Sunday, March 13, 2016

Where Anesthesia Residents Go After Graduation

The American Society of Anesthesiologists conducts a survey of CA-3's every year about where they are headed after residency. As the academic year starts winding down, it might be helpful to look back to see what last year's graduating class had planned for their post-residency career.

The ASA sent a survey to all CA-3's it had on their email list. Out of 1,481 residents in its membership list, it had 1,391 email addresses on file. After they sent out the poll in May 2015, it received responses from only 192 residents or 14%. That is admittedly a very small sample but still the best data that is available.

Geographically, the respondents were pretty spread out, with about a third of them from the Northeast, a little less from the South, a fifth from the Midwest, and the rest from the West. About two-thirds of the responses were from men.

When the survey was sent out, 97% had confirmed job offers. More than 55% of the residents joined anesthesia groups with partnership tracks while 20% joined groups with no partnership track, 18% are becoming employees of health care organizations, and the rest joined anesthesia staffing companies. The mean starting salary was over $289,000 which was virtually unchanged from 2014. But if you want to make more money, then head West with a reported mean salary of almost $315,000.

How do residents decide where they want to work? The most common answer was Geography. This was followed by Schedule Flexibility, Job Description, Monetary Compensation, and Call Requirements. Considering all the major changes in the healthcare system right now, Stability of the Hospital System surprisingly ranked last.

Those seeking academic careers were more likely to have come from the Northeast, probably since there is a higher concentration of research oriented programs there. In general most CA-3's applied to 4-9 different practices with about twenty percent applying to more then ten. Over 80% received up to three job offers with the rest getting more acceptances.

Overall 44% said they were heading for fellowship training. The most popular fellowships, in descending order, are Pediatrics, Cardiothoracic, Critical Care, and Regional. When asked why they were doing fellowships, the most common answers were because they were interested in the field and wanted to learn more about it, and because they felt it would make them more desirable in the job market.

Some of the wise comments from the CA-3's last year that just went through the job market wringer:

  • "Fellowship not necessary in this market."
  • "Okay, but certainly not flourishing."
  • "Very difficult job market; practice models are mostly employment with very few partnership tracks available; management companies seem to be taking over."
  • "I took a lot less money to supervise fewer CRNA's."
  • "Tighter than most years but improving. National anesthesia companies providing much worse benefits and lifestyle than any other groups." 
  • "Get involved in your state society to network. Do your residency in a region you'd like to work. Don't be a complainer or a lazy resident. Work hard and be a team player."

That last advice, if followed, will probably give you greater job satisfaction and security than all the fellowship training in the world. Good luck to the class of 2016.

Friday, March 11, 2016

Anal Sex Questions Answered

Okay, so this has absolutely nothing to do with anesthesiology but it brought a smile to my face when I read it. The American Journal of Gastroenterology published a study on the practice of anal sex. And I bet you didn't realize anal intercourse needed a scientific inquiry.

So what's the lowdown on going to Brokeback Mountain? Well, out of over 4,000 people in this retrospective study (I guess you can't really do a prospective study on this subject), 37% of women and 5% of men have had their brown eye poked. White people are more likely to perform it than blacks. And if you have only a high school degree, you are more likely to ride along the Hershey highway than if you have a college degree or did not graduate high school.

And one last thing. In this case, smaller is definitely better. Unless you'd like to wear Depends after dancing the chocolate cha-cha. Have a nice weekend.

Tuesday, March 8, 2016

Sacrificing Physician Morale To Save Medicare Pennies

Here's another example of why doctors are always getting screwed when lawmakers without any skin in the game make up rules about healthcare. Medicare has decided that in order to save costs from all the expensive drugs that physicians prescribe, they are going to cut the reimbursement for administrating the medications.

Under Medicare Part B, doctors get a fee of 6% of the cost of the drug that they give to a patient in the office or other medical facility. So if a $100 drug is given to a patient, the physician will get a fee of six whole dollars from the government along with the $100 cost of the drug. If the drug costs $1,000, the doctor gets $60 plus the cost of the medication. Sounds pretty skimpy to me already when one considers that the $6 fee has to cover all the risks of administering that $100 drug.

With the new proposal, Medicare wants to increase reimbursements if the doctor prescribes a cheaper drug and cut the fee if a more expensive drug is used. Now the new rules state that doctors will only get 2.5% of the cost of the drug while earning an additional flat rate of $16.80. So now a doctor who administers a $100 drug will receive $19.30 while a $1,000 drug will only net $41.80.

Think about the numbers for a minute. The government saves $18.20 on a $1,000 drug, or 1.7% ((1060-1042)/1060). But for the physician, his reimbursement just got cut by 30% ((60-42)/60). In the meantime, the pharmaceutical company still gets to sell its drug at $1,000. Where is the outrage? Where were our so called advocates in the AMA when these plans were being devised? The drugs companies can continue making billions of dollars and their CEO's raking in hundreds of millions while physician livelihoods are getting chopped by double digits. While government employees are striking over inadequate pay raises, doctors quietly submit to working harder for less pay because we're afraid of tarnishing our image.

I predict that this latest experiment in healthcare authoritarianism will fail miserably. It doesn't make sense when one considers the usual capitalist market forces. If a doctor is getting less money for prescribing an expensive drug, is he likely to switch to a cheaper drug that will reimburse him even fewer dollars? No. A rational person would prescribe even more of the expensive medication to make up for lost income. Using the above as an example, even though the reimbursement for giving the cheaper drug has gone up, it still doesn't make up for the higher fee the doctor gets from giving the expensive drug. So now the doctor has every incentive to give more patients the expensive drug to compensate for lower reimbursements.

The real cost drivers of this scenario, the drug companies and the patients who insist on having expensive drugs so that they feel they are getting their money's worth, get off scot free. But no American lawmaker would dare vote for a British style government rationing system. And they can't resist all the money the pharmaceutical lobbyists throw at them. That leaves doctors out of the loop and holding the bag.

Sunday, March 6, 2016

Macho Macho Anesthesiologists

The latest issue of the ASA Monitor has a great picture of one of the pioneering giants of anesthesiology, John S. Lundy, MD. As you can see in the undated photo from an article in the Monitor, Dr. Lundy is demonstrating to a group of physicians how to intubate a patient. However I was most struck by what the doctors were wearing in the operating room. These guys were all donning scrubs that wouldn't look out of place at your local Gold's Gym.

What's with all the sleeveless tops? Though a couple of the guys in the picture have the guns to dress the part, most of them look like they need to go do some biceps curls for a few weeks before they expose their flabby arms to the world.

Maybe once again Dr. Lundy was ahead of his time. With all the controversies about long sleeve clothing causing patient contaminations, he was miles ahead of the rest of us in preventing bacterial contamination that plague medical facilities around the world today. Or perhaps he just liked showing off his bazookas.

One last thing, can anybody tell me what is that thing that is hanging off the IV bottle on Dr. Lundy's right side? Part of it overlies his right arm. It looks like it maybe some sort of syringe that is hooked up to the IV but I can't tell for sure.

Saturday, March 5, 2016

My First MOCA Minute

The American Board of Anesthesiology has been surprisingly progressive in their reforms of the anesthesia Maintenance of Certification (MOCA) process. Ahead of other medical specialties, the ABA has done away with the nonsensical Part 3 Simulation exam and the much feared and despised recertification exam at the end of each certification period.

Instead the ABA has instituted a new program called MOCA 2.0. Instead of a once a decade pass/fail exam that could potentially ruin one's career, the ABA started the MOCA Minute. It's an annual series of 120 computerized questions that one takes at home that after ten years is equivalent to the previous recertification test. It's essentially open book without all the intimidation and expense of the previous exam. Only thirty questions can be answered each quarter to prevent people from doing it all at the end of the year. After doing my first MOCA Minute, my verdict is that I like it.

It is very easy to register for MOCA 2.0. Basically they want your credit card information. Then each quarter the ABA will send you reminders to take the MOCA Minute. I received a couple of emails from them before I got around to taking the test. The questions are pretty easy. There is a gimmicky countdown clock that ticks down 60 seconds as soon as each question pops up. I don't know the purpose of this timer since just reading the questions and the multiple choices takes longer than one minute. There is no penalty for taking as long as necessary to answer a question. After you answer it, it will instantly tell you if you answered correctly and give a brief explanation of the answer. Again there is no penalty for answering wrong. It took about one hour to go through all thirty questions and explanations. It gets easier as you go along since several questions and topics repeat themselves. Thus the percent of correct answers go up the more questions that are taken.

This process is a much more relevant way for anesthesiologists to maintain their medical knowledge and certification. It does away with the intimidation and expense of the previous recertification. Is it perfect? I think there are a couple of areas that could be improved upon. First get rid of that 60 second timer. It is not relevant at all to the exam. I think it is only there because of the name MOCA Minute. The MOCA Minute ideally should count towards one's CME requirements. Right now I still need to purchase CME tests for the CME requirements for recertification and state medical licensure. If I'm already spending time reading and learning, why doesn't the MOCA Minute count towards my CME requirements? It isn't just about the money, is it? Finally please get ride of Part 4 of MOCA 2.0. It's purpose is nebulous and just adds more tedium to the already onerous recertification process.

Thank you ABA for listening and acting on the concerns of your members. Your proactive approach to the maelstrom that is angering physicians nationwide should be emulated by the other medical boards.

Thursday, March 3, 2016

The Perilous Journey From Anesthesia Resident To Attending.

It's almost that time of year again, when CA3's are ready to take wing and depart the comfortable confines of residency and start their professional careers. It is a period of great excitement and anxiety. This is when cocky senior residents suddenly realize they are finally on their own and have no attending backup for the inevitable screwup that will occur.

In the annual report of the California Society of Anesthesiologists, Dr. Adam Djurdjulov has a nice essay titled "Easing the Transition from Residency to Private Practice". He gives a few pearls about the action plan all CA3's should follow before they finish their residencies. Use all the resources that are still at your disposal before going out on your own. Even though oral boards still seem so far away, now is probably the best time to start practicing for the exam. And don't be the locker slammer of the anesthesiology department. It shows you have little respect for your departmental colleagues or your profession.

As I see the CA3's make their anesthetic plans for each patient and competently carry them out, I always admire their confidence and enthusiasm. But there is so much more to practicing anesthesiology than being able to regurgitate a book chapter in Miller. I hope they all use their remaining time in training to ask lots of questions and really explore the profession with their attendings.

Wednesday, March 2, 2016

How Wonderful Is The Anesthesia Lifestyle?

We often hear about how great the anesthesiology lifestyle is. After all, it is one of the ROAD specialties that are so highly coveted by medical students. But does reality match perception? How do anesthesiologists actually feel about their work/life balance? The 2016 Medscape Lifestyle survey provides some clues.

Medscape polled over 15,000 physicians on their feelings of burnout and bias for this survey. It doesn't say how many of those were anesthesiologists. If anesthesiologists truly had the fantastic lives that people imagine, you would think that we would all love to come to work every day, make our six figure incomes, and drive home in our German luxury cars to happy spouses and children in our mini mansions in the suburbs without a care in the world. But the survey says otherwise. Exactly 50% of those surveyed said they felt burnout at work. Burnout is defined as lack of enthusiasm for work, feelings of cynicism, and low sense of personal accomplishment. That sounds like a lot of people for a job that is supposedly heaven on earth. In fact, anesthesiologists are right in the middle of the pack amongst all physicians, with Critical Care, Urology, and Emergency Medicine having the highest rates of burnout and Endocrinology, Ophthalmology, and Psychiatry the least. I'm surprised that urologists feel that miserable since it's considered one of the more humane subspecialties of surgery.

Why do anesthesiologists have such a high rate of burnout? The top reasons given are: too many bureaucratic tasks, spending too many hours at work, feeling like a cog in a wheel, impact of Obamacare, increasing computerization at work, income not high enough, difficult colleagues to work with, difficult patients, and maintenance of certification requirements. This can be broken down to lack of autonomy at work, with surgeons and administrators telling us how to do our jobs all the time. We also have no control over the types of patients we see since we're not the ones who bring them into the hospital. We have no control over reimbursements. And we don't get paid enough for all this aggravation. So yes, anesthesiologists are simply just cogs in a wheel.

Only 32% of anesthesiologists polled said they were happy at work. That number sounds low but is actually more than the average physician. Dermatologists, ophthalmologists, and psychiatrists not surprisingly had the highest happiness ratings. Rheumatology, Critical Care, and Internal Medicine ranked the least happy at work.

There's a lot more information in the Medscape survey that you should check out, including which gender is happier at work and the surprisingly high number of physicians who use marijuana.

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.