A Cure For Irrelevance
Anesthesiology used to be a job that was attractive for people who don’t like patients very much. The drill was: meet patient 5 minutes before surgery, do case in OR without interruption, drop off in PACU, done. Minimal need for personal interaction with patient, no need to listen to complaints about back pain and demands for antibiotics for a cold, no risk of getting called in the middle of the night with a fever. Early anesthesiologists were on the cutting edge of medical innovation, nobody else could do what they did, and patients were just glad anesthesia existed. Anesthesiologists like to think they still are on the cutting edge, but the old drill is no longer enough. Health care providers who are not anesthesiologists now do the meet-patient-do-the-case-drop-off all the time. Nurses do sedation and CRNA’s do all kinds of cases up to and including heart surgery. This scares the folks at the American Society of Anesthesiologists (ASA) and results in the turf wars I have talked about on this site before. It also results in questions from med students, who wonder (again) about the stability of the field.
Looks like anesthesiologists are going to have to become real doctors.
Of course I don’t mean by this that anesthesiologists aren’t doctors, in the sense that we all went to med school, did residency, and take care of people during surgery. But we have paid a lot of attention to the technical aspects of patient care and been glad to hand the patient part of patient care to others. Being a doctor means caring for a patient body and mind, throughout health and illness. Anesthesiologists want to “do the case”. We have to come closer to “caring for the patient.” The best of us already do. The rest of us must.
Here’s a typical example of an outpatient surgical case. Patient has a problem of some kind. Surgeon meets patient, examines him, decides he needs surgery, discusses the pros and cons with him and his family, schedules the procedure and any pre-operative tests the surgeon thinks the patient might need. Patient is healthy and so the surgeon waives the need to go to the pre-op clinic, where nurses and anesthesiologists see patients in preparation for surgery. Patient arrives on day of surgery and is greeted by a nurse, who does all the initial work of making the patient feel comfortable and screening for potential problems. At this point the nurse is now caring for the patient, no doctor in sight. Now comes the anesthesiologist. He reviews the information the surgeon and nurse have compiled in the patient’s chart. “Hi, How are you? I’m your anesthesiologist. Anything to eat or drink today? Any problems with anesthesia in the past? No? Great! I’m going to put your IV in and then we’ll get going.” So far this doctor has said Hi, read some paperwork, and done a minor procedure that nurses can do just as well. The anesthesiologist then gives the patient a sedative and wheels him to the OR, where the anesthesia is done. Here is where the ASA gets nervous, because it is in the OR that “midlevels” are gaining favor as a cheaper alternative. Then the anesthesiologist wheels the patient over to recovery, gives report, and that’s the end of it. The nurse again takes over, only calling the anesthesiologist if there is a problem. The nurse decides when patient is ready to go home. The nurse calls whoever is in charge of anesthesia, who comes over and signs a form that says “yes, indeed, this person can go home safely.” Next case.
Is there any part of that that demands four years of medical school and four years of residency? Yes, knowledge of anesthesia is required, but nothing in the previous paragraph suggests that a doctor, trained with the medical knowledge to care for body and mind throughout health and illness, has to do any of it. The problem is the old paradigm (I hate that word) no longer applies, as nurses get advanced training and anesthesia gets safer. As Jason Whang , author of The Innovator’s Prescription: A Disruptive Solution for Health Care, says “You can’t defend a profession by putting up regulatory and payment barriers to stop the barbarians at the gates.” Anesthesiologists have to start to truly care for the patient through the whole process. The anesthesiologist has to be The Doctor. The Guy. The one everyone, including the patient, looks to as directing the care of the patient body and mind, in health and illness. The person who, when she walks by, leaves whispers of awe in her wake. We are doctors. We need to doctor. Then the world will know that we are still needed.