TEE Quiz..

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I read an essay on the NY times.thought its a must to share it with you all

A Doctor by Choice, a Businessman by Necessity By SANDEEP JAUHAR, M.D.

To meet the expenses of my growing family, I recently started moonlighting at a private medical practice in Queens. On Saturday mornings, I drive past Chinese takeout places and storefronts advertising cheap divorces to a white-shingled office building in a middle-class neighborhood.

I often reflect on how different this job is from my regular one, at an academic medical center on Long Island. For it forces me, again and again, to think about how much money my practice is generating.

A patient comes in with chest pains. It is hard not to order a heart-stress test when the nuclear camera is in the next room. Palpitations? Get a Holter monitor — and throw in an echocardiogram for good measure. It is not easy to ignore reimbursement when prescribing tests, especially in a practice where nearly half the revenue goes to paying overhead.

Few people believed the recent pledge by leaders of the hospital, insurance and drug and device industries to cut billions of dollars in wasteful spending. We’ve heard it before. Without fundamental changes in health financing, this promise, like the ones before it, will be impossible to fulfill. What one person calls waste, another calls income.

It is doubtful that doctors and other medical professionals would voluntarily cut their own income (even if some of it is generated by profligate spending). Most doctors I know say they are not paid enough. Their practices are like cars on a hill with the parking brake on. Looking on, you don’t realize how much force is being applied just to maintain stasis.

I recently spoke with a friend who dropped out of medical school 20 years ago to pursue investment banking. Whenever we meet, he finds a way to congratulate me on what he considers my professional calling. He often wonders whether he should have stuck with medicine. Like many expatriates, he has idealistic notions of the world he left.

At our most recent meeting, we talked about the tumult on Wall Street. Like many bankers, he was worried about the future. “It is a good time to be a doctor,” he said yet again, as I recall. “I’d love a job where I didn’t have to constantly think about money.”

I didn’t bother to disillusion him, but the reality is that most doctors today, whether in academic or private practice, constantly have to think about money. Last January, Dr. Pamela Hartzband and Dr. Jerome Groopman, physicians at Beth Israel Deaconess Medical Center in Boston, wrote in The New England Journal of Medicine that “price tags are being applied to every aspect of a doctor’s day, creating an acute awareness of costs and reimbursement.” And they added, “Today’s medical students are being inducted into a culture in which their profession is seen increasingly in financial terms.”

The rising commercialism, driven in part by increasing expenses and decreasing reimbursement, has obvious consequences for the public: ballooning costs, fraying of the traditional doctor-patient relationship. What is not so obvious is the harmful effects on doctors themselves. We were trained to think like caregivers, not businesspeople. The constant intrusion of the marketplace is creating serious and deepening anxiety in the profession.

Not long ago, a cardiology fellow who had been interviewing for jobs came to my office, clearly disillusioned. “I was naïve,” he said. “I never thought of medicine as a business. I thought we were in it to take care of patients. But I guess it is.”

I asked him how he felt about going into private practice. “I’ll be too busy vomiting for the first six months — I won’t have much time to think about it,” he replied.

Of course, there has always been a profit motive in medicine. Doctors who own their own imaging machines order more imaging tests; to take an example from my moonlighting work, a doctor who owns a scanner is seven times as likely as other doctors to refer a patient for a scan. In regions where there are more doctors, there is more per capita use of doctors’ services and testing. Supply often dictates demand.

But financial considerations have never been as prominent as they are today, probably because so many hospitals and doctors, especially in large metropolitan areas, are in financial trouble. More and more doctors are trying to sell their practices, or are negotiating with hospitals for jobs, equipment or financial aid.

At hospitals, uncompensated care is increasing as patients suffering from the economic downturn lose health insurance. Admissions and elective procedures — big moneymakers — are declining. Hospitals are cutting administrative costs, staff and services.

“More and more you’ll see people in medicine get M.B.A.’s,” a doctor told me at a seminar, in a prediction borne out in my experience. “We are in a total crisis, and I don’t know the answer.”

I must admit that part of me wants to see doctors master the business side of our profession. When I hear about executives at health companies getting tens of millions of dollars in bonuses, I am nauseated by the blatant profiteering. As a loyal member of my guild, I want to see doctors exert more control over our financial house.

And yet the consequences of this commercial consciousness are troubling. Among my colleagues I sense an emotional emptiness created by the relentless consideration of money. Most doctors went into medicine for intellectual stimulation or the desire to develop relationships with patients, not to maximize income. There is a palpable sense of grieving. We strove for so long, made so many sacrifices, and for what? In the end, for many, the job has become only that — a job.

Until I went into practice, I never had an interest in the business side of medicine. I sometimes yearn to be a resident or fellow again, discussing the intricacies of a case rather than worrying about the bottom line. “You need to learn a little of the private-practice mind-set,” a doctor friend recently advised me. “You can’t survive with your head in the clouds.”

But something fundamental is lost when doctors start thinking of medicine as a business. In their essay, Dr. Hartzband and Dr. Groopman talk about the erosion of collegiality, cooperation and teamwork when a marketplace environment takes hold in the hospital. “The balance has tipped toward market exchanges at the expense of medicine’s communal or social dimension,” they write.

How this battle plays out will determine to a great extent what medicine will look like in 20 years. This is about much more than dollars and cents. It is a battle for the soul of medicine.

Sandeep Jauhar is a cardiologist on Long Island and the author of the recent memoir “Intern: A Doctor’s Initiation.”

Smiling Child.. Finally

You could never see a smile on her face. Lagmavva, a cute little 8 year old from North Karnataka hardly ever sported a grin on her face for all the 15 days that she was under our care. She was one of the bluest 'tets' that has been operated on in MSR-NH so far. Surgery was uneventful but for some confusion regarding the exact RV/LV pressure ratio post CPB( we all agreed finally that it was less that 0.75..). Nevertheless, child was successfully weaned off the CPB with stable hemodynamics with minimal inotropic supports and normal sinus rhythm. We extubated her on first POD, since all the necessary parameters were within acceptable limits. All of us, members of the surgical team, rejoiced secretly for this favorable outcome. But our joy was to be only shortlived since, much to our disappointment and dismay, the cardiologist found  residual VSD with'sizeable' shunt on post op echo. How ever, she also suggested that, since all the pieces are not really fitting approriately in the jigsaw puzzle it would be prudent to do a catheterisation study to grade the VSD and measure Qp/Qs. Cath was done and fortunately proved that VSD wasn't all that significant and Qp/Qs is 1. So, with her cardiac problem sorted out, we heaved a sigh of relief and proceeded with her futher management  so that she can be discharged from the ICU. But then, she had different plans for us !

She refused to take anything orally except coffee( a lots of coffee.. sometimes 6 cups straight!). If forcibly fed, she used to vomit everything with in few minutes. Her past history revealed similar problem since almost 2 months along with history of intermittent abdominal pain. We sought evaluation by pediatrician, pediatric surgeon and pediatric cardiologist. They didn't find anything grossly abnormal with her and one of them even suggested that it could be because of some psychiatric problem. The latter opinion looked more plausible to us also, since the child hardly used to smile, always used to be withdrawn from her surroundings and used to be hyper irritable. This repeated vomiting episodes soon after food intake continued for almost a week after discharge from our post op ICU. So. we decided to get an endoscopy done for the child. We had the dubious honour of anesthetising the child for the fourth time( Cath study, surgery, cathstudy again and finally for the endoscopy !). This turned out to be a very wise move.. it was found on endoscopy that the child had a stricture oesophagus because of reflux oesophagitis due to hiatus hernia! The stricture was dilated with balloon and child was shifted to ward. After a really long time she could eat a meal and retain it too.  

She started smiling after that. And it was a wonderful sight !  I wanted to share it with you all and hence this post..

Pediatric cardiology is one of the most active departments in our hospital. like us they have entered into blogosphere. here is the link.

http://narayanapediatriccardiology.blogspot.com/2008/12/welcome-to-pediatric-cardiology-blog.html

For the travelling anaesthetist..

No, this post is not about "Travelling Fellowship"! Its for all those my dear brotheren who are bitten by "Travel Bug", who have a mandatory requirement for taking off atleast once in 3-6 months on a vacation so that they can come back to this dreary world, rejuvenated. These two links will help you plan your travel, especially if you are planning to drive down to that place.

Both links are best loaded by Internet Explorer 6.0 onwards.. There are interactive maps with some very useful features. Hope it will be of use to you..

http://www.mapxl.in/path-finder/map_routing.phtml?config=routing

http://www.mapsofindia.com/driving-directions-maps/