Thursday, November 28, 2019

The Childcare Double Standard

The boss was frantically emailing all the anesthesiologists the other day. Apparently somebody called in "sick" and couldn't cover their call, an all too frequent occurrence around the holidays, or any long weekend for that matter. Can somebody please pick up an extra call so that the OR's can continue to run smoothly?

Almost immediately, one of the female anesthesiologists piped up and announced that she couldn't take an unplanned call. She has "childcare issues" and couldn't be expected to help out her partners. Somehow I'm not surprised by this but it still irks me.

Why is it the women can pull the childcare card out at their convenience to get out of work while the same would not be acceptable for men. I remember years ago when my children were small and both of them and the wife all fell sick with a cold. I asked for a day off to help out at home. You would not believe the earful I got from the boss about how this was totally unacceptable. He just couldn't understand why I needed to stay at home to take care of my sick family and how this was burdening the rest of the anesthesiologists who have to cover for my absence. I wound up getting more time off from work than I asked for as punishment for my impudence.

But nobody blinks twice when women say they need to take time off to take care of the family. As a matter of fact, nobody dares question women about why they want to take a day off. It's just assumed they have family issues they need to help with. If men ask for time away, it couldn't possibly be for domestic issues--they must want to drink beer and catch a ball game or hit the beach. They couldn't have a legitimate reason for leaving work.

The implication when women say they have childcare issues at home and can't help out is that only men should be asked next time. Why ask the women when ninety percent of the time they will say no while the men do not have that option. Yet they want pay parity with their male colleagues even though they don't want to put in the hours?

Let's see what happens as medicine becomes a progressively female profession. Women now make up over fifty percent of medical students. What happens when the majority of physicians are female? Will a patient's healthcare access be limited by their doctor's sniffling three year old at home? Who's going to take care of the emergency at 10:00 PM when most of the doctor's can't be expected to leave their family at home to come in? Will medical costs rise because the hospital has to hire more physicians?

Maybe male doctors should have a #MeToo movement of our own--I also don't want to take extra calls to cover for somebody else's domestic issues. But the double standard against men keeps me from getting away with it.

Friday, November 22, 2019

Is Private Practice Dead For California Anesthesiologists?


California often foretells social trends that later spread throughout the rest of the country. Gay marriage and legal medical marijuana use are two quick examples. There's another trend that may soon sweep the country to the detriment of anesthesiologists everywhere. And that is the inexorable passage of laws to prevent patients from receiving so called surprise medical bills after receiving medical treatments.

This happens when a patient receives care at a hospital which is contracted with an insurance company, and thus in the company's insurance network, but gets treatment from physicians who may not be in the same network. This most commonly occurs with independent contractors like anesthesiologists or radiologists. So a few weeks after the treatment is completed, the patient thinks the insurance company has already paid the bills when, surprise!, another medical bill comes from physicians the patient may not even remember working with. Anger ensues. Phone calls are made. Letters to Congress are written. Thus we get laws like California's AB 72 and the proposed HR 1384, the Medicare For All Act of 2019.

To understand what a nightmare AB 72 has become for anesthesiologists here in the Golden State, read this excruciating letter from an anonymous physician reporting to the California Society of Anesthesiologists. The law gives all the advantage and leverage to the insurance companies. I've read other incidents very similar to this letter.

Since out of network anesthesiologists are no longer allowed to bill patients the difference between what the insurance company will reimburse and what the physician feels his work is worth, the insurance company can dictate how much money they are willing to pay. They know that according to AB 72, they only need to pay 125% of Medicare's rate for out of network services. They have no reason to negotiate with anesthesia groups for contracts that pay more.

Worse for anesthesiologists specifically, Medicare has been underpaying anesthesiologists for decades. This is the so called 33% problem. Whereas other physicians receive Medicare payments at about 75% of private insurance rates for the same services, Medicare has been giving anesthesiologists only about one third that of private insurance. Here is a brief history of how that came about.

So it's clear that many anesthesiologists are at a huge disadvantage when it comes to negotiating with insurance companies. We already receive less from Medicare than other medical specialties. Then AB 72 allows insurance companies to demand anesthesia contracts that are well below current market rates since they know they have us over a barrel. They will try to get the contracts down to as close to Medicare rates as possible plus 25%. Anesthesia groups who refuse to lowball the contract negotiations get their contracts cancelled and have to accept whatever the insurance companies offer.

Anesthesiologists have no leverage against these leviathan insurance companies. Most are small private groups that just want to go to work every day and provide safe anesthesia care for their patients. They don't have armies of lawyers and accountants to bring to the negotiating table. Pleading for public sympathy usually falls on deaf ears. The ASA's threat that these surprise medical bill laws will cause a decrease in availability of services rings false. Doctors are not going to quit their practices because they're getting paid less. The public already thinks doctors are overpaid anyway, especially anesthesiologists.

There are only a few solutions to this issue. One is to overturn these laws. That isn't likely to happen since the public seems happy with not having to pay their medical bills. The second resolution is to increase Medicare reimbursement for anesthesiologists. If we can get anesthesia Medicare payments to parity with other doctors, most anesthesiologist would be satisfied with that and call it a day. Again that is unlikely as Medicare is already billions of dollars in debt and just a few short years from bankruptcy.

What's left for anesthesiologists is to forego the independent contractor model that most of us have been working under and become hospital employees, thus freeing us from worrying about being in network with insurance companies. The hospital system will take care of the high stakes drudgery of negotiating insurance rates. That is not as far fetched as many anesthesiologists fear. There are far more anesthesiologist employees than one thinks. VA hospitals' anesthesiologists are employees. As are state university affiliated hospitals. HMO hospitals also employ their own anesthesiologists. These anesthesiologists may not make as much money as private practice anesthesiologists, but they have job security as the government is unlikely to cut payments to their medical employees. And their benefits are probably better than what private practice doctors can afford on their own, like retirement benefits, health insurance, and paid vacation time.

As this presidential election heads towards a referendum on the feasibility of Medicare For All, anesthesiologists can only stand on the sidelines and ponder what living under the 33% problem will be like for their livelihoods. They may realize that they can't live as they have before. The Golden Age of anesthesiology may be passing right before our very eyes as we face lower reimbursements for our services and price competition from below from other anesthesia providers.

Wednesday, November 20, 2019

Which Doctors Get Sued The Most?

Do anesthesiologists still have a bad reputation for getting sued the most? Luckily that doesn't seem to be the case any more. Thanks to all the major safety innovations that anesthesiologists have advanced in the field of medicine, the stigma of anesthesiologists as being uniquely more susceptible to medical malpractice has faded. However that doesn't mean that we should let our guards down.

Medscape has released its latest survey on which physicians face the most malpractice lawsuits. In a poll of over 4,000 doctors, general surgeons won the dubious honor of being the most likely to get sued. As a matter of fact, the top ten are heavily populated with surgical fields, such as urology, ENT, and OB/GYN. Even some of the non surgical fields who are in the top ten, like GI and cardiology, I suspect, are there because they are highly procedure oriented, similar to surgeons. The surgical fields are more likely to face malpractice claims because usually one event can be pinpointed that led to a bad outcome. A patient being treated for chronic illnesses is less likely to know exactly what and who were negligent in their care.

Emergency medicine, number seven on the list, with its high concentration of difficult, unpredictable patients, are likely to face malpractice simply because they have little long term rapport with most of their patients, setting themselves up for getting sued. Anesthesiologists just barely squeak into the top ten of physicians likely to face lawsuits. Despite all our emphasis on patient safety, bad things happen and anesthesiologists are easy to blame since we face the same minimal patient relationships as ER physicians.

Geography also plays a role in how likely physicians will get sued. If you live in a red state, watch out. Most of the top ten are in states that President Trump won in 2016. Kentucky is where one is most likely to get a lawsuit according to Medscape.

Luckily most lawsuits are found in favor of the physician. In their survey, one third of the doctors reported that they settled before going to trial. Most doctors stated that they were eventually dropped from the suit or they were found innocent. Only three percent of doctors said they went to court and were found liable. Those are pretty good odds.

If monetary awards are ordered, over fifty percent report paying less than $500,000. The blockbuster awards that make news are extremely rare. According to the doctors who responded, only about a tenth of the lawsuits involved payouts over $1 million.

There's a lot more information that you can glean from the survey. Maybe you can gain some insight into your own practice to prevent a medical malpractice suit. Or maybe these things are frequently beyond our control and we just have to hope for the best.

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.