A Surgeon's Loneliest Responsibility

We often denigrate surgeons who hold the view that they are the captain of the ship. They think they are fully in charge of the operating room and everyone else has to do their bidding. We scoff at such antiquated thinking. Don't they realize that surgery is a team approach, with the entire operating room staff responsible for the welfare of the patient?

We sneer at such attitudes, but guess what--when the shit hits the fan, the only person in the operating room who approaches the patient's family is the surgeon. When there is a death in the OR, such as a trauma patient, it's not the entire OR staff who walk the long walk to the family waiting room to disclose the passing of their loved one. It is the surgeon alone. The rest of us merely go about our business cleaning up the operating room to get it ready for the next case. But the anguished cries echoing down the hall are not easily ignored.

Worse are the unexpected complications that can occur in the operating room. Whether it be a pneumothorax from a poorly attempted central line by the anesthesiologist or a sponge inadvertently left inside the patient because the nurses didn't do a proper final count of the equipment, the culprit rarely is the one who has to go to the waiting room to tell the family about the complication. We recently had a patient who died on the OR table. Unfortunately, this happened after the case was finished and the surgeon had already gone out to tell the family that the operation was a success. Guess who had to go back out there to notify the kin of this tragic turn of events? While the rest of the OR personnel kept their heads down safely behind the security doors, naturally it was the surgeon who had to face the music and answer all the angry accusations hurled at him outside in the lobby.

So next time before you accuse a surgeon of being an imperious bastard, just remember that great power comes with great expectations. Unless the anesthesiologist or nurse in the OR are willing to go right out there with the surgeon to confront the family after an unanticipated event, we should give the surgeon some slack if he wants to act like the overlord of the OR. I suspect most of us would rather leave that unpleasant task to the surgeon alone.

Happy Ether Day

Today marks the 169th anniversary of the first public demonstration of an anesthetic being used for surgery. The seminal event took place on October 16, 1846 at the Massachusetts General Hospital in an operating theater now known as the Ether Dome. That was when a dentist by the name of William Morton used a new substance called ether to anesthetize patient Gilbert Abbott so that his surgeon, John Warren, could remove a tumor from the jaw. After the operation Mr. Abbott declared that he experienced absolutely no pain. Thus the age of anesthesia was born. The operation was nicely chronicled in a New England Journal of Medicine article published that year, voted the most important article ever published in that august journal. For more interesting historical facts about anesthesiology, head on over to the Anesthesia History Association's website.

Working For Insurance Companies

Medical Liability Monitor released its statistics on the cost of medical malpractice premiums for 2015. It said that premiums have stayed relatively flat for the past year after a slow decline over the previous seven years. The premium changes however aren't spread uniformly. They decreased slightly in the Northeast, Midwest, and West, up 0.9% in the South, and up 9% in Texas, North Carolina, and Georgia. (Whatever happened to the medical malpractice reforms in Texas? Weren't they supposed to deter malpractice claims and decrease insurance costs?)

What astonished me the most was the chart on the difference in prices between the localities with the cheapest insurance premiums and the most expensive. These prices are for $1 million for individual claims and $3 million for any given year. For internists, malpractice insurance only costs $3,375 per year in Minnesota. However if you live in Miami-Dade County, it will set you back $47,707. For general surgeons, the cheapest insurance can be found in Wisconsin, $10,868. However if the surgeon lives in Miami-Dade County, The Doctor's Company will want $190,829 for the same policy. Now if you're an OB/GYN, better move on over to central California, where insurance only costs $16,240. You probably wouldn't want to live in Long Island, New York where it will wring $214,999 from your wallet. I'll repeat that. In Nassau and Suffolk counties on Long Island, an OB/GYN will need to make an after tax income of $215,000 just to buy malpractice insurance.

How can any doctor make enough money just to buy insurance? This doesn't even count all the other insurance that he will need such as health, life, property, etc.  And let's not forget that Uncle Sam wants his fair share from the evil 1% who are obviously preventing the other 99% of the population from a good living because of the "rich".

According to the Medscape Physician Compensation Report for 2015, OB's make $235,000 in the Northeast. General surgeons make $323,000 in the Southeast. Can insurance cost so much that it take away 90% of a doctor's income? How can one make a business case to work there? It's no wonder some physicians elect to go bare and not carry any malpractice insurance at all. It keeps the lawyers from the money grab of frivolous lawsuits while allowing the doctor to maintain a decent lifestyle from all the money they save by not buying insurance. Sounds like a plan.

Truth

What can happen when the anesthesiologist exits the room and leaves the CRNA in charge of the patient.

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.