Saturday, February 21, 2015

Healthcare Driven By Media Hysterics

Our endoscopy suite right now is in complete turmoil. If you haven't heard the news yet because you've been on a 48 hour call shift, UCLA Medical Center released a bombshell of a press release yesterday. They've had two people die and five other people infected with the highly resistant bacteria CRE or carbapenem resistent enterobacteriaceae. The patients came into contact with the bacteria after undergoing ERCP with contaminated duodenoscopes. Up to 180 other people who had the procedure performed from October 3, 2014 to January 28, 2015 are being asked for follow up at the hospital to determine if they too have been contaminated.

When the news broke late Wednesday afternoon, our own hospital went into crisis mode. The following morning, swarms of epidemiologists and microbiologists invaded the GI department. Every scope was taken down from their storage racks and cultured. Multiple meetings involving the highest levels of the hospital administration were quickly convened to deal with the hundreds of calls from worried patients and the news media, even though our hospital has never had any known transmission of CRE through a GI procedure. Patients are cancelling cases out of doubt and fear. When they do come, they are demanding full accounting of how our facility cleans the scopes, as if they had any clue which scope washing techniques works the best.

Olympus, the maker of the duodenoscopes, is already facing lawsuits from infected, and potentially infected, patients. Funny how there were no suits before this became big news. But as soon as the cameras start rolling, lawyers just suddenly pop out of nowhere, each seeking face time on TV to express their outrage at the manufacturer for making a "defective" product.

The Food and Drug Administration is also circling the wagons. People now accuse the FDA of knowingly approving a medical device that could potentially transmit harmful pathogens between patients. They may be fast tracking new cleaning protocols for duodenoscopes, which will probably involve outsourcing the cleaning using expensive gas sterilization with ethylene-oxide, a known carcinogen.

Though the UCLA deaths and infections are terrible events, I can't help but wonder why this has suddenly become front page, network news material. Gastroenterologists, the FDA, and the scope makers have known about this potential flaw in the design ever since it was approved for use. This is not new news. The only reason the duodenoscope continues to be supported by the government is because there is no real alternative for these patients who need an ERCP performed for acute cholangitis, pancreatic cancer, or a host of other pancreato-biliary diseases. But as soon as the four letters U-C-L-A becomes involved, then the entire weight of the masses comes crashing down on all the affected institutions.

As an example of the persecution being heaped on UCLA just for having those famous initials, there was an even more severe outbreak of CRE last year that nobody outside that local area and GI doctors know about. The highly esteemed Virginia Mason Medical Center in Seattle had eleven patients die after contracting CRE from infected duodenoscopes. That certainly did not make any front page headlines anywhere. Even earlier than that, the University of Pittsburgh Medical Center also suffered a rash of CRE infections that were traced to ERCP's. In that instance nobody died.

But now, just because UCLA is the targeted institution, a whole new way of taking care of a medical device will probably be instituted across the entire nation. This is going to cost the hospitals, and eventually the consumers, millions of dollars to prevent a few infections out of half a million ERCPs performed every year in this country. Healthcare consumers in the U.S. are demanding absolute protections with minimal costs. They are going to realize eventually that you just cannot have it both ways.

Thursday, February 19, 2015

Howard University Replaces CRNA's With Anesthesiologists. Why That Is A Bad Sign.

The American Society of Anesthesiologists trumpeted this news all over social media yesterday. Howard University Hospital has fired eight CRNA's and replaced them with anesthesiologists. The ASA contends the facility has realized that anesthesiologists provide superior levels of care to patients as the reason for the staffing change.

But if you look at the hospital's press release, it says nothing about the poor quality of care by CRNA's at their facility as the reason for the change. It clearly states that the hospital has been in financial distress and is seeking ways to save money. It has hired an outside corporation, Paladin Healthcare Capital, to outsource its daily operations. According to the newspaper article, "The changes at Howard are a result of the ongoing effort to turn around its finances."

So the fact is that Howard didn't hire anesthesiologists to give their patients superior care. They were brought in to save money. If they cost more than the CRNA's, they probably would not have been hired due to the hospital's poor financial situation.

Think about that for a minute. The anesthesiologists were hired because they are cheaper to use than the nurses. How can that be when anesthesiologists are supposedly making six figure salaries and rank in the upper echelons among physician salaries? The answer is that CRNA's also make six figure salaries, particularly in expensive areas like Washington, D.C. In addition, the CRNA's would be considered full time employees. Full time employees have the added costs associated with full time work, like health insurance, malpractice insurance, union negotiated break times, paid time off, fixed daily schedules, and pension plans. These are all very expensive, and rising, costs that the hospital has to bear.

On the other hand, the anesthesiologists are likely to be considered independent contractors who pay for their own benefits. The anesthesiologists will have to work for every dollar they earn and be responsible for all their own financial risks, freeing the hospital from these expenses. You think the anesthesiologists will demand a morning break, lunch break, and afternoon break during the work day? Only if they want to see a lower salary and ire from the OR director. They are hired to work, not take fifteen minutes off for a bathroom break. You have to leave by 3:00 PM in the middle of a case because you don't want to miss your zumba class? You want to come back to work tomorrow?

This is indeed sobering news for anesthesiologists. No matter how much the ASA is trying to spin this as a win for us, it actually implies that hospitals value our work no greater than the CRNA's. In the future, anesthesiologists may have to get used to receiving the equivalent incomes of nurses if they want to be gainfully employed.

Sunday, February 15, 2015

Change MOCA. Sign The Petition

A reader of this blog has sent me an email asking me to publicize a petition to demand that the American Board of Anesthesiologists change the current cumbersome rules for maintaining our board certificates. Dr. Thomas Gallen, M.D., M.P.H., is a cardiothoracic anesthesiologist in Indiana. Here is his email to me, which he gave me permission to reprint:

MOCA costs a minimum of $5,000 over 10 years and countless hours of your time in travel and activities of [at best] questionable educational benefit. I/We am/are not opposed to CME nor even to the possibility of mandatory tests but the current system is burdensome and bloated.

We are reaching an age in medicine when the cost-value of everything we do is questioned and I suggest that logic be applied to MOCA as well. Other boards are beginning to question their "practice performance and improvement" components among other components and I ask you now to support me in asking the American Board of Anesthesiology to do the same.

Please read and sign the following petition. This is unlikely to be a final accepted solution but rather a demonstration of Anesthesiologist opposition to our governing Board's decision to monetize the business of certification against our best interests. You are highly encouraged to pass this petition on to your friends, to every Anesthesiologist you know and ask them to do the same. You have the utmost gratitude of my self and the colleagues who have already signed and those who follow you.

You can like and share on Facebook here:

Thank you for your consideration.

Most sincerely,
Thomas Gallen M.D., M.P.H.

Longtime readers know that I have been a persistent critic of the maintenance of certification process for years. If you use the search bar on this page and look up MOCA, you will see the numerous posts I've made criticizing the ABA for this cumbersome and expensive coercion. In fact, I wrote so many posts about MOCA that some readers complained I had nothing better to write about so I put this subject to rest.

But now I see that I merely jumped the gun. Before, the majority of practicing anesthesiologists were rewarded lifetime board certificates so they didn't give a damn about their younger and more vulnerable colleagues who had to pay dearly to take yearly CME courses and fly long distances for tedious simulation and written exams. But the ABMS made a crucial decision recently that significantly widened their base of enemies. The physicians who hold lifetime certification now have a qualifier attached to their certificates. Unless they are also enrolled in this extortion, their certificates will read, "Certified, not participating in MOC."

Clever little bit of legalese, right? The doctor is still considered board certified but unless he starts paying into this unproven program, everybody, especially the lawyers, will be able to see that he hasn't maintained the proper continuing medical education as suggested by the medical board. The doctor's medical judgement just became that much easier for a malpractice lawyer to annihilate.

So please go to the petition website and sign it. I don't know how much of an effect this will have at the ABA, especially since there are literally millions of dollars at stake for the organization. But if the ABIM can start noticing the dissatisfaction with their MOC and begin a new conversation of implementing changes, it doesn't hurt for thousands of anesthesiologists to do the same to the ABA.

Wednesday, February 11, 2015

How Much Does Obama Hate Doctors? Let Me Count The Ways.

We knew President Obama hates doctors. Frankly he dislikes anybody who works really hard for his money and becomes successful at it. Unfortunately for the country, he is in a position of power to redistribute income as he sees fit. This is especially bad news for physicians, as his new Medicare funding proposals demonstrate.

In his latest budget plans, he wants to decrease Medicare spending by nearly $400 billion over the next ten years. How does he plan on finding such enormous savings? Hold on to your wallets because this gets really scary.

The president wants to decrease the amount of money Medicare pays to teaching hospitals and the doctors that work and educate there. He will reduce the amount of money Medicare reimburses these teaching hospitals for noncollectable debt, like care for the poor or homeless, which in most tertiary care facilities is a significant percent of the population.

He also proposes keeping physician reimbursements static, with no adjustments for inflation. In other words, physician payments will shrink in real terms from their already low Medicare rates. This is projected to save $100 billion over ten years.

President Obama also want to cut the amount of money Medicare pays towards residency training programs. This idea would save $16 billion over the next decade. Cutting residency training is particularly ironic since Obamacare is supposed to bring in millions more patients into the healthcare system. There are already too few primary care doctors willing to see the Medicare patients we already have. How can reducing the number of physicians being trained help Obamacare succeed if there are not enough doctors to allow patients to be seen in a timely manner?

The list goes on and on. Again it emphasizes income redistribution, taxing more well off seniors with higher copays and paying less to drug companies for medicines given to low income patients. This Medicare plan is like a slow stranglehold on the healthcare system and physicians. The whole enterprise dies a slow death until the only survivors left are low cost providers like nurse practitioners. That's fine if the president thinks it's normal for people to go to the drug store to get their routine check up.

Hopefully Congress will give this plan the respect it deserves and a truly serious reform for the teetering Medicare and Medicaid plans will emerge. In the meantime, we can see how clearly why doctors will never be able to trust the actions of this president. Just keep telling yourself "Two more years. Two more years."

Tuesday, February 10, 2015

One Distinction Anesthesiologists Would Rather Not Have.

I came across this article from Becker's Hospital Review. Titled "Compensation growth among physician specialties," I thought this looked promising. I could use a little good cheer after reluctantly predicting the end of anesthesiology as we know it.

The article concerns a physician survey conducted by SullivanCotter and Associates. They are a consulting firm specializing in physician compensation. There is no information on the number of physicians who participated in the survey or any other demographic data so take it for what it's worth.

The information initially looked promising. In general, nearly every specialty saw its reimbursements rise from 2013 to 2014. Great. I'll just look down this chart to see how well anesthesiologists fared. Okay. Urology. Up 7%. Good. Next. Gastroenterology. Up 6%. This shows promise. According to the Medscape Physician Compensation Survey, anesthesiologists usually rank right up there with GI in earnings so we couldn't be that bad. So I keep looking down the long comprehensive chart. And keep looking. And looking.

Pediatrics, up 5%. Hospitalist, up 4%. Family Medicine, up 3%. Where is this going? Did they forget to survey anesthesiologists? Just when I was starting to think that anesthesiologists were not included in their compensation poll, I arrive at the rock bottom of the chart. And guess who resides down there. Anesthesiologists, DOWN 2%.

WTH. Granted the median compensation is still pretty good at $368,510. But we were the only medical field to show a decrease in earnings year over year. Our services aren't even valued enough to maintain our previous year's income, which would actually be a decrease when inflation is taken into account.

Is this another sign that the anespocolypse is upon us? One year's worth of data doesn't make a trend. We'll have to wait another year or two to discover if it's time to start moonlighting in a profession where there is real pricing power and you don't have to take sh** from anyone--nursing.

Monday, February 9, 2015

Blame Anesthesia

I love this flow chart from the Gomer Blog. Having come from the surgery side of the ether screen, I'll let you in on a little secret--this protocol is what they teach surgery residents at their M&M conferences. That's how surgeons can become instant pricks as soon as they start private practice.

How Hard Is It To Match Into Anesthesiology? The Surprising Answer.

FiveThirtyEight has a very informative article about how the whole Match process came about. It gives an historical perspective of the horrors experienced by medical students and hospital residency programs prior to the institution of the Match. Some students would take the first offer that was proposed, whether they really wanted to go there or not, in fear of not receiving a residency position later on. Others would drop their commitment to a program when a better offer came around, leaving programs in a lurch. The Match has done a pretty good job of bringing order to this chaos.

The history of the Match started with algorithms developed using game theory. That's right, the future doctors of America have their whole professional lives dependent on how games are played. Developed by American mathematicians Lloyd Shapley and David Gale, the algorithms were first used to describe how to match up men and women for marriage. Since then, the program has been able to successfully match nearly 95% of medical students with a residency spot, with nearly 80% able to get one of their top three choices.

Now ideally every single student would be able to receive the residency of his or her choice. But of course it doesn't happen that way. Some residencies are much more competitive than others, resulting in a low match number for students. Meanwhile the less popular specialties go begging for applicants. They have no choice but to accept nearly everybody who shows even a hint of interest in going there. Therefore students who wanted to go into the undesirable programs were almost guaranteed to get in. The National Residency Matching Program has produced a tidy little graph detailing how competitive each specialty has in attracting medical students.

Last year, the NRMP showed that Plastic Surgery and ENT were some of the hardest fields to enter. Only about three-fourths of 4th year US medical students successfully matched into those programs. The numbers were even more abysmal for other students, like foreign medical graduates. They were able to get into those spots less than half the time.

By contrast, the least competitive programs had match rates of nearly 100%. For 2014, the surprising wallflower was Diagnostic Radiology. It was nearly impossible for future radiologists to not get into a radiology training program last year. Even FMG's had almost a 75% likelihood of matching into radiology.

While predictably Pathology and Internal Medicine were shunned by many medical students, look who rounded out the top five in the most unwanted residencies--Anesthesiology. It was actually easier to match into anesthesia than, horrors!, Family Medicine. This was especially true for FMG's, who had about a 75% chance of getting into anesthesia compared to 50% for Family Medicine.

Of course this shouldn't come as a surprise to anybody who's been paying attention. Demand for anesthesiologists have been falling for some time now. The number of practicing anesthesiologists have increased at twice the rate of the general population growth for the last decade. Meanwhile the anesthesia residency program directors keep cranking out more new graduates every year. According to the NRMP, the number of PGY-1 spots in Anesthesiology has increased from 797 in 2010 to 1,049 last year.

The writing may be on the wall for the future of anesthesiologists. It is rapidly becoming a saturated medical specialty with too many providers scrambling for too few good jobs. Factor in the competition from non physicians, the anesthesia job market is on the verge of crashing under its own weight. Good luck to all the medical students on Match Day who want to go into Anesthesiology.

Wednesday, January 28, 2015

The Finger Pointing Begins. The Joan Rivers Malpractice Lawsuit

You knew it would come to this. For all the talk about medical staff teamwork in the operating room, when the sh** hits the fan, each person is on his own, trying to save his own butt from the wrathful vengeance of the malpractice attorney. In the medical malpractice lawsuit filed by the late Joan Rivers's daughter, each doctor is now essentially blaming each other for the comedienne's untimely death last September 4th during a simple endoscopy.

During the official investigation following her demise, a note was found in the chart that was handwritten by the anesthesiologist, Dr. Renuka Bankulla, that said she tried to find the ENT surgeon who had performed the laryngoscopy and possible vocal cord biopsy, Dr. Gwen Korovin, when Ms. Rivers went into cardiac and respiratory arrest. However Dr. Bakulla couldn't find Dr. Korovin in the room to perform a cricothyrotomy to open up the patient's airway even though she was there only minutes prior to the arrest. The suit speculates the Dr. Korovin fled the room at the first sign of trouble because she was not credentialed to perform procedures at the Yorkville Endoscopy center.

The attorney for Dr. Korovin counters that she was in the room all along. In fact, the faithful doctor was the last person to leave the room when the patient was taken away by ambulance. Just because the anesthesiologist didn't see her doesn't mean she had left the room. However, Ms. Rivers's lawyer wonders why, when Joan wasn't able to get any air into her lungs, the surgeon didn't take over the airway and performed the emergency operation. Said Jeffrey Bloom, the attorney, "She's an airway specialist. Why isn't she stepping forward and saying 'I'll do it' or 'You do it'. Instead she obviously did nothing."

Naturally much more will come out as the lawsuit proceeds. More witnesses will be testifying as to the whereabouts of Dr. Korovin, including the testimonials from the GI doctor and two other anesthesiologists and nurses that were in the room when disaster struck.

This is an important lesson for all anesthesiologists. You may think you are good buddies with your favorite surgeon, going out and playing golf or fishing together. Maybe you send each other Christmas cards or your children play soccer on the same junior high team. But when trouble hits, that friendship will quickly dissolve into acrimony.

A few years ago, one of our anesthesiologists was working with a highly likeable orthopedic surgeon. The surgeon was always friendly and loved to tell corny jokes in the operating room. Everybody wanted to work him. Then one day, after a simple joint procedure on an elderly female patient, the surgeon wrote a narcotics order after she had already been transferred out of recovery and to the floor. The patient consequently had an unwitnessed respiratory arrest and died. The inevitable malpractice suit was filed and now the surgeon was blaming the anesthesiologist for oversedating the patient while in recovery leading to the arrest from a routine narcotics order when she went to her room. That happy face mask quickly disappeared when facing a multimillion dollar lawsuit. A tough education no anesthesiologist should forget.

Thursday, January 22, 2015

The ASA's New Sexist Home Page

ASA's new home page
With the start of a new calendar year, the American Society of Anesthesiologists has unveiled a brand new home page on their website. They are quite proud of it and hope you like it too. They even provide a convenient link to their web editor so you can express your amazement at the good use of your annual dues to keep their home page fresh and engaging. You know of course that dripping sarcasm is difficult to express on a written page.

So here is my problem with the new site. There is nothing wrong with the new design. It is less cluttered and more prominently offers links to pages that you are most likely to use, like the current news or log in page. But the contents on this particular page are beyond sexist. Their first feature of the year is a discussion on pain in women. I object to the society pandering to females when pain is a universal ailment. Everybody feels pain. Why is the ASA focusing on predominantly female problems like fibromyalgia? And now the ASA claims they have expertise in treating PMS?

What happened to the other half of the world's population that also experiences pain? When I get back from the gym after benching 250 pounds, I get a soreness in my chest and shoulders. What's the ASA's answer to that? After a long weekend trip in the Santa Monica mountains mountain biking, my knees and thighs are screaming for relief. Will the ASA also offer a rose oil rubdown as treatment? Men suffer pain too. We just don't bring as much attention to it as we probably should because, well, we're men. And we can take it.

The other part of the new home page that I find extremely objectionable is the lack of diversity being shown. The slide show that scrolls across the top of the page currently only features one kind of anesthesiologist. I'll give you a hint: none of them are men. All the anesthesiologists pictured are women, even though they make up a minority of the ASA membership. Is this the ASA's idea of membership diversification? Did I miss the memo that January is Women Anesthesiologists Month? The links associated with those pictures aren't even gender specific. They involve subjects like Practice Management and paying your membership dues, neither of which are gender related. Yet every single image is of a female anesthesiologist. Has the ASA been hijacked by the National Organization for Women?

Exclusion of men does not make the ASA more inclusive. The ASA should be embracing all anesthesiologists, not just the politically correct ones. I've never heard anyone complain that there are too many male anesthesiologists. Don't stir up a gender controversy when there is none to begin with.

The Ultimate Sacrifice

Dr. Michael Davidson
We like to think doctors are kind, selfless people, working tirelessly to help the sickest and neediest human beings with little regards for our own well being. Unfortunately, not everybody feels the same way. The shocking murder two days ago of Dr. Michael Davidson, a cardiothoracic surgeon at Brigham and Women's Hospital in Boston, once again underscores the precarious situation physicians face every day when dealing with people who may not be thinking rationally when confronted with severe illness, either in themselves or in a family member.

Dr. Davidson was shot in his own medical office by the son of a deceased former patient, Stephen Pasceri. He then turned the gun on himself and died of self inflected gun shot wounds. Police investigations have not yet revealed the reasons why Mr. Pasceri decided to shoot the surgeon. His family is equally baffled by the violence, stating they felt their mother received good care while under Dr. Davidson's watch.

Dr. Davidson was only 44 years old. He was essentially just getting started with what was supposed to be a long and brilliant career. When you take into consideration the extremely long road that's required to become a cardiac surgeon--medical school, surgical residency, cardiothoracic fellowship--it's clear that he had only been in practice a few years. It's tragic that so much sacrifice he took to become a surgeon could be so easily extinguished by a crazed individual with no regard for human life. He leaves behind three children and a wife who is seven month pregnant.

This isn't the first time a surgeon, was murdered by a disgruntled individual in his own office. Back in 2013, a urologist, Dr. Ronald Gilbert in Orange County, was shot and killed by a patient unhappy with his prostate surgery performed 21 years prior to the shooting. He was not the patient's surgeon but was unlucky enough to have been chosen by the gunman for retribution.

More commonly, doctors and nurses have to deal with verbal and sometimes physical abuse from our patients regularly. Any healthcare professional can easily rattle off instances where patients have swung at them with fists, or tried to kick them while lying on a gurney. We've been yelled at, spit upon, threatened with legal action, all while we're doing the best we can to heal the patient. Sometimes we wonder if facing these confrontations is worth the sacrifice to our own dignity and well being. The answer of course is yes, because taking care of patients is our ultimate goal, no matter how much we too have to suffer before they understand that.