Archive for the ‘Anesthesiology’ Category

For several years now, I’ve been the social media curmudgeon in medicine. In a 2011 New York Times op-ed titled “Don’t Quit This Day Job”, I argued that working part-time or leaving medicine goes against our obligation to patients and to the American taxpayers who subsidize graduate medical education to the tune of $15 billion per year.

But today, eight years after the passage of the Affordable Care Act, I’m more sympathetic to the physicians who are giving up on medicine by cutting back on their work hours or leaving the profession altogether. Experts cite all kinds of reasons for the malaise in American medicine:  burnout, user-unfriendly electronic health records, declining pay, loss of autonomy. I think the real root cause lies in our country’s worsening anti-intellectualism.

People emigrated to this country to escape oppression by the well-educated upper classes, and as a nation we never got past it. Many Americans have an ingrained distrust of “eggheads”. American anti-intellectualism propelled the victory of Dwight Eisenhower over Adlai Stevenson – twice – and probably helped elect Bill Clinton, George Bush, and Donald Trump.

Don’t make the mistake of thinking that American anti-intellectualism today is exclusive to religious fundamentalists and poorly educated people in rural areas. Look at the prevalence of unvaccinated children in some of America’s most affluent neighborhoods, correlating with the location of Whole Foods stores and pricey private schools. Their parents trust Internet search results over science and medical advice.

Remember when physicians were heroes?

For a long time, physicians were exempt from America’s anti-intellectual disdain because people respected their knowledge and superhuman work ethic. The public wanted doctors to be heroes and miracle workers. The years of education and impossibly long hours were part of the legend, and justified physician prestige and financial rewards. Popular TV series in the ‘60s and ‘70s lionized the dedication of Ben Casey, Marcus Welby, Dr. Kildare, and Hawkeye Pierce. In real life, heart surgeons Michael DeBakey, who performed the first coronary bypass operation in 1964, and Christiaan Barnard, who performed the first heart transplant in 1967, became famous worldwide.

But over the next decades, greater opportunities for women to enter medicine coincided with a decline in public respect for physicians. Though many women in medical school and residency worked just as hard as men — or harder — to prove themselves, the money and prestige didn’t follow. Women physicians working full-time today earn an average 28 percent less than men, a gender wage gap that persists across specialties.

Could it be that the anti-intellectual tradition in America tolerates highly educated men in the doctor’s role, but can’t quite stomach giving the same respect and pay to highly educated women? Nearly everyone has heard of the Apgar score for assessing the health of newborn babies, but how many people know that Virginia Apgar, who developed it in 1952, was a physician?

Less formality, less respect

Even as more women entered the medical profession, other social trends dimmed the public image of physician infallibility. The tragic Libby Zion case in 1984, in which exhausted residents made a series of errors resulting in the death of the 18-year-old college freshman, prompted the first-ever law to limit resident work hours.

While Depression-era parents raised the “baby-boomer” generation to work hard without questioning it, their grandchildren in Generation X demanded extended parental leave, shorter work days, and more vacation time. “Work-life balance” became their mantra. Workplaces everywhere became more informal and dress codes more casual.

Patients and hospital staff began to address physicians by their first names. (As a Baylor medical student, I would have loved to see the fallout if anyone in the operating room at Methodist Hospital had addressed Dr. DeBakey as “Mike”.) Younger physicians, especially women, went along with it so they wouldn’t seem elitist or unfriendly; they started answering their phones saying, “This is Emma,” instead of  “This is Dr. Smith.” It should come as no surprise that the line between physician and non-physician “care providers” began to blur.

The trap of “evidence-based medicine”

The concept of “evidence-based medicine” gained traction, mandating that every disease and procedure must be managed according to a standardized set of guidelines. Never mind that science evolves, and that early research findings often don’t pan out in large-scale studies. Forget that some published research proves to be fraudulent or tainted by conflict of interest. Ignore the fact that a protocol that works well for one disease may be exactly the wrong treatment for another, and that many patients have multiple diseases.

Individual physician judgment today is presumed wrong if it defies a standardized protocol. Compliance with checklists is viewed as proof of quality care. Ezekiel Emanuel, one of the architects of the Affordable Care Act, has even suggested that medical training be cut by 30 percent, as he believes healthcare by protocol makes all that book-learning unnecessary. In this view, all “providers” are interchangeable pawns.

Today, young physicians start their careers in a world where their advancement and pay may depend on patient satisfaction surveys, and the Internet fuels distrust of medical advice. They spend their days functioning as data-entry clerks, with more face-time in front of a computer than with patients. Innovation is stifled. Their clinical decisions are reviewed for compliance with protocols, and their hospitals are run by administrators for whom the delivery of healthcare quickly and cheaply is the main objective. They fear replacement by mid-level “providers” who can be trained to follow a protocol without question.

Today’s medical students and residents see the dissatisfaction all around them, and they note the growing number of physicians who want to change careers. Many look for pathways out of clinical care from the start of their training, obtaining additional degrees — in public health, information technology, bioengineering, or business administration — that can lead to creative careers outside medicine. Some young physicians turn away from clinical care to become entrepreneurs, designing smartphone apps or using mobile vans to deliver IV therapy for hangovers.

The dystopian future

American anti-intellectualism is growing worse. Our national inability to debate political issues with reason rather than emotion is a symptom of this disease. So is the distrust of higher education and of experts in every field including medicine. I wonder every day if we are being honest with college students about the future when we encourage them to apply to medical school.

The Association of American Medical Colleges predicts a shortage of up to 120,000 physicians in 2030, both in primary care and specialties. A third of currently practicing physicians will be older than 65 within ten years. They’ll be retiring soon, and too many young physicians already are looking for an exit strategy. Even if we train more physicians, if the malaise in American medicine doesn’t get better we won’t keep them in clinical practice.

Unless something changes, we may find ourselves in a dystopian future with only 10 physicians who spend all their time in Washington writing “evidence-based” protocols, while people without the education to realize the full implications of what they’re doing will decide at your bedside which protocol applies to you. Are you feeling lucky?

This article appeared first in “The Conversation” on April 25, 2018, under the title “Why it’s so hard for doctors to understand your pain”. 

We’re all human beings, but we’re not all alike.

Each person experiences pain differently, from an emotional perspective as well as a physical one, and responds to pain differently. That means that physicians like myself need to evaluate patients on an individual basis and find the best way to treat their pain.

Today, however, doctors are under pressure to limit costs and prescribe treatments based on standardized guidelines. A major gap looms between the patient’s experience of pain and the limited “one size fits all” treatment that doctors may offer.

Concerns about the opioid epidemic make the problem worse. Opioids – including heroin and fentanyl – killed more than 42,000 people in the U.S. in 2016. Four in 10 of these deaths involved prescription painkillers such as hydrocodone and oxycodone. Physicians are increasingly reluctant to prescribe opioids for pain, fearing government scrutiny or malpractice lawsuits.

Where does this leave the patient whose experience of pain is outside the norm? How can physicians in all specialties identify these patients and do our best to manage their pain, even when their needs don’t match our expectations or experience?

Pain differences

Some pain is a natural part of healing. But that pain can vary depending on who is experiencing it.

Let’s start with a question that for years perplexed physicians who specialize in anesthesiology: Do redheads require more anesthesia than other patients? Anecdotally, many anesthesiologists thought they did, but few took the question seriously.

Finally, a study examined women with naturally red hair compared to women with naturally dark hair when under standardized general anesthesia. Sure enough, most of the red-haired women required significantly more anesthesia before they didn’t react in response to a harmless but unpleasant electric shock. DNA analysis shows that nearly all redheads have distinct mutations in the melanocortin-1 receptor gene, which is the likely source of the difference in pain experiences.

Cultural norms also can determine how different groups of people react to pain. In the U.S., for instance, boys playing sports and young men in military training traditionally have been encouraged to act stoically and “shake it off” when hurt, while it has been more socially acceptable for girls and women to react emotionally in comparable circumstances. As a result, medical personnel may subconsciously take male complaints of pain more seriously, assuming that a man must be in severe pain if he’s complaining at all.

Many people believe that women’s pain is consistently undertreated, and often blamed on “hormones” or “nerves.” Women more commonly suffer from fibromyalgia, autoimmune diseases including lupus and inflammatory arthritis, and migraine headaches, among other painful conditions that can be hard to control. Recently, research has identified genetic explanations for why these conditions strike women more often than men.

More women than men had at least one prescription for opioids filled in 2016. Though women are less likely to die of opioid overdose, they may become dependent on prescription opioids more quickly than men.

Race and ethnicity, too, can play a role in the experience of pain. The unequal treatment of pain, even cancer-related pain, among minority patients is part of the tragic legacy of racial discrimination in the U.S. In 2009, a major review article concluded that “racial and ethnic disparities in acute pain, chronic cancer pain, and palliative pain care continue to persist.” For example, minority patients who presented to emergency departments with abdominal pain are 22 to 30 percent less likely to receive analgesic medications than white patients with similar complaints.

In spite of research showing that non-Hispanic white patients show less sensitivity to pain than do black patients and patients of Hispanic ancestry, these inequities persist. The stereotype of the stoic Northern European patient may have a basis in genetics more than personality. The minority patients demonstrated a lower threshold for experiencing pain and a lower tolerance for acute pain, suggesting that they need more medication for adequate pain relief.

The hope of genetic research

My guess is that the next decades will bring an explosion in research illuminating the genetic mechanisms behind pain experiences. Genetic differences can help explain why some patients develop certain diseases while others, exposed to the same environmental factors, never do. Some patients undoubtedly are more sensitive to pain from the start than others, based on genetic factors that the medical community doesn’t yet understand.

At UCLA, where I work, the Institute for Precision Health obtains a sample of blood from nearly every surgical patient. By analyzing each patient’s genetic data, we hope to explain why patients often respond so differently after the same type of surgery, injury or illness.

Furthermore, chronic pain is associated with long-lasting changes in gene expression in the central nervous system. Simply put, the experience of pain changes a patient’s nervous system at the molecular level. These changes are linked to behavioral expressions of pain. Emotional factors – including a history of previous traumatic stress or depression – increase the chances that a patient will become dependent on opioids after experiencing pain.

The best physicians can do in the short term is to respect what patients tell us and try to gain insight into any of our own biases that could lead us to underestimate a patient’s experience of pain.

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Once again, it’s Physician Anesthesiologists Week, and it’s a great time to celebrate our specialty’s many successes and accomplishments.

But we’re wasting an opportunity if we don’t also take this week to consider the state of the specialty today, and what it could or should mean to be a physician anesthesiologist 20 or 30 years from now.

There is no question that a seismic shift is underway in healthcare. Look at how many private anesthesiology groups have been bought out by—or lost contracts to—large groups and corporations; look at how many hospitals have gone bankrupt or been absorbed into large integrated health systems. Mergers like CVS with Aetna are likely to redefine care delivery networks. Where does a physician anesthesiologist fit into this new world?

An even better question to ask is this: Is your group or practice running pretty much as it did 20 years ago? If so, then my guess is that you are in for a rude awakening sometime soon. One of two scenarios may be in play:  either your leadership is running out the clock until retirement and in no mood to change, or your leadership hasn’t yet been able to convince your group that it can no longer practice in the same expensive, antiquated model. As one academic chair said ruefully, at a recent meeting, “They’re like frogs being slowly boiled. They just don’t feel what’s happening.”

The perspective beyond the ramparts

As CSA President, I’ve had the opportunity recently to attend two remarkable meetings:  the ASA’s Strategic Dialogue Summit, which took place on January 18-19 in Chicago, and the CSA’s Winter Meeting January 22-26 in Maui. The planners of both meetings took the forward-thinking step of inviting people from outside the walls of the ASA and of traditional academic anesthesiology. They weren’t just telling the attendees—and each other—what they wanted to hear.

The ASA Strategic Dialogue Summit was organized by Immediate Past President Jeff Plagenhoef, MD, FASA, and President James Grant, MD, MBA, FASA. It brought together more than 40 anesthesiologists from private, corporate, and academic practice, both ASA loyalists and outsiders. Some of us who were there practice clinical anesthesia every day; others haven’t touched an anesthesia machine in years.

The meeting gave us an opportunity to speak candidly about the specialty of anesthesiology:

What threatens the specialty?

Are current payment models stifling progress, and what can be done?

How will new technologies make us obsolete or help us work smarter?

Are we training too many anesthesiologists, or should we train more?

How should training be revised to meet the needs of the future?

What disruptive innovations are just over the horizon?

The participants can’t say more than that at present, as we are considering the next steps that the process should take:  whether and when to engage different demographic groups of anesthesiologists in the dialogue, and involve outside stakeholders (such as third-party payers, patient advocate groups, healthcare administrators, and other physician specialties).

Beyond the Strategic Dialogue Summit, these questions should be considered by all of us, as we think about our profession and where we are going from here.

How trauma surgery reinvented itself

A prominent surgeon, Gregory Jurkovich, MD, FACS, of the University of California at Davis, gave a fascinating talk at the CSA Winter Meeting on how the specialty of trauma surgery has reinvented itself over the past 20 years in response to a crisis.

Back in 2001, the US faced a critical shortage of surgeons who were willing to take trauma call for emergency departments, Dr. Jurkovich explained. The cases often occurred at night and on weekends, and the pay didn’t begin to match the work involved. Younger surgeons going into practice no longer considered emergency call a duty as previous generations had done. Emergency departments became severely overcrowded, and the harm to patients from delays in care turned into a national scandal.

The leaders in surgery had to face facts. The profession of surgery as it existed in 2001 wasn’t delivering the best possible care to trauma and other emergency surgical patients, Dr. Jurkovich said. Not all general surgeons or orthopedic surgeons, let alone sub-specialists, were willing to assume care of emergency cases, and a surgeon who rarely sees trauma cases probably shouldn’t be managing them anyway.

A new Committee on the Future of Trauma Surgery, with broad representation from surgical boards and subspecialties, convened in 2003. The committee members decided that they didn’t want to let the specialty of trauma surgery die out, and they didn’t want to turn all non-operative care over to non-surgeons or hospitalists.

They decided to create a new specialty, which would serve emergency patients better, offer an attractive career and lifestyle, and stand as a valuable specialty in its own right. The new specialty would provide critical care training as well as operative training in trauma and other acute emergencies.

The new specialty came to be called “Acute Care Surgery”, and it has been a resounding success, Dr. Jurkovich said. It consists of a two-year fellowship after general surgery, combining trauma care, general surgery, and surgical critical care, and there are now 25 fellowship programs. Graduates work for academic and private hospitals alike, typically on a salary plus stipend basis. Their practices may include routine emergency cases (appendectomy, bowel obstruction) along with trauma cases, and acute-care surgeons admit and make rounds on surgical intensive care patients. Their round-the-clock availability helps avoid dangerous operative delays.

The shift-based work appeals to younger surgeons who seek a more predictable schedule, Dr. Jurkovich said. He pointed out generational challenges which affect surgery and every other specialty today, with more women entering medical school than ever before, more interest in a “balanced” lifestyle, and less interest in general practice than in subspecialty “niches”.

What lessons can we learn?

If the specialty of anesthesiology needs to reinvent itself—redesign what we do and how we do it—it isn’t too late if we start now. The exact solutions and details of implementation will vary by location and practice setting. But inaction, and futile attempts to defend the status quo, are the biggest threats.

For the past several years, I’ve had the privilege of traveling and speaking with anesthesiologists from a wide variety of practice settings, during my work as a CSA officer, a delegate to the ASA, and now as CSA President. The problems and the fears are evident; many anesthesiologists feel as though we are being squeezed in an ever-tightening vise of production pressure and cost constraints. The question is how to break free.

Here are my crystal ball’s top three best-case predictions—those of you who are in practice 20 or 30 years from now will have a chance to see how right or wrong they turn out to be!

The training of anesthesiologists will break the mold of today’s iron-fisted control by the ACGME, the RRC, and the match system.

We’ll no longer insist that every program train every resident with exactly the same cookie-cutter requirements. Residency and fellowship programs will develop and excel along different lines. Some will focus on scientific research, some on the economics and operational management of healthcare, and others on the clinical management of patients and teams in procedural settings. Cross-training with other specialties will expand, and anesthesiology’s influence will expand accordingly.

You’ll never hear the question, “But how will we get paid for it?”

If a peri-procedural service needs to be delivered, anesthesiologists will figure out how to do it safely and efficiently, without being hobbled by fee-for-service constraints. New care models will involve sedation nurses, ICU nurses, pharmacists, and other staffers—in addition to anesthesiologist assistants and nurse anesthetists—under the direction of anesthesiologists across the continuum of every episode of care that includes an interventional procedure. The current rigid supervision ratios and definitions will no longer apply.

Technology will redefine delivery of care.

Operating suites will have command centers where multiple rooms can be viewed and monitored simultaneously. Physician anesthesiologists will no longer spend disproportionate amounts of time performing nursing and pharmacy tasks: injecting drugs into IV lines, or mixing antibiotics. Better drug delivery systems, with feedback loops and decision support, will replace minute-to-minute manual fine-tuning. As we work smarter, the desires of upcoming generations for predictable schedules AND career satisfaction can be fulfilled.

If we face the future squarely, and make changes now that set our specialty up to survive and thrive, we can bring the joy back to the practice of anesthesiology. Then we’ll have good reason to celebrate Physician Anesthesiologists Week for many years to come.

 

When you tell anyone in healthcare that “sedation” to the point of coma is given in dentists’ and oral surgeons’ offices every day, without a separate anesthesia professional present to give the medications and monitor the patient, the response often is disbelief.

“But they can’t do that,” I’ve been told more than once.

Yes, they can. Physicians are NOT allowed to do a procedure and provide sedation or general anesthesia at the same time – whether it’s surgery or a GI endoscopy. But dental practice grew up under a completely different regulatory and legal structure, with state dental boards that are separate from medical boards.

In many states, dentists can give oral “conscious” sedation with nitrous oxide after taking a weekend course, aided only by a dental assistant with a high school diploma and no medical or nursing background. Deaths have occurred when they gave repeated sedative doses to the point that patients stopped breathing either during or after their procedures.

Oral surgeons receive a few months of education in anesthesia during the course of their residency training. They are legally able to give moderate sedation, deep sedation or general anesthesia in their offices to patients of any age, without any other qualified anesthesia professional or a registered nurse present. This is known as the “single operator-anesthetist” model, which the oral surgeons passionately defend, as it enables them to bill for anesthesia and sedation as well as oral surgery services.

Typically, oral surgeons and dentists alike argue that they are giving only sedation – as opposed to general anesthesia – if there is no breathing tube in place, regardless of whether the patient is drowsy, lightly asleep, or comatose.

The death of Caleb Sears

Against this backdrop of minimal regulation and infrequent office inspections, a healthy six-year-old child named Caleb Sears presented in 2015 for extraction of an embedded tooth. Caleb received a combination of powerful medications – including ketamine, midazolam, propofol, and fentanyl – from his oral surgeon in northern California, and stopped breathing. The oral surgeon failed to ventilate or intubate Caleb, breaking several of his front teeth in the process, and Caleb didn’t survive.

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The real surprise – to me, at least – came more than halfway through Dr. Atul Gawande’s keynote address at the opening session of the American Society of Anesthesiologists’ annual meeting in Boston.

Much of his talk on October 21 celebrated the virtues of checklists and teamwork, topics that have turned into best-selling books for the well-known surgeon and professor of public health. “We are trained, hired, and rewarded to be cowboys, but it’s pit crews we need,” he said.

Then Dr. Gawande posed this question to the packed room: “What are the outcomes that matter?”

He answered his own question somberly. “The most unsafe operation is the operation that shouldn’t be done,” Dr. Gawande said. “Does the operation serve the patient’s goals or not?”

“We’ve all been there,” he continued. “Taking people to the operating room and wondering what we’re doing.”

Those are comments I’ve heard from anesthesiologists many times before, but I never thought I’d hear them from a surgeon.

Flogging the dead

For any of us who practice anesthesiology in a major hospital – doing cardiac, thoracic, or liver cases, for instance – there are days when all our efforts are spent on behalf of a patient whose health is unsalvageable. “Flogging the dead” is a phrase sometimes used to describe prolonged and futile care in the operating room or ICU.

Sometimes aggressive interventions are driven by a family that wants “everything” done, because in their innocence the family members have no idea how terrible and dehumanizing the process of postponing death can be.

In other circumstances, however, the decision of whether to do surgery is driven by the mission and the financial motivation of the health system to provide care. If care doesn’t occur, if the surgery isn’t done, no one gets paid.

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