Thursday, May 31, 2012

Do We Owe Residents a Job?

While attending the Resident's Research Day, a resident approached me and asked if he could meet with me.  "I am happy to meet with you, " I replied, "But if you are looking for job, I do not anticipate hiring anybody in the near future."  He still wanted to meet with me so we did a week later and I told him the same thing.  He already had a 0.5 position at a suburban hospital and was looking for something more.  I told him we could offer him locums on a weekly basis and that some people looked for people to do call on weekends.  He left a little disappointed and felt I little guilty that I couldn't help him out more.  Should I?

I went into my residency fairly confident that I would get a good job when I finished.  Things had changed by the time I finished and although I send my resume to just about every place I could conceivably work in, I got few nibbles.  I did end up getting quite a good job in a nice community for which I am grateful (and sometimes wish I never left).  When I did my fellowship orals, 4 other people did theirs at the same time as me.  I was the only one of the group of 5 who had a job after my residency.  Things got worse during the 1990s to the point that we actually tried to talk medical students out of anaesthesia as a specialty because there would be no jobs for them.  Suddenly things shifted, people died, people retired, people cut down, operating rooms opened and in the late 90s the residents who had gone into anaesthesia despite our warnings not to, had their pick of good jobs.  This persisted into this century until fairly recently.  Because of the perceived shortage, there was a doubling of residency positions.

The impression I get is that while in the larger centres, jobs are hard to come by; many of the larger "rural" hospitals are still hard to staff.  Every time somebody asks me for a job, I always ask them if they have considered any of the other hospitals outside of our city and our evil sister city.  They usually have some excuse.  These hospitals it is true, tend to smaller which means more call and the communities lack the amenities of the city.  These are hospitals however that were once places that specialists considered working in.  I remember in the early 1990s when a larger rural hospital posted a job, resulting in a feeding frenzy among the final year residents as to who would get it.  Rural hospitals do not really seem to looking for our residents either.  They seem to have gotten into the pattern of recruiting from overseas (mostly South Africa).  Our University Department recently had to assess the training of a SA anaesthesiologist going to work at a rural hospital 5 hours away.  Our chairman asked why this hospital had not tried to recruit any of the finishing residents, some of whom didn't have full-time jobs yet (assuming any of them would consider working there)?

The main problem is that operating room numbers have not kept pace with the population growth.  Our metropolitan area had 800,000 people when I moved here in 1992 and now has 1 million people.  Logically this should mean 25% more operating rooms.  There are in fact more or less the same number as in 1992.  Meanwhile we seem to do more "urgent" cases after hours.  We recently built a modest size hospital in suburbs; it has 4 operating rooms.  These will be staffed by GP-anaesthesiologists; there has as far as I know been no effort to have it staffed by specialists.  Our evil sister city, recently to great fanfare opened a brand-new hospital.  This new hospital will result in no net increase in operating rooms; rooms at other hospitals are being closed in order to allow it to use its brand-new ORs.

The problem of physician over-supply is not limited to anaesthesia.  Even in the 1990s certain specialties like neurosurgery, ENT and cardiac surgery turned out residents, knowing there would not be jobs for them in Canada.  Most of them went to the US which was able to absorb them quite well until recently.  A rational person would ask why we are training specialists for non-existent jobs or for jobs in other countries and there is of course only one rational answer.  For service of course.  We can't expect a cardiac surgeon to actually look after his patients can we?  Radiation oncology is now massively over-subscribed, a graduating resident wrote a lament recently wondering why this could not have been anticipated 5 years ago when he was applying for a residency.

A city our size could easily absorb to a point all the graduating residents.  We might all have to take a couple of extra weeks of holidays a year.  In time we might actually enjoy it and wonder why we didn't think of this earlier.

The question is:  "Do we owe our residents a job?"

University Tuition

Years ago, I used to give a lecture every year to the medical school on pain.  I felt evangelical about teaching medical students about pain then which made me overlook some of the downsides of which there were many.  The major downside was that I wasn't paid for my time,  and because I just can't interrupt the OR list for an hour to run over to the next building to give my lecture, I had to take the whole day off.  Further complicating matter was the medical school's habit of occasionally rescheduling the lecture on short notice.  I also had to attend curriculum meetings that lasted for hours and in a minute of stupidity agreed to sit in on a half day medical student case presentations.  Eventually I learned to work around the call schedule to minimize my income loss and having got a good Power Point presentation, I only had to make minor adjustments every year.  I think I actually enjoyed it a bit; I used to be one of those people who sat in the back row of the lecture theatre not paying much attention and now I was a real Medical School Professor.  I did this for 10 years.  For the last 2 or 3, I started hinting that many they should find someone else but they kept on asking me.

The last year I gave my lecture, just before I started, the class president asked if he could talk to the class for a minute.  The University had just raised tuition again and he and a group of students were planning to meet with the Dean to see if they could do anything about this.

I then started my lecture.

I prefaced by stating words to the effect that, I supported the students 100%, that tuition they were paying was ridiculous;  further that I was not getting 1 cent from the University to give the lecture, and that most of the doctors who did medical school teaching received no remuneration.  So I concluded, where was the money going?  Then I gave my lecture.

Nobody ever said anything, but my career as a Medical School Lecturer was over; I was never asked back.
Strangely enough about 3 years ago the University actually started paying me for teaching.  I don't teach much but I sleep soundly at night accepting the money.

Students in Quebec have recently gone "on strike" over what the mainstream press describes as modest tuition increases.  This has resulted in some violence which is of course widely publicized.  It has also resulted in some fairly draconian legislation by the provincial legislature which has brought out more people onto the street. Tuition even after the fee increases will still be the lowest in Canada.   One way to look at this is that tuition in the rest of Canada is too high not that tuition in Quebec is too low.  Regardless tuition still only covers a portion  of the cost of educating a student so you could look at it as tuition being a tax imposed on students (and their parents).  In effect it could be argued that increasing tuition prevents low income students from accessing a program which is still heavily subsidized.  Also Quebec is in the middle of another corruption scandal and folks are looking at how much government money ended up in various people's pockets and asking just why are the students being asked to pony up more money.

The increases are it is true just a couple of hundred dollars a year.  Put this in perspective.  Periodically (actually quite a bit over the past 20 years), the government will announce a tax cut.  Somebody will point out that the average person will only reduce his tax bill by a few hundred dollars as opposed to somebody in my income range who might save thousands of dollars.  Instantly that person will be attacked as an elitist who doesn't understand the value of a couple of hundred dollars to the working man.  I don't even mind having a couple of hundred dollars thrown my way.  So a couple of hundred dollars is a big deal.

Here is how old I am.  In my first two years of University, my yearly tuition was $428.  That is $1854 in 2012 dollars. In my third year, a 25% increase was imposed, raising the rate to $535.  And there were protests although nothing like is happening in Quebec.  It was after all the 70s, it was still possible to get a good summer job, and student loans and grants were generous. Medical school tuition was much higher but it only cracked four figures in my last year.  Consequently I graduated owing only $10,000 most it incurred in my last year and I got bored with dealing with the bank and paid it off during my first year in practice.

Tuition for Sciences at my old Alma Mater is now $4700, 2.5 times inflation.  Medicine is $16,000, over 6 X the inflation adjusted $1000  I paid in 1981. Are students getting an education that is 2.5 X better than in the 1970s let alone 6 X better?  I doubt it.

I now have one son graduated from University and one son still in school.  I was able to take advantage of the income attribution rules that those of us in the 1% have and set up mutual funds for them soon after their birth, which had a far whack of cash in (not as much as my investment adviser predicted) when they were 18.  When the government allowed RESPs with the $400 yearly grant, we put money in those.  On top of that our children won the odd scholarship and between that they have been able to attend University and graduate debt-free, not really have to work during summers or deal with the whole student loan BS.

Student loans are of course a whole form of welfare for the banks.  What a sweet deal that is.  The government pays the interest while the student is in school and if the student defaults, the government picks up the tab.  Where can I get a deal like that?

When I was "a student leader" during my time in University, I was invited to a dinner where the University president Dr. Douglas Kenny gave a talk.  Dr. Kenny had an interesting proposition that I have heard repeated a few times since then.  He proposed making University "free" or rather the students would automatically get their tuition and reasonable living expense covered.  When they graduated, or ceased going to school, they would start paying this back as a surtax on their income.  For example if we said the surtax was 5% to pick a number, and they owed $1000 in income tax, they would pay another $50 as a surtax.  This means that the investment banker or ophthalmologist would pay back their "loan" quite quickly whereas the philosophy major working at Starbucks would pay it back quite slowly.  Because it would be administered through the tax system, most of the student loan bureaucracy would be eliminated.  Variations on this have been proposed including free education in return for national service, something we already offer our military.

These proposals however make so much sense that there is very little chance that they will ever be accepted. 

Sunday, May 27, 2012

Just a minor case

This is really sad. 

No I mean it, nobody should have to have gone through what this poor man's wife went thru; he shouldn't be a widower, his children should have their mother still.  And good for him for channeling his grief into trying to help others by educating and improving practices.

It does show something.

Surgery (and anaesthesia) are something to be respected.  From time to time I run into a patient who is scared shztless about his upcoming surgery.  These are for the most part ASA 1 or 2 patients having "minor" surgery.  I always tell them that it is quite normal to feel that way; surgery is something that should be respected.  Too many patients approach surgery with a cavalier indifference.  In the Pain Clinic I see a lot of people whose lives have been ruined as the result of surgery.  Without exception they all want another operation. We all see the patients in the Pre-assessment clinic or in the holding area who just can't seem to understand why we are asking them all these questions.  After all it is just a minor case.

We also get this response from surgeons when we suggest that the patient's diabetes needs to fixed or that the chest pain they have been having needs to be investigated, "Oh its just a quick case."

It is interesting watching the video, seeing what went down.   It appears as if she was having sinus surgery; a shared airway we all learned to respect very early in our residency.  I would have to question using a laryngeal mask although I realize many respected anaesthesiologists advocate this.  I like to have the airway secured while the ENT surgeon is messing around (while I know that they can and do accidentally extubate the patient).  Not that I don't like LMAs.  I use them for over half my cases but almost never in a head and neck case.  I suspect what happened in this case was that they couldn't intubate the patient so decided to go with a LMA, converting a Can't Intubate Can Ventilate airway to the much feared Can't Intubate Can't Ventilate airway.  I have never understood the logic of pushing a large LMA blindly down an airway you have already traumatized although I have done this myself and "got away with it". 

I have fortunately never been involved in a can't intubate, can't ventilate situation.  There has been the odd time when I thought I might be headed down that road but something intervened.  It is surprising that with an ENT surgeon in the room and the nurses even bringing in a trach set, nobody thought of doing a trach.  Of course I remember watching an ENT surgeon at the C of E doing a trach and thinking, "I hope my life never depends on you doing a trach on me!"

It is interesting that her widower works in the aviation industry, one industry that takes safety seriously (as I like to reassure myself before every take-off and landing.)  When it suits their agenda our administration is always exhorting us to imitate the aviation industry in our "quality" practices.  This is why we now have our safe surgery checklist.  There is a lot to learn from the aviation industry except that there is one huge difference.  If a pilot screws up badly, he dies along with his passengers. Therefore everybody, in the plane at least, has a real big incentive to make sure everything goes smoothly.  That doesn't include the ground crew or the air traffic controllers of course and we hear of the the odd suicidal pilot.  In contrast if you screw up in the OR, at the worst you may get a rough ride at M+M rounds, you might face an unpleasant interview with your chief, you might get a College complaint or you might get sued.  The bottom line is that in most cases you will be back to work.

But we have to remember that patients die during and after routine surgery from other causes.  They can succumb to an infection with sepsis, they can have a myocardial infarction or a pulmonary embolism.  These are for the most part unrelated to anaesthesia.  The difference is that there is usually very little hand-wringing when a patient dies from these causes although I would bet they are far more common than any direct anaesthetic related mortality.  It is however not possible to have most surgeries without an anaesthetic so why do we treat any anaesthetic death related or not related to competency differently.  Not that we shouldn't feel remorse or empathy when a patient has a bad outcome.  (Unfortunately the first thing most of us think about when this happens is "well at least it wasn't my fault".)

When people ask me what the risk of dying during anaesthesia is; I have a pat answer.  I tell them it is the same as being killed in a car accident on the way home.  One very anxious patient when I told her that replied, "Oh that is really high".  To which I replied, "You must be a really bad driver."

Thursday, May 3, 2012

Here's a good idea, why not just do stuff because it's the right thing to do.

I found this link on the Medical Post.  The jist of the article is the "surprising:" finding that pay for performance does not enhance medical care.

The one constant I have found during my medical career is that without exception people want to make the most money they can by doing the least work they can.  This can also be extrapolated to organizations if you want.  There are of course workaholics that we all know but they benefit in other ways.  Quite frequently because of the volume of work they do, they are well compensated (including taking advantage of after hours incentives by doing their elective cases after hours) and by working hard they avoid stressful family situations( not to mention opening up a perfect cover for the extramarital affairs so many of them seem to be involved in).  Quite frequently physicians and other people perceived as workaholics, don't work all that hard, rather they expect other people to work hard for them.

It should be no surprise that if you offer carrots to intelligent psychopathic individuals (which describes 90%) of doctors, that they are going to find a way to get those carrots in the most efficient way possible.  About two years ago for example our medical society negotiated a complex care fee for family doctors.  The idea was that for every patient who met certain criteria, they would be able to once a year bill about $200 for the care of the patient.  An incentive for doctors who kept patients with chronic problems keeping in mind the many aspects of the care of these patients don't fit fee for service codes.  The economists who reviewed the fee estimated the average family doctor would bill 7 of these a year.  Within a month or some many family docs were billing 7 of these a day.... every day.  There are ways of auditing this which they probably didn't anticipate and of course auditing is never a pleasant task.  I somehow don't think the poor patients with the chronic conditions are getting any better care from their doctor despite him getting the extra $200 a year.  (Some of them I suspect probably never realized they had a chronic problem).

This of course reminds me of a story somebody told me.  A long time ago our province brought in a fee for "lifestyle" counselling which paid about twice what an office visit paid.  Very quickly they noticed one doctor was billing 40 of these a day.  Somebody called him and asked him how he was able to do this.  He told them that at the end of the visit he would say, "try to stop smoking".  This fee no longer exists.

The fee for service system is of course a mini pay for performance scheme where the more patients you get through, the more you get paid.  This doesn't of course say anything about quality of care but at the very least patients do get seen.  In fact often the best care is no care at all, and there doesn't seem to be a way of paying for that.

About 7 years ago our neurosurgeons negotiated an alternate payment plan which is sort of like a salary.  They were able to negotiate from a position of strength and got quite a sweet deal.  When I worked in neurosurgery, it was a very busy and efficient room (s), always fully booked, with cancellations filled immediately.  The list usually ran into the evening and cases on the weekends were the rule not the exception.  That meant on the week you did neuro you worked quite long hours but made a nice wad of money.  That was until they went on the APP.  All of a sudden the neuro room ran until 1500 every day, there were gaps in the list and weekend or evening work became a thing of the past.  The number of back surgeries, tumour "debulkings" and other heroic cases  procedures plummeted.  It was at the same time hard to argue that at a societal level, patient care was any worse than before they went on the APP.  You could probably argue it was a little better.

It would be nice if physicians and society in general just did what really needed to be done because it was the right thing and not because there was some financial incentive involved but I am not holding my breath.

Wednesday, May 2, 2012

One Problem per Visit

Somebody posted a picture of a sign from a doctor's office advising patients they can only have one problem for each visit. This is something I have heard about recently, it was the first time I had seen a sign.

I was a general practitioner for 3 mostly unhappy years.  I was not very good at it.  I didn't realize I was not very good at it.  That of course was a bad combination.  Now I look back nostalgically on my three years on the front lines.  I am not sure why. At the same time I am now becoming more of a consumer of medicine than in the past so I have somewhat of a passing interest in what goes on in what we now call primary care.

The person with multiple complaints was always a frustration for a busy or even not a busy general practitioner.  There were several types.

The list maker brought in a long list of complaints or requests.  Many people feared or hated these people.  I actually never understood that.  You knew exactly at the beginning of the visit what you were up against, you could deal with the most severe or pressing complaints and try to get them to make another appointment to talk about the other ones.

The symptom shopper was another case all together.  These individuals would start out with a minor complaint which you could deal with fairly easily and just as you were wrapping up the visit hit you with the bomb-shell, "I've been having crushing chest pain", "I have a lump in my breast", "I missed my last two periods".  Quite often these came after you had individually dealt with 3-4 other minor complaints each presented one after the other.  Not infrequently you had already examined them and they had their clothes back on before the bombshell dropped.

Or the ones who brought family members without appointments or worse wanted to talk about family members' medical problems (at least if they actually brought the family member, you could bill for the visit).

And of course all these types of patients always came at the end of the day, when you were running late or quite frequently when they had arrived late for their own appointment.

This was all prompted by a visit to my family doctor last week.  I have had the same family doctor for 20 years now.  His office used to be a block away from my house, I've moved, he's moved and he is now a fair hike away from where I live.  I never used to go in much myself.  I am pretty healthy plus it is a lot quicker to just talk to one of my fellow specialists.  We had somebody from the Wellness program of our medical society talk to us a few years ago and we got a lecture about how we should all have a family doctor so I try to behave.

I take pregabalin for meralgia peresthetica which I self diagnosed a few years ago.  Like most doctors, I self treated myself with samples before I figured I had better come clean with my FP.  Unfortunately he only gives me 3 months supply and his office will not phone in refills.  Therefore every few months I have to fax him to bypass his desk-dragon and he refills my Rx.  The last time I was warned that he would do this but only if I agreed to come in for a history and physical.  I did and saw his locum who actually allowed me to have refills.

I have also developed gout over the last few years and it just happened that on the day I phoned to make an appointment to get more pregabalin, I had a crippling attack like I hadn't had in years.  Therefore when the receptionist asked me what my appointment was for, I say, "gout".

Come the day of the appointment I drive 20 minutes to his office arrive early and sit in the waiting room.  After a while somebody who could have been an MOA but could have also been a nurse practitioner summoned me into an examination room and hooked me up to the automatic blood pressure cuff.  "You're here for gout?", she said.  "Actually, " I confessed, "I was having an attack of gout when I phoned but I do need a new prescription."  A frown came over her face.  "You should have told us that, " she lectured, "we plan long long your appointment will be based on what you tell us."  She started to go on and I figured I had better interrupt her.  "You know", I said, "I am also a physician."

"Well I hope you run your practice differently!" she replied.

About 5 minutes later my FP arrived, refilled my pregabalin, as well as my colchicine and diclofenac.  And he didn't even complain.  Oh yes my blood pressure was normal and he is going to refer me to the dietician.