Wednesday, January 11, 2006
Medpundit Looks At His Financials
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Ugh: I just spent the better part of the afternoon...:
"Ugh: I just spent the better part of the afternoon doing my least favorite task - reveiwing the financials of my practice. It doesn't look pretty. With Congress electing to decrease my pay by 4%, and my malpractice premium set to increase by 30% you can see it's not going to be a good year. The cost of supplies has been steadily going up, too, as have the cost of services. My medical waste haulers upped their fees by 20% in the past six months due to rising gas prices.
The Medicare cut may not sound like much, but it translates into a loss of about $2-3 per patient visit. And it isn't just limited to Medicare patients. Insurance companies base their rate of reimbursement as a percentage of Medicare fees. They might, say, pay 110% of whatever the fee Medicare pays. A practice that sees 25-30 patients a day will make $50-$90 less a day in 2006. That adds up quickly. Assuming a five-day work week, that adds up to $13,000 to $23,000 less over the course of the year. And despite what you might read in the newspapers, the majority of patients who pass through a doctor's office have health insurance - so the cut goes across the board.
How does that translate into day to day life? It means that my staff didn't get a cost of living raise this year. It means that I'll have to drop their health insurance if the premiums increase. And it means that I'm working harder - double booking patients when I can and adding an extra half day to my work week. Hopefully, I'll break even and avoid a decline in my own wages."
Thursday, December 1, 2005
How do you mark a surgical site?
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The American Academy of Orthopaedic Surgeons has a policy on marking surgical sites titled Guidelines for Implementation of the Universal Protocol for the Prevention of Wrong Site, Wrong Procedure and Wrong Person Surgery. It's worth reviewing and comparing to your institutions policy. For example:
- Make the mark at or near the incision site. Do NOT mark any non-operative site(s) unless necessary for some other aspect of care.
- The mark should be unambiguous (e.g., use initials or "YES" or a line representing the proposed incision; consider that "X" may be ambiguous).
- The person performing the procedure should do the site marking.
There's much more to the guideline, but your current policies are most likely to be at variance with the above three points. One of the surgery centers I work at, for instance, marks the surgical site with an 'X'. I've explained to them that 'X' is ambiguous (does X mark the spot, or does X mark 'not this one'?) and even explained the details of a malpractice case in which marking with an X came into play. Another hospital was in the habit of marking both sides ('L' and 'R'). Also confusing. Finally, several centers have the nurse preparing the patient for surgery to mark the site. Also not a good idea.
Sunday, November 6, 2005
You Anesthesiologist Today Was...
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I finally ordered my own business cards. I've had generic one available but always had to write in my own name (despite being with the group for well over two years) so decided it was time for an upgrade.
Picking the pattern was tough, but I decided on a tranquil image (that happens to be one of the MacOS X desktop images):
Rejected images included a dark tunnel with a light at the end, and anything with pearly gates.
This decision was evidence based (of course). Giving patients a business card before anesthesia increases their recall of your name to about 50% rather than the 10% that remember it without. It should also help them see they are being cared for by a physician. There's room on the back for 'anesthetic' and 'comments', too.
Thursday, November 3, 2005
Pre-emptive Patient Positioning
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Many surgeries require the patient to be in a position other than supine (flat on their back) for the surgery to be done. Shoulder surgery, for example, is often done with the patient in a semi-sitting or 'beach chair' position. Certain hip surgeries are done with patients on their side as well. General anesthesia is induced with the patient supine, then people have to move the patient (who is now akin to a very heavy sack of potatoes) into the right position. It's time consuming, risks staff injury, and jeopardizes the airway. The few accidental extubations I've had have occurred when the patient was being moved. Does it have to be this way? If the case is amenable to an LMA, I think the answer is 'no.'
If I'm caring for a patient who will require a general anesthetic and an LMA would be suitable, I've taken to positioning the patient before induction of anesthesia. I then pre-oxygenate, perform an IV induction, and place the LMA. The OR staff and surgeons like it because a) it saves time and b) it saves their backs. I like it because there's no move during which my airway can potentially be compromised (and because it saves time and saves my back). There's a benefit to the patient, too. Namely, they can tell us while awake whether our positioning is comfortable for them. Is the axillary role in the right place? Do they need a pillow under their knees in? Is their bottom up against the back of the table in beach chair? Is their ear properly padded in the lateral position? Think Different (but always, Think Safe).
Sunday, October 9, 2005
I Am A Propofologist
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I've decided to change my title from 'Anesthesiologist' to the more descriptive 'Propofologist.' Maybe it's because I've been doing lots of sedation for colonoscopies and esophagogastroduodenoscopies (EGD) for which I use propofol/lidocaine only. When someone asks for anesthesia services, especially outside the operating room, what they're really asking for is someone who can give propofol to the point of loss of consciousness--hence the (new) term. Your heard it here first.
Monday, August 22, 2005
NYT: Sick and Scared, and Waiting, Waiting, Waiting
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NYT: Sick and Scared, and Waiting, Waiting, Waiting
Medicine from the patient's side. A must read article no matter what specialty you're in.
Saturday, April 23, 2005
When can nursing mothers resume breastfeeding after surgery?
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When can nursing mothers resume breastfeeding after surgery?:
" the very small amount of propofol eliminated in breast milk within the first 24 hours after induction of anesthesia represents such minimal infant exposure to the drug that it provides insufficient justification for interruption of breastfeeding, Avram said. "
Studies are under way by the same group for other commonly used drugs. My advice to nursing patients is to pump and discard once, then resume normal breast feeding.
Wednesday, March 23, 2005
C. difficile Outbreaks, Anyone?
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Our hospital has pulled all 3M Avagard hand disinfectant from the operating rooms, preferring instead that surgeons go back to the old fashioned surgical hand scrub. At the same time, we are apparently seeing more nosocomial Clostridium difficile infections. C. diff. is not a reportable pathogen, and this was felt to contribute to the outbreak Canada experienced recently. Avagard does not inactivate C. diff. spores. Co-incidence? I don't think so.
The CDC page for healthcare providers on C. diff. provides an interesting nugget:
"If your institution experiences an outbreak, consider using only soap and water for hand hygiene when caring for patients with Clostridium difficile-associated disease; alcohol-based hand rubs may not be as effective against spore-forming bacteria."
Has anyone else seen this at their facilities?
Saturday, March 12, 2005
Obstetrical deaths in the UK--Anesthesia component
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Why Mothers Die 2000-2002 - Report on confidential enquiries into maternal deaths in the United Kingdom
Chapter 9--Anaesthesia
The anesthesia chapter concludes:
"The management of haemorrhage is a shared responsibility of midwifery, obstetric, anaesthetic and blood transfusion personnel. Anaesthetists should be ready to suggest that the obstetrician summons help in the face of major haemorrhage regardless of the obstetrician’s grade or experience. Good communication is vital and regular practice of emergency drills is crucial, particularly in units with a high turnover of staff."
I would like to think that many of the problems pointed out in this report would not happen in the United States, but that would be intellectually dishonest. If you provide anesthesia for obstetrical patients as I do, it's worth reading over this report for the lessons that are applicable in the US.
Wednesday, March 9, 2005
"If you're wrong, I'll sue you."
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That's what the patient was overheard to say after I finished a discussion with her about why she would not need prophylactic antibiotics before a nasal procedure. Her medical history was significant only for a 'heart murmur' (which I could not auscultate). No workup or echocardiogram had been done to rule in a structural cardiac abnormality. The patient denied signs or symptoms of valvular heart disease including mitral valve prolapse, and had a very good exercise tolerance. I quoted the AHA Recommendations which, it turns out, admit that....
"There are currently no randomized and carefully controlled human trials in patients with underlying structural heart disease to definitively establish that antibiotic prophylaxis provides protection against development of endocarditis during bacteremia-inducing procedures. Further, most cases of endocarditis are not attributable to an invasive procedure. "
"If you're wrong, I'll sue you" was reportedly spoken by the patient after I had left the bedside. As I saw it, I had three choices:
- Tell her I would not provide her an anesthetic for this elective surgery as she had revealed herself to be a litigious patient.
- Reschedule her surgery after an echocardiogram had been performed to elucidate the origin of the murmur.
- Give her the antibiotic and get on with things.
Part of why I had such a strong emotional reaction upon hearing this was almost certainly because I have been in practice over eight nearly nine years and have yet to be named in a suit (the average physician is sued once every eight years). And because some very talented surgeons have left Pennsylvania because of the malpractice environment (and have been replaced by considerably less talented surgeons).
After I talked it over with the surgeon (who asked me to proceed so as not to put him in a difficult position) I gave her the antibiotic and got on with things...but not until after I had listed for her every possible complication of both the antibiotic dose and the anesthetic she was about to receive, including brain damage and death.
Now, all the informed consent in the world isn't going to stop a patient from suing regardless of outcome if they want to sue. I decided to save my charm, humor, and best bedside manner for patients that have the good sense not to talk about bombs while they're waiting in line at airport security.
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Dec Feb
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