Tuesday, November 19, 2019

Tips And Tricks For Anesthesia SimStat

Unless you like to humiliate yourself at a live simulation center in front of judgmental anesthesiologists you don't even know, the ASA's Anesthesia SimStat is for you. This is probably the easiest and least intimidating way to fulfill your MOCA Part 4 requirements. The ASA is currently selling five scenarios in SimStat. They represent everything from an appendectomy to trauma to labor and delivery, a pretty wide gamut of cases. After you complete all five, you'll be done with your Part 4 needs for half your MOCA cycle.

SimStat can be a bit tricky if you're an anesthesiologist who's been working in an outpatient ASC for a decade and don't remember the difference between dopamine and dobutamine. But have no fear, I'm here to give some tips and tricks to successfully complete SimStat as quickly and painlessly as possible. And here's my first hint--you don't need to know the difference between dopamine and dobutamine to do this.

Starting SimStat can be a bit tedious. You have to go through an orientation video with each scenario. The first time is helpful. By the fifth time, it's just a bore. The robotic voices in the simulations are also annoying. The voicing and graphics makes it obvious the ASA didn't spend Fallout level money to design this. But you can't get your credits unless you do the orientation.

Then you are dumped into a scene usually with a virtual colleague who suddenly has to leave in the middle of a case and you assume responsibility. All hell breaks loose in about five to ten minutes after your colleague leaves. You have to assume that you will go through each event at least four to five times before you pass it. The first time is just to understand exactly what they are looking for, either malignant hyperthermia, intravascular regional injection, or other life threatening complications. Once you realize what you're facing, each time you repeat it becomes progressively easier.

Now for some tips on how to successfully complete your games, er, anesthesia simulations. When you start the scenes, always remember to introduce yourself to the team and the patient through the dialogue box. You will get points taken off if you don't. This can be quite absurd as the patient could be in severe distress and you still have to take time to stop and do it. Then don't forget to read through any medical records available. Again points docked if you don't.

When each scenario begins, it moves relatively slowly before the complications pile up. This is the time to draw up any emergency resuscitation drugs you might need, just like in real life when preparing for cases. Once you've gone through the scene a couple of times, you'll know which drugs to get early on.

I like keeping the dialogue box open at all times and placed to the side of the screen. The dialogue box can give you clues about what you're supposed to do next, such as call a code or ask for a second anesthesiologist to assist.

Like any good role playing game, sometimes you have to search for clues and objects around you to get to the next level. There were a couple of times where what I needed was BEHIND me, which wasn't at all obvious. You have to use your arrow buttons to turn around to get what you need to keep the patient alive. So don't forget to look around you if you seem to come to a dead end (no pun intended).

I found that opening up the references box was very helpful in conducting a successful resuscitation. Maybe you forgot the treatment for MH. Or it's been awhile since you've renewed your ACLS certification. They are there in the references to help you save the patient.

You will need to score at least 70% to complete each scenario. Luckily they round up your score so one time I only scored a little over 69.5% and they let me pass anyway. Woohoo!. Most of the time the points just keep adding up for each virtual intervention you do. However they will also deduct points for doing something especially egregious, like if your patient dies.

One deduction I found particularly annoying was talking back to the surgeon. The virtual surgeon was being a real a**hole and we're not supposed to react to it. So don't fall for the talking back choice in the dialogue box. What is the ASA trying to teach anesthesiologists, just bend over and let surgeons abuse us?

So those are just some of the tricks that I hope will help you complete SimStat quickly and painlessly. Remember that you'll most likely need to take each one a few times before finishing so don't get frustrated. Each scene is good for five points towards MOCA Part 4. So when you finish all five, you're good to go until the next half of your MOCA cycle. Good luck.

Monday, November 18, 2019

Anesthesia SimSTAT. How The ASA Is Making Board Recertification As Painless As Possible

Yes I've ranted about the American Board of Anesthesiologists' Maintenance of Certification in Anesthesiology (MOCA) for quite some time. First of all, the doctors who really need to continue lifelong learning to maintain their medical knowledge are grandfathered out of MOCA's requirements. They get to keep their board certification for the rest of their lives without reading a single page of books or studying for any exams. Then there is the question of whether physicians who have to recertify through MOCA are really any more qualified than those who don't. I don't think you'll find many older anesthesiologists who think they are not as smart as their younger colleagues or more dangerous to their patients.

But since the ABA has to follow the rules set by the ABMS, MOCA is a fact of life for an increasingly large number of anesthesiologists. After all, lifetime board certificates for anesthesiologists ended nearly 20 years ago. The last anesthesiologists who received lifetime certificates are already more than halfway through their careers.

Since MOCA is here to stay, at least it's nice to see that the ABA has been receptive to the loud complaints about the complexity of keeping up with its onerous requirements. One of the most significant changes it made to maintain certification was the elimination of a single winner take all, make it or break it exam at the end of the MOCA cycle. This was extremely intimidating as your whole career could be derailed by one bad exam result. Now you just need to take short online quizzes called the MOCA Minute every year for ten years. The scoring system is a bit opaque despite the ABA's explanations on their website. But let's just say they're not in the business of kicking anybody out of their jobs.

The next hurdle the ABA tackled was the simulation requirement for MOCA Part 4. I know colleagues who were scared to death about Part 4. This was perhaps the most time consuming and expensive portion of MOCA. You needed to make a reservation at an ABA approved simulation center, which is usually in a big city academic facility possibly hundreds of miles away. The simulations are expensive, usually at least a couple of thousand dollars. This doesn't even count the time away from work, transportation costs, or hotel stays if you had to travel a long distance. Then just the thought of going through an oral board type exam, but this time in front of other anesthesiologists, was perhaps the worst part of the entire MOCA experience. Though there are other ways to complete Part 4, most of those involved starting research projects and how they would change their practice based on the results. Seriously, who has time to do that when you're in the OR ten hours a day?

Now the ASA has come to the rescue, assuming you're willing to part with some cold hard cash. The ASA has an online simulation called Anesthesia SimStat. For a cool $1125, if you're an ASA member (and I hope all my anesthesiologist readers are), you get to fulfill your Part 4 requirements from the comfort of your living room or office. Any gaffes you make will only be known to yourself. Nobody's judging your inability to think on your feet or make a critical differential diagnosis. It's all done in the privacy of your own place.

Anesthesia SimStat is truly an exam for the next generation. It is anesthesia through the sensibilities of a video game. I have taken all the scenarios and I've come away impressed, though I was never an avid gamer. It is private, relatively cheap, and meets a requirement to keep one's employment. I predict it will be a big boon for the ASA and anesthesiologists alike. Next I will give some insight in how to "win" at Anesthesia SimStat.

Thursday, October 24, 2019

Death By Tesla

Sad news about a fellow ASA member today. Dr. Omar Awan, a 48 year old anesthesiologist from Davies, Florida, was killed when his Tesla crashed into trees while going over 70 mph. Law enforcement who showed up were unable to open the doors because the handles were flush with the body panels and didn't pop out like they were designed to do in an accident when the airbags are deployed. Bystanders commented that the car caught on fire and burned very quickly due to all the batteries. The police had to quickly retreat.

An autopsy report showed that Dr. Awan suffered no broken bones or any serious internal injuries. He died from smoke inhalation. Conceivably, he should have survived the crash if he was able to be pulled out from the car. Though the accident occurred eight months ago, the family has filed a wrongful death lawsuit against the car company because of the faulty door handles.

I've personally seen Teslas where the door handles act very strangely. I remember one time driving down the street, a Tesla Model S had its handles pop out every time the car came to a stop at a stoplight. It would then retract when the car started moving again. I thought there is something really wrong with that car. My kids think Teslas are cool, since half their friends own Teslas at home. However, I tell them that for now it is more of a science experiment than a real quality working automobile. We don't want to be part of any car company's beta testers.

RIP Dr. Awan.

Monday, April 15, 2019

Anesthesiologists Are Making More Money Than Ever

Despite all the concerns about the changes in the healthcare industry, physicians appear to be doing quite well. Medscape just released its latest annual report about physician compensation. For 2019, the survey shows that primary care doctors earned 21.5% more than in 2015. For specialists, the pay increase was 20%. That's well above the consumer price index and shows the fear of Obamacare may have been overblown.

Anesthesiologists are still some of the top earners in medicine. Sure we don't reach quite the heights like Cardiology or Orthopedics, but our income is still ranked in the top ten of all physicians. Medscape reports that in 2019, anesthesiologists reported an average compensation of $392,000. That compares to $358,000 back in 2015, an increase of 9.5%. While that's not the 20% increase of other specialists, it still keeps us in the upper echelon, though not in the top five as in previous surveys.

Could the reason that anesthesia income hasn't risen as much is because more women are entering the field? Another part of the survey shows that the specialties that women gravitate towards, like primary care, tend to have lower income. But that's not necessarily because of sex discrimination. The poll shows that women work about ten percent fewer hours than men. Meanwhile the top income earners like ortho and cardiology have much fewer women in their ranks. Or perhaps we are just training too many anesthesiologists for the market to bear.

To sum it up, anesthesiologists' incomes are still rising. It's not going up as quickly as other specialties but it is still a respectable compensation. And I would much prefer to be an anesthesiologist than some face disfiguring ENT surgeon any day.

Friday, April 12, 2019

Sadly, Anesthesiologists Are Still Abusing Drugs

A new survey has been conducted to update information first gathered in the 1990's on the incidence of drug abuse among anesthesiologists. This time, information was gathered from anesthesia residency program directors for the period 2007-2017. The rate of response for the survey was 35% with 52 directors answering the questionnaire.

What the researchers discovered is as disheartening as the earlier poll. Among 2,100 residents in the programs that responded, 3.7% had substance abuse problems. The most common drug that was used was IV opioids with 39%. This was followed by Propofol (20%), and alcohol (15.2%).

The rate of anesthesia faculty abusing drugs was 1.16%. The most common substances used were alcohol (50%), IV opioids (23.7%), and smaller percentages of prescription medications, street drugs, and anesthetic agents.

For anesthesia residents who are found to be abusing drugs, it could be the end of their anesthesia careers. While 52% of the programs will pay for treatment, 13% felt it was the resident's own responsibility for their rehab. Worse, 43.6% of programs do not allow the residents to come back to finish their training. By comparison, the programs paid for faculty treatment 70% of the time. Many programs also continued to pay faculty salary and benefits while they're on sick leave.

These numbers demonstrate that we as a profession have a long way to go to identify and help people who may become or are already addicted to drugs. The rate of resident drug abuse is twice the percentage from twenty years ago. Anesthesiologists already have the highest rate of drug abuse and suicide among medical professionals. The ASA leadership and residency program directors need to conduct more education to prevent the next generation of anesthesiologists from falling into the abyss.

Saturday, March 30, 2019

Anesthesiologists Have One Job

It was late in the afternoon and I was about to relieve another anesthesiologist for the day. I walked into the operating room and met the anesthesiologist, who was talking with another anesthesiologist in the corner. I guess they wanted to chat away from the operating table so that they wouldn't disturb the surgeon while he was busy doing the case. Unfortunately, they were also far away from the anesthesia monitors, which were not visible from where they were standing.

Exchanging pleasantries, we walked back to the patient so that I could be given a report before I took over the case. When we glanced at the monitors, the first thing we both noticed was that the patient's systolic blood pressure was in the 60's. The blood pressure alarm had been muted so nobody noticed the dangerously low hypotension. Reacting quickly, my colleague gave a small bolus of phenylephrine which quickly brought the pressure back up to the 90's.

This incident perfectly illustrates the one job that anesthesiologists have to perform at all times--vigilance. From this single chore flows all our other responsibilities. It doesn't matter if you're the master of neuroanesthesia or an ace in the cardiac room. If you're not constantly watching the patient every second they are under your care, then you're not doing your job to ensure patient safety.

That's why distractions are so dangerous in the OR. Whether it is cellphone internet surfing or gabbing with colleagues, patient monitoring has to take place above all other activities. Nothing else will define an anesthesiologist's career like missing an event leading to patient harm because one is busy reading their Facebook feed.

Luckily the patient suffered no harm. But what if I hadn't walked into the room at that moment? What if the two of them remained in the corner away from the patient for a longer period of time and nobody intervened? How long do you think the patient's heart and brain can tolerate mean arterial pressures in the 40's? It's not the surgeon's job to monitor the patient while performing his meticulous work. You probably wouldn't want them to anyway. So anesthesiologists, don't f*** this up.  You have only one job in the OR. If you can't handle that then you probably need to go into a different line of work.

Tuesday, March 26, 2019

Drinking As Much As You Want Before Surgery Can Decrease PONV.

The American Society of Anesthesiologists has very clear guidelines for deciding when patients should stop any oral intake before surgery. These guidelines were made to prevent patients from aspirating gastric contents upon induction of anesthesia. For years, the rules were no solid foods up until six hours before surgery and no clear liquids two hours before the procedure.

Granted there have always been complaints from patients about how miserable they feel by the time they get to preop from having to fast for such a long period of time. It's especially bad for patients whose procedures take place in the afternoon and were given instructions to be NPO after midnight. Since this is by no means settled science, there is ongoing research to help remedy the situation.

Some have advocated letting patients drink carbohydrate rich fluids to help with the hypoglycemia that makes the patients feel so deprived. However, they still say nothing by mouth for two hours before surgery. Now the British have done something even more bold than Brexit--all you can drink right up to going into the operating room itself.

In a followup to a study first published in the European Journal of Anesthesiology in 2017, researchers in the UK allowed patients to drink as much as they want immediately before surgery. Covering over 30,000 patients, the study showed that the rates of postop nausea was lower for patients who had unrestricted fluid intake, 3.8% compared to 5.2% for patients who could take clear liquids up to two hours before. Postop vomiting was also lower, 2.2% to 2.8%.

The $64,000 questions is what concerns anesthesiologists the most. What are the aspiration risks with unlimited po fluid intake before anesthesia? Surprisingly, they were very good. Only two patients suffered aspiration of gastric contents. Both patients had risk factors including BMI>35 and history of gastric reflux. That compares to a normal aspiration risk of 1 in 8,000 anesthesia patients.

The researchers speculate that patients who were allowed unlimited drinking before surgery had less postop nausea and vomiting because hunger itself can cause nausea. Their conclusion is that the risks of gastric aspiration is low enough that it justifies patients being allowed to drink fluids to prevent the higher likelihood of PONV.

These numbers look very promising on paper. However, in the much more litigious U.S. legal system, I think I will continue to follow the ASA's guidelines instead. People normally go hours during the day without eating or drinking anything. They can certainly do that the day of their operations.

Monday, March 25, 2019

When Did Medicine Become A Branch Of The Democratic Party?

Physicians used to be considered pretty conservative in their political views. They were considered very learned and commanded respect from their patients and communities; the definition of pillars of society. You probably didn't see too many physicians rolling around naked in the mud at Woodstock. Nor did you see them burning their draft cards/bras or march in antinuke rallies.

But times have changed. Medical societies, which are of course composed of physicians, seem to be veering more and more toward leftist ideology. The causes they espouse come right out of the Democratic party playbook.

The latest example is the American Academy of Pediatrics endorsement for a soda tax. They believe that taxing sugary drinks will lower heart disease and diabetes. They naively believe that the extra money from the tax should go towards subsidizing government programs to encourage people to eat healthier foods.

This is despite evidence that these soda tax policies don't work. When it was instituted in Philadelphia, the results showed that most people just bought their soda outside the city limits to avoid the tax. The tax hurt the business owners, many of whom were small businesses and minorities, who lost customers when they decided to buy their soda elsewhere, along with their other grocery needs. Another unforeseen consequence of the soda tax was that alcohol sales went up. If you have to pay extra for your soda, why not just step up to something else?

This soda tax endorsement is just one more piece of evidence that medicine has become a leftist organization. Along with medicine's endorsement of Obamacare and climate change, it's clear that this is no longer your father's or mother's medical practice.

Sunday, March 17, 2019

Doctors Who Cheat

Amid the Hollywood actresses and hedge fund titans who were caught in the college cheating scandal, two healthcare professionals were also charged with using the services of Rick Singer, the mastermind behind this scheme to get children of the wealthy into elite colleges.

The first is Dr. Gregory Colburn, MD. He is a radiation oncologist in San Jose, CA. Graduating from UCLA, he has been in practice for over 20 years. He and his wife allegedly paid nearly $25,000 to have his son take an SAT exam with a corrupt proctor present to boost his score. When news came out, online reviewers quickly gave him one star. He is now being investigated by California's Medical Board and could have his medical license suspended.

The next medical professional's motive is a little more puzzling. Dr. Homayoun Zadeh was the director of periodontology at USC's School of Dentistry. He supposedly paid $55,000 to have his daughter recruited at USC as a lacrosse player, even though she doesn't play the sport. They reportedly had to refinance their house to make the payments. When word of his arrest became public, USC quickly fired him from the dental school.

I just wonder why Dr. Zadeh felt he needed to cheat to get his daughter into USC. She should have a huge advantage over most USC's applicants since her father is a tenured professor at the university. Unless she's a really mediocre student, what made the parents think she needed that extra boost to get her in?

While this episode is truly embarrassing and sad, I can understand the angst these parents are facing to get their children into "elite" schools. My own kids are very shortly going to start applying to college. There is enormous pressure for them to go to top flight schools, mainly as a vanity project for the parents. I personally went to a state university and have done well professionally, but in good school districts with many upper middle class families, the social pressure to one up other parents for bragging rights can become toxic.

I feel worse for the children. Whether they were complicit or not, having their parents' names splashed in headlines across the country must be incredibly traumatizing and stigmatizing. Knowing their parents have lost their jobs and their reputations, it makes you wonder if it was worth it. In hindsight, it obviously isn't.

Saturday, March 16, 2019

What Do Anesthesia Program Directors Want?

Congratulations to all the medical students on another successful Match Day. I want bore you with the details about how anesthesiology did this year. As usual, there were more programs and spots available over last year despite increasing concerns about training too many anesthesiologists. However some of the increase can be attributed to osteopathic programs that are now part of the unified Main Residency Match. As usual, over 98% of positions were taken, though only two-thirds were filled by US senior med students. That compares with over 90% US seniors in highly desirable residencies like ENT or orthopedic surgery.

What I found more newsworthy is the NRMP's survey of program directors. For practically forever, med students have wondered what qualities residency directors look for when seeking applicants for their programs. That is one of the top questions I get asked every year. We now have concrete answers thanks to the NRMP.

The NRMP director survey is done for each specialty. Obviously I'm just going to talk about anesthesia directors. So what are the factors that make a student more desirable?

As you can see, the number one issue that makes a student competitive for an interview is the board scores, particularly Step 1. This is followed by the letters of recommendation, grades in the clerkship, Dean's letter, and class rank. Surprisingly, even though students sweat for weeks working on it, your personal statement isn't really all that important.

When it comes to how programs rank all their interviewees for the Match, the number one factor is interactions with faculty, followed by interpersonal skills, interactions with housestaff, feedback from residents, and board scores. This proves what I've been telling students all along--if you're credentials are strong enough to make it to the interview stage, the rest is all about personality and interactivity. It doesn't matter if you're the most brilliant student this side of Stephen Hawking. If you come across as an arrogant jerk during the interviews or a shrinking wallflower, you will not get ranked highly.

So go check out the rest of the survey by clicking on the link above. You'll find other interesting tidbits like the average anesthesia residency received over 800 applications, but interviewed less than 150. And how Canadian students are really screwed on American Match Day. Again congratulations to all.