Tuesday, April 25, 2017

Shocking News. Anesthesiologists Lie.

I've mentioned before that anesthesiologists are notorious for not being completely truthful on their anesthesia records. During an operation, the only person continuously keeping track of a patient's vital signs is the anesthesiologist. This has led to anesthesia records that are suspiciously too perfect. How can a patient undergoing open AAA repair have vital signs that barely deviate during the entire case? Yet I've seen records from other anesthesiologists that look exactly like railroad tracks stretching across the state of Kansas.

Now that many anesthesia records have moved into the digital realm, the opportunity to fudge the vital signs are more limited. The computer records every number, good or bad. Yes one can go back and change the measurements to their liking, but the computer documents that a change has occurred, and who changed it. At last, anesthesia records that are true to life.

But apparently not quite. Clever, or deceitful, anesthesiologists have still found ways to lie on their records. A study out of the University of Michigan shows that anesthesiologists are still trying to cover their asses on their records. The authors examined 434,554 records at the university from 2006-2015. Out of that huge database, they found that there were only 238 self reported medication errors. That works out to just 5.5 errors per 10,000 patients. The researchers are incredulous that such a small rate of medication errors really happened. By comparison, a study in the Canadian Journal of Anesthesia in 2012 found a reported medication error rate of one per 203 anesthesia records.

The most common medication error in the Michigan study was poor judgement, such as giving a drug that the patient is allergic to. The second most common error was giving the wrong drug. The errors caused almost ten percent of patients temporary harm, including prolonged intubation, unplanned admission to the hospital, or cancellation of the case.

So is this a problem isolated to the University of Michigan? It's highly likely that many institutions face the same issue. The authors suggest that anesthesiologists should be encouraged to be more forthcoming with their medical errors. An institution that wants more open communication without fear of retribution would greatly aid in identifying costly errors that lead to unnecessary patient suffering. Good luck with that.

Monday, April 24, 2017

Job Market For Anesthesia Residents

Each year, the ASA conducts a survey of all the CA3 anesthesia residents to gain insight into the job prospects of these graduating seniors. This month's ASA Monitor has the results of the latest poll. It is based on emails the ASA sent to the residents from May, 2016. Of 1,585 residents with email addresses the ASA had on file, only 122 responded back. So obviously it is a very small sample size and may not be completely representative of the entire class.

At the time of the survey, 97% of the residents already had jobs lined up. Of those going into private practice, a majority of 55% were heading for jobs with partnership track. Only 13% took jobs in academic institutions. Most of the residents applied from 4-9 job positions and received offers from 1-3 locations. The mean starting salary was $299,605. This compares to $289,036 from the class of 2015. The most important factors in determining their job preferences were: geography, job description, and of course, money.

A large minority of 47% said they would be starting a fellowship instead of going directly into the job market. The reasons most often cited for doing so were their interest in the subspecialty and improving their job prospects. The most popular fellowships were cardiothoracic, pediatric, pain medicine, and critical care. Interestingly nobody in the survey said they were going into OB.

What kinds of private practice jobs were the residents starting? About 55% were going into a partnership track. Only 13% were going into jobs without partnership track. Another 20% were starting as hospital employees, like an HMO. Only 12% were going to work for an anesthesia staffing company. Over the last three years, the number of graduates becoming hospital and staffing employees has been trending up.

With 97% of graduating anesthesia residents finding jobs, it looks like the job prospects for newly minted anesthesiologists are still decent. However, it appears more are seeing the appeal of working for the Man instead of working for themselves. Perhaps the uncertainty of Obamacare and onerous rules to get reimbursed from insurance companies is starting to catch up with the new physicians. As hospital systems and insurance companies merge and become increasingly monopolistic, maybe this is the canary in the coal mine and points to the future of anesthesiology.

Saturday, April 22, 2017

Are Oral Boards Necessary?

Oral board examinations are the bane of all new anesthesia residency graduates. It's the cloud that hangs over their heads throughout their entire first year of medical practice until they finally submit to the exams and, usually, pass. But for weeks and months prior to the test, the anticipation and stress it causes can wreak havoc on the young doctors' social and professional life.

The latest issue of Anesthesiology has a study that examines whether passing the written and oral anesthesia boards makes a difference in whether anesthesiologists are later disciplined by their state medical boards. The researchers looked at anesthesiologists who entered ACGME approved residencies from 1971 to 2011. Altogether, they had nearly 50,000 anesthesiologists in the study.

They found that there were over 2,000 incidences that affected the anesthesiologists' medical licenses, either with loss of the license or its restriction. The most common events that led to disciplinary action was substance abuse, not surprising for anesthesiologists. This was followed by license/board violation, malpractice, unprofessional conduct, and inappropriate prescribing. Men were found to be more likely to face state medical board action than women. American medical graduates are also at higher risk for discipline than international graduates.

The authors found that anesthesiologists who did not pass their written and oral boards on the first attempt had little to no higher risk for future licensure loss than those who did. The doctors who did not pass their oral boards faced the same risk of legal action by the medical boards as those who failed both the written and oral boards. The incidence of state board action in the two groups, those who only passed the written and those who passed neither, were not significantly different.

The study concludes that the ability to pass the oral board examination requires the sacrifice and discipline that will carry forward to a long and successful career in medicine. Just passing the written boards is not good enough. The rigor and clear headed thinking that's needed to be successfully board certified will reward the participants for decades to come.

So residents, get cracking on those review books and mock oral exams. It will be worth it in the end.

Wednesday, April 19, 2017

Medical Malpractice Reform Is Still Alive

One of the knocks against the recent Republican plan to repeal and replace Obamacare was that it contained no provisions for medical tort reform. If it did, maybe the AMA and other medical societies would have been more supportive of the ill-fated plan.

But looky here--malpractice reform has not died in this Republican Congress, yet. H.R. 1215, the Protecting Access to Care Act of 2017, is slowly working its way through the marbled halls of Congress. Introduced by Republican representative Steve King of Iowa, it would put a cap on noneconomic damages at $250,000. However states can increase the cap on their own if they desire. This applies to any care that is partially subsidized by the federal government either through a subsidy or tax benefit. Theoretically that would include almost everybody who's on Medicare, Medicaid, TriCare, or Obamacare (ironic isn't it). I would think any hospital that received tax exempt status as a nonprofit would also be included.

In addition, H.R. 1215 would place a statue of limitations for a lawsuit at three years after the injury or one year after the discovery of the injury, whichever comes first. For minors under six years old, it's the same rules or until the age of eight, whichever comes later.

The bill has limits for how much contingency fees malpractice lawyers can earn from their clients. It is 40% of the first $50,000; 33.3% of the next $50,000; 25% of the next $500,000; and 15% of amounts over $600,000.

Naturally the liberals and lawyers are up in arms over this. They're going to trot out the usual sob stories of patients and families horribly damaged by physician incompetence and how tort reform would prevent them from seeking justice. Nobody ever brings up the fact that malpractice reforms work because lawyers could care less about their clients. If the payout isn't there, they will refuse representation in cases with little merit. They will only take on cases with a decent chance of winning, which is what it should be all along.

Democrats in the house are already trying to sabotage the bill. One would increase the cap on liability to $1,128,000, which is the inflation adjusted amount of $250,000 from 1975. It would also index the cap to future inflation. Another would start chipping away at the reform by exempting accidental retained foreign body or wrong sided or patient surgery.

So irrespective of your opinion about President Trump and the Republican party, all physicians and healthcare providers should put aside their partisan divisions and rally their Congressional representatives to support this measure. Passage of this bill would almost immediately give patients more access to affordable medical care without the federal government trying to remake the entire health insurance industry. Signing H.R. 1215 into law would also instantly make allies of the whole healthcare industry to whatever plan the Republicans come up with next to reform Obamacare.

H.R. 1215 is currently sitting in the House Judiciary, Energy, and Commerce Committee.

Tuesday, April 18, 2017

Numbers Don't Lie. Anesthesiologists Are More Qualified Than CRNA's.

Forget the false equivalency that the AANA tries to propagate. Real life hard numbers don't lie. Anesthesiologists are eminently more qualified to treat their patients than CRNA's. The ASA's When Seconds Count campaign clearly demonstrates the superior and more rigorous training anesthesiologists undergo compared to CRNA's. How can anybody reasonably say that 2,500 hours of nurse training is the same as 16,000 hours of training by anesthesiologists? One has to be toking on their medical marijuana to not see the difference.

Despite the very obvious disparity in experience, the AANA continues its aggressive tactics to legalize independent practice for CRNA's. After losing the battle to have the VA hospitals use nurse anesthetists without physician supervision, they are now focusing their sights, and their money, on Capitol Hill. H.R. 1783, deceptively titled Improving Veterans Access to Quality Care Act, would write into law the requirement that VA hospitals allow independent practice for advanced practice nurses, which includes CRNA's. This is the AANA's way of circumventing the decision made by the Department of Veterans Affairs just a few months ago.

Though the department is unlikely to revisit the issue so shortly after they already made a decision, the ASA will need to be vigilant to make sure the bill doesn't get snuck into some larger legislation without anybody noticing. Can't put anything past people who refuse to acknowledge the distinction between having 2,500 versus 16,000 hours of training.

Monday, April 17, 2017

Anesthesiologist Compensation 2017

I used to be super excited to report Medscape's annual physician compensation report as soon as they were released. I couldn't wait to tell my readers how great the income of anesthesiologists are. This year, not so much. Medscape's report has been out for nearly two weeks and I can barely get myself to write about its findings.

No, anesthesiologists still make one of the highest incomes in medicine. This year, Medscape found that anesthesiologists made an average of $364,000 per year. That compares to $360,000 last year, or a rise of about 1%. Yes the money is still good, but we are steadily falling behind other fields. By comparison, plastic surgery saw their income rise 24% in one year, allergy and immunology 16%, and ENT 13%. Even orthopedics, who already have the highest average salary in the survey, saw their salaries increase 10% to $489,000.

Whereas last year anesthesiology came in seventh place, this year we rank ninth. We were leapfrogged by both dermatology, $386,000, and ENT, $398,000. But to be fair, ENT wasn't specifically broken out into its own category a year ago.

Even though our incomes are stagnating, anesthesiologists in general feel pretty satisfied with what we've got. We rank fairly high in feeling well compensated for our work, with 57% satisfied with our incomes. But we can always ask for more. A plurality of 44% think anesthesiologists should make 11-25% more money than what they are making now. Another 32% want 26-50% more. Dream the impossible dream.

So what does this plateauing of anesthesia income mean? If we agree that the laws of supply and demand are immutable, it would appear that the anesthesiology job market has reached an equilibrium. Graduating ever more anesthesiologists and CRNA's will only exacerbate the issue. Until the forecast of an older patient population becomes reality and increases demand for anesthesia and surgical services, it would appear anesthesiologists' incomes are unlikely to see a significant bump for awhile.

Sunday, April 16, 2017

Don't Be Rude To Your Doctors

Remember this classic scene from the movie "Terms of Endearment"? This 1983 tear jerker starred Shirley MacLaine as a desperate mother trying to tend to her hospitalized daughter. Scenes like this helped her win the Oscar for best actress that year.

At the time, I, along with nearly every other naive movie watching public, applauded how much she cared for her daughter and raised our collective fists at the callous reaction of the nurses. They appeared to be more concerned about charting their patients than actually looking after them. Now I know better. If any family member raised such histrionics nowadays, the nurses are more likely to call hospital security than to rush to the nearest Pyxis to administer analgesics.

There is a good reason we don't like patients or family running amok being rude to our staff and demand to be catered to their every whim. It lowers the quality of the hospital care that the patient receives.

The New York Times highlights an article from the journal Pediatrics that studied how doctors and nurses react to being treated poorly by family members. They used NICU staff "treating" plastic baby dolls who were then verbally insulted by an actor playing a parent. The actor would say something like, "We should have gone to another hospital where they don't practice Third World medicine." The authors found that subsequent care of the "baby" declined, with poorer diagnostic and procedural skills and less communication within the team.

So next time you go to the hospital and are not satisfied with the care being received, please try to work it out pleasantly with the staff. Screaming, yelling, insulting, and demeaning the caretakers won't help you get better care. You'll just wind up being blacklisted and barred from entering the hospital again.

Friday, April 14, 2017

Brachial Artery Monitoring Is Safe

There are many gospels in medicine that are taught but have not received close scientific scrutiny. Just look at the latest ACLS protocol for resuscitation. Quickly, before they change it again in a year and you have to pay more money to renew your certification and memorize new algorithms.

In the latest issue of Anesthesiology, a study has come out that puts to rest one dogma that has been taught to anesthesiologists since the start of invasive monitoring was invented: never cannulate the brachial artery. We usually try to monitor the patient through the radial artery because it is superficial and relatively easy to access. However, sometimes the patient has had too many ABG's drawn from that site or patient has poorly palpable radial pulses. Then it is always tempting to go to the brachial artery.

But, no, no, no, we were told never to insert a catheter into the brachial artery. The main offense is that there is little collateral circulation to the upper extremity if the catheter reduces the blood flow to the arm or the artery becomes thrombosed. Then you're dealing with an ischemic dead arm that may require surgery to correct.

In the article from the Cleveland Clinic, the researchers evaluated over 21,000 patients from 2007 to 2015 who had brachial artery catheters. The looked for complication over the subsequent six months. The authors found that there were only 41, or 0.19%, patients who had complications that could be attributed directly to the catheter. Of those, only 33 were considered vascular complications. Eight had infection at the site of the catheter. They did not record any neurologic injury from brachial artery catheters.

Overall, the authors state that brachial artery catheterization does not have any more rates of complications than radial artery monitoring. One more "truth" that has been debunked.

Thursday, April 13, 2017

How Likely Are You To Die During Surgery

This is probably one of the topmost concerns in most surgical patients' minds and something anesthesiologists get asked almost daily. What are the chances I'll die during surgery? For healthy patients, we almost always pooh pooh away the inquiry and say in our most reassuring voices that it is very rare, especially for young healthy patients. But exactly how rare is it? Now here is a study that tries to answer that question.

In the latest Anesthesiology News, researchers from UC San Diego looked at a database of over 1.5 million patients classified as ASA I or II who underwent surgery. Eleven percent had emergency surgery and 80% had general anesthesia. They found that overall 0.11%, or about one in one thousand, died within 30 days of surgery. As expected, different operations carried different levels of risk. Thoracic surgery had a 30 day mortality rate of 0.55% while general surgery had 0.3% and plastic surgery had 0.03% risk.

The researchers also looked at different patient factors that affected mortality risks. As expected, things like age, length of surgery, difficulty of surgery (expressed as number of relative value units) can determine the riskiness of the operation.

Surprisingly, a small innocuous bump up from ASA I to ASA II was enough to cause an increased risk. In a time when the average age of our surgical patients seem to approach 80, age greater than a relatively youthful 65 increases mortality rates. Men are SOL when compared to women in likelihood of dying. Curiously, some of these elements wouldn't seem to qualify a patient for an ASA II status, such as preoperative sepsis and pneumonia.

So next time your patient asks you if they will die during surgery, you now can answer confidently the risks are extremely low and you have the numbers to back it up.

Tuesday, April 11, 2017

If Hospitals Were Run Like United Airlines

It's getting late in the day. Unfortunately the operating rooms are still full and there are still more patients waiting in preop for their procedures. The patients are all set to go, hospital gowns on and IV's in place. But the OR retirement party for a colleague is set to begin at 6:00 PM sharp. And nobody wants to miss this open bar farewell to one of their colleagues.

The nurse manager then quickly walks through the ward and asks each patient if they are willing to be rescheduled for another day. We won't even charge them for the IV and LR that are already running. What a deal! Surprisingly, few people are willing to wait for another day for their surgery.

"I took a day off from work for this operation. Do you know how hard it is to take time off to come to the hospital?"

"We drove for two hours to come here for nothing? No way will I want to do that again for no reason."

"You mean I fasted and took that nasty bowel prep for nothing? I will have to do that again if I reschedule my operation? Forget it."

The nurse manager then tries to sweeten the incentive. She offers to pay for the patient's parking garage ticket. Who could resist that offer?

Surprisingly not one person took the bait. How about a meal ticket to the hospital cafeteria? Free low sodium white meat turkey with low fat gravy! Will that do the trick? To her exasperation, again nobody is willing to leave voluntarily. It is now getting close to party time. Something drastic needs to be done. So she does the only thing she can think of, because her training is woefully inadequate to deal with uncooperative patients like this. She calls in hospital security.

Security comes to preop and asks how they can help. She tells them to start hauling away patients to the dressing room to get them the hell out of there. But where to begin. Okay don't pull the pediatric patients. Then you'll have to fight TWO angry adult parents. How about that 85 year old lady over there? No, you'll probably break one of her hips then we'll have to stay late tonight to fix it.

Well, how about that guy over there? He won't cause us any trouble. And he's alone right now so there won't be anybody to defend him. Let's go get him. Security approaches the man and tells him he has to leave. The guy protests and says he can't accommodate them. He claims he's a doctor and he would have to reschedule all of his office patients and throw his whole office into chaos if he doesn't get his procedure today.

The nurse manager and the officers are unsympathetic. They've heard these sob stories before. The time is now getting dangerously close to the party. The time for action is now. When the patient continues to be belligerent, they do the only thing they can think of. They grab him by both arms and physically drag him out of the gurney and to the dressing room, blood dripping out of his torn IV site, slamming the door shut behind him to let him think twice about his obstinance. "And don't come out until you're dressed and ready to go!" the officer yells through the door.

The unfortunate incident was captured by several visitors' cellphones and posted on Twitter where they quickly became viral. Angry emails and news coverage rained down on the hospital. "How can a hospital do this to a vulnerable patient?" they scream.

The CEO of the hospital mumbles some inadequate explanation about uncooperative patients after having made extravagant gestures to get them to voluntarily leave. Since nobody was receptive to the offers, the hospital had no choice but to do what's within our rights. People can have expectations of their hospital stay but nobody has a right to it so it's not really our fault, is it. Besides, we're the only full service hospital in town so you really don't have a choice about where you get your healthcare.

It was a fabulous retirement party after all.