Posts Tagged ‘Anesthesiology’

Reimagining anesthesiology

Author’s Note: This is the text of the Leffingwell Honorary Lecture delivered at the annual meeting of the California Society of Anesthesiologists on April 9, 2022. Slides are available on request.

It is truly an honor to be here, and I want to thank Dr. Ronald Pearl and the California Society of Anesthesiologists for your kind invitation to speak.  I was quite surprised to receive it.  I’m neither a department chair nor an eminent researcher.  I find the concept of being a “thought leader” or an “influencer” frankly horrifying. Physicians aren’t sheep, and we don’t need to be led to think.

What I am is a well-trained writer. I owe that to my college professors and my editors at the Wall Street Journal, who were pitiless with their red pencils and equally quick to point out poor writing, or sloppy thinking, or both.

Since I never wanted to become a department chair, or a politician, or ASA President, I haven’t hesitated to say what I think about the sad state of healthcare – or really, anything else. I mean, if no one disagrees with you, have you said anything worth hearing?

Alexandr Solzenitsyn was right: “Truth seldom is pleasant; it is almost invariably bitter.” You may not agree with some or any of the ideas I’m going to talk about today, but if that’s the case, I hope you’ll be inspired to come up with better ones! I’m going to zero in on some of the hard truths about our profession and offer some thoughts about what we can and perhaps should do going forward.

Now I’ve never for a moment regretted becoming a doctor. I wanted to be a doctor since I was a kid and read a book my father gave me, published in 1960, called “All About Great Medical Discoveries.”  It had a horrifying and yet fascinating chapter about how terrible surgery was before anesthesia was invented, and how anesthesia made modern surgery possible.

In the 40 years – yes, 40 years — since I graduated from medical school, I’ve never regretted going into anesthesiology. It’s a wonderful field. We have the honor of being with patients and safeguarding them through some of the most critical moments in their lives.

There are amazing young people entering our field, I’m happy to say, so from that point of view, the future is promising.  In this year’s match, I believe there was only ONE unfilled position. But there are storms and riptides threatening our profession, and that is why we need – urgently – to rethink, redesign, and reimagine the practice of anesthesiology.

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I found myself on the wrong side of the ether screen earlier this year, having surgery on my left hand to release Dupuytren’s contracture, a genetic gift from my father and (maybe) generations of our Viking forebears.

Wondering how long it will take to heal – and when I’ll get some (any?) grip strength back in my hand – leads to reflection on the combination of brain and brawn necessary in the clinical practice of anesthesiology, something we don’t think much about when we’re young and fit.

Obviously, our clinical work demands intelligence. But we should ask this question: does it need to be as physically arduous as it currently is?

Would we reduce burnout, and keep clinical anesthesiologists in the workforce longer, if we devoted some of our collective brain power to making our workplaces less physically punishing and more ergonomically friendly? This is not an idle question to ask, considering that 55 percent of anesthesiologists (more than 23,000) in active practice are age 55 or older, according to AAMC data.

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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.”

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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. Read the Full Article

If you think about scope-of-practice creep at all, you may think immediately of the advocacy efforts so many physicians have made to preserve physician-led care and discourage independent practice by nurse anesthetists or physician assistants.

You may not have paid as much attention to the current momentum to grant independent practice to nurse practitioners, or NPs, nationwide.

In addition to the District of Columbia, 28 states allow NPs full practice authority to treat and prescribe without formal oversight. Half of these states grant NPs full practice authority as soon as they gain their licenses; the other half allow it after the NP practices with physician oversight for a period of time.

My home state, California, is one of the states that has always required physician oversight. Last fall, however, Governor Newsom signed a bill, Assembly Bill 890, that will allow NPs to practice independently after they have completed a three-year transition period, practicing under physician supervision.

That was when I started to worry.

Preop assessments that make us laugh or cry

No doubt everyone who practices anesthesiology or surgery has encountered preoperative medical assessments, H & Ps, or “clearance” notes that have been so far off the mark they’re laughable. I’m not just talking about the three-word “cleared for surgery” note scrawled on a prescription pad. I recall in particular:

A consultation at a VA hospital that “cleared” my cirrhotic patient with massive ascites and coagulopathy for his inguinal hernia repair under spinal anesthesia but not general.

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