Posts Tagged ‘Anesthesiology’

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.)

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.

Read the Full Article

Is it time to unionize?

Remember the dark days of the pandemic in March and April, when the true risk of caring for COVID patients started to become clear?  Remember when you could be censured by a nursing supervisor or administrator for wearing a mask in public areas lest you frighten patients or visitors?

Right around then, a third-year resident at UCLA decided to wear a mask wherever he went in the hospital, as testing wasn’t readily available yet for patients, and visitors still had full access. Someone with a clipboard stopped him and said he couldn’t wear a mask in the hallways. The resident politely responded that yes, he could. Why? Because his union representative said so. The discussion ended there.

The resident enjoyed backup that his attendings lacked because all UCLA residents are members of the Committee on Interns and Residents/SEIU, a local of the Service Employees International Union (SEIU). This union represents more than 17,000 trainees in six states and the District of Columbia.

As CMS threatens further pay cuts for anesthesiology services and other third-party payers are likely to follow suit, many attending anesthesiologists are asking:  Why can’t we form a union? Alternatively, why can’t the ASA function like a union and negotiate on our behalf?

Read the Full Article

Practice without fear

This article, with advice for residents about the future of anesthesiology, was published first in the October 2020 issue of Anesthesiology News

You may be weary of being told that our profession is facing a time of unprecedented threat – from third-party payers, from the government, from non-physician practitioners. You’ve heard it so often that your brain is tuning it out. Is the threat level exaggerated for dramatic effect? Is it better just to go on with your day and not think about it at all?

That would be a mistake. The real question is:  How should we deal with the upcoming “market adjustment” that almost certainly will result in lower anesthesiologist compensation? In the face of gloomy reality checks, how can we promote pride in our profession and recruit the best medical students? How can we continue research that will reduce risk and improve outcomes? How do we avoid becoming irrelevant or extinct, like Kodak, Xerox, Sears, and now Hertz? It’s time to face the future.

The threats are real

Unfortunately, the “unprecedented threat” claim is all too real. Department chairs everywhere  worry that they will not be able to maintain the compensation rates that anesthesiologists have enjoyed up to now. Why?

The Medicare Trust Fund is expected to become insolvent as soon as 2024. The chair of the Medicare Payment Advisory Commission (MedPAC), Michael Chernew, PhD, recently commented, “We are very dedicated to finding payment models to promote efficient delivery of care.” No one could possibly think this will mean anything other than lower payments to physicians.

Scope-of-practice expansion is gaining ground. On March 30, CMS issued an array of “temporary” waivers and new rules, waiving the requirement that a nurse anesthetist must work under the supervision of a physician. How likely are these new rules to be reversed under a new administration, whether Republican or Democratic? Whether or not you live in an “opt-out” state may not matter in the near future.

Hospitals were in trouble even before the COVID-19 pandemic. Many have gone bankrupt; others are merging with larger health systems. At present, around 80% of hospitals subsidize their anesthesiology departments to the tune of millions of dollars each year. Realistically, can these subsidies continue? Probably not. Will hospital administrators seriously consider cheaper staffing models for delivering anesthesia care? Probably yes.

Make yourself indispensable

First, it would be wise to assume that a downward “market adjustment” to anesthesiologist compensation is coming. Plan for it now. Stop yourself from spending to the full extent of your income, and put away all you can in a tax-deferred retirement account.

Read the Full Article

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