Friday, August 24, 2018

Bigger Is Better, Even In Anesthesia

This is a cautionary for all anesthesia practices and residents evaluating anesthesia groups to join after graduation. Olean General Hospital in New York has just informed its anesthesia providers, Southern Tier Anesthesiologists, that it has decided to go with a different group for their anesthesia needs. Bye bye. And don't let the door hit you on the way out.

What's particularly galling is that STA had no conflicts with the hospital prior to them seeking proposals from others. STA members asked directly if there were any issues with their work and the hospital denied any work or personality conflicts. Ultimately the work contract was awarded to another anesthesia group out of Buffalo who were willing to work for less money.

STA had been OGH's exclusive anesthesia providers for 24 years. And OGH has been the exclusive hospital to STA for the last fifteen. Unfortunately they may just have been too small to compete with groups that are much larger and have economies of scale. STA only has six anesthesiologists and two CRNA's. Meanwhile, hospitals and insurance companies are merging at a furious pace. OGH is part of a much larger hospital group, Kaleida Health. When large corporations start running hospitals, loyalty takes a back seat to the bottom line.

For the anesthesiologists in STA, the future looks bleak. It's unclear if they will be absorbed by the Buffalo group if they are willing to work for less money. Otherwise, there are no other hospitals within an hour drive and the physicians will have to move away to find other jobs.

While it may be desirable to work in quaint small towns with Mayberry quality lifestyles, medicine isn't practiced like the 1950's anymore. Corporate medicine is creeping into even the smallest medical practices. I've had personal friends who thought they found the perfect anesthesia jobs after residency. Then one day, they show up for work and find out their hospital has negotiated with a different anesthesia group willing to work for less money. They were suddenly unemployed. Devastating.

In order to compete, doctors will need to team up or get run out of town by companies with billions of dollars in revenue and no compunction to fire staff at will if it helps their stock holders. I wish all the luck to the members of Southern Tier Anesthesiologists in their careers and hope they land somewhere that will provide a more stable job environment for themselves and their families.

Monday, August 20, 2018

The Fallacy Of The Universal Time Out

Scott Baker, MD

Is it possible to legislate away human error? It would appear not. Despite the best intentions of hundreds of bureaucratic agencies and thousands of rules governing every conceivable aspect of medical practice, plain old human error still rears its ugly head to make sensational news headlines about the latest grievous injury to a patient.

Last week, an Iowa woman sued her surgeon, Dr. Scott Baker of Sioux Falls, SD for removing the wrong body part. In 2016, Dena Knapp of Iowa was supposed to have an adrenal mass removed by Dr. Baker. Instead, the surgeon was notified by the pathology department afterwards that he had removed a kidney, not the adrenal. To make matters worse, Ms. Knapp states that the surgeon lied to her about the mistake and claimed he did not get all of the mass and needed a second operation, never informing her that he had accidentally removed a healthy kidney. She went to the Mayo Clinic for her second operation. Now she claims that her one remaining kidney is starting to fail and she is suffering from severe mental distress and pain.

Can you see the difference between the adrenals and the kidney?
This incident has so many open questions. It also points out the fallacy of imposing more and more rules on people in order to prevent human error. First of all, let's agree that the surgeon made a huge error in judgement when he somehow mistook a kidney for the adrenals and took the wrong one out, even if they are right next to each other. However, I'm curious about what the rest of the surgical team  was doing when the error took place? As part of the Universal Protocol required by the Joint Commission, every member of the team in the operating room had to confirm the correct patient, surgical procedure, and site of the procedure prior to the start of the operation.

So that begets the question, where was the rest of the OR staff when the kidney was being removed? Did the nurse or the surgical tech, who would have been right there to document the specimen being removed from the patient, not notice that they were being handed a kidney and not an adrenal? Was the surgeon's assistant not confident enough to tell Dr. Baker that he was resecting the wrong organ?

For that matter, what about the anesthesiologist in the case? We are an integral part of the surgical team and consider ourselves leaders in patient safety. That includes being an active participant in the Universal Time Out. Did the anesthesiologist not notice that the surgeon had removed the kidney by accident? Was anything said to the surgeon by anybody in the OR when the nephrectomy was taking place? So many unanswered questions that I'm sure will be aired out in court very soon.

This is just the latest medical malpractice case to make headlines since the practice of Universal Protocol was conceived in 2004. No matter how many rules are enacted, the best protection for the patient is one of the simplest--stay vigilant.

Don't Google Check Your Attending


Now is the season when medical students all over the country start doing away rotations in their desired fields hoping to gain experience and come away with a favorable letter of recommendation for their residency applications. We are currently trying to accommodate dozens of students each month who come and go through our hospital who are undergoing this ritual.

In general, most of the students are great to work with. They are eager to learn and still in awe of some of the amazing work we do in anesthesia. Many have little experience in our specialty other than what they see on TV or over the drapes during their surgery rotations. It's a pleasure to have them around.

But that doesn't mean that they are all easy to work with. We love it when they ask great smart questions about what they are seeing in the operating rooms. However I recently had one student who loved asking questions but then would quickly look up Google on his smartphone to double check the answer I gave him. This was beyond annoying.

If you just want to learn from Google, why bother going to a far away rotation to questions everything somebody is trying to teach? Sure maybe my own fragile ego may have something to do with my insecurity when I'm up against an omniscient presence like Google. But I don't like being told while I'm teaching that my MAC number for Sevoflurane was just a fraction of a decimal point different from that almighty search engine. I find it rude when I'm questioned about every nugget of wisdom I'm trying to impart on our future anesthesiologists while I'm in the process of doing so. It got to the point where I stopped teaching that particular student anything. Instead we just sat there and talked about his personal life and interests, which frankly he seemed far more receptive to than anesthesia.

Every anesthesia attending I discussed this situation with agreed that the student should be more tactful in how they question their instructors. Don't Google check your attending unless you're invited by them to look something up together as a shared learning experience. If you question something that was said, you can always look it up later and perhaps ask another attending about the discrepancy in information. But to constantly berate your teacher with the internet will quickly shut down the conversation and leave you poorer for it. And that's not why students spend thousands of dollars and months of their lives to gain experience to be smart physicians.

Saturday, August 18, 2018

The Genius of Sting



I have been a fan of Sting since his Police days in the 1980's. Well, mostly early Sting music anyways. His later solo career works just became too mellow for me. So while driving home from work the other day, I was listening to the oldies station (God when did my favorite music migrate to the oldies station?) when they started playing Sting's "If I Ever Lose My Faith In You". I've heard it hundreds of times before but not recently. Then I suddenly caught these lyrics in the second verse.

Some would say I was a lost man in a lost world.
You could say I lost my faith in the people on TV.
You could say I'd lost my belief in politicians.
They all seemed like game show hosts to me.

What?! This song was released back in 1993. Yet the lyrics are so prescient of our current times and politics. In four simple lines he so perfectly encapsulates the present day controversies regarding fake news, Russian collusion, lost emails, special counsels, qualifications for higher office, etc.

Sting, wherever you are, you are truly a genius.


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.