Archive for the ‘Residency’ Category

Practice without fear

This article, with advice for residents about the future of anesthesiology, was published first in the October 2020 issue of Anesthesiology News

You may be weary of being told that our profession is facing a time of unprecedented threat – from third-party payers, from the government, from non-physician practitioners. You’ve heard it so often that your brain is tuning it out. Is the threat level exaggerated for dramatic effect? Is it better just to go on with your day and not think about it at all?

That would be a mistake. The real question is:  How should we deal with the upcoming “market adjustment” that almost certainly will result in lower anesthesiologist compensation? In the face of gloomy reality checks, how can we promote pride in our profession and recruit the best medical students? How can we continue research that will reduce risk and improve outcomes? How do we avoid becoming irrelevant or extinct, like Kodak, Xerox, Sears, and now Hertz? It’s time to face the future.

The threats are real

Unfortunately, the “unprecedented threat” claim is all too real. Department chairs everywhere  worry that they will not be able to maintain the compensation rates that anesthesiologists have enjoyed up to now. Why?

The Medicare Trust Fund is expected to become insolvent as soon as 2024. The chair of the Medicare Payment Advisory Commission (MedPAC), Michael Chernew, PhD, recently commented, “We are very dedicated to finding payment models to promote efficient delivery of care.” No one could possibly think this will mean anything other than lower payments to physicians.

Scope-of-practice expansion is gaining ground. On March 30, CMS issued an array of “temporary” waivers and new rules, waiving the requirement that a nurse anesthetist must work under the supervision of a physician. How likely are these new rules to be reversed under a new administration, whether Republican or Democratic? Whether or not you live in an “opt-out” state may not matter in the near future.

Hospitals were in trouble even before the COVID-19 pandemic. Many have gone bankrupt; others are merging with larger health systems. At present, around 80% of hospitals subsidize their anesthesiology departments to the tune of millions of dollars each year. Realistically, can these subsidies continue? Probably not. Will hospital administrators seriously consider cheaper staffing models for delivering anesthesia care? Probably yes.

Make yourself indispensable

First, it would be wise to assume that a downward “market adjustment” to anesthesiologist compensation is coming. Plan for it now. Stop yourself from spending to the full extent of your income, and put away all you can in a tax-deferred retirement account.

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The Hahnemann Disaster

Though the news at first stayed local in Philadelphia and the northeast, it’s gaining traction nationwide. ZDoggMD is on it. Bernie Sanders held a rally.

What happened? The venerable Hahnemann University Hospital, the main teaching hospital for Drexel University College of Medicine in Philadelphia, is bankrupt and will soon close its doors after more than 170 years as a safety-net hospital serving inner city patients.

Why should we care? After all, there are other teaching hospitals in the immediate area with capacity to absorb the patients, and they had several months’ warning to prepare.

We should care for many reasons, but I’ll start with the plight of the 570 residents and fellows who are being displaced from their jobs. Getting a residency position in the first place is a perilous process – there aren’t enough spots for all the graduating medical students who want them. Only 79% of the more than 38,000 applicants in 2019 snagged a first-year or internship position in a residency program.

So the Hahnemann residents – the “Orphans from HUH”, as they’ve started to call themselves – are scrambling on their own to find new jobs at a time when most residents are thankfully settling in to the new academic year. There’s no organized program to help them.

Even for the residents who’ve already found new positions, there are other boulders in the road. To begin with, they haven’t been released yet. They can’t start their new jobs and the Medicare funding for their positions is still tied up in bankruptcy court.

They’re still at work, wandering around a nearly empty Hahnemann with only a handful of patients left. The ER isn’t admitting any new patients and will shut down completely on August 16. The labor-and-delivery ward has closed. The new interns aren’t gaining any real experience and will be lagging behind their peers wherever they go.

“Doctors have been writing notes to update plans of care and people have come in as part of the liquidation to take away their computers,” a third-year internal medicine resident named Tom Sibert, MD, told Medscape reporter Marcia Frelick last week.

Tom Sibert? Any relation? Why yes; he’s my son. You can understand, I’m sure, why I went into full-blown mama lion fury when the Hahnemann situation blew up, and why I was beside myself with worry until he locked in an acceptance to an excellent program where he’ll finish his training.

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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.”

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In the interests of full disclosure, I acknowledge with delight that I have a non-time limited board certificate from the American Board of Anesthesiology (ABA), issued before the year 2000. I can just say “no” to recertification.

The more I learn about the American Board of Medical Specialties (ABMS) and its highly paid board members, the more disillusioned I’ve become. It’s easy to see why so many physicians today have concluded that ABMS Maintenance of Certification (MOC) is a program designed to perpetuate the existence of boards and maximize their income, at the expense primarily of younger physicians.

Lifelong continuing education is an obligation that we accepted when we became physicians, recognizing that we owe it to ourselves and our patients. That is not at issue here. We have an implicit duty to read the literature, keep up with new developments, and update our technical skills.

The real danger of MOC is this:  It is rapidly evolving into a compulsory badge that you might soon need to wear if you want to renew your medical license, maintain hospital privileges, and even keep your status as a participating physician in insurance networks. If physicians don’t act now to prevent this evolution from going further, as a profession we will be caught in a costly, career-long MOC trap. The only other choice will be to leave the practice of medicine altogether, as many already are doing.

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This column ran first in the online magazine for medical students, “in-Training”

In case you were wondering — robots won’t replace anesthesiologists any time soon, regardless of what the Washington Post may have to say. There will definitely be a place for feedback and closed-loop technology applications in sedation and in general anesthesia, but for the foreseeable future we will still need humans.

I’ve been practicing anesthesiology for 30 years now, in the operating rooms of major hospitals. Since 1999 I’ve worked at Cedars-Sinai Medical Center, a large tertiary care private hospital in Los Angeles.

So what do I think today’s medical students should know about my field?

A “lifestyle” profession?

For starters, I have to laugh when I hear anesthesiology mentioned with dermatology and radiology as one of the “lifestyle” professions. Certainly there are outpatient surgery centers where the hours are predictable and there are no nights, weekends, or holidays on duty. The downside? You’re giving sedation for lumps, bumps, and endoscopies a lot of the time, which can be tedious. You may start to lose your skills in line placement, intubation, and emergency management.

Occasionally, though, if you work in an outpatient center, you’ll be asked to give anesthesia for inappropriately scheduled cases on patients who are really too high-risk to have surgery there. These patients slip through the cracks and there they are, in your preoperative area. Canceling the case costs everyone money and makes everyone unhappy. Yet if you proceed and something goes wrong, you can’t even get your hands on a unit of blood for transfusion. To me, working in an outpatient center is like working close to a real hospital but not close enough — a mixture of boredom and potential disaster.

The path I chose is to focus on high-risk inpatient cases. I especially enjoy thoracic surgery, with the challenges of complex patients and one-lung ventilation. You can bring me the sickest patient in the hospital setting — where I have all the monitoring techniques, resuscitation drugs, blood products, bronchoscopes, and anything else I might need — and I’ll be perfectly happy. The downside: a practice like mine tends to be stressful and tiring, and I never know the exact time that the day will end. Hospitals that offer Level I trauma and high-risk obstetric care are required to have anesthesiologists in house 24 hours a day, 365 days a year. There’s no perfect world.

What type of person is happy as an anesthesiologist?

Even though women comprised 47% of the US medical school graduates in 2014, only about 33% of the applicants for anesthesiology residency were women. I’d be interested to hear from all of you as to why fields such as pediatrics and ob-gyn tend to be so much more attractive to women, because I genuinely don’t understand it. But I do have a few thoughts as to the type of person who is happy or unhappy as an anesthesiologist.

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