Turns Deadly

I've been following this horrible story out of India the last few days. Over a dozen women have died and dozens others become seriously ill after undergoing a tubal ligation, part of the government's attempt to rein in out of control birth rates in that developing nation.

Initially suspicion fell on the surgeon, Dr. R. K. Gupta. He reportedly performed 83 sterilization procedures in a span of six hours, though some witnesses claim it was as little as two hours. For all that work he received $100. That is a short day for him because he reportedly has done as many as 300 procedures in one day. The rules say no more than 30 sterilizations should be done at a time. However his breach of protocol didn't seem to affect his standing as the local government honored him last January for having performed 50,000 tubal ligations.

Patients describe the clinic as an assembly line. Each case was performed in a matter of minutes with only local anesthesia. There was little regard for patient discomfort. With such a fast turnover, there was little time for proper sterilization of the surgical instruments. Dr. Gupta reportedly dipped his equipment into a pool of disinfectant just long enough for one patient to be taken off the procedure table while another one was put on. While that may be the standard of care over there, that would be a "Saw" horror movie here in the U.S.

Now there are reports that other women have fallen sick after receiving sterilization. Fingers are now being pointed at possibly tainted samples of ciprofloxacin and ibuprofen that each woman is given after the surgery.

Regardless of the cause of these women dying after attempting to control their reproduction, it is very sad that so few Indian men will do the same thing. Up to 37% of Indian women have their tubes tied, the highest in the world, versus less than 1% of men with vasectomies. Vasectomy is a safe, outpatient procedure that really can be done in just a few minutes with a much lower risk for major complications like sepsis or organ injury. The Indian government even offers higher cash incentives for men to undergo sterilization. Men receive 2,000 rupees ($33) while women get $1,400 ($23) for going through a much riskier and invasive operation.

A husband of one of the victims was interviewed after receiving $3,300 as compensation from the state. He complained it will do him no good now as he has three children to take care of on his own. Perhaps he should have sucked it up as a man and gotten a vasectomy instead having his poor dead wife suffer because he couldn't bear the thought of having his scrotum cut.

The Most Self Loathing Anesthesiologist In The World

I usually don't like to comment on the opinions of other anesthesiologists, much less dump on them. After all their opinions are their own and why should I try to refute their beliefs. But I just read an opinion piece in the widely seen and respected site KevinMD. Written by Dr. Shirie Leng, it is so outrageous and preposterous that I felt I needed to make a counterpoint.

Titled, "Anesthesiologists have to start to truly care for patients," Dr. Leng, a former nurse, starts off by stating that anesthesiology is for people who don't like to relate with patients. She describes the interaction between a patient and an anesthesiologist as thus, "He reviews the information the surgeon and nurse have compiled in the patient’s chart. “Hi, How are you?  I’m your anesthesiologist.  Anything to eat or drink today?  Any problems with anesthesia in the past?  No? Great!  I’m going to put your IV in and then we’ll get going.”

I don't know about Dr. Leng, but my bedside manners are much friendlier and more refined than what she depicts. If that is how she talks to her patients, I wouldn't want her to be my anesthesiologist either. While my time with patients are constrained by necessity, that doesn't mean I can't have a meaningful exchange with them and their families. As a matter of fact I have patients who ask for me by name whenever they need to come back for another procedure. All good anesthesiologists have been blessed with the appreciation of grateful patients. Maybe Dr. Leng just hasn't had the privilege of being loved by her patients if she thinks that's how patients see us.

Naturally this drivel has generated quite a bit of publicity for herself, the way a bad wedding video can go viral for no other reason than that it was bad.  So she wrote a response post on her blog with a blatantly backhanded compliment of anesthesiologists. I'm not going to bother linking to that nonsense since I don't believe I want to give her any more exposure than she already has. But let's just say she doesn't appear to love any anesthesiologist except maybe herself and her anesthesiologist husband.

For any medical students out there contemplating anesthesiology, obviously don't believe everything you might read about this profession. Talk to an anesthesia attending that you respect and get their perspective. I bet he or she can regale you on how crucial a good anesthesiologist is for patient care. We truly save lives every day. As for me, I feel lucky every day that I work in a job I love. I wouldn't have it any other way.