Thursday, February 18, 2016

Is Anesthesia Boring?

Not true, even though it may look like it.

Is anesthesiology boring? That is a question I sometimes get from medical students when they rotate through their anesthesia rotation. Isn't anesthesia a very monotonous way to make a living, injecting the same three syringes of drugs every time, all day, every day? Doesn't it get tedious doing the same thing over and over again for the rest of your life?

I guess if you put it that way, anesthesia does sound boring. But here's the thing. It is only dull if every patient an anesthesiologist encounters is exactly the same. But every human body is unique. Even though we may look like we perform the exact same process with each anesthetic given, in fact every patient gets their own sedation that is custom tailored to their specific needs. A patient with critical aortic valve stenosis undergoing a hernia operation would not get the same anesthetic as someone with severe mitral valve regurgitation having the same procedure.

Our patient population is as varied as any internist's patient list in the hospital. Nobody ever said internal medicine is boring. Or maybe they do. But somehow all the various comorbidities we deal with get overshadowed by the operation itself. Whereas the internist is a hero for ordering an ECG on a patient with new onset rapid atrial fibrillation, anesthesiologists do the same thing except we still need to make sure the patient can make it safely through an emergency small bowel resection. Who's the hero now?

Frankly there also isn't anything wrong with doing the same thing repeatedly until one becomes an expert at the job. Does anybody say Steph Curry is boring to watch because he practices his basketball shots thousands of times per year? Is Roger Federer's job boring because he makes his tennis shots look so effortless? There is no shame in doing something ten thousand times until it looks completely second nature. In any field of medicine, the key to its mastery is repetition. Surgeons become experts at doing appendectomies because they've done it thousands of times during their careers. Internists become lauded for their effective treatments of congestive heart failure because they've faced the same issue hundreds of times a year. So why should anesthesia be considered boring because we have the experience to make our jobs look easy?

So for all the medical students out there who thinks anesthesiology is boring, remember that every patient who enters a hospital is a potential candidate for the operating room. While the patient may have an army of subspecialists taking care of them on the floor, the anesthesiologist who will be overseeing the patient in the OR is doing the work of all those other doctors, but by himself while a surgeon is trying to cut and bleed them to death. Nothing simple or dull about that.

Tuesday, February 9, 2016

Los Angeles Is A Terrible Place To Start A Medical Practice

People hear all the time the horrors of commuting in LA. But unless you actually live here, you don't really understand the tediousness and frustration of driving in stop and go traffic for miles at a times. I recently left work at the hospital a little after 5:00 PM. I knew the commute would be a long one but on this particular day I was even more exasperated than usual. As you can see by my odometer, after driving for over half an hour, I had covered a distance of only three miles. Only twenty more miles to get home.

Why don't I live closer to my workplace? Because a doctor's income is barely sufficient to purchase a house big enough to raise a young family on the Westside of LA. Almost all our staff who have small children live just as far away from the hospital as me in order to have access to good public schools and park space. We are experiencing an exodus of young anesthesiologists in our staff who either want to move away to afford a better lifestyle or their spouses refuse to consider the sacrifices they would need to make in order to live here. So unless ninety degree temperatures in the middle of February is your first priority in finding a place to work, LA is a terrible city for doctors to practice, especially if you're just starting out your career.

Friday, January 29, 2016

A Doctor Shops For Obamacare

It was all a lie. In one of the biggest untruths ever told to the American public, President Obama promised that passage of the Affordable Care Act would not affect their relationships with their physicians or insurance companies. Whether that was just a cynical way of fooling the public into supporting his plan or he is completely clueless about medical economics, we now know that many Americans will have to change their healthcare because of the ACA. I should know. I just became another victim of the lie.

I had a wonderful health insurance plan. Since I am a private contractor, with my own medical corporation for my anesthesia practice, I have to buy my insurance in the individual market. I've had the same plan since I finished residency over a decade ago. It had a low deductible, a wide range of doctors to choose from, and it was cheap. Then it all started to change.

For the last several years my insurance premiums were increasing at 15-20% per year. As a physician I thought I could afford the increases since I made a decent income and I could write it off as a business expense. I had been reluctant to change my insurance because it is a grandfathered plan, one that was in place before the passage of the ACA. The insurance company kept warning me that if I changed plans, I could never, ever get the same plan back.  But after another 20% increase in my latest notification, I was looking at monthly premiums that could pay for a mortgage on a decent sized house in the Midwest. Our insurance agent explained to us that we were victims of the insurance death spiral. Because the plan was so generous, only the sickest people kept the plan. Consequently the insurance company had to raise their premiums to make the plan solvent. As the premiums kept rising, more and more people dropped out, leaving only the very sickest people still in it who needed the plan's benefits.

My wife thought we were crazy paying this much for insurance, especially with three young children to raise and me driving a twelve year old Honda. Reluctantly, we decided we needed a new health insurance plan. Thank you President Obama. We called the insurance company, cancelled our long treasured plan, and had them stop automatic withdrawal from our bank account. Though it was a difficult decision, I felt a huge burden lifted by not having to pay those extraordinarily outrageous premiums anymore.

Where does one go to buy health insurance now on the individual marketplace? In California, one goes to Covered California, the health insurance exchange set up by the state to sell Obamacare plans. The site has improved significantly since it opened two years ago. It's almost bug free now and easy to navigate. It still classifies plans based on different metals: bronze, silver, gold, and platinum. They all essentially cover the same benefits. The differences are the amount of monthly premiums and the amount of the deductible. We chose a silver plan which is a good compromise between the premiums and the level of deductibles one is responsible for paying. Even though my income does not allow me to receive any subsidies from the government to pay for insurance, the new plan instantly lowered my monthly premiums by over fifty percent. Yeah.

Now the bad. The plan has a narrow network of physicians. Before we selected it, we had to call all our doctors to see if they used it. This is where things got messy. Our pediatrician used it but our dentist did not. Then the pediatrician's office manager says he may not keep using the same insurance company after March. But we needed to know now so that we can choose which plan to purchase. This kind of conversation never took place with our old insurance. There goes the promise of keeping our old doctors with passage of the ACA.

The Obamacare plan also has an enormous deductible. It carries a family deductible of over $18,000 per year. It essentially has become a catastrophic insurance plan, with us being responsible for everything unless a major health disaster happens to us. We could have chosen a gold or platinum plan with lower deductibles, but then the monthly premiums start approaching my old plan's payments while providing worse benefits. Thankfully on my income we think we can handle a health calamity even if I have to sell some assets to do it. But how does this help people who don't make six figure incomes?

So as we start out a new year, we have shed one of the major financial burdens that confronted us every single month. Yet I don't feel any more secure about my health and fiscal situation. I feel like we've been railroaded into buying inferior insurance and we could not do anything about it.

Thursday, December 10, 2015

The Worst Question To Ask When Interviewing For Residency

What do medical students look for when they are interviewing for a residency spot? What sorts of questions should they be asking when they go on their interviews? Should they ask about the intensity of the patient workloads? Does the quality of the weekly conferences make a difference? Should they inquire about how many research papers are published by the program's residents? Or for the truly crass, should the students ask about the vacation schedule and salary?

I was walking through the hospital the other day and passed a whole gaggle of medical students coming for residency interviews. As they were being led by a current resident, she asked them if they had any questions. One intrepid interviewee then boldly asked, "Do you guys have a gym?" I almost stopped in my tracks as I heard that. It took all of my self restraint from reaching out to slap that idiot upside the head. The resident guide kept her cool and gamely replied that the hospital does not have a gym for the residents but that there are plenty of gyms nearby they can sign up for.

The gym question is so wrong on so many levels. First of all, while the ACGME has relaxed the rules for residency hours, it is still a total grind. You will be exhausted like you've never been exhausted before. You think you're tired during medical school but you haven't experienced total and complete mental and physical fatigue until you've gone through residency. What makes that person think he will have time to go exercise on a routine basis?

Second of all, if you did have the time to work out, you probably should be spending that time more wisely doing medically related activities, like reading and research. With restrictions on work hours, residents have even less time during their three to five year residency commitments to gain all the knowledge they should to become competent physicians afterwards. With the vast explosion in medical information, it is almost incomprehensible that anybody can adequately prepare to become a doctor in such a short amount of time. Going to the gym four times per week? Forget about it.

Finally, what does the gym question say about the priorities of that particular student? He is advancing his career to better understand the human condition and help sick people. But one of his main concerns is how the residency program will help him maintain his big guns and six pack abs. Though maintaining one's health is important, that is not the responsibility of the residency program. Find your own time to exercise in residency. Don't expect a program to offer five star hotel amenities. Remember, if the programs had their way they would still make residents work one hundred plus hours per week with every third night call. They couldn't care less if by the time you finish training you've shrunken down to a pale and ghostly 120 pound weakling.

Sure I knew some residents who could have it all. One of the smartest residents I ever met was in my residency class. She just blew everybody away with her intelligence and wit. She knew every question the attendings threw at her during grand rounds. She seemed to write up papers and abstracts on a monthly basis. And she always had great stories to tell about her latest activities, like kayaking around Catalina Island or surfing in Costa Rica. But I also think she was hyperthyroid and a bit manic. She only needed four hours of sleep each night, if that. So unless you plan on cutting your sleep by half during your training, don't plan on having much time for your workout regimen unless you don't mind being a mediocre resident. But at least you will look fabulous in the naked selfies you post on Snapchat.

Tuesday, December 1, 2015

I'm Already A Relic

If you know what this is, you are old.
At the age of 47, I am now officially an old anesthesiologist, a relic. I had an illuminating conversation with one of our anesthesia residents about the monitoring of patients while under sedation. Now mind you this resident is a CA-3 and smarter than a whip. He'd already easily passed the early board exam required by the ABA nowadays for anesthesia residents. We discussed the role of capnography, the physiology behind the pulse oximetry, and the indications for arterial lines.

Then I asked him about the precordial stethoscope. All I got was a blank stare. I asked him if he knew what a precordial stethoscope was. He replied that he thought he had read about it in a textbook once. Did he ever see an anesthesiologist use one? No. Not even during their rotation through Children's Hospital? No. Oy!

I then fished out my precordial stethoscope from my bag, which for some inexplicable reason I still carry around. He held it and gazed at it with befuddlement and amusement. He asked about how it worked. I explained that we used to have round double sided tape that fit over the bell of the stethoscope which was then affixed to the patient's chest wall. The earpiece was custom made for each of us with an actual mold of our ear canal. I showed him how my candy apple red device fit snugly and perfectly into my ear. With this stethoscope, I explained, the anesthesiologist can hear instant changes in the patient's respiratory and cardiac status without relying on electronic devices.

The resident just looked at me with bemusement and a little sadness. It's the pathetic look you give somebody who still treasures their old eight track tapes or AMC Gremlin. When we have so many electronic wonders at our disposal that precisely measure every important body function then automatically inputs the data into the electronic anesthesia record for permanent archiving, why would anybody still use an old analog stethoscope? How can a simple rubber tube connected to the ear possibly be of any worth to the modern anesthesiologist?

While the precordial stethoscope may not be "better" than all the electronic gizmos that we attach to patients, the level of intimacy we attain with our patients by actually having be physically close to them is itself informative. By sitting or standing next to the patient, we can derive information that is is not picked up by our electronics. Important things like the color of the patient's skin, pressure points that may cause injury, how a patient starts developing increased airway resistence.  Important information like this is easily missed when the anesthesiologist is only staring at his computer monitors or, worse, cellphone.

It makes me wonder about where the future of anesthesiology is heading. Are we all destined to become mere observers of the events unfolding in the operating room, like a security guard watching over a bank of video monitors in a department store? Or is there still a role for us to become more actively involved in the care of the anesthetized patient?

Monday, November 30, 2015

Anesthesiology Is Bad For Your Health

Business Insider recently ranked the least healthy jobs in the country. They determined this list based on data from the U.S. Dept. of Labor. The factors they used included the risks of job exposure to radiation, disease and infection, hazardous conditions, risks of burns, cuts, bites, and stings, and prolonged sitting (!). Without further ado, here are some of the surprising occupations that made the Top 25 list of the most unhealthy jobs in America.

Coming in, tied for 24th place, is Radiology. Radiologists may be surprised to learn that their job is as bad for their body as their 24th place brethren Metal Furnace Operators. I couldn't think of any jobs that could be more disparate. Radiologists work in air conditioned, quiet darkened rooms while furnace operators work near giant vats of molten metal. How could they possibly have the same level of health risks? Well according to the data, radiologists have increased exposure to radiation (unlikely since most of them aren't actually anywhere near machines that emit the radiation unless they are doing an interventional procedure), disease and infections (again not the radiologists I've seen who wouldn't go anywhere within ten feet of an actual patient), and sitting (duh). The risks for a metal furnace operator goes without saying. Between the two, I'd choose radiology any day.

ICU nurses come in 21st place, below Service Unit Operators (oil, gas, mining). These are the guys who make sure oil fields and mining operations are working smoothly. Again there is probably an overemphasis on exposure to disease and contaminants because I'd take an ICU nursing job in a minute compared to working in the oil fields. I'm pretty sure many oil workers would feel the same.

Further down the list we get more incongruous job comparisons like EMT's, which is tied at 17th with Mining Machine Operators and both are considered more unhealthy than garbage collectors, I mean Refuse Material Collectors. 

Finally four of the top five least healthy jobs in America are medically related. Anesthesiology is ranked as the third most dangerous job for your well being. This is mainly due to high exposure to disease and infections, contaminants, and radiation. What, no mention of sitting on the job? At lease we're not the absolute most unhealthy job in the country, which belongs to your dentist. Their daily risks of being subjected to infections and contaminations is without a doubt. However I'm not so sure about the sitting category. Most dentists I know don't sit very much. They are running from room to room checking on their dental hygienists rather than sitting down with one patient for a prolonged period of time.

So take this list for what it's worth. If any medical student is thinking about going into anesthesiology, just realize that you are heading into a field which will damage your health more than a nuclear plant operator, waste water treatment worker, and embalmers. Otherwise just remember that other lists have called anesthesiology one of the best jobs in America

Saturday, October 17, 2015

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.

Friday, October 16, 2015

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.

Thursday, October 15, 2015

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.

Wednesday, October 14, 2015


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