Nepal? I don’t know anyone in Nepal. Yet not long ago I received a courteous email from a physician there, asking my permission to translate an article of mine into Nepali. The topic: advice for older patients who need anesthesia. He wants to distribute it to patients and publish it in his local newspaper.

I asked how he came across the article. He was browsing online among anesthesia blogs, and found mine, “A Penned Point“. Now “blog” isn’t a word Jane Austen would have recognized. It is a lumpish merger of “web” and “log”, and is generally defined today as a website on which an individual records opinions. The proliferation of blogs–like Tribbles–may be seen as a pernicious trend, but it demonstrates the power and reach of the Internet. Business Insider estimates that 22% of the people in the world own smartphones, an increase of 1.3 billion smartphones since 2009. In social media, once you put content out, you have no idea how far it will travel.

Many physicians consider social media a frivolous waste of time. Certainly they can be horribly misused–think of the cyber-bullying that goes on among teenagers. But used wisely, social media can be valuable communication tools. Here follows a brief guide to social media for physicians, admittedly subjective, with caveats included.

The doctor with an opinion

We all have opinions. Occasionally, we want the world to know about them. If you want to publish an opinion column and don’t want to create your own blog, there are online sites where your submission may be welcome. Probably the best-known public site for medical topics is KevinMD, which is curated by Dr. Kevin Pho, a New Hampshire internist. He came early to the game, starting his blog in 2004, and now has over 1000 regular contributors, myself included. You can submit a 500-700 word piece on almost any topic within medicine, aimed at an audience of physicians or at the general public. There’s a good chance that if you can put together a coherent sentence, Kevin will find a place for it. Brace yourself for the comments: Kevin’s readers tend to hold opinions as strongly as the writers do.
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“The creatures cause pain by being born, and live by inflicting pain, and in pain they mostly die.”–C. S. Lewis

The problem of pain, from the viewpoint of British novelist and theologian C. S. Lewis, is how to reconcile the reality of suffering with belief in a just and benevolent God.

The American physician’s problem with pain is less cosmic and more concrete. For physicians today in nearly every specialty, the problem of pain is how to treat it responsibly, stay on the good side of the Drug Enforcement Administration (DEA), and still score high marks in patient satisfaction surveys.

If a physician recommends conservative treatment measures for pain–such as ibuprofen and physical therapy–the patient may be unhappy with the treatment plan. If the physician prescribes controlled drugs too readily, he or she may come under fire for irresponsible prescription practices that addict patients to powerful pain medications such as Vicodin and OxyContin.

Consider this recent article in The New Republic: “Drug Dealers Aren’t to Blame for the Heroin Boom. Doctors Are.” The writer, Graeme Wood, faults his dentist for prescribing hydrocodone to relieve pain after his wisdom tooth extraction. As further evidence of her misdeeds, he says, first she “knocked me out with propofol–the same drug that killed Michael Jackson.” Wood uses his experience–which sounds as though it went smoothly, controlled his pain, and fixed his problem–to bolster his argument that doctors indiscriminately hand out pain medications and are entirely to blame for patient addiction.

But what happens to doctors who try not to prescribe narcotics for every complaint of pain, or antibiotics for every viral upper respiratory infection? They’re likely to run afoul of patient satisfaction surveys. Many hospitals and clinics now send a satisfaction questionnaire to every patient who sees a doctor, visits an emergency room, or is admitted to a hospital. The results are often referred to as Press Ganey scores, named for the company that is the leading purveyor of patient satisfaction surveys. Today these scores wield alarming power over physician incentive pay, promotion, and contract renewal.

Now hospital payments are at risk too.  Beginning in 2002, the Centers for Medicare & Medicaid Services (CMS) began work with the Agency for Healthcare Research and Quality (AHRQ) to develop a standardized survey of patients’ perceptions of hospital care, now known as the HCAHPS (Hospital Consumer Assessment of Healthcare Providers and Systems) survey. Press Ganey submits HCAHPS data to the government on behalf of its many clients. At first, the HCAHPS survey was intended as a tool to allow objective comparisons of hospitals on topics important to consumers, including:

How well doctors and nurses communicate with patients
How responsive hospital staff are to patients’ needs
How well hospital staff manage patients’ pain
Whether key information is provided at discharge.

But since 2007, hospitals that fail to report “required quality measures”, which include HCAHPS results, receive less payment from CMS. The government’s “Value-Based Purchasing” program bases only 70% of hospital performance scores on actual clinical care, and a full 30% on the HCAHPS survey’s report of the “patient experience of care”–including patient satisfaction with pain management.

“Never deny a request”

A patient who isn’t pleased with the experience of care may give bad marks overall, whether the problem was a long wait or a doctor who doesn’t heed requests for a medication or a test.  But any physician who is associated with the low scores will earn the ill will of hospital administrators, who fear reduction of the hospital’s already slim Medicare/Medicaid payments, and of the CEO, whose salary incentive component may be at risk too.  Never mind that Press Ganey scores are often based on small numbers of returned questionnaires, too small to be statistically significant.

Do these pressures affect how physicians deliver care? It would be surprising if they didn’t. A family physician, Dr. William Sonnenberg, wrote recently, “The mandate is simple: Never deny a request for an antibiotic, an opioid pain medication, a scan, or an admission.” He believes Press Ganey “has become a bigger threat to the practice of good medicine than trial lawyers.”

The Atlantic published a recent article: “When Physicians’ Careers Suffer Because They Refuse to Prescribe Narcotics.” The author, Richard Gunderman, highlighted the fallacy in satisfaction scores, noting that “patient perceptions may prove downright misleading.” Patients often visit multiple emergency rooms and physician offices asking for narcotics, Gunderman reported, and “the problem of prescription drug abuse and drug-seeking behavior is abetted by a robust and growing black market for prescription medications.” Still, physicians are at risk for being hired or fired on the basis of patient satisfaction data, without critical review of the source.

Do high patient satisfaction scores correlate with better health? Or higher quality care? So far, the answer is no. A recent study of hospitalized patients showed that many patients prefer “shared decision-making” with their physicians, but it results in longer inpatient hospital stays and 6 percent higher total hospitalization costs. A prospective study of over 50,000 clinic patients showed that the 25% who were most satisfied with their care had higher odds of inpatient admission, greater total expenditures, greater prescription drug expenditures, and–perhaps most surprising–higher mortality.

Forbes writer Kai Falkenberg, in her article “Why Rating Your Doctor Is Bad For Your Health,” concluded that “giving patients exactly what they want, versus what the doctor thinks is right, can be very bad medicine.”

Today, over 12% of primary care visits and over 32% of emergency department visits involve opioid or benzodiazepine prescriptions, according to the results of a study presented last month at the American Academy of Pain Medicine’s annual meeting, and these rates are steadily increasing. The study’s co-author, Dr. Ming-Chih Kao, said that between 1999 and 2006 there was a 250% increase in fatal overdoses in the US, and more than half involved more than one drug, usually opioids and benzodiazepines. Patients may lack resources to cover services like physical therapy and mental health treatment, and they urge physicians to prescribe opioids and benzodiazepines instead.

Unintended consequences

The recent history of opioid use and abuse in the US illustrates how well-intentioned actions so often have unintended consequences. There was a time when physicians hesitated to prescribe opioids even for cancer pain, let alone non-malignant pain, for fear of addiction. That philosophy started to change in 1986, when Dr. Russell Portenoy published a paper in the journal Pain concluding that “opioid maintenance therapy can be a safe, salutary and more humane alternative to the options of surgery or no treatment in those patients with intractable non-malignant pain and no history of drug abuse.” Pharmaceutical companies began to promote new formulations including OxyContin for the treatment of pain.

A major upswing in the government’s interest in pain management followed in the 1990s, as the AHRQ issued guidelines advocating more aggressive treatment of pain. In 1998, the Veterans Health Administration premiered a national strategy intended to improve pain management for its patients, and defined “Pain as the 5th Vital Sign”. The new strategy required use of a numeric rating scale for pain in all clinical encounters. The Joint Commission quickly added the achievement of low pain scores to its measures of hospital quality, and issued a major monograph in 2003 called “Improving the Quality of Pain Management Through Measurement and Action.” CMS began to rate hospitals on the basis of patient satisfaction scores, and the rest is history.

Now political pressure in the opposite direction–against narcotic prescription–is escalating, as the Centers for Disease Control and Prevention is urging doctors to use opioids more sparingly. The state of Washington passed a law restricting opioid prescription, and other states are considering similar measures, while patients with chronic pain scramble to find treatment. In 2010, a new formulation of OxyContin was introduced in order to make it more difficult to dissolve or crush. The result, reported in the New England Journal of Medicine in 2012, was that the selection of OxyContin as a primary drug of abuse decreased, but the abuse of other opioids–including fentanyl, hydromorphone, and heroin–rose markedly.

Physicians are caught in the vise between patient satisfaction surveys and the epidemic of prescription drug abuse and overdose. Government and regulatory intervention, as well-intentioned as it may have been, has only led to worse problems and disastrous outcomes. Fed-up physicians are leaving clinical medicine for jobs in hospital administration, consulting, or industry wherever they can. Is anyone surprised?


We hold these truths to be self-evident:

A hospital administrator with a clipboard is in search of a physician who isn’t following “evidence-based guidelines”.

There are fads in medicine just as there are in fashion—today’s “evidence-based medicine” may be tomorrow’s malpractice.

Did your hospital, like so many, abruptly switch from povidone-iodine antiseptic solution to ChloraPrep® for cleaning a patient’s skin before surgery?  If so, I’m sure the staff was told that ChloraPrep would be more effective and cheaper.  No doubt, they were also warned of the extra precautions that must be taken with ChloraPrep to prevent operating room fires, since ChloraPrep contains highly flammable 70% isopropyl alcohol in addition to chlorhexidine.  Even the fire risk apparently wasn’t enough to make hospitals think twice before switching antiseptics.

You (and your hospital’s staff) may not have heard this news. The US Department of Justice (DOJ) announced last month that CareFusion Corp. would pay the government a $40.1 million settlement to resolve allegations that the company violated the False Claims Act by paying kickbacks to boost sales of ChloraPrep and promoting it for uses that aren’t FDA-approved.

Who received kickbacks?  According to the DOJ’s press release, the complaint alleged that “CareFusion paid $11.6 million in kickbacks to Dr. Charles Denham while Denham served as the co-chair of the Safe Practices Committee at the National Quality Forum, a non-profit organization that reviews, endorses, and recommends standardized health care performance measures and practices.”  Another physician with close ties to CareFusion, Dr. Rabih Darouiche, was the lead investigator on a 2010 NEJM article which concluded (not surprisingly) that Chloraprep was “significantly more protective” than povidone-iodine against surgical site infections.

The Leapfrog Group, launched by the Business Roundtable in 2000, claims that its hospital survey is “the gold standard for comparing hospitals’ performance on the national standards of safety, quality, and efficiency.”  On January 30, Leapfrog announced that it accepted the resignation of Dr. Denham, who had served as chair of Leapfrog’s Safe Practices Committee since 2006, amid concerns that Dr. Denham had failed to reveal his “potentially compromising relationship with CareFusion.” At the same time, Leapfrog said it would undertake “a thorough scientific review of its full slate of endorsed safe practices.”

Are you still feeling good about evidenced-based medicine?

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No HIPAA for us in healthcare

badge of shame

We guard the privacy of patients in my hospital zealously—we take care of a lot of celebrities since we’re right in the shadow of Beverly Hills.  And of course we live in terror of HIPAA violations, those federally mandated HHS rules that protect individually identifiable healthcare information and could bring down “civil money penalties” upon us if we don’t keep our patients’ medical records strictly confidential.

But for healthcare workers—physicians, nurses, technicians, even medical supply vendors—in LA County, the usual privacy rules don’t apply any more.  Now everybody gets to know at least some of our medical history:  whether or not we’ve been vaccinated against influenza.

How will anyone know whether or not I’ve had this year’s flu vaccine?  Because policy dictates that I must publicly say so, whether I want to “out” that information or not.

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AA seal

This column was written on behalf of the American Society of Anesthesiologists, and was first published by KevinMD on December 22, 2013.

When you need anesthesia for surgery or a diagnostic procedure, of course you want to know who’ll be giving you anesthesia.  If you live in Texas, Florida, the District of Columbia, or 14 other states, you may be lucky enough to have an anesthesia team taking care of you that includes a physician anesthesiologist and an anesthesiologist assistant, or “AA”.  If you live in many other states–including my own state of California–care from an AA isn’t yet an option.

Many Americans have never heard of anesthesiologist assistants.  Even many physicians are unaware that the profession exists.  But for more than 45 years, AAs have worked alongside physician anesthesiologists in exactly the same way that physician assistants (PAs) work with a surgeon, internist, or pediatrician–using teamwork to deliver the best possible medical care to their patients.

Today, there are more than 1400 certified AAs in the U.S.  Why are they limited to practicing only in certain states?  It’s a complicated question.  The answer involves the fierce opposition of nurse anesthetists to the very existence of the AA profession, our complex American system of state licensure, and the economics of healthcare.

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We were startled to learn recently that Sheridan Healthcare Inc., a physician services company based in Florida, has bought one of the largest private anesthesiology group practices in California, the Medical Anesthesia Consultants Medical Group Inc. (MAC) of San Ramon.

The deal, which closed November 14, is Sheridan’s first in California, and “provides a platform that will accelerate our expansion in the California marketplace,” said John Carlyle, Sheridan’s CEO, in a recent statement.

By all accounts, MAC is a well-respected and highly successful anesthesia practice, with more than 100 physicians—shareholders, non-shareholders, and independent contractors—who provide anesthesiology services to five hospitals and 23 ambulatory surgery settings in northern California.  So why did this group decide to sell?

Was this a hostile takeover, or did hospital administrators force the group’s hand?  Not at all, says a senior partner in the MAC group (who prefers not to be named).  The senior shareholders actively sought a purchaser, hired an investment bank to broker the deal, and voted unanimously to approve it.  Apparently, there are no plans yet to hire nurse anesthetists or change the MD-only composition of the group.  Hospital administrators didn’t instigate the sale but all supported it, the anesthesiologist said. “For us right now, it looked like the right thing to do.”

It’s doubtful that the non-shareholders in MAC are quite as enthusiastic.

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VA seal

The latest salvo in the federal government’s war on physicians comes to us courtesy of the Veterans Health Administration (VHA), which is proposing drastic policy changes to expand nursing scope of practice in all veterans’ hospitals.

A newly drafted VHA Nursing Handbook would eradicate all existing VHA policies concerning physician supervision, and would designate all advanced practice registered nurses (APRNs), including nurse anesthetists, as licensed independent practitioners (LIPs).  This means that they would be able to practice on their own without any requirement for physician oversight or support.  In 2011, the Office of General Counsel upheld the VA’s claim of the right to authorize APRNs to function as independent practitioners “regardless of the scope of practice defined by their licensure.”

And if a nurse practitioner or a nurse anesthetist would rather practice in a care team with a physician, that’s too bad.  The new policy wouldn’t be optional.  As the Office of Nursing Services (ONS) bluntly if ungrammatically stated in an explanatory document, “If the APRN does not want to attain independent status they would not be able to practice as an APRN in the VHA.”

The new VA policy would supersede any state law or individual hospital policy requiring physician supervision or defining limitations to nursing scope of practice.  “A local policy that restricts APRN privileges is not appropriate,” the ONS document asserts, noting that APRNs are to function “at the top of their license” and that current medical staff bylaws in many VA hospitals “will most likely need to be revised.”

The long-standing VHA Anesthesia Service Handbook would be supplanted by the new rules.  It supports team-based care integrating the different skills of physicians and nurses, and specifies that “care needs to be approached in a team fashion taking into account the education, training, and licensure of all practitioners.”  It also provides flexibility to individual VA Chiefs of Anesthesiology to set their own department policies.  These concepts, apparently, are now out of favor.

The California Society of Anesthesiologists (CSA) and the American Society of Anesthesiologists (ASA) strongly oppose the new proposed policies.  They note that patients in veterans’ hospitals are 14.7 times more likely to have poor health status than the general population, and 14 times more likely to have 5 or more medical problems, according to a study in JAMA Internal Medicine.  Veterans are more likely to have complications during a surgical procedure, and they deserve physician-level expertise on their anesthesia care teams.  CSA leaders Peter Sybert MD and Mark Zakowski MD were instrumental in obtaining the co-signatures of California Representatives Julia Brownley, Paul Cook, and Raul Ruiz MD on a letter to the Secretary of Veterans Affairs, urging the retention of the team care concept and the current policy directives in the VHA Anesthesia Service Handbook.

What can we do as individuals to speak up against the VHA’s proposed mandate for APRN independent practice? Contact our U.S. Representatives and Senators by phone or email.  For anesthesiologists, the ASA Grassroots Network has drafted an email appropriate to send to lawmakers on the proposed VHA nursing policy changes, and will send it for you with your signature.  Or call senators and congressmen at their offices and speak to their healthcare legislative aides.   The new policy handbook is nearing its final version, so timing is critical.  Our veterans deserve better.


Not so many years ago, surgeons wouldn’t operate on patients they considered too old to tolerate the stress of anesthesia and surgery.  Today, though, patients of every age—from Baby Boomers to the Greatest Generation—undergo anesthesia safely for surgery and diagnostic procedures.

Realistically, even if you believe that 60 is the new 40, concerns about having anesthesia are different for 60-year-olds and their parents than for 20-somethings.  Here are answers to ten frequently asked questions about anesthesia for those of us–myself included–who no longer need to worry about being asked for ID if we order a drink.

Who will be giving me anesthesia? 

It’s important to find out who will be in charge of your anesthesia care.  In some hospitals, a physician anesthesiologist (a medical doctor who specializes in anesthesia) will be personally taking care of you.  In others, a physician anesthesiologist may be supervising anesthesiologist assistants, residents, or nurse anesthetists on an anesthesia care team.  Sometimes a nurse anesthetist may work alone without physician oversight, though this is not permitted in many states.  Ask your surgeon or call the hospital in advance to make sure a physician anesthesiologist will be on site.

What is the chance of a serious complication from anesthesia? 

Better medications and monitoring equipment have made anesthesia remarkably safe, which is why we can offer anesthesia today even to patients in their 90s.  A better question to ask would be this:  What is my chance of complications from the whole experience of anesthesia and surgery? The American College of Surgeons has developed an easy-to-use online calculator that can predict your outcome risk depending on the type of surgery, your age, and any medical problems you already have.  The analysis estimates your chance of a heart attack, pneumonia, infection, and other problems that may occur after anesthesia and surgery.

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surgeon gloves

We’ve run amok with wearing gloves in the hospital.  And by “we” I mean every healthcare worker in sight.  I see people putting on gloves before they’ll give a patient a clean warm blanket.  This is not only ridiculous, it’s actually harmful.  Here’s why.

We learned the hard way in the 1980s, during the early days of the AIDS epidemic, that the HIV virus and other potentially lethal microorganisms are carried in blood and body fluids. The Centers for Disease Control and the World Health Organization developed the concept of “universal precautions”, which applies during all patient-care activities that may involve exposure to blood, body fluids, mucous membranes and non-intact skin.  Observing “universal precautions” means that you always wear gloves in those situations because you may not know ahead of time if a patient carries HIV, hepatitis, or any other infectious disease.  You don’t want to get infected yourself, or inadvertently infect another patient.

But when did “universal precautions” come to mean that you have to wear gloves before you touch your patient at all?

The downside of hand hygiene campaigns is that they discourage us from normal human contact with our patients.  If you’re worried that the hand hygiene police will detect a deviation from protocol and report you to your hospital’s Infectious Disease authorities, there’s an easy way to avoid the problem. Steer clear of the patient.  And with the advent of the ubiquitous electronic health record, doctors and nurses are under tremendous time pressure to complete all the required data entry fields and move patients through the system.  When you think about it, not touching the patient saves time that could be more efficiently spent at the computer keyboard.  There’s a win-win situation, you might think.  But is it really?

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Wait. Who’s burned out?

dreamstime match

How the Affordable Care Act is worsening physician burnout, and why women physicians may be at even higher risk

To the literal-minded, burning out is the fate of light bulbs and matches.  But whether you read the popular press or medical journals today, you’re likely to find writers who are deeply concerned about “physician burnout”.

What defines “physician burnout”, and who exactly is suffering from it?  Is burnout an actual clinical syndrome, a slang term connoting fatigue and boredom, or a hazy combination of the two?  Which medical specialties have the highest rates of burnout, and are men or women physicians more susceptible?  The more you read, the more you realize how much pop psychology and sloppy language are clouding an important issue.

A perfect example of murky logic comes to us courtesy of Dr. Danielle Ofri, who wrote a recent piece for Time called “The Epidemic of Disillusioned Doctors”.  She claims that young women physicians who work in salaried primary care positions are more “resilient” than other doctors, and less likely to become disillusioned about medicine.

Now disillusionment and burnout aren’t identical concepts.  You can be quite disillusioned about the politics of medicine, and pessimistic about the future of private practice, while you take care of your patients every day with dedication and enthusiasm.

But in Dr. Ofri’s view, disillusionment and burnout are twin states of mind, and they are the harbingers of medical errors, substance abuse and depression.  The doctors she considers least likely to suffer such problems are those in her own demographic subset.  “The newer generation of female, salaried, primary-care doctors have the most optimistic outlook on medicine,” she writes.  “This bodes well for patients.”

Wait a moment.  May we see the data to back up this claim?  The source that Dr. Ofri refers to is a 2012 publication from The Physicians Foundation, a nonprofit organization that surveyed more than 13,000 physicians.  The survey addressed professional satisfaction and morale, among other issues, and reached conclusions rather different from Dr. Ofri’s.

“The majority of female physicians, employed physicians, and primary care physicians, though less pessimistic than their male, practice owner and specialist peers, are nevertheless pessimistic about the medical profession and express low levels of morale,” the report concluded, wryly noting that younger physicians “simply may not have practiced long enough to become disaffected.”

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