It’s a nightmare that doesn’t end for the family of 24-year-old Marek Lapinski, who suffered cardiac arrest recently during the removal of two wisdom teeth in a southern California oral surgery clinic.  The former college football player had no known health problems prior to the surgery, but died three days later in a hospital intensive care unit.

While the circumstances of Mr. Lapinski’s death are still being investigated, the case highlights a critical issue.  Sedation and anesthesia carry risks, no matter how routine the surgery may be.  Patients are entitled to full disclosure about the qualifications of the personnel who will administer sedation or anesthesia for any procedure, and to a complete discussion of the risks and benefits of the type of anesthesia that will be used.  There may be minor operations, but there are no minor anesthetics.

Anesthesia that is given in hospitals is tightly regulated, but office-based surgery and dental clinics are not necessarily held to the same standards.  Regulations vary from state to state.  Perhaps the most worrisome aspect is that the same physician or dentist who is performing the surgery may be in charge of the anesthesia as well, directing an assistant who has no formal anesthesia certification to give powerful sedative medications.

According to a Fox 5 interview with Mr. Lapinski’s family, he began coughing during the wisdom tooth surgery, and then received propofol, a potent surgical anesthetic medication.  Shortly thereafter, the oxygen levels in his blood deteriorated, and he went into cardiac arrest.  His medical records were made public by the family, showing that Mr. Lapinski received other sedative medications including fentanyl, midazolam, ketamine, and methohexital in addition to propofol.

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My son has been accepted into medical school, we learned last week, and I must say I’m about as happy a mother and a physician as you could find anywhere.  For everything that’s wrong with the American healthcare system today, medicine is a wonderful profession and it’s still the greatest honor in the world for a patient to have faith in your skills and care.

It will be interesting to see how my son navigates the still controversial issue of how to manage family and “work-life balance”. How do you do justice to the trust that was placed in you when that invitation to medical school was extended?  That trust came from the college faculty members who recommended you, the medical school faculty who evaluated your application, the public whose tax dollars help support your medical training, and the patients–now and in the future–who will need you to take care of them.  No, that doesn’t imply that you’ve accepted a life sentence to work 80 or 100 hours a week until the day you retire.  But it does imply that all those people believed that you accepted the calling to make the practice of medicine one of the highest priorities in your life.

You’ll hear the argument that the desire for “work-life balance” is a generational thing, not a gender issue–that young men in their 20s and 30s today don’t want to work as hard as their fathers did at their age.  That may be true.

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New research just out in the journal Psychology and Aging says pessimists live longer and healthier lives. If this is true, then contemplating the future of anesthesiology ought to make us immortal, because our professional prospects don’t look bright.  As we teach residents to do what we’ve always done, shouldn’t we ask ourselves honestly if we’re training them for a future that doesn’t exist?

Especially here in California, it seems likely that our predominantly MD-provided, fee-for-service practice of anesthesiology will not survive indefinitely, and perhaps not for long.  We can blame the reelection of President Obama and the passage of the Affordable Care Act if we like, but the reality is that market forces were eventually going to catch up with us whether or not Mitt Romney went to the White House.

In a way, we’re the victims of our own success; we’ve made anesthesia so safe that everyone thinks there’s nothing to it. But that’s exactly the point.  Technology has indeed made anesthesia much safer.  When I started learning anesthesia, pulse oximetry and end-tidal CO2 monitoring were new to the market, unproven, and scarce. Now they’re everywhere. We fear the difficult airway less now that we have video laryngoscopes readily at hand.

Since technology is so much better, why do so many of us still believe that every case requires the costly expertise of a board-certified anesthesiologist?  Read the Full Article

Don’t be surprised if patients start asking more questions than usual about awareness under anesthesia.  We can all thank a recent article in The Atlantic magazine, with a large-print headline on the cover:  “Awake Under the Knife”.  Written by a UCSF medical student, the article not only assures everyone that awareness can happen, but takes pains to point out that anesthesiologists can’t always prevent it.

The article’s author, one Joshua Lang, seems sincere in his effort to describe the science behind one type of awareness monitor known as the bispectral index (BIS), and the even more interesting research of Dr. Giulio Tononi, at the University of Wisconsin, in the neuroscience of sleep and consciousness.  But you had to read the entire article to get to that information.  The first half, loaded with anecdotes about awareness, is superficial at best, and leads me to wonder if the author’s real aim is to make a name for himself as the next Atul Gawande.  Perhaps he should take the trouble to finish medical school first. Read the Full Article

I originally wrote this column just before Thanksgiving one year, but the recent tragic deaths of the Newtown first-graders make it timely once again.  For families who have lost a child, each holiday brings fresh grief, hurdles to face, and mourning for celebrations that will never happen.

The glittering commercialism and noisy cheer of any American holiday can be stressful for most of us.  But for the parent who’s lost a child during the past year, facing the first of many holidays with an empty place at the table can make already unbearable grief so much worse.

No one in modern America expects a child to die.  Children only die in nineteenth century novels and third-world countries, or so we’d like to think.

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When you walked into the voting booth on Tuesday, November 6, did you do so with a feeling of calm certainty that the man who would get your vote for President was unquestionably the best choice, or even the only possible choice?  Did you feel confident that your candidate’s political party fully supports your political views as well as your personal values?

For many physicians, I suspect that the answer to those questions was not a resounding “yes”.  Perhaps more so than in any previous election that I can recall, there were elements in each party’s platform that many thoughtful physicians might have a hard time accepting.  The extreme left and right wing contingents within the Democratic and Republican parties argue for wildly different policies, but does either of them truly represent the best interests of our profession or our patients?

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In my hospital’s preoperative area, upright on her bed, sat an unhappy middle-aged lady who needed an operation to treat complications from her previous bariatric surgery.  She hadn’t lost weight and clearly was feeling discouraged about practically everything.  She was physically uncomfortable, couldn’t even keep down her own saliva because her lower esophagus was obstructed, and was in tears.

As her anesthesiologist, I came to evaluate her prior to surgery.  In fairly short order, I got her a tissue and a warm blanket, listened to her tale of woe, and finished my pre-anesthetic examination.  Nothing special.  At the end, she said,  “You’re so nice.  Were you a nurse before you were a doctor?”

Ouch.

No, I told her, I wasn’t.  Never a nurse; always a doctor.  She looked surprised.

And that little narrative may help to explain why we (physicians as a group) are having so much trouble with public relations, and  with the onslaught and success of mid-level caregivers who want to practice medicine without a license.  Their PR is better than ours because their PR task is easier:  patients already think mid-level health care personnel, especially nurses, are basically nicer and more sympathetic than we are.

Just look at the recent coverage of Hurricane Sandy.  News reporters on radio, TV, print, and online repeatedly and justly praised the heroic efforts that nurses made during the evacuation of patients from dark, flooded hospitals, and showed photos and video clips of nurses hand-ventilating premature infants.  But not once did I hear a mention of the attending physicians and residents who were no doubt working right alongside the nurses, let alone the respiratory therapists, orderlies, and all the other personnel.  Nurses got all the credit in the public’s view.

Anesthesiologists and nurse anesthetists represent perhaps the most visible part of the physician/mid-level conflict, but other physicians are at risk as well.  The American Academy of Family Physicians (AAFP) has recently made public its opinion that nurse practitioners shouldn’t run medical homes, but the Affordable Care Act supports independent practice for nurse practitioners–including admitting privileges to hospitals–just as it supports independent practice for nurse anesthetists.

The latest unbelievable turn of events is Medicare’s decision in favor of nurse anesthetists practicing interventional pain medicine without physician supervision.  Just so we’re clear, this means that a nurse anesthetist with no special qualification other than Medicare’s blessing can bill Medicare for performing invasive pain management procedures that physicians ordinarily train to do with four years of medical school, at least four years of residency, and a fellowship.  These are procedures so risky that my hospital wouldn’t consider me qualified to do them despite my MD degree and anesthesiology residency, because I haven’t taken advanced training in interventional pain management.

What are we going to do to turn around this public perception that doctors are curt, mean, and unsympathetic? And that nurses are always better, kinder, and maybe even smarter?  And can do everything doctors can do, just as well?

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Every once in a while, a new catch phrase appears that you hear or read rarely at first. Then suddenly you meet it everywhere, and it progresses rapidly from novelty to irritant.

The latest phrase to reach the active loathing stage for me is “reach out”.  In the past few weeks it seems that everybody–mortgage brokers, politicians, you name it–wants to reach out and make sure I’ve heard the special message they have for me. Generally this message presages an attempt to separate me from some amount of money.

The spiel typically goes something like this:  “Dr. Sibert, I wanted to reach out to you and let you know about…”  Whatever it is, I can virtually guarantee I don’t want to know about it, and it will make me recoil like a cat from a lawn sprinkler.  What’s particularly annoying about this introductory gambit is its implication that I was in need of being reached out to, or rescued.  In effect, the message suggests that the writer is in possession of valuable information without which I will flounder or sink.

This brings me to a point about modern manners.  Often, phrases that are used to convey politeness or helpfulness today contain a veiled insult, and aren’t genuinely polite at all.  Take, for instance, the greeting you often hear on the phone or from a receptionist:  “How may I help you?”  Consider for a moment what this question actually conveys.  The person asking the question makes two presumptuous assertions.  The first is that I am a hapless individual in need of help, and the second is that he or she is uniquely qualified to offer any of the many kinds of help that I might need.  This is very different from the simpler and more courteous question that was usually asked in times past:  “May I help you?”  This query simply asked if the speaker might offer any assistance.  It did not imply that the other party was incompetent or helpless, or that the speaker possessed superior powers.

When my husband and I traveled in Japan, we were particularly struck by the difference in manner between the salesclerks in Japanese shops and department stores compared to many in America.  If a wait of any length takes place in Japan, the staff members seem genuinely regretful and say “Thank you for waiting” as soon as they are able to attend to you.  In the United States, if salesclerks even notice that you have been kept waiting, they are more likely to say, “Thank you for your patience.”  I’ve always found this annoying.  The assumption that I have waited patiently is nearly always wrong.  I would react much better to a simple “I’m so sorry that you’ve been kept waiting,” and acknowledgement of the fact that waiting is generally irritating and inconvenient.

There are so many other misuses of the English language in print and other media today.  So little that is labeled “amazing” actually is.  The words “affect” and “effect” may not be used interchangeably.  The word “impact” is a noun, not a verb.  And a tire or a diaper may need changing or it may need to be changed; it does not “need changed”.  Texting may in fact augur the death of elegance in the English language as we have known it.  But that, dear reader, is a topic for another day.

Really, sir.  What were you thinking?

I’m talking to you—the anesthesia provider (I hate to think that you might be an anesthesiologist) who allowed himself to be videotaped while a patient injected his own induction dose of propofol.  Most people know something about propofol even if they aren’t in the anesthesia business–that’s the medication that Dr. Conrad Murray gave Michael Jackson to everyone’s sorrow.

I would insert the link here, but the video has been removed from YouTube.

Apparently the patient, a young man in his late teens or early twenties, needed anesthesia and decided it would be great fun if he could give his own drugs and film the adventure.  “Jackass” comes to the operating room.

The video shows the young man lying on an operating table with an anesthesia machine and monitors in view.  A tall, middle-aged man in blue scrubs, with a mask dangling around his neck, puts a pulse oximeter on the patient’s finger and hands him a 20-cc syringe of what appears to be propofol.  The young man starts to inject it and pushes the first 10 cc into the IV tubing, then laughs and says he feels dizzy.  He’s told to finish the injection, which he does, barely.  Then his eyes roll back.

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I gained a certain notoriety last summer by suggesting in a New York Times op-ed that it isn’t a good thing for growing numbers of physicians to work part time.  American-trained physicians have an obligation, it seems to me, to make full use of our professional skills because there is a shortage of doctors and because American taxpayers provide so much of the funds for our training.  Now, in a new article in the Atlantic magazine–“Is Medical School a Worthwhile Investment for Women?”–two Yale professors suggest that physicians might as well work full time or more because, if we don’t, medical school is an investment of time and money that doesn’t make financial sense.

This article didn’t surprise me at all.  It specifically points to the example of American primary care doctors who are less well compensated than specialists. Using a tool called net present value (NPV) calculation, Professors Keith Chen and Judith Chevalier compared the costs of earning a degree against the income earned over the likely course of a career.  They compared the NPV of training as a physician assistant (PA) compared to a primary care physician, and also looked at gender differences in anticipated earnings.

Their conclusion?  “We found that, for over half of woman doctors in our data, the NPV of becoming a primary-care physician was less than the NPV of becoming a physician assistant,” the authors wrote.

Was this true for men as well?  No, said the authors.  Most men are better off financially if they become physicians.  But women physicians tend to earn less than their male counterparts, and they also tend to work less.  A male physician “earns more per hour relative to the male PA than the female doctor earns relative to the female PA,” the authors noted.  “However, a big part of the difference comes from an hours gap. The vast majority of male doctors under the age of 55 work substantially more than the standard 40 hour work week. In contrast, most female doctors work between 2 to 10 hours fewer than this per week.”

The professors concluded, “Even though both male and female doctors earn higher wages than their PA counterparts, most female doctors don’t work enough hours at those wages to financially justify the costs of becoming a doctor.”

After reading the Atlantic article, I don’t doubt the reasoning behind it but have other questions to raise.

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