The Impossible Situation

One of the common problems on the anesthesia oral boards is the "impossible" situation. A patient's medical problems, surgical needs, and anesthetic risks all create conflicting priorities such that no course of action is without significant risk. Whatever you decide - cancel a case, proceed with a general anesthetic, try a spinal, optimize medical therapy - will ultimately end in some complication. It is a game of weighing risks and benefits and trying to choose the lesser evil. Examiners use these questions to get an appreciation of whether the examinee can reason through difficult situations, appropriately articulate the risks and benefits with each decision, and commit to a choice and handle its complications. These are some of the more stressful situations that come up in oral boards; hopefully I'll be ready for them. I'm going to take this week off blogging to prepare.

Preparing for Oral Boards

The anesthesiology boards have two parts, a written examination and an oral examination. While this used to be the case with most specialties, many have done away with the oral part. For anesthesiology, I think it is here to stay. The written test focuses on medical knowledge, understanding of physiology, pharmacology, and disease states, interpretation of data, and textbook facts. However, a critical part of being a safe and effective anesthesiologist is the medical decision making in what we do. Since so much of anesthesia is real-time, we don't always have the luxury to break open the textbook, look up information, or consult our colleagues. The oral exam assesses our thought processes, response to changing situations, and clinical reasoning, It probes the grey area of medicine, the weighing of risk and benefit, the approach to uncertainty, and the situations which have no right answer. I think in this respect, it is an exam that is here to stay.

Of course, the process isn't the easiest. It's time-consuming and expensive. Over the last year (and again in the next year), every few weeks, hundreds of newly minted anesthesiologists fly across the country, stay at a hotel, and take this standardized exam. Dozens of examiners, well-established professors and community practitioners, also fly across the country to administer the test. It's a little mind-boggling how much goes into this. (One wonders whether someday it'll be digitized).

We are all nerves and stress while we take this test, just over an hour of examination time. We get two patient scenarios, and for each one, two examiners proceed with rapid-fire questions trying to befuddle and stump us. The scenarios never go smoothly; part of the test is to assess how we manage surgical and anesthetic complications. You never know when you get the right answer since the virtual patient will always do poorly. The examiners also probe in increasing depth, asking question after question until all you have is, "I don't know." They want to see how candidates do under stress, and it's fair, because real life anesthesiology is stressful. The good examiners reveal nothing, and an hour and a half later, we are ushered out, dazed and shocked. At least that's how I imagine the experience to be.

I have been studying quite a bit; the exam can cover any aspect of anesthesiology, including areas I don't currently practice such as neonatal anesthesia, cardiac bypass, and pain management. But since it's more than just medical knowledge, I am working on how I present myself, my communication, and my thinking under time pressure. I'll probably take a break from the blog in a few weeks as I get closer to the test.

No Longer a Resident

I've noticed a substantial change in how I'm perceived and treated now that I'm no longer a resident. Though I've always been treated with respect, now that I'm an attending, I've noticed that my interactions with other health care providers is different. When I express an opinion, it's taken seriously. When I make a decision, it's not questioned. I'm asked to do far less busywork that is unrelated to my specialty. My fellow health care providers - surgeons, nurses, consultants - really feel like colleagues, equals. When I was a resident and fellow, I could sense a hierarchy, which no longer seems to exist.

I'm sure that to some degree, this is a result of working at a community hospital with no residents. All physicians are equal members of the medical staff. The culture does not have to deal with those in training. At an academic center, I've always noticed that even among attendings, experience and rank makes a difference. A young attending may be questioned more, relegated to more tedious duties, taken less seriously. I'm quite fortunate that for me, such prejudices are minimal if they exist at all.

It feels really nice to be done with training, to be recognized for my expertise. I never minded being a resident or fellow, and I don't mind being asked to do busywork or to justify my decisions. But my life feels so much smoother now that such things are a rarity.

Solo in the Operating Room

All through residency, we are never by ourselves during the induction or start of anesthesia. An attending has to be in the case at all its critical points. Even though I may manage an entire anesthetic independently, I always had a shadow in the back of the room, ensuring that my decision making was sound, that I didn't miss anything. Now as an attending myself, I end up being solo in the room. In some ways, it's not that different; during the latter part of residency and during fellowship, I became comfortable anesthetizing someone and securing the airway. But there's still a psychological strangeness to it. I have to be sure, really sure, about each of my decision points. In residency, if something went wrong and I didn't know how to fix it, I always had someone to turn to, a crutch to lean on. Now, the buck stops here. That takes getting used to.

The truth is, I'm not really on my own. The wonderful thing about my anesthesia group is that all my colleagues and I are a team. We collaborate, help each other, call on each other. For difficult cases, I don't hesitate to see if someone can lend me a hand. In an emergency, I can always call for help, even in the middle of the night. The anesthesia group is structured this way for patient safety. I'm not truly alone; I just need to recognize when I need someone else.

Nevertheless, that moment before induction of anesthesia, I always hesitate. I go through my mental check-list. I take a deep breath. What we do isn't trivial. I am glad I've been well-trained.

Health Care Innovation Contests

I probably should have mentioned this earlier, but Medstro is hosting several competitions soliciting ideas for health care innovation. Sponsored by The American Resident Project, this is a forum to try to stimulate ideas on creating value, connecting underserved populations to care, using technology, and promoting team-based structures. Open to anyone - physicians, medical students, start-up entrepreneurs, patients - these contests crowdsource your ideas on how to make our health care system better. I am one of the many judges and I've been reading dozens of entries, all of which are exciting, creative, and potentially game-changing. The deadlines are coming up soon, but if you have an idea, a solution to one of the myriad of problems we face today as health care providers and patients, then please let us know. We want to hear from you.

Airway Equipment in Private Practice

In training, we get used to having a wide array of devices for placing a breathing tube. This is the purpose of education; each device helps us better familiarize ourselves with airway anatomy, anesthetic techniques, and decision-making in challenging cases. But the truth is, only a handful of techniques have been shown to be definitively better than standard laryngoscopy in clinical trials. Most of the other fancy devices are just that. So in private practice, where it isn't cost-efficient to stock every single gadget and gizmo, we have only a minimum selection of devices. At first, this feels like a disappointment, but over time, I've realized I simply don't need access to every single new device. In fact, it's probably better to be proficient at only a few approaches rather than mediocre at many. With a gum-elastic bougie, video laryngoscope, and fiberoptic bronchoscope, I should be able to intubate any patient. And, those are the techniques (along with an intubating LMA) which have been shown through trials to be the most effective in the difficult airway. I do miss the unusual techniques (gum-elastic bougie, intubating with an Aintree catheter, lightwand) that I no longer use. But I also feel that I've gotten better at my technique with simple direct laryngoscopy since I have fewer backups to bail me out.

Pre-Ops in Private Practice

There are many differences between academics and private practice. For someone like me, who spent the last five years in an academic medical center, the change can be a little jarring. Some of it has to do with money; if something doesn't justify its cost, then in private practice, it's eliminated. In academics, research, teaching, and the latest evidence are emphasized. In private practice, safety, conservative management, and efficiency are king. I don't think either perspective is necessarily better or worse; it's simply a difference in mission.

Even before a patient arrives for surgery, the process is quite different. In residency, patients go to a "pre-anesthesia clinic." They are seen by a resident or a nurse practitioner who reviews their medical history, checks their medications, and ensures that they are appropriate for elective surgery. An anesthesiologist determines what laboratory and other tests (like EKG or chest X-ray) are necessary prior to surgery. The patient receives information on how to prepare for their operation, gets an overview of what to expect, and asks questions. However, preoperative clinics end up costing a hospital or anesthesia group; pretty much everything we do is not reimbursed by insurers. There may be some cost savings if the pre-op clinic decreases last-minute cancellations or reduces complications. But overall, it's a thankless endeavor. It also requires a lot of coordination; we try to schedule appointments right before or after a patient meets their surgeon. But if one clinic is delayed, it can greatly impact the other. I've had many patients coming from out of town complain because the process of getting ready for surgery takes all day.

This kind of thing is not practical in private practice. Our surgeons have offices in many locations, and it would be impractical to have all our patients go to a separate anesthesia clinic after their surgical appointment. We don't have the staffing to see every pre-operative patient; in residency, that clinic had over five nurse practitioners a day along with a resident and an attending. Furthermore, we don't necessarily like the idea that the person seeing the patient pre-operatively is different than the physician caring for them on the day of surgery. To make things more efficient, the anesthesiologist caring for a patient gives her a phone call the night before surgery. It can make the end of my day quite long, but it allows me to ask for whatever information I think is necessary and gives me the opportunity to introduce myself to a patient. I think it minimizes inconvenience to the patient. However, there are limitations. I don't do a physical exam until the day of surgery. If I identify something that needs to be optimized, I don't have much time or opportunity to do so. I don't control what tests are ordered. Nevertheless, it ends up being the most cost-effective way to ensure our patients get a reasonable pre-operative evaluation.

Spice

As I try to make some chili oil with ghost peppers, I think of the strange sensation of spice. To me, spicy foods have a terribly irresistible attraction, even when they're so hot, I'm suffering. And spice has an odd medical association with neuropathic pain. I've even had patients describe pain to me, not just as "hot" or "burning" but actually "spicy." What is it about this perception that some of us crave and others fear?

The active component of chili peppers, capsaicin, is a fascinating compound. In fact, when it was discovered that some spiders have capsaicin in their venom, it became the first compound found in both plant and animal anti-mammal defense mechanisms. Exposure to mucous membranes, skin, and the lungs can cause medically significant irritation. Yet, it's not an entirely bad compound. Some of us love our spicy foods because capsaicin can induce a sense of euphoria, perhaps from release of endorphins. We actually treat neuropathic pain like shingles with patches on the skin. The two faces of spice fascinates me. How can something evolve to be a highly irritating defense mechanism, yet give us such pleasure and reduce pain when used in particular forms?

Image of ghost peppers shown under Creative Commons Attribution Share-Alike License, from Wikipedia.

Book Review: The Golem and the Jinni

One of the best books I read recently was Helene Wecker's The Golem and the Jinni. It is an impressive first novel and reminds me strongly of Jonathan Strange & Mr Norrell. As historical and fantasy fiction, it takes place at the end of the 19th century, a time period I love. She describes the adventures of two magical beings, a golem and a jinni, who encounter each other in New York City. The juxtaposition of these fantastical creatures with turn-of-the-century New York actually isn't that strange. They are immigrants that live within pockets of immigrants, trying to understand and assimilate into human culture. To me, this novel evokes the experience of strangers entering a strange land, and the magic in it doesn't feel gimmicky; rather it feels quite natural, as if such things ought to belong.

Her plot is engaging, fascinating, and inventive. Her characters are memorable and easy to sympathize with. The writing is accessible and beautiful. I never felt bogged down by the book, and though it takes a leisurely pace, it meanders and dips into such intricately described lands and situations that the reading went fast. I really loved this book; it was a well of relaxation that sopped up the stress of my last few weeks.

Image shown under Fair Use, from Wikipedia.