Friday, June 29, 2018

Jahi McMath Has Died. Again.

The family of Jahi McMath released news that their daughter has passed away. If you don't remember who Jahi was, she was the adolescent who suffered anoxic brain death after complications from a tonsillectomy and uvulectomy for sleep apnea in 2013. She suffered her second death last week after complications from an abdominal surgery.

Multiple doctors declared the child brain dead five years ago yet the family refused to accept the diagnosis. Even though there was no blood flow to the brain, the family pointed to such findings as twitching of the fingers and toes. Most doctors would say those are spinal reflexes that has nothing to do with brain activity but they found a sympathetic judge who kept the child on a ventilator in the hospital until they found another facility in New Jersey willing to take this "patient".

This case had huge implications for the anesthesia community. For years afterwards, the ASA's CME material repeatedly emphasized the active ingredients in the metabolism of narcotics and how to be extra careful sedating obese young patients in recovery. In all the years before the McMath case, they never discussed this issue once. 

Thanks to the Jahi McMath media circus, at least there was tremendous educational opportunity for physicians. She did not die twice in vain.

Sunday, June 17, 2018

The Anesthesiologist Who Attacked Senator Rand Paul Is Sentenced

Image result for image leaf blower

Remember the bizarre story last year when Senator Rand Paul of Kentucky was attacked by his next door neighbor? The neighbor was an anesthesiologist by the name of Rene Boucher. The incident left the senator with multiple broken ribs and lung contusion. Now it has come to a conclusion.

Dr. Boucher pleaded guilty to the assault and has been sentenced to 30 days in jail. He will also pay a $10,000 fine and serve 100 hours of community service. This sentence seems light to me considering that he pummeled the senator when his back was turned and was unprovoked. His lawyers had requested a 21 month sentence.

During the court hearing, we find out that Senator Paul was not as seemingly innocent as first appears. It seems that the two neighbors did indeed have a longstanding dispute over lawn maintenance. Senator Paul dumped a bunch of grass and tree clippings right on the property line between the two. This was no ordinary pile of leaves. This was a 10 foot by 5 foot stack that sat there for a few weeks.

When Dr. Boucher complained, the senator did nothing about it. Eventually the doctor brought in a dumpster and had it hauled away himself. Then Senator Paul did the same thing again. Then again the anesthesiologist had a dumpster come remove it. This repeats itself several more times. At one point Dr. Boucher even set the pile of grass on fire, burning himself in the process. He asked for the homeowners association to do something about this but they were not responsive.

The last straw came when Senator Paul, who sounds like a big asshole, blew grass clippings over into his neighbor's house. That's when the doctor turned rogue and blind sided the senator. Sounds like Rand Paul was the neighbor from hell. Wonder how he is taking care of his lawn this year?

Thursday, January 11, 2018

What Cars Do Doctors Drive?

Surprise! What your doctor likely drives.
When I picture for you the image of a doctor driving carefree along the sunny California coast or along the boulevards of Beverly Hills, what kind of car do you see in your mind? A Porsche Carrera GTS? A Bentley Continental GT? Maybe even a Ferrari 488 GTB? Well, the latest Medscape Physician Lifestyle and Happiness report has the answer for that.

In a survey of over 15,000 doctors, some of the questions were related to the wheels they own. If you thought that physicians usually drive some exotic European import to work, you'd be mostly wrong. According to the responses, the most popular make of cars among doctors is a Toyota, with 21%. The second most common car driven by doctors is a Honda with 16%. As you can see, many doctors are quite practical and frugal in the types of vehicles they own.

But then you get to the next three: BMW, Lexus, and Mercedes. Now these are the more stereotypical cars that one would expect physicians who make six figures are more likely to possess. However each of these brands holds less than ten percent market share among doctors. The rest of the top ten are Ford, Subaru, Chevrolet, Acura, and Audi.

No longer your typical doctor's car. Sad.
What are the least favorite cars among physicians? Bringing up the bottom are Lincoln, Kia, and Cadillac, each with about 1% ownership with doctors. Then they are followed by Dodge and Volvo. I find it sad that storied nameplates like Lincoln and Cadillac, once the epitome of wealth and success, are now irrelevant among the monied set.

Even though nearly all physicians make six figure incomes, does the medical specialty influence the type of cars they drive? I mean, any doctor could theoretically afford a Mercedes if they wanted one. In reality the specialty you practice does make a difference. Toyota is owned  by more primary medical doctors than specialists 23% to 20%. Honda also has more PMD's in their corner 18% to 16%.

But once you look at the luxury imports, the reverse happens. Far more specialists than PMD's own BMW, 11% to 6%. Same with Lexus 9%-7% and Mercedes 9%-7%. Is it more evidence that PMD's don't make enough money in this country compared to the specialists? Is it an indictment of our healthcare system that prizes costly interventions over preventive care? You be the judge.

It would have been interesting if the survey broke down the types of cars owned by the age of the physician. The report notes that over 50% of the respondents are under the age of 50. In fact, nearly one fifth of the respondents say they are in the 28-34 year old age bracket. That's extremely young, practically fresh out of residency. They will be the ones most likely to still be driving the old Honda and Toyota they had in college while they are trying to set up a practice and pay off student loans.

So next time you see a Mercedes GT-R roaring down the street, know that it is unlikely to be driven by a physician. The driver is more likely to be a Wall Street titan or business mogul than a doctor. We sacrificed years of our lives to go through medical school. Practicality and delayed gratification are in our blood. It would be uncharacteristic for doctors to blow their money on such exotic rides. Unless you're a plastic surgeon in Beverly Hills.

The Lonely Lives Of Anesthesiologists

Medscape has just released its latest clickbait physician survey. This time it's the 2018 Lifestyle and Happiness report. Who wouldn't want to click on a link with that title? While we'd like to think that doctors are all living lives filled with milk and honey, doctors do in fact possess varying degrees of contentment.

According to this poll of over 15,000 doctors, exactly half say they are extremely or very happy outside of work. Only ten percent claim they are extremely or very unhappy in their personal lives.

Who are these happy doctors? The top four are in Allergy and Immunology, Dermatology, Emergency Medicine, and Ophthalmology. Notice these are the fields where doctors may have more free time away from the hospital than most. About sixty percent of these doctors claim to be very happy.

The most unhappy doctors work in Cardiology, Public Health, Oncology, and Infectious Disease. Here, less than half are happy outside of work. The nature of their work, dealing with sick cancer and heart patients, probably contribute to their ennui. Anesthesiologists wind up in the middle of the pack, with 50% stating they are happy outside work. This is about the same as previous surveys.

When asked if they are introverted or extroverted, a large plurality said they are a little bit of both. The most introverted physicians are in Public Health, Pathology, Rheumatology, and Public Health. The most extroverted doctors are pretty predictable: General Surgery, Urology, OB/GYN, and Gastroenterology. In general, doctors who go into a procedural field tend to be more gregarious in my experience. Interestingly anesthesiologists are neither the most introverted or extroverted. We're just vanilla.

Maybe that explains why anesthesiologists have so few friends. When asked how many close friends they have, the doctors mostly answered between 1 to 3 friends or 4 to 6 friends. But when broken down by physicians with three or fewer close friends, anesthesiologists ranked near the top. The top four most lonely doctors are Pathology, Critical Care, Radiology, and Anesthesiology. This tends to feed into the perception that pathologists, radiologists, and anesthesiologists are more socially awkward than their more outgoing colleagues like the surgeons.

Perhaps we need to shed some of our fuddy duddy image and live it up a little. While we like to be perceived as the doctors who most care about patient safety, maybe we should also be the doctors who care about where the next kegger is going to take place. With the best paying job in America, we should try to be the life of the party for once.

Wednesday, January 10, 2018

Anesthesia Books In The News

This doesn't happen very often, but it occurred twice recently--reviews of anesthesia books. The first one was in the Wall Street Journal. "Anesthesia, The Gift of Oblivion and the Mystery of Consciousness" by Kate Cole-Adams seems to linger on the issue of intraop awareness. The author relates horror stories of patients who are wide awake during surgery and can feel everything.

As if that's not bad enough, Ms. Cole-Adams writes about subconscious awareness during surgery. These patients don't remember anything when they wake up from anesthesia but under hypnosis, they are able to recount words spoken by the OR staff while they are anesthetized.

Though the review was published two weeks ago, it just recently prompted a response from James Grant, MD, president of the ASA. You can read it in the published comments at the bottom of the article and also here on the ASA website. Naturally he defends anesthesiologists as diligent physicians who are looking after the patients' best interests and that any surgical recall is extremely rare, occurring in about one in ten thousand cases.

The New York Times also reviewed the same book from Ms. Cole-Adams but it also reviewed a second book, "Counting Backwards, A Doctor's Notes on Anesthesia," by Henry Jay Przbylo. This review was written by a neurosurgeon/author and is much more sympathetic to anesthesiologists than the WSJ article.

Dr. Przbylo is an anesthesiologist and he relates the history of anesthesia and how it has evolved. He uses the standard analogy of anesthesia as being similar to flying in an airplane. Most of the time the flight is uncomplicated and routine. Occasionally it can be harrowing and rarely fatal. But there is nothing the patient/flyer can do about it except lean back and enjoy the ride.

There you have it. Two books about anesthesia, one more sensational while the other one probably more educational and enlightening. Start off your new year right by reading two books about your profession instead of binge watching another season of "Game of Thrones." You'll feel better equipped to answer questions from your patients when they confront you about the fears of anesthesia.

Anesthesiology Still The Best Paying Job In America

This is beginning to sound like a broken record. The latest statistics from CNBC show that anesthesiologists have the best paying job in America. We have an average salary of $269,600 according to the U.S. Bureau of Labor Statistics.

As a matter of fact, the top eleven best paid jobs are all in healthcare. The number two job is surgery with a salary of $252,910 followed by OB/GYN with a pay of $234,310. The top nonmedical career field is petroleum engineer, with a salary of $147,030. Lawyers, a career once associated with steady high income, clocks in at sixteen, with a mean salary of $139,880.

Despite these great numbers, they all appear suspect. The physician salaries seem low compared to Medscape's annual compensation survey that showed anesthesiologists last year made on average $364,000. Lawyers' mean salary may be only $140,000 but they have a much greater variation in their compensation compared to doctors. Many earn much less than $100,000 while some make well over $1 million. The data also don't look at the medical subspecialties that earn much more than mere anesthesiologists, such as neurosurgery, gastroenterology, or interventional cardiology, many of whom earn well over half a million dollars per year.

So for all you naysayers who claim the best days of medicine are in the past, there's still hope for continued good times in the medical field. As the old saying goes, while past performance may not predict future results, it's still a good starting point to have.

Saturday, January 6, 2018

Are Young Doctors Better?

In this Sunday's New York Times op-ed, Dr. Haider Warraich, a cardiovascular medicine fellow at Duke University, makes a fairly convincing argument that young physicians are better doctors than their older colleagues.

He cites research that shows patients treated by younger doctors have a lower mortality. They are less likely to overprescribe medications and order unnecessary tests. Young physicians are also not as likely to be brought before their state medical boards for disciplinary action.

Why is that? Older doctors are more set in their ways. They may not be as familiar with the newest medications or the latest protocols to treat a medical condition. Their skills may not be up to date with the latest techniques. And let's face it, we've all seen the curmudgeonly doctor who refuses to change his ways no matter how archaic their thinking may be.

The older doctors benefit from their ability to maintain their board certification for a lifetime. While new doctors have to pay exorbitant fees and spend countless hours to keep their ability to practice medicine, older physicians can continue to use information they learned in training decades earlier to muddle through their careers and nobody will call them out on it.

Due to this leniency a large number are continuing to work past the usual retirement age. About twenty percent of doctors are currently over 65 years old. That is expected to rise to a third in only three years. Personally in our anesthesia group, we have many partners who have elected to work part time instead of retiring, thus limiting the ability of the group to hire new younger doctors to freshen the blood in the organization.

Yet it is the young doctors who will be looked upon with suspicion from their patients. When patients and their families remark on how youthful their doctor looks, that is not a compliment. They are questioning in an oblique way the qualifications and experience of the physician that is sitting in front of them. Unfortunately there isn't a simple way to allay their fears short of bleaching one's hair white. The smart patients will welcome the enthusiasm and knowledge that a younger doctor brings to the table because sometimes experience isn't the best teacher. It's the training, not the wrinkles.

Thursday, January 4, 2018

Anesthesia Resident Commits Suicide

It's so sad when you read about events like this. Wayne Hendrix, MD, an anesthesiology resident at the Medical College of Wisconsin committed suicide the last week of 2017. The 43 year old doctor charged into Froedtert Hospital in Milwaukee brandishing a gun. He then hid himself in one of the operating rooms and gave himself a lethal injection of fentanyl. When the SWAT team entered the room, they found him already down.

Dr. Hendrix had previously been diagnosed with depression. He was divorced with two small children who resided with the ex wife. Reports say he had also just broken up with a girlfriend. His family said he also had an alcohol addiction and attempted suicide in 2016. This was a troubled soul who was unable to overcome all his demons.

To most of us it's unfathomable why somebody so young and full of potential would end their lives at such a tender age. They seemingly have their whole lives ahead of them and the possibilities are endless. Yet either because of mental illness, substance abuse, or myriad other reasons, they just couldn't make it past one more day.

Anesthesiologists have long had a reputation for being the group of physicians most likely to suffer from drug addiction. Male anesthesiologist may have the highest suicide risks among all doctors. Dr. Hendrix had previously been diagnosed with depression with a difficult personal life. I hope anybody reading this will recognize the cries for help either within themselves or in their acquaintances and seek the medical attention they need before they become another terrible statistic.

Wednesday, January 3, 2018

When The Vagina Is A No Go Zone

This post has nothing to do with anesthesia. But I find the subject matter eye opening and highly amusing. Dr. Jen Gunter, a Canadian OB/GYN and blogger, wrote about seven trendy vaginal inserts that happened in 2017 and why they should horrify any physician and any sane person in general.

Some of these are promoted by celebrities, such as jade eggs which were endorsed by the actress Gwyneth Paltrow. I've never even heard of jade eggs for the vagina until I read the blog. Others trends were popularized by the internet, such as inserting a peeled cucumber into the vagina to make it smell fresh. Or applying glitter to the vagina to make it...shiny?

So please do yourself a favor and consult your physician if you're thinking of putting something in your vag-vag that may not be, how should I say this, approved by a medical professional. You may save yourself or significant other a whole lot of trouble in the future.

Texas Anesthesia Group Pleads Guilty To Fraud

So sad when I read about anesthesiologists who wind up on the wrong side of the law, either out of stupidity or greed. Limbic Partners, LLC, an Irving, TX medical management group started by three anesthesiologists, pleaded guilty to defrauding insurance companies

The founding physician partners, Herbert Brown, Brian Rudman, and Maulik Parikh, were accused by the government of billing insurance companies for millions of dollars for anesthesia services that were not performed. The cases in question took place from 2011 to 2013.

The company would send bills for work done by a CRNA when that person was already working at a different facility at the same time. Or an anesthesiologist with the company would take care of a patient but the doctor was not in the insurance company's network. They would just tell the billing company to insert a different doctor's name who was in the network. Not terribly slick. 

The attorney general's office accepted the plea and Limbic Partners will pay $933,251 in restitution. They've also paid back over $133,000 to the insurance companies that they defrauded. However, like the massive bank fraud that nearly collapsed the U.S. economy in 2008, none of the leadership of the company are being held accountable. Isn't American capitalism great?