Working with Surgeons II

The optimal team has mutual respect between the surgeons and anesthesiologists. Last week, I had a patient requiring a brainstem surgery for a vascular malformation. These surgeries require central venous access for administration of vasopotent medications such as nitroprusside, esmolol, and phenylephrine. We decided to place a subclavian central line, but this became quite technically challenging, taking twice as long as it usually does. Last night on call, a patient presented for facial surgery, but the surgeons had difficulty identifying the facial nerve. They called in a second attending from home to dissect out the nerve to prevent it from being damaged.

In both these cases, one team took much longer to accomplish their task while the other team waited. But in both circumstances, the surgeons and anesthesiologists treated each other with respect and patience. The surgeons didn't hurry us as we troubleshot the central line, and when the ENT surgeons called in a backup physician, I knew it was the right decision for the patient.

But the truth is, such collegial relationships don't always exist. In part, we don't fully understand the difficulty of what the other person is doing. When I look over the drapes, I can't appreciate how much focus, effort, and precision the surgeon has; I only see the amount of blood loss and the time taken. It's easy for me to be frustrated with how the case is going. Intubating a young, healthy, thin patient takes ten seconds; if a surgeon sees the anesthesiologist struggle with a challenging airway without understanding why it's difficult, he may become exasperated at the delay. It's easy to discount what we don't know. But as we become further specialized in our fields, we also learn to respect other practitioners as experts in their domain.

Working with Surgeons I

One of my readers, Pat, asks, "Do you ever find it difficult to work with surgeons?"

This is a great question and a tricky one to answer. There are so many levels of complexity. The surgeon and the anesthesiologist have a codependent relationship; without a surgeon, an anesthesiologist has no work and without an anesthesiologist, a surgeon cannot operate. Our ultimate goal is the safe care of a patient, but often our motivations, priorities, thoughts, actions, and personalities conflict because the safe care of a patient is not always straightforward.

Surgeons and anesthesiologists differ quite a bit in our approach to the patient. Anesthesiologists are risk-averse; we are conservative, prepare for the worst-possible scenario, and consider ourselves protectors or guardians of the patient. This is reinforced not only by culture and training, but also by the fact that anesthesia is not therapeutic. Putting someone to sleep doesn't cure them of anything. The best we can do is to wake someone up exactly the way they were when they went to sleep; we can't make them any better. Anesthesia is simply a means to an end - the surgery.

And that's why the surgeon is usually more risk-taking than the anesthesiologist. You have to be, to take a scalpel and cut into someone with the confidence that you will make them better. The surgeon is the one in the spotlight, the star of the show.

So the two can get into conflicts when the anesthesiologist thinks a surgery is too risky and a surgeon wants to take the risk. The ideal way to approach this situation is to discuss the risks and benefits of proceeding or not and determining what the patient wants. But such ideal situations do not play out each time. I'll write more about working with surgeons tomorrow.

Dynamic

Every day is different. It is one of the wonderful yet challenging things of residency. While we get some continuity - rotations on pediatrics, months in the ICU, an expectation of how the operating room should be prepared - we also work with different patients, surgeons, attendings, and cases every day. It keeps us on our toes. And it also explains why we always have something to talk about - a patient interaction, a crisis situation, a perplexing question.

Last weekend, because of hospital construction, the power source switched from our regular mains power to backup generators. While many machines including the anesthesia machine and ventilator worked, I had to review what to do in a complete power failure. How do you get vital signs? How do you maintain anesthesia? Does the oxygen supply fail? What alternate light sources are there? We had an ongoing case, and I prepared laryngoscope blades as extra flashlights, checked my batteries on intravenous anesthetic delivery pumps, pulled out the old-school auscultation-based blood pressure cuff, and readied the machine to go into a low-consumption mode if the alternate generators failed and we went on battery power. Luckily, everything went fine and eventually, the hospital returned to mains power, but preparation is paramount, especially with a patient undergoing surgery.

Altruism and Blood Donation

Philosophers debate whether there is a such thing as true altruism, and interestingly, blood donation is an often-studied example. Altruism or selflessness differs from loyalty or duty in that one sacrifices something for another - often a stranger - with no expectation for compensation or benefits. Often, the act of giving is complemented by a feeling of personal gratification, and philosophers debate whether this internal satisfaction makes "true altruism" impossible.

Why do we do this? Doesn't the theory of evolution imply that we should look out for ourselves and our DNA rather than that of a stranger? We do seem to act in this way. Some studies show that kinship - as indicated by facial resemblance and similar names - increases trust and helping behaviors. Politicians take advantage of this by using kinship terms to increase buy-in from their audience. It makes sense that we'd protect our children or relatives, but why sacrifice our time, energy, and possessions on the welfare of someone completely unrelated?

Perhaps for complete strangers, altruism persists because helping others - even strangers - may be better for the group as a whole. Sometimes, we expect reciprocity in altruism; we aid victims of natural disasters hoping that someone would give us aid had that befallen us. And some people are generous to cultivate that reputation of generosity; publically announcing donations increases the size and frequency of those donations.

So why do we donate blood? Say a blood donation involves no material benefit; you don't get cookies or a sticker or even acknowledgement. You don't know who your blood will go to, or even if it will be used at all; perhaps your blood will simply sit in the blood bank until it expires. Even in these austere circumstances, some people will be donors. Why? Even if there's nothing in it for them, and even if they don't know if any good will come from it, they are still willing to sacrifice something. Philosophers examine questions like these in hopes that it will elucidate more about human nature.

Image of Jacques Louis-David's Belisarius Asking for Alms is in the public domain.

A Little Pediatrics

I've returned to Santa Clara Valley Medical Center, where I had two months last year. One of the wonderful things about the Valley anesthesia rotation is that you see everything. On my first day back, I found myself in a bunch of pediatric cases. A four year old needed her tonsils removed; a 2 month old had a small infection requiring drainage; a five year old fell off the jungle gym and broke her elbow. After spending months seeing only adults, it was a refreshing experience to recall my pediatric anesthesia rotations. It surprised me to find out everything came back quickly, and I had a fun and wonderful time taking care of adorable kids.

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Does Experience Make Physicians Better?

This seems like a dumb question. We assume experience makes doctors better. Our most revered teachers have been practicing since before we were born. We defer judgment on difficult cases to the physicians who have "seen it all." But is this right?

I'm sure this question is not cut-and-dry. Some things - instinct, gut reaction - develop with age; others - reading the latest journal articles - are found more frequently in the young graduate. Still others may have no difference. But I want to plant a seed of doubt out there: experience is not always the best thing.

The problem with experience is that the more patients or cases one sees, the more likely one is going to see that dreaded rare event. A surgeon may go ten years replacing knees without a problem, but by pure chance, replaces a knee that gets infected a decade later. After that, he may want extra unnecessary antibiotics. Why? Because of that one infection. This is irrational.

The anesthesia for a standard laparoscopic case rarely requires more than one IV. But if you practice enough, you're bound to run into that case where the laparoscopic case converts to open, involves a lot of bleeding, and requires better access. The anesthesiologist, trained to address "the worst possible scenario," may start placing two IVs in standard laparscopic cases. But perhaps this is overtreatment.

It's easy to be swayed by that one bad case. Experience means we will run into that one bad case - which could have been pure chance. How do we make sure we account for the outliers in our experience without treating every experience like it could be an outlier?

In-Training Exam

Exams never end; luckily, those in medical training are no stranger to standardized tests. We recently had our annual in-training exam, given nation-wide so we can see how we do relative to anesthesia residents elsewhere. I wrote about this last year, and upon rereading the blog, I realize how much I've grown. Having done the subspecialty rotations (pediatrics, obstetrics, cardiac), I found fewer topics obscure, though there were still questions of basic pharmacology that challenged my memory.

Exams are a simple, tried-and-true way of testing knowledge base. But we find ourselves more and more in a world where knowledge is not the be-all and end-all of things. What is known about science and medicine is changing so rapidly that much of what I know now will become obsolete, irrelevant, or disproven in a decade. Indeed, the test reflects this; there are many questions on drugs that are no longer used because better alternatives and replacements have been discovered. Furthermore, we have much improved access to knowledge. Perhaps a generation ago, a physician would have to flip pages through a large reference book or hunt for papers in a dark library to find something out. But now, our computers in the operating room or phones on the wards can give us real-time information. It turns out finding knowledge isn't hard, but filtering it, interpreting it, and utilizing it appropriately is the challenge.

Tests will never go away; I'm resigned to that fact. But I think they need to adapt to the changing world of medicine, science, and knowledge today. The traditional knowledge-based standardized test - with questions vetted years and years ago assessing recall of obscure facts - is an obsolete dinosaur, and we need instead to formulate examinations that engage those faculties physicians today need - critical thinking and interpretation of data, experiments, and conclusions.

Bariatrics

Anesthesia for gastric bypass and similar weight-loss surgeries reminds me of the multisystem effects of morbid obesity on health. Although most patients presenting for these surgeries are young, they suffer many medical conditions as a result of their body mass. The anesthesia is higher risk because of gastroesophageal reflux, obstructive sleep apnea, a restrictive lung pattern, occasional right heart strain, and the effect of the abdomen on the diaphragm; as a result, they can be difficult to intubate and ventilate. Many patients have high blood pressure, diabetes, and hyperlipidemia. The hospitalization increases risk of venous thrombosis and pulmonary embolism. Of course, the surgery is meant to control the obesity which hopefully reduces the risk of all these other medical conditions.

Unfortunately, obesity is skyrocketing in our society today. There is a well-known public health map which colors all the states by rate of obesity.

This is from 2011. As you look back in the last twenty years, the colors have changed dramatically, indicating an overwhelming rise in body mass index. We keep on hearing how bad of a public health phenomenon this is, but it's simply not slowing. Whether the solution is to eliminate soft drinks from schools or to encourage daily exercise or to regulate fast food, I don't know.

But this is going to have huge implications for anesthesia. Obesity has real and significant risk for patients undergoing surgery. Although I think of bariatric surgery as gastric bypass, sleeves, and other weight-loss measures, the truth is, bariatric patients are getting all kinds of surgery. As anesthesiologists, we have to attend to these individual patients, but we also have a responsibility to advocate for public health measures, better education, and primary care services to slow this epidemic of obesity.

1700

Happy Match Day! Today, thousands of eager graduating medical students find out their residency "match" - where they will spend their next three to seven years of training. It reminds me of the passage of time, that soon I will be in my final year of anesthesia, and that my friends a year above me will find themselves in practice or fellowship. I remember my match day - that anticipation, nervousness, and excitement hearing from the faceless computer that determines our fate.

Similarly, my peers from internal medicine are graduating this year. I formed such wonderful bonds, friendships, and camaraderie my intern year as we toiled, learned, commiserated, and grew together. Now, I am so thrilled for them as they enter fellowships and find jobs. All of them are outstanding physicians and I love hearing where everyone is going and what they will be doing. Congratulations!

The Right Words

In medical school, we are reminded not to use medical jargon around patients; use words the patient will understand. But as medical students, we're just learning the vocabulary and it's so much easier for us to use laymen's terms. As we go on in residency and our careers, it's easier and easier to forget what patients know and understand. Recently, one of my attendings told a patient he'd be "prone." In medical jargon, prone is a positioning term meaning on one's belly (so the back is exposed to the surgeon). But when I witnessed the interaction, I had a feeling the patient thought he'd be quite vulnerable. We have to watch what we say.

Book Review: Ready Player One

I have to say, I haven't found a book this hard to put down in a long while. I read Ready Player One by Ernest Cline as I was supposed to be studying for my in-training exam; that was the wrong time to start this book. I sped through it, loved every moment of it, and pined after I finished. The first novel by Ernest Cline, this is a futuristic science fiction novel that indulges in the past. He spins a yarn about a dystopic world where everyone lives in virtual reality yet has an obsession with the 1980s. The pop culture references he throws out - from music, movies, video games, clothing, fads - are so much fun. The story mirrors the kind of quest so often seen in early computer games that I loved. The writing reads easily, and the pages turn quickly. Like Ender's Game, this may quickly become the science fiction novel I recommend to friends. Give it a whirl - if you like the genre, the 1980s, or quest novels featuring the unlikely teenage narrator overcoming all the odds - this is for you.

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In Retrospect: Choosing Anesthesia

One of my readers, Josh, asked me to comment on how I chose anesthesia as a specialty, and as I looked at things in retrospect, I thought it would be an interesting post. I have never been someone who makes decisions easily, and I struggled away deciding between internal medicine and anesthesia. On the other hand, I have also been someone who's been quite satisfied with my choices, and I rarely regret the decisions I make. Consistent with this, I have absolutely no regrets going into anesthesia.

I love medicine, and for me, anesthesia is medicine in the operating room. The things I like most about medicine are the acute inpatient concerns: the cardiovascular effect of an arrhythmia, the treatment of an overwhelming infection, fluid management in a patient with congestive heart failure undergoing surgery. These are the daily issues of an anesthesiologist and intensivist. I've never been incredibly interested in outpatient medicine, and perhaps it is because medical students and interns don't spend a lot of time in clinic. But adjusting a levothyroxine dose, struggling with an overzealous hemoglobin A1c, and long-term management of psychiatric illnesses were never my thing. These aspects of medical content guided me towards anesthesia, though I am certain that some medical subspecialties would have appealed to me as well.

But interesting medical content can be found everywhere, and differences between medicine and anesthesia extend beyond that. The anesthesiologist is a proceduralist, as much as an emergency physician, and becomes more comfortable with hands-on interventions than a general adult medicine practitioner. The time course of anesthesia (and even critical care) is an order of magnitude quicker than medicine; I get an instant response in blood pressure from pushing labetalol compared to a clinic doctor who increases metoprolol and books an appointment for the patient months later. Yet anesthesia lacks a lot of things, most notably continuity of care. There are no patients who identify me as their primary doctor, and perhaps there is less recognition and prestige compared to the master diagnostician or amazing family practitioner.

I think, though, when I chose a residency, the most important influence was the culture of the specialty. Though it gives rise to stereotypes, each field has its own personality. Because of that (moreso than medical content), I was dissuaded from joining the surgeons, obstetricians, pediatricians, and psychiatrists. I liked the medical doctors who exhibited an orderly, methodical, and critical approach to diagnosis. They appreciated evidence based medicine, addressed patients as a whole, and had an appreciation for the theoretical and book-learning in medicine. But occasionally, I found rounds to have a little too much repetition. Anesthesiologists tend to be fairly easy-going and laid-back with most things yet demanding with attention to detail to that which matters. We tend to multitask well and enjoy the smooth sailing when things go well, yet remain vigilant and respond immediately when something unexpected happens. The role-models I found in anesthesia and critical care have been the type of doctors I wanted to become, and I think that's what persuaded me to go into the field.

Looking back, I have no doubt it was the right choice for me. Work is immensely satisfying, allows a balance with the other priorities in my life, caters to my personality, and gives me the opportunity to take care of patients directly in real time. I would definitely choose anesthesiology again.

Health Care Economics V

This is probably the last post for a while on the topic of health care policy and economics, but I wanted to end discussing whether outside parties should influence physician decision making. Let's say there are two equivalent drugs, one much more expensive than the other. Shouldn't we (as a society) limit the use of the more expensive medication to circumstances when the cheaper one fails? Shouldn't we limit the use of brand-name medications to circumstances where there is no generic or the generic fails? How about applying this to surgeries and devices? Imagine if there were a general consensus that no one get elective spine surgery or devices for spinal pain until failing conservative treatment. By avoiding unnecessary high cost interventions, we'd save so much money as a whole. And this could be applied to smaller things as well: what if Medicare didn't reimburse blood transfusions if the hemoglobin were above 8 and there was no acute bleeding? Or if a internal jugular central line was placed without ultrasound, the physician would be penalized?

We are already inching toward this. Financial incentives encourage physicians to practice better medicine; because some nosocomial or iatrogenic occurrences won't be covered by insurance, hospitals have moved to make these events much less likely. There are incentives for us to give peri-operative antibiotics on time, make sure our heart failure patients are discharged on appropriate therapy, and discontinue urinary catheters early. How far should these measures go?

I don't think they will get very far. Physicians hate having their autonomy curtailed. Influenced by past experiences, patient desires, unsubstantiated beliefs, and economic reward, they occasionally prescribe the brand-name drug or more expensive medication even if medically, there is no strong reason for it. They will continue to operate, order radiology tests, and recommend surgeries even if this costs the system. We believe medicine to be too complex for algorithms or generalizations or blanket rules. And trained as independent critical thinkers, we resent the fact that non-physicians try to regulate what we can and cannot do. Furthermore, in most cases, it's unclear that a regulatory agency, insurer, or policymaker can determine a universal approach to a problem. For example, I don't think checking PSAs as a screening tool makes sense, and it certainly costs the system a lot. But if Medicare were to stop reimbursing PSA screening, we'd have a outcry of disbelief. Primary care physicians and urologists would come out of the woodwork with stories about how they saved someone's life by checking it. Though it may save the system a lot of money, physicians will fight tooth and nail to prevent a government agency, insurance company, or other entity from making medical decisions for them.

Health Care Economics IV

Who should make money from health care? Although a pretty innocuous question, it is loaded with controversy. Let's start with the players who are clearly for-profit. Pharmaceutical companies invest millions of dollars into designing new drugs. The time and cost of getting a new medication through the pipeline can be staggering, and this is why they have a protected patent time. During this time, brand name drugs can be exorbitant as there are few or no competitors. Although the intention is for pharmaceutical companies to recoup the cost of innovating, designing, creating, and testing, some drugs (particularly statins and antidepressants) have made the company and shareholders quite wealthy. Big Pharma occasionally has welfare programs for those who cannot afford the expensive drugs, but that covers only a fraction of patients. At some level, the cost of healthcare is driven up by costly drugs. Is this ethical? Say a new drug comes onto the market which cures HIV. The absolutely ethical thing is to distribute this widely, like we would a vaccine. But the economic decision is to sell it to the highest bidders, an issue even more complicated because curing all HIV would then eliminate demand for the drug. Device companies often have similar interests.

What about hospital administrators? The Time article attacks CEOs who make a fortune running their non-profit hospital. Indeed, there are examples of CEOs at academic hospitals who make more money than university presidents. But being in top hospital administration is not an easy job. Few people are willing to take on such responsibility, and fewer still have the skills necessary. The risks are high; a badly publicized case, a poorly timed inspection, a dearth of donors, an infection outbreak, equipment failure, or a dozen other things can get the CEO fired, even if it weren't preventable. Upper management needs leadership, communication, decision-making, financial savvy, and many other skills to be successful. Does this deserve a salary in the millions? I'm not sure who decides.

Are doctors pocketing the money from healthcare? Not really. We do make a comfortable living, but when normalized for the years of education required (while incurring debt), a business degree or career in law is much more practical. Some doctors do make a fortune consulting for device or pharmaceutical companies, but that involves conflicts of interest beyond the scope of this post. And there is a lot of discrepancy between medical specialties as well. But as a whole, the huge cost of healthcare is not lining the pockets of physicians.

Lastly, what about those insurance companies? Like pharmaceutical companies, they are run (for the most part) as for-profit businesses whose primary concern is the shareholder, not the patient. As a result, we see those practices the Obama administration has called egregious: capping payments, denying patients for insurance, excluding pre-existing conditions, charging exorbitant rates. And hopefully with the new health care law, such offenses will become rare.

Are there other players? Overhead really isn't driving costs up. Perhaps malpractice insurers and lawyers are pocketing a good amount of money. Non-profit hospitals that make a lot of money occasionally return that to the community by expanding facilities and hiring more staff. But in a sector that costs so much of GDP, where's the money going?

Health Care Economics III

Why does everything cost so much? In the Time article, there are a dozen examples of things that are overpriced like an acetaminophen tablet for $1.50 or a troponin blood test for $200 when Medicare would pay $14. The article discusses a "chargemaster," a comprehensive list of all the services and products a hospital might provide and the charge that would be billed. The article then notes that this charge has very little to do with the cost of the service or product to the hospital; they appear to be arbitrarily high values.

The problem, I think, is that hospitals and insurance companies approach the table with an attitude like haggling.

This is the Flowing Hair dollar, the first dollar coin issued by the U.S. government, minted between 1794 and 1795. Before it was sold two months ago, no one knew its actual monetary worth, and so something like haggling makes sense. The seller starts high and the buyer starts low. The coin ended up selling for over $10 million.

Unfortunately, this seems to be the attitude hospitals take when negotiating with insurers. If you mark up the cost of an X-ray or rituximab or crutches by ten-fold, then giving a 60% discount to an insurer is not that bad of a deal. Bargaining (or haggling) allows price discrimination, where a seller (hospital) can raise its price with a buyer that is more eager (an insurer with a healthier population or a clientele of high end businesses). But this leaves one person out: the individual who needs emergency care and has no bargaining power whatsoever.

This is why in the Time article hospitals say, "Very few people pay the chargemaster prices" yet the uninsured or underinsured individuals needing care receive a bill way higher than what would be sent to an insurance company. It also creates this paradox where those who can afford it the least (the uninsured or underinsured) are charged the most for health care. It also explains why many policymakers and physicians advocate for universal health care - so that no one gets into the bind that victims find themselves in the Time article.

I personally don't think costs are driven up substantially by "free care" we give. The fact that county safety net hospitals care for illegal immigrants, the homeless, the jobless, the uninsured does cost-shift prices to the insured and those who can pay, but I can't imagine it would drive up cost anywhere close to the discrepancy between the chargemaster and the cost to a hospital.

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