The real surprise – to me, at least – came more than halfway through Dr. Atul Gawande’s keynote address at the opening session of the American Society of Anesthesiologists’ annual meeting in Boston.

Much of his talk on October 21 celebrated the virtues of checklists and teamwork, topics that have turned into best-selling books for the well-known surgeon and professor of public health. “We are trained, hired, and rewarded to be cowboys, but it’s pit crews we need,” he said.

Then Dr. Gawande posed this question to the packed room: “What are the outcomes that matter?”

He answered his own question somberly. “The most unsafe operation is the operation that shouldn’t be done,” Dr. Gawande said. “Does the operation serve the patient’s goals or not?”

“We’ve all been there,” he continued. “Taking people to the operating room and wondering what we’re doing.”

Those are comments I’ve heard from anesthesiologists many times before, but I never thought I’d hear them from a surgeon.

Flogging the dead

For any of us who practice anesthesiology in a major hospital – doing cardiac, thoracic, or liver cases, for instance – there are days when all our efforts are spent on behalf of a patient whose health is unsalvageable. “Flogging the dead” is a phrase sometimes used to describe prolonged and futile care in the operating room or ICU.

Sometimes aggressive interventions are driven by a family that wants “everything” done, because in their innocence the family members have no idea how terrible and dehumanizing the process of postponing death can be.

In other circumstances, however, the decision of whether to do surgery is driven by the mission and the financial motivation of the health system to provide care. If care doesn’t occur, if the surgery isn’t done, no one gets paid.

If the anesthesiologist walked up to the bedside of an elderly, frail patient who is scheduled for a risky operation, and explained bluntly that the patient might die a prolonged and dismal death in the ICU, there would be hell to pay if the patient or the family decided to back out. The preoperative holding area, five minutes before surgery, isn’t the time or place to have that conversation. Yet that’s often when we meet our patients for the first time.

The “risk of death” is always mentioned in the informed consent documentation, but may be framed by physicians and nurses alike as a theoretical concern rather than a real possibility. The surgeon, the anesthesiologist, and the hospital are incentivized to do cases, not to step on the brakes and stop an operation. This is true even when the operation may fix a specific surgical problem but could lead to worse health, more pain, or loss of independence during the last months of life.

“Our goal is not survival at all costs”

One lesson that Dr. Gawande said he has learned from talking to patients is that people have priorities in life other than just survival. The goals will differ from person to person. If we don’t ask patients these difficult questions, Dr. Gawande said, “the care we provide may be out of alignment with their priorities.” That kind of care may cause more suffering than it alleviates.

One patient told Dr. Gawande that he would be okay with his quality of life so long as he could “eat chocolate ice cream and watch football.”  That’s better than any living will in terms of clarity, Dr. Gawande said.

He advised asking a patient, “What’s your understanding of where you are in your illness? What abilities are so critical to your life that you can’t imagine living without them?” Understanding the patient’s goals and fears can help the patient, the family, and the medical team reach the best decision about a plan of care, Dr. Gawande said.

“Our goal is not survival at all costs,” Dr. Gawande asserted. “Nor is our goal a good death. The goal is for our care to match their goals. To deliver the right care, at the right time, every time.”

For this fundamental change in the culture of healthcare to occur, payment models must change too, Dr. Gawande said. “A switch from fee-for-service to fee-for-value is absolutely critical for us to work successfully as teams. We have to be part of driving the reinvention of how we’re paid.” The team’s success should be linked to an outcome that is optimal in the view of the patient and the family, even if the decision is not to do surgery.

Dr. Gawande praised the many contributions of anesthesiology to improving processes of care and promoting patient safety. But he urged the ASA to “move from safety to outcomes as your priority.”

To achieve the best outcome consistent with each patient’s goals, Dr. Gawande said, “we need to work as teams before and after they come to the hospital. We need to be willing to take part in the experiments and drive the experiments so that we are paid as teams for better outcomes.”

9 COMMENTS

What,If the patient or the relatives sue the doctor that a particular line of treatment which offered a possible cure has been denied to them?.the decision making in patient care has shifted to patients and relatives knowledge of the possible lines of therapy available.

Andrew Kadar, MD

Thank you Karen for an excellent summary of Dr. Gawande's talk. I also highly recommend reading "Being Mortal" for a more extensive coverage of the issues he discussed. I would especially like to have gastroenterologists think of outcomes before booking a terminal patient for a PEG.

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No, I’m not talking about putting fentanyl into my own veins — a remarkably bad idea. I’m questioning the habitual, reflex use of fentanyl, a synthetic opioid, in clinical anesthesiology practice.

I’ve been teaching clinical anesthesiology, supervising residents and medical students, in the operating rooms of academic hospitals for the past 18 years. Anesthesiology residents often ask if I “like” fentanyl, wanting to know if we’ll plan to use it in an upcoming case. My response always is, “I don’t have emotional relationships with drugs. They are tools in our toolbox, to be used as appropriate.”

But I will say that my enthusiasm for using fentanyl in the operating room, as a component of routine, non-cardiac anesthesia, has rapidly waned. In fact, I think it has been months since I’ve given a patient fentanyl at all.

Here’s why.

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karen

Dear Ms. Taylor, I fear that you misinterpret my intent. Nowhere do I recommend eliminating ALL opioids from anesthesiology or pain medicine. I spend my working life treating pain during and after surgery. Long-acting opioids such as hydromorphone are frequently a component of postoperative pain management, whether given intravenously or via an epidural catheter. Of course chronic pain patients deserve the best possible treatment. My post simply discusses how my practice has changed in light of the opioid crisis, and why I have reduced the use ...Read More

karen

Dear Docofalltradez, Never do I venture to tell any physicians, other than my residents, what they should or should not do. I agree with you that such broad directives are possible only with the hubris of a bureaucrat or administrator. I simply explained in this post how I have changed my practice and why. Fentanyl and short-acting opioids such as remifentanil do indeed seem to induce OIH to a greater degree than longer-acting opioids such as hydromorphone or methadone. Another fascinating recent study suggests that esmolol, ...Read More

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(This post chronicles the recent Los Angeles visit of ASA President Jeff Plagenhoef, MD, and his Grand Rounds presentation at USC. It originally appeared on the website of the California Society of Anesthesiologists. Above, Surgeon General Jerome Adams, MD, MPH, left, with Dr. Plagenhoef.)

“Who kicked whom off the anesthesia care team?” asked ASA President Jeff Plagenhoef, MD, FASA. Which professional association refuses to work amicably with the other, he inquired of his audience at the University of Southern California on September 15, as he delivered a powerful Grand Rounds address to the Department of Anesthesiology.

In his talk, “Professional Citizenship:  Responsibilities Shared by All Anesthesiologists”, Dr. Plagenhoef emphasized that physician anesthesiologists and the American Society of Anesthesiologists (ASA) fully support nurse anesthesia practice within the physician-led anesthesia care team. In his practice as Chair of the Department of Anesthesiology at Baylor Scott and White Hillcrest Medical Center in Waco, Texas, Dr. Plagenhoef works with nurse anesthetists and with certified anesthesiologist assistants (CAAs).

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Peter M. Lucas, MD

Dominica; Yes, I have been following the development of Anesthesia Assistants. It looks like they may provide a good solution. There is a significant regulatory hurdle for them. Furthermore, if their salary requirements are indeed very close to that of anesthesia nurses, it will be difficult to fit them into many small to medium practices.
Great article and I do believe there is a time and place for an anesthesia care team. I chose to be in a physician only anesthesia team for my practice. Here are my in-depth thoughts. https://krissymd06.com/2017/10/19/the-physician-anesthesiologist-vs-crna-debate/ Thank you Karen for your outstanding opinions!!

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The Practical Art of POCUS

The longer you practice a profession, the easier it is not to bother to learn the next new thing. We may think we’re doing just fine without that new drug, or that new piece of expensive equipment. We’ve seen how the new drug sometimes turns out to have more side effects than benefits, and how the equipment may gather dust in the corner because no one really needed it in the first place.

That isn’t going to happen with point-of-care ultrasound, or “POCUS”, I’m willing to bet. As I learned at a weekend conference on POCUS, jointly hosted by the anesthesiology departments at UCLA and Loma Linda University, the practical applications for bedside patient care are multiplying, and the technology is improving all the time. Ultrasound isn’t just for cardiologists and radiologists any more.

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Dr. Sibert, thank you very much for attending the workshop. Your post elegantly describes the overall message of what this course is focused on. It is my sincere hope that our specialty continues to embrace point of care ultrasound to improve our physical examination, as other acute care specialties have already done. Websites such as www.foresightultrasound.com and www.pocuseducation.com provide more educational material, as well as information for our course for next year. Again, thank you very much for your interest, and we hope ...Read More

Eduardo

(Errata sheet-Corrected version) Very interesting topic and right in point for me: I recently (last week) went to Buenos Aires, Argentina Anesthesia Annual Congress and this year much emphasize was done on ‘hands-on’practices and a lot in Ultrasound procedures and Regional Anesthesic US assisted. I can feel much anxiety and challenged by a shock of new skills that are abruptly for me, got in surface, even I’ve been good at the art of 'hand skills' and observation (can’t find proper slight adjectives for description). I got ...Read More

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Emory University held graduation ceremonies on August 5 for the 2017 Class of Anesthesiologist Assistants (AAs), who received Masters of Medical Science degrees. While the traditional academic regalia can’t fail to evoke Harry Potter in the minds of many of us, there is some magic in the processional and the music that always makes graduation a moving, meaningful event. I had the honor of delivering the commencement address, reprinted here.

Distinguished faculty, graduates, honored guests:

It is a great pleasure and an honor to be here, and to congratulate all the graduates of the Emory University Class of 2017 on your tremendous accomplishment. Just think about all you have learned in the past two years! You’ve transformed yourselves into real anesthesia professionals, able to deliver first-class care to patients at some of the most critical times in their lives.

Today is a great time to become an anesthesiologist assistant. Just two days ago, Dr. Jerome Adams was confirmed as our country’s Surgeon General. He is the first-ever physician anesthesiologist to have that honor. Even better, he is from Indiana, where he was the State Health Commissioner, and of course Indiana is among the states where CAAs are licensed to practice. We know that Dr. Adams understands the principles of the anesthesia care team. Dr. Adams gets it – who AAs are, what you do, and how well qualified you are to care for your patients.

Another happy thought – the Secretary of Health and Human Services today is Dr. Tom Price from Georgia, an orthopedic surgeon, and a former Representative in Congress. His wife, Betty, is a physician anesthesiologist who currently serves in the Georgia state legislature.

Whatever your opinions about politics (and believe me, we’re not going there today), whether your blood runs red or blue, I think we can all celebrate the fact that we now have people in key positions who understand anesthesia; whose presence in Washington is great for AAs, for patients, and for the practice of safe, team-based anesthesia care.

All About Great Medical Discoveries

As I thought about what to say to you today, the first thing that occurred to me is that this summer marks 30 years since I finished my anesthesia training. You might be curious to know if I ever had any second thoughts, any regrets about that career choice. My answer is a resounding “no”.

I was lucky enough to get interested in anesthesia at an early age. I brought something to show you. This book was published in 1960. It’s called All About Great Medical Discoveries, and I read it when I was a little girl about 8 or 9 years old, in Amarillo, Texas. Here’s what it had to say about anesthesia, in a chapter called “The Conquest of Pain”:

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6 COMMENTS

David Denyer

that commencement speech was the best thing Ive read in a long time. Wisdom at every point! Thank you for all that you do for our profession and cant wait to work out there in California soon!

Gina Scarboro

Dr. Sibert, Thank you for the words of wisdom and encouragement for the Emory AA Program graduates. We appreciate your leadership and example of professional advocacy! Best, Gina Scarboro CAA

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