Sunday, August 16, 2020

What Would Steve Jobs Think About Reaction To Coronavirus?

One of the things about living through a pandemic is that you have a lot more time to do leisurely activity since schools, summer camps, and vacation spots are all closed. Therefore I tried to catch up on some reading. One of the books I read is the biography "Steve Jobs" by Walter Isaacson. It is a fascinating story about the complex history of Jobs and his eccentric personality. I can relate to much of the book as I remember reading about a lot of it as they happened 30-40 years ago. 

I came across a passage that I thought is so meaningful for our current coronavirus afflicted times. Isaacson describes how Jobs was a firm believer in people meeting each other to talk and exchange ideas. When he designed the headquarters for Pixar, he made sure that the structure would naturally lead people to congregate in a central atrium. He even went so far as to initially design only two bathrooms in the entire building so people would have to gather in one area. Wrote Isaacson, 

Despite being a denizen of the digital world, or maybe because he knew all too well its isolating potential, Jobs was a strong believer in face-to-face meetings. "There's a temptation in our networked age to think that ideas can be developed by email and iChat," he said. "That's crazy. Creativity comes from spontaneous meetings, from random discussions."

What would Jobs think about the work from home and online education trends in the country? Many companies, especially the high tech industry in Jobs' own Silicon Valley, have told their employees to work remotely. Likewise, teachers are now refusing to resume classes in school and are staging sickouts. While millions of people are still working or have returned to work, teachers feel they are not essential workers and demand to stay home. This despite the fact the parents and students across the country feel online learning is inferior to real classroom involvement. What's worse, college students have to continue paying exorbitant tuition and fees even though classrooms are closed.

As the panic surrounding Covid 19 continues, are we teaching a generation of workers and students that they should run away from adversity, even if they are the generation least likely to get sick from the disease? Are the students being taught to cower in fear of the unknown instead of striving to conquer what ails society by going to school and returning to work? Steve Jobs, one of the great geniuses of the last half century, would probably have scoffed at this remote learning and work trend. As millions of people at hospitals around the country continue to work daily, despite a hospital being a natural aggregator of sick Covid patients, I can't help feeling that this reluctance to return to pre-Covid normalcy will be with us for a very long time.

Friday, August 14, 2020

Pandemic Paradise

Lot more gridlock now.

I hate to say it because it sounds so callous, but this coronavirus pandemic has made living in Los Angeles so pleasant. Yes I know thousands of people have died and millions of people have lost their jobs. But there are many millions more people who are still working, and that includes most healthcare workers. 

The situation isn't so dire as it was a few months back. At that time, we didn't really know what we were dealing with. Images from Italy and New York portrayed apocalyptic images of doctors and nurses overwhelmed with the sick and dying. But frankly, they were the exception, not the rule. In fact, hospitals and surgery centers across the country lost billions of dollars because they sat empty as patients were too afraid to seek medical care and operating rooms went dark. 

No traffic! Love it.
I wrote about how deserted the freeways were here in the city. As the stay at home orders forced businesses to close and millions of people were laid off, LA looked like a scene from the Twilight Zone. There was no traffic any time of day or night. I could zip down the 405 freeway at 5:00 PM going 80 mph. It was amazing.

Now things have improved. Restaurants have started opening up. I see packed tables socially distanced apart appearing along sidewalks and parking lots as people enjoy their meals al fresco. The hospital and surgery centers are busier than ever as the backlog of cases are slowly getting whittled down. Traffic has even picked back up. At the worst moments in the spring, my commute time was less than half the usual time. Now my commute is back up to about seventy-five percent of my previous time. I actually have to avoid the 405 now during peak rush hour and take local streets again, like a true Angeleno. It's still a vast improvement from the previous gridlock though.

I hope the economy picks back up quickly for everybody so we can continue to live our American prosperity. But for those of us who are working harder than ever, this time is indeed a blessing as getting around town is easier than ever. Now if only more places, like museums, movie theaters, and shopping malls, opened up, I will have somewhere to go during this golden era of LA freeway driving.

Thursday, August 13, 2020

Boston Murderer Gets Life Sentences For Killing Two Anesthesiologists

With all the overwhelming news about the coronavirus and the presidential election, I overlooked a very important story a few months ago. Remember that horrifying double murder of two anesthesiologists in Boston in 2017? Drs. Lina Bolanos and Richard Field, an engaged couple working at Harvard Medical School, came home from work and were confronted by an intruder. They were bound and their throats slashed. The murder, Bampumin Teixeira, used to work in the building as a concierge and had access to the premises. He committed two murders for a simple robbery.

Well justice has been rendered. In December of last year, he was found guilty of the murders and received two consecutive life sentences with no possibility of parole. This doesn't even count the sentences for his other crimes including armed robbery, kidnapping, and home invasion. 

Mr. Teixeira exhibited erratic behavior throughout the trial, including threatening the prosecutor and shouting in the courtroom. He had to be dragged out and watched the proceedings on TV from a separate room. He showed no remorse when he learned of his sentence.

RIP good doctors.

Tuesday, August 11, 2020

How To Improve Your Hospital's National Ranking

US News & World Report recently released its latest rankings of the nation's hospitals. Eagerly awaited each year, it is a source of pride and free publicity for numerous hospitals. A high position in the survey is frequently cited in radio, print, television, and online advertisements, sometimes literally the day after its publication.

Naturally hospital administrators are eager to figure out how to improve their rankings in the survey. This is even more true if there is a rival hospital in town. Wouldn't USC's Keck Hospital love to leapfrog UCLA's Ronald Reagan Medical Center in the LA hospital market. 

While looking through the list, it seems to me that there is an easy and effective way to get one’s hospital into a better position. The US News survey is subdivided into seventeen subspecialties. These include Cancer, Rehab, Orthopedics, and others. Ten of those are surgical subspecialties like Urology, Orthopedics, Neurosurgery, and GI Surgery. So obviously the best way to improve the hospital score is to improve the surgical rankings. And what can the surgery departments do to improve their positions? Hire a good anesthesiology department of course.

Think about what a good anesthesiologist can bring to the hospital. Anesthesiologists can improve patient satisfaction by treating patients effectively for postop pain and nausea. Anesthesiologists can help decrease the infection rate of cases. Through the concept of the perioperative surgical home, anesthesiologists can increase the flow through of the patient through the hospital, allowing the patient to recover more quickly and saving the hospital money at the same time.

To all the hospital administrators who are reading this post. Find the best anesthesiology group you can afford. The increase in productivity and morale in the operating rooms and the surgical units will more than pay for itself as anesthesiologists use our professional training to improve perioperative care and drive efficiency and satisfaction among your patients. Increased US News hospital ranking is just icing on the cake.

Saturday, August 8, 2020

White Doctors More Likely To Suffer Burnout

Here is one white privilege that is rather unexpected. Researchers at Stanford University have found that white physicians suffer a higher rate of burnout than other races. In a survey of 4,424 doctors, they calculated that white doctors have a burnout rate of 44.7%. This compares with burnouts of 41.7% in Asians, 38.5% Black, and 37.4% Hispanic.

Traditionally, primary care doctors have higher burnout than specialists and minority doctors tend to practice in primary care. However the researchers speculate that white doctors have different expectations of their careers compared to others. Many white physicians come from a multigenerational family of doctors so they may fondly remember the experiences of being a doctor from decades ago. By comparison, minority doctors are more likely to be first or second generation. Therefore the current medical environment doesn't feel so different.

Perhaps burnout is really a matter of expectations. If you feel lucky to be practicing medicine because you're the first one in your family to go to medical school, you'll be less likely to complain about your difficult job than someone who attends a family reunion where all the doctor family members gather to gripe about the government, insurance companies, patients, etc. It's all about perspective.

Tuesday, August 4, 2020

Did Medical Racism Kill Rep. John Lewis?

I'm just going to be a little provocative here today. Last week, Democratic Georgia Congressman and Civil Rights icon John Lewis was laid to rest after a brief battle with stage 4 pancreatic cancer. He announced his diagnosis back in December 2019. At the time, he was girding for a fight with the disease, stating, "While I am clear-eyed about the prognosis, doctors have told me that recent medical advances have made this type of cancer treatable in many cases, that treatment options are no longer as debilitating as they once were, and that I have a fighting chance." Unfortunately his fight came to an end July 17, 2020.

Contrast that with two other very famous people who coincidentally were also diagnosed with stage 4 pancreatic cancer recently: Alex Trebek, the game show host, and former Democratic Nevada Senator Harry Reid. Trebek was diagnosed in February 2019 while Reid was diagnosed in May 2018.

Trebek has been very vocal about his treatments. He's been chronicling his chemotherapy with the public routinely, recently announcing his one year anniversary of his diagnosis. He said last September he was not doing so well. He had lost 12 pounds and his CA-19 numbers were still elevated. So he started an experimental immunotherapy treatment on a compassionate use case. Remarkably it worked well. His CA-19 numbers went from 3,500 before the treatments to under 100 now. 

Sen. Reid was also doing poorly with his cancer in 2019. Surgery and chemo had failed to halt the progression of the disease. He then got in touch with billionaire physician Patrick Soon-Shiong and got enrolled in the same treatment program as Trebek. Now, two years after his diagnosis, Reid is cancer free.

So what is this miracle drug that is eliminating stage 4 pancreatic cancer? They are using a medication called Abraxane that in combination with other treatments like interleukin-15 and natural killer cells form a "triangle offense" to eliminate metastatic pancreatic, breast, or lung cancers. The regimen is so new it is still undergoing phase 2 trials in the U.S.

This raises the question of whether Rep. Lewis was offered the same treatment protocol. He was the last of the three to be diagnosed with pancreatic cancer yet he is the first to succumb to it. Both Trebek and Reid appeared to respond quickly to Abraxane, within months. Was Lewis given the same opportunity? It's couldn't be about money. I'm sure Rep. Lewis, a congressman for decades, is well off financially. It also couldn't be about VIP's getting different treatments compared to ordinary people as Lewis is as VIP as it gets. Was his cancer stage much worse than the other two such that it was meaningless to offer him this miracle cure? Is it a coincidence that the two survivors are white men while the black man died from his disease?

Due to privacy concerns we will probably never know the answers to these questions. But it seems to add to the confounding statistics that Black men die at a higher rate than white men for the same diseases, even if they are socioeconomically equal.

Sunday, August 2, 2020

Which Specialties Will Make You Rich?

Most people think that all doctors are rich, right? One definition of rich is somebody who makes more money than you. If that is the case, then nearly all doctors are richer than the average American. But to really understand how well off somebody is, you need to look at their net worth. A high income doesn't mean anything if it is frittered away and there is nothing left to show for it. A Charles Schwab Modern Wealth Survey reported that most people considered a net worth of $2.3 million as a definition of being wealthy. That is a considerably higher bar to hurdle than just merely have a high income.

For most physicians, that is a difficult, though not impossible goal to achieve. Obviously if you're just starting out, $2.3 million in net worth sounds like a pipe dream. But as your career flourishes, the goal gets closer and closer within your grasp. And certain specialties have an innate advantage in achieving high a net worth.

While the average person thinks $2.3 million defines the wealthy, physicians have a different point of view. Most doctors would probably be happier with $5 million in net worth. Can't show up at the country club driving a Mercedes when your colleagues roll in with their Bentleys and Aston Martins. So here are the ten specialties that have the most doctors who have a net worth of over $5 million courtesy of Medscape.

1. Orthopedics, 19%
2. Plastic Surgery, 16%
3. Gastroenterology, 16%
4. Cardiology, 15%
5. Oncology, 15%
6. Dermatology, 15%
7. Otolaryngology, 14%
8. Urology, 14%
9. Radiology, 13%
10. Ophthalmology, 13%
*11. Anesthesiology, 12%

Medscape Physician Compensation Survey 2020
Medscape Physician Compensation Survey 2020

Naturally most of the fields in this list are also the same ones who have the highest incomes. But making a lot of money doesn't guarantee that you'll end up with a high net worth. If you spend all your money on fancy cars, bad investments, and multiple wives and children, you can still end up a pauper despite making a six figure income. I know doctors who are working well into their 60s and 70s because of poor life choices over the years.

While this list looks impressive, fifty percent of all physicians have net worth of under $1 million. Since there are no ages associated with these statistics, it's probably safe to say that most of the doctors under 50 years don't have a net worth of $5 million. In fact, in some fields like pediatrics and family medicine, over 40% have net worth of under $500 thousand.

So all you millenial physicians just starting your careers, keep saving into those tax deferred accounts and other wealth building plans. Five million dollars may seem impossible to attain at your current situation, but keep plugging away. Compound interest and six figure incomes will work to your advantage in the future.

* I just had to add anesthesiology to the list to show how close we are to the top ten of wealth generating specialties.

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.