There’s been a great divide between the medical and surgical specialties ever since I can remember. Surgeons believe internists perseverate too much when decisions need to be made. Internists consider themselves the true intellectuals of medicine. I suppose anesthesiologists like me fall somewhere in the middle–we work in surgery, but have to take care of all the medical problems the patient brings to the OR table. Does that make us the last true generalists?
Recently I brought my patient from the OR back to the medical ICU and gave report to the nurse; made sure that the vent settings were appropriate and that the arterial line waveform was crisp. When the patient was stable and settled in, I headed over to the ICU desk to finish the paperwork. The case had been a video-assisted lung decortication and evacuation of empyema, a two-hour procedure involving one-lung ventilation and considerable blood loss, in an elderly patient with a host of underlying medical problems. Sitting next to me at the ICU desk was a young medicine resident. He turned to me and asked, “What was the indication for putting in an art line?”
For a second, I thought he was kidding, so I didn’t immediately reply. “No, really,” he said. “Was there an event or what?”
Once a mother, always a mother. I was amused to hear myself answering him with the soothing tone and simple words one uses with a fractious child. “Well,” I said, “the event was thoracic surgery. They’re working near things like the heart. Only one lung can be ventilated during the operation, with a special double-lumen tube, so we may want to check blood gases. And it’s nice to know what the blood pressure is all the time.”
Then I went back to the OR, where no one asks why you need to place an arterial line in a critically ill patient who’s having major surgery. During the walk across the bridge from the ICU tower, I had time to ponder why the disconnect between medicine and surgery seems to be getting worse.
Anesthesiologists love to pick on medical ICU teams for their apparent terror of overhydrating patients–we particularly enjoy getting a septic patient with ischemic bowel who is on a norepinephrine infusion with a 22 gauge IV for access. But our surgical colleagues have their own lacunar infarcts when it comes to medical management. It’s sort of fun to watch an orthopedist’s eyes glaze over when we try to explain why it matters that his patient has near-systemic pulmonary artery pressures. Or to see the deer-in-the-headlights look of the bariatric surgeon who’s told that his patient has drug-eluting coronary stents, and must receive aspirin before and after her gastric bypass.
But personal amusement aside, it can’t be good for there to be so much isolation between medicine and surgery that one hand clearly has no idea what the other is doing. Sometimes I feel like an ambassador shuttling between two countries where the people speak different languages and worship different gods.
Way back when, there was such a thing as a rotating or flexible internship, which gave interns at least some view of both sides of the medicine/surgery fence. There was value for the future internists in scrubbing on a ruptured AAA; they may not have enjoyed it much, but at least by the end they understood what the case involved and why it required invasive monitors.
Today, however, medical students graduate and move straight into either a medical or surgical track. The surgical residents tend to learn a little medicine along the way as they take part in managing their patients’ coexisting medical problems, or at least deciding which consult to request. The internal medicine residents, on the other hand, rarely have the chance to see what actually happens to their patients during surgery. They’ll call for a VATS lung biopsy in a patient who is teetering on the brink of death, not seeming to realize that if they can’t ventilate the patient on two lungs, I won’t be able to ventilate with just one.
If medicine residents had the chance to come to the OR with their patients once in a while, it might improve the quality of the internal medicine “clearance”. We all have our favorite examples. “Avoid hypoxia and hypotension,” they advise. Thank goodness; I would never have thought of that. Or they’ll advocate spinal anesthesia for a patient who’s coagulopathic due to advanced liver disease, which would be an efficient way to produce an epidural hematoma and permanent nerve damage. Really, if you’ll just tell me what’s wrong with the patient, I can figure out what kind of anesthesia will work best.
There were a lot of advantages to the concept of the flexible internship, though I don’t think we are likely to see it reappear. In the meantime, it looks as though my job as an anesthesiologist will be to work at the intersection between the medical and surgical spheres. It’s a challenge to keep up with developments in internal medicine and the constant appearance of new drugs, so that I can manage my patients’ underlying diseases before, during, and after surgery. Other anesthesiologists focus on pediatrics, obstetrics, or ICU care. At the same time, we all have the pleasure of seeing the latest in surgical techniques and gadgetry just by showing up for work.
Since Dr. House, expert in everything, is just a fictional character who’s in his last season anyway, maybe the anesthesiologist will end up being the closest thing to the general practitioner of the 21st century. Who knew?
Interesting post. I think pediatric intensivists like me also tend to bridge the gap, a gap which I agree with you is real. Most of us have had some training in anesthesiology (6 months, in my case)and spend a lot of time every day with surgeons caring for surgical patients, since few institutions can afford the luxury of separate surgical and medical ICUs for children, however much the surgeons would like them. That makes us generalists, too — we’re sort of like general practitioners for the very sick or injured child.
But, like you, I am often astonished by the cluelessness about how surgery is practiced shown by pediatric trainees at all levels and more than a few pediatricians. This seems especially true for trauma patients, most especially neurotrauma.
I love these specialists who think they are “keeping up” with internal medicine by reading through a patient’s med list. Imagine being treated for hypertension by this doctor – sodium nitroprusside for bp of 142/94.
I’m not sure I understand your comment, but thank you for reading!
Reading though a patient’s medication list is an important part of any preoperative evaluation, but it’s meaningless if the reader is unfamiliar with the medications. If you are working with anesthesiologists or nurse anesthetists who would treat a blood pressure of 142/94 with sodium nitroprusside, then I would seriously advise you to go to a different hospital should you need anesthesia care in the future.
All the best,
We are luckier in Australia, as all doctors must do at least 2 years in the hospital rotating though medicine, surgery, emergency medicine etc, before enrolling in specialist training. It means the internal physicians remember what it’s like to have to hold the damn laparoscopic camera for hours, and the surgeons remember why their patients are on beta blockers. In my opinion it allows specialists to be better doctors.
Wow…I mean wow. Another myopic blog entry about one’s area of medical expertise. If I had a nickel for every disaster left at my ICU door by “anesthesia”, I could retire. You seem to forget that an operation occurs in a surgical suite and after a short “recovery period” the anesthesia service just walks away. That leaves the CCM team ( that you seem to belittle) to diurese the excessive volume infused during surgery and accomplish the 3 weeks of vent weaning that often ensues. I’m sure you see yourself as a competent physician and perhaps you are. Sadly, You have fallen prey to the one maxim all we physicians are most prone to assume,” Every doctor thinks he/she is right…the difference is…I AM!” Also remember: medical residents and students often ask stupid questions and say stupid things. It’s their job. Our job is to team them. BC: Int Med/ Pulm/ CCM/ Sleep
Thanks for writing! Perhaps the value of reading someone else’s “myopic” view is at least you learn that there IS another point of view.
After big cases, there’s inevitably third-spacing of fluid that then has to be mobilized. However, we have to maintain intravascular volume during the case in order to preserve some degree of organ perfusion. If many patients weren’t so depleted when they came to the OR in the first place, perhaps the swings wouldn’t be quite so radical.
In any event, I’m pleased to hear from you. A little more dialogue on both sides of the “great divide” can’t be a bad thing.
On an historical note, it’s interesting that ICUs essentially began as post-anesthesia recovery rooms that never closed.
As another fellow anesthesiologist at a major teaching institution, I thoroughly understand the gap between medical and surgical thinking. I do agree with some of what your saying. I was always taught that the anesthesiologist is the internist in the OR. I definitely do not propose that I know outpatient medicine all that well. But I do agree that I too sometimes get irritated when my cardiologist colleagues “clear” patients for surgery or write “do not give the CHF patient too much fluid.”
As we pursue the true “surgical home” and our specialty of anesthesiology moves back towards critical care, the gap you mentioned between inpatient medical and surgery may be filled. But for now, if an orthopedist has patient with an electrolyte disorder, they consult medicine.