IS PRIVATE PRACTICE ANESTHESIA DOOMED?

the anesthesia consultant

Physician anesthesiologist at Stanford at Associated Anesthesiologists Medical Group
Richard Novak, MD is a Stanford physician board-certified in anesthesiology and internal medicine.Dr. Novak is an Adjunct Clinical Professor in the Department of Anesthesiology, Perioperative and Pain Medicine at Stanford University, the Medical Director at Waverley Surgery Center in Palo Alto, California, and a member of the Associated Anesthesiologists Medical Group in Palo Alto, California.
email rjnov@yahoo.com
phone 650-465-5997

Latest posts by the anesthesia consultant (see all)

What is the future of private practice anesthesiology?

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First off, let’s define “private practice.” The Merriam-Webster online dictionary defines private practice as: “a professional business (such as that of a lawyer or doctor) that is not controlled or paid for by the government or a larger company (such as a hospital).”

In my community the dentists are all in private practice, as are most of the accountants, psychologists, and attorneys. Why should anesthesiologists be any different? Let’s look at the issues.

A private practice single-specialty anesthesia group will usually provide anesthesia for similarly self-employed surgeons who are in private practice. How does the business work? When a single-specialty anesthesia group provides a service, the group decides the cost of that service, and the group sends a bill to the patient’s insurance company or to Medicare or Medicaid for that amount. How much will they get paid? It depends. Medicare and Medicaid cap their payments at a small fraction of an anesthesiologist’s typical fee. For insured patients, the anesthesia group collects whatever the insurance company pays, along with the deductible or co-pay the patient owes through their insurance plan. The collected amount, minus the group’s overhead (office employee salaries, office rent, office supplies, malpractice insurance, and health insurance for their own families) equals the anesthesia group’s profit.

A private practice anesthesia group needn’t be a physician-only group. In many private practice anesthesia groups, physician anesthesiologists supervise multiple nurse anesthetists in multiple operating rooms. These groups are still single specialty anesthesia groups. Physician anesthesiologists pay their nurse anesthetists as employees as well as their other expenses, and then divide the profit.

In recent years the prevalence of the private practice model is decreasing. The model is being replaced by jobs where the anesthesiologists are employees. Employees of whom?

One employee model is the multispecialty group model, in which all medical specialties work in parallel under one umbrella organization. Examples of this are the Permanente Medical Group (of Kaiser Permanente), Sutter Health in California, Mayo Clinic, and university groups such as Stanford Health Care in my neighborhood. The essence of this model is physicians are salaried, and income is divided amongst the different specialties. Surgical specialties such as anesthesiology and all surgeons earn less than they would in a self-employed private practice model, with some of the income from their services going to primary care specialists like family practitioners, internists, and pediatricians. It’s a symbiotic system since the referrals to the surgical specialists commonly originate from the primary care doctors in the first place. In this model an anesthesiologist will earn less money per case, but may increase his or her income by doing more cases.

A second employee model is the for-profit national physician corporation. The national corporation may purchase anesthesia private practice groups to gain access to their hospital and/or surgery center contracts. The corporation pays an up-front payment to the current anesthesiologists of each smaller group at the time of purchase. The parent corporation collects all future anesthesia bills, and pays out a decreased fee to the anesthesiologists who are now employees. The difference between the collected fee and the anesthesia pay-out equals the profit bottom line of the purchasing corporation, which may be a publically traded company.

A third employee model occurs when a single anesthesiologist or a smaller company attains an exclusive contract for a hospital or a surgery center. This solitary anesthesiologist or smaller company then employs other anesthesiologists at a lower set rate or salary, then contracts to have all billing and collecting done, and keeps the difference between the collected rate and the rate paid to the employees as profit.

One of the reason employee models are increasing in frequency is that the private practice of primary care medicine and the private practice of surgery are both shrinking. If more and more primary care doctors join large multispecialty groups or a national company, and if more and more surgeons join large multispecialty groups or a national company, there will be a paucity of patients for a freestanding anesthesia group to attend to. These trends are not going away.

As a result, today’s graduates from anesthesia residencies and fellowships are finding decreasing opportunities in true private practices, and increased offers to become someone’s employee. This means some of the anesthesia income will be shared with or siphoned off by other people.

Can young anesthesiologists do anything to reverse this trend? It depends. Private practice opportunities still exist in many geographic areas of the United States, if a new anesthesiologist is flexible about where he or she is willing to live. If you’re determined to stay in an overcrowded, underpaying marketplace, you may find nothing better than a salaried job at a modest income.

What is a modest income? Is $250,000 a year a modest income? That number sounds like a large income to most Americans. However if the doctor worked 60 hours per week and was awake all night performing anesthetics every fifth night, and if the collected fees for that individual’s anesthesia work that year totaled $750,000, then that individual was being paid significantly less than they earned.

How can you tell if your employer is paying you less than you earned? Find out what they are collecting per anesthesia unit of time, and do the math. Compare that number to what they are paying you. See my article on anesthesia billing as a reference for this.

Many private practice groups will survive. In the words of Charles Darwin, it will be survival of the fittest. Private practice groups will have to change and adapt to maximize their chances for survival. They will have to provide a higher level of service, and become more involved outside the operating room, in perioperative leadership, and in their local hospital politics and economics.

The anesthesia job market is part of the free marketplace in America, and Adam Smith’s invisible hand will drive individuals toward the best and highest paying opportunities. If you’re a young anesthesiologist, can you do anything to avoid the trend toward low salaried jobs? You can refuse to settle for poorly-paying jobs. Move to a marketplace that pays you well for your time. You may choose to not settle for a salary which is a mere fraction of what you are earning, especially if you are keeping patients alive at 3 a.m. while healthcare businessmen and stockholders are sleeping.

Medscape lists the best states for doctors to practice in. Flexibility in geography may yield a superior opportunity for you.

Medscape recently reported the average yearly income for anesthesiologists in the United States as $364,000. If your yearly income is $250,000 (this would be $114,000 under the average), then somewhere in the United States there are anesthesiologists with an income of $364,000 + $114,000 = $478,000, to maintain the average yearly income that Medscape reported.

When you input “private practice anesthesiologist” into Indeed.com, you’ll find multiple job offers. The private practice of anesthesia may be shrinking, but it’s far from gone.

 

The most popular posts for laypeople on The Anesthesia Consultant include:

How Long Will It Take To Wake Up From General Anesthesia?

Why Did Take Me So Long To Wake From General Anesthesia?

Will I Have a Breathing Tube During Anesthesia?

What Are the Common Anesthesia Medications?

How Safe is Anesthesia in the 21st Century?

Will I Be Nauseated After General Anesthesia?

What Are the Anesthesia Risks For Children?

 

The most popular posts for anesthesia professionals on The Anesthesia Consultant  include:

10 Trends for the Future of Anesthesia

Should You Cancel Anesthesia for a Potassium Level of 3.6?

12 Important Things to Know as You Near the End of Your Anesthesia Training

Should You Cancel Surgery For a Blood Pressure = 178/108?

Advice For Passing the Anesthesia Oral Board Exams

What Personal Characteristics are Necessary to Become a Successful Anesthesiologist?

 

LEARN MORE ABOUT RICK NOVAK’S FICTION WRITING AT RICK NOVAK.COM BY CLICKING ON THE PICTURE BELOW:

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10 WAYS PRIVATE PRACTICE ANESTHESIA DIFFERS FROM ACADEMIC ANESTHESIA

the anesthesia consultant

Physician anesthesiologist at Stanford at Associated Anesthesiologists Medical Group
Richard Novak, MD is a Stanford physician board-certified in anesthesiology and internal medicine.Dr. Novak is an Adjunct Clinical Professor in the Department of Anesthesiology, Perioperative and Pain Medicine at Stanford University, the Medical Director at Waverley Surgery Center in Palo Alto, California, and a member of the Associated Anesthesiologists Medical Group in Palo Alto, California.
email rjnov@yahoo.com
phone 650-465-5997

Latest posts by the anesthesia consultant (see all)

Academic and private practice anesthesia differ. I’m fortunate to be a member of the clinical faculty in the Department of Anesthesia, Perioperative and Pain Medicine at Stanford University. Stanford is a unique academic hospital, staffed by both academic and private practice physicians. From 2001 until 2015, I served as the Deputy Chief of Anesthesia at Stanford, an elected officer who leads the private practice/community section of the anesthesia department.


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Stanford anesthesia residents frequently question me about how the world of private practice differs from academia. I began my writing career by penning a series of Stanford Deputy Chief Columns. These columns originated as a forum to educate residents using specific cases and situations I found unique to private practice.

Although some anesthesia residents continue in academic medicine, most pursue careers in community or private practice. In 2009, the Anesthesia Quality Institute published Anesthesia in the United States 2009, a report that summarized data on our profession. There were 41,693 anesthesiologists in America at that time, and the demographics of practice type were: academic/teaching medical center 43%, community hospital 35%, city/county hospital 11%, and ambulatory surgery center 6%. Per this data, the majority of American anesthesiologists practice outside of teaching hospitals.

How does community anesthesia differ from academic anesthesia? I’m uniquely qualified to answer this question. I’ve worked at Stanford University Hospital for 34 years, including 5 years of residency training and one year as an Emergency Room faculty member, but my last 25 years at Stanford have been in private practice with the Associated Anesthesiologists Medical Group.

Here’s my list of the 10 major adjustments residents face transitioning from academic anesthesia to private practice/community anesthesia:

  1. You’ll work alone. In academic medicine, faculty members supervise residents. In private practice, you’re on your own. This is particularly true in the middle of the night or when you are working in a small freestanding surgery center where you are the only anesthesia professional. In these settings, you have little or no backup if clinical circumstances become dire. An additional example is the performance of pediatric inhalation inductions. During residency training, a faculty member starts the IV while the resident manages the airway. In private practice you’ll do both tasks yourself. I’d advise you to adopt a senior member of your new anesthesia group as a mentor, and to question him or her in an ongoing nature regarding the nuances of your new practice. (Note that certain private practices, especially in the Midwest or Southeastern U.S., utilize Anesthesia Care Teams, where anesthesiology attendings supervise nurse anesthetists, but this model is less common in California).
  2. Income: your income will be linked to your production. The good news is that you’ll earn more money that you did as a resident. Your income will be linked to the amount of cases you do. You’ll earn more in a twelve-hour day than you do in a four-hour day, so you have an incentive to do extra cases. A job where newly hired physicians have equitable access to workload is desirable.
  3. Income: your income will be linked to the insurance coverage of your patients. Privately insured patients pay more than Medicare and Medicaid patients. You may earn more working a four-hour day for insured patients than you earn working twelve hours working for the government plans of Medicare and Medicaid. It’s too early to know how much Obamacare and the Affordable Care Act will alter physician salaries. A job with a low percentage of Medicare and Medicaid work is desirable.
  4. Vacations. You’ll have access to more vacation time than you did in academic training. Most jobs allow a flexible amount of weeks away from clinical practice, but you will earn zero money during those weeks. It will be your choice: maximize free time or maximize income.
  5. Recipes. You’ll tend to use consistent anesthesia “recipes,” rather than trying to make every anesthetic unique, interesting or educational, as you may have done in an academic setting. Community practice demands high quality care with efficient inductions and wakeups, and rapid turnovers between cases. Once you discover your best method to do a particular case, you’ll stick to that method.
  6. Continuing Medical Education (CME). In an academic setting, educational conferences are frequent and accessible. After your training is finished, you’ll need to find your own CME. In California the requirement is 50 hours of CME every 2 years. Your options will include conventions, weekend meetings, and self-study at home programs. Many physicians find at-home programs require less investment in time, travel, and tuition than finding out-of-town lectures to attend.
  7. Malpractice insurance. You’ll pay your own malpractice insurance. As a result, you’ll be intensely interested in avoiding malpractice claims and adverse patient outcomes. You’ll become well versed in the standards of care in your anesthesia community.
  8. No teaching. No one will expect you to teach during community practice. You may choose to lecture nurses or your fellow medical staff, but it’s not required.
  9. No writing. No one will expect you to write or publish scholarly articles. You may choose to do so, but you will be in the minority.
  10. 10.  Respect. You’ll experience a higher level of respect from nurses and staff at community hospitals and surgery centers than you receive during residency. Nurses and staff accept that you are fully trained and experienced, and treat you as such. Free food at lunch and breakfast is common. Some hospitals have comfortable physician lounges where medical staff members gather. Teams of physicians work together at the same community hospitals for decades, and form strong relationships with the nurses, techs, and their fellow medical staff. It feels terrific to collaborate with the same professionals week after week.

Academic training is an essential building block in every physician’s career. If and when you choose to venture beyond academia into community anesthesia, this column gives you some idea what to expect. I recommend you find a mentor to help you adjust to the challenges of your new practice setting, and I wish you good luck with the transition.

 

The most popular posts for laypeople on The Anesthesia Consultant include:

How Long Will It Take To Wake Up From General Anesthesia?

Why Did Take Me So Long To Wake From General Anesthesia?

Will I Have a Breathing Tube During Anesthesia?

What Are the Common Anesthesia Medications?

How Safe is Anesthesia in the 21st Century?

Will I Be Nauseated After General Anesthesia?

What Are the Anesthesia Risks For Children?

 

The most popular posts for anesthesia professionals on The Anesthesia Consultant  include:

10 Trends for the Future of Anesthesia

Should You Cancel Anesthesia for a Potassium Level of 3.6?

12 Important Things to Know as You Near the End of Your Anesthesia Training

Should You Cancel Surgery For a Blood Pressure = 178/108?

Advice For Passing the Anesthesia Oral Board Exams

What Personal Characteristics are Necessary to Become a Successful Anesthesiologist?

 

 

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Published in September 2017:  The second edition of THE DOCTOR AND MR. DYLAN, Dr. Novak’s debut novel, a medical-legal mystery which blends the science and practice of anesthesiology with unforgettable characters, a page-turning plot, and the legacy of Nobel Prize winner Bob Dylan.

KIRKUS REVIEW

In this debut thriller, tragedies strike an anesthesiologist as he tries to start a new life with his son.

Dr. Nico Antone, an anesthesiologist at Stanford University, is married to Alexandra, a high-powered real estate agent obsessed with money. Their son, Johnny, an 11th-grader with immense potential, struggles to get the grades he’ll need to attend an Ivy League college. After a screaming match with Alexandra, Nico moves himself and Johnny from Palo Alto, California, to his frozen childhood home of Hibbing, Minnesota. The move should help Johnny improve his grades and thus seem more attractive to universities, but Nico loves the freedom from his wife, too. Hibbing also happens to be the hometown of music icon Bob Dylan. Joining the hospital staff, Nico runs afoul of a grouchy nurse anesthetist calling himself Bobby Dylan, who plays Dylan songs twice a week in a bar called Heaven’s Door. As Nico and Johnny settle in, their lives turn around; they even start dating the gorgeous mother/daughter pair of Lena and Echo Johnson. However, when Johnny accidentally impregnates Echo, the lives of the Hibbing transplants start to implode. In true page-turner fashion, first-time novelist Novak gets started by killing soulless Alexandra, which accelerates the downfall of his underdog protagonist now accused of murder. Dialogue is pitch-perfect, and the insults hurled between Nico and his wife are as hilarious as they are hurtful: “Are you my husband, Nico? Or my dependent?” The author’s medical expertise proves central to the plot, and there are a few grisly moments, as when “dark blood percolated” from a patient’s nostrils “like coffee grounds.” Bob Dylan details add quirkiness to what might otherwise be a chilly revenge tale; we’re told, for instance, that Dylan taught “every singer with a less-than-perfect voice…how to sneer and twist off syllables.” Courtroom scenes toward the end crackle with energy, though one scene involving a snowmobile ties up a certain plot thread too neatly. By the end, Nico has rolled with a great many punches.

Nuanced characterization and crafty details help this debut soar.

Click on the image below to reach the Amazon link to The Doctor and Mr. Dylan:

41wlRoWITkL

Learn more about Rick Novak’s fiction writing at ricknovak.com by clicking on the picture below:  

DSC04882_edited

 

 

KEEPING ANESTHESIA SIMPLE: THE KISS PRINCIPLE

the anesthesia consultant

Physician anesthesiologist at Stanford at Associated Anesthesiologists Medical Group
Richard Novak, MD is a Stanford physician board-certified in anesthesiology and internal medicine.Dr. Novak is an Adjunct Clinical Professor in the Department of Anesthesiology, Perioperative and Pain Medicine at Stanford University, the Medical Director at Waverley Surgery Center in Palo Alto, California, and a member of the Associated Anesthesiologists Medical Group in Palo Alto, California.
email rjnov@yahoo.com
phone 650-465-5997

Latest posts by the anesthesia consultant (see all)

Clinical Cases:  You’re scheduled to anesthetize a 70-year-old man for a carotid endarterectomy, a 50-year-old man for an arthroscopic rotator cuff repair, and a 30-year-old woman for an Achilles tendon repair.  What anesthetics would you plan? “Keep It Simple, Stupid…” The KISS principle applies in anesthesiology, too.

 

Discussion:  In 1960, U.S. Navy aircraft engineer Kelly Johnson coined the KISS Principle, an acronym for “Keep It Simple, Stupid.” The KISS principle supports that most systems work best if they are kept simple rather than made complex. Simplicity should be a key goal in design, and unnecessary complexity should be avoided. The KISS Principle likely found its origins in similar concepts such as Occam’s razor, Leonardo da Vinci‘s “Simplicity is the ultimate sophistication,” and architect Mies Van Der Rohe‘s “Less is more.”

Let’s look at the three cases listed above.  For the carotid surgery, you choose an anesthetic regimen based on dual infusions of propofol and remifentanil, aiming for a rapid wake-up at the conclusion of surgery.  For the arthroscopic rotator cuff repair, you fire up the ultrasound machine and insert an interscalene catheter preoperatively.  After you’ve inserted the catheter, you induce general anesthesia with propofol and maintain general anesthesia with sevoflurane.  For the Achilles repair, you perform a popliteal block preoperatively.  After you’ve performed the block, you induce general anesthesia with propofol, insert an endotracheal tube, turn the patient prone, and maintain general anesthesia with sevoflurane and nitrous oxide.

All three cases proceed without complication.

Ten miles away, an anesthesiologist in private practice is scheduled to do the same three cases.  For each of the three cases she chooses the same anesthetic regimen:  Induction with propofol, insertion of an airway tube (an endotracheal tube for the carotid patient, and a laryngeal mask airway for the shoulder patient and the ACL patient, and an endotracheal tube for the prone Achilles repair), followed by sevoflurane and nitrous oxide for maintenance anesthesia and a narcotic such as fentanyl titrated in as needed for postoperative analgesia.  The carotid patient is monitored with an arterial line, and vasoactive drugs are used as necessary to control hemodynamics.

“Wait a minute!” you say. “Elegant anesthesia requires advanced techniques for different surgeries. Why would a private practitioner do all three cases with nearly identical choices of drug regimen?  Why would a private practitioner fail to tailor their anesthetic plan to the surgical specialty? Total intravenous anesthesia and ultrasound-guided regional anesthesia are important arrows in the quiver of a 21st-century anesthesiologist, aren’t they?”

In my first week in private practice, just months after graduating from the Stanford anesthesia residency program, the anesthesia chairman at my new hospital emphasized relying on the KISS Principle in anesthesia practice.  He stressed that the objective of clinical anesthesia wasn’t to make cases interesting and challenging, but to have predictable and complication-free outcomes. Exposing a patient to extra equipment (two syringe pumps), or two anesthetics (regional plus general) instead of general anesthesia alone, adds layers of complexity, and defies the KISS principle.

There are no data indicating that using two syringe pumps and total intravenous anesthesia will produce a better outcome than turning on a sevoflurane vaporizer.  There are no data demonstrating that combining a regional anesthetic with a general anesthetic for shoulder arthroscopy or Achilles tendon surgery will improve long-term outcome.

The KISS principle opines that most systems work best if they are kept simple rather than made complex, and doing two anesthetics instead of one adds complexity.  I’ve learned that an anesthesiologist should choose the simplest technique that works for all three parties:  the surgeon, the patient, and the anesthesiologist. The hierarchy from most simple to complex might look something like this:  (1) local anesthesia alone, (2) local plus conscious sedation, (3) a regional block plus conscious sedation, (4) general anesthesia by mask, (5) general anesthesia with a laryngeal mask airway, (6) general anesthesia with an endotracheal tube, or (7) general anesthesia plus regional anesthesia combined.  The combination of drugs used should be as minimal and simple as possible.

If all three parties (the surgeon, the patient, and the anesthesiologist) are okay with the patient being awake for a particular surgery, then the simplest of the first three options can be selected.  If any one or all of the three parties wants the patient unconscious, then the simplest option of (4) – (7) can be selected.

I’m not an opponent of regional anesthesia.  Ultrasound-guided regional anesthesia is a significant advance in our specialty for appropriate cases, and substituting regional anesthesia for a general anesthetic is a reasonable alternative. Compared with general anesthesia, peripheral nerve blocks for rotator cuff surgery have been associated with shorter discharge times, reduced need for narcotics, enhanced patient satisfaction, and fewer side effects (Hadzic A, Williams BA, Karaca PE, et al.: For outpatient rotator cuff surgery, nerve block anesthesia provides superior same-day recovery after general anesthesiaAnesthesiology  2005; 102:1001-1007). On the other hand, meta-analysis has demonstrated no long-term difference in outcome between regional and general anesthesia for ambulatory surgery.  (Liu SS, Strodtbeck WM, Richman JM, Wu CL: A comparison of regional versus general anesthesia for ambulatory anesthesia: A meta-analysis of randomized controlled trialsAnesth Analg  2005; 101:1634-1642). Why perform combined regional anesthesia plus general anesthesia for minor surgeries?  Are we doing regional blocks just to showcase our new ultrasound skills? If there is an ultrasound machine in the hallway and an ambulatory orthopedic patient on the schedule, these two facts alone are not an indication for a regional block. Patients receive an extra bill for the placement of an ultrasound-guided block, and economics alone should never be a motivation to place a nerve block.

In a painful major orthopedic surgery such as a total knee replacement or a total hip replacement, a regional block can improve patient comfort and outcome. This month’s issue of Anesthesiology a retrospective review of nearly 400,000 patients who had total knee or total hip replacement.  Compared with general anesthesia, neuroaxial anesthesia is associated with an 80% lower 30-day mortality and a 30 – 80% lower risk of major complications (Memtsoudis et al., Perioperative Comparative Effectiveness of Anesthetic Technique in Orthopedic Patients, Anesthesiology. 118(5):1046-1058, May 2013).

Many outpatient orthopedic surgeries performed under straight general anesthesia require only modest oral analgesics afterward.  I had general anesthesia for a shoulder arthroscopy and subacromial decompression last month, and required no narcotic analgesics post-op.  If I’d had an interscalene block, the anesthesiologist could have attributed my comfort level to the placement of the block.  No block was necessary.

Achilles repairs don’t require a combined regional–general anesthetic. Achilles repairs simply don’t hurt very much. One surgeon in our practice does his Achilles repairs under local anesthesia with the patient awake, and the cases go very smoothly.  Other surgeons in our practice insist that a popliteal block be placed prior to general anesthesia for Achilles repairs, a dubious decision because (a) it defies the KISS Principle, and (b) the surgeon has no expertise in dictating anesthetic practice.

Every peripheral nerve block carries a small risk. Although serious complications are unusual, risks include falling; bleeding; local tissue injury, pneumothorax; nerve injury resulting in persistent pain, numbness, weakness or paralysis of the affected limb; or local anesthetic toxicity.  Systemic local anesthetic toxicity occurs in 7.5–20 per 10,000 peripheral nerve blocks (Corman SL et al., Use of Lipid Emulsion to Reverse Local Anesthetic-Induced Toxicity, Ann Pharmacother 2007; 41(11):1873-1877).

Use the simplest anesthetic that works.  Assess whether combined regional–general anesthetics are necessary or wise.  I realize that complex anesthetic regimens are routine aspects of a solid training program, because residents need to leave their training program with a mastery of multiple skills.  But once you’re in private practice, my advice is to take heed of the KISS Principle.

 

The most popular posts for laypeople on The Anesthesia Consultant include:

How Long Will It Take To Wake Up From General Anesthesia?

Why Did Take Me So Long To Wake From General Anesthesia?

Will I Have a Breathing Tube During Anesthesia?

What Are the Common Anesthesia Medications?

How Safe is Anesthesia in the 21st Century?

Will I Be Nauseated After General Anesthesia?

What Are the Anesthesia Risks For Children?

 

The most popular posts for anesthesia professionals on The Anesthesia Consultant  include:

10 Trends for the Future of Anesthesia

Should You Cancel Anesthesia for a Potassium Level of 3.6?

12 Important Things to Know as You Near the End of Your Anesthesia Training

Should You Cancel Surgery For a Blood Pressure = 178/108?

Advice For Passing the Anesthesia Oral Board Exams

What Personal Characteristics are Necessary to Become a Successful Anesthesiologist?

 

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Published in September 2017:  The second edition of THE DOCTOR AND MR. DYLAN, Dr. Novak’s debut novel, a medical-legal mystery which blends the science and practice of anesthesiology with unforgettable characters, a page-turning plot, and the legacy of Nobel Prize winner Bob Dylan.

KIRKUS REVIEW

In this debut thriller, tragedies strike an anesthesiologist as he tries to start a new life with his son.

Dr. Nico Antone, an anesthesiologist at Stanford University, is married to Alexandra, a high-powered real estate agent obsessed with money. Their son, Johnny, an 11th-grader with immense potential, struggles to get the grades he’ll need to attend an Ivy League college. After a screaming match with Alexandra, Nico moves himself and Johnny from Palo Alto, California, to his frozen childhood home of Hibbing, Minnesota. The move should help Johnny improve his grades and thus seem more attractive to universities, but Nico loves the freedom from his wife, too. Hibbing also happens to be the hometown of music icon Bob Dylan. Joining the hospital staff, Nico runs afoul of a grouchy nurse anesthetist calling himself Bobby Dylan, who plays Dylan songs twice a week in a bar called Heaven’s Door. As Nico and Johnny settle in, their lives turn around; they even start dating the gorgeous mother/daughter pair of Lena and Echo Johnson. However, when Johnny accidentally impregnates Echo, the lives of the Hibbing transplants start to implode. In true page-turner fashion, first-time novelist Novak gets started by killing soulless Alexandra, which accelerates the downfall of his underdog protagonist now accused of murder. Dialogue is pitch-perfect, and the insults hurled between Nico and his wife are as hilarious as they are hurtful: “Are you my husband, Nico? Or my dependent?” The author’s medical expertise proves central to the plot, and there are a few grisly moments, as when “dark blood percolated” from a patient’s nostrils “like coffee grounds.” Bob Dylan details add quirkiness to what might otherwise be a chilly revenge tale; we’re told, for instance, that Dylan taught “every singer with a less-than-perfect voice…how to sneer and twist off syllables.” Courtroom scenes toward the end crackle with energy, though one scene involving a snowmobile ties up a certain plot thread too neatly. By the end, Nico has rolled with a great many punches.

Nuanced characterization and crafty details help this debut soar.

Click on the image below to reach the Amazon link to The Doctor and Mr. Dylan:

41wlRoWITkL

Learn more about Rick Novak’s fiction writing at ricknovak.com by clicking on the picture below:  

DSC04882_edited

 

 

CHALLENGES FOR THE NEXT 25 YEARS OF ANESTHESIA

the anesthesia consultant

Physician anesthesiologist at Stanford at Associated Anesthesiologists Medical Group
Richard Novak, MD is a Stanford physician board-certified in anesthesiology and internal medicine.Dr. Novak is an Adjunct Clinical Professor in the Department of Anesthesiology, Perioperative and Pain Medicine at Stanford University, the Medical Director at Waverley Surgery Center in Palo Alto, California, and a member of the Associated Anesthesiologists Medical Group in Palo Alto, California.
email rjnov@yahoo.com
phone 650-465-5997

Latest posts by the anesthesia consultant (see all)

The past 25 years brought remarkable advances in clinical anesthesia practice, including pulse oximetry, end-tidal gas monitoring, propofol, and the laryngeal mask airway.  I posed this question to our Stanford anesthesia faculty who specialize in private practice:  In your opinion, what are the most important problems for anesthesia to address in the next 25 years?

Their answers:   “I think medicine as I have known it in my career will be unrecognizable 25 years from now.  There may be a few well-trained anesthesiologists who provide one-on-one anesthesia for the few patients who are willing to pay for it.  Our society has decided that it doesn’t want to pay for this kind of care for everyone.  I think the systems for providing anesthesia care will be unrecognizable to us in 25 years.   Since this change is going to come whether or not we like it, I would like to see our excellent academic Anesthesia Departments lead the way.  It is time for anesthesia leaders to take over the training of all those who provide anesthesia care so that we can maintain and improve the scientific advances that have been made in the last 25 years.   I think we all agree that some practitioners are over-trained and some under-trained for what they do for most of their careers.  I would like to see more sub-specialization earlier in training.  I would like to see our academics come up with possible solutions to providing high quality anesthesia care in a more cost effective way.  I think real team approaches, robotics and advances in information technologies should be tried to accomplish this goal.   If we don’t come up with more cost-effective ways it will be mandated by those who pay the bills, and I don’t think we will like their solutions.”    Lynn Rosenstock, M.D.  Past-President, Santa Clara County Medical Association;  Past-President, Associated Anesthesiologists Medical Group (AAMG), Stanford.

“I think economic pressures are driving academicians to practical efficiency and marketing pressures are driving private practitioners to offer ‘state of the art.’   In terms of tools that we use, the next 25 years will hopefully reveal enough understanding of mechanisms of consciousness, memory, sleep, and pain to allow us to have medications and techniques to more precisely target cells with minimal damage.  Real time 3-D Echo and 4-D MRI will finally get the resolution and size reduction needed for usage.  Robotic and mobile miniaturized anesthesia machines are likely coming down the pipeline too.”  Charles Wang, M.D. Department of Anesthesia, Palo Alto Medical Clinic (PAMC)..

“I hope that major improvements in pain management for the post-op patient come along before we retire.”  Bruce Halperin, M.D. AAMG.

“Problems will be:  1) to continue to increase safety while being pressured to do more for less;  and  2) to continue to train future generations of anesthesiologists when staffing and research needs at university settings don’t allow for significant one-to-one teaching.  Residents often provide manpower first and receive education as a secondary benefit.”  Chris Cartwright, M.D., PAMC.

“My thoughts are that we will find opioids without respiratory depression, and be able to use them to decrease the risk of anesthesia so that anybody can do anesthesia for any patient. That is my guess.” Joe Weber, M.D.  PAMC.

“I think that the biggest problem to be addressed in the next 25 years is finding drugs with specific desirable effects, without the side effects we deal with now, such as respiratory depression and nausea.   I am sure that more receptor-specific drugs will be in use by then.”Mike Cully, Hoag Hospital, Newport Beach.
“First, I would expect the problems of the three ‘R’s’:    Retirement, Recruitment, and Retention of anesthesiologists.  Second, I foresee models of delivering care to maximize physician extenders . . . yes, non-M.D. providers of care.   Third, there will be more delivering of care outside of our traditional settings.   Fourth, there will be more partnerships between physicians and care settings . . . i.e. the foundation model for delivery of care.   Fifth,  I expect the digitalization of information and record keeping, and finally, the impact of totally noninvasive surgery that does not require any anesthesia!”  David Berger, M.D.  Alta Bates Hospital.

“I think the biggest problem our specialty will face in the next two and a half decades is an indirect result of the epoch-changing advances you site prior to your question.   I suggest that our specialty is becoming complacent and apathetic and developing a dangerous attitude of entitlement.  The problem is the preservation of our professional status as physician specialists and our individual professionalism, ethics, and autonomy.  These things are the soul and core of what it means to be a physician, and are being eroded by the increasing power and influence of corporate business in medicine, and the ever tightening choke hold of governmental regulation.  There are a number of reasons why the practice of anesthesiology is particularly vulnerable in a way that our surgical colleagues and other physicians are more insulated.  We can accelerate this process of degradation by making short-sighted choices, or become proactive, patient advocacy oriented participants in the evolution of American medicine.  This must be a specialty-wide movement, however, not just limited to the few who are involved beyond one’s own narrow and immediate self interest, for us to successfully maintain the achievements of which we are so proud.”  Mark Singleton, M.D.,  Good Samaritan Hospital Group, San Jose.

“First, I would expect the problems of the three ‘R’s’:    Retirement, Recruitment, and Retention of anesthesiologists.  Second, I foresee models of delivering care to maximize physician extenders . . . yes, non-M.D. providers of care.   Third, there will be more delivering of care outside of our traditional settings.   Fourth, there will be more partnerships between physicians and care settings . . . i.e. the foundation model for delivery of care.   Fifth,  I expect the digitalization of information and record keeping, and finally, the impact of totally noninvasive surgery that does not require any anesthesia!”  David Berger, M.D.  Alta Bates Hospital.

“I think the biggest problem our specialty will face in the next two and a half decades is an indirect result of the epoch-changing advances you site prior to your question.   I suggest that our specialty is becoming complacent and apathetic and developing a dangerous attitude of entitlement.  The problem is the preservation of our professional status as physician specialists and our individual professionalism, ethics, and autonomy.  These things are the soul and core of what it means to be a physician, and are being eroded by the increasing power and influence of corporate business in medicine, and the ever tightening choke hold of governmental regulation.  There are a number of reasons why the practice of anesthesiology is particularly vulnerable in a way that our surgical colleagues and other physicians are more insulated.  We can accelerate this process of degradation by making short-sighted choices, or become proactive, patient advocacy oriented participants in the evolution of American medicine.  This must be a specialty-wide movement, however, not just limited to the few who are involved beyond one’s own narrow and immediate self interest, for us to successfully maintain the achievements of which we are so proud.”  Mark Singleton, M.D.,  Good Samaritan Hospital Group, San Jose.

 

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