Tuesday, September 29, 2009

My Time is More Valuable Than Yours Part Two

A couple of weeks ago I was sitting in the lounge waiting for something and I struck up a conversation with one of the other anaesthetists who was also waiting for his surgeon to arrive. (I have never added it up but I suspect I have now spent months of my life waiting for surgeons to arrive) It was however the excuse for why the surgeon was late that struck me.

The surgeon had phoned ahead and told the OR he would be starting late because he had to take his oldest daughter to her first day of school. How sweet. How nice for the anaesthetist who gets to cool his heels, along with the nurses while the Kodak moment is occurring. How many of the nurses are missing their children's first day of school because if they show up late, they might actually get in trouble? And of course the surgeon will want everybody to be extra efficient the rest of the day so he finishes on time after starting late so that he can get home early to debrief his daughter on her milestone day, maybe even pick her up from school.

I of course missed both my children's first days of school. I'm still not sure what constitutes the first day of school, is it playschool, kindergarten or Grade One. Never mind, I missed all 6 of them.

I have long accepted that part of being an anaesthesiologist means you work when other people want you to work. If I have enough warning about important events, I take the day off if I can. Sometimes I have gotten somebody to take over my room so that I can get to that late afternoon concert, soccer game, hockey practice or "leaving ceremony". I coached hockey for a year. One of the parents commented on why, if I was a doctor, was I able to make almost every game and practice. I didn't bother explaining, the amount of horse trading, begging and soul selling I had to do. On call is different with call schedules usually made three months in advance and the complexity making it difficult to switch. When the "oh by the way" evening school concert happens to fall on my call day, I have in the past found somebody to come in for a few hours in the evening. Often I just missed them. It is the price I have to pay for being able to call myself Dr. and earn 6 figures.

The point is our family oriented surgeon could have switched OR days with one of his partners or he could have given up his time that day. (His wife is an ophthalmologist, why does he have to work at all?) Open OR time is usually snapped up within minutes. But he didn't because his time is way more important than everybody else's.

Why did I think of this just now? I was on call last night and the same surgeon had a presumably strangulated or incarcerated hernia he wanted to do. When we were ready to send for the patient and phoned him, he announced he couldn't come until after 2000 because his wife an ophthalmologist was at journal club and he was baby sitting his children. This fellow has a nanny (I know this because he was talking about how he bought a car for her) and I am sure there are lots of teenagers in the neighbourhood who would love to babysit his perfect children just like we had to do when I was on call and my wife wanted to do something.

Sunday, September 27, 2009

Medical Students

A while ago I was walking towards my room first thing in the morning when I saw what could clearly only be a medical student hanging around outside. Immediately one thought came to my mind, " Please let him be for the urologist and not for me". Fortunately he was for the urologist and I had as pleasant a day one can have in a urology room. I did feel bad about how I thought when I saw the student however when I related the story to another staff member, she said feels exactly the same way when she sees a student in her room.

I used to love teaching. I really believed that anaesthesia was the coolest specialty, I wanted every medical student to go into it. I wanted to teach everybody to intubate. Even those people who had a clear career path mapped out already, I thought I could help. The future internists I felt I could teach them not to write those stupid consults; the future surgeons I felt I could teach to, well just not be so stupid. I loved having students in the Pain Clinic; I was evangelical about chronic pain back then.

No more. I decided I wouldn't take students in the Pain Clinic over 10 years ago (I make exceptions for students who contact me personally). Conditions of my hospital appointment require me to take medical students (and RT students and paramedic students) in the OR; that doesn't mean I have to enjoy it.

There is no single reason.

I like to work alone. In the OR I work with the nurses and with (or against) the surgeon. Medical students somehow ruin that dynamic. I have what I call my crease. That is a triangle with the three points being the patient, the machine and the anaesthetic cart. I don't like people in my crease; medical students get in my crease. In the Pain Clinic at least one patient every day is either going to cry or else call me an asshole. Why would I want someone to witness that.

I have gotten older. When I started medical students were often only a few years younger than me, occasionally my age or older. Just about every medical student now was born after I graduated from medical school. Generation gap city. (This also applies to residents but I can actually get some work out of them).

Over two years of interviewing prospective residents, I have learned that most medical students' shit doesn't smell. All that volunteer work, overseas missions etc. Sometimes I just don't feel worthy having them in my crease.

How many times can one explain how an anaesthetic machine works or the difference between a depolarizing and non-depolarizing muscle relaxant. Or explaining why we don't use halothane and enflurane like they learned about in pharmacology (actually I can't explain why we don't use them anymore).

I feel I have to entertain them and I usually run out of material by about 10 am.

Nowadays you have to be so careful about what you say.

As students have to make their life decisions so early in medical school, many students are doing an elective in order to get a letter of reference from you or from the fool who agreed to coordinate students for your department. This means that you have to fill out an evaluation and woe to you if you check anything less than excellents dooming them to a career in radiation oncology. A colleague of mine at another hospital who coordinates students says she spends a great deal of time dealing with complaints about such evaluations. By the way, when I got to interview prospective residents I read some of those reference letters and couldn't believe what was written because I have never seen a student that was as good as some of those letters made them out to be.

Certain cases of course aren't good for teaching. The patient is too complex, the operation too risky, tension in the OR, having to do things quickly no time to explain why. I always feel bad telling them they should go and read for a while but sometimes the best way to help me is not to "help" me. One introduction since I trained is the laryngeal mask. I love this device and use it for about half my cases, many of whom I used to intubate. I just can't see modifying my technique for teaching purposes. Actually a couple of years ago I was assigned a medical student for a week which is normal at our hospital. By Friday he hadn't intubated a single patient. Friday I had a list of arthroscopies, who I usually do with an LMA. I felt sorry for the poor guy (even though he wanted to go into ortho) and so I modified my technique so he could intubate. Anyway, they were all smokers who coughed, bucked, horked and generally desaturated post-op and of course my student missed all five intubations.

I of course did an anaesthesia rotation as a student and again as an intern. Some staff were friendly and pleasant to work with, some were not. It was the ones that weren't friendly (and the prospect of 6 months on internal medicine) that lead me to not apply for anaesthesia right away. I realize the necessity to teach the incoming generation just as I was taught. Next time I see a student in my room however, I will be keeping my head down and avoiding eye contact.

Wednesday, September 16, 2009

Making the Most of Your Pain Clinic Appointment

In our area and I suspect even in areas with better funded healthcare systems there is a shortage of people willing to deal with chronic pain and consequently a long wait list for new appointments. As one of the docs who does see new patients it appalls me at how patients waste theirs and my time when they finally do actually get an appointment.

Here are some suggestions.

1. Just because I can't charge you for your missed appointment doesn't mean I'm not pissed off. (That doesn't make sense of course I am pissed off.) Not just at the consult fee I am out. Just about every week I deal with a sob story from a family doctor or patient advocate and I have to try to figure out how to fit the latest sad story of the week into an appointment. So when you miss your appointment, someone else didn't get an appointment.

2. If you are late for your appointment, I may not be able to see you. If I do see you don't be surprised if I am in a hurry. Try being late for the bank or the airlines.

3. Your medical records are your property. While it would be nice that your family doctor sent all the relevant records with his referral; this usually doesn't happen. If you bring them in yourself I will actually have them to peruse. If you bring in a huge binder however, I will try to read them but much later.

4. There are about 200 types of yellow pills. I can't guess which one you are on or were on. Your pharmacy can give you a print-out of everything you've been on in the last few years. It would however be nice to know what didn't work, what gave you side effects etc.

5. Please don't call all the doctors, you have seen in the past, idiots. The first thing I think about when I hear this is how you are going to be calling me an idiot in six months.

6. Your WCB or Disability Claim may be really important to you. All I can go is send them a copy of my consultation. The semi-retired antiquarian doctor who is responsible for your disability/WCB file has already made up his mind. The best advice I can give you is to forget about it and get on with your life. If that isn't possible you need to see a lawyer.

7. It's not possible to be allergic to anti-depressants as a class. That is like saying because you are allergic to broccoli, that you can't have tomatoes.

8. Try and figure out what your goals are. Then think how realistic those goals are. Then try and figure out what your goals are again. Your family doctor may have some goals for you as well. They may not be what you have in mind. Try and discuss this before your pain clinic appointment.

9. Just about everything I will prescribe for you and everything everybody else has prescribed for you in the past has side effects. What you need to do is weigh how bad your pain is and whether you are going to put up with the side effects.

10. Even in the unlikely situation where I actually have all your records, I may want to ask you all the questions again. It's called getting a fresh perspective. Don't keep telling me, "its all in the chart".

11. I realize medication is expensive. Don't complain about the cost of the medication I prescribed unless you: Don't smoke; Don't drink bottled water; Don't own a cell phone better than mine.

12. If your last three MRIs were normal, I am not going to order another one. In fact in 16 years treating chronic pain patients I am still waiting for an MRI that actually helped me with my diagnosis and treatment.

13. I am not going to write a letter to authorize out of country treatment by the doctor you found on the internet.

14. Please don't bring in forms to be filled out at your first visit. These forms are legal documents, I need to get to know you before I can fill them out. Please don't expect me to lie on the forms. I could face professional discipline or your insurer could sue me. When you get turned down please don't blame it on me; what you think is disabled and what insurers think is disabled are two entirely different conditions.

Friday, September 4, 2009

Calling vs. Trade?

Great Z's blog has hit the nail on the head.

People basically are not altuistic. Everybody has some motivation for what they do.

A number of years ago a national society on whose executive I sat, had Patch Adams talk at their annual meeting. This was at the instigation of a Big Pharma company who offered to pay for Patch Adams, take him or leave him. Because I was on the executive I happen to know that Patch's fee was greater than $10K. Not in Bill Clinton's or Wayne Gretzky's ($99,000)range but still not bad for one hour's work. Like many people I saw the movie with Robin Williams which by the way, the real Patch didn't like. One of the issues Patch mentioned repeatedly during his talk was that he only earned $400 per month. While it is possible that most of his $10K+ fee went to some worthy cause, I'm sure Patch has somewhere nice to live, eats okay and is generally well taken care of.

Why did I go into medicine? My father was a professional, it was instilled into us early on that we had to be professionals. Other professions didn't appeal to me; it was medicine by default. One of the biggest draws was not the money but rather the fact that even in bad times, I was likely to be employed. I make a nice living, I am more or less happy. A lot of people I work with or know make less and are equally or more happy.

Tuesday, September 1, 2009

How to save on health care costs

This lady wrote an article on how to save health care costs.

Articles like this always leave me split. The progressive in me says, "right on"; the physician in me says, "bullshit". There is a mixture of both in this article.

Firstly, unless you are a radiologist or a pathologist who owns a lab; you don't make money by ordering tests. If you are a radiologist or a pathologist you aren't allowed to order tests although certainly radiologists often come very close to doing so. I agree there are too many tests ordered and what she has cited certainly sounds eggregious. However as a nurse practitioner, she could simply look at the lab req. and tell her family doc, "no I don't want all these tests".

Likewise when she had the swollen knee, why didn't she just tell her FP, "all I want are some anti-inflammatories or physio". If her doctor is like me, he will find it a hell of lot easier to write an Rx for diclofenac than to fill out an MRI requisition.

There are some reasons why doctors like their patients to come in at regular intervals for prescription refills rather than phoning it in. In her case it sounds unnecessary but her FP probably can't tell the less controlled, less compliant diabetic in his practice, " You have to come in every 3 months but she doesn't" Actually he can. As someone who now takes regular medication, my FP also only gives me 3 months supply and won't refill over the phone. And it pisses me off. So I fax him to get past his secretary and he does a refill. Professional courtesy.

When I was an FP years ago and there was a small glut of FPs. Those of us starting our practices used to call patients in far more than necessary to build up their patient numbers. Now that there is a doctor shortage maybe this needs to be reviewed.


25 years ago if you told me I was going to be on fee for service 25 years later, I would have said you are nuts. 25 years later, still on FFS.

No question salary would save $$$ possibly at the expense of patient care and convenience, however I am still waiting for an offer.