Cage Fight At The VA

There is a cage fight going on at the Veterans Affairs hospital near you. It involves the VA's recent proposal to allow advanced practice nurses (APRN's) to practice to the "full extent of their education, training, and certification without the clinical supervision of physicians, regardless of individual state regulations." The ASA is having none of this.

This is the number one battle right now for the ASA. It's importance to the society and specialty is bigger than Obamacare, bigger than MACRA. Though NP's could potentially supplant physicians in other specialties like internal medicine, anesthesiology is uniquely susceptible to being replaced by nurses in clinical practice.

Medscape has lined up the president of the ASA, Daniel J. Cole, M.D. and the president of the AANA, Juan Quintana, DNP, MHS, CRNA, to go mano a mano to breakdown this controversy. Reading the interviews tells me that the two sides will never come to terms with each other. It's war. It's a fight to the death. Both sides are talking past each other, reciting their respective journal statistics without acknowledging the merits of the other. This will not end until one combatant is down on the mat, bleeding profusely out of every orifice, barely conscious. Then victory will be declared until the next president of the U.S. is elected, fresh lobbyists are hired, and new members of Congress are bribed. Then the fight will be renewed once again.

While the entire article is worth reading, I could barely get past the terrible picture of Dr. Cole in the article. Here's a screenshot.

Why is the man purple? He looks like he got some terrible spray tan going on where they loaded the nozzles with blueberry juice instead of tanning pigment. Or maybe he just came back from a blueberry pie eating contest where the contestants aren't allowed to use their hands. Regardless this horrible picture is very distracting and unfortunately lowers the quality of Dr. Cole's arguments. Looks count.

By comparison, Mr. Quintana's skin tone is more appropriate in his picture.

Not to sound too paranoid, but I think there is some conspiracy going on in the graphic design studio at Medscape to make the anesthesiologists' side less credible. Step it up Medscape. There is no place in your supposedly nonpartisan news coverage for this kind of blatant favoritism.

The Hypocrisy Of Natural Childbirth

I love this editorial in the New York Times. Titled "Get the Epidural," the author Jessi Klein explores why some women think it is better and more natural for deliveries to be performed without the comfort of an epidural anesthetic.

Says Ms. Klein, "But how often do people really want women to be or do anything 'natural'? It seems to me the answer is almost never. In fact, almost everything natural about women is considered pretty horrific. Hairy legs and armpits? Please shave, you furry beast. Do you have hips and cellulite? Please go hide in the very back of your shoe closet and turn the lights off and stay there until someone tells you to come out. (No one will tell you to come out.) It's interesting that no one cares very much about women doing anything 'naturally' until it involves their being in excruciating pain. No one ever asks a man if he's having a 'natural root canal.' No one ever asks if a man is having a 'natural vasectomy.'"

There it is. Not only do women have to undergo unnecessary pain during labor for the questionable benefits of "natural" delivery, it is also a highly sexist attitude to condescend women who do choose to have an epidural. So get the epidural. You and your newborn baby will enjoy their birth day more.

Pokemon Go For Doctors

The worldwide craze of the new game app Pokemon Go has people wandering all over the streets looking for Pokemon characters. Some are getting into trouble by running into signs or even getting robbed. Wouldn't it be wonderful if we could harness that kind of intensity from medical students so they devote their energy into improving their medical skills? How about planting Pokemon characters into different body surfaces and orifices to motivate students to examine their patients more thoroughly? Here are a few suggestions.

Yes sir. With a treasure hunt like this for students to explore, they will all become expert clinicians in no time.

Finding The Anesthesiologist In The Bathroom

This is another sad story about how addiction ruins careers, reputations, and lives. Carlisle, PA anesthesiologist Gregory Theodore was found to have overdosed on Demerol while working at Carlisle Regional Medical Center.

His surgeon was trying to find him when wasn't answering his page. He went to the bathroom and could hear the beeper going off behind a stall door. When he managed to get the door open, he found the anesthesiologist unconscious on the seat with a syringe in his lap. When awakened, Dr. Theodore claimed he didn't feel well and had given himself some Zofran. However when he was sent down to the ER, he told the emergency physician that he had been taking Demerol for several years.

He is being charged by the Attorney General with administration of a controlled substance, acquiring a controlled substance, refusal to keep records of controlled substance, theft by unlawful taking, and possession of drugs with intent to manufacture or deliver. Dr. Theodore, your life is now totally f****d up. I hope you get the treatments you need, and a very good lawyer, to turn your life around. His formal arraignment is scheduled for July 21st.

As thousands of medical students graduate shortly and start their residencies, remember that no amount of stress is worth starting an addiction for. It may make you feel better for a very short period of time, but eventually it will completely devastate your life.

The Purple Patch

When King of Pop Michael Jackson died from propofol abuse, the drug became forever known colloquially as the "Michael Jackson drug". Now the devastating news that Prince has died from an overdose of fentanyl may bring notoriety to that pharmaceutical. Will fentanyl forever be linked to the singer's death? Can we expect to hear people call a fentanyl patch the Purple Patch?

Or maybe a fentanyl lozange a Purple Pop?

It's probably making the marketing department of these drugs start singing "Let's Go Crazy."

The Stress Of Running Late

"Oh dear! Oh dear! I shall be too late!"
From Alice In Wonderland

The stress of driving through LA rush hour when you're running late. There is nothing you can do except crank up the radio to your favorite chill music and accept your fate.

California Wants Its Money Back From Radiologists

Imagine when you were a teenager and you mowed your lawn to earn your allowance every week. Then suddenly your parents announce that they think they've been paying you too much and will withhold a portion of your money until the overpayments have been returned. How would you feel? Would you continue to mow the lawn or go on strike? What if you can't go on strike and have to keep mowing that lawn with the reduced payments?

That is exactly the predicament facing California radiologists now. Back in 2010, California was facing an historic state budget deficit, mainly due to its own fiscal incompetence. To help balance the budget, the legislature enacted cuts to Medi-Cal payments to doctors, the state's Medicaid program. The law said that no radiology services could exceed 80% of Medicare's already measly reimbursements.

Unfortunately the Department of Health Care Services did not get around to implementing the new rule until July 20, 2015. Now the DHCS wants to claw back money from radiologists to right this oversight. It wants the radiologists to return the excess money they've been receiving since October 2012.

Normally when the government says they've overpaid you, they want the whole amount returned in one big lump payment. But since they feel for the little guy and understand that would probably bankrupt most of the radiologists in the state, the DHCS has decided that they would reimburse the doctors 20% less than what they should be receiving until the money has been returned whole to the state.

The irony is that now the state is swimming in a budget surplus. Every special interest group is hungrily eyeing that extra money for themselves. Yet they are taking back money from doctors for services fairly rendered years ago. And the radiologists have no say in this travesty. Goes to show that when you sleep with snakes, you're gonna get bit.

Tank For The Memories

One of the really cool things about living in a major city like Los Angeles is that you can get experiences that are unavailable anywhere else. Today, the very last space shuttle external fuel tank is being moved from a barge in Marina Del Ray to its final resting place at the California Science Center. I took the opportunity to drive down to Inglewood to take a few pictures. Memories of past American space program glories almost brought tears to my eyes.

Once at the museum, it will be rejoined with one of four existing space shuttles in the country, the Endeavor. Eventually, the display will look like this for kids too young to know what the space shuttle looked like.

This will be the only place in the whole world where one can see the entire space shuttle launch configuration intact. Gosh it's good to live in LA.

Cheating Your Way Into Anesthesia Residency

You would think that anybody who enters medical school would hold the highest ethical standards. Their integrity should be above reproach. After all, they are making life and death decisions about their patients every single day. Nobody wants a shady doctor with questionable credentials. But alas that is not always the case.

In the February issue of A&A Case Reports, researchers at West Virginia University Anesthesiology Residency Program evaluated the personal statements of all their residency applicants after the 2014 Match for signs of plagiarism. What they found was discouraging.

They used plagiarism scanner software to look through 472 applications to their program. These were split between 228 U.S. applicants and 244 international applicants. Five were eliminated for technical reasons. The plagiarism program pulled out 82 out of 467 personal statements for possible plagiarism. These were then reviewed by the three authors of the study. At least two of the three had to agree that the statement was plagiarized from another source.

After the human review, the authors concluded that nine American applicants (4%) had plagiarized their statements while 33 international applicants (14%) had some plagiarized material. Overall 9% of the personal statements had unoriginal passages. Two of the U.S. and 17 of the international applicants contained more than 10% plagiarized content. One student's personal statement had more than 58% plagiarized material. The most common source for plagiarizing passages were from www.medfools.com/personal, a collection site of personal statements.

Sadly, some people either don't care about honesty and personal integrity or they don't think they are smart enough to get into residency without cheating. You have to wonder how these people got through college and medical school in the first place. For international students, they may think their English is not good enough to get them into an American residency so they hope to sneak in by copying other people's material. But with the advent of scanning software, students will hopefully realize that a bland but honest personal statement is much more acceptable than a stellar one written by somebody else. Nobody should ever have to question the trustworthiness of their doctor.

When To Call For An Orthopedic Consult

Remember how we belittled orthopedic surgeons in the hilarious Orthopedics Vs. Anesthesia video? It was a perfect encapsulation of the stereotype about the big dumb orthopedic surgeon vs. the intellectual anesthesiologist. Now the orthopods have returned the favor. In a GomerBlog post, the "College of Orthopedic Surgery" sets out guidelines to hospitalists and emergency physicians about when it is appropriate to call for an orthopedic consultation.

It mentions with obvious glee that orthopedic surgeons are probably a lot smarter than the people who are calling for the consults. Since it is such a competitive match, they most likely have higher USMLE Step 1 scores than anybody else.

The list asks that somebody review the X-ray first before calling in a consult. Don't just order it and call the surgeon before looking at it. And try to remember the name of the bone that is broken. "Tibula" is not an actual bone. If the radiologist reads the film as "Unremarkable study" then don't call the orthopod. If the patient has a diabetic foot ulcer or foot celllulitis, call podiatry. That is not an orthopedic problem.

There are more funny guidelines in the post to help us clueless non-orthopods figure what is an orthopedic injury.