Friday, February 28, 2020

Panic At The Costco

Just how bad are people freaking out over the coronavirus? Here's a picture of the bottled water section at our local Costco. Normally there is a mountain of plastic bottles here. On this day, there were almost none.

It wasn't just water that people are starting to hoard. In our supermarket, an entire row of vinegar was nearly empty. Usually the giant one gallon jugs of vinegar are left languishing at the bottom of the store shelf as who needs a whole gallon of vinegar at one time. Now they are all gone.

I'd like to think that my neighbors are all well educated and level headed. But the steady bombardment of news about the coronavirus is starting to sow anxiety and trepidation into people who usually don't give into their worst primal fears of survival.

Never mind that so far less than 3,000 people around the world have died from Covid-19. Most of those are in countries with suboptimal healthcare systems and afflicted mainly the elderly and frail. By comparison, the U.S. had over 40 MILLION people with the flu and over 40,000 deaths just from this past flu season alone. Yet we have to spend millions of dollars in public service announcements to get people to take their flu shots.

So as the stock market keeps crashing lower every day (BUYING OPPORTUNITY!) and meetings around the world get cancelled, let's try to keep this virus outbreak in perspective. The most common symptoms for people who are healthy are just mild flu-like illness. This is not the end of the world like some Hollywood science fiction movie. We will all get through this just fine. After all, we still have ten more years to go of living on this earth before we all succumb to climate change.

Tuesday, February 18, 2020

Is Gastroenterology The Best Medical Field?

Cha Ching!
Is gastroenterology the best field in medicine? Gastroenterologists enjoy some of the highest incomes among physicians. Some 18 million colonoscopies are done each year in the US, making it the most commonly performed procedure in the country. GI is estimated to bring in almost $3 million in revenue per physician in 2019, double what it made only three years ago. By some calculations, gastroenterology is responsible for $1 TRILLION in medical expenditures each year.

With eye opening numbers like these, it's no wonder that the smart money is starting to pour into gastroenterology. Private equity investors are buying up GI practices to get in on this hot action. The investors are cutting expenses by consolidating office and equipment expenses. They are also able to negotiate better insurance reimbursements by forming larger groups.

GI is relatively easy to make money through buyouts. Many gastroenterologists practice in ambulatory surgery centers that are usually already highly profitable. Purchasing multiple ASC's gives them higher purchasing power and a more efficient backoffice. They are making their businesses even more profitable by bringing inhouse other expenses like pathology and anesthesia services. Why pay another physician a fee when you can pay them a set salary?

So is GI the best field in medicine? From a financial standpoint, it sure looks like a winner. The fees generated from endoscopic procedures would make any general surgeon hopping mad with envy. GI doctors can do dozens of procedures per day in each ASC, generating tens of thousands of dollars in revenue. Surgeons by comparison may only do two or three operations on a good day. As endoscopy gets more advanced, GI doctors are also slowly encroaching on the general surgeons' bread and butter of treating bowel diseases, with the advantage of not making any painful incisions. It looks like GI is ready to take over the medical world. The smartest people in the financial world certainly believe that.

Monday, February 17, 2020

"The Gig's Up". San Diego Anesthesiologist Caught Literally With His Pants Down.

Bradley Glenn Hay, MD

Anesthesiologists have long had a reputation for being the physicians who are most likely to have a drug addiction. One third of all medical residents who are treated for an addiction are anesthesiology residents, even though they make up less than five percent of all residents. Eighty percent of anesthesiology residencies reported having at least one resident with substance abuse problems. Almost twenty percent of anesthesia residencies have reported at least one fatal overdose in a ten year period. As you can see, drug addiction weighs disproportionately heavily on anesthesiologists and the profession.

So it's extremely disheartening to find an anesthesiologist in the news due to his substance abuse. Bradley Glenn Hay, MD, an anesthesiologist at the UC San Diego hospital system is being sued for causing patient harm while being under the influence of drugs. In his deposition, which you can read here, Dr. Hay states that he has been addicted almost throughout his residency and professional career. He started out as a heavy drinker in college, drinking a twelve pack of beer three to five times per week. He then moved on to heavy liquor like vodka and tequila. He would go to class or on rounds either drunk or with a hangover. He had been involved in two traffic accidents from DUI. Both times he underwent diversion treatments without much success.

Once he started anesthesia residency at UCSD, he started abusing narcotics. His drug of choice was usually fentanyl. He would check out far more narcotics than most anesthesiologists would use for a case. He would then give himself most if not all the drugs, causing his patients to wake up from surgery with extreme pain. Frequently he would "waste" leftover narcotics in a syringe with a witness when he had actually replaced the syringe with saline, giving himself the drugs he needed for himself. He would even talk his CRNA into falsifying the anesthesia records to make it look like they gave all the narcotics that were checked out.

Then in January 2017, he went to the staff restroom and shot up with some sufentanil, a narcotic far more potent than fentanyl. He almost immediately collapsed. The staff found him lying face down in a pool of vomit, with his pants down by his ankles. When he was revived, he saw all the staff standing around him and realized what happened. "Well I'm caught. The gig's up," he confessed.

He and the hospital are now being sued by former patients for causing bodily harm. Two lawsuits have claimed that while Dr. Hay was under the influence, his patients had received inadequate amounts of anesthesia. They claim to suffer awareness of their surgeries while experience excruciating pain but were too weak to let their predicaments be known. UCSD is being sued for essentially covering up Dr. Hay's addiction from his patients, nearly 800 over a two year period.

This is just a horrible tragedy all around. Hundreds of patients at UCSD may have suffered unbelievable horror movie scenarios while having surgery. The surgeons involved may have lost the faith of their patients. The hospital will spend millions of dollars in legal fees and fines for allowing this anesthesiologist to practice in their facilities. And Dr. Hay may never work as an anesthesiologist again. He has already lost his California medical license and his ABA board certification. I hope he finally gets the successful drug treatment he should have received prior to his overdose.

Monday, January 20, 2020

Social Justice Anesthesia

Et tu Anesthesiology? Recently, medicine has come under fire for promoting ideas that are more akin to social justice ideology than medical facts. In a widely reported op-ed in the Wall Street Journal last year, Dr. Stanley Goldfarb, former associate dean of the University of Pennsylvania School of Medicine bemoaned the intrusion of topics like climate change and gun control into the already overburdened medical education system. This leaves less time for students to learn about actual disease processes and caring for the patients that are sitting in front of them.

Now the journal Anesthesiology has published a social justice article of its own. In the January 2020 issue, a paper by Angela Jerath, MD, et al, titled "Socialeconomic Status and Days Alive Out Of Hospital After Elective Noncardiac Surgery," the authors attribute  the environment that the patients come from for varying rates of successful care. Naturally those who live in the lowest quintile of median neighborhood household income had higher rates of postoperative complications and 30 day mortality. Sounds like something straight out of the Democratic party agenda.

I fail to see how this article has anything to do with anesthesiology. It reads more like something that should be published in Health Affairs. What am I supposed to do with this information? Am I supposed to accept that my poorer patients will have higher rates of complications and mortality? Am I supposed to lobby my Congressional representative to give everybody a basic universal income to lift them up to a different quintile of economic status? If Anesthesiology begins to pivot more to these social justice articles instead of publishing more information about how I can improve the anesthesia I administer to my patients, I'm going to find less need to read the journal.

Sunday, January 19, 2020

Diary Of My First Half Marathon

4:00 AM The alarm rings. Didn't get much sleep. I'm feeling too anxious. Am I ready for my first half marathon? Yes I am! I've been running for months and it all comes down to this. I'm as ready as I'll ever be. No time to back out now.

6:00 AM I finally make it into the parking lot of the Rose Bowl. Gridlocked traffic for miles around. Outside temperature--39ºF. Holy shit. It's cold here at the Rose Bowl. I'm not ready for this.

7:00 AM This is it. Been trying to stay warm for the last hour. I'm ready to get this started. No more second guessing or negative thoughts. It's time. The starting gun goes off. Here we go!

Mile 1 I'm doing this! This isn't so bad. Look at all those putzes waiting in line for the porta potties already. Why didn't they go before the start of the race?

Mile 2 This hill is a bitch. I'm short of breath already. How am I going to last another 11 miles?

Mile 4 Holy shit. The lead runners are already returning. They don't even look like they're breaking a sweat.

Mile 6 Hmm. These honey gels taste pretty good. I wonder if Costco sells these?

Mile 6.5 Halfway there! Woohoo!

Mile 7 I love all these supporters on the side cheering us on. They're so ebullient and encouraging. They also have really clever signs. I like "On a scale of 1-10, you're a 13.1!" Also "I had a better sign but the Astros stole it!" But my favorite one was "Smile if you farted!" I didn't fart but that sign made me smile.

Mile 8 I'm just cruising here on autopilot now. Good chance to reflect. I think I'm living my best life now. I'm healthier than I've ever been. From the fat kid in high school who couldn't run even one lap around the track, now I'm running my first half marathon. I've got a wife who loves me, most of the time, and kids who aren't getting into any serious problems academically or socially. Life doesn't get better than this.

Mile 10 After that last hill, it's all downhill from here. I can even see the Rose Bowl again.

Mile 11 Oh shit I'm hitting a wall right now. I can barely lift my legs to take the next step. So tempting to cut across the parking lot and make a beeline into the Rose Bowl entrance.

Mile 12 My music app is playing "Torture" by The Jacksons in the '80's play list. It's uncanny how much the internet knows your every thought and action.

Mile 13 This is it. The last mile. I've got a second wind and everybody is hustling to cross the finish line now.

Mile 13.1 Running out onto the Rose Bowl field is such a thrill. This must be how the UCLA football players feel when they play their home games.

Oh man, I think I'm going to faint. All this water, bananas, and Goldfish crackers are not helping. I better lay down for awhile before I totally black out. I don't want to embarrass myself if they have to call a paramedic to treat me.

Back home My legs feel like they weigh a hundred pounds each. I don't want to move off the couch, ever. But it's all been worth it. Another bucket list item I can check off. Living my best life.

Friday, January 10, 2020

Princeton Professors Blame Doctors For Expensive Healthcare

During this election year, there is a lot of debate about reining in the cost of American healthcare and expanding access. The most famous is Medicare For All advocated by Democratic candidates Sen. Bernie Sanders and Elizabeth Warren. Projections for the cost of implementing Medicare For All run as high as $32 TRILLION.

Who is to blame for the outrageous amounts of money that the healthcare industry is sucking from the national economy every year? Many people blame the greedy pharmaceutical companies and their six figure drug treatments. Others blame the scheming lawyers who file nuisance medical malpractice lawsuits that drive up the cost of doing business in medicine. Now two economists from Princeton University have said point blank that it is rapacious physicians who are sucking the system dry.

Princeton economists Anne Case and Angus Deaton presented at the American Economic Association meeting in San Diego recently. They pointed out that the U.S. spends one trillion dollars more for healthcare than the second most expensive system, Switzerland's. That one trillion dollars works out to about $8,000 per person in the U.S. They label this a poll tax on every person in the country.

Despite this added cost, they claim that the American system is not improving the lives of its citizens. They point to decreasing life expectancy and increased mortality from drug and alcohol abuse. But they had especially scathing words for doctors.

According to Mr. Deaton at the conference, "We have half as many physicians per head as most European countries, yet they get paid two times as much, on average. Physicians are a giant rent-seeking conspiracy that's taking money away from all of us, and yet everybody loves physicians. You can't touch them." They point out that of the top one percent of income earners in the U.S., sixteen percent are physicians.

Ouch. I sure would hate to be their doctors knowing that they think they are being ripped off by their physicians. First of all, as economists, they must surely understand the most basic laws of supply and demand. If the U.S. has half as many doctors per capita as Europe, doesn't it make sense that we get paid more here? If there were twice as many doctors practicing as there are now, I'm pretty sure physician income would drop just from normal economic competition. But guess who controls the training of doctors here? It's the U.S. government who determines how many residency spots they are willing to pay for. Simple economics.

Then there is the issue of how much physicians really cost in the overall scheme of medical spending in the U.S. Some estimate that doctors are less than nine percent of the total healthcare spending here. That is less than Germany (15 percent), Australia (11.6 percent) and France (11 percent). Are we really going to halve physicians' incomes which would have a miniscule affect on the entire healthcare spending morass but lead to massive physician dissatisfaction probably cause many to quit the profession?

It just goes to show that these ivory tower eggheads do not really live in the real world. They have their job security and well funded expensive health insurance which are out of reach of many working class people. These are the same people that advised the government on developing a healthcare system where they thought they can keep their doctors if they like them. What a bunch of hooey these people are peddling.

Thursday, January 9, 2020

Anesthesia Team Not Paying Attention Leads To Brain Damaged Teen

Anesthesiology is an amazing profession. That's why it was voted the most important development in medicine in the last 150 years by the New England Journal of Medicine. Despite all the slings and arrows aimed at anesthesiologists from insurance companies and the government, it continues to be one of the highest paying professions in the country. As the American Society of Anesthesiologists gears up to celebrate the annual Physician Anesthesiologists Week, let's never forget how quickly our patients can suffer when we don't maintain constant vigilance.

This is the sad story of a healthy eighteen year old girl who went in for cosmetic surgery and wound up brain damaged for life. Emmelyn Nguyen of Thornton, Colorado was getting breast augmentation when supposedly the plastic surgeon, Dr. Geoffrey Kim, and the CRNA, Rex Meeker, left the operating room with the patient unattended for fifteen minutes. When they returned, they realized that Emmelyn had been hypoxic and in cardiac arrest. They performed CPR and were able to get her circulation back, but not before she had suffered permanent brain injury.

The family says she is now in a persistent vegetative state. She is unable to feed herself and only responds to pain. She requires 24 hours constant care. Emmelyn had saved up $6000 for her dream procedure. Dr. Kim reimbursed the family the $6000 about a month after the incident. Somehow I don't think it's the money that the family is angry about. As the ASA motto goes, "when seconds count". When fifteen minutes pass without any monitoring, those seconds turn into a lifetime of heartache and suffering.

A reader pointed out an error in my original post. Dr. Kim was the surgeon, not an anesthesiologist. I have changed my post to reflect that.

Tuesday, January 7, 2020

Anesthesia Salaries Still Tops In 2020

As we start a new year, and a new decade, let's look back on how the field of anesthesiology has done financially. According to a couple of recent surveys, anesthesiologists' salaries are still some of the most lucrative in medicine.

According to the latest US News & World Reports, anesthesiologists have the highest median salaries of any profession in America. If you recall, a median is where fifty percent are higher and fifty percent are lower. So anesthesiologists have a median salary of $267,020. The number is based on the US Bureau of Labor Statistics. To me that number seems a bit low, especially out here in coastal California where the cost of living is so high. I think it would be fair to say that more than half of the anesthesiologists in southern California make more than that.

The second highest salaries were reported by surgeons, with a median of $255,110. They are followed by ENT ($242,370), OB/GYN ($238,320), and orthodontists ($225,760).

A different survey conducted at Doximity looked at the job offers that were being made for specialties that are most in demand by employers. Here the numbers are quite a bit higher. Anesthesiologists are being offered jobs that pay about $405,000. However, we're not the highest paid specialty. Radiologists can receive $428,572 while cardiologists can command $453,515. But it's nice to know anesthesiology is in the top ten of the most in demand specialties.

But if we looked at the highest paid physicians overall, nobody can top neurosurgeons, who can rake in $616,823. They are followed by thoracic surgeons ($584,287) and orthopedic surgeons ($526,385). I didn't know radiation oncology can be so lucrative, with salaries of $486,089 and ranking fourth on the list.

It's good to see that anesthesiology hasn't been affected negatively yet by all the surprise billing legislation, competition from CRNA's, or the Medicare 33% rule. Our incomes are still higher than average, we're top ten in physician demand, and we have the best lifestyle in medicine. This decade is starting off on the right foot.

Wednesday, December 4, 2019

Cheers! Beer May Actually Be Good For You

In a surprising confluence of news, a couple of articles came out recently extolling the virtues of drinking beer. However, they both emphasize that moderate intake is all you should do to gain the benefits, not the frat party alcohol drenched keggers you used to attend in college.

In the first news item, researchers in Amsterdam have found that Belgian beer seems to promote improved gut bacteria because their beer have more good probiotics. The probiotics are thought to help with weight loss and promote better sleep patterns. The mechanism seems to be that some Belgian beers are fermented twice, unlike other beers which are fermented only once. During the second fermentation, yeast similar to ones used to make yogurt are added. This kills off harmful bacteria that maybe living in your intestines.

The second article came out in the Wall Street Journal. In an interview with the Detroit Pistons's basketball player Andre Drummond, he recounts how he was able to lose weight by drinking one beer per day. Apparently NBA players are now pressured to actually get smaller. Giant players like Hall of Famer former Los Angeles Lakers player Shaquille O'Neal are out of favor with teams. Drummond was advised to lose some weight during the off season. The 6' 10", 279 pound player accomplished that by not eating red meat and increasing his fish intake. And his personal chef recommended he drink one beer per day.

Drummond says he's not a natural beer drinker. He has to force himself to drink that one beer with his lunch. But the results show how his diet has improved his game. His stats in points and rebounds are now being compared to the great Moses Malone.

So now you don't have to feel guilty if you feel like knocking back a cold one every day. If your doctor documents in your medical chart that you have an alcohol dependency, just show them the health benefits of drinking beer. If you remember to keep the libations in moderation, then beer may promote more healthy living.

Tuesday, December 3, 2019

Why You Have To Show Up So Early For Your Surgery

Few things are more aggravating for the operating room staff than patients who show up late for their surgeries. Many patients don't know, or don't care, that the OR schedule is planned to the minute. If one thing doesn't go as scheduled--the patient or doctor show up late, the OR equipment isn't ready, the patient has a difficult IV in preop--then the entire day in that room gets messed up. The other cases fall further and further behind schedule. Yet some patients still think they can just waltz into the hospital at 7:55 AM for their 8:00 case. Sorry it doesn't work that way. This is not like making an appointment for your mani-pedi.

We tell our patients to come to the hospital ninety minutes before their procedures. Why so early you ask? There are numerous ways that the schedule can get tripped up between the time the patient leaves the house to when they actually go into the operating room. First of all, if you've never been to the hospital where you're having surgery, you might easily get lost on the way. When you get here, you have to find parking which may not necessarily be close to the hospital building (all the good parking spaces are reserved for MD's and hospital volunteers by the way).

Even if somebody drops you off at the front door so you don't have to make the long trek from the parking lot, you still have to find your way to hospital registration so they can check you into the system. Remember that there may be dozens of people coming in to do the exact same thing you're doing. So this might take awhile.

After you register, you'll be led to preop holding. Here you'll have to change out of your clothes into the skimpy hospital gown. And most likely you'll want to make a quick trip to the restroom. Depending on your mobility, this could take longer than you think. Sometimes the staff may have to check in your valuables like your phone or wallet because those can't be taken into the OR.

Now the real work starts. The preop nurse will start asking you a whole bunch of questions about your personal history. Some of the questions may not seem relevant to why you're there in the first place but all patients get asked the same questions. So be patient and don't get snarky; they're just doing their jobs.

At some point the same nurse, or if you're lucky another nurse, will start your IV. Did you bring your veins today? Since you've been good and remained NPO since midnight, most likely you're a bit dehydrated and cold so your veins are going to be flat and potentially difficult to access. If your veins are small and flat, sometimes they have to wait for the anesthesiologist or an IV team to come start the vein after they've unsuccessfully poked you a few times.

Then you have to talk to your anesthesiologist. If the anesthesiologist is particularly diligent with history taking and physical exam and you're not an ideal ASA 1 patient, the interview could take a 5-10 minutes or more. Then the operating room nurse will come and talk to you too, asking all the same questions as everybody else up to this point. Finally the surgeon will meander in, smile his thousand watt grin, and declare you ready for surgery.

But wait! There's one more thing. You haven't signed your consent yet. The nurse will then go over your consent and explain the procedure in detail again, including all the possible complications. If you're a good patient and do what the staff ask you, you'll sign on the dotted line without question. If you're smart and independent thinking, you'll want to read through the entire 10 point legalese filled paper and ask why you're consenting for potential complications like MI, stroke, even death when you're just there for a simple procedure. You aren't really signing up for possible death from a routine colonoscopy, are you? So if you have more questions to ask your surgeon or anesthesiologist, this will further increase the amount of time spent in preop.

As you can see, coming into the hospital for a procedure is not as easy as walking into a Starbucks and expecting service instantly. There are multiple obligations that have to be performed before one gets into the operating room. I haven't even mentioned other possible sources of delays like getting blood tests or ECG's before the surgery. So please come to the hospital when the doctor's office tells you to show up, not the time of the actual procedure. You'll save yourself and the OR staff a lot of aggravation.