What it’s like to be a female anesthesiologist…

To promote the series #asawoman started by @nataliecrawfordmd (from Instagram)
.
.
Throughout medical school, residency, fellowship, even now in private practice… patients have often judged a book by its cover. They’ve thought I was their nurse, volunteer, high school student or college student shadowing, almost everything but the person who will lead their anesthetic care. While this can seem deflating given all the extra work and studies one puts in to become a physician, I’ve changed my mindset re: my patients’ initial thoughts on me.
.
.
First of all, thank goodness they think I’m super young! I have my mom’s genes and beautiful skin to thank!! At this rate, I hope I start to look 30 when I hit 50. When patients ask my age, I happily oblige them with a bold 39. Then I see a look of relief over their faces. I, of course, ask them how old they think I am….and I get the range of: just graduated college to mid-20s. Awesome!! I use it as a bonding moment and icebreaker with my patients. Sometimes with the right patient, I joke with them that it’s my first day… it usually entertains a good laugh. Then, I go into an overly technical schpeel on risks/benefits of anesthesia, expectations, PACU recovery. This typically solidifies to the patient that it’s not my first day on the job. Additionally, many patients tell me in the PACU that they feel better than their prior experience or better than their expectation and are quite grateful for my care.
.
.
There are a lot of men in my anesthesia group. Sometimes, after I introduce myself to the patient, they’re shocked that a woman anesthesiologist would be delivering their care. In this day and age, I’m shocked that a lot of patients still assume that a male physician will oversee their care. When caring for female patients with this mentality, I purposefully address a gentle and vigilant anesthetic plan. With my male patients with this mentality, often times they’re happy to talk about the “happy juice” cocktail they’ll get and some much deserved relaxation knowing that I will carry a watchful eye over their surgery and anesthetic.
.
.
Lastly, since becoming pregnant with my first and currently pregnant with my second… I feel I have a better understanding of the worried/concerned parents who are at the bedside to be with their child about to enter surgery.  Oftentimes, the parents think I’m young and want to know where I trained and when I graduated.  I offer them this info, and continue speaking to the patient (their child) about their concerns or questions.  I make sure the parents know everything that will go on re: anesthetic plan, how the patient will feel in recovery and risks/benefits of anesthesia options.  I TAKE MY TIME with the parents and the patient.  While my age and gender often work against me (even though it shouldn’t!), I make sure the controllable worries by the parents are addressed.  I speak to the parents after the surgery.  They go into the recovery room and see their child (older than 13 at our hospital) comfortable and recovering.  While I can’t change my appearance (nor would I want to…), I can change perceptions of women physicians.  We are every bit as capable of everything our male colleagues can do.  In addition, we tackle pregnancy, motherhood, businesses, and everything in between.  #asawoman As A Woman, I feel more empowered now than ever before.

Women in Anesthesiology

American Medical Women’s Association

American College of Physicians: Women in Medicine

Bias, Bravery, and Burnout: The Journey of Women in Medicine

Please immunize your kids.

I don’t get too frazzled by things in general.  It’s important as an anesthesiologist to keep your cool and to keep your wits about you.  Well, I just about lost it today when the topic of vaccines came up and someone sent me this video.  Granted, I did my due diligence and watched that video.  I’m typically open to suggestions and people’s opinions.

First of all, my criticism isn’t about his holistic or chiropractic care.  My criticism is about his “expertise” in medicine and vaccines, which he isn’t qualified to opine.  The guy in the video has absolutely no understanding of how statistics work.  Going to a website to show data where you just show numbers of deaths doesn’t validate your point.  Sadly, it’s shocking to me to see that people believe in this hack.  I can’t even put it politely because it’s people like him who spread the word that vaccines are harmful and cause more harm than good… and people actually believe him.

So, let me present you with real data that shows the value in vaccines coming from an M.D. and not a chiropractor.  By the way, look at the makeup of the scientific advisory panel of this organization.

Here’s a video I would rather watch: ZDoggMD


The Facts

10 Facts on Immunization from the World Health Organization

UNICEF: Immunization Current Status

WHO: Q&A on Immunization and Vaccine Safety

WHO: Antibiotic Resistance and Vaccines

WHO: Immunization coverage and fact sheet

WHO: Vaccine Hesitancy

Wikipedia: Eradicated Diseases

ChildTrends: Databank Immunizations

OECDdata: Childhood Immunizations

 


The Studies

Our World in Data: Vaccinations


Pros vs. Cons

ProCon.org: Vaccines

ProCon.org: The History of Vaccines

WHO: 6 Common Misconceptions of Vaccines

8 Common Arguments Against Vaccines

Vaccine Safety Commision

PublicHealth.org: Understanding Vaccines

Open Forum Infectious Diseases, Volume 4, Issue 3, 1 July 2017.  Vaccine Rejection and Hesitancy: A Review and Call to Action.


Implications for the Future

Physicians face the burden of the anti-vaccine argument

 


My Take

I want the best for myself, my family, and my friends.  I will continue to be a voice for pro-vaccines.  Given all the existing research and statistically significant data, I do believe that vaccines are beneficial in preventing disease.

Key points:

  • Do your research
  • Listen to the experts in the field (not quacks who pretend)
  • Do no harm
  • Get vaccinated!  You’re protecting yourself and others around you!

You’re done with residency/fellowship. Now what?

You have devoted the last decade of your life to medical school, residency, and fellowship. It’s time to get out into the real world for a REAL job. Where do you want to live? What type of practice would you like?

workhoursdoc
From AMA

Timing is everything.  Start early!

I started my fellowship in August.  During my elective pediatric hearts rotation, I met a team of physicians who were very encouraging and asked if I had a job yet (this was October).  I told them I didn’t have a job yet, but I wanted to stay in California.  Maybe it was my lucky day, but one of the lady docs I worked with sat on the application committee for my current job.  She encouraged me to apply to their anesthesia group.  After going through the proper channels, I got a phone call from the anesthesia group saying they would like to interview me for a position.  I had my interview in November and heard back in December that I had a job.  Everything happened in such quick succession.  When I left residency, I knew I wanted to be in southern California.  Thank goodness I matched into a fellowship spot in Southern California!  It makes it easier if you know what area/region/state you want to practice in.  Keep in mind that some states are more friendly to physicians than others.

2018 Best States to Practice Medicine

//d2e70e9yced57e.cloudfront.net/wallethub/embed/11376/doctors-geochart1.html

Source: WalletHub

 

After you’ve decided on a location to practice, figure out the type of practice options that are available in the area.

Luckily, I was working in the city that I wanted to be in, so I could easily survey the hospitals and find out who was hiring.

Physician Group Practice Trends: A Comprehensive Review. Journal of Hospital and Medical Management. 2016.

Do your research. 

What type of practice works for you?  Do you want a large academic center with a physician-led team approach to healthcare?  Do you want to practice in a private practice setting in a team or solo?  There are so many practice models out there — I wish residencies explored/explained more of these options.  Fortunately, I knew a solo-practice physician-only model would work best for me.

10 Ways private practice differs from academic anesthesia

Keep in mind the number of hours you want to work.  What are the opportunities for working more or less?  How many vacation weeks will you get?  Is there paid-time-off?  Will you have a salary or productivity-based income?  How many calls/month will you take?  Is there a discrepancy between new hires vs. senior partners in access to vacation/salary/calls/etc.?  Is there fairness in scheduling?  How long will it take to make partner?  What’s the buy-in amount?  Is there a buy-out when you leave/retire?  I didn’t know to ask these questions when I was going through the process of looking for my job.  Don’t forget to ask about retirement options and health insurance coverage.  Also, ask if it’s possible to work at another hospital or surgery center in the area or if there is a non-compete clause in the contract.

The Interview

Bring your best self to the interview.  The people who are interviewing you want to know more about you.  Tell them about your hobbies, lifestyle, goals for the group, plans for the future.  Engage your interviewer and ask them how long they’ve been with the group.  How do they enjoy their time?  Keep in mind that they’re interviewing you because you look great on paper.  They want a chance to get to know you better.  Show them your best self, especially all your hobbies and interests outside of medicine.  Keep the conversation casual and inviting.

The Contract

Read over the contract carefully.  My group has a one year contract that is revisited yearly and is the same for every member of our 250+ physician group.  Before I started, some people recommended a contract attorney specializing in medical contracts to read it over.  I didn’t find it necessary in my case as my contract was the same for every physician in my group and the language was very clear to understand.  Use your own judgement.  If you don’t understand the contract, get some help.

 

What recommendations did you find helpful in your job search and interview?

What additional help can I include in this post?

Responsibility for your own health

I was shocked to see that the NHS could ban surgery for the obese and smokers.  That’s socialized medicine.  You take a conglomerate group of people (the UK) on a limited budget for healthcare… and basically find the cheapest most cost-effective way to deliver healthcare.  But in a way, it’s empowering patients to take responsibility for their own health.  Smoking, for sure — I agree 100% that surgery should be banned for this population.  Obesity is a bit trickier — there’s genetics and environmental factors at play in this one.  I don’t think anyone chooses to be obese.  But, people do have the power to change their eating and exercise habits.  Despite these efforts, there are some people who are still obese…. and these people should not be faulted.

Why single out the obese and smokers?

obesity-and-cv-disease-1ppt-44-728
From SlideShare
obesity-and-cv-disease-1ppt-43-728
From SlideShare
tobacco-health-statistics
From TobaccoFreeLife.org

Smokers and the obese have elevated surgical risk and mortality, which means more cost to treat and hospitalize and provide ongoing care.

150423sambydisease
From HealthStats

I think the NHS is on to something here.  They’re opening doors to moving the liability and responsibility away from physicians and towards patients.  This is a plus.  Outsiders may see it as separatism and elitist to only provide care for people who are healthy.  But look at the facts and the data…. obesity has a lot of co-morbidities associated.  Smoking has a lot of co-morbidities associated as well.  Why should physicians be penalized for re-admissions, poor wound healing, longer hospitalizations when the underlying conditions themselves are already challenging enough?  In fact, I would urge insurance companies to provide incentives to patients/the insured with discounted rates for good and maintained health and wellness.  With all the technologies, medications, and information out there, it’s time patients take responsibility for their own health.  I take responsibility for mine — watching my diet, exercising, working on getting enough rest, maintaining activities to keep my mind and body engaged, meditating for rest and relaxation.  It’s not easy, but my health is 100% my responsibility.  I refuse to pass the buck to my husband, my family, my physician, etc.  I do what I can to optimize my health and future — and if that doesn’t work… I call for backup.

Patients need to change their mindset re: health.  It is not your spouse’s responsibility to track your meds.  It is your responsibility to know your medical conditions and surgical history.  The single most important (and thoughtful) thing a patient can do is keep an up-to-date list of medications, past/current medical history, surgical history, and allergies to bring to every doctor’s appointment and surgery.  This helps streamline and bring to the forefront your conditions and how these will interplay with your medical and surgical plan and postoperative care.  Please do not forget recreational drugs, smoking habit, and drinking habit in this list.  It is very important to know all of these things.  Also, your emotional history is very important.  Depression, anxiety, failure to cope, etc.  This all helps tie in your current living situation with stressors and your medical history.

Links for educating yourself in taking responsibility for your health:

obesity
From SilverStarUK.org

Suprascapular Blocks

Trends are evolving in decreasing intraoperative and postoperative opioid use.  Therefore, anesthesiologists are constantly learning new regional techniques to help with postoperative pain.  For shoulder surgeries, I’ve moved away from interscalene blocks toward supraclavicular blocks.  I think the interscalene block provides a better block of a total shoulder surgery, however, certain patient comorbidities often make the supraclavicular block a better choice.

Nice paper from Anesthesiology, Dec 2017: Suprascapular and Interscalene Nerve Block for Shoulder Surgery: A Systematic Review and Meta-analysis. Anesthesiology 12 2017, Vol.127, 998-1013.

Nowadays, it seems that suprascapular blocks are gaining in popularity (I’d probably use it to supplement the supraclavicular block.

Supplies and Technique (from USRA):

Suprascapular Nerve

ssn1

How to position the ultrasound probe:

ssn5
From USRA

05_1_a_shoulder-suprascapular-artery-and-nerve_dsc_5085_copy

Ultrasound Image

ssn4
From USRA.  SSM = supraspinatus muscle
SSA = suprascapular artery
SSN = suprascapular nerve
TZM = trapezius muscle
STSL = superior transverse scapular ligament

05_1_c_shoulder-suprascapular-artery-and-nerve_labels

Useful Links


Update: June 19, 2018

Comparison of Anterior Suprascapular, Supraclavicular, and Interscalene Nerve Block Approaches for Major Outpatient Arthroscopic Shoulder Surgery: A Randomized, Double-blind, Noninferiority Trial. Anesthesiology 7 2018, Vol.129, 47-57.

PEEP Alone Atelectasis
From Anesthesiology, July 2018
  • Conclusions: The anterior suprascapular block, but not the supraclavicular, provides noninferior analgesia compared to the interscalene approach for major arthroscopic shoulder surgery. Pulmonary function is best preserved with the anterior suprascapular nerve block.

Methadone and Acute and Chronic Pain Management

We had a journal club where we discussed this article: Anesthesiology, May 2017; Clinical effectiveness and safety of intraoperative methadone in patients undergoing posterior spinal fusion surgery: a randomized, double-blinded, controlled trial.

  • IV Methadone 0.2 mg/kg vs IV hydromorphone 2mg at surgical closure in 2+ level spinal fusion
  • Decreased postop IV and opioid requirements and pain scores.  Improved patient satisfaction

Questions:

  1. Is there a pain service following these patients postoperatively?
  2. Exclusions: do you include OSA and BMI>45 patients?
  3. Is ETCO2 and PCA enough to combat respiratory depression on the floor?
  4. Are any discharged on the same day after receiving this dose — think total knees and single level lamis?
  5. Will this improve or worsen the opioid epidemic?
  6. Are surgeons on board with tackling pain multimodally for the benefit of the patient?
  7. For pain follow-up, are there psychiatry, homeopathy, palliative care, PT, holistic approaches for the patient?

Methadone Dose Conversion Guidelines

Intraop Lidocaine for postop pain

Intraop Ketamine for postop pain

Literature search:

Sys Rev 2014: Effectiveness of opioid substitution treatments for patients with opioid dependence: a systematic review and multiple treatment protocol.

Am j of Pub Health, Aug 2014. Determinants of Increased Opioid-Related Mortality in the United States and Canada, 1990–2013: A Systematic Review.

Br J Clin Pharmacol. 2014 Feb; 77(2): 272–284. Long term outcomes of pharmacological treatments for opioid dependence: does methadone still lead the pack?

PLoS One. 2014; 9(11): e112328. Methadone Induction in Primary Care for Opioid Dependence: A Pragmatic Randomized Trial (ANRS Methaville).

Curr Psychiatry Rev. 2014 May; 10(2): 156–167. Genetics of Opioid Dependence: A Review of the Genetic Contribution to Opioid Dependence. 

Drug Alcohol Depend. 2016 Mar 1; 160: 112–118. Methadone, Buprenorphine and Preferences for Opioid Agonist Treatment: A Qualitative Analysis. 

Croat Med J. 2013 Feb; 54(1): 42–48. Risk factors for fatal outcome in patients with opioid dependence treated with methadone in a family medicine setting in Croatia. 

J Med Toxicol. 2016 Mar; 12(1): 58–63. Pharmacotherapy of Opioid Addiction: “Putting a Real Face on a False Demon”. 

Syst Rev. 2014; 3: 45. Sex differences in outcomes of methadone maintenance treatment for opioid addiction: a systematic review protocol.