Archive for the ‘Advice’ Category

How reporter Jan Hoffman and the New York Times manage to insult female physicians and get their facts about anesthesia so wrong all at the same time.

My husband and I, both anesthesiologists, enjoy our Sunday mornings together — coffee, the New York Times, a leisurely breakfast. No rush to arrive in the operating room before many people are even awake.

Today, though, seeing reporter Jan Hoffman’s front-page article in the Times — “Staying Awake for Your Surgery?” — was enough to take the sparkle out of the sugar. Her article on how much better it is to be awake than asleep for surgery reminded me why I left a plum job as a reporter for The Wall Street Journal to go to medical school — because reporters have to do a quick, superficial job of covering complex issues. They aren’t experts, but seldom admit it.

Physician anesthesiologists across the country are likely to face patients on Monday morning who wonder if they ought to be awake for their surgery. The answer to that question may well be “no”. But according to Ms. Hoffman, that answer reflects “physician paternalism”, and makes us opponents of the “patient autonomy movement”, because a patient should have the right to choose to be awake.

It’s not that simple.

Knee scope? C-section? Being awake is nothing new

Ms. Hoffman decided to stay awake for her knee arthroscopy, which is hardly front-page news. Many people, especially athletes, are fascinated to watch their own knee surgery. But the spinal anesthetic Ms. Hoffman enjoyed is still a type of major anesthesia, and it required anesthesia expertise for its safe insertion and her smooth recovery. Cardiac arrest may occur under spinal anesthesia, even in young and otherwise healthy patients, and every patient needs to understand that “awake” isn’t the same thing as risk-free.

As recently as 20 years ago, most orthopedic surgeons wanted their patients asleep under general anesthesia for any major operation such as a total hip or knee replacement. It was physician anesthesiologists who gradually turned opinion in favor of regional anesthesia by developing spinal needles that reduced headache risk, and ultrasound-guided techniques that made nerve blocks safer, faster, and more reliable. The “patient autonomy movement” had nothing to do with it. Ms. Hoffman’s implication that anesthesiologists have been the followers rather than the leaders in regional anesthesia is especially insulting to the American Society of Regional Anesthesia and Pain Medicine (ASRA), founded in 1923.

Obstetric anesthesiologists deserve credit for demonstrating that expert regional anesthesia — epidural and spinal anesthesia for cesarean section — plays a major role in today’s low rates of complications and death during childbirth. The Society for Obstetric Anesthesia and Perinatology (SOAP) is about to celebrate its 50th year of advocating for the health of pregnant patients and newborns, and for safe, awake childbirth. Dr. Virginia Apgar, lest we forget, was an anesthesiologist first and the inventor of the Apgar score second.

When “awake” isn’t an option

Today’s “minimally invasive” surgical techniques, such as laparoscopy, have made surgery possible for millions of patients with less pain, smaller incisions, and faster recovery. But here’s a fact that Ms. Hoffman may not appreciate:  general anesthesia makes these techniques possible.

General anesthesia with complete muscle relaxation is often a must for minimally invasive and “robotic” surgery performed with small cameras and other instruments inserted into the chest or abdomen. I often tell my residents never to use the word “paralysis” around patients because it might alarm them unnecessarily. “Say ‘muscle relaxation’ instead,” I advise. But the fact is that the patient’s muscles must be paralyzed under anesthesia for the surgeon to work on a motionless target.

The patient’s breathing has to be precisely controlled, which means that the anesthesiologist must insert an endotracheal (breathing) tube and manage the settings on the ventilator to breathe for the patient until the operation is done. For some operations, the patient must be in a steep head-up or head-down position, with both arms snugly tucked at the sides, and must remain in that position for hours.

After the patient is safely asleep under general anesthesia, we give “muscle relaxants” to block the ability to move, breathe, or cough. The actions of these medications are reversed at the end of surgery so that the patient starts to breathe again. Then we allow the patient to wake up. This is all part of the profession and specialty of anesthesiology. Like the making of sausage and political deals, we keep this part of the work quietly behind the scenes. I can’t imagine that any patient would want to be awake for it.

Cheaper surgery without anesthesia?

Absolutely. It’s cheaper to have surgery without anesthesia. If I needed a small procedure that could be done in my doctor’s office under local anesthesia, of course that’s what I would choose. A good rule to live by is not to take any medication you don’t need, and that includes pain-killers, sedatives, and anesthesia medications.

But Ms. Hoffman is misleading patients to make them think that they can opt to have a procedure without anesthesia as a “personal budget” choice.

Even if a patient prefers local anesthesia or minimal sedation alone, the procedure might not be tolerable due to anxiety, pain, or the inability to lie still. That’s not always possible to predict. If the patient needs the option of converting to deep sedation or general anesthesia, then the services of the anesthesia department’s physicians and nurses will be involved and must be scheduled in advance. They aren’t free, any more than the services of your surgeons and operating room nurses are free. There isn’t a “bench” of anesthesiologists on stand-by just in case you need us. Either we see a patient in advance, perform a pre-anesthesia assessment, remain with the patient during the procedure, and supervise the recovery period — or we’re not involved at all, and will be busy taking care of patients elsewhere. That’s reality.

Watch who you call ‘paternalistic’

As a specialist in thoracic anesthesia, I’ve had plenty of opportunity to reflect about the importance of my job. As I watch a surgeon do a delicate dissection to peel lung cancer away from a major artery in the chest, I sometimes think how one tiny patient movement or cough could lead to catastrophic bleeding. It’s my job to make sure that doesn’t happen, and to keep the patient’s oxygen level safe while only one lung is being ventilated.

If I tell my patient in the morning that surgery has to be done under general anesthesia, I’m not being paternalistic. Nor does that decision depend on “the flexibility of the anesthesiologist”, as Ms. Hoffman would have it. Many operations — minor ones as well as major — can’t be done without general anesthesia.

Ms. Hoffman did my future patients no service by suggesting that being awake for surgery is necessarily better.(Please visit the American Society of Anesthesiologists website for accurate information about anesthesia.) Her simplistic views may mislead patients to believe that a Google search and a quick read of the New York Times will equip them to choose the anesthesia flavor of the day off a menu. If you want to push back against “authority figures”, it would be better to take that energy elsewhere and let your anesthesiologist and your surgeon — many of whom today are women — do our work.

Finally, I question the wisdom of allowing Esther Voynow, the patient featured in Ms. Hoffman’s story, to drive herself home after surgery on her right wrist. While she may have been perfectly awake, that isn’t the only skill involved in driving a car. If she had caused an accident, the surgeon and the hospital would have risked serious liability. The only good news about that questionable decision — there was no anesthesiologist involved.

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A version of this post appears as a Letter to the Editor in the New York Times.  

Is there a direct connection between communication skills and the art of successful leadership? Most of us would agree that there is. But is there a direct connection between blogging and leadership? That may be more of a reach.

Can the process of writing a blog help to develop communication skills that will prove useful in leadership? In my opinion the answer is yes, but a qualified yes. Writing a blog won’t help anyone become a good writer who never learned to write competently in the first place. Perhaps even more important, writing a blog won’t help anyone become a thought leader who hasn’t developed any original thoughts.

Communicating a vision

To make a real mark in history, a leader has to communicate a vision that people understand. The vision must be powerful enough to motivate them to follow. In decades past, for instance, the men who became President of the United States typically were graduates of liberal arts education, trained in the arts of debate, oratory, and essay composition. They knew how to make their points.

No matter which end of the political spectrum you favor, most of us would agree that Presidents John F. Kennedy and Ronald Reagan were gifted communicators. Though obviously they benefited from the help of speechwriters behind the scenes, both were skillful writers on their own, as proved by their private documents and letters.

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This column ran first in the online magazine for medical students, “in-Training”

In case you were wondering — robots won’t replace anesthesiologists any time soon, regardless of what the Washington Post may have to say. There will definitely be a place for feedback and closed-loop technology applications in sedation and in general anesthesia, but for the foreseeable future we will still need humans.

I’ve been practicing anesthesiology for 30 years now, in the operating rooms of major hospitals. Since 1999 I’ve worked at Cedars-Sinai Medical Center, a large tertiary care private hospital in Los Angeles.

So what do I think today’s medical students should know about my field?

A “lifestyle” profession?

For starters, I have to laugh when I hear anesthesiology mentioned with dermatology and radiology as one of the “lifestyle” professions. Certainly there are outpatient surgery centers where the hours are predictable and there are no nights, weekends, or holidays on duty. The downside? You’re giving sedation for lumps, bumps, and endoscopies a lot of the time, which can be tedious. You may start to lose your skills in line placement, intubation, and emergency management.

Occasionally, though, if you work in an outpatient center, you’ll be asked to give anesthesia for inappropriately scheduled cases on patients who are really too high-risk to have surgery there. These patients slip through the cracks and there they are, in your preoperative area. Canceling the case costs everyone money and makes everyone unhappy. Yet if you proceed and something goes wrong, you can’t even get your hands on a unit of blood for transfusion. To me, working in an outpatient center is like working close to a real hospital but not close enough — a mixture of boredom and potential disaster.

The path I chose is to focus on high-risk inpatient cases. I especially enjoy thoracic surgery, with the challenges of complex patients and one-lung ventilation. You can bring me the sickest patient in the hospital setting — where I have all the monitoring techniques, resuscitation drugs, blood products, bronchoscopes, and anything else I might need — and I’ll be perfectly happy. The downside: a practice like mine tends to be stressful and tiring, and I never know the exact time that the day will end. Hospitals that offer Level I trauma and high-risk obstetric care are required to have anesthesiologists in house 24 hours a day, 365 days a year. There’s no perfect world.

What type of person is happy as an anesthesiologist?

Even though women comprised 47% of the US medical school graduates in 2014, only about 33% of the applicants for anesthesiology residency were women. I’d be interested to hear from all of you as to why fields such as pediatrics and ob-gyn tend to be so much more attractive to women, because I genuinely don’t understand it. But I do have a few thoughts as to the type of person who is happy or unhappy as an anesthesiologist.

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Here’s a doctor’s health tip for patients that I’ll bet you haven’t heard before.

If you’re a patient who walks into a hospital for an elective procedure of any kind–surgery, or a diagnostic test–and you find out that Joint Commission reviewers are on site, reschedule your procedure and leave. Come back another day, after the reviewers have left.

Why? Because every single person who works there will be paying a lot of attention to Joint Commission reviewers with their clipboards, and scant attention to you.

The Joint Commission has the power to decide whether the hospital deserves reaccreditation. Administrators, doctors, nurses, technicians, clerks, and janitors will be obsessed with the fear that the reviewers will see them doing something that the Joint Commission doesn’t consider a “best practice”, and that they’ll catch hell from their superiors.

For you as a patient, any idea that your clinical care and your medical records are private becomes a delusion when the Joint Commission is on site. Their reviewers are given complete access to all your medical records, and they may even come into the operating room while you’re having surgery without informing you ahead of time or asking your permission.

Perhaps physicians and nurses have an ethical duty to inform patients when the Joint Commission is on site conducting a review. Right now, that doesn’t happen. Does the patient have a right to know?

Unintended consequences

How did any private, nonprofit organization gain this kind of power? Why do American healthcare facilities pay the Joint Commission millions each year for the privilege of a voluntary accreditation review? It’s a classic tale of good intentions, designed to improve healthcare quality, that turned into a quagmire of unintended consequences and heavy-handed regulation.

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Nepal? I don’t know anyone in Nepal. Yet not long ago I received a courteous email from a physician there, asking my permission to translate an article of mine into Nepali. The topic: advice for older patients who need anesthesia. He wants to distribute it to patients and publish it in his local newspaper.

I asked how he came across the article. He was browsing online among anesthesia blogs, and found mine, “A Penned Point“. Now “blog” isn’t a word Jane Austen would have recognized. It is a lumpish merger of “web” and “log”, and is generally defined today as a website on which an individual records opinions. The proliferation of blogs–like Tribbles–may be seen as a pernicious trend, but it demonstrates the power and reach of the Internet. Business Insider estimates that 22% of the people in the world own smartphones, an increase of 1.3 billion smartphones since 2009. In social media, once you put content out, you have no idea how far it will travel.

Many physicians consider social media a frivolous waste of time. Certainly they can be horribly misused–think of the cyber-bullying that goes on among teenagers. But used wisely, social media can be valuable communication tools. Here follows a brief guide to social media for physicians, admittedly subjective, with caveats included.

The doctor with an opinion

We all have opinions. Occasionally, we want the world to know about them. If you want to publish an opinion column and don’t want to create your own blog, there are online sites where your submission may be welcome. Probably the best-known public site for medical topics is KevinMD, which is curated by Dr. Kevin Pho, a New Hampshire internist. He came early to the game, starting his blog in 2004, and now has over 1000 regular contributors, myself included. You can submit a 500-700 word piece on almost any topic within medicine, aimed at an audience of physicians or at the general public. There’s a good chance that if you can put together a coherent sentence, Kevin will find a place for it. Brace yourself for the comments: Kevin’s readers tend to hold opinions as strongly as the writers do.
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