Friday, March 10, 2017

Best Music Streaming Service For The Operating Room

For some reason the anesthesiologist has become the de facto music DJ in the operating room. Funny since I never took an elective in DJ 101 in medical school or residency. But since we are presumably the only members in the operating room who have "free" time to put on everybody's favorite tunes, people just expect anesthesia to provide the entertainment while they "work". Music is so integral with the job of an anesthesiologist that I've devoted several posts to them. I wonder if Ralph Waters or Virginia Apgar ever got requests to play their surgeons' favorite radio stations while they were busy revolutionizing anesthesiology.

When I first started my career in the early aughts, CD's were still the standard way to play music. I remember anesthesiologists whose carts were stuffed with CD's, all the better to ensure that the surgeon's favorite music format was available. Then the iPod came along and revolutionized OR music. Suddenly people had thousands of songs at the ready in their pockets. In fact, this took away some of the burden of being a DJ since the surgeons often brought their own iPods with them. We just plugged it in and played the folder they requested.

No nobody carries iPods. Instead we all have phones. But phones aren't ideal for playing music since the surgeon doesn't want the tunes to be interrupted by an incoming call. So once again the anesthesiologist is in charge. But CD's are dead. Everybody now streams their music instead of carrying around a bunch of MP3 files. All you need is a phone or computer that can log into the internet and a good Wi-Fi signal.

Since there are dozens of excellent music streaming services out there, I'm going to give you my opinion of only the ones I've tried. It's not all encompassing and my tastes are pretty mainstream. Almost all of them have a free tier and a paid tier. I always use the free services. I have enough hands reaching into my wallet to pay for another subscription service. I need to mention that I am NOT endorsing any of these services or getting paid for mentioning them. I'm just doing this as an educational service for my fellow anesthesiologist. So here is the rundown.

Apple Music--I never use it. Why? Again because I'm cheap. They don't have a free service with ads. It's either pay a monthly fee or nothing. Plus I never feel hip enough to listen to their main music channel Beats 1. So pass.

Amazon Music--Since I am an Amazon Prime member, this service is free. Unfortunately they've recently introduced another tier of membership that requires a monthly fee. Naturally I haven't signed up for that. But the free section is pretty nice. One nice perk is that virtually every single CD you've ever bought from Amazon has their MP3 files automatically loaded into your Music app. Therefore your old CD's are available with the click of a button without having to carry them around. I was amazed how many CD's I had bought over the last two decades. The reason I don't use Amazon Music that much is that their themed playlists are pretty limited. The lists don't have a great number of songs in each so it gets pretty repetitious.

Pandora--This was what everybody was using a couple of years ago. It was a revelation to be able to request virtually any song ever recorded and it just starts playing through your speakers. So why don't I use it anymore? I got seriously annoyed with it when I would request a song or artist and Pandora would start substituting what they think I would like to hear instead. If I want to listen to Louis Armstrong, I want to hear Louis Armstrong. I don't want it to play something else it thinks I would like too. Too many frustrations so it is gone from my life.

Spotify--This one is so close to residing in my home row of app buttons. They play what I want them to play. It is mostly free. If I want to listen to Joshua Tree by U2, I can get it without them streaming something else they think I might want to try. Sure the album would play in random order in the free tier but I can live with that. So why isn't it my default streaming service? Again their computer generated playlists are pretty small. Over the long course of a multilevel spine operation I don't want to hear the same song three times or have to search for another channel to play. Though I don't use Spotify every day I still keep it as my backup.

I Heart Radio--This is my go to streaming service for a year now. In fact I'm listening to it as I'm writing this. (FYI I'm not at work while I'm writing.) Why has I Heart Radio captured my heart? As you can probably guess, it's free. Yes they have a subscription tier but I haven't found a need to go there. You can listen to terrestrial radio stations if you like, as long as they're part of the I Heart Media corporation. The most popular stations in Los Angeles are on there, like KIIS FM and KBIG. But mostly I use the service because they have excellent playlists. I usually play I Heart 70's, I Heart 80's, I Heart 90's, etc. playlists depending on the age and tastes of the surgeons. They have hundreds of playlists to choose from and you can listen to them almost all day without hearing a repeat. Many people in the OR have asked me where I got the music since the selection is so good. They frequently guess Spotify and are surprised when I say I Heart Radio. They almost always say they are going to download the app to try.

So for all you anesthesiologists who have to suffer through another request for music by your surgeon, I hope this helps. With the modern miracle of music streaming, we no longer have to lug around a bunch of physical music media to satisfy everybody's tastes and whims. This is probably the greatest advance in the well being of the anesthesiologist since the invention of the skin temperature sticker.

Thursday, March 9, 2017

Rude Canadians. Who Would Have Thought?

Our Canadian friends up north have a well deserved reputation for being friendly, intelligent neighbors. It's hard to imagine they could be rude to anybody. However a very ugly and public dispute has erupted within their ranks, surprisingly between their own physicians.

The Ontario Medical Association recently concluded contract negotiation with the provincial government for physician pay. This is what happens in a single payer system where all the doctors are essentially employees of the government. The contract called for annual pay raises of 2.5% for four years. Apparently this was considered not worthy for consideration by a majority of the membership. Then the sh** started hitting the fan.

One anesthesiologist emailed the OMA president Virginia Walley, MD, "You are a c***. Crash and burn as you deserve to do!! This will be a no vote and the end of the OMA. Sincerely, F*** YOU and the OMA!!!" OMG!!!! This is coming from an ANESTHESIOLOGIST, one of the most respected and intelligent of all physicians.

Other members of the OMA leadership who were involved in the contract negotiations or who publicly supported the contract have also come under withering criticism. They've been accused of having a mental illness, told off in a foreign language, and even been threatened with physical harm.

What's going on here? Why is there so much animosity with our northern colleagues? Clearly, being an employee of the government is not all it's cracked up to be. Is the stress of being in a single payer healthcare system finally catching up to the doctors? They really have nothing to complain about when American physicians have been facing shrinking reimbursements for years. But when one gets used to the utopia that is universal healthcare, any little disruption can cause one to lose their bearings.

Oh, and to the anesthesiologist who wrote that horrible email to the president of the Ontario Medical Association. You've lowered yourself to the level of our genital grabbing president. If you are unhappy with your government pay consider moving to the States. You'll fit right in.

Wednesday, March 8, 2017

Day Without An Anesthesiologist

Another day, another meaningless protest. Ever since the inauguration of President Trump, it feels like there has been a protest nearly every single day. Some people might say this is a healthy expression of democracy in action. I say it's another reason for people to skip work and school.

Today has been designated the Day Without A Woman. Women are staying away from their jobs and stores to prove how important they are. Ironically this boycott by women only goes to show how inconsequential we as individuals are in society. Life goes on whether we show up or not.

By contrast, if you have a day without an anesthesiologist, all hell would break loose. Suddenly ASC's and hospitals around the country would virtually shut down. Their main profit centers, the operating rooms, would go silent, depriving the centers of their life blood. Pain scores would shoot up as the expert care of our pain specialists are removed. There will be lots of broken teeth and traumatized airways as inexpert intubations prevail. Hearts would go unmended. Cancers unresected. Broken hips unreplaced. It would be a calamity.

So all those women can go out there with their pussyhats and march all they want. If nobody notices any difference with them gone, did they really make that much of a contribution? But watch out if anesthesiologists walk out en masse. The country would come crumbling down before the first surgeon can ask, "Is anesthesia here yet?"

It's Anesthesia's Fault

It's a common refrain among surgeons that if something goes wrong, it's always anesthesia's fault. Whether there was excessive intraop bleeding or prolonged postop ileus, inevitably the surgeon will deflect responsibility and tell the patient it was the actions of the anesthesiologist that led to the complication.

Now there is a study to try to identify the extent to which the anesthesiologist is responsible for surgical morbidity and mortality. Presented at the ASA annual meeting last year, the authors evaluated one million cases culled from the Medicare database. They looked at three surgical procedures in particular: AAA repair, CABG, and colectomy. From these, they attempted to eliminate all possible other causes of surgical complications so that the focus was only on the anesthesiologist involved in the case.

What they found was that the anesthesiologist was responsible for 3.1%-4.5% of complications. As a matter of fact, the difference in complication rates between the lowest performing and highest performing anesthesiologists varied by a factor of three. For comparison, they found that surgeons were responsible for 4.2%-5.2%.

So maybe there is something to the myth that everything is anesthesia's fault. By everything I mean 3%-5% of cases. But if there is even one legitimate anesthesia complication, it will naturally balloon up to encompass all the ills of the operating suite. It's a good thing we have a great lifestyle to compensate for this insanity.

Tuesday, March 7, 2017

Anesthesia On Autopilot

For years people, mostly medical students, have feared that anesthesiology would succumb to the inevitable advances in technology. Anesthesiologists would be relegated to the role of observers while robots did the actual work. Witness the high expectations of the automated Sedasys system for infusing propofol.

But reality always has a way of sneaking back into the picture. Skilled anesthesiologists look like they're replaceable because they make everything look easy. But that is only possible through years of education and hard work. While one might be able to program a robot to give anesthesia in ASA 1 patients, life will throw you an unexpected curve. As the video above of a Tesla on Autopilot shows, machines are only as capable as their programmers. And no programmer is going to write software that will cover every single possibility that might crop up during a case.

At that point, do you want to be the patient that crashes into the barrier at 70 miles per hour behind robot controlled anesthesia, or would you rather be the one being steadily guided by human hands around an innocuous bend in the road?

Tuesday, January 17, 2017

Medicare For All?

President elect Trump has stated that his plan to replace Obamacare would allow everybody access to health insurance. While the Republican Congress struggles to decide what to replace the PPACA with, perhaps Trumpcare would be another version of the old public option, a Medicare for all.

It doesn't sound as preposterous as it seems. What are some of the advantages of allowing universal access to Medicare? First of all, it would have almost immediate bipartisan Congressional support. Universal Medicare was championed by Bernie Sanders during the primaries. Much wasted bloviating on both sides of the aisle would be eliminated by implementing universal Medicare instead of arguing about tax credits and and pandering to the wealthy.

Medicare is also widely accepted throughout the country. Virtually every hospital and physician already accepts Medicare. There would be far less concern about narrow hospital and physician networks. You can just go to your old doctor and the plan will be accepted. The claim that you can keep your doctor if you like your doctor will finally be true.

Universal Medicare is portable. Change jobs? Keep your Medicare. Move across state lines? Same Medicare in all fifty states. Universal Medicare would also drive competition in the health insurance market. Already hundreds of counties have only one choice for health insurance. Universal Medicare would give these companies more competition to lower prices and allow people to buy insurance if the private companies don't offer any plans. In essence, the entire country becomes one giant risk pool for health insurance, which was one of the goals of Obamacare.

Don't forget people actually like Medicare. It's one of the untouchable pillars of the federal government. It would have immediate mass appeal. Intuitively it makes sense to most people. This is what people think of when they talk about universal health insurance in other industrialized countries. Its appeal would make the legislation much easier to pass.

How to pay for it? People will buy into it just like they purchase any other health insurance plans. Unlike regular Medicare, people will buy the insurance, with the premiums based on income. The more money you make, the more you pay for Medicare plans.

Business deductions for health insurance could also be eliminated to help pay for universal Medicare. Right now this sweetheart deal brokered in the early 20th century gives unfair advantage and income to people who work for companies that offer health insurance. Small business owners, private contractors, part time workers, and millions of others don't get this deal. Removing health insurance deductions for businesses would free up billions of dollars and remove price distortions in the health insurance markets.

So could Trumpcare be a form of Medicare for all? It's hard to fathom what goes on under his orange hair every day but who knows? He is not beholden to either political party and can put forward his own plans without worrying about appeasing the right or the left. He just might do something this bold and Big League.

Monday, January 16, 2017

Meet Tom Price

If you have any questions about who is going to lead the medical care of this country for the next several years, the New York Times has a lengthy article about Dr. Tom Price, the nominee for the next secretary of health and human services. It recounts his ascent from a community orthopedic surgeon to majority leader of the Georgia Legislature and now potential boss of the largest expenditures in the federal budget.

In a one sentence blurb, the article briefly mentions that Mr. Price has a plan to replace Obamacare with something better and more substantive. While the mainstream press may keep harping on the Republicans' lack of a real plan to get rid of the PPACA, Mr. Price has already published very long and specific ideas he introduced as the Empowering Patients First Act. So next time you hear some uneducated colleague moan about Republican grandstanding, you can just point to Mr. Price's website and show them that there are plans in place if one cares enough to make an effort.

Thursday, January 12, 2017

RIP Obamacare

The Senate early this morning has started the long process of repealing the flawed PPACA. In a party line vote, they elected 51-48 to begin dismantling this monstrosity and start exploring better alternatives.

The Democrats are vociferously defending their beloved former president's plan despite all the evidence that it is failing and needs a major overhaul anyway. Insurance premiums are skyrocketing again. More doctors are getting excluded from the insurance companies' ever tighter networks. Hundreds of counties in the country have only one insurance company to choose from, if they can afford it. Millions of people are still forgoing insurance coverage despite tax penalties and favorable coverage.

Hopefully any new plan created will truly allow you to keep your plan and your doctor if you really want it. Wouldn't that be a refreshing change? RIP Obamacare 2010-2017. You won't be forgotten and you definitely won't be missed.

Thursday, January 5, 2017

Best Paying Job In America Is...

CNN and is out this morning with their list of the best paying jobs in America. Ranking right at the top of the list for the highest compensation in the country is anesthesiology. We earn a median income of $335,000 per year. PayScale says top anesthesiologists earn can $466,000. And I know a lot of anesthesiologists who make much more than that. Right behind anesthesiologists are radiologists. They earned a median salary of $316,000 with top pay of $492,000. They are followed by physicians (general), petroleum engineers, and dentists.

It's interesting that this list differs from Medscape's annual list of physician compensation which routinely ranks orthopedics as the top paying medical profession. Anesthesiologists usually land in the top ten of all physicians but never number one.

However, just because we have the highest paying profession in the nation doesn't mean we have the best job. PayScale has a different list for that. Instead of highest income, if you count work satisfaction, highest job growth, and relatively good money, phone app developers have the best job, with a median pay of $97,100. Goes to prove that money can't buy happiness and you shouldn't go into medicine just for the income.

Monday, January 2, 2017

Liberals Are Out Of Touch

The Republican Congress is set to start repealing Obamacare this week when it convenes in Washington. As the New York Times reported, the Democrats are throwing up road blocks every chance they get go keep it from happening. House Democratic Leader Nancy Pelosi describes the virtues of the law as "successful in meetings its goals of reducing cost, increasing access and improving quality of care."

Oh talk about fake news. What does this multimillionaire from the San Francisco know about how the PPACA is actually working? Reducing costs? Show me one shred of evidence that medical costs are going down anywhere. After the law went into effect, costs did not increase as much as previously projected, but they went up nonetheless. Even that was a temporary event since expenses are now expected to rise at a much faster rate than the last few years.

Maybe she meant that insurance costs went down for people who bought health insurance through the exchanges. That would only be true if you leave out the huge government subsidies that allowed people to buy their insurance for a couple of hundred dollars per month. Millions of others receive zero subsidies. They are paying every cent that the insurance companies are charging. And this year they increased the premiums by double digits to cover their large losses working within the law. So I don't agree that taking more of my tax dollars to pay for somebody else's insurance should be construed as lower costs. It's just passing the buck.

Obamacare has famously brought less medical access to patients than before. Remember the infamous promise the president made before the law passed? You can keep your doctor if you want? That was a complete lie. Now we have plans with the tiniest networks that the insurance companies can assemble to keep their own costs down. Many doctors also refuse to take patients with Obamacare insurance. This leads to patients have more access to insurance but they have less access to actual medical care.

As far as stating that Obamacare has improved the quality of care, again where's the beef? If it was so easy to improve medical care with a simple wealth redistribution law, why didn't we do it earlier? Yet we are always being negatively compared to the wonderful European systems where people routinely live to 90, have BMI's of 21, and have zero birth defects. Please show me any evidence that Obamacare has improved medical quality. And having every doctor spend thousands of dollars to move their patients' charts to computerized systems doesn't count.

Therefore the Democrat's desperate attempts to maintain Obamacare as their soon to be former president's legacy is based on nothing but lies. These Congressmen and their families don't purchase health insurance through the PPACA. They all get subsidized government health insurance that are not available to the general public. Let Nancy Pelosi and Chuck Schumer buy their insurance through the law they famously passed without reading first and see how they would like it.