I love my anesthesiologist!
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.