Tuesday, June 2, 2020

Where Are The Medical Scolds?

Remember a few weeks ago during this interminable pandemic? People were starting to chaff under the restrictive stay at home orders and social distancing guidelines. Mass demonstrations against these government edicts began to pop up all around the country as people clamored to get back to work and restore their livelihoods.

Instead of supporting their fellow citizens who were on the verge of financial ruin through no fault of their own, a bunch of healthcare workers stood in the streets in their possibly coronavirus infected scrubs to act as human barriers against the protesters. They looked like they were emulating the tank man at the Tiananmen Square uprising in China.

One physician made an indignant plea on YouTube after visiting her local Target store. She was appalled at all the customers who weren't wearing their masks and accused them of being immoral. She freaked out that this was endangering the lives of medical workers by not practicing the proper social distancing and wearing protective coverings.

The press lionized these medical professionals for standing up to the so called ignorance of the selfish population who only wanted to live their own lives free from bureaucratic interference. These were the new social justice warriors who needed to be paid attention to during these difficult quarantined times.

Now flash forward to this past week. There are massive demonstrations throughout the country in the aftermath of the George Floyd death under the knee of a police officer in Minneapolis. Thousands of people are marching shoulder to shoulder through the streets. Some are wearing masks though I suspect it's not for health reasons.

Yet where are the medical scolds to come out and defy these massive crowds? Where is the righteous indignation that all these people dare to endanger themselves and the healthcare workers by deliberately allowing themselves to get exposed to the coronavirus? Where's the outrage at this defiance of the medical establishment? 

Could it be that the earlier stand of the physicians against protesters was more about their political views than the health of the population? Now when thousands of marchers are congregating over a police killing, there is nary a concern for virus transmissions. The politicians who before were threatening to arrest people for walking outside with their families are suddenly encouraging the masses to express their impassioned views even if they are blocking the streets and disrupting businesses. There is no mention of extending the lockdowns as the Michigan governor had threatened last month after peaceful protestors surrounded her capital building.

So color me skeptical about this whole pandemic quarantine. Countries like Sweden, Japan, and Taiwan demonstrated that lockdowns are not necessary to combat the coronavirus. This financially catastrophic episode in America appears more and more politically motivated than healthcare driven. The country followed the orders of epidemiologists like Dr. Anthony Fauci, believing that their physician oaths to first do no harm guided their recommendations. After 40 million people suddenly found themselves in the unemployment line and politicians have decided it's acceptable for thousands of people to gather together after all, we wonder if this was the biggest political con job on the American public ever perpetrated. 

Monday, March 23, 2020


The coronavirus pandemic continues unabated through much of the world. Despair is starting to weigh on society as millions of people have lost their jobs and our freedom of movement has been curtailed by the government with no recourse for dissent. Through this natural disaster, a morbid theme has emerged for the Corvid-19 virus--Boomer Remover.

Used mostly by the young, boomer remover shows their disdain for the elderly and who they think is the source for much of their misery. While they are trying to carry on and party like the young are wont to do, they are being forcefully suppressed by their supposedly more educated and worldly elders. They have been thrust into the worst US economy in at least a generation, and maybe as bad as the Great Depression of the 1930's just as they are graduating from school and starting their families and careers.

However, it is the baby boomer generation that is feeling the brunt of the Corvid-19 chaos. First of all, the disease is much deadlier among the elderly than the young. The death rate for those under 50 years old is less than one percent. After that, the rate increases exponentially until after the age of 80 where the death rate is almost fifteen percent. That's why the college kids feel like they can party on Miami beaches with little consequence for their own health while the country watches in horror.

Then the government guidelines ask that those over 60 years old should stay home since they are the ones most likely to suffer severe illness from the virus when they get infected. This has caused many of them to miss precious work just when they are getting set to retire. In our practice, our older partners have voluntarily stopped working for the last two weeks. I don't know how much longer that can last as they are making zero income sitting at home.

The stock market crash has also disproportionately affected the baby boomers. The financial crash of 2008 forced many in our group to work past their expected retirement age. This caused our partnership to become too top heavy as the older anesthesiologists refused to retire, making it difficult to hire younger partners. After eleven years of a bull market, we finally had an exodus of retirements in the last two years. Wouldn't you know it, the market crashed again. Who knows when people can feel whole enough again in their retirement accounts to contemplate hanging up the shingles.

So the younger generation may feel that they are the ones bearing the brunt of this economic collapse because of government mandates beyond their control. But the term #BoomerRemover may be more accurate than they realize. The increased mortality associated with the disease and the financial difficulties that will crush their retirement savings may cause a calamity for the boomers that are yet to be calculated.

The Unhealthy Dependency Of Anesthesiologists

I've mentioned in the past about the anesthesia profession as being highly dependent upon the well being of their surgeons. Though the ASA would hate me for saying it, anesthesiologists have almost a parasitic relationship with the doctors on the other side of the blood brain barrier. The surgeon is the doctor who brings the patient, and the money, to the facility. The anesthesiologist is the doctor who feeds off this relationship. Sure the surgeon wouldn't be able to do his case well with a bad anesthesiologist, but there are a lot more anethesia providers around than there are surgeons with lots of well paying patients.

The Covid-19 pandemic has brought this dependency into stark relief. With hospitals everywhere overwhelmed by the number of Covid-19 patients being admitted, all elective and many nonemergent surgeries have been cancelled across the country. Unless the patient has cancer or is in imminent death without surgery, the cases are being rescheduled for a later time. The tricky part is nobody knows when a better time can be found as the end to the pandemic is nowhere in sight.

Subsequently anesthesiologists are hurting financially everywhere. The Boise Anesthesia Physician Associates just laid of 53 of their CRNA's for lack of work. The anesthesiologists themselves are not drawing a salary so their employees can work another month before they are let go. Then after that who knows? Their banker would not extend a line of credit without the doctors using their personal assets like their homes for collateral. Their hospital still needs anesthesia providers for critical care and intubating expertise but they need far fewer of those than the number who used to work in the OR.

In my facility, the operating schedule has dropped by well over fifty percent in the last week. The suddenness of this change has been breathtaking. Just two weeks ago people were planning their summer vacations and watching their stock portfolios hitting record highs. Now we're all talking about how to reuse our N95 masks and calculating how we'll ever pay for our kids' college education, much less thinking about our decimated retirement funds.

This has truly been a black swan event. Whereas the 9/11 terrorist attack and the 2008 financial meltdown also brought the stock market to its knees, there was very little change in the need for surgeries. In 2008 many of the plastic surgery offices were hurt as the high end Beverly Hills clientele lost money in real estate and had to cut back on their cosmetic surgeries. But they were a small minority of the operating schedule overall.

This time it's different. When all elective surgeries are cancelled, there really is no escape course for the anesthesiologist, or surgeon. Many of the ambulatory surgery centers in town have been closed by government mandate since they're not considered essential businesses. Nobody is allowed to go outside anyway as we're all supposed to be sheltering in place at home. The worse part is that nobody knows when all this will end. It could start improving in a month or two. Or maybe it won't get better for six months or more.

Currently we have far more anesthesiologists than necessary for the number of cases we have each day. They're talking about rotating on off days so that everybody has at least a little bit of work. It's a level of financial uncertainty that is rarely experienced by well paid physicians. The coronavirus may ultimately remake the American healthcare system as we know it.

Sunday, March 22, 2020

We Are Now Living The Green New Deal

No traffic in Los Angeles!
Thanks to the panic of Covid-19, we are now living in the world of the Green New Deal. You remember what that was, right. That was when the country, and the world, was free and prosperous enough to contemplate what the climate will be like a decade in the future. Thanks to far left liberal politicians like New York Congresswoman Alexandria Ocasio Cortez, the predictions were that the world will end in a decade unless drastic action was taken to prevent climate change.

They proposed the elimination of all use of fossil fuels. Everything would have to be powered by electricity obtained from clean renewable energy sources like wind or solar, but not nuclear. There would be no more airplanes, automobiles driven by fossil fuels, and boats. Homes and businesses would not be allowed to turn the lights on unless the electricity came from clean energy. And even cows were demonized for emitting too much methane into the atmosphere.

The GND was rightly mocked for being impractical and unrealistic, a fantasy of the privileged elite who don't have to drive to work every day to earn their paychecks. They idolized their beliefs to the point of declaring a teenager who espoused those views to become Person of the Year by Time magazine despite having no formal education in environmental science.

Now we know what living in a GND world is like. Through (overly?) draconian actions taken by the government to prevent the spread of the coronavirus, the American economy has ground to a halt. Practically all air travel has stopped as people are told to hunker down. All cruise ships have cancelled their trips. Millions of people have lost their jobs because all nonessential businesses are told to close until further notice to prevent gatherings of crowds. Millions of children and college kids are out of school with no clear idea when they will return to finish the school year, if at all.

The consequences of these actions have been terrifying. Billions of dollars have been lost in the economy as people are confronted with no income. The stock market is crashing by astonishing amounts almost every day. The federal government is looking at spending trillions of dollars to prop up the economy and it may still not be enough. People are panic buying and hoarding food and survival supplies. There are long lines to purchase guns as people think civilized society is hanging by a thread.

The only bright side for me personally is that my commute to work has been cut in half. A traffic map I took in the middle of the afternoon on a weekday showed virtually no traffic jams anywhere in LA County. Normally there would be red lines through all the freeways. Now they're all green. Los Angeles really is glorious when it's easy to get around. The skies are wonderfully blue. It's easy to see the distant snow on top of Mt. Baldy. The air feels crisp and clear. The only problem is that there is nowhere to go despite so little traffic as everything is closed.

For all those who talked a few months ago about the urgency of implementing the Green New Deal, be careful what you wish for. It's easy to advocate for those policies when you know there is little likelihood of their implementation. This current crisis is just a taste of the chaos that will happen to society if those ideas ever come to pass.

Thursday, March 12, 2020

A World Without Vaccines

Okay all you anti vaxxers out there. This is what the world looks like if man had never invented vaccines. Not pretty is it? You refused to immunize your children against deadly plagues like measles and polio. You go on internet tirades and troll anybody who expresses the necessity of giving children their vaccinations. You cheer on quacks and celebrities who preach their uninformed opinions about the potential complications of vaccines.

Now the world is faced with a pandemic from the coronavirus. How many of you still think the whole vaccine business is a profit making scheme cooked up by the pharmaceutical industry with the tacit approval of a government influenced by highly paid lobbyists? If we had a Covid-19 vaccine tomorrow, would you rush to get it for yourself and your family? Or would you stand by your principles and refuse to accept it, hoping for herd immunity to keep your loved ones from getting sick?

It's tough to stand by your medical convictions when it seems the whole world around you is one step from calamitous chaos and civilization is hanging by a very fragile thread. But for you anti vaxxers out there, rebelling against the miracle of modern medicine should be par for the course, right? We'll let you stay in the back of the line when the coronavirus vaccine is invented so that you won't betray your core beliefs.

Sunday, March 8, 2020

The Road Not Taken

To do anything truly worth doing, I must not stand back shivering and thinking of the cold and danger, but jump in with gusto and scramble through as well as I can.
                                                                                         Og Mandino

I let a virus defeat me. The Los Angeles Marathon was today and I wasn't there. Now I'm overwhelmed with regret.

Against all medical and governmental advice, the organizers of the LA Marathon, along with the city government, proceeded with the race today. They set up some precautionary steps to make everybody feel safer. The organizers banned participants from six especially affected countries like China and South Korea. They put out more hand sanitizers along the route. And they advised runners and roadside viewers to stay at least six feet away from each other. As if it's possible to corral 27,000 runners into a small starting gate and maintain six feet of distance between each other.

Social media lit up with outrage that the event was still happening. Dozens of conferences, concerts, and other large public gatherings have been cancelled. Yet out of sheer greed, or hubris, the city allowed the marathon to continue. They did however tell runners who aren't feeling well not to come. What a laugh.

The statistics would support the city's decision. Roughly 80% of people infected with coronavirus will get very mild flu-like symptoms, or none at all. The mortality rate is about 1-3% so far. In general, marathon runners are on the more healthy side of the overall population spectrum and unlikely to come down with severe symptoms. So I was actually ready to go ahead and check off another bucket list item today.

Then the hammer came down. My wife was adamantly opposed to me running this race. She called the mayor's office and California governor's office to try to get them to cancel the event. There were online petitions to convince the organizers to stop this from spreading what is already described as a worldwide pandemic. She threatened to kick me out of the house for at least two weeks if I ran.

Finally I had to relent. The negative consequences of running this marathon outweighed the positives. What if I did catch the coronavirus? Even though runners from the six most affected countries were banned, the participants come from all 50 states and dozens of other countries. There's no way the race could guarantee a disease free environment.

If I ran, I could potentially be spreading the disease to my own family before I showed any symptoms. The kids would then spread it to their schools before anybody realized they were infected. I would be out of a job for at least a couple of weeks, jeopardizing our financial situation if even one runner out of 27,000 turned out to be positive for Covid-19.

So I sat out the race. I didn't set my alarm clock to get up at 4:00 AM. I rolled out of bed well after the sun came up, like my usual Sunday morning. But now I'm consumed with what could have been. The weather outside is gorgeous, perfect for running. There was a light rain last night so the air is clean and crisp. The temperature is neither too hot or too cold. There are fluffy clouds floating over the city, providing brief respites of shadow for the runners under the unrelenting Southern California sun. In other words, perfect running weather.

For now I've lost my motivation to keep running. Next year seems so far away and I'm not sure I can keep up my desire for running a marathon that long. I don't even feel like maintaining my strict diet for now. Sure there are other marathons throughout the year. But this is the LA Marathon, my hometown event and one of the premier marathons in the country.

So you'll forgive me if I wallow in my own self pity for awhile and gorge on a pint or two of chocolate chip cookie dough ice cream. Nothing feels worse than self defeat.

Friday, March 6, 2020

Plastic Surgeon Required To Use Anesthesiologist

Dr. Geoffrey Kim
Here's a followup to the tragic story of an outpatient plastic surgery case gone horribly wrong. Emmelyn Nguyen is an 18 year old girl who was having breast augmentation in a Denver surgical facility by Dr. Geoffrey Kim. After induction of anesthesia, the surgeon and his CRNA somehow were not monitoring Ms. Nguyen closely. She suffered cardiac arrest and was revived but now has permanent anoxic brain injury. She now requires 24/7 monitoring and support.

Dr. Kim initially had his medical license suspended. But now with a settlement with the Colorado Medical Board, he can resume his practice immediately but will have his license on probation for three years. He will also need to undergo more medical education and work with a board certified anesthesiologist.

Enough said.

Saturday, February 29, 2020

A More Holistic Approach To Finding Good Residents Or Just More Political Correctness

The recent news that the USMLE Step 1 will no longer issue a numerical score has stunned the medical community, especially all the medical students who have yet to take the test. The test takers will now only receive a pass/fail instead of the all important number that's used by residency programs everywhere to screen for acceptable candidates.

Why did the NBME, which administers the test, make this change? Their explanation is that they are trying to de-emphasize the importance of the Step 1 score so the students can concentrate on their clinical clerkships without being distracted by studying for the exam. Apparently some students are so anxious about the Step 1 that their clinical work suffered while they crammed for the test.

However there are some pretty notable flaws to this switch to pass/fail. The most obvious one is that now the emphasis will be on Step 2, since that still retains the numerical score. This comes at the even more crucial senior year when students are trying to juggle residency applications, impress their residency programs with their clinical excellence, and studying for Step 2 with its all too crucial score. I can't imagine that this change will make the students feel any less nervous about their prospects.

Then there is the conundrum residency directors now have in trying to winnow the number of applicants to their programs. Many subspecialty residencies, particularly the highly competitive ones like orthopedics, ENT, dermatology, use the Step 1 score as the first cutoff for choosing which applicants to ask for interviews. There's the absolute minimum score below which a program will not request an interview. Then there is the upper score where students will definitely be asked to come. Everybody else is in a gray zone. Because of this change to pass/fail, all applicants are now effectively in the gray area. Now admission directors will have to use soft evidence of an applicant's excellence, like research conducted or letters of recommendation.

If you've heard something similar to this before, that's because the move away from ranking students based on a number has been prominent in college undergraduate acceptance for years. There is a growing movement among colleges to do away with SAT and ACT exam scores. The University of California recently but just narrowly decided to keep these tests as part of their application requirements.

The reason colleges are removing test scores is because they have a high correlation with a student's socioeconomic status, not necessarily their ability to succeed in college. Students from high income families go to better high schools with more resources like AP classes to help them sail through the SAT. They also have more opportunities to take exam prep courses to give them a leg up on kids who can't afford those after school classes. Now many colleges emphasize a "holistic" approach to accepting high school students to college. They give students extra credit for coming from disadvantaged backgrounds and poor family situations.

However this creates its own complications. Look at the recent lawsuit against Harvard University. It's student admissions office was accused of discriminating against Asian Americans. Many of them had perfect SAT or ACT exam scores yet were denied acceptance to the school. Harvard's holistic approach to finding undergrads seemed to gloss over their high achieving test scores and instead punished them for a far more subjective "personal rating". They were considered less sociable and creative than their non-Asian American applicants.

Will this be the future of residency programs? While a large percentage of medical students are minorities, will the still mostly white residency directors judge the students on their race and perceived advantages in becoming doctors? Seems like this is just another lawsuit waiting to happen as some people are denied entrance to the most competitive programs and questions linger about why somebody got chosen over others since there are really no objective criteria anymore.

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.