“What’s this I hear?” said the CA-1 resident earlier this year as we were setting up for our first morning case. “You’re going to retire?”

“Why yes,” I said. “That’s correct. In April.”

He shook his head. “No,” he said firmly. “I know you have another two years in you.”

That was very kind, and I appreciated it, as I did this text message from a senior resident: “If you try to leave before July, I’ll report you for resident abandonment.” It’s always better to leave while they still want you to stay, as opposed to lingering long past your sell-by date, right?

Even two years earlier, if anyone had told me I’d be ready to retire from clinical anesthesiology in spring 2022, I would have laughed at the idea. I always felt that the many sacrifices my parents made (and all the tax dollars the public spent) to give me an excellent education conferred an obligation to use it for good – to continue practicing medicine and caring for patients even after I became eligible for Medicare. Is that an antiquated concept? Maybe, but I believed in it nonetheless.

I also think it’s a shame that when an anesthesiologist leaves clinical practice all those years of practical bedside experience – all the tricks you can’t learn from the books – go to waste. There really isn’t a way in American anesthesiology practice for an emeritus anesthesiologist to contribute clinically once you’ve pushed that last syringe of propofol and you walk out of the operating room for good. You can see senior surgeons or internists making clinical rounds with a team to observe and impart some of their hard-earned wisdom, but there’s no comparable role for a senior anesthesiologist other than to come to Grand Rounds occasionally and pontificate.

Easing into retirement?

Some people advocate “easing into retirement” as a way of slowing down without leaving the profession completely. What does that mean? It could mean cutting back on clinical hours or working part-time. It could mean opting out of the long, difficult cases in the main OR, or going to work in an ambulatory surgical center. Those options appealed to me about as much as plunging a toilet.

What’s always been fun for me in anesthesiology – maybe “fun” is the wrong word – is dealing with the unusual cases that call for actual decision-making as opposed to following a protocol. I never minded managing a difficult airway or staying to finish a tough case when I felt it would be irresponsible to turn it over to a harried, overburdened call team. Vascular, bariatric, pancreatic, thoracic – I was happy with any of those case lists. To handle those cases well, in my opinion, you should do them all the time, not just occasionally.

Once in a while it wasn’t bad to have an easy morning with a plastic surgery free flap, but by lunchtime I longed to be elsewhere. Would I care to spend the day drawing up syringe after syringe of propofol in an outpatient center and rushing to turn over rooms in five minutes – no, thank you. I’m delighted that there are people who enjoy outpatient work, but I’m not one of them.

Yet in the autumn of 2021, a switch flipped and suddenly I knew I was ready to stop doing what I had been doing since the start of my CA-1 year in July 1984 – practicing clinical anesthesiology full time, day after day. It would be a full stop, not a gradual easing out.

What flipped that switch?

Naturally, more than one factor influenced the “full stop” decision.

Health system policies may be well-intentioned, but I refuse to spend time ever again on recurrent, mandatory “e-learnings” about sexual harassment or implicit bias. If that’s the price of employment, I respectfully decline. Life is short.

Physically, I knew I was tired. As the years creep by, all of us develop our share of physical woes. A lumbar compression fracture – sustained as I lifted the head of a 300-lb patient being turned to the lateral position – was a warning call. Anesthesiology, as I’ve noted in a previous ASA Monitor column, is more demanding physically than it should be, and that problem won’t disappear any time soon. Today’s clinical practice calls for stronger bones and more stamina than I have.

Did the pandemic have anything to do with it? Perhaps. It’s been a rough two years for all of us.

But I think the most important question weighing on my mind was how I could be sure to know if my cognitive ability started to slip, if my reaction time wasn’t as quick, if I started to lose my clinical edge.

“Conditions that undermine cognition may erode insight,” as neurologist Gayatri Devi, MD, MS, and colleagues noted in their 2021 article, “Cognitive Impairment in Aging Physicians.” Many of us have known colleagues who should have left clinical practice long before they actually did. I was determined not to be one of them.

During the last few months and especially the last weeks of my pre-retirement countdown, I remember thinking how dreadful it would be if a patient of mine suffered a bad outcome, and if I were forced to ask myself if it would have been the same in the hands of a younger colleague. Mercifully, that question never arose. When I took the last patient to the PACU, I felt a tremendous sense of thankfulness and relief.

But don’t you miss working?

Do I miss my job? Six months later, I can honestly say that the answer is no. I don’t have to set an alarm unless I’m heading to the airport. I’m still writing and serving on editorial boards. I’m going to the gym more often. I see more of my grandchildren. I’m honored to be chairing the California Society of Anesthesiologists’ January meeting in Maui. (Don’t miss it! We have a fantastic lineup of speakers!)

And to the apparent surprise of many of my friends, I’m back in school – I’ve started a master’s degree program in theological studies, reading so many wonderful books that I’ve never before had time or energy to read. Truthfully, I feel as though I’ve been let out of jail.

Many of us, though, want to keep working clinically longer than I did for a multitude of reasons. Interestingly, in the United States anesthesiologists historically have tended to work far longer than they do in the United Kingdom. A 2021 article in BJA Education reports that in the UK, only 17.2% of anesthesiologists work clinically beyond the age of 55, whereas in the US 40% continue working. (Those numbers are based on pre-pandemic survey data; they may be lower today in both countries.)

I would be the last to suggest that there should be a mandatory cut-off age for American clinical anesthesiologists the way there is for airline pilots, at 65. In an excellent editorial, “Cognitive Screening in Aging Physicians,” psychiatrist Lawrence Whalley, MD, argues that no system is foolproof for detecting mild cognitive impairment, and that coercion to undergo neurocognitive testing at any specific age is unwarranted. “Repositories of knowledge (crystallized intelligence) are well preserved and can increase with age,” he believes.

Given the current demand for anesthesiology services, it makes sense to consider how we can do a better job of keeping older anesthesiologists in the workforce, of creating new roles for them, without jeopardizing either their own physical health or the safety of patients. Many of us still have much to teach and contribute. A number of retired anesthesiologists volunteered to help staff ICUs in New York City at the worst of the COVID-19 pandemic, doubtless saving many lives in the process.

In Dr. Whalley’s words, “Although public safety must remain a priority, fellow physicians share a collegial responsibility to care for and support older physicians who wish to continue in practice. This can never be overlooked and should be embedded in future health care systems.” I hope that’s a concept we all can embrace.

This article appeared first in the ASA Monitor issue of December, 2022

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References

1. Devi G, Gitelman DR, Press D, Daffner KR. Cognitive Impairment in Aging Physicians: Current Challenges and Possible Solutions. Neurol Clin Pract. 2021 Apr;11(2):167-174. doi: 10.1212/CPJ.0000000000000829. PMID: 33842070; PMCID: PMC8032410.

2. Garfield JM, Garfield FB. The ageing anesthetist: lessons from the North American experience. BJA Educ. 2021 Jan;21(1):20-25. doi: 10.1016/j.bjae.2020.08.007. Epub 2020 Nov 5. PMID: 33456970; PMCID: PMC7807987.

3. Whalley LJ. Cognitive Screening in Aging Physicians: Faith in Numbers. Neurol Clin Pract. 2021 Apr;11(2):89-90. doi: 10.1212/CPJ.0000000000000833. PMID: 33842058; PMCID: PMC8032417.

When Arnold Schwarzenegger was governor, he decided that you and I don’t need to have physicians in charge of our anesthesia care, and he signed a letter exempting California from that federal requirement. Luckily most California hospitals didn’t agree, and they ignored his decision.

When he needed open-heart surgery to replace a failing heart valve, though, Governor Schwarzenegger saw things differently. He chose Steven Haddy, MD, the chief of cardiovascular anesthesiology at Keck Medicine of USC, to administer his anesthesia.

Now some people in the federal government have decided that veterans in VA hospitals all across the US should not have the same right the governor had—to choose to have a physician in charge of their anesthesia care.

That’s right. The VA Office of Nursing Services has proposed a new policy to expand the role of advanced practice nurses, including nurse anesthetists, in the VA system. This new policy in the Nursing Handbook would make it mandatory for these nurses to practice independently. Physician anesthesiologists wouldn’t be needed at all, according to this proposal, even in the most complicated cases – such as open-heart surgery.

If this misguided policy goes into effect, the standard of care in VA hospitals will be very different from the standard of care other patients can expect. In all 100 of the top hospitals ranked by US News & World Report, physician anesthesiologists lead anesthesia care, most often in a team model with residents and/or nurses.

The new policy isn’t a done deal yet. The proposal is open for comment in the Federal Register until July 25. Already thousands of veterans, their families, and many other concerned citizens have visited the website www.safeVAcare.org and submitted strongly worded comments in opposition. I urge you to join them.

Physician-led care teams have an outstanding record of safety, and they have served veterans proudly in VA hospitals for many years. Many university medical centers have affiliations with their local VA hospitals, where their faculty physicians deliver clinical care and conduct research. UCLA, for example, sends anesthesiologists to the VA hospital in Los Angeles, so that our veterans get the same high-quality care as wealthy patients from the enclaves of Brentwood.

Many of our veterans aren’t in good health. They suffer from a host of service-related injuries, and they have high rates of chronic medical disease. Some have been among the most challenging patients I’ve ever anesthetized. Their care required all the knowledge I was able to gain in four years of medical school, four years of residency training in anesthesiology, and countless hours of continuing medical education.

No VA shortage of anesthesia care

It’s clear, of course, why the VA is proposing the change in the Nursing Handbook. The reason is the scandal over long waiting times for primary care. Proponents argue that giving nurses independent practice will expand access to care for veterans.

But there’s no shortage of physician anesthesiologists or nurse anesthetists within the VA system. The shortages exist in primary care. A solution that might help solve the primary care problem shouldn’t be extended to the complex, high-tech, operating room setting, where a bad decision may mean the difference between life and death.

The VA’s own internal assessment has identified shortages in 12 medical specialties, but anesthesiology isn’t one of them. The VA’s own quality research questioned whether a nurse-only model of care would really be safe for complex surgeries, but this question was ignored. The proposed rule in the Federal Register lists as a contact “Dr. Penny Kaye Jensen”, who in fact is not a physician but an advanced practice nurse who chooses not to list her nursing degrees after her name. The lack of transparency in the proposal process is disturbing.

In 46 states and the District of Columbia, state law requires physician supervision, collaboration, direction, consultation, agreement, accountability, or direction of anesthesia care. The proposed change to the VA Nursing Handbook would apply nationally and would override all those state laws, which were put in place to protect patients.

In Congress, many senators and representatives on both sides of the aisle recognize the need to continue physician-led anesthesia care for veterans. Representatives Julia Brownley of California’s 26^th District and Dan Benishek, MD, of Michigan’s 1^st District are strong advocates for veterans’ health. They have co-authored a letter (signed by many in Congress) to VA Secretary Robert McDonald, urging him not to allow the destruction of the physician-led care team model as it currently exists within the VA system.

Governor Schwarzenegger’s heart surgery is a matter of public record. He has spoken about it openly on television, and he graciously invited the whole operating room team to his next movie premiere. I was lucky enough to go to the premiere too, because his anesthesiologist, Dr. Haddy, happens to be my husband.

But I didn’t set out to write this column on behalf of my husband. I’m writing on behalf of my father, who is now 93, landed on the beach at Normandy on D-Day, and miraculously survived the rest of the war as a sniper. And I’m writing on behalf of all the men and women who have served our country, and who deserve the best possible anesthesia care from physicians and nurses who want to work together to take care of them. If we don’t defeat the proposed change in the VA Nursing Handbook, they all lose.

No one wants a hospital-acquired infection—a wound infection, a central line infection, or any other kind.  But today, the level of concern in American hospitals about infection rates has reached a new peak—better termed paranoia than legitimate concern.

The fear of infection is leading to the arbitrary institution of brand new rules. These aren’t based on scientific research involving controlled studies.  As far as I can tell, these new rules are made up by people who are under pressure to create the appearance that action is being taken.

Here’s an example.  An edict just came down in one big-city hospital that all scrub tops must be tucked into scrub pants. The “Association of periOperative Registered Nurses” (AORN) apparently thinks that this is more hygienic because stray skin cells may be less likely to escape, though no data prove that surgical infection rates will decrease as a result.  Surgeons, anesthesiologists, and OR nurses are confused, amused, and annoyed in varying degrees.  Some are paying attention to the new rule, and many others are ignoring it.  One OR supervisor stopped an experienced nurse and told to tuck in her scrub top while she was running to get supplies for an emergency aortic repair, raising (in my mind at least) a question of misplaced priorities.

The Joint Commission, of course, loves nothing more than to make up new rules, based sometimes on real data and other times on data about as substantial as fairy dust.

A year or two ago, another new rule surfaced, mandating that physicians’ personal items such as briefcases must be placed in containers or plastic trash bags if they are brought into the operating room.  Apparently someone thinks trash bags are cleaner.

Now one anesthesiology department chairman has taken this concept a step further, decreeing that no personal items at all are to be brought into the operating room–except for cell phones and iPods.  That’s right, iPods, not iPads.  This policy (of course) probably won’t be applied uniformly to high-ranking surgeons or to people like the pacemaker technicians who routinely bring entire suitcases of equipment into the OR with them.

What’s particularly irrational about this rule is that cell phones likely are more contaminated with bacteria than briefcases or purses, even if they’re wiped off frequently.  And I have to ask how an iPhone 6+ meets eligibility criteria while the barely-larger iPad mini doesn’t.  Again, please show me the data demonstrating that this will reduce infection rates, unless someone is making it a habit to toss briefcases and iPads onto the sterile surgical field.

Show me the money

I wish I could say that the driving force behind hospitals’ fear of infection is simply the wish for patients to get well. Unfortunately, it’s probably driven as much by financial motives as benevolent ones.  Today, Medicare won’t pay for care related to surgical site infections, and it fines hospitals whenever too many patients need to be readmitted within 30 days of discharge.  In 2014, a record 2610 hospitals–including 223 in California–were penalized, and will receive lower Medicare payments for all patients over the next year, not just those who were readmitted.

What does this mean at the grassroots level?

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“I’m here to say ‘Yes, they can,’ which is different from ‘Yes, they always do,’” says James Moore, MD, President-Elect of the California Society of Anesthesiologists (CSA).

To the contrary, enthusiasm for electronic medical records (EHRs) is part of a “syndrome of inappropriate overconfidence in computing,” argues Christine Doyle, MD, the CSA’s Speaker of the House.

The two physician anesthesiologists (and self-identified “computer geeks”) squared off in a point-counterpoint debate in New Orleans as part of the American Society of Anesthesiologists (ASA) annual meeting, with Dr. Moore defending the benefits of EHRs and Dr. Doyle arguing against them. Dr. Doyle chairs the ASA’s Committee on Electronic Media and Information Technology, while Dr. Moore leads the implementation of the anesthesia information management system (AIMS) at UCLA.

Legibility, accuracy, quality

Dr. Moore defined safety in anesthesia care as “minimizing patient injury resulting from or occurring during anesthesia, and keeping surgeons from harming patients any more than they have to.” He said that computerization contributes to safe anesthesia care by improving legibility, offering clinical decision support with readily available reference information, and providing alerts and reminders.

Computer tracking of the anesthetized patient’s vital signs is more accurate, Dr. Moore said. It prevents the “normalization” of blood pressure that tends to appear on the paper record. Quality reports are easier to generate and outcomes are easier to measure with EHRs in place, he noted. “Postop troponin levels and acute kidney injury are easy to track.”

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Since the death of comedian and talk-show host Joan Rivers, more information has surfaced about the events on the morning of August 28 at Yorkville Endoscopy. But key questions remain unanswered.

News accounts agree that Ms. Rivers sought medical advice because her famous voice was becoming increasingly raspy. This could be caused by a polyp or tumor on the vocal cords, or by acid reflux irritating the throat, among other possible causes.

So Ms. Rivers underwent an endoscopy by Dr. Lawrence B. Cohen, a prominent gastroenterologist, to evaluate her esophagus and stomach for signs of acid reflux. At the same time, a specialist in diseases of the ear, nose, and throat (ENT) reportedly examined her vocal cords (also known as vocal folds).

We don’t know exactly how much or what type of sedation Ms. Rivers’ may have received, though several news sources have reported that she was given propofol, the sedative associated with the death of Michael Jackson. No physician who specializes in anesthesiology has been identified on the team taking care of Ms. Rivers, and we don’t know who was in charge of giving her propofol.

It seems clear that at some point during Ms. Rivers’ endoscopy and vocal cord examination, there was a critical lack of oxygen in her bloodstream.

Was laryngospasm the cause?

Giving sedation for upper endoscopy is tricky, as any anesthesia practitioner will tell you. A large black endoscope takes up space in the mouth and may obstruct breathing. Any sedative will tend to blunt the patient’s normal drive to breathe. But most patients breathe well enough during the procedure, and go home with no complaints other than a mild sore throat.

News reports have speculated that the root cause of Ms. Rivers’ rapid deterioration during the procedure could have been laryngospasm. This term means literally that the larynx, or voice box, goes into spasm, and the vocal cords snap completely shut. No air can enter, and of course the oxygen in the bloodstream is rapidly used up.

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