Archive for the ‘Politics’ Category

My patient and his wife didn’t understand that an anesthesiologist is a physician, despite his having been cared for by anesthesiologists during past procedures. They thought only CRNAs give anesthesia. What are we doing so wrong with our messaging, and how can we fix it?

One recent afternoon in the GI endoscopy suite (not my favorite place to work, but that’s a topic for another day), I walked up to the bedside of my next patient and introduced myself as I always do.

“Hi,” I said, holding up my name badge for the patient and his wife to see. “I’m Dr. Sibert.  I’m with the anesthesiology department and I’ll be looking after you today.”

The patient was an otherwise healthy man in his mid-30s, having his fifth endoscopy this year for a chronic though serious problem. My questions were few and he understood very well what was about to happen.

The consent process concluded, I asked if the couple had any other questions. The wife did.

“You’re a doctor when you’re not giving anesthesia?” she asked.

Wait. What?

 I’m seldom speechless, but this question took me by surprise. “Why yes,” I said, unsure how to respond.

“You’re a doctor, and you give anesthesia,” the patient’s wife said, making sure she heard correctly.  “Usually we’ve had CRNAs.”

“Yes,” I said. “I’m a doctor, and I give anesthesia all the time. I’m actually an MD who specializes in anesthesiology.”

The patient’s wife seemed slightly embarrassed but happy to acquire this new (to her) information — that doctors give anesthesia too, and that anesthesiology is a specialty practiced by physicians.

“So it must take a lot more training,” she mused. I confirmed that was true, and outlined the years of medical school, residency, and often fellowship training that we undertake to become fully qualified.

Since the patient and his wife seemed interested, I explained that there’s more to anesthesiology than the brief sedations he had experienced in the GI suite. I explained a little about my own specialty — thoracic anesthesia — and the challenge of ventilating each lung separately for lung operations. I went on to mention some of the other subspecialties including pediatric and cardiac anesthesiology.

At the mention of cardiac anesthesiology, a light bulb seemed to go off in the patient’s mind. “I think I had a cardiac anesthesiologist one time,” he said.

At that point, the GI team was ready to begin his procedure, so there was no more time to chat.  I gave the patient’s wife my business card with my title:  Clinical Professor of Anesthesiology and Perioperative Medicine. We headed to the procedure room. The circulating nurse and I hooked up his monitors; I started the propofol infusion. I watched his breathing and vital signs until the endoscopy was completed, turned the propofol off, and watched him wake up.

So many questions

This brief encounter left me with so many unanswered questions, and the unhappy feeling that no matter how much we may have done to try to explain the profession of anesthesiology to the lay public, clearly we’re not getting through.

This patient and his wife were not uneducated or economically disadvantaged. This was not their first encounter with the healthcare system; he had undergone four prior procedures at our teaching hospitals this year. If he received care from nurse anesthetists, they would have been under the medical direction of anesthesiologists. California is an opt-out state, but our health system does not permit nurse anesthetists to practice unsupervised.

How could the patient and his wife believe that all his prior anesthetic care had been given by nurse anesthetists?

Gender bias?

 My first hypothesis was that perhaps the patient had been taken care of by a mix of female anesthesiologists and female nurse anesthetists, all wearing the same nauseatingly pale green scrubs. It could be hard to tell one person from another — let alone remember who’s who — in the fast-moving assembly line of an outpatient GI endoscopy suite.

But when I looked up the patient’s previous records, that wasn’t the case at all.  Here’s the roster of anesthesia personnel for his four prior procedures, in chronologic order from first to most recent:

Female anesthesiologist and male nurse anesthetist

Male anesthesiologist, solo

Male anesthesiologist and male nurse anesthetist

Female anesthesiologist, solo

It turned out that the male anesthesiologist who worked solo was indeed a cardiac anesthesiologist, exactly as the patient recalled after our conversation jogged his memory.

So the total number of anesthesiologists who cared for this patient before I did was four — two women and two men — and the total number of nurse anesthetists was two, both men. Yet the impression he and his wife retained was that CRNAs gave him anesthesia. What can we make of that?

First names??

I’m sympathetic to the kindly impulse that can lead some of us to introduce ourselves by first names instead of using the title “Doctor”. We don’t want to seem elitist in the eyes of patients or staff. But is this a good idea?

There is evidence that reduction of “hierarchy” can improve patient safety by making it feel less threatening for anyone junior — whether in terms of age, professional rank, experience, or education — to question what is happening or about to happen. That’s the theory behind programs such as “Team Strategies and Tools to Enhance Performance and Patient Safety (TeamSTEPPS®)”.  Timothy Clapper, PhD, writing about the experience with TeamSTEPPS at Weill Cornell Medical College, states: “Healthcare workers may not speak up, even when it could make a difference for patient safety because they do not want to be wrong, are unsure, or do not want to hurt someone’s feelings.”

However, Dr. Clapper also notes: “From a communication standpoint, hierarchies are beneficial for healthcare teams, especially when time and clarity is an issue. Team members prefer to have a clear leader on their team. An effective leader operating in a suitable level of the hierarchy can quickly assign tasks and roles, especially during emergent cases to ensure task coverage and minimize delays. In healthcare systems, physicians regularly take on leadership roles and decision-making responsibilities.”

For physicians to assume those leadership roles, the key is for each person in the room to understand who among them is a physician and who is not.

If everyone on the team is introduced on a first-name basis, it may not be clear at all who is who, and which personnel are in leadership positions. This may be especially true when some people on the team are youthful trainees who rotate on and off teams in the course of their training. Is “Annabelle” an attending physician, a resident, a nurse, a nurse anesthetist, a physician assistant, a medical student, or a technician?  Confusion is almost inevitable when you can’t tell the players without a scorecard, and confusion can be lethal in a crisis.

First and last names??

Even when both first and last names are used, without the title “Doctor” in front of the name, a listener may not appreciate that the speaker is a physician.

The Editor of the ASA Monitor, Steven Shafer, MD, wrote a column in the August 2021 issue, explaining that he introduces himself to patients by saying, “Hello, I’m Steve Shafer. I’m the anesthesiologist who will be caring for you today.” He assumes that using the term “anesthesiologist” is sufficient to communicate the message that he is a physician with subspecialty training in anesthesiology.

This may work for many patients, but not all.  A recent survey by the American Medical Association found that 70% of patients recognized an anesthesiologist as a physician, 22% did not, and 8% were unsure. Several years ago, in the interest of truth in advertising, the ASA decided to champion the term “physician anesthesiologist”. Unfortunately, “physician anesthesiologist” is clumsy and difficult to say out loud without tripping over your own tongue. Does anyone use it in everyday conversation?

Which brings me back to my patient and his wife, and the fact that my self-introduction as “Dr. Sibert” created a moment of clarity that had been missing before.

What could have happened in the previous encounters?

Perhaps the anesthesiologists introduced themselves as Dr. Shafer does.

Perhaps the anesthesiologists who were supervising nurse anesthetists met the patient only briefly in the procedure room right before the case started, while the actual preop interviews were done by the CRNAs. This approach enables the anesthesiologist to duck into the room and quickly tick off the attestation boxes for preop assessment, assessment prior to induction, and presence at induction all at the same moment. However, in this scenario it’s unlikely that the patient will remember meeting the anesthesiologist at all.

Perhaps the term “CRNA” is just easier than “anesthesiologist” to say and remember.

Perhaps nurse anesthetists are simply better at promoting their brand.

We need to acknowledge a problem

Whatever the reason, I think we need to acknowledge that there is a problem. We can’t have it both ways:  abandoning formal titles and then complaining that no one knows we’re physicians. We can’t assume that our profession is going to get the respect it deserves if we’re reluctant to refer to ourselves as “Doctor”.

We can’t delegate the responsibility for doing the preoperative assessment to nurse anesthetists and then wonder why patients don’t know that an anesthesiologist was involved in their care.

We shouldn’t downplay our critical role in the operating room by introducing ourselves with our first names. Everyone on the team needs to know who the attending anesthesiologist is. This may be even more important if the attending anesthesiologist is young or female or both, and doesn’t necessarily look the part of a senior physician. During the time-out in the operating room, my standard response is, “I’m Dr. Sibert, with anesthesiology.”

With patients, I routinely introduce myself to patients as “Dr. Sibert”, trying as best I can to convey a smile behind my mask. I explain if I’m supervising a nurse anesthetist or a resident, or if I’ll be taking care of the patient by myself. I give out my business card liberally, making sure that my patients have a way to contact me after surgery if any issue should arise, and at the same time making it clear that I’m a board-certified physician who specializes in anesthesiology.

I have a hard time imagining Dr. Michael DeBakey in his prime ever introducing himself as “Mike”, and I won’t be saying, “Hi, I’m Karen,” anytime soon either.  All of us in anesthesiology have worked long years to become the physicians we are today. We need to own it, or else stop wondering why the public doesn’t know who we are.

(Author’s note:  This commentary and the accompanying illustration appeared first online in the November issue of the ASA Monitor on October 27, 2021.)

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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We’re very fortunate in anesthesiology. We’re seldom the physicians who have to face families with the terrible news that a patient has died from a gunshot wound.

But all too often we’re right there in the operating room for the frantic attempts to repair the bullet hole in the heart before it stops beating, or the blast wound to the shattered liver before the patient bleeds to death.

Despite all the skills of everyone in the operating room – surgeons, anesthesiologists, nurses, technicians – and all the blood in the blood bank, we’re not always successful. A death on the OR table is a traumatic event and a defeat; we remember it decades later.

So yes, this is our lane too. Memories haunt me of the times when mine was the last voice a gunshot victim heard on this earth, telling him he was about to go to sleep as he went under anesthesia for the last-ditch, futile attempt to save him.

I use the pronoun “he” intentionally, as every one of those cases in my professional life has been a young man. My experience is representative; most gunshot victims aren’t the random targets of mass shootings. They are overwhelmingly male (89 percent), under the age of 30 (61 percent), and over half are from the lowest income quartile.

The National Rifle Association (NRA) is way off base in telling physicians to mind their own business as it did in its infamous November 7 tweet. Human life is our business. Pediatricians have every right to remind parents that gun security, and keeping guns out of the hands of children, are vital to their well-being right up there with getting them vaccinated.

At my house, we’ve always kept our guns padlocked in a safe that our children couldn’t have broken into with a crowbar. We’re not NRA members, but we enjoy going to a shooting range on occasion. I learned gun safety during my officer training in the Army Reserve Medical Corps. My husband and I are firmly in the category of gun-owners who take both the right and the responsibility with the utmost seriousness.

Physician opinions on gun control and gun ownership vary just as much as the opinions of the rest of the population. What doesn’t vary is our collective sense of responsibility for public health and our support for better, more readily available, mental health care.

The solutions to America’s horrific rate of gun-related deaths aren’t easy or obvious. But the NRA isn’t helping matters with its thoughtless and incendiary social media message.

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