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I love my anesthesiologist!

October 19, 2014

Alright, now that I’ve officially offended all the anesthesiologists I know, let me try now to convince my readers that I’m actually a big advocate of physician anesthesiologists.  They just need to be used in the right way.

The American Society of Anesthesiologists (ASA), the governing body for the specialty, has recently responded to the growing popularity of having people other than anesthesiologists give anesthesia by proposing what they are calling the Perioperative Surgical Home.  This is a terrible name for something that might turn out to be a good idea.  Here is what the position statement says:

“The ASA is currently developing the Perioperative Surgical Home (PSH) model of care.  The PSH model is a patient-centered and physician-led multidisciplinary and team-based system of coordinated care that guides the patient throughout the entire surgical experience, from decision for the need for surgery to discharge from a medical facility and beyond.”

There are a couple of ways in which anesthesiology is currently practiced in the hospital setting that are detrimental to the status that physician anesthesiologists fear they are losing.  The first is that patients are assigned to anesthesiologists the night before.  This practice is unique among physicians.  Usually patients go to a specific doctor, develop a relationship with that doctor, and both parties develop some ownership of the perioperative course.  Most patients don’t come to a specific anesthesiologist, have no relationship with the one they are assigned, and do not consider the anesthesiologist “their doctor”.  It is like a nurse being assigned to a group of patients for the day or a waitress being assigned certain tables.  You own it for the day but tomorrow you’ll have a different assignment, maybe in a different building or a different town, doing cases that are completely different.  This makes anesthesiologists look like employees.

Secondly, there is the matter of breaks.  My husband is one of the anesthesiologists at my hospital that “runs the floor”, meaning he coordinates all the rooms and anesthesiology providers to make sure things get done in a timely manner and that room is left for emergencies.  The worst part of his job is getting all the people working alone breaks and lunches.  Anesthesiologists, when they are working alone in a room, that is, they aren’t supervising two or more rooms with residents or CRNA’s, expect to be given a 15 minute morning break and a lunch break.  These breaks might be a nice thing to have, but they reinforce, in a very powerful way to everyone in the room, that anesthesia providers are interchangeable. They can all do the same thing.  It doesn’t matter.  The surgeon certainly doesn’t consider himself interchangeable, and doesn’t expect to be broken by another surgeon.  The internist in the office doesn’t expect that in the middle of a patient visit another doctor might pop in and continue the interview to give the other doctor a break.  Getting breaks makes us look like employees.

And if we are all just employees and can all do the same thing wouldn’t hospitals choose to hire the ones they can pay the least?

What if anesthesia was run in a different way?  After a surgeon and patient decide that surgery is required, what if the surgeon said:   “you’re going to need an anesthesiologist for your surgery.  Here are the ones that practice in the hospital in which your surgery will take place.  All are good but I have worked a lot with X and Y and would definitely recommend them.”  The patient then selects an anesthesiologist, just as they selected the surgeon, and makes an appointment with that doctor.  Patient and anesthesiologist meet, perhaps in a pre-op clinic, discuss the options for anesthesia, get to know each other, and agree on a plan.  Then the booking office schedules patient, surgeon, and anesthesiologist at a mutually agreed-upon time.  When the patient then comes for surgery the conversation between the anesthesiologist and the patient, instead of introductions, goes something like “Hey! There’s my anesthesiologist!  How you doin’ doc?”  “Great, good to see you again.  How’s the dog?  Any questions about the things we discussed at our last meeting?”  The doctor can assess the patient while talking to him, noting changes from the last time, different breathing patterns, changes in anxiety level or level of consciousness.  The patient has had time to process what the doctor has said and can now ask any questions he may have or discuss changing the plan.

During the operation the anesthesiologist may have more than one patient, in fact he usually does, for revenue and educational reasons.  Here’s where the CRNA comes in.  The CRNA “does the case” in the sense that he is present and monitoring the patient throughout the case.  But the anesthesiologist is frequently in and out of each room and always present during critical times.  He has agreed with the CRNA on how to take care of the patient and they do it together.

After surgery, instead of dropping the patient off in the PACU and relying on the nurses, the PACU resident, and the surgical staff to manage his post-operative pain medication, fluid management, etc.  the anesthesiologist continues to be in charge of the patient’s care.  That anesthesiologists time is scheduled in such a way that he can see the patients he has anesthetized that same evening and again the next morning, looking for complications or assessing whether his pain management strategy is working for this patient that he now knows fairly well.  During the whole period the doctor has not relinquished ownership of any part of the patient’s course.  The patient is his patient.  The patient knows that the anesthesiologist is his doctor. If the patient needs help once he has gone home, he knows he can call his anesthesiologist. If he needs surgery again, he can call up his anesthesiologist, whom he now knows and trusts.

If anesthesia worked this way we wouldn’t need rhetoric and regulation to defend our profession.  It wouldn’t need defending.

 

 

 

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6 Comments
  1. You gotta be kidding me? Offended? Why? I thought the post was pretty factual. If people are offended by the facts, that is their problem. Trust me, I see it a LOT.

  2. * I totally concur with your post! I would totally feel more comfortable, as I am sure most would, with an anesthesiologist that followed me throughout my pre- and post procedure and was available when I needed her/him in comparison to one I only saw maybe twice throughout my entire procedure and recovery.

  3. Ivanonymous permalink

    Even if the steam shovel can provide routine anesthesia more cheaply and conveniently than John Henry, I don’t mind at all if John Henry wants to offer an extra human touch to those who are willing to pay more for it. But if John Henry and his friends band together to require that everyone pay extra for artisanal anesthesia, then I’m disappointed in them. Of all the occupations that economic progress has dumbed down and cheapened (for the enrichment of the world!), aren’t the anesthesiologists among the best prepared to adapt, even if just by being affluent and educated? Rather than form defensive cartels to secure their own employment and status (no mere employees here!), maybe they could be models for other doctors, showing how to gracefully adapt to dumber jobs in smarter systems.

    The approach to anesthesia proposed by the ASA would almost certainly be better than the scattered, disorganized approach we’ve got now. But it would also cement the basic disorganization in place, adding another brilliant individual to a team that’s already struggling to keep up with each other’s activities through a dumb dumb dumb system of faxes and incompatible EHRs. (Not to mention the expense and difficulty of scheduling operations if each patient insisted on bringing their own surgeon and own anesthesiologist!)

    How much more exciting to imagine a future where a single health record that was truly meaningful (to people and to computers) moved with me as a patient. Not just from OR to PACU, but from place to place if I moved, or as different doctors retired or had kids or took a vacation. My response to different pain management approaches would be included there, to improve on and refine, and to be available in any hospital, even if I was in an accident while on vacation or if my “personal” anesthesiologist was tied up with another case. And so on.

    Pie in the sky? Well, it’s certainly true that there’s lots of hard work to do. And maybe it’s not quite the work that anesthesiologists trained for, and do best. But they could at least use their influence in the existing system to do more to bring about a better system, even if it meant some sacrifices of status and job security and such. I honestly earnestly wish that more doctors were trying harder to imagine a happy world freed from the bulk of the work they do. Or with it spread around very differently, at least.

  4. Kent permalink

    I can see why you are backpedaling, you have lots of friends that are anesthesiologists. I’d probably do the same in your shoes. But your comments were dead-on. Anesthesiologists are highly trained but interchangeable technicians, and that’s where it ends. There simply isn’t the doctor-patient relationship that surgeons and internists and the like have. And so it comes down to defending their turf from others without an M.D. degree that can learn to do what anesthesiologists are doing. The interesting thing to watch over the next few years is whether they can manipulate the levers of power to protect their pay and position from competitors.

    • Eric permalink

      Kent the problem is that they are not technicians. They are physicians that treat disease process the same exact way as internist, surgeons, ER physicians, intensivist, etc. If an OR was run by a bunch of technicians I can guarantee outcomes would be worse and the system would be limited in complexity of cases and patient populations they could handle.

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