"I can't complain but sometimes I still do,
Life's been good to me so far"
Joe Walsh
I know I whine a lot in this blog. I am really not a negative person. I have a whole lot to be thankful about.
1. I have been married to the same smoking hot wife for over 26 years.
2. I have two great adult children and I actually got one to move out of the house.
3. I belong to the best anaesthetic department in the province and I am the boss.
4. I make a ton of money. Money can't buy happiness but it sure can rent a lot. Sure a lot of doctors make more than I do but who wants to work as hard as they do or do what they do?
5. At 53, I am actually in better shape physically then I was at 43... or 33.
6. I live in a great neighbourhood. Who cares if rich kids buy drugs across the street?
7. I was raised by two educated parents in a middle class neighbourhood. I went to the best high school in the province. My parents instilled the values of a university education but never insisted on what we took. When I phoned my mother to tell her I had been accepted to medicine, she said,"Oh I guess that's what you wanted."
8. I am in a specialty I like. During the first year of my residency , I remember thinking, "this is what I was born to do."
9. I have a great staff in the Pain Clinic.
10. Sure I spent over 13 years at the Centre of Excellence but I had at least 4 chances to escape before I pulled my parachute. Truth is, I must have liked it a little there. I also with very little resources and support established a Pain Clinic there which has evolved into something much bigger. Too bad I don't work there anymore.
11. I won an award.
12. Surgeons actually aren't that bad to work with. I actually like most of them. Even the psychopaths are entertaining, watching all the games they play.
13. I also really admire nurses. Not just because I married one. Sometimes when I am bored I watch surgery and I am just amazed at how the OR nurses anticipate what the surgeon wants and keep track of all that equipment. Floor nurses of course do a great job doing what must be a really shitty job. If you want to get the lowdown on a patient, you ask the nurse.
14. Quite a few administrators are really hard-working individuals who if you divided their salary by the number of hours they worked would be making less per hour than most of their underlings. Much of what they do is affected by how much money they have and by politics; two things they have no control over.
So why don't I blog about that.
Well...
When I started my blog 4 years ago in addition to having stuff to get off my chest, I actually hoped that people would read it. I am by nature a sarcastic person; sarcasm is the lowest form of humour but it is humour. It is also usually negative. I could write about the list of arthroscopies I did where nothing happened but that would be pretty boring so I would rather write about the horrendoplasty I was involved with. Likewise I could write about some of the really great people I have met and worked with over the years but that would also be boring so writing about assholes and sociopaths is much more interesting and sooooo therapeutic.
I will try to more positive.
I can't promise anything though.
Monday, April 25, 2011
Sunday, April 24, 2011
Finger pointing; a life of blame.
My fellow blogger the Anesoboist is becoming more cynical.
This reminds my of several incidents in my professional life. Surgery is of course an inexact science. People do not always get the outcomes that they were promised, many times they are left worse off than before. To cut and saw another human being requires a huge ego and a lot of self confidence. It is therefore difficult to accept that when what you promised the patient didn't turn out that it was simply bad karma or maybe even your fault.
Fortunately it is not possible to do most surgeries without an anesthesiologist so you have a living human being to blame.
It is of course possible to be blamed for a case you were not even involved in. When I was resident, I was sitting minding my own business in a general room. There was a general surgery case going on next door and at the end of the case they were one sponge short. The staff surgeon therefore un-scrubbed and dug into the garbage. After some time he found the missing sponge. It was in the same strata as the central line kit. It was therefore "obvious" that the anesthesiologist had surreptitiously removed a sponge from the sterile table for his central line without telling the nurses. After appropriately venting his spleen in his room, he had some spleen left over, so went into my room where he regaled at length the surgeon with his accusations. I wasn't paying much attention until one of the nurses came over to me and said, "he is really taking anesthesia's name in vain." As I have said I wasn't paying attention and replied,"You should hear what we say behind his back." That was the wrong thing to say apparently. He got right in my face and yelled, "Well it was bloody irresponsible" and stormed out of the room. I actually had to ask exactly what it was he was upset about. It was then that I learned it was possible to be blamed for something that went on in the next room.
The first night on call as a staff anaesthesiologist, there were actually no emergency cases booked at the end of the day so I was able to go home. Around 1830, I got a call from a gynaecologist. "I have a lady with a pelvic mass that I need to remove," said the gynie. "Unfortunately I have an evening office so I can't start until after 2000". "Fine," I said, " But if something else gets booked, it will have to go ahead of your case." Seconds later the phone rang and ortho had booked a case. I went in, the case of course took longer than it should have and because the hospital only had two nurses on evenings there was a long turnover and it was 2300 before we were ready to do the pelvic mass. I was sitting in the lounge waiting for the patient to come into the room when I heard the GP who had come in to assist, on the phone to his wife. "We are running late," he said, "anesthesia bumped our case." I should have confronted him and pointed out that we were starting late because the surgeon hadn't been available earlier but he was a nice guy who became our family doctor and delivered my number two son. I also found out why the gynie had an evening office. It was so he could golf in the afternoon.
About a year later, I found out from the recovery room nurses that Dr. P a surgeon long past his best-before date had been sniffing around recovery room asking about the open cholie we had done two days ago. Apparently the patient had aspiration pneumonia. The patient was obviously still in hospital so I went up to see her. Did I mention she was a lawyer? I was able to read in the chart that she indeed had pneumonia, as did her husband and that her blood culture had grown strep pneumonia. Sounds like a community acquired pneumonia to me, I thought. This hadn't stopped Dr. P's son, an intensivist from writing a consult stating she definitely had aspiration pneumonia. I spoke with the patient who was quite reasonable and accepted the fact that her pneumonia had very little to do with her surgery. I wrote a note in the chart which started, "while it is nice to learn about potential complications of anaesthesia, even by such a back-handed method...." A few days later Dr. P. approached me to sort of apologize. "She is a lawyer," he reminded me; translation it is better that you get sued than that I get sued.
Being blamed for turnovers comes with the game. Early on my career I was working with a plastic surgeon who had a morning list with another surgeon having the afternoon list. The surgeon had an emergency case he wanted to do at the end of his list. He was quite quick and could normally do this. Unfortunately his first case went 30 minutes over, the turnovers were glacial and he just ran out of time. I could see that as the morning went on he was getting more and more pissed. As it happened his wife was working in the room that day. "I wonder who he is going to blame for this," I wondered. I shouldn't have wondered. After dumping his last case in the RR, he pulled me into his office where I received one of the ten worst tongue lashings of my life for delaying his list.
One of my colleagues told me of an interesting story. He was approached many years ago to come to internal medicine grand rounds where they were presenting a case of Halothane hepatitis. He didn't review the chart of the patient they were presenting until the day of rounds. After the case had been presented, the question came to him, "Dr. H, do you think this patient had halothane hepatitis," "No," said my colleague. "Why," came the question. "Because she had a spinal," said Dr.H.
Internal medicine...fail!
(I have always suspected most cases of "Halothane hepatitis" were actually hepatitis C,D,E,F or G which is hardly good grounds to abandon such a safe and inexpensive drug.)
We always joke about "anaesthetic bleeding". Sometimes this isn't a joke. A the CofE. I was doing a cystectomy. On opening it was found that the bladder tumour was invading the pelvic wall. A less excellent surgeon would have said,"she has had a good life" and closed. Not this surgeon and so I had about 6 hours of major blood-letting. Fortunately I knew the surgeon and had "come to play" with a 7 Fr. CVP, large bore peripheral and an art line. None the less she lost about one blood blood volume, developed a coagulopathy and ended up in ICU. I heard from an anaesthesiologist at another hospital where the surgeon also worked that he had been slagging me in the doctor's lounge. Apparently I had caused the coagulopathy by giving too much fluid.
The CofE was of course a culture of blame except you didn't just have to deal with surgery, internal medicine and ICU. Your anesthesia colleagues were always ready to enthusiastically join in, in true Lord of the Flies style should something go wrong.
I could go on. What really concerns me is the number of times I may have been blamed for a bad outcome where I never found out about it.
Part of this is of course our fault. We often see patients in a rushed fashion, we ask them a whole bunch of questions(some they have been asked already, some they haven't but should have been), we dress mostly like the rest of the OR staff, there is very little to distinguish me from one of the porters. We warn them about things like dental damage and other bad things that might happen to them. We never see patients post-op. It is pretty easy to blame somebody like that.
I have often thought it would be interesting to go up to a patient's room when something surgical goes wrong and actually tell the patient what happened. "Did you know that it was the surgical resident who 'accidentally' ruptured your spleen." "By the way how do you like your scar, the student intern closed" "Did you know that your surgeon didn't get any sleep last night?" "This happened to his last total hip by the way".
This reminds my of several incidents in my professional life. Surgery is of course an inexact science. People do not always get the outcomes that they were promised, many times they are left worse off than before. To cut and saw another human being requires a huge ego and a lot of self confidence. It is therefore difficult to accept that when what you promised the patient didn't turn out that it was simply bad karma or maybe even your fault.
Fortunately it is not possible to do most surgeries without an anesthesiologist so you have a living human being to blame.
It is of course possible to be blamed for a case you were not even involved in. When I was resident, I was sitting minding my own business in a general room. There was a general surgery case going on next door and at the end of the case they were one sponge short. The staff surgeon therefore un-scrubbed and dug into the garbage. After some time he found the missing sponge. It was in the same strata as the central line kit. It was therefore "obvious" that the anesthesiologist had surreptitiously removed a sponge from the sterile table for his central line without telling the nurses. After appropriately venting his spleen in his room, he had some spleen left over, so went into my room where he regaled at length the surgeon with his accusations. I wasn't paying much attention until one of the nurses came over to me and said, "he is really taking anesthesia's name in vain." As I have said I wasn't paying attention and replied,"You should hear what we say behind his back." That was the wrong thing to say apparently. He got right in my face and yelled, "Well it was bloody irresponsible" and stormed out of the room. I actually had to ask exactly what it was he was upset about. It was then that I learned it was possible to be blamed for something that went on in the next room.
The first night on call as a staff anaesthesiologist, there were actually no emergency cases booked at the end of the day so I was able to go home. Around 1830, I got a call from a gynaecologist. "I have a lady with a pelvic mass that I need to remove," said the gynie. "Unfortunately I have an evening office so I can't start until after 2000". "Fine," I said, " But if something else gets booked, it will have to go ahead of your case." Seconds later the phone rang and ortho had booked a case. I went in, the case of course took longer than it should have and because the hospital only had two nurses on evenings there was a long turnover and it was 2300 before we were ready to do the pelvic mass. I was sitting in the lounge waiting for the patient to come into the room when I heard the GP who had come in to assist, on the phone to his wife. "We are running late," he said, "anesthesia bumped our case." I should have confronted him and pointed out that we were starting late because the surgeon hadn't been available earlier but he was a nice guy who became our family doctor and delivered my number two son. I also found out why the gynie had an evening office. It was so he could golf in the afternoon.
About a year later, I found out from the recovery room nurses that Dr. P a surgeon long past his best-before date had been sniffing around recovery room asking about the open cholie we had done two days ago. Apparently the patient had aspiration pneumonia. The patient was obviously still in hospital so I went up to see her. Did I mention she was a lawyer? I was able to read in the chart that she indeed had pneumonia, as did her husband and that her blood culture had grown strep pneumonia. Sounds like a community acquired pneumonia to me, I thought. This hadn't stopped Dr. P's son, an intensivist from writing a consult stating she definitely had aspiration pneumonia. I spoke with the patient who was quite reasonable and accepted the fact that her pneumonia had very little to do with her surgery. I wrote a note in the chart which started, "while it is nice to learn about potential complications of anaesthesia, even by such a back-handed method...." A few days later Dr. P. approached me to sort of apologize. "She is a lawyer," he reminded me; translation it is better that you get sued than that I get sued.
Being blamed for turnovers comes with the game. Early on my career I was working with a plastic surgeon who had a morning list with another surgeon having the afternoon list. The surgeon had an emergency case he wanted to do at the end of his list. He was quite quick and could normally do this. Unfortunately his first case went 30 minutes over, the turnovers were glacial and he just ran out of time. I could see that as the morning went on he was getting more and more pissed. As it happened his wife was working in the room that day. "I wonder who he is going to blame for this," I wondered. I shouldn't have wondered. After dumping his last case in the RR, he pulled me into his office where I received one of the ten worst tongue lashings of my life for delaying his list.
One of my colleagues told me of an interesting story. He was approached many years ago to come to internal medicine grand rounds where they were presenting a case of Halothane hepatitis. He didn't review the chart of the patient they were presenting until the day of rounds. After the case had been presented, the question came to him, "Dr. H, do you think this patient had halothane hepatitis," "No," said my colleague. "Why," came the question. "Because she had a spinal," said Dr.H.
Internal medicine...fail!
(I have always suspected most cases of "Halothane hepatitis" were actually hepatitis C,D,E,F or G which is hardly good grounds to abandon such a safe and inexpensive drug.)
We always joke about "anaesthetic bleeding". Sometimes this isn't a joke. A the CofE. I was doing a cystectomy. On opening it was found that the bladder tumour was invading the pelvic wall. A less excellent surgeon would have said,"she has had a good life" and closed. Not this surgeon and so I had about 6 hours of major blood-letting. Fortunately I knew the surgeon and had "come to play" with a 7 Fr. CVP, large bore peripheral and an art line. None the less she lost about one blood blood volume, developed a coagulopathy and ended up in ICU. I heard from an anaesthesiologist at another hospital where the surgeon also worked that he had been slagging me in the doctor's lounge. Apparently I had caused the coagulopathy by giving too much fluid.
The CofE was of course a culture of blame except you didn't just have to deal with surgery, internal medicine and ICU. Your anesthesia colleagues were always ready to enthusiastically join in, in true Lord of the Flies style should something go wrong.
I could go on. What really concerns me is the number of times I may have been blamed for a bad outcome where I never found out about it.
Part of this is of course our fault. We often see patients in a rushed fashion, we ask them a whole bunch of questions(some they have been asked already, some they haven't but should have been), we dress mostly like the rest of the OR staff, there is very little to distinguish me from one of the porters. We warn them about things like dental damage and other bad things that might happen to them. We never see patients post-op. It is pretty easy to blame somebody like that.
I have often thought it would be interesting to go up to a patient's room when something surgical goes wrong and actually tell the patient what happened. "Did you know that it was the surgical resident who 'accidentally' ruptured your spleen." "By the way how do you like your scar, the student intern closed" "Did you know that your surgeon didn't get any sleep last night?" "This happened to his last total hip by the way".
Thursday, April 21, 2011
MAFAT
MAFAT as any surgeon will tell you very early in your career means Mandatory Anesthetic Fzcking Around Time. They will tell you this with great glee when they should be scrubbing, prepping or actually operating on the patient.
About a year ago when I took over as Department Head or in newspeak Site Leader I had a farewell interview with my predecessor, who is a living legend both in the anesthetic and medical communities. I was expecting some very insightful words to inspire me to reach the heights of notoriety that he had reached, however most of the time he spent telling me to make sure that I never let certain anesthesiologists do certain lists or work with certain surgeons. "They just cannot handle the work", was the way he put it.
I consider myself to be a pretty efficient anesthesiologist. I remember a few years ago an older nurse who had been trained by the nuns telling me that she had been taught by one nun that, "the biggest sin is wasting somebody else's time". I had never really thought about it, but I hate to wait, I hate to have my time wasted why should I waste other people's time. I was fortunate to be mentored in my residency by three role models who just happened to have the same first name as me.
The Samurai warrior was a Japanese Canadian pediatric anaesthesiologist who was always in a hurry but at the same time incredibly compulsive. Very stressful as a junior resident to work with but at the same time in retrospect a great education.
The Bull was an English anesthesiologist, very much less compulsive than the Samurai, but still hard driving wanting to get the cases started and finished as quickly as he could.
Dr. Gadget loved monitors and other toys which he of course applied quickly to the patient. One day one of the nurses remarked, "One day he is going to catch up with himself". I remember as a resident working with him and finishing two CABGs by 1430, a record that will never be broken.
All three of them taught me that you can be fast and still be safe.
In anaesthesia we typically work alone so the only insight I get into the work habits of others is when I work with a resident. Usually when a resident is doing something stupid, I figure that they must have learned this from somebody because no rational person could have figured out how to be so stupid on their own. The first case I did with a resident at the CofE I remember several times having to tell him to "get on with it", an expression I learned from the great Ernie Hew during an elective at Mt. Sinai. The epidural is not going to get done by you staring at the patients back!
One annoying habit that residents have which I can only assume someone is teaching them is what I call the appetizer approach. This is where the resident will give a little of the fentanyl du jour and then ask the patient several times, "are you feeling it yet?". OK this is not a restaurant, I am about to have surgery, I am in a cold room, if I look to one side I can see the weapons being prepared by the nurses, and now some idiot is making me dizzy and nauseous and asking me if I am feeling it. For the love of God, put me to sleep.
Some things like art line, central lines and epidurals take longer; they are going to take a lot longer if you don't think about them until the last minute, don't tell the nurses and the techs you are doing them and to quote again the great Dr. Hew, don't get on with it.
A lot of MAFAT is of course beyond our control. Surgeons especially those in teaching hospitals live in a delusional universe where after they scrub out and leave the room, the wound closes itself, the patient awakes immediately, the room cleans itself, the next patient arrives on time with his consent signed and the IV starts itself. All with no time elapsed. To their dismay the rest of us live in another universe. Long turnovers frustrate me too. When I have to wait 30 minutes between cases, I feel I have to rush and cut corners to make up for everybody else's inefficiencies. I call it "wait and hurry up".
At the same time our fee schedule has devolved into a situation where for the most part we are paid by the hour. This means if I do 5 cases in 8 hours, I get paid the same as if I do 4 cases in 8 hours. Or if I do 5 cases in 8.5 hours because I am less efficient, I actually make a little more. Multiply that 0.5 hours by 250 work days and we are talking about some serious cash. Not that this ever crosses the mind of some of my colleagues. Never.
Periodically administration approaches us about extending the day or working on Saturday to clear up a perceived backlog of cases, total joints are the current cause. I have learned that the best way to shut them up is to suggest that they first look at using the time they have more efficiently. End of discussion.
As I am reminded, patients don't come to hospital for an anaesthetic however we are only part of team. As my band teacher told us over and over again, a band is only as good as its weakest member. I try not to be that person.
About a year ago when I took over as Department Head or in newspeak Site Leader I had a farewell interview with my predecessor, who is a living legend both in the anesthetic and medical communities. I was expecting some very insightful words to inspire me to reach the heights of notoriety that he had reached, however most of the time he spent telling me to make sure that I never let certain anesthesiologists do certain lists or work with certain surgeons. "They just cannot handle the work", was the way he put it.
I consider myself to be a pretty efficient anesthesiologist. I remember a few years ago an older nurse who had been trained by the nuns telling me that she had been taught by one nun that, "the biggest sin is wasting somebody else's time". I had never really thought about it, but I hate to wait, I hate to have my time wasted why should I waste other people's time. I was fortunate to be mentored in my residency by three role models who just happened to have the same first name as me.
The Samurai warrior was a Japanese Canadian pediatric anaesthesiologist who was always in a hurry but at the same time incredibly compulsive. Very stressful as a junior resident to work with but at the same time in retrospect a great education.
The Bull was an English anesthesiologist, very much less compulsive than the Samurai, but still hard driving wanting to get the cases started and finished as quickly as he could.
Dr. Gadget loved monitors and other toys which he of course applied quickly to the patient. One day one of the nurses remarked, "One day he is going to catch up with himself". I remember as a resident working with him and finishing two CABGs by 1430, a record that will never be broken.
All three of them taught me that you can be fast and still be safe.
In anaesthesia we typically work alone so the only insight I get into the work habits of others is when I work with a resident. Usually when a resident is doing something stupid, I figure that they must have learned this from somebody because no rational person could have figured out how to be so stupid on their own. The first case I did with a resident at the CofE I remember several times having to tell him to "get on with it", an expression I learned from the great Ernie Hew during an elective at Mt. Sinai. The epidural is not going to get done by you staring at the patients back!
One annoying habit that residents have which I can only assume someone is teaching them is what I call the appetizer approach. This is where the resident will give a little of the fentanyl du jour and then ask the patient several times, "are you feeling it yet?". OK this is not a restaurant, I am about to have surgery, I am in a cold room, if I look to one side I can see the weapons being prepared by the nurses, and now some idiot is making me dizzy and nauseous and asking me if I am feeling it. For the love of God, put me to sleep.
Some things like art line, central lines and epidurals take longer; they are going to take a lot longer if you don't think about them until the last minute, don't tell the nurses and the techs you are doing them and to quote again the great Dr. Hew, don't get on with it.
A lot of MAFAT is of course beyond our control. Surgeons especially those in teaching hospitals live in a delusional universe where after they scrub out and leave the room, the wound closes itself, the patient awakes immediately, the room cleans itself, the next patient arrives on time with his consent signed and the IV starts itself. All with no time elapsed. To their dismay the rest of us live in another universe. Long turnovers frustrate me too. When I have to wait 30 minutes between cases, I feel I have to rush and cut corners to make up for everybody else's inefficiencies. I call it "wait and hurry up".
At the same time our fee schedule has devolved into a situation where for the most part we are paid by the hour. This means if I do 5 cases in 8 hours, I get paid the same as if I do 4 cases in 8 hours. Or if I do 5 cases in 8.5 hours because I am less efficient, I actually make a little more. Multiply that 0.5 hours by 250 work days and we are talking about some serious cash. Not that this ever crosses the mind of some of my colleagues. Never.
Periodically administration approaches us about extending the day or working on Saturday to clear up a perceived backlog of cases, total joints are the current cause. I have learned that the best way to shut them up is to suggest that they first look at using the time they have more efficiently. End of discussion.
As I am reminded, patients don't come to hospital for an anaesthetic however we are only part of team. As my band teacher told us over and over again, a band is only as good as its weakest member. I try not to be that person.
Monday, April 18, 2011
Cars
I am not really a car person. Like all boys I played with Dinky Toys and Hot Wheels but then I grew up.
A few years ago, my wife showed me a picture of a car. "Isn't this beautiful?" she said. I thought for a second. "You are beautiful, music is beautiful, scenery is beautiful; cars are tools. They sometimes get you to where you want to be; that's all." Which more or less summarizes my attitude towards cars.
I obviously work with people who don't share my lack of enthusiasm and I get to park next to all lot of cars which could be called beautiful if I was that way inclined. I have noticed a few things about expensive cars. For the most part they are driven by very hard-working doctors, the kind who don't have a lot of leisure time. So...the best part of their day is driving their expensive car 15 minutes each way in traffic to work. Sounds like somebody really needs to get a life. And of course the faster a doctor's car is theoretically able to go, (assuming they ever got to drive it anywhere else than too and from work,) the more likely they are to be late.
This is all precipitated by the fact that I leased a new car last week. The lease on my Volvo S40 expires at the end of this month. I was given the choice of buying it out or handing back the keys. I decided I really had no attachment to this car and didn't really want to shell out $16K to keep it when for no money down I could get a brand new car. (I guess I do like cars a little bit.)
Every time I start to get a new car, I resolve that this is time I am going to do it right. I am going to test drive lots of different cars, I am going to bargain hard, I am going walk out of the dealership if they don't give me the price I want. I am not going to get any of the options I don't want. I am definitely not going to get the undercoating or the upholstery treatment.
So what did I do.
I test drove 1 car, a diesel VW Jetta. I liked it, I fit in it and they had one in the colour I liked. If you can believe the dealer it gets 60 mpg on the highway(I mostly drive it 5 minutes to work, when I don't walk or bike). I showed it to my wife and we decided to lease it.
So we start to haggle on the base price. I am figuring we'll lop off $2K right off the get go. The dealer of course points out that diesels get sold quickly and they can't bargain much. I wimp out and start with a $1K off and we settle at $500. What I should have done since I was really in no hurry was to threaten to go to another dealer, in another city if necessary. I am such a wimp and anyway if you are leasing we are really talking about less per month than I spend on lattes.
Now off to the finance manager for lease. I always find this the bad cop to the good cop of the sales man. First I have to ask a whole lot of personal questions about my credit history etc. Taking all this information, he goes off for a few minutes and comes back with a print out of my bank balances, and all my credit card balances. Talk about big brother is watching. This is all complicated by my split personality as a personal corporation in addition to a person.
The finance manager's job is not just limited to assessing your credit-worthiness. His real job is to sell you the paint and upholstery treatment. This adds another $1K onto the price and is now pushing the monthly lease payment up to $100 more than I thought I was going to pay assuming I had also negotiated with more balls. Should I waiver, he of course reminds me that this is a lease and there will be dire consequences in 4 years, if having turned this down, I have a paint chip or a stain. (Dealers of course used to sell you the undercoating which has sort of become a joke; I remember years ago solemnly signing a long and detailed waiver after I declined the undercoating.)
With this information, I then had to arrange insurance coverage by phone so that I could pick up the car (after of course the paint and uphostery treatment had been applied). The insurance guy of course tries to sell me all kinds of extra riders and doodads. I try to explain that all I want is exactly the same coverage as the car I am giving up. I am of course calling from the OR, in the time that I have been on hold and listening to all the options, things have changed, alarms are going off and the surgeon wants the table raised or lowered.
On pick up day I of course made the mistake of going after work and before supper. Before getting the keys I have to make another visit to the finance manager's office to sign the lease agreement. This is of course not the sole purpose of this visit. The finance manager has more to sell me. Would I like to purchase a service plan against door dings and uphostery tears. For $20 extra a month, if such an event occurs, somebody will come to my house and fix it. "Can I think about it?" This offer is only available at the time or purchase. He again reminds my that this is a lease with dire consequences. He gives the example of a cigarette burn. I point out that I don't smoke. By this time it is 1900 hours, I started work 12 hours ago, lunch was at 1100. All I want to do is drive my new car home (we are having a late winter/early spring snowfall so I don't even get to take it for a longer spin), have supper and drink a beer.
Repeat in 4 years.
A few years ago, my wife showed me a picture of a car. "Isn't this beautiful?" she said. I thought for a second. "You are beautiful, music is beautiful, scenery is beautiful; cars are tools. They sometimes get you to where you want to be; that's all." Which more or less summarizes my attitude towards cars.
I obviously work with people who don't share my lack of enthusiasm and I get to park next to all lot of cars which could be called beautiful if I was that way inclined. I have noticed a few things about expensive cars. For the most part they are driven by very hard-working doctors, the kind who don't have a lot of leisure time. So...the best part of their day is driving their expensive car 15 minutes each way in traffic to work. Sounds like somebody really needs to get a life. And of course the faster a doctor's car is theoretically able to go, (assuming they ever got to drive it anywhere else than too and from work,) the more likely they are to be late.
This is all precipitated by the fact that I leased a new car last week. The lease on my Volvo S40 expires at the end of this month. I was given the choice of buying it out or handing back the keys. I decided I really had no attachment to this car and didn't really want to shell out $16K to keep it when for no money down I could get a brand new car. (I guess I do like cars a little bit.)
Every time I start to get a new car, I resolve that this is time I am going to do it right. I am going to test drive lots of different cars, I am going to bargain hard, I am going walk out of the dealership if they don't give me the price I want. I am not going to get any of the options I don't want. I am definitely not going to get the undercoating or the upholstery treatment.
So what did I do.
I test drove 1 car, a diesel VW Jetta. I liked it, I fit in it and they had one in the colour I liked. If you can believe the dealer it gets 60 mpg on the highway(I mostly drive it 5 minutes to work, when I don't walk or bike). I showed it to my wife and we decided to lease it.
So we start to haggle on the base price. I am figuring we'll lop off $2K right off the get go. The dealer of course points out that diesels get sold quickly and they can't bargain much. I wimp out and start with a $1K off and we settle at $500. What I should have done since I was really in no hurry was to threaten to go to another dealer, in another city if necessary. I am such a wimp and anyway if you are leasing we are really talking about less per month than I spend on lattes.
Now off to the finance manager for lease. I always find this the bad cop to the good cop of the sales man. First I have to ask a whole lot of personal questions about my credit history etc. Taking all this information, he goes off for a few minutes and comes back with a print out of my bank balances, and all my credit card balances. Talk about big brother is watching. This is all complicated by my split personality as a personal corporation in addition to a person.
The finance manager's job is not just limited to assessing your credit-worthiness. His real job is to sell you the paint and upholstery treatment. This adds another $1K onto the price and is now pushing the monthly lease payment up to $100 more than I thought I was going to pay assuming I had also negotiated with more balls. Should I waiver, he of course reminds me that this is a lease and there will be dire consequences in 4 years, if having turned this down, I have a paint chip or a stain. (Dealers of course used to sell you the undercoating which has sort of become a joke; I remember years ago solemnly signing a long and detailed waiver after I declined the undercoating.)
With this information, I then had to arrange insurance coverage by phone so that I could pick up the car (after of course the paint and uphostery treatment had been applied). The insurance guy of course tries to sell me all kinds of extra riders and doodads. I try to explain that all I want is exactly the same coverage as the car I am giving up. I am of course calling from the OR, in the time that I have been on hold and listening to all the options, things have changed, alarms are going off and the surgeon wants the table raised or lowered.
On pick up day I of course made the mistake of going after work and before supper. Before getting the keys I have to make another visit to the finance manager's office to sign the lease agreement. This is of course not the sole purpose of this visit. The finance manager has more to sell me. Would I like to purchase a service plan against door dings and uphostery tears. For $20 extra a month, if such an event occurs, somebody will come to my house and fix it. "Can I think about it?" This offer is only available at the time or purchase. He again reminds my that this is a lease with dire consequences. He gives the example of a cigarette burn. I point out that I don't smoke. By this time it is 1900 hours, I started work 12 hours ago, lunch was at 1100. All I want to do is drive my new car home (we are having a late winter/early spring snowfall so I don't even get to take it for a longer spin), have supper and drink a beer.
Repeat in 4 years.
Sunday, April 10, 2011
Terms of reference, terms of schmeference !
After years of waiting, dexmedetomidine is now available in Canada. I have been in the business long enough to know that there are no panaceas and the best thing since sliced bread is still sliced bread, however we felt dexmedetomidine might be useful in the MRI suite where we anaesthetize obese claustrophobic patients and for other uses. Consequently we placed a request into our pharmacy committee for the addition of dex.
Anaesthetic drugs which cost $40 are low priority in comparison with other more important drugs like the latest cancer drug which will increase life expectancy by one month in 10% of patients, so I wasn't expecting much. A couple of days ago, I got this from our new P and T committee.
Here is an update on the status of your request:
“Dexmedetomidine for Procedural Sedation” was on the agenda for the late March provincial P&T meeting.
Because the March meeting was the first time the group had met, more than half of the five hour meeting was spent reviewing the Committee’s structure and Terms of Reference.
Consequently, the committee ran out of time to discuss a few of the agenda items and “Dexmedetomidine for Procedural Sedation” was one of those items.
“Dexmedetomidine for Procedural Sedation” will remain on the agenda for discussion at the next meeting.
The plans are that the committee will meet every two months initially.
That is right. This committee spent 2.5 hours reviewing its structure and terms of reference. About 2 years ago all the health regions in the province were amalgamated into one single region. Up until recently we didn't even have a P and T committee which was the reason given for not approving drugs. Now we have one and it has finally met and spent one half of its meeting time looking at its navel. P and T committees aren't a new thing, every region had one, before that every hospital had one. It is pretty certain that every member of the new super-committee had been on a P and T committee.
What is the name of this blog again?
This gave me an unpleasant flashback to the last millennium and the first reorganization of health care I was involved in. At that time our newly formed region decided they were going to develop and region-wide chronic pain program. The timing was auspicious; there were people actually interested in doing this and with downsizing and closing of hospital beds there was actually ample physical space in which to have one. Moreover somebody had actually spent two years under the previous administration drawing up a plan complete with a budget that we could actually have rolled out within a few months.
Instead of just doing this, we did the logical thing and formed a committee. Once a week from 1600 to 1800 we would meet to discuss how we were going to deliver chronic pain management to the community. But first we had to develop a mission statement. This took 2 or 3 meetings. Then we had to define what exactly chronic pain was. This took 2 or more meetings (I'm not making this up). We had two all day retreats on weekends during which the stakeholders were consulted and more meetings. After a while I figured that the fix was in and stopped going. I was right of course. While we were busily filling flip charts, the entrepreneurial physiatrist who was chairing the committee had been negotiating directly with the government and guess who got all the money? 15 years later I more or less do things the way I did 15 years ago. I should get over this but I won't.
Anaesthetic drugs which cost $40 are low priority in comparison with other more important drugs like the latest cancer drug which will increase life expectancy by one month in 10% of patients, so I wasn't expecting much. A couple of days ago, I got this from our new P and T committee.
Here is an update on the status of your request:
“Dexmedetomidine for Procedural Sedation” was on the agenda for the late March provincial P&T meeting.
Because the March meeting was the first time the group had met, more than half of the five hour meeting was spent reviewing the Committee’s structure and Terms of Reference.
Consequently, the committee ran out of time to discuss a few of the agenda items and “Dexmedetomidine for Procedural Sedation” was one of those items.
“Dexmedetomidine for Procedural Sedation” will remain on the agenda for discussion at the next meeting.
The plans are that the committee will meet every two months initially.
That is right. This committee spent 2.5 hours reviewing its structure and terms of reference. About 2 years ago all the health regions in the province were amalgamated into one single region. Up until recently we didn't even have a P and T committee which was the reason given for not approving drugs. Now we have one and it has finally met and spent one half of its meeting time looking at its navel. P and T committees aren't a new thing, every region had one, before that every hospital had one. It is pretty certain that every member of the new super-committee had been on a P and T committee.
What is the name of this blog again?
This gave me an unpleasant flashback to the last millennium and the first reorganization of health care I was involved in. At that time our newly formed region decided they were going to develop and region-wide chronic pain program. The timing was auspicious; there were people actually interested in doing this and with downsizing and closing of hospital beds there was actually ample physical space in which to have one. Moreover somebody had actually spent two years under the previous administration drawing up a plan complete with a budget that we could actually have rolled out within a few months.
Instead of just doing this, we did the logical thing and formed a committee. Once a week from 1600 to 1800 we would meet to discuss how we were going to deliver chronic pain management to the community. But first we had to develop a mission statement. This took 2 or 3 meetings. Then we had to define what exactly chronic pain was. This took 2 or more meetings (I'm not making this up). We had two all day retreats on weekends during which the stakeholders were consulted and more meetings. After a while I figured that the fix was in and stopped going. I was right of course. While we were busily filling flip charts, the entrepreneurial physiatrist who was chairing the committee had been negotiating directly with the government and guess who got all the money? 15 years later I more or less do things the way I did 15 years ago. I should get over this but I won't.
Sunday, April 3, 2011
To Tired to Work?
I just realized that this May I will be celebrating an anniversary; 30 years of night call. Not an auspicious one but one deserving of reflection.
Nobody in my family was in medicine, so I had no idea of what the lifestyle of a doctor was. I figured it would be like on MASH where Hawkeye and Trapper John sipped Martini's in the swamp in between tormenting Frank Burns and boinking the nurses. Or maybe like Doc Adams who spent most of his time arguing with Festus in between digging bullets out of the Marshall. I at least figured that I would only be seeing really sick people who needed urgent attention. Why else would you work after hours?
I was moonlighting in emergency during my residency and was suturing up a rare treat, an unobnoxious drunk around around 1 am. "You must be pretty smart to be a doctor," said the drunk. "If I am so smart," I replied, "what the hell am I doing here at one in the morning on a Saturday." Even back then I had it figured out but I am apparently no smarter.
I am pretty certain that anaesthesiology is the only specialty that works harder on call than they did 25 years ago when C/S rates were under 20%, labour epidurals were uncommon and fractures were actually treated with closed reductions.
This has become an issue lately because of complaints by my colleagues related to on call especially on weekends. Our department like many around the city has developed what is at face a very civilized call system. Nobody is on first call for 24 hours. We have a Day Call who works from 0700 to 1600 after which he becomes second call until 0700 the next morning. Night call starts at 1600 and goes until 0700 the next morning. Night call usually follows Day Call which means that after being on Day Call you don't work.
This system works well on weekdays, it is weekends when it is beginning to break down. The problem is that if you are Day Call on Friday or Saturday; you effectively become second call for the next 24 hours after which you become first call. This should not be a problem as second call should normally only be coming in for life and limb threatening emergencies when first call is tied up. Think again, our OR is staffed to run two rooms until 1100 on weekdays and from 0800 to 1600 on weekends. On top of that we have a not that busy Caseroom which we also have to cover. Increasingly surgeons and administrators are asking (demanding) that we run two rooms on evenings and weekends. This means that it is possible to work until 2300 on Friday, be called in at 0900 on Saturday and then work until 0700 Sunday. It is unusual to work all night, however the Case Room can make for a lot of interrupted sleep.
We could of course fix this by having a second call on weekends that is separate from Night Call. The problem with this is that we are a relatively small department and to bring in a second call would result in call every 1 in 3.75 weekends during the year and 1 in 2.75 during the summer (somebody else calculated that not me). Most people are prepared to just grin and bear it. Many weekends are not that busy. Adding a second call in addition to increasing our weekend call load would dilute our income from on call.
Switching to shifts is an interesting option and one that emergency docs have been doing for years. As one staffman explained to me during my residency however, the reason we work 24 hours or longer on call is so that we get more weekends off. As most of our work is done during the weekdays, shift work is something that would be harder to schedule for anaesthesiology without a lot more redundant manpower.
But what about if we only did cases that actually need to be done? Imagine being on call and only doing appendectomies, compound fractures, and caesarian sections. You would still be on call as often but would be earning a lot less under the fee for service system. Occasionally I get a day or an evening on call where there is nothing booked, and the Case Room is completely quiet. Those times are almost as bad as working. There you are tethered to being within a 20 minute radius from the hospital, if you and your wife go out you have to take 2 cars. Start doing something and the phone is sure to ring. So you sit around watching mindless TV or reading; later on you go to bed for a fitfull sleep worrying that you are going to sleep through the phone. It was a lot worse before cell phones; I can remember going out with a pocketful of change for the pay phone in case my beeper went off. So the answer is that most of us want to work but not a lot.
On call work is very surgeon dependent. One man's emergency is another man's put it off until Monday. Kidney stones are a case in point. Some surgeons like to operate on all of them before something happens (like the patient passes it). Others are happy to send them home with some analgesia. Our hospital actually has a stone room on Fridays to allow urologists to do their urgent stones during the day. This still doesn't stop a small sub-group of urologists from booking stones on weekends. (As an aside in my first job, one of the urologists before he went home on Friday would in his illegible scrawl, book "John Smith" and "Bob Jones" for ureteroscopies on Saturday morning. His rationale was that two patients were sure to present during the evening or night and he wanted to go first. He died in his sleep a year or so after I left, which may or may not be karma.) Many surgeons believe that if they are going to be on call they want to work. Many years ago an orthopedic surgeon was caught telling patients on his wait list for arthroscopy to go to the ER with "locked knees". Much less egregious abuses of on call operating time still occur. The chief of surgeon recently confirmed what I had always believed. As he said, if we (which means if I) am not busy and I have a patient with a gall bladder who is not coping well at home I will call them in. There are also surgeons who figure that if they have to do one case, they may as well do two. The less urgent case is always booked first, so that you have to do the more urgent case regardless of how late it is or what else is booked. I could go on with examples.
Surgeons it is true also take call and often take call more often that do anaesthesiologists. Surgeons do have much more control over their workload however, there are very few surgical cases that have to done right away. If they are feeling tired, they can and do put cases off until the next day. Surgeons also have several layers of buffers between them and the patient; nurses, hospitalists, interns and residents. They are therefore only seeing the tip of the iceberg of their on call work. The problem is of course that while we have multiple surgical subspecialties, we only have one (or two) anaesthesiologists. These means that after the orthopedic surgeon decides around 8 pm that he has had enough and puts off the rest of his huge trauma list until the next day, we are still stuck with whatever appys, D+Cs and the real emergencies that come through the door. I am now starting to accept what I should have always known. I am just not as sharp after 8 hours of working. I start to cut corners, I do stuff I know I shouldn't do. Sometimes looking back at a specific case all I can think is, "what was I thinking?" This is not limited to anaesthesia. I have blogged in the past about operating on no sleep. Having recently had the "pleasure" of some long ortho trauma lists on Saturday I have noticed that as the day goes on the work get sloppier. Locking the IM nail that was easy at 0900 seems to take a lot more time at 2000. I remember watching a really tired Ob-Gyn trying to do an ectopic laparoscopically late at night and it was not pretty.
A couple of years ago at a meeting, I ran into some anaesthesiologists around my age who I worked with in my first job before in a long moment of insanity I moved to the C of E. The discussion topic we arrived at was the techniques we use to stay awake during cases late in the evening and at night. One person had an interesting technique. She would sit in the chair of anaesthesia and lean on the machine so that if she fell asleep she would not fall off her chair. There are other techniques of course: playing your music loud if the other people in the room will allow it, turning up the volume on the monitor, setting alarms to go off all the time, talking to the nurses. I remember late at night trying to stay awake during a really boring head and neck case. One of the nurses finally took pity on me and brought in some Readers Digests. "Read these," she said, "that will keep you awake." I started bringing in books and magazines. I once read most of an entire novel during an all night case.
Some cases of course are easier to stay awake during that others. Ruptured aneursyms, major traumas come to mind. Adrenaline and the need to actually do something during the case keep you awake. Sometimes the effect of having done 12 hours of mind numbing orthopedics, makes you less fresh.
Compounding matters is that I no longer recover well from those all nighters. I have never been able to sleep well on call. The odd time when from shear exhaustion I do sleep, I am groggy almost drunk when I am awakened. I am crabby when I am tired. I say things I shouldn't say. I have gotten in trouble for this in the past. I did one in three call for most of my internship and for 6 months in my residency. I have no idea how I survived. I would quit Medicine if I knew I had to do it again.
If you get a group of anaesthesiologists together long enough, the conversation will inevitably come down to call and the whining will start. This is my whine.
Nobody in my family was in medicine, so I had no idea of what the lifestyle of a doctor was. I figured it would be like on MASH where Hawkeye and Trapper John sipped Martini's in the swamp in between tormenting Frank Burns and boinking the nurses. Or maybe like Doc Adams who spent most of his time arguing with Festus in between digging bullets out of the Marshall. I at least figured that I would only be seeing really sick people who needed urgent attention. Why else would you work after hours?
I was moonlighting in emergency during my residency and was suturing up a rare treat, an unobnoxious drunk around around 1 am. "You must be pretty smart to be a doctor," said the drunk. "If I am so smart," I replied, "what the hell am I doing here at one in the morning on a Saturday." Even back then I had it figured out but I am apparently no smarter.
I am pretty certain that anaesthesiology is the only specialty that works harder on call than they did 25 years ago when C/S rates were under 20%, labour epidurals were uncommon and fractures were actually treated with closed reductions.
This has become an issue lately because of complaints by my colleagues related to on call especially on weekends. Our department like many around the city has developed what is at face a very civilized call system. Nobody is on first call for 24 hours. We have a Day Call who works from 0700 to 1600 after which he becomes second call until 0700 the next morning. Night call starts at 1600 and goes until 0700 the next morning. Night call usually follows Day Call which means that after being on Day Call you don't work.
This system works well on weekdays, it is weekends when it is beginning to break down. The problem is that if you are Day Call on Friday or Saturday; you effectively become second call for the next 24 hours after which you become first call. This should not be a problem as second call should normally only be coming in for life and limb threatening emergencies when first call is tied up. Think again, our OR is staffed to run two rooms until 1100 on weekdays and from 0800 to 1600 on weekends. On top of that we have a not that busy Caseroom which we also have to cover. Increasingly surgeons and administrators are asking (demanding) that we run two rooms on evenings and weekends. This means that it is possible to work until 2300 on Friday, be called in at 0900 on Saturday and then work until 0700 Sunday. It is unusual to work all night, however the Case Room can make for a lot of interrupted sleep.
We could of course fix this by having a second call on weekends that is separate from Night Call. The problem with this is that we are a relatively small department and to bring in a second call would result in call every 1 in 3.75 weekends during the year and 1 in 2.75 during the summer (somebody else calculated that not me). Most people are prepared to just grin and bear it. Many weekends are not that busy. Adding a second call in addition to increasing our weekend call load would dilute our income from on call.
Switching to shifts is an interesting option and one that emergency docs have been doing for years. As one staffman explained to me during my residency however, the reason we work 24 hours or longer on call is so that we get more weekends off. As most of our work is done during the weekdays, shift work is something that would be harder to schedule for anaesthesiology without a lot more redundant manpower.
But what about if we only did cases that actually need to be done? Imagine being on call and only doing appendectomies, compound fractures, and caesarian sections. You would still be on call as often but would be earning a lot less under the fee for service system. Occasionally I get a day or an evening on call where there is nothing booked, and the Case Room is completely quiet. Those times are almost as bad as working. There you are tethered to being within a 20 minute radius from the hospital, if you and your wife go out you have to take 2 cars. Start doing something and the phone is sure to ring. So you sit around watching mindless TV or reading; later on you go to bed for a fitfull sleep worrying that you are going to sleep through the phone. It was a lot worse before cell phones; I can remember going out with a pocketful of change for the pay phone in case my beeper went off. So the answer is that most of us want to work but not a lot.
On call work is very surgeon dependent. One man's emergency is another man's put it off until Monday. Kidney stones are a case in point. Some surgeons like to operate on all of them before something happens (like the patient passes it). Others are happy to send them home with some analgesia. Our hospital actually has a stone room on Fridays to allow urologists to do their urgent stones during the day. This still doesn't stop a small sub-group of urologists from booking stones on weekends. (As an aside in my first job, one of the urologists before he went home on Friday would in his illegible scrawl, book "John Smith" and "Bob Jones" for ureteroscopies on Saturday morning. His rationale was that two patients were sure to present during the evening or night and he wanted to go first. He died in his sleep a year or so after I left, which may or may not be karma.) Many surgeons believe that if they are going to be on call they want to work. Many years ago an orthopedic surgeon was caught telling patients on his wait list for arthroscopy to go to the ER with "locked knees". Much less egregious abuses of on call operating time still occur. The chief of surgeon recently confirmed what I had always believed. As he said, if we (which means if I) am not busy and I have a patient with a gall bladder who is not coping well at home I will call them in. There are also surgeons who figure that if they have to do one case, they may as well do two. The less urgent case is always booked first, so that you have to do the more urgent case regardless of how late it is or what else is booked. I could go on with examples.
Surgeons it is true also take call and often take call more often that do anaesthesiologists. Surgeons do have much more control over their workload however, there are very few surgical cases that have to done right away. If they are feeling tired, they can and do put cases off until the next day. Surgeons also have several layers of buffers between them and the patient; nurses, hospitalists, interns and residents. They are therefore only seeing the tip of the iceberg of their on call work. The problem is of course that while we have multiple surgical subspecialties, we only have one (or two) anaesthesiologists. These means that after the orthopedic surgeon decides around 8 pm that he has had enough and puts off the rest of his huge trauma list until the next day, we are still stuck with whatever appys, D+Cs and the real emergencies that come through the door. I am now starting to accept what I should have always known. I am just not as sharp after 8 hours of working. I start to cut corners, I do stuff I know I shouldn't do. Sometimes looking back at a specific case all I can think is, "what was I thinking?" This is not limited to anaesthesia. I have blogged in the past about operating on no sleep. Having recently had the "pleasure" of some long ortho trauma lists on Saturday I have noticed that as the day goes on the work get sloppier. Locking the IM nail that was easy at 0900 seems to take a lot more time at 2000. I remember watching a really tired Ob-Gyn trying to do an ectopic laparoscopically late at night and it was not pretty.
A couple of years ago at a meeting, I ran into some anaesthesiologists around my age who I worked with in my first job before in a long moment of insanity I moved to the C of E. The discussion topic we arrived at was the techniques we use to stay awake during cases late in the evening and at night. One person had an interesting technique. She would sit in the chair of anaesthesia and lean on the machine so that if she fell asleep she would not fall off her chair. There are other techniques of course: playing your music loud if the other people in the room will allow it, turning up the volume on the monitor, setting alarms to go off all the time, talking to the nurses. I remember late at night trying to stay awake during a really boring head and neck case. One of the nurses finally took pity on me and brought in some Readers Digests. "Read these," she said, "that will keep you awake." I started bringing in books and magazines. I once read most of an entire novel during an all night case.
Some cases of course are easier to stay awake during that others. Ruptured aneursyms, major traumas come to mind. Adrenaline and the need to actually do something during the case keep you awake. Sometimes the effect of having done 12 hours of mind numbing orthopedics, makes you less fresh.
Compounding matters is that I no longer recover well from those all nighters. I have never been able to sleep well on call. The odd time when from shear exhaustion I do sleep, I am groggy almost drunk when I am awakened. I am crabby when I am tired. I say things I shouldn't say. I have gotten in trouble for this in the past. I did one in three call for most of my internship and for 6 months in my residency. I have no idea how I survived. I would quit Medicine if I knew I had to do it again.
If you get a group of anaesthesiologists together long enough, the conversation will inevitably come down to call and the whining will start. This is my whine.
Subscribe to:
Posts (Atom)
Posts
