Archive for the ‘Medicine’ Category

Nurses argue that they can perform many hands-on tasks of anesthesia care just as well as we can. So why are we still doing those tasks?

As we orient our brand-new, fresh-faced CA-1 residents to the operating room each year, I ask this question. Has anyone explained to them that much of what they’ll need to learn in the first couple of months is how to be a nurse?

We watch them struggle to draw up propofol into a syringe without spraying white foam all over themselves. We emphasize the critical difference between a surgeon’s order of 5000 units of heparin to be given SQ or IV. We teach residents how to inject medications into line ports using sterile technique, how to label a syringe correctly, and how to chart IV fluids and urine output.

Is this why they went to medical school?

Before a mob assembles with torches and pitchforks, let me be clear: there is much more to learn beyond these nursing and pharmacy tasks on the road to becoming a qualified anesthesiologist. But why are we still doing these tasks when other physicians don’t do likewise?

Do our intensivist colleagues mix up and inject antibiotics? Do our cardiology colleagues load infusion pumps with potassium or magnesium drips? Of course not. That would be a waste of their time and education.

It’s time to redesign anesthesia care delivery. We should be charting the course, not executing every change of sail. We should be performing the diagnostic and intellectual work of physicians all the time, not just some of the time. If we don’t, we shouldn’t be surprised if we continue to lose control over the future of our profession. It’s way too expensive to pay a physician to do the tasks of a nurse.

How did we get here?

Let’s look all the way back to the second half of the 19th century, when the use of ether, chloroform, and nitrous oxide for surgical anesthesia spread rapidly. During the American Civil War, according to medical historian Shauna Devine, PhD, “Union records show that of more than 80,000 operations performed during the war, only 254 were done without some kind of anesthetic.” Most often, the anesthetic was chloroform. “The practice was for the operating physician’s assistant to place the chloroform on a piece of cotton or towel, which had been fashioned into a cone, and then placed over the patient’s nose and mouth, preferably in the open air.”(1)

Nurses or surgical assistants gave many of these anesthetics; most American physicians weren’t interested. One notable exception in the early 20th century was Ralph Waters, MD. He described his experience starting general practice in Sioux City, Iowa, in 1913:

“A few more or less full-time surgeons, who were looked upon as specialists, employed nurses to administer ether in the mornings at hospitals and act as office nurses in the afternoons. A majority of us, ‘occasional’ surgeons, depended upon each other to act as anesthetist as occasions demanded, or sometimes we ‘borrowed’ the nurse-technician of one of our more glamorous surgical colleagues.”(2)

Outcomes were variable and sometimes tragic. A true scientist, Dr. Waters devoted the rest of his career to anesthesiology, joined the faculty of the new medical school at the University of Wisconsin in 1927, and founded the first anesthesiology residency program. However, the model of anesthesia care delivery as the practice of nursing by then was well established in America. It took decades for academic anesthesiology programs to proliferate in the U.S., but the model in America continued to be one person at the bedside, giving medications and monitoring the patient – and that person could be either a physician or a nurse.

Practicing at the top of my license?

In a fascinating ASA Monitor article a few years ago, authors Marc Steurer, MD, DESA, and Michael Ganter, MD, DESA, examined differences in the delivery of anesthesia care in the U.S. compared with Europe. Among the chief disparities:

1. “Most European countries mandate two professionals to provide anesthesia (physician and assistant, e.g., certified registered anesthesia nurse): this means that an anesthesiologist and an assistant are both present during all critical events of the anesthesia (e.g., induction and emergence). In contrast, in the U.S., the anesthesia physician may provide anesthesia alone without a trained assistant.”

2. “In most western European countries, the clinical anesthesiologist is more longitudinally involved in patient care…Not only do anesthesiologists govern the prehospital portion of emergency medicine, but also once the intrahospital care begins. Together with the primary team, an anesthesiologist is usually involved in the care of the most ill medical and surgical patients in the hospital. Also in those settings, the anesthesiologist stays with the patient for the entire critical period and provides a very helpful continuum of care. In Europe there is also a heavy involvement of anesthesiologists in both medical and surgical ICUs. Additionally, operation room (O.R.) management, preoperative and pain clinics as well as services for palliative care have been a mainstay for even small anesthesia departments for a long time. This contrasts to most U.S. practices, where anesthesiologists have predominantly focused on the intraoperative and critical care period. The broader and more longitudinal scope of practice positions European colleagues well for the development of the field.”(3)

Very interesting. These European anesthesiologists are functioning as physicians.

As an American anesthesiologist, on the other hand, I am not practicing anywhere near the top of my license much of the time. There’s satisfaction in seeing all my syringes neatly labeled and lined up in a row, but is that how I should be using my time, energy, and education? Checking the circuit and filling the vaporizer? Our residents are expected to fetch their patients in the preop holding area and – single-handedly – push the gurneys down the hall to the operating rooms, no matter how large the patient or how small the resident. No doubt they feel that their average $200,000 in medical school debt is worth it in job satisfaction, and that being a physician is all they hoped it would be.

The ICU model of care

We need to do a total restructure of procedural care to function along the same lines as ICU care, where physicians direct the care of multiple patients. Pharmacists and registered nurses – sedation nurses and critical care nurses – could be involved as part of a cost-effective bedside care team, flexing the composition of the team to the complexity of the case. Cardiologists, GI and ER physicians supervise RNs giving sedation; why don’t we?

With today’s technologies, it’s possible to monitor multiple sites at the same time. I don’t have to stay tethered to my patient with a plastic earpiece and a length of IV tubing to listen for breath sounds. (Raise your hand if you’re old enough to remember those days.) Physicians who specialize in anesthesiology can be freed up to do actual physician work, putting our medical diagnostic skills to use and functioning as team leaders, not as pawns on the OR chessboard interchangeable with nurse anesthetists in the view of too many hospital administrators.

As American healthcare moves away from fee-for-service payment into a model of giving total care to populations, which appears inevitable, we have an opportunity to redesign anesthesiology. We don’t have to be bound by 1:4 ratios and other arbitrary rules tied to submitting bills for specific services to third-party payers.

We can figure out how to provide the right care to each patient at lower cost. We can allow anesthesiologists to function as doctors of medicine all the time, not just when there’s a crisis or when we’re not busy doing bedside nursing tasks in the operating room.

To me, that sounds like a far better job description.

              (Author’s note: This commentary was first published online in Anesthesiology News on September 8, 2021.)

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1. Devine S. Chloroform and the American Civil War: The art of practice and the science of medicine. PBS: Mercy Street Blog; online publication Feb 22, 2016. Accessed June 13, 2021.

2. Gillespie N. Ralph Milton Waters: A brief biography. British Journal of Anaesthesia: Vol 21 Issue 4, April 1949; 197-214. https://doi.org/10.1093/bja/21.4.197

3. Steurer M, Ganter M. Comparison and contrast of anesthesia practice in Europe and the U.S. ASA Monitor: December 2015, Vol 79; 18-20.

Author’s note: This article was written in late March, 2020, for publication in the American Society of Anesthesiologists’ monthly magazine, the ASA Monitor. It was published online ahead of print on May 8, 2020.

As you read this, we will be at least six weeks further down the road of the COVID-19 pandemic than we are today. We may have answers to the questions that are causing us sleepless nights. With the benefit of that hindsight, what should we have done differently if we had known in March what we know today, in May?

There are two ways to look at this: the “macro” view and the “micro” view. The first refers to national policy, and the second looks at what we are doing as physicians, in our own hospitals. Let’s start with “micro”, as that’s what we have the most ability (perhaps) to influence.

Did we get serious about personal protective equipment (PPE) too early or too late? Did we waste it on asymptomatic, healthy patients before the pandemic really got started? Or did we fail to take it seriously enough, endangering ourselves, colleagues, and patients?

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Do you think I went too far in my last blog post, calling out some journalists as “pontificating parasites” who love nothing more than to slam physicians and blame us for the cost of healthcare?

If you do, then you must not have read Elisabeth Rosenthal’s latest salvo in the Feb. 16 New York Times, where she says physicians are in “a three-way competition for your money” with hospitals and insurers, as if we’re all equally well-funded players at a craps table.

Even National Public Radio, often no friend to physicians, acknowledges that physician pay adds up to a mere eight percent of total US healthcare costs.

What stings even more, hearing that kind of accusation from Ms. Rosenthal, is that she used to be a physician herself before she quit emergency medicine to edit Kaiser Health News. I’m sure it’s a better gig: no nights, no weekends, no holidays. But, as Julius Caesar noted, it’s always worse when the stab in the back comes from someone you thought of as a colleague, if not a friend.

Surprise medical bills

The topic of Ms. Rosenthal’s one-sided op-ed is out-of-network billing, also known as “surprise” billing. Emergency physicians (along with anesthesiologists) may be the doctors most often accused of not being “in-network” with insurance companies and sending patients large “surprise” bills after the fact.

However, the American College of Emergency Physicians (ACEP), which represents Ms. Rosenthal’s former colleagues, is no happier than anyone else about out-of-network bills. “Much of this conflict over surprise billing is playing out in the media,” ACEP notes, “and insurers have been trying their hardest to paint emergency physicians in a bad light.”

ACEP is right. The facts about out-of-network bills, and the history behind them, differ from what Ms. Rosenthal would have the public believe.

What is a narrow network?

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If physicians are “muggers” and co-conspirators in “taking money away from the rest of us”, then journalists and economists are pontificating parasites who produce no goods or services of any real value.

I don’t think either is true, but the recent attacks on physicians by economists Anne Case and Angus Deaton, and “media professional” Cynthia Weber Cascio, deserve to be called out. You could make a case for consigning them permanently, along with the anti-vaccination zealots, to a healthcare-free planet supplied with essential oils, mustard poultices, and leeches.

My real quarrel with them — and with the Washington Post, which published their comments — is that they have the courage of the non-combatants: the people who criticize but have no idea what it’s like to do a physician’s work. More about that in a moment.

Ms. Cascio was enraged by the bill from her general surgeon, who wasn’t in her insurance network at the time she needed an emergency appendectomy. She doesn’t care — and why would she? — that insurance companies increasingly won’t negotiate fair contracts, and it isn’t the surgeon’s fault that Maryland hasn’t passed a rational out-of-network payment law like New York’s, which should be the model for national legislation. She doesn’t care that Maryland’s malpractice insurance rates are high compared with other states, averaging more than $50,000 per year for general surgeons. She just wants to portray her surgeon as a villain.

The two economists are indignant that American physicians make more money than our European colleagues, though they don’t share our student loan debt burden or our huge administrative overhead for dealing with insurance companies. They resent that some American physicians are in the enviable “1%” of income earners. But do they have any real idea what physicians do every day?

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“Each man or woman is ill in his or her own way,” Dr. Abraham Verghese told the audience at the opening session of ANESTHESIOLOGY 2019, the annual meeting of the American Society of Anesthesiologists. In his address, titled “Humanistic Care in a Technological Age,” Dr. Verghese said, “What patients want is recognition from us that their illness is at least somewhat unique.”

Though we in anesthesiology have only limited time to see patients before the start of surgery, Dr. Verghese reassured listeners that this time has profound and immense value. He pointed out that there is “heightened drama around each patient” in the preoperative setting. “Everything you do matters so much,” he said. What patients look for are signs of good intentions and competence, and the key elements are simple: “the tone of voice, warmth, putting a hand on the patient.”

Dr. Verghese, a professor of internal medicine at Stanford University and the acclaimed author of novels including the best-selling Cutting for Stone, believes that patient dissatisfaction and physician burnout are the inevitable consequences of today’s data-driven healthcare system, where physicians seldom connect with patients on a personal level or perform a thoughtful, unhurried physical examination. “Our residents average 60 percent of their time on the medical record,” he said.

“It’s the ‘4000 clicks’ problem,” Dr. Verghese said, citing a study in which emergency room physicians averaged 4000 mouse clicks over a 10-hour shift, and spent 43 percent of their time on data entry but only 28 percent in direct patient contact.

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