To the Editor:

I am heartsick about the surgeon's perioperative experience recounted in the summer 2004 issue of the APSF Newsletter. I take him at his word that he considers anesthesia a team member, a colleague, and that he did not receive a true consultant's expertise.

Unfortunately, the vast majority of surgeons want what I call “Nike Anesthesia”—Just Do It. They don't want to find out that the patient has trepidation and may be better off rescheduling for another day. Surgeons don't want to find out the their patient is a previously undiagnosed hypertensive or diabetic. Many surgeons do not do even vital signs in their offices before scheduling surgeries. I recall 1 surgeon arguing with me about an undiagnosed hypertensive with a diastolic of 140, rechecked multiple times, who was coming in for a knee scope. Another incident involved a middle-aged woman coming for blepharoplasty, who was clearly having angina and a left strain pattern on the EKG. When I stated I would cancel the case, the nurse administrator asked why we couldn't do the case under straight local. When the surgeon arrived, he thanked me and transferred the patient who underwent PTCA within hours. The administrator is always standing right behind the surgeon—more cases equal more billings. Meanwhile, anesthesia risk is increasing, production pressure is unbearable, and the system cannot continue this way.

We have only to look as far as Selye and the Yerkes-Dodson curve to know that we are on the path to destruction. The productivity levels business has enjoyed over the past 4 years are simply not sustainable. Now business is complaining about worker's compensation claims. Business blames the doctors, the ambulatory surgery centers, and the implant manufacturers, but they do not take a look inward at the stresses the workers are under. ACCIDENTS ARE A STRESS-RELATED DISEASE. Whether those accidents are as (thankfully) mild as a lack of common courtesy and consultation in this case, or as egregious as delivering a fatal dose of the wrong drug—accidents kill and maim every day. What we pay for in controlling hours worked and and in more flexible scheduling, along with surgeons abandoning the "Captain of the Ship" mentality, we will more than pay for in lower unemployment and higher morale—leading to fewer sick days and fewer accidents.

Stephanie Jo Dyer, MD

To the Editor:

Surgeon’s Experience Is Not An Isolated Case back to top

I noted with great interest the letter from the anonymous surgeon/patient about his poor experience with “anesthesia providers” and his appeal for “professionalism.” I wish this were an isolated case. I know from years of both academic and private practice that it is not.

I have spent roughly half of my career in academic medicine, most recently in one of the premier anesthesia departments in the United States, at least as such things are judged. Usually academic ranking is centered on academic performance goals (grants, publications, residency pool, and so forth). Medical centers grade themselves, at least until recently, on aggregate patient outcomes. Only recently have “customer service” concepts been championed at large, prestigious university medical centers. My colleagues, brilliant men and women with an in-depth knowledge of the science of medicine and impressive academic resumés, are justifiably proud of the professional standing. However, they often act like the Rodney Dangerfield of medicine, complaining ad nauseam that they don’t get the professional respect they deserve from patients and fellow physicians, especially surgeons. The letter from a colleague/patient explains, better than any words of mine, why this is something we frequently invite upon ourselves.

During the half of my career spent in small community hospitals, I have had the chance and the will to be an actively participating member of my hospital medical staff, the community it serves, the emergency medical system that provides urgent access to healthcare, and the process of evaluating every patient that presents for anesthesia care. I learned early (from some folks in academic practice--physicians and nurses alike) that the only person having “routine” anesthesia is me. Every patient, even our surgeon/author, is appropriately concerned about his or her welfare and wants us to demonstrate through words and actions that we are as well. Quite aside from the obvious fact that a cursory review of other people’s assessment is not a safe practice, it smacks of casual disregard for the feelings of the person under our care. I cannot tell you the number of times an interview of substance (total time 10 minutes or less) reveals new information not obtained by anyone up to that point or casts important new light on available information. That chest pain diagnosis of reflux might seem inconsistent with lack of relief by acid inhibitors and occurs mostly with exertion described by the patient. Perhaps I’ll consider a beta-blocker preoperatively. You get the idea.

We, as practitioners of medicine, can complain at every opportunity, change our description of ourselves (i.e., the whole “perioperative medicine” thing), and insist that others recognize and yield to our superior training. Until such time as we as individuals consistently comport ourselves as physicians, acquiring information directly through history and physical examination where indicated and caring for, not just taking care of, our patients, those efforts will be so much smoke in the wind. Technology is an important aid to medical practice and anesthesia in particular, but it is the “laying on of hands” and the demonstration of concern and compassion that define the art and profession of medicine. Respect is earned, not applied for.

Michael W. Russell, MD
Nags Head, NC

To the Editor:

Reader Calls For Professionalism back to top

After reading the letter concerning the surgeon patient I felt like I would have PONV for him. That was a case of non-professionalism. I know that we are all short on time, but I always introduce myself as the anesthesiologist and ask if there are any questions before explaining the type of anesthetic to be used. The whole scenario was poor perioperative care.

Whenever I have a colleague as a patient, I try to do the case myself, just out of courtesy, but if I am unable to do it personally, I ask one of our senior residents to do the case.

My wife (also a physician) had a similar experience at one of the local hospitals, but the anesthesiologist came by to mention his name once. I had surgery 3 weeks ago at our hospital, and one of my colleagues put in the block and stayed with me for the entire case. It was truly great to have him present.

I would like to think that we are all professionals and not just technicians.

Joseph L. Skibba, MD, PhD
Albuquerque, NM

To the Editor:

Perception May Be Problem Separate From Vigilance back to top

Regarding the article “Reading in the OR” in the Fall 2004 issue, have the authors considered that, under appropriate circumstances, reading might actually improve vigilance in the OR? In my opinion, and in my experience, reading can actually function as a means to keep one’s mind alert during periods of mental hypo-activity.

Eschewing outside stimuli, such as music, conversation, reading, and so on, may seem at first glance to be the most rigorous and admirable way to maintain vigilance, but is that really the case? We all know that there are periods during the anesthesiologist’s day when his or her mental capacity is not being fully utilized. The mind will occupy itself one way or the other: I would submit that daydreaming might be a greater hazard than other activities that actually encourage a more alert mental status.

Of course, it is incumbent on the practitioner who chooses to read, converse, check e-mail, or whatever in the OR to honestly assess his own level of vigilance during these activities. Perhaps one physician will find himself too distracted by certain kinds of music, another by a specific kind of reading (novels, for example), or another by engaging in political debate in the OR, while another will find that he loses track of time and lessens his vigilance if he does not engage in some additional mental activity while providing anesthesia care.

In each case, we must currently rely on the practitioner’s self-assessment. Perhaps, rather than condemning certain activities out of hand, a better approach might be to devise a method for individual physicians to better assess their own mental capacity for vigilance during a variety of activities and in a variety of situations. I think this would be quite difficult, but it’s worth considering.
The public relations aspect is a completely separate issue, in my opinion, and admittedly a significant one. But is it helpful when observers who “feel” that patient safety is compromised by reading in the OR publicly condemn the practice despite any evidence in support of their view? It’s interesting that those who denounce OR reading are often engaged in the academic practice of anesthesia. Although they certainly have as much right to their opinion as anyone, in the absence of data I would give more credence to the intuition of those who have years of experience, day in and day out, providing safe, solo, hands-on anesthesia care to their patients.

Bryan Bohman, MD
Palo Alto, CA

To the Editor:

Varied Stimulus May Combat Boredom, Increase Awareness back to top

From the vantage point of the sharp end of the anesthetic care needle, the recent opinion letter from Drs. Monk and Giesecke generates a number of thoughts. Whatever the formal title, the person who lives within an arms length of an anesthesia machine usually spends 50% or more of his or her waking hours planted in a chair trying to create and maintain physiologic boredom. However, once this state has been achieved, this person must then deal with the very real, but underappreciated, stress of remaining vigilant despite little or no stimulus.

This is, with a quality anesthetic, akin to monitoring the curing of (admittedly precious) concrete. Music, conversation, moving about, and brief reading interludes all serve to energize the senses, and in fact I would submit increase, rather than decrease, situational awareness by prompting a re-scan of the data, rather than just staring at the colored numbers. However, while I am not swayed by the ethical resource of Bill Clinton, I realize that my view may not carry the day. If that is the case, realize that the reading time left at days’ end is precious, priorities must be set, and some items, such as this very newsletter, may not make the cut.

C.F. Ward, MD
San Diego, CA

To the Editor:

Reader Applauds Attention to Fatigue back to top

Bravo to Dr. Ellis for his remarks regarding fatigue and long work hours in the Fall 2004 issue. Now one even has to make sure that a resident is not too tired to drive. Is this being done in other critical occupations? How much sleep does the President get before sending our troops into combat?

In my practice we are off the day after taking call; many practices that I am familiar with function in this fashion.

It always bothered me that surgeons could start long, elective cases late at night or work during the night, only to continue with their elective schedule the next day.

Unfortunately, many of the important changes to health care cannot occur because of lack of funding. When we do make a change it is at the discretion of JCAHO, and it often lasts for the duration of the inspection.

Steven Ginsberg, MD
Bridgewater, NJ

Editor’s Note: Stay tuned for an upcoming Special Issue of the APSF Newsletter addressing issues of fatigue, human performance, and patient safety with guest editor Steve Howard, MD.