Tuesday, July 21, 2015

Anesthesiologists Are Like Herding Cats

I have some good news to share with my loyal blog readers. After working for over a decade in my anesthesia group, I recently received a job promotion. Now instead of just being a worker bee anesthesiologist, I have a more managerial position. Before you congratulate me on my career advancement, let me just describe to you what my new responsibilities encompass.

First of all, I get a small, small pay raise. It works out to about an extra $50 per week. Hooray! That doesn't even cover the cost of taking the family out to the movies. My new job description also doesn't include the ability to hire or fire anybody. That privilege still resides with the current Chief of our group. However what I do get to do is hear everybody's grievances about each other. And there are a lot of that.

I have to entertain complaints from anesthesiologists about nurses, surgeons, and fellow anesthesiologists. If a surgeon doesn't like the way his anesthesiologist is working, I get to hear about it. When a nurse feels one of our partners is too engrossed in his cellphone instead of on the patient, I'm the one who has to convey the message to the offender. Don't even get me started on the petty complaints our partners have against each other.

Before I got this promotion, I was totally oblivious to all this backroom drama. I came to work in the morning, shut myself in the operating room for the next eight to ten hours, then left the hospital after a job well done. Not only do I still have to keep doing those same tasks, but now I'm answering emails and text messages all day. Then there are the meetings. My work calendar has never been so full of meetings. There are conferences that meet regularly to try to resolve earth shattering disputes like how to get the janitorial services to clean the operating rooms more quickly. Or why the break room doesn't have enough shelving for everybody's lunch bags. Or how some anesthesiologists talk too much during an operation.

As any newly promoted manager will tell you, once you are not your peers' equal, you are no longer "us". You suddenly become one of "them". Which means there are no more sharing jokes about the incompetence of the group management because now I am one. The previously chummy relationships have become more formal, even a bit frosty. Edicts on proper conduct in the OR that come from above are now my responsibility to enforce to my colleagues. And that's when I realized why some surgeons dislike anesthesiologists so much.

Managing anesthesiologists can sometimes feel like herding cats. We are so used to working independently in the operating room that we don't take kindly to having somebody telling us what to do. So when I was tasked to pass along a message to a colleague that he is getting complaints about his slow inductions, causing the surgeon and the whole OR staff to wait, I not only got a frosty reception, I was nearly thrown out of the room. Since I have no powers of enforcement, like monetary penalties or job termination, my fellow partners can do that to me with impunity. In fact, some have turned the tables around and complained about me to our Chief, claiming my newly high handed and authoritarian demeanor was not tolerable.

Don't get me wrong. I love my new responsibilities. After working so long in the loneliness that can be the workday of an anesthesiologist, I suddenly feel the added tasks I do make my job interesting again. I enjoy my fellow anesthesiologists coming to me for help when they have a problem they need fixing. Or sometimes all they need is an ear for them to unload their issues. I feel I'm good at that kind of thing. And my bosses think I am too. I would take on these new duties even if I had to do it for free. But don't tell my Chief that.

Sunday, July 19, 2015

What Doctors Eat On Call

You would think that doctors, with all our lecturing about healthy diets and exercise, would be paragons of nutritional correctness. But we are human just like everybody else. One of the first lessons medical students learn is that when they are on call, they should eat and drink whenever they can because the opportunity may not present itself again until hours later. So it's not uncommon for us to have the most atrocious diet while at work.

I was on call the other day and hadn't had a chance to eat anything, other than a furtive bite of a granola bar I had in my pocket. Finally, by around 9:00 PM, the operating rooms were starting to settle down. I dragged myself to the break room to get some water and what did I see when I opened the door? A bright red half eaten bag of Doritos was sitting on the table. Now anything that is sitting out in the break room is fair game. I looked around the room but it appeared I was all by myself.

I looked into the bag. There wasn't that much left, maybe a couple of servings at most. I told myself I will eat just one chip, not only because Doritos aren't exactly a health food, but because other people may want some too. I reached into the bag and brought out a perfectly triangular and unbroken chip. When I popped that in my mouth, a rush of endorphins rushed through my body. It felt like the most satisfying morsel of food I had ever eaten in my whole entire life. I didn't realize how famished I was until my tongue was coated with that delectable nacho cheese powder.

Well who can stop with just one chip? But now I wanted more. Not just more. I wanted it all. I don't care if other people working that night didn't have a chance to eat the Doritos. That bag was mine, MINE! Since there was still nobody in the break room, I quickly snatched the bag and headed to my call room. Once in the privacy of my room, I greedily reached into the package and grabbed another chip, followed by another and another. Before I knew it, I was tipping the bag upside down over my mouth to get the last crumbs of Doritos at the bottom. Then I was licking my nacho cheese covered fingers hungrily. If I could devour my cheese powder covered fingers for a snack, I think I would have that night.

Then it was over. The Doritos bag was empty. My orange colored fingertips held no more nacho cheese. And I was left suffering a deep sensation of guilt for absconding with a bag of chips from the break room. And these truly are empty calories. I felt no more fulfilled now then when I first started eating the chips. But my pager started beeping and I had to get back to work. Even if they are empty calories, they're calories just the same, enough to get me through another few hours of work.

Besides, nobody will ever know how pathetic I was when confronted with a bag of Doritos. Unless my Doritos breath gives me away. I kept that surgical mask over my face the rest of the night.

Saturday, July 18, 2015

The Scariest Chart A Doctor Will See

This chart should frighten the bejeezus out of doctors. It comes from the July, 2015 issue of the ASA Newsletter. It's included in an article explaining how the new SGR fix, now known as MACRA, is supposed to work. In a nutshell, the graphic illustrates how the government takeover of American medicine is going to decimate the economic livelihood of physicians.

As you can see, during the first five years of MACRA, Medicare will entice doctors into the program with a tiny little 0.5% bonus payment each year, which doesn't even cover the cost of consumer inflation, let alone healthcare inflation. But then, in 2019, once doctors have become fat and happy with the new system, the hammer will start too fall. Medicare will start paying, or more accurately, penalizing physician reimbursement based on a set of bureaucratically selected criteria on "performance".

These factors encompass an entire bowl of alphabet soup acronyms: PQRS, VBM, MU, CPIA. I won't get into the definition of each one as that would take a lot of time and frankly, I'm not even sure of their exact meanings. You'll just have to read the article for yourself. But the bottom line is that if doctors don't measure up to these new government rules, their paychecks will start to shrink, dramatically. In ten years, which is when MACRA will sunset, physician compensation could be cut a maximum of 9% each year. For typical doctors' incomes, we're talking about $20,000 to $50,000 that will be eliminated based solely on how some faceless government workers decide how well you follow their rules. You'll also notice that this is all based on negative reinforcement. There is no bonus for doing well, only penalties for not performing as well as the feds think you should. As a matter of fact, if every single doctor doesn't do what the government wishes, Medicare may actually save more money. So you can see how if Medicare decides it needs to reduce its budget, it can easily complicate the rules anytime it wants to cut physician payments at its whim. Talk about an abusive codependent relationship.

So the American Medical Association may be crowing about how they finally rid medicine of the hated SGR. But out in the real world, working physician will only likely face more pain for years to come.

Monday, June 29, 2015

What Is Anesthesia?

Because we anesthesiologists are so bad at explaining our purpose in the operating room, our good friends from The Joint Commission have developed this colorful poster of what patients can expect when they go in for a procedure. I guess the ASA could use some education on how to effectively teach patients about anesthesia. Compare the TJC's succinct, graphically intensive poster to the ASA's Lifeline to Modern Medicine website that tries to do the same thing:
Yeah the ASA should use some of the millions they receive from our annual dues and hire a better graphic artist.

Tuesday, June 23, 2015

Anesthesiologist Caught On Recording Insulting Patient

An anesthesiologist in Virginia lost a $500,000 malpractice suit when a patient recorded the conversation inside a GI procedure room. The patient had set his cellphone to record so that he could remember his post colonoscopy instructions. He accidentally left it on when he went in for his study.

What he found was shocking and humiliating. He heard the gastroenterologist, Dr. Soloman Shah, and the anesthesiologist, Dr. Tiffany Ingham. make derogatory comments about his masculinity and anatomy. They snidely remarked about the man's penis, saying a lesion may be syphillis, TB, or even Ebola. The anesthesiologist suggested the patient should "man up" when he was squeamish about getting his IV line started. The anesthesiologist, for no good reason, even lied and wrote on her record that the postop diagnosis included hemorrhoids when in fact the patient did not have the condition.

For these comments, the jury found Dr. Ingham guilty of defamation and awarded the plaintiff $100,000. Then they piled on $200,000 for medical malpractice, even though as far as we know, the anesthetic was fine. And then the jury gave the man another $200,000 for punitive damages. Shockingly, Dr. Shah was let out of the case. This was despite the fact that he too was heard on the audio agreeing with and contributing to the derogatory comments. Either he had a much better malpractice attorney than the anesthesiologist, or he had much worse malpractice insurance.

What's the lesson here? Anesthesiologists should treat their patients as well when they're asleep as when they're awake. In fact, they should take care of their sedated patients even better since they have no way to defend themselves while they are in such a vulnerable position. And if you hear anyone else in the OR making stupid remarks about a sleeping patient, remember that you too can be found liable for being an accessory to defamation.

Saturday, May 30, 2015

Preaching To The Choir

There are some scientific papers out there that are so original and groundbreaking that they change the paradigm of science and medicine as we know it. Think about Watson and Crick's discovery of DNA or Marshall and Warren's description of H. pylori. These are truly revolutionary research that changed the course of medicine and well deserving of their Nobel prizes. This paper presented at the recent Digestive Disease Week, the preeminent GI conference in the country, isn't one of them however.

Presented at DDW by Dr. Otto Lin from the Virginia Mason Medical Center in Seattle, the study compared the effectiveness of the Sedasys system of propofol infusion with moderate sedation that GI docs normally administer. The Sedasys patients were first given 50-100 mcg of fentanyl followed by propofol infusion from the machine. The control group of patients received only midazolam and fentanyl. A total of 1,466 patients participated in the study. Of those, 1,013 underwent a colonoscopy, 285 had EGD's, and the rest had both.

So how did the robots do? According to Dr. Lin, the patients and physicians very much preferred propofol over the simple cocktail of Versed and fentanyl. Patients went to sleep faster, woke up quicker, and had better retention of facts after the procedure. Patients reported less pain during the procedure and less grogginess afterwards. However their overall satisfaction between the two modalities was not statistically different. Nine patients reportedly suffered laryngospasm that required mask ventilation to break. There were also cases of agitation and discomfort attributed to "monitoring" issues. Dr. Lin's team was so confident about Sedasys that they even started using the machine for off label uses such as complex colon polypectomies and endoscopic ultrasounds. However they didn't have enough numbers of those complicated cases to make any recommendations.

The researchers and GI docs present at the meeting hailed this paper as strong proof that propofol given by a machine is as safe and effective as one administered by an anesthesiologist. Naturally the GI audience in attendance would only see the results that were trumpeted by their GI colleagues instead of noticing the obvious and serious flaws in the study.

First of all, the study authors compared the use of propofol against a standard cocktail of Versed and fentanyl. That is hardly original work. There have been numerous papers detailing the superiority of propofol sedation against a combination of benzos and narcotics in GI procedures. It is well known that patients wake up faster, feel less confused afterwards, have superior amnesia of the procedure, and are able to leave the recovery room faster. So none of this paper's results are surprising. What they should have used as a control was propofol when given by an anesthesiologist to see if those criteria are any different when matched up against Sedasys. With this fundamental flaw in the study, the paper is essentially meaningless.

Then there is the question of the nine cases of laryngospasm among their patients. Nine episodes of laryngospasm seems excessive to me. The numbers sound even worse when one considers that the laryngospasms probably occurred within the 285 patients who underwent EGD's, not the 1,013 cases of colonoscopies. So nine patients with airway obstruction severe enough to recover positive mask ventilation is a very high rate of this complication.

I also wonder who provided the mask ventilation to break the laryngospasm. Was it the gastroenterologist? Would he have just dropped his scope in the middle of the case to run to the head of the bed to slap the mask on the patient? Was it the GI nurse who probably hadn't masked a patient since her last ACLS course a couple of years earlier? Or did they have to emergently scream for help from the nearest anesthesia provider to rescue their patient before they died on the procedure room table? My guess is that it was the latter since the GI knows that no anesthesiologist would willingly turn away from a patient whom they have never met or discussed the risks and complications of receiving propofol but is willing to help their fellow human being from dying of a needless complication of incompetent sedation.

So yeah the GI docs love the results of this "study" on the effectiveness of Sedasys. It tells them exactly what they wanted to hear. But with an estimated seven million EGD's performed in the U.S. each year, that translates to nearly 25,000 cases of laryngospasm and airway emergencies that require active intervention to keep the patient from dying if Sedasys is used for all of them. Those alarming numbers about Sedasys should be what concerns gastroenterologists and federal health regulators, not how much money they think they are saving from cutting out the anesthesiologists.

Friday, May 15, 2015

Today I'm Ashamed To Be A Republican

I normally consider myself a conservative Republican. My political sensibilities were informed during my formative years by the administration of great Californian, President Ronald Reagan. So it was with some dismay when I read about the political debate in the California Senate over a vaccine bill.

Because of the measles outbreak that occurred last winter at Disneyland, California is attempting to pass a bill that would eliminate personal and religious exemptions to children getting the MMR vaccine. The only excuse for not getting vaccinated would be if a physician states that the child is immunocompromised and can not tolerate the vaccine.

Thank goodness some sanity is returning to the vaccine debate. As you can imagine, hundreds of parents have been demonstrating in the state capitol over this proposal with their usual lame uninformed excuses of autism, personal choice, etc. So it was with sad disbelief when I saw the Republican members of the Senate side with these parents. Senate Republican leader Robert Huff says, "I don't believe the [measles] crisis we have seen rises to the level to give up the personal freedoms we enjoy in a free country." SB 277 passed through the Senate Committee by a vote of 25 to 10 with most Republicans voting no.

It saddens me as a conservative to see these Republican pander to the antivax crowd. They claim the bill will intrude on a parent's right to choose how to raise a child. Well, you know what a country where anybody can do as he pleases is called? It's called anarchy. A civilized country has to set limits on some personal freedoms in order to function. What if somebody decides they don't want to stop at a red light because it would interfere with how he wants to drive? Is it intruding on his personal driving habits even if it means a safer driving environment for everybody else on the road? Suppose I want to carry a gun on an airplane because I don't trust the government to keep me and my family safe? It's clear that if people feel they want to do something regardless of public safety in the name of personal choice, the country would quickly descend into chaos.

Besides, who do these California Republican Senators think they are trying to curry favors with? They must know that most of these anti vaccine parents are part of the limousine liberal establishment that are prevalent in LA's Westside and the San Francisco Bay area. These abortion loving, gun controlling, climate change evangelists will never side with Republican candidates no matter how many times they vote to allow parents to withhold vaccinations. If California Republican elected officials truly believe that personal choice takes precedence over the welfare of the general public, then maybe I need to renounce my GOP affiliation, as have the vast majority of the state's residents, and look elsewhere for intelligent political representation.

Tuesday, May 12, 2015

Waze Must Be Banned

How can one drive while looking at this screen?
Doctors have always been at the forefront of public health. We have strongly advocated for smoking cessation, low fat and low salt diets, and increased exercise. That's why we should also be more vocal about the scourge of distracted driving, and in this case, the fiendishly addictive nature of the smartphone app Waze.

For those who are unfamiliar with Waze, it is a navigation app that acts as a traffic monitor. Users of the program enter the condition of the traffic they are currently driving in which allows others to see how bad the road congestion is, thereby allowing them to bypass to a less congested path. This information is critical in densely trafficked cities like Los Angeles. Since users can also input various road hazards like police speed traps, it also allows scofflaws to avoid run ins with the law.

It is this active participation of its users that makes Waze dangerous to drivers. Users, myself included, are constantly looking at the phone to look for traffic congestion up ahead and away from the immediate surroundings. But to report the traffic conditions to Waze, the user must also enter the information, thus taking their eyes off the road. No matter how quickly they can press the simple icons in Waze to input the data, it is still taking their minds away from driving.

Waze compounds this problem by enticing its users to become even more diverted. Drivers get points for putting in road information. It becomes a game to see who can add more points to their total. Waze even offers little virtual candy points for consistent users. The more data they enter, the more points they get, and the more distracted driving is involved.

Since it is now a social media world, Waze also allows one to chat with other Waze users on the road. Now how can somebody drive properly if they are constantly seeking chat buddies nearby?

I know Waze tries to mitigate this problem by allowing the use of voice commands. But it has been shown that the imprecise nature of voice commands in noisy cars cause drivers to take their eyes off the road due to frustration with the system.

Many cities and states have banned the practice of texting and driving because it can be even more dangerous than drunken driving. With the increasing use of safety features like antilock brakes and airbags, automobile fatality rates have been trending down for years. Driving apps like Waze may cause an unfortunate reversal in this pattern. I personally vow to minimize the amount of time I spend on Waze, just as soon as I get my 25 candy points up ahead.

Monday, May 11, 2015

People Care More About White Teeth Than Their Grandparents

I received this junk mail in my mailbox the other day. It is an ad for a local dentistry office promoting some of its services. As you can see, dentists do a lot more these days besides root canals and teeth cleaning. What caught my eye is the only price listed on the whole sheet--$399 for one hour of teeth whitening. Wow, that seems like a lot of money for one hour of work. My teeth better look like the freaking surface of Hoth after they're done for that price.

Then I got to thinking about how much my services are worth. Do people value anesthesia as much as they do white teeth? To find out, I downloaded Medicare's physician payment worksheet, this one is for 2012. The worksheet has a list of all the procedures that were billed to Medicare and what the program actually paid out to physicians. Private insurance pay more to doctors than the government's Medicare program. However since each insurance company pays each doctor differently depending how their rates are negotiated, looking at Medicare data provides a more uniform look at how much money physicians are getting for performing certain services.

The results are quite sobering. Out of the thousands of payments Medicare made to anesthesiologists that year, only a little over 500 cases received more than $400. You may bill the feds $6,390 for giving anesthesia for a CABG on pump, but they will only reimburse you $376. Think you're going to get $4,384 for anesthesia on a carotid endarterectomy? Think again. Medicare thinks your time and malpractice risks are worth only $371.69. The list goes on and on. Spinal cord surgery? You: $3,498. Medicare: $357.40. Knee Arthroplasty? You: $3,991. Medicare: $349.82.

There are regional differences in how much Medicare compensates. But the prices between what anesthesiologists are asking for and what the program will pay just seem so out of sync that one has to wonder who determines these numbers to begin with? Are they merely pulled out of thin air? Magical thinking on the part of physicians? Perhaps doctors deliberately set their prices into the stratosphere in the hopes that private insurance will actually pay that much money. But how many anesthesiologists will hit the jackpot and actually receive the reimbursement that they asked for, like the $1,320 for a ten minute colonoscopy?

As the country's population continues to get older, more and more patients will be on Medicare. Don't forget the millions of people who are enrolled under Obamacare's expanded Medicaid program, which pays much less than even Medicare. Add in the stagnant physician wages that has been written into law under the AMA sponsored SGR fix, it's easy to see why doctors are pessimistic about the future of medicine in the U.S. Is it any wonder that the U.S. News and World Report recently ranked dentistry as the best health care job in the country over nurses and physicians? When people are willing to pay $399 out of their own pockets for white teeth but quibble over a $20 copay for life saving medicines, than you know it is time to get out of Dodge.

Sunday, May 10, 2015

What Do CRNA's Really Want?

Recently, a bill came up in the California legislature to allow the use of anesthesiologist assistants to practice in this state. Never heard of AA's? Anesthesiologist assistants have a Master of Science in Anesthesia degree and are licensed to work under the direct supervision of an anesthesiologist. They are currently allowed to work in 17 states and the District of Columbia. An AA graduates from training with a minimum of 2,000 hours of clinical work. There are currently about 1,700 AA's working in the country.

The California bill, AB 890, is sponsored by Democratic Assemblyman Sebastian Ridley-Thomas and the California Society of Anesthesiologists. Why does California, or any state, need AA's? To allow greater access to health care, of course. According to Dr. Paul Yost, president of the CSA, "So many more patients are entering the health system and more baby boomers will be needing care."

So who would oppose granting patients increased access to medical care? Ironically, it's CRNA's. Even though their political mantra has always been that CRNA's are needed because there are not enough anesthesiologists available for all the cases that need to be performed, they are angrily opposing the passage of AB 890. There is even an AA opposition letter that is circulating on the web that is very much a rough draft at the moment.

Why would CRNA's be against having more healthcare providers available to take care of patients? Just follow the money. AA's can do everything that CRNA's do, except they are under the supervision of an anesthesiologist. AA's don't have privileges to work independently and they have no desire to do so. They know they are not doctors and would rather have an MD take the responsibility of making critical decisions in patient care. They are here to help the anesthesiologist, not supplant them.

CRNA's, on the other hand, wish to act and be treated like physicians. They want to work without anesthesiologists looking over their shoulders, even though their level of training is far below what most anesthesiologists would consider adequate for independent practice. If AA's are allowed to work in the biggest state in the country, they will severely hinder the expansionist agenda of CRNA's. If anesthesiologist assistants can work the same cases as CRNA's, but with the built in safety net of an experienced anesthesiologist present, why wouldn't you want to hire more AA's? This is where the nurse anesthetists are going to have to show their true colors. Who are they really advocates for, patients or CRNA's?