Anesthesiologists And Lashes

While doing some research on anesthesia and eye injuries, I came across this rather amusing website for eyelash extensions. Now lash extensions are the bane of my existence. First of all, I don't understand people who don't appreciate the natural beauty of their God given physical features. I guess I'm just not into nips and tucks. To me they are more a sign of vanity than beauty. But as an anesthesiologist, fake eyelashes just gives me one more thing to worry about when all I want to do is keep your life safe while undergoing surgery. Instead I have to preoccupy a neuro circuit to decide how best to protect your eyes without disrupting those ostentatious inch long spider legs dangling from your lids.

Nevertheless, I have to admire the earnestness of the writer, Megan, of this beauty webpage. She talks about a job category that I had never heard about, or even gave a second thought to, the "lash artist". There are even expensive courses offered to teach a person how to become proficient in the creative arts of eyelashes. Megan writes, "Many times anesthesiologists are oblivious to the finely placed lash extensions, which is proof of a good lash artist." An inattentive and busy anesthesiologist may not properly appreciate the hard work that goes into these long hairy appendages which leads to, "rough awakening without lash extensions."

Megan's advice for lash extenders is to, "Notify your anesthesiologist of your lashes and talk about the different options to keep your lashes while protecting your eyes." She personally recommends using silk tape over Tagaderm or paper tape. Her reason? She says it's more natural and, "who doesn't like silk?"

In all sincerity, she tells her readers, "Your anesthesiologist will surely be impressed with your knowledge coming into surgery and they might even learn." She signs off the post with "xoxo, Megan". Well Megan, I welcome any discussions my patients have about their concerns with surgery and anesthesia. However while I'm trying to discuss the seriousness of anesthetics and their potential life threatening complications, the idea of putting a priority on keeping lash extensions intact ranks right down there with what shoes you wore to the hospital today. Yes I will listen attentively to your fears of waking up with disjointed lashes, but internally I am rolling my eyes at the preposterousness of the situation. The OR staff too will guffaw with derision when they hear how preoccupied your reader is with her unnaturally lengthy lashes while her body is about to be wracked by the ravages of the surgeon's knife.

I'm sorry Megan. We anesthesiologists and the entire operating room team have a million and one things to worry about besides how your eyelashes will survive surgery. How they will look in postop is the last thing on our minds.

xoxo,
ZMD

What This Seasoned Stock Watcher Thinks About Talking Head Analysts

As the stock market continues its extreme volatility lately, I am seeing a whole bevy of research analysts, hedge fund managers, and general know-it-alls come out on TV and print explaining the causes for the current massacre (which none of them had the foresight to say "sell" a few weeks ago) and prognosticating on what the future will portend. My problem with all these talking heads is that, my god, they all look so young. Seriously some of these guys look like they've just graduated from college. What can these young 'uns teach me about investing that I haven't already learned through the school of hard knocks?

When stocks last crashed in 2008, these guys and gals had barely finished grad school. Their MBA's were probably still inside their unopened moving boxes in their first rent controlled apartment in downtown Manhattan. During the dot com implosion of the early 2000's, these future analysts were still attending toga parties (or whatever college fraternities do these days) and giving themselves serious liver damage and STD's every weekend. As the market swooned in 1994 during the previous Great Recession, these overcompensated chart watchers were probably just trying to fathom the opposite sex. Of course, during the great market crash of 1987, these kids were still clinging to their mothers' legs as they got dropped off at kindergarten.

So what do these people have to teach ME about how the markets work? What can they say that I haven't already seen multiple times in my long grizzled life? Why are they getting paid multiples of my salary espousing cliches about buying and holding for the long term when their very existence isn't even considered long term in my portfolio? How can they be making so much money when they are so frequently wrong?

Maybe I'm turning into the cranky old coot we used to make fun of as we rode our bicycles over his well manicured lawn.

Fun With ICD-10

ICD-10 is almost upon us. In case you don't know what ICD-10 is, it is a list of over 16,000 medical diagnoses put together by the World Health Organization that classifies every potential human health problem. Originally ICD-10 was supposed to be implemented last year. But after an outcry from thousands of doctors, clinics, and hospitals that claimed they weren't ready yet, the program will finally begin this fall.

Our hospital has been ready to use ICD-10 from its original starting date last year so we are set to go. The hospital's electronic medical record has already converted all previous ICD-9 codes into ICD-10 codes. Sometimes when I'm bored, I just type in random activities into the computer to see what kind of ICD diagnoses have been classified by the WHO.

Here, you can see that I typed "boat" into the search bar. What comes up are 120 different items that pertain to a diagnosis involving a boat. This includes falling off a ladder in a boat. Falling down the stairs in a boat. Falling from one level of a boat to another. Getting burned in a fire while on a boat. It is truly astonishing how granular the WHO organizes medical issues.

Other modern day health concerns include the overuse of video games. Here, inflammation of your joints caused by playing Nintendo actually has its own code.

Heavy users of the Playstation also get a category in our EMR's list of medical difficulties.

Xbox users are out of luck. Your inflamed, gnarled hands are not considered significant enough to be categorized by the WHO.

This raises the question of how the WHO decides which health concerns are important enough for the group to assign a specific ICD code. For instance:

Getting struck or bitten by a dolphin carries its own specific ICD number. Don't laugh. You don't have to work at Sea World for it to happen.

However, if you get injured by a whale, the WHO doesn't think that deserves its own diagnosis.

Yet orca injuries do get the blessing of the WHO. Go figure.

And if you work near large aquatic reptiles down in the bayou, you better know whether the one that bit your patient belongs to

an alligator or

a crocodile. The WHO feels these are two separate diagnoses. If you misclassify the injury, your insurance company might deny your payment for including the wrong diagnoses in your billing.

That is just a miniscule amount of medical problems that ICD-10 attempts to organize. Is it a quixotic endeavor to attempt to classify every single medical problem? The bureaucrats at the WHO are certainly giving it their best shot. In the meantime, their work can be used for an entertaining amusement when you are bored out of your mind in the middle of a long tedious case. Makes you realize how lucky you are you haven't fallen down the stairs of a boat while playing your Nintendo DS.

The Operating Room Is Freezing Cold Because Of...Sexism?

We make all sorts of excuses for why the operating room temperature is always so freezing cold. Now we may have a more scientific explanation for this. An article in the New York Times discusses why office buildings are frequently set so cold that many female workers feel the need to wear sweaters and use heating fans at work while their male colleagues still complain about sweating through their suit jackets.

This environment was first studied back in the 1960's when scientists developed a "thermal comfort model" for what temperature makes people to feel comfortable. It takes into consideration factors such as metabolic rate, air temperature, radiant temperature, and clothing insulation to determine the ideal environmental temperature. The equation looks something like this:

PMV = [0.303e^-0.036M + 0.028]{(M – W) – 3.96E^-8ƒ_cl[(t_cl + 273)⁴ – (t_r + 273)⁴] – ƒ_clh_c(t_cl – t_a) – 3.05[5.73 – 0.007(M – W) – p_a] – 0.42[(M – W) – 58.15] – 0.0173M(5.87 – p_a) – 0.0014M(34 – t_a)}

However, as it turns out, this model was based on an ideal 40 year old male who weighs 70 kg. Presumable this applies to the size of surgeons at that time too, who back then were overwhelmingly male. 

This may have been true back in the 60's but most modern men are bigger, frequently much bigger, than this hypothetical male. A 70 kg American male is now a rare minority. Along with an increase in size of the body, the metabolism rate also goes up. Therefore operating room temperatures continue to get ratcheted down as our ever larger male surgeons keep complaining of hot OR's while covered from head to toe in water proof protective gowns.

Meanwhile the rest of us in the OR's who are relatively skimpily outfitted in our scrubs and may not have the same metabolic rate as the surgeons are left chilled to the bone, rubbing our hands to restore circulation to the fingertips while absconding with every blanket available in the blanket warmer. The small female circulating nurses wrap so many blankets around themselves that they look like they're wearing flannel burkas. And the poor patient laying on the operating room table suffers the most of all, wearing nothing except a cold layer of wet betadine that has been applied to the skin. 

Now some people are discussing the possibility of changing the formula to account for the fact that women have metabolism rates that are 20-30% lower than men. There should also be adjustments for the larger diversity of people that work in the hospitals now compared to fifty years ago. Patients should be at the top of the list for reasons to adjust the operating room thermostat. Their health and successful outcomes depend on it. Surgeons should just buy stronger antiperspirants and deodorants for the sake of their patients. 

Our Anesthesiologists Make Too Much Money.

You know the old saying, "You can't be too rich or too thin"? Well, doctors know that one can be way too thin. But apparently some of my colleagues also take issue with the former and feel they are so well compensated that they don't want to work anymore.

This manifests itself almost daily usually around 4:00-5:00 PM. After they finish their lineup of scheduled cases, these anesthesiologists can't get out to the parking lot fast enough. Sometimes they run out the door in such a hurry that they leave all sorts of paper trash, used syringes of drugs, and other refuse lying on the anesthesia machine and cart for others to pick up. But what gets brought to my attention is that there are more cases that need to be done but now no anesthesiologists to do them.

Surgeons will add cases throughout the day to be started after the scheduled cases are completed. The tricky part is that some anesthesiologists don't want to keep working. They saw their schedule from the night before and make plans for afterwork the following day. Nearly every afternoon I get calls from surgeons asking me why there are no anesthesiologists to work in the OR when there are patients to take care of. The nurses are on the clock so they don't care if they work or not.

So now it's time to beg and cajole my colleagues to please stay and take just one more case, even though there may be ten cases on the addon list waiting to get started. But some of these guys quickly turn off their pagers and won't answer their cell phones as they race out of the parking lot in their German luxury cars. They don't care that they are burdening their on call partners and surgical colleagues who now may have to work well into the night to get all the surgeries finished. They have made enough money for the day and no amount will entice them to come back.

This ritual also has a seasonal factor. The beginning of the year is when we have the best work ethic. As fee for service anesthesiologists, we all start January 1 with $0 of income. But usually by midyear, the combination of summer vacations and high compensation lead many of us to start tapering off the work load. By the winter holidays, it is a real chore to find anesthesiologists willing to pick up extra cases. Nobody wants to take on more cases when it just means they'll get bumped up to a higher tax bracket. Unfortunately that is when the hospital is at its busiest.

So if you want to have surgery, try to schedule it near the beginning of the year. Because by Thanksgiving, you could be stuck in the waiting room for hours wondering why your case hasn't gotten started yet. And it's not necessarily because the OR's are too busy, but because there is nobody available to give the anesthesia.

Why Medicine Isn't Like Amazon.com

The New York Times expose (hit piece?) about Amazon.com was definitely eye opening. After reading it, I am both impressed and disgusted at how the online shopping site runs its business. The article even includes a link to Amazon founder Jeff Bezos's guiding principles on why his company has become such an unstoppable success. Presumably anybody who follows his guidelines can surely reap the same accomplishments as him.

However, when I looked through the list, I realized how polar opposite the business of medicine is from Amazon. Maybe this is why the country's healthcare system spends more money than anybody else in the world yet receives poorer marks from its citizens on health and satisfaction. Here are Mr. Bezos's doctrines and why medicine doesn't fit the mold.

1. Customer Obsession--Medical professionals are obsessed that so much medical care is granted for free to our indigent patients/customers. Some figures put the amount at $85 billion annually. Obamacare aims to reduce the number of uninsured. But with Medicaid level reimbursements, the compensation is just enough to keep the system starving itself into oblivion over a longer period of time.

2. Ownership--Doctors don't own the patients. Insurance companies and the government own them. We are just here to do the work.

3. Invent and Simplify--Medicine's rule is to make things more complicated than necessary. Ask doctors how they like their electronic medical record system and you'll get a spiel on the frustrations of the needless complications it has added to their daily lives.

4. Are Right, A Lot--We maybe right a lot, but nobody's listening. Patients google their symptoms and come into the medical office telling their doctors what to do for them. Faceless insurance adjusters second guess physicians daily on the right treatment for patients. Malpractice lawyers? Their whole raison d'etre is accusing doctors how stupid they are.

5. Hire and Develop The Best--You know where the best and brightest youths in this country are heading? Amazon, Google, Facebook, Apple, Goldman Sachs, JP Morgan. Kids aspire to entire fields where they can make a lot of money and/or develop potentially revolutionary products. Medicine is neither. Doctors who become very wealthy don't practice medicine. They're in business administration or life science research.

6. Insist on the Highest Standards--Doctors and patients may insist on the highest standards of care, but the insurance companies won't pay for it. But if doctors don't do it, they will sue the pants off of you. So it's just more uncompensated care that physicians and hospitals have to swallow.

7. Think Big--Medicine wants to think big, but then the Department of Justice brings down an antitrust ruling to keep the businesses as inefficient and fragmented as possible. Good for the payers. Not so much for the medical field.

8. Bias For Action--You try to get patients out the door but then they accuse you of dumping them. Then they penalize you when the patient is readmitted within 30 days. So why hurry?

9. Frugality--$1,000 per pill? Nobody wants frugal medicine. They want free medicine.

10. Learn and Be Curious--That is the mantra being advanced by the American Board of Medical Specialties. But then they force their cumbersome and expensive Maintenance of Certification program on all doctors leading to a nationwide revolt. Doctors don't want to learn and be curious after they have their precious little certification clutched in their hands.

11. Earn Trust--Patients don't trust doctors any more than doctors believe patients are telling them the whole truth. Why do you think there are so many conspiracy theories about children's vaccines and how they are a scheme concocted between the pharmaceutical industry, doctors, and the government.

12. Dive Deep--Clock in, clock out. Eventually we're all going to become employees of the system anyway so why bother.

13. Have Backbone; Disagree and Commit--Pretty soon you'll get a call from the hospital's Patient Advocate office asking why a patient's family is filing complaints about your disagreeable character. Then you'll have to take time off from work to face a hospital committee explaining why that family is a bunch of wackos who is making life miserable for anybody who has to be involved in their relative's care.

14. Deliver Results--Patient survived the operation. I'm out the door to my S Class in the parking lot on the way the gym where I get my real satisfaction in life.

One Million Page Views, Thanks To You.

I know that I've been rather lax in my writing recently. I can't blame it all on my recent promotion. Rather, life just has a way of taking over any snippet of free time that I have. But despite my now infrequent posting, readers continue to come back to this blog to learn about the anesthesiology profession and the random musings of this anesthesiologist.

Thanks to all these readers, I recently crossed the ONE MILLION pageview milestone. I know that that is pretty miniscule when compared to the thousands of websites out there that routinely pull in millions of pageviews each month. However, it has been an unexpected and rewarding accomplishment for me. I passed the 500,000 pageview mark back in December 2013, four and a half years after this blog was started. Now a mere one and a half years later, I doubled that number. Thank you to all the readers who made this happen.

As you can see from the map at the top, my readers hail from all over the world. Like the 500K pageview map, the only countries that haven't had a single reader browse my pages are mainly located in sub Sahara Africa, where they have much bigger problems to deal with, central Asia, and North Korea. One of these days, when Kim Jong-un needs his questions about anesthesia answered, one of his minions will surely visit my blog.

The following is a Top Ten list of my most popular posts. There isn't much change from the previous Top Ten list. People are still obsessed about where their bodies are the filthiest. Medical students and anesthesia residents are still inquiring about the anesthesia profession. As for new entrants into the Top Ten, for a few brief weeks the revelation of the shockingly low rates of reimbursements made by Medicare caused this blog to be shared and read thousands of times around the country.

1. The Dirtiest Part Of The Body.

2. Doctors Should Get Kudos For Accepting Medicare Patients.

3. Why I Chose Anesthesiology.

4. The Easy Way To Decide What Kind Of Doctor To Be--Take A Test.

5. Anesthesia Menu Board.

6. Surgery, A Siren That Will Break Your Heart And Crush Your Soul.

7. How To Get Into An Anesthesiology Residency.

8. The Difficult IV.

9. Do 345 Doctors=1 Geek?

10. Orthopedics vs. Anesthesia.

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.

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.

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.