Mental Health and Economics

This is a post about money and medicine, but not in the sense that immediately comes to mind. Those who study the epidemiology of psychiatric diseases note a really interesting fact. The prevalence of mental illness increases as a country's economic wealth increases. This happened in post-war America, and is happening now in China. There are a lot of potential reasons for this; as the average wealth of a society increases, the poor who previously did not seek medical care are able to enter the health care system. In poor countries, mental health is grossly underfunded; perhaps as countries gain wealth, they are able to build up those systems. Most likely, the prevalence of disease has always been the same, but the illnesses are better recognized and diagnosed. Maybe in an aging society, diseases like dementias become more pronounced. Although once proposed, I'm not sure that wealthier societies have a direct causal relationship to more psychiatric problems.

I wanted to write a post about this because the vast majority of medicine - doctors, hospitals, media spotlights, research, awareness - neglects mental health. Worldwide, the prevalence of these diseases is increasing and its economic impact is astounding. While illnesses like depression, anxiety, obsessive-compulsive disorder, PTSD, and schizophrenia may not cause that many deaths, it severely impairs patients. The burden on family is huge, and the costs to health care systems should not be underestimated.

Even so, pharmaceutical companies have made and are making fortunes from these diseases. Antidepressants represent an enormous market and will become even bigger as third-world countries become wealthier. Is this the right solution? Are these pills sufficient or necessary to the management of mental health? Are they effective enough to justify their cost? Are we devoting enough resources to research, awareness campaigns, support systems, and nonpharmacologic approaches to tackle this global problem?

It is easy, especially for me, to write about crazy anesthetics or cutting-edge surgery or life-and-death critical care cases. But if that's all I did, that would be missing the point. Even though we all specialize in some small sliver of medicine, we need to be cognizant of the big picture, thinking about diseases with the most burden, and promoting ways to mitigate their impact.

Smoking in Europe

Between finishing fellowship and starting my job, I spent a few weeks in Germany and the Czech Republic. One thing that really struck me was the prevalence of smoking, especially among the youth. Frankly, it was shocking, especially coming from California. I think I had the same reaction I get when I encounter lifestyles that we don't see often in California, such as vociferous anti-gay or pro-gun activists. While I know people like that exist, my social circles just don't include any. In any case, the number of smokers really got to me. I think most doctors have some sort of large-scale grand health-related wish: vaccinations, improved care to HIV/AIDS patients, attention to peripartum morbidity, clean water in third-world countries, tacking social inequity in health care delivery, etc. Mine used to be reduction of waste in health care systems (both physical waste and unnecessary tests, procedures, and medications). But now I think stopping smoking would be a close second.

Real Estate in the Bay Area

This is not really related to medicine, but it is a pertinent nightmare about living in the bay area. Over the last few months, we started throwing around the possibility of buying a house. In the last year or two, a surprising number of our friends have made that impressive first purchase around here. On the other hand, our friends practicing medicine in other parts of the country have been happily living in beautiful, large properties for years. While I had heard a lot about trying to buy in the bay area, I wasn't ready for the shock of it. The housing market is a little ridiculous around here. Before ultimately renting, we made a few offers for houses, averaging around fifteen percent above list price, and for most of the places, we weren't even close. The crazy silicon valley competitors here have distorted the market so much that even bidding hundreds of thousands of dollars above the list price isn't enough to secure a house. Ultimately, we realized it wasn't in the cards this year; we'll give it some time and see where the market goes.

...And In Conclusion

After a bit of soul searching and a lot of conferring with mentors, I decided to take a private practice position in Mountain View. The group of 30 or so anesthesiologists runs incredibly smoothly under very focused leadership. I'll have the opportunity to do operating room anesthesia, labor and delivery, and attend in the intensive care unit. It really allows me to participate in all the aspects of anesthesia that I wanted to do. The members of the group are all very friendly and happy, and I look forward to getting to know them better. I took about three weeks off between finishing fellowship and starting the job so it's coming soon. I'm a little nervous but I think this will be great for me.

The Job Hunt V

I ended up considering six different job opportunities as well as one that was primarily non-clinical (multidisciplinary translational research). The groups varied from small (ten anesthesiologists) to moderate (forty anesthesiologists). They were all-physician practices that did not employ nurse anesthetists. Some operated in only one location while others had contracts with many different small surgicenters and surgeons. There was considerable variation financially, with differences in expected salary up to $100,000. Some groups did everything from neuroanesthesia to obstetric anesthesia to pediatric cases to trauma. Others had a very narrow scope. Call schedules weren't that different between groups, and depended mostly on whether obstetrics and trauma needed to be covered. Most groups were subsidized by the hospital they contracted with. Most groups appeared to have great relationships with their surgical colleagues and administration; some even had prominent leadership presence. As I am additionally trained in critical care medicine, I was also interested in opportunities to work in the ICU, and among private practice groups, this was very rare.

One aspect of private practice physician groups I had to learn about was the concept of "buy-in." For many groups, when a physician initially joins, they are an employee rather than a partner or shareholder. They may have to work for several years at a lower salary and without a vote before they can become a partner of the group. This is known as the "buy-in." There was significant variation in how this was set up, but for all groups, voting on business matters was limited to only a subset of physicians, and for most groups, salary and bonuses depended on how long someone had been part of the group. I don't particularly like the concept of the buy-in, but it seems to be a non-negotiable constant in many practices.

The Job Hunt IV

Whereas applications for undergrad, medical school, residency, and fellowship usually involve extensive essays and short answer questions, jobs usually only want a CV. My cover letter was short, only a paragraph. I sometimes wonder how groups differentiate between applicants since I'm pretty sure my CV looks very similar to those of other graduating residents or fellows. Perhaps this is why connections and networking matters so much.

Then, there's usually a short telephone interview and then an all day in person interview. Unlike medical school or residency, the process goes two ways; I am as critical in evaluating the potential job as they are in evaluating me. Well-trained highly motivated doctors with integrity are a huge value to the group, and they spend a lot of time trying to recruit us. As a result, the interview process is very benign and cordial, at least in my specialty. I try to meet and talk to as many members of the group as possible to get the widest perspectives of what it's like to work there. Sometimes, recent members have differing opinions than the old guard. Each group and hospital has a different flavor of patients and procedures, different relationships with staff and surgeons, and different ways of managing the finances. Unlike prior application processes, it's hard to compare one opportunity with another. It's not always apples to apples. Early on, I learned there's no perfect job for me, and I have to figure out what I'm willing to sacrifice.

The Job Hunt III

For me, the process was strangely straightforward. Because of my wife's job and our preferences, we only looked in the Bay Area. The job market here involves a lot of inquiries and networking. I basically went through all the groups I had heard about and all the hospitals that existed in the Bay Area. I asked around for insights and opinions about the groups. I did some researching to get a sense of how big they were, the hospitals and surgical centers they served, and the demographic of the group. Then I sent a quick email to the leadership of the group. During the process, everyone was cordial, but most groups were not looking to hire.

In anesthesiology, at least, the market goes through ebbs and flows. When there is a lot of uncertainty in health care, as with the Affordable Care Act, changing reimbursements, and shifting supply-demand structures, physician groups tend to batten down the hatches, ready for a lean season. There is uncertainty at every level; hospitals have to stay out of the red, groups have to renegotiate contracts, even large health care systems like Kaiser try to move to predict the future. Thus, when I started looking, jobs were scarce, but over the year, I realized most of the scarcity was a result of doctors being conservative. Once they realized the Affordable Care Act didn't ruin everything and other policy changes transitioned smoothly, they became more willing to expand their group.

The Job Hunt II - Geographic Variations

Even within the United States, medicine is highly geographic. In medical school, we all learn about and lament geographic disparities in health care delivery and outcomes. However, when we start looking for a job, we're just as reluctant to go to rural America. It's unfortunate, and yet a harsh reality. It seems that the best way to get physicians into places that need them is to recruit medical students from those areas and backgrounds.

Nevertheless, geography is perhaps the most important factor for a graduating resident in search of a community position. Even a year before I finished, I started getting postcards from places that were desperate for an anesthesiologist. If you're interested in the Midwest or South, a job awaits. These really aren't bad options; given the salary increase moving from resident to attending and the low cost of living in many of these places, it is a great way to work down debt. Furthermore, many of these areas are in need of well-trained physicians, and it can certainly fulfill that desire many of us have when we first enter medicine to really help a community.

Nevertheless, because of family, friends, our social network, our fear of inclement weather, our personal desires and goals, or any dozen other reasons, we tend to stay in the place we did our training, and often, that means in places that are replete with physicians. The Bay Area, for example, is a tight market. When I first started sending out letters of inquiry, half of my emails got no response, and a quarter got a "Thank you for your interest, but we're not looking to hire." Only a few groups were actively and publicly recruiting; most were only looking around through contacts or not necessarily in need of another doctor. Thus, all my colleagues in the Bay Area felt intense pressure if they wanted to stay. In fact, more than half my residency and nearly 90% of my fellowship class ended up leaving this area because there simply weren't acceptable jobs. This can be really scary, and it's why even for a well-trained highly qualified physician, finding a job isn't a walk in the park.

The Job Hunt I

The job search can start incredibly early for residents or fellows transitioning into practice. We are often intimidated by the process because it's so open-ended and vague. Up until now, our paths have been defined and prescribed. When applying to medical school, most of us choose the "best rated" school we get into (though I'm not sure how good such measures are). Because residency is determined by a match, we apply to many places but get told where we end up. Jobs, on the other hand, are entirely different. For those of us not going into academic practice, choosing a job has a myriad of variables and a flavor of subjectivity that scares us. How strongly do we weigh location, salary, call schedule, scope of practice, culture of the group, first impression, or prestige? With a rolling schedule of hiring, do we take the first job we get or hold out for something better? This is our first opportunity to make a real salary; some of us tell ourselves we have to get it right. But unlike medical school and residency, jobs are not set in stone, and outside of medicine, people change jobs and careers frequently. As a first job, we don't even know what we're looking for. We know how to rate educational experiences and training environments, but actual practice is very different. Whereas we want complex patients and difficult cases to learn from, we may not want to make that our everyday job. When you combine such uncertainties with the perfectionist personalities that go into medicine, you can easily see why we are so stressed about the job hunt.

Surgical ICU

All in all, I really enjoyed my time as a fellow on the surgical ICU. It was much better than being a resident as I had entirely a supervisory role, better hours, an improved understanding of the politics and relationships with surgeons, and a honed skill set. It became my final rotation of my fellowship, and I felt a little nostalgia as I rounded in the east ICU one last time. The last week of the rotation was the one in which chief residents moved on, junior residents moved in, and interns began, so I helped smooth the transition for many. We had some long-term patients who had been there for weeks, and by the end, we had resolved the critical care issues for most of them, and that was wonderful closure. I was very glad to finish my fellowship at the home base at Stanford, and I have a few weeks to write about the exciting things to come in my career.

Ownership

When a surgical patient goes to the intensive care unit, her treating physician and team changes to the ICU attending and team, regardless of who was in charge before. This can sometimes create conflicts in patient ownership. A surgeon who takes a high-risk patient to the OR and sends him to the ICU afterwards relinquishes control over the patient's care. If a patient has a complication and goes to the ICU, the surgeon has to step back and let us fix his problems. Obviously this distinction isn't so black-and-white. But it can lead to too many cooks in the kitchen.

We put a lot of weight into what the primary surgeon and team want. After all, they were at the surgery, and sometimes, they have additional information. For example, a patient whose tissues are extremely fragile in surgery will be at higher risk for wound dehiscence. This may not be reported but if a patient has a rocky post-op course, it may become relevant. The surgeon also knows the patient's anatomy the best, understands his own surgical strengths and weaknesses, and feels incredibly invested in the patient's outcome.

Yet it's important not to let the primary surgeon run the patient's ICU course. Critical care medicine is its own subspecialty. A couple decades ago, most ICUs were run by physicians who were not specially trained in critical care. The poor outcomes at that time lead national agencies like the Leapfrog Group to advocate ICU physician staffing. Whether a patient has medical problems, traumatic injuries, or post-operative complications, we can take care of their multiorgan failure, resuscitation, management, and treatment. We cannot expect general surgeons to stay up-to-date on intensive care medicine. Dedicated intensivists should be able to bridge surgical concerns with critical care medicine to take the best care of our patients.

SICU and Palliative Care

Back to regular blogs. When I was on the surgical ICU service, I struggled a lot with the issue of palliative care. Compared to the medical ICU, palliative care was consulted much less, if at all. This is a cultural bias among surgeons. There is the sentiment that if we start talking about the end of life, comfort options, or reasons not to pursue aggressive treatment, then we have failed. This, of course, is not true. Palliative care is not a binary decision; one can involve principles of palliation while pursuing curative treatments. However, not everyone views it this way.

Although patients on the surgical ICU service are more likely to recover than patients on the medical service, we still have extremely sick people. Patients with severe traumatic injuries leading to brain damage, multiple re-operations for cancer, and severe comorbid diseases often end up in the SICU. I strongly feel that a balanced presentation of medical options is the most appropriate, and this often means talking about the end of life. No matter how good the surgeon, how careful our care, we cannot stave off death forever. I am aggressive in trying to understand a patient's wishes, especially around cardiac arrest and resuscitation. I want to know if we are setting them up for a future they do not want.

This is not to say that I want to "pull the plug" on our patients. In fact, our sickest patient on the service was someone who had cardiac failure after a cardiac arrest, severe pulmonary hypertension with pulmonary pressures equal to system pressures (a scenario many would call fatal), renal failure, liver failure, and systemic infections. We found out after a week of being intubated on a mechanical respirator that he would not want to be dependent long-term on such machines. After long talks with his durable power of health care, we proceeded to treat him aggressively. Another week later, we extubate him. He starts talking the following day. When we put his illness in the context of his wishes, we still felt it was worth putting him through the ICU stay. The important thing here, though, was the conversations we had to weigh the risks and benefits of all we did and talk about palliative care as a real possibility.

In talking to the surgeons over the course of the month, I realized that their mentality is very different from medicine doctors. For the most part, a surgeon takes a patient to surgery because he thinks he can make her better. By removing the gallbladder, taking out the cancer, or replacing the joint, his aim is to improve the patient from her baseline. On the other hand, most inpatient internal medicine hospitalists are reactive. A patient comes in with pneumonia, heart failure, or a stroke, and the goal is to get her as close to her baseline as possible. We cannot get them better than their pre-illness state. For the medicine patients, some won't do well, and palliative or comfort care may be appropriate. With the surgical patients, however, to talk about the end of life or giving up is tantamount to saying that we have offered something elective in hopes of improving life but wound up worsening it. There is a sense of guilt, shame, and silence.

I hope that having a multidisciplinary surgical ICU helps balance these intense cultural factors. Our goal is to care for our patients as best we can, and sometimes involving our palliative medicine specialists is critical.