Saturday, August 1, 2020

How To Find The Perfect Anesthesia Job

There's a really good article in this month's ASA Monitor that describes the choices one has to make to find a job in anesthesia that is both satisfying and rewarding. Some of the suggestions are obvious but others may make you think about what aspects of a job are acceptable to you personally.

Their first suggestions is to decide where you want to live. Most people wind up working where they did their training. It's pretty obvious since that's the job market you know and the professional network you've developed. Since the location of your residency match frequently is based on where you want to live, this just makes sense. But don't forget that many people have to take their spouse's concerns into consideration too. Maybe the spouse wants to move back closer to their family and not where they've been stuck in training all these years.

Next you have to consider if you want to be involved in research, educational training, or neither. When I finished residency, I knew I didn't want to do any research or teach residents. I went straight to the private practice model. But now that I've had years of experience, I have started getting move involved in working with residents and even done some simple research projects. Luckily I am able to do that without changing job locations. So keep an open mind as your preferences may evolve over time.

Do you want to do your own cases or supervise others? I absolutely wanted to do my own cases when I first started out. As a new residency graduate, I didn't feel comfortable supervising CRNA's. I didn't have enough self confidence to tell other people how to give anesthesia. And some of them probably wouldn't pay any attention to me anyway as they can claim many more years of experience compared to me. But now that I've been working for nearly two decades, I'm more open to supervising others. I know many anesthesiologist who love to supervise CRNA's. They feel perfectly comfortable lounging in the break rooms while the nurses work in the OR.

What kinds of cases do you want to do? Do you want to do a bunch of knee scopes and hernia operations all day or do you want to go hardcore and work at a Level 1 trauma center and deal with whatever medical catastrophe rolls in through the ER? 

Here's literally the big money question--how do you want to be paid? Do you want to receive a salary or do you want a fee for service model? A set salary is preferred by many as it usually involves a more predictable work environment, either at an academic or government institution. You also get the benefits and perks associated with these locations. However if you're looking to make a lot of money, fee for service is where it's at. Your daily schedule is more unpredictable, as it's impossible to know ahead of time how many cases the surgeons are going to book, but this is where the you can make far more income.

Then finally, make sure you have a good feeling for how the other anesthesiologists feel about working there. Though it may be difficult to get an objective opinion of the job during your interview, it never hurts to ask them what their opinion is. Do the partners steal cases from each other after they've performed a wallet biopsy? Do the new guys take all the holiday and weekend calls? How long have they been working there? Is there a revolving door of anesthesiologists? These are important factors to think about when interviewing to see if a new job will fit your personality and lifestyle.

So there is a lot to think about when deciding what is your perfect anesthesia job. Answering these questions will narrow your choices considerably and make it easier to decide. And remember, sometimes things don't work out and you realize your choice was not the correct one. That's okay. You're still a physician anesthesiologist and you can take your skills anywhere you want. Nobody is forcing you to work at a place that doesn't fit your needs. Good luck.

Friday, July 31, 2020

What Anesthesiologists Hate

Recently there was a Twitter post by an emergency medicine physician who asked what it is that each medical specialty hates the most. This quickly went viral as doctors started piling on. That got me thinking. What do anesthesiologists hate the most? Well it didn’t take long before I had a fairly long list. Not surprisingly many of them relate to surgeons. But I dislike many things I have to deal with every day that can ruin my usual sunny disposition. Here are some of the items I came up with, in no particular order.

1. Surgeons who tell me how to do my job. I’ve written before that this is one of my biggest pet peeves. I don’t even like telling other anesthesiologists how to give anesthesia. What makes a surgeon think he can tell me how to do something he has no training or competence in?

2. Surgeons who lie. If you’re going to be late, then just own up to it. Don’t tell the OR you’ll be here in five minutes or you’re just parking your car then show up 45 minutes later. We can handle the truth. Stop acting like a lying three year old. 

3. Being called anesthesia. We have names. Surgeons get the courtesy of being called Dr. So and So. Why can’t the staff extend the professional courtesy to us too? If you don’t remember our names you can always ask or just address us as Doctor, which we are.

4. Taking calls. This is probably something all doctors hate. That’s why we’ve had colleagues who leave our group to work at surgery centers where there are no night calls, even if there is less job stability and you’re working at the whim of the surgeon.

5. Morbidly obese patients. If I had to choose between a patient who is 97 years old or a patient who is 500 pounds, I’d choose the 97 year old each time. A morbidly obese patient just makes everything more difficult and dangerous. It’s not just the airway that is problematic. Blood pressure and ECG monitors don’t work as well. IV access can be nearly impossible. Moving the patient becomes a massive team effort. There is potential for greater injury to the staff and the patient. Morbid obesity is the bane of healthcare and this nation.

6. ASA 4 or greater. Another reason why anesthesiologists flee to the surgery centers. Nobody wants to deal with an ASA 4 patient who comes to the OR in septic shock with a heart rate of 125 and hemoglobin of 7 with a single 22 gauge IV in one hand. And when you flush it, it blows. 

7. Patients who tell me where to start their IV’s. Most of the time it is helpful when patients tell me where they’ve had the most success in getting IV’s placed. But if all I see is one single vein that looks like it might not blow up after I poke it, don’t tell me that spot hurts and you always tell people not to start the IV there. You’d rather I poke you five times trying to find a vein then a single stick in one that is most readily accessible?

8. Colleagues who leave a mess of the anesthesia workspace. I can feel my frustration rising when I come in to work in the morning and the anesthesiologist from the previous night has left a complete mess on the anesthesia cart and anesthesia machine. Half filled syringes lie everywhere. Used drug vials are scattered on every surface. The cleaning crew are taught not to touch any anesthesia equipment so the mess stays until somebody decides to throw everything out. Please clean up after yourselves people when you leave the room. Show some courtesy to your fellow anesthesiologist.

9. Doctors who think we’re “just” anesthesia as if we’re not real physicians. It’s amazing how prevalent this attitude is. I’ve questioned specialists about their consultation note on a patient and they talk down to me like I have no business asking them since I’m “just” anesthesia. Like I have no clue about cardiac or pulmonary or renal physiology. 

10. Getting rushed by the OR. Why is it the anesthesiologist is called to come see a patient in preop ASAP but the surgeon can walk in 30 minutes late for a case and nobody dares utter a peep? Even the patient, who is complaining loudly to everybody within earshot about how his case is delayed will greet his surgeon with all smiles. This inequality in treatment always astonishes and frustrates me. 

This is just a quick list I jotted down. It is by no means comprehensive. There are a lot more if I wanted to bore you with the details. But suffice it to say the one redeeming factor that makes this job worthwhile is because anesthesiology is one of the best jobs in the country.

Wednesday, July 29, 2020

Has Anesthesiology Become One Of The Hardest Residencies To Get Into?

Here are some interesting statistics about the recent Match Day results from the latest issue of the ASA Monitor. This year, there were 1,884 anesthesiology positions available for the Match. This includes both CA1 and CA2 spots. By the end of Match Day, 1,873 positions were taken. Only eleven spots remained unfilled. That turns out to be a 99.4% match rate for anesthesiology. This compares similarly to other highly competitive residencies like orthopedics and ENT which also had a 99.4% match rate success. This is even more impressive when one considers that the number of anesthesiology residency positions has been increasing every year, from 1,590 spots in 2016 to 1,788 in 2018 and this year's 1,884, an increase of 18.5% in four years.

These kinds of statistics wouldn't seem possible for those of us who were around to remember the disastrous match rates for anesthesiology back in the 1990s. At that time, false analysis of the manpower needed for anesthesia jobs declared that there was going to be an excess of anesthesiologists and not enough jobs available. This caused medical students to avoid anesthesiology like the plague, or the coronavirus in contemporaneous terms. The number of students matching into anesthesiology went from 1,025 in 1992 to a bottom of 324 in 1996. That's not a misprint. Back then anesthesia residency programs couldn't give away their spots. It's taken a long slow road to improve to the current state of exclusivity for anesthesia again.

So what accounts for this recent surge in popularity of anesthesiology? Perhaps the warnings about a catastrophic oversupply of anesthesiologists and subsequent collapse of their incomes have finally been buried. Anesthesiologists consistently are in the top ten of income earners as measured by various surveys of physicians. Maybe it's the so called lifestyle that most young people prefer these days. The days of living at the hospital 18 hours a day no longer appeals to the newest generation of physicians, or anyone else for that matter. Or could it be that ambitious young doctors have realized that anesthesiology isn't just about intubating patients and passing gas. It encompasses the whole physiologic complexity of human disease, from cardiothoracic to neuro to OB to pain and regional medicine. Anesthesiology is no less challenging than any other medical or surgical fields.

Whatever the case, there doesn't appear to be any slowdown in the interest in anesthesiology or the number of positions being offered each year for Match Day. One day perhaps when our fellow medical students find out we matched into anesthesiology, they'll think we got in because we are really smart, not because we did it for the lifestyle and money.

Tuesday, July 28, 2020

What Do You Get When Anesthesia Residents Party? A Coronavirus Outbreak

More news of anesthesiologists behaving badly. However this is more out of hubris than greed. The University of Florida Health system in Gainesville reported that 18 members of their anesthesiology department came down with the coronavirus after attending a private party. The afflicted include fourteen junior residents, two senior residents, a fellow, and an administrative employee (attending?).

The occasion for the party is vague. Some described it as a farewell party for graduating residents while others say it was a welcoming party for the new residents. It was probably a little of both. What is known is that there were up to 30 members of the department at this party. Afterwards the chairman of the anesthesiology department, Timothy Morey, MD notified the hospital on July 10th that members of the department had come down with Covid.

The hospital had kept a lid on this news until the university's own news organization, Fresh Take Florida, published it this week. It never notified the public or the government out this outbreak. Dr. Morey said all the sickened members were kept home in self quarantine. Because of privacy reasons they will not reveal who attended this party or who got infected.

This goes to show that in a free society it is getting increasingly more difficult to keep people from socializing over a long period of time. Unless we are willing to take drastic measures like China where they literally welded people's doors shut so they can't go out, we will hear more stories of social gatherings and virus outbreaks. Even people who are at the center of this pandemic and have all the information available to them will not be immune to the innate human need to gather and celebrate.

Beverly Hills Anesthesiologist Charged With Multi-Million Dollar Insurance Fraud

It breaks my heart every time I read and write about anesthesiologists who have gone astray. But unfortunately it is a fact of life that some people lose their moral bearings as they pursue their shallow materialistic desires through depraved and unethical actions.

Well known Beverly Hills anesthesiologist, Randy Rosen, MD, has been charged with a massive insurance fraud scheme. He and his girlfriend are accused of billing insurance companies $676 million for unnecessary procedures and receiving $52 million in payments. Their bail, originally set at $52 million, has since been reduced to $16 million.

The doctor would pay "body brokers" a few hundred dollars to bring in drug addicts to his clinic for outpatient procedures where he'd implant a device that's supposed to help ease their addiction symptoms. The procedure takes just a few minutes and he would charge insurance companies thousands of dollars. According to a text message from Rosen (I hesitate to give him the title Dr.), "The procedure takes me less than 5 minutes. So on an hourly that would be about 120k. Lol." He would also bill insurance companies for radiologic studies that never took place or send his patients to his girlfriend's laboratory for blood tests and getting kickbacks. 

There are real world consequences from this couple's greed. At lease one patient died when he didn't get the proper addiction treatment he needed, instead relying on the naltrexone implant that Rosen performed. That patient's insurance was billed $59,000.

In the meantime, the couple were living it up, remodeling a mansion high in the hills of Brentwood and buying exotic cars and jewelry. If Rosen is found guilty of his charges, he faces 88 years in prison. Let's hope somebody with such a lost moral compass never practices medicine ever again.

Monday, July 27, 2020

The Richest Doctors In The World

Do you think doctors make a lot of money? They can but not by practicing medicine. Forbes list of billionaires in the world includes six physicians and none of them practice clinical medicine.

1. Thomas Frist, MD. Founder of HCA Healthcare, the largest hospital company in America. Net worth: $11.6 billion

2. Patrick Soon-Shiong, MD. Inventor of Abraxane. $6.7 billion

3. Phillip Frost, MD. Inventor of Opko Health. $2.4 billion

4. Gary Michelson, MD. Retired spine surgeon and inventor. $1.7 billion

5. James Leininger, MD. Founder of Kinetic Concepts. $1.5 billion

6. George Yancopoulos, MD. Chief Medical Scientific of Regeneron. $1.4 billion

The lesson here is that if you think you can make it rich seeing a bunch of Medicare and Medicaid patients, you are in the wrong field.

Sunday, July 26, 2020

Anesthesiologists Make Excellent Incomes, Until Coronavirus Happened

Normally when Medscape releases its annual Physician Compensation Survey, I can't wait to announce the results to all of you. Every year, the numbers just keep going up. Last year's survey, which encompasses survey results on income in 2018, showed anesthesiologists made $392,000. When the 2020 survey results were published back in April, the self reported compensation for anesthesiologists were even better, reaching $398,000.

Unfortunately, that data is now completely obsolete. Medscape conducted the survey prior to February 10. And we all know what happened after that. The coronavirus decimated much of the world economy and medicine was not spared. Over half of medical practices reported a decrease in their revenues and sixty percent said their patient volumes have softened. News of practices closing and staff laid off, some permanently, are widespread. 

At our own hospital, surgical volume dropped off a cliff in April and May during the worst of the first wave of the pandemic. We were running a bare bones operation as all elective surgeries were cancelled. Like the rest of the country, we were left on our own to figure out how to adequately test our patients for Covid, how to secure adequate supplies of PPE, and how to staff the operating rooms safely. Everybody in our group applied for the government's Paycheck Protection Program loan just to carry ourselves over during the worst of the crisis. 

Now the situation may have turned a corner. All those elective cases that were postponed have been put back on the operating schedule. We are facing a huge demand for OR time as old cases compete for new cases to get done. Overhanging all this activity is the threat that the government could shut down the economy at any time on a whim and Covid cases continue to increase in the aftermath of all those rioters and protesters. 

We won't get a complete picture of how the coronavirus has affected physician compensation until we've navigated all these lockdowns and feast or famine patient interactions. Medscape Physician Compensation 2021 will make for very illuminating reading.

Saturday, July 25, 2020

Your Inner Neanderthal May Be Causing You Pain

Are you the type of person who is sensitive to pain? Do you reach for the Percocet at the first sign of a headache? Perhaps it's not your fault that you are more acutely aware of pain than others. It maybe because of a Neanderthal gene you inherited eons ago.

Scientists who examined these ancient genes found a variant that alters an ion channel in nerve cells. This causes the channel to initiate pain perception more readily than those who don't have the gene. The Neanderthal genes are more commonly found in people of European and Central and South American descent.

So next time you tell your doctor that you need a refill of Norco along with a prescription of Dilaudid for breakthrough pain, tell her that it's not your fault. It's your Neanderthal genes making you sick.

Friday, July 24, 2020

Best of Both Worlds

Imagine a job where you get to practice medicine but don't have to go through medical school. Then while treating your patients you are not legally responsible for your actions if something goes wrong. On top of that you make more money than many actual physicians? What kind of dream job is this? A certified nurse anesthetist, of course.

Working as a CRNA just got a whole lot sweeter after a court in North Carolina declared that they are not responsible for their actions because they are really just a "nurse" who can't be held liable for what they do. This involves a tragic case of a three year old child who suffered a cardiac arrest and anoxic brain injury after the CRNA and physician anesthesiologist induced her with sevoflurane for a cardiac ablation. 

The anesthesiologist was able to settle the case out of court but the hospital and the CRNA went to trial. At the trial the judge found the CRNA not liable because of a 1932 ruling by the North Carolina Supreme Court that said nurses are not responsible for their actions. As the judge wrote, "The Court reasoned that nurses 'are not supposed to be experts in the technique of diagnosis or the mechanics of treatment.'" Therefore the current appeals court could not rule against the precedent set by the NC Supreme Court, even if it occurred nearly 80 years ago.

So now CRNA's, at least in North Carolina, have the best of both worlds. They can claim they are just as skilled and intelligent as physician anesthesiologists. Yet when the s*** hits the fan, they can also claim they cannot be held liable because the courts said nurses are not experts in diagnosis or treatment.

Seriously who would want to be a physician anesthesiologist when CRNA's have the best job in the world

Wednesday, July 22, 2020

The Best Non-Political Reasons To Wear A Face Mask

It's pretty common sense to wear a face mask to keep from breathing in anything that might be harmful. It's been practiced for hundreds of years. Unfortunately that act of self protection has turned into a political battle. It's become a litmus test of a person's adherence or rebellion towards authority.

While that battle rages, I think wearing a mask is great. But it has nothing to do with my political affiliation or opinion of the effectiveness of the country's battle against Covid. There are lots of terrific practical reasons why I think we should all wear face masks, even after we conquer this terrible episode of human history. Here are my personal observations after wearing a face mask daily for the last four months.

1. You never have to trim your nose hair. No more lectures from the Queer Eye For The Straight Guy team about how important it is to trim your nose hair. Just let it grow until you can braid it. Nobody will ever know.

2. You don't have to worry about food getting lodged in your teeth. You know how you worry whether there is a small piece of salad stuck in your teeth after lunch? No problem anymore if you're wearing a mask.

3. Bad Breath. This applies to both you and the patient. That breakfast of onion bagels with sour cream and chives cream cheese spread followed by a cup of strong Starbucks? The only one who can smell your breath is you.

4. Don't you hate it when a giant zit starts growing on your nose? Face mask it and you won't feel like your pimply fifteen year old self all over again.

5. Make elevators safe again. Everybody's experienced that fearful feeling when somebody in the elevator rudely coughs or sneezes. You try to hold your breath the instant it happens but inevitably you breathe in that person's respiratory droplets and viruses. If everyone is wearing a mask, there no worry of catching something contagious because you were too lazy to walk up one floor to get to work.

6. I don't want to make my frown upside down. Some people like myself just have natural frowny faces. It's a chore to always remind myself to turn up the corners of my mouth so patients don't think I'm mad at them. Now I can just draw a smile on the outside of my mask and look like I'm smiling ALL THE TIME. Whoopee!

7. My dentist can kiss my ass. With my mouth covered all the time, why should I spend thousands of dollars on teeth whitening and dental care? I can let my teeth rot to the core and nobody would notice. The mask would also cover up all the bad breath (see #3).

8. Shaving accidents. The world no longer has to know all the shaving nicks and cuts on my face because I'm too cheap to get a new blade. 

9. That cheesy mustache. Feel like growing a handlebar mustache like your great uncle who performed in a barbershop quartet but are worried about the ridicule? Wear a mask and go for it.

10. Nothing wrong with tongue or lip piercings. Express your inner emo. Now you too can get your perioral body parts that are covered by a mask pierced to your heart's content and still look prim and professional. 

As you can see there are tons of good reasons to wearing a face mask that are applicable even after we get over the pandemic. Masks--they aren't just for surgeons anymore.