To the Editor:
I am an ABA Certified Anesthesiologist with 15 years post-residency experience in community hospitals. I have become increasingly concerned with the matter of "production pressure." If ever there was an unworthy appellation coined for a shameful and inconsistent concept, this certainly qualifies. My observation of this phenomenon over a significant period of time leads me to conclude that it has no positive connotations. It is shameful because it frequently results in a departure from patient advocacy in order to meet other competing goals, e.g., 1) deferring to a surgeon’s schedule in order to avoid complaints of delay, postponement, or cancellation directed to an unsympathetic administration, 2) denying patients their legal right to informed consent and an adequate work-up due to a given facility’s inefficiencies and imposed time constraints, 3) the perceived need to protect a business arrangement or exclusive contract in an environment where "production" is prized above quality or safety.
For example, when an 82-year-old, hypertensive, diabetic patient on multiple medications is treated with the same lack of laboratory work-up as a 30-year-old, ASA 1 patient on no medications, then I am of the opinion that we have exceeded the limit for rational laboratory parsimony. Similarly, consider the 59-year-old, obese patient with newly diagnosed diabetes and poorly-controlled hypertension who was admitted 24 hours earlier with cellulitis of the foot who has still not received any work-up upon arrival in the operating room for "emergency" incision and drainage. A stat EKG also shows atrial flutter with a rapid ventricular response (120s in the absence of fever or signs of sepsis), evidence of previous infarction, age indeterminate, with current ischemic changes in the lateral leads. Which is the higher priority emergency: toe pus or cardiovascular stabilization? In a profession that prides itself on skill—not just technical skills, but skills of clinical acumen and judgment—I must conclude that in such cases some "board certified" anesthesiologists have included under "clinical judgment" a heavy reliance upon lady luck. The reality is that, frequently, the patients survive their procedures and anesthetics. What should I conclude from this? Have I missed something? Has pre-anesthetic assessment for the purpose of patient preoperative stabilization and the mitigation of chronic disease exacerbation become passé? Has the oft-touted improvement in anesthesia morbidity and mortality statistics (although the incidence of adverse events for MAC anesthetics may be increasing again) rendered patient work-up and preparation obsolete because it may be inconvenient to a surgeon’s schedule?
My training and experience inform me that the most important determinant of a good outcome is a rational, well thought-out anesthetic plan incorporating appropriate flexibility and based upon a thorough pre-anesthetic work-up. Vigilance does not begin with the pushing of a medication or the onset of an anesthetic. In the absence of knowledge, one is left with ignorance. I refuse to accept that any of my anesthesia colleagues possess sufficient clairvoyance to dispense either frequently or occasionally with an appropriate medical work-up, particularly when such obvious and powerful conflicts of interest as mentioned above are present.
It would seem that board certification no more guarantees consistent and persistently high standards of medical care than a license to drive implies the ability to handle a vehicle on a rain slick highway or an increased propensity to obey the speed limit. I contend that the historical insecurities of anesthesiology are alive and strong and have created many environments in which certain approaches to daily patient care would result in candidate failure if advocated during an oral board examination. The only moderating influence to this is the tort system, but the implementation of this extreme process implies a bad outcome for a lot of people. It is not really what one says during an oral board exam that counts, it is how one performs for the rest of his or her professional life. There are plainly many situations in which it is very difficult to "grasp the challenge" or to "educate" the vested power elite in order to induce positive change. Many times I have heard the saying: "It takes a death to result in change." Everyone correctly clucks the tongue with an appropriate "tsk, tsk," when speaking of "production pressure" and commiserates about this very real and dangerous antagonist to patient safety. However, the implementation of actions to ameliorate and eliminate the palpable hazards of this disreputable and ultimately counterproductive phenomenon are frequently lacking.
Pressure should be exerted upon institutions and medical staff to create environments in which each patient is provided a timely and appropriate work-up. Anesthesiologists should not be positioned to succumb to the temptation to abandon their responsibilities to patients in order to protect their jobs. Job insecurity seems to be where all the pressure focuses; this is unworthy of the discipline as well as those practitioners who hold a high view of anesthesiology and our responsibilities to patients. As long as hospital CEOs and various physicians pander to "customers" according to a business-oriented model of patient care, this situation will not improve. However, there is another approach that has been resurrected under the terminology of "systems thinking" that is first and foremost patient-based. (See national editorial by Cal Thomas, "Hospitals: Heal Thyselves," June 22, 2006, Tribune Media Services, 2225 Kenmore Ave. Suite 114, Buffalo, N.Y. 14207). This approach is reportedly enjoying a productive trial in numerous hospitals in St. Joseph, Missouri, and the Pittsburgh, Pennsylvania, areas.
I would suggest that the ASA provide leadership in proposing a practical and flexible model for institutional organization that could result in improved efficiency and thoroughness in preoperative evaluation for use in all practice settings. Individual anesthesia groups clearly are no more up to the challenge of suggesting and implementing such a proposal than they were in developing a difficult airway algorithm. If hand-washing still remains an issue among some physicians over a century after the establishment of the germ theory of disease, then why should anyone think that the more complex matter of anesthetic pre-assessment should receive its just consideration at some local levels. This is a national problem and deserves a high-profile national emphasis. I have consistently found organization to be preferable and more productive than confusion, and it decidedly contributes to better perioperative control and predictability.
Ronald L. Hedderich, MD