Posts Tagged ‘Medical education’

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.

            How the ACGME and ABA are infantilizing resident training

Not long ago, my patient in a complex thoracic case developed progressive bradycardia followed by a malignant-looking multifocal atrial arrhythmia that didn’t generate any blood pressure.

“Get out some epinephrine!” I said to my resident, who was standing closer than I was to the drug cart. The resident quickly drew up a milligram of epi, but then paused. I could almost see the thought bubble overhead: “Should I print out a label? Put a tamper-proof cap on the syringe?”

The resident – perhaps spurred on by the look in my eyes – made the right call, pushing epi immediately into the IV line and not stopping first to clean the injection port with alcohol for 15 seconds. The patient responded right away with return of sinus rhythm and a blood pressure consistent with life.

This brief but intense drama led me to ponder (not for the first time) whether the protocols and rules that infuse our days are improving safety or leading to paralysis when decisions must be made. Sometimes you have to act as you think best, accepting the possibility that your action may be vulnerable to criticism.

Even if you follow the protocol today, tomorrow it may change. Wearing masks all the time at the start of the COVID pandemic was considered a bad idea – until it wasn’t. On average, 20% of the recommendations in clinical practice guidelines don’t survive intact through even one review – on the next updated version, they’re downgraded, reversed, or omitted.

Today’s resident education process isn’t helping residents face the inevitable ambiguity of medical decision-making. No wonder residents get rattled when they find that one attending does things far differently from another. The ACGME and ABA are turning residency training into an infantilizing experience. Residents are used to studying to the test, and on the test there’s only one right answer.

Anesthesiology trivial pursuit

I don’t envy residents today. When I peer over their heads in the OR to see what they’re looking at on the computer screen, it’s often a multiple-choice question in preparation for the ABA basic exam, which looms over their first two years like an executioner’s axe. Never once has the question had any relevance to the patient or the case. The question itself seems to be part of an anxiety-ridden trivia game, geared toward testing the ability to prep for the test, not the gain of medical knowledge with any connection to patient care.

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It’s early May in Los Angeles, and dystopian reality is here – storefronts boarded up; people (if they’re out at all) wearing sinister-looking black facemasks. Inside the hospital, everyone wears a mask all the time, no one gathers in clusters to chat, and even the tail-wagging therapy dogs must be sheltering at home because they’re nowhere to be seen.

One change I didn’t see coming was a metamorphosis in airway management.

Guidelines developed for the intubation of COVID-19 patients are evolving into the new normal whether a patient is infected or not. This is even more remarkable since anesthesiologists consider ourselves experts in airway management, and many of us (how can I put this kindly?) hold firmly to our opinions. Who would have thought old habits could change? But airway management this year is different and scarier. Remember when we didn’t think of it as hazardous duty?

Who still “tests” the airway?

Consider the question of whether to “test the airway” before giving any neuromuscular blocker (NMB) during a routine anesthesia induction. Some of us believe that it offers a measure of safety, because you can back out and wake the patient up if you can’t ventilate. Those (like me) who don’t do it quote studies that demonstrate more effective mask ventilation with larger tidal volumes after NMB, and point out that if you can’t ventilate, most people will give NMB anyway.

That controversy seems to have gone into hiding. Today, the guidelines for intubating a patient with proven or suspected COVID-19 recommend rapid-sequence induction (RSI) to reduce the risk of the patient coughing and spraying the area with aerosolized coronavirus. No one in that situation seems worried about testing the airway.

What about the patient who is asymptomatic, and has a recent negative COVID-19 test result? There is legitimate concern that the patient could still be in the early, asymptomatic stage of infection, and the incidence of false negative results from COVID-19 testing could be as high as 30%. By that logic, we should treat every patient as a PUI, and perform RSI on all comers. It would be interesting to survey anesthesia professionals and see how many now perform RSI as their default approach. Certainly, residents now ask me on nearly every case if the plan is RSI, and I hear from colleagues at other institutions that my experience isn’t unique.

What about extubation?

If we don’t want coughing on intubation in the era of COVID-19, logically we wouldn’t want it on extubation either. Awake extubation, especially in the hands of novices, can include an alarming display of coughing and struggling by the patient, accompanied by cries of “Open your eyes! Take a deep breath!” by the person at the head of the table. More coughing follows as the tube comes out. In contrast, a recent review article on the care of COVID-19 patients advises removing the endotracheal tube “as smoothly as is feasible”. For our colleagues in the United Kingdom who are accustomed to deep extubation, this is routine. In America, it isn’t.

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Elegy for giant conventions

ANESTHESIOLOGY 2019 may have been the last old-school, convention-size, professional meeting I will ever attend. I could be wrong, but it may mark the end of an era. Disruptive change to the convention business model was inevitable, though hastened by COVID-19. On June 5, ASA leadership announced that the 2020 annual meeting will be virtual — for the first time, but perhaps not the last. Does this news herald disaster or opportunity?

When I was a resident attending my first ASA annual meeting, the huge convention center struck me as the mother lode of anesthesiology knowledge, with lectures and workshops that couldn’t be found anywhere else. Today, I wonder why I would travel across the country to attend a refresher course lecture in a freezing-cold meeting room, when I can watch similar content on YouTube or VuMedi for free, in comfort?

Professional associations could take this moment to move decisively into the video/podcast market. Speakers could record their own lectures, pro-con debates, and panel discussions, and societies like ASA and CSA could post all the content on proprietary video and podcast channels for members to access year-round. Think of the money we could save in travel and the cost of renting convention centers. Giant conventions at the ASA level are limited to only a few cities, most of which wouldn’t be my choice to visit.

The future of exhibit halls?

Corporate interest in buying exhibit space at anesthesiology meetings was fading fast, even before COVID-19. Why pay to send people and equipment to exhibit halls when mergers and acquisitions have centralized all the purchasing power? As recently as ten years ago, many anesthesiologists were able to influence which laryngoscopes or epidural kits their departments would order. Today, people who negotiate purchasing contracts typically work in the central offices of health systems, not in operating rooms. Today, most of us can do little more than complain about our inadequate stock of video laryngoscopes or the maddening electronic health record we’re compelled to use.

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For several years now, I’ve been the social media curmudgeon in medicine. In a 2011 New York Times op-ed titled “Don’t Quit This Day Job”, I argued that working part-time or leaving medicine goes against our obligation to patients and to the American taxpayers who subsidize graduate medical education to the tune of $15 billion per year.

But today, eight years after the passage of the Affordable Care Act, I’m more sympathetic to the physicians who are giving up on medicine by cutting back on their work hours or leaving the profession altogether. Experts cite all kinds of reasons for the malaise in American medicine:  burnout, user-unfriendly electronic health records, declining pay, loss of autonomy. I think the real root cause lies in our country’s worsening anti-intellectualism.

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