Tuesday, April 14, 2009

Surgeons v. Anesthesiologists: Why the Tensions?

I often get frustrated when patients attribute to their surgeons more concern for their overall medical well-being and perioperative safety than I have observed. Don't misunderstand - I think surgeons do care about their patients, but I also think they can be fairly goal-oriented and single-minded about operating, sometimes when an operation should be delayed in favor of managing pressing medical issues.

To be fair, I have worked with many wonderful surgeons, especially at St. Boonie's, who deeply care about their patients and open-mindedly listen to anesthesiologists if the latter bring up safety concerns that mean possible cancellation of scheduled operations. Frustrating for all, and potentially costly, but ultimately the right course of action for the patients in question. (That's not to say that some anesthesiologists don't go overboard with the gate-keeping and perhaps apply their standards too conservatively; I've seen that too.)

I've also had surgeons physically help me every step of the way when I've encountered difficult airways, with the helpful, team-spirited attitude, "If we haven't got the airway, we haven't got anything." The chief of surgery at St. Boonie's is like that; Caroline Walsh is like that; one of the young surgeons at New Hospital has been like that. One of the neurosurgeons at New even advocated for my monitoring needs during assisted ventilation of a patient in the recovery room, which I thought exceptionally in-tune and helpful of him.

On the whole, though, what I typically see is a lot of exasperation from surgeons whenever a medical condition precludes speedy progress to the O.R. - perhaps because in many hospital systems, these conditions can easily remain undiscovered or unevaluated until right before the scheduled procedure. I always wonder: didn't they look through the chart themselves and see that the lab value was egregiously abnormal, or examine the patient and hear the lung crackles practically from across the room? Surely they, too, did a history and physical, as we're all expected to do?

The usual pattern I see is this:

-An anesthesiologist reviews a patient's history/chart, does a physical exam, and spots a concern - unevaluated cardiac disease, new heart rhythm problem, wheezing on auscultation of the lungs, a potassium value that is acutely too high or too low, or some such potential danger.

-No one else in charge of the patient's care seems to have noticed the problem, thought it significant as a safety risk for anesthesia and/or surgery, or done anything about it prior to surgery.

-The anesthesiologist delays surgery until the patient's condition is "optimized" or the problem corrected (unless the surgical procedure is an emergency).

-The surgeon gets mad, because he or she wants to help the patient by getting the main job done - the tumor excised, the lung biopsy sent to pathology, the hernia repaired.

If it were up to some surgeons, I suspect they'd go ahead and operate on a patient with a potassium of 2.8 or a loud murmur that could be undiagnosed aortic stenosis. The patients would be none the wiser. Most patients don't realize that if they didn't have an anesthesiologist watching their back, they'd be brought into the O.R. by their surgeons despite some increased risk that could be detected and reduced by a preop evaluation specifically geared toward assessment of anesthetic and surgical risk. (Not that ALL risky conditions are easily detected or successfully addressed; but the anesthesiologists at least try very hard not to miss them.)

The GOOD surgeons understand that the practice of surgery is still the practice of medicine, and that patients need to be seen as more than specimens to be sliced and diced. The GOOD surgeons engage in teamwork with the anesthesiologists and don’t resent it when we bring up concerns they may or may not have considered. The GOOD surgeons don't act on exasperation at the prospect of a civilized discussion regarding the safety of a given procedure for a particular patient, will listen to a competent anesthesia consultant when concern is warranted, and won't personally resent the ensuing delay, postponement, cancellation, or what-have-you.

A good surgeon will also respect an anesthestist’s or anesthesiologist’s instructions inside the O.R. when safety is at issue. Rarely have I seen this to be a problem. Usually when I ask the surgeon to stop operating for a minute, for example because I want to assess a patient’s EKG without them tugging on organs or causing interference with EKG wires, the surgeon will graciously stop. The command is not personal; the patient’s safety is at issue; and no surgeon wants a patient coding on the table.

But I did encounter one surgeon whose behavior I consider among the most appalling I’ve seen. I'll call her Dr. Myrtha Banshee.

I was working with a pleasant and competent nurse anesthetist the day Dr. Banshee's patient, a school-age child named Elly, came to New Hospital for surgery. I spoke to Elly and her family prior to surgery and gave them my usual pediatric anesthesia spiel. Dr. Banshee arrived, already irritable (which, according to the nursing staff, was fairly typical). Elly was living with and being raised by relatives but asked to see her mother before we went to the O.R. Her mother was invited in to give her a kiss. Because of this brief delay, we arrived in the O.R. four minutes past the scheduled surgery time - not bad, reallly, considering the way most hospital schedules go.

Dr. Banshee was displeased. She was in a hurry because her secretary had scheduled her office hours half an hour after the scheduled time for this procedure. This surprised me; the procedure usually took about an hour if you factored in the anesthetic and wake-up time.

Dr. Banshee had asked the nurse anesthetist if the patient could remain on the transport stretcher for the surgical procedure and he had initially said yes. I said I wanted Elly on the proper O.R. table, and we moved her off the stretcher onto it. Banshee asked loudly, "Why is the patient on the O.R. table instead of the stretcher?"

"Dr. T. just asked me to move her," replied the nurse anesthetist.

"Why?" she asked, turning to me, her resentment emanating from her like black smoke billowing from a smoldering fire.

"Because," I answered, as matter-of-factly but emphatically as I could, "if this kid CODES and DIES, I don't want to be performing CPR on a stretcher."

That silenced her for a second, but then she muttered, "Everyone ELSE is willing to do it on the stretcher."

"Well, good for them," I said. "For me it's easier to provide a safe anesthetic on the O.R. table." She couldn't argue with that, but according to the nurse anesthetist she had some choice words for me after I left the room and spent the rest of the case irate and complaining.

Before leaving the room I helped the nurse anesthetist with the induction of the anesthetic. We had agreed that I would place the I.V. once he had given the child enough anesthetic gas to get him to a deep state of unconsciousness.

Kids take several minutes to get anesthetized enough to be ready for the application of painful stimulus. For surgeons the wait can be frustrating, I'm sure. But touch a kid the wrong way before she's ready, and a dreaded pediatric anesthesia complication can occur: laryngospasm. A spasm of the vocal cords that closes off the airway, making mask ventilation difficult if not impossible. Kid's oxygen saturation goes down precipitously; kid turns blue; lack of oxygen causes the heart rate to fall; you've got a code on your hands...unless you can break the laryngospasm and intubate the kid in time. No one wants laryngospasm.

Myrtha Banshee was already infuriated by our "delay" getting into the O.R. "That mother doesn't even have custody," she hissed. "She had no right to be allowed to talk to the patient right before surgery." I thought this a heartless attitude; I was surprised to learn later that Dr. Banshee is a mother herself. But on top of this so-called delay, she had to wait for the patient to "go under." That proved too much for her patience. The nurse anesthetist warned her, "She's still a little light," but she paid no attention and inserted an instrument into one of the child's orifices. The child flinched, of course - even with the mind unaware, the body reacts if a certain level of anesthesia hasn't been reached. I got an I.V. in quickly and administered medication to deepen the anesthetic. The nurse anesthetist intubated the child without incident, and the surgery proceeded.

I left the room feeling angry and having lost every shred of respect for that surgeon.

About half an hour later I went back to the room to check on things, and the nurse anesthetist whispered in my ear, "She punctured an artery. We've lost about a hundred cc's." And this was the case she wanted to do on the transport stretcher?! Myrtha Banshee got control of the bleeder and finished the surgery, complaining the entire time about the scheduling and the way the O.R. was being run.

That night, the call person had to bring this kid back to the O.R. to manage a known and not-uncommon complication of the original surgery. I couldn't help feeling resentful all over again when I heard about it.

I can deal with most surgeons, even the crabby ones. I see them as members of the same team who ultimately want what I want: a patient well-cared for. This surgeon never wanted the same thing and was never on the same team. When surgeons or other anesthesiologists experience trouble or a complication, my usual reaction is sympathy, and it certainly doesn't make me think less of them; this surgeon, however, inspires nothing but incredulity at behaviors and attitudes I simply cannot respect.

I hope I don't have to work with that kind of surgeon too often.


ER dude said...

Surgeon: keep the patient's BP up, please.

Anesthesiologist: if only you wouldn't poked at him/her so much [with significant blood loss] that his/her vital signs fluctuate.

Conflict of interest....

T. said...

ER Dude - LOL! Cute, but we do know the low BP is usually due to OUR stuff rather than the surgeons'.

There's a small movement (Advocacy/Inquiry) in simulation education to reduce some of the communication tensions that can happen in the O.R. I'm highly in favor of it.

A surgeon at BIDMC gives an example, showing the difference between counter-productive and potentially productive:

"The sat's 85! What the hell are you doing to my patient?"


"I'm noticing you've got a sat drop there. Anything I can do to help you manage that?"

Totally different tone/approach. I think the team-work one achieves a lot more for both the patients and the docs - I've seen that in action, and I do try to implement it most of the time.

Transor Z said...

T., Ugly! Good job fighting the good fight.

Those types always get theirs, although they are not always aware it is happening to them. :)

In the law, you find diva trial lawyers who treat court clerks like dirt. Strange how their hearings tend to be among the last to be called and their filings sometimes get "misplaced"... And you certainly see people whose skills do not justify their egos and bratty attitudes.

What can you do?

Unknown said...

The pendulum does swing both ways however. My grandmother just went in for some surgery and had been running an elevated blood level (sorry, but I do not recall what it was that was up). Elevated, but not out of bounds, and something that was well known in her medical history. The anesthesiologist wouldn't put her under because of the level. My mother is a CCRN and said it was okay. My grandmother's physician called in and said it was okay. The surgeon said it was okay. Everyone but the anesthesiologist was ready to go as it was. But the anesthesiologist was crabby and stuck to his same script. He eventually conceded the point, the surgery went off without a hitch.

Sometimes the anesthesiologist can stick to their "optimal levels" a little too tight to the detriment to the patient, doctor's schedules, etc.

T. said...

That's true, Karl C - as I wrote in the post, I have indeed seen some standards applied too conservatively or over-cautiously.

For the most part, though, from what I've experienced, anesthesiologists try to be careful, attentive, conscientious, and safe without being unreasonable or inflexible.

RB said...

This is fascinating. And horrifying to hear that some surgeons can be so heartless. I just had my first major surgery ever, just about 2 weeks ago. I was so impressed with the anesthesiologist, the assisant to the anesth., the surgeon, the nurses. I was at the Faulkner in Boston. A very positive experience all around! It's good to know YOU are out there in the field doing good work, too.

Suldog said...

Is there some sort of ethics board to which you could report such behavior? I'm not asking if you want to, but is there some sort of board of review for such things/ And, also, if there is such a thing, and if you wouldn't want to report such behavior, may I ask why? Not trying to get up in your grill - just curious, on all counts. Thanks!

T. said...

RB - so glad you had a good experience at the Faulkner! Spent some time there during my training days and had a pretty good impression. Thanks for the encouragement.

Suldog - I think I've seen you at Anali's First Amendment? I love that blog and its author.

To answer your question in general terms, there is indeed usually a way to address incidents like this, both formally and informally, within any hospital.

Without going into the details of what has/hasn't been done specifically for this particular situation, I can tell you that in GENERAL when I have a problem with a surgeon or nurse I first try to speak to that individual privately, to see what's understood/not understood about a given situation, and if there are any discrepancies among the various expectations that come into play.

Some surgeons, for example may misinterpret a strong directive from an anesthetist or anesthesiologist as a personal order - "Don't touch my patient" - even when not phrased as one, rather than seeing it as a safety necessity because of pediatric physiology and the pharmacologic behavior of certain anesthetics (for example, inhaled gases versus IV medications). If that understanding just isn't there or has been forgotten, then the "assault" is attributable to ignorance combined with impatience, rather than just plain old displaced hostility.

If a conversation reveals intransigent ill-will, though, then obviously the individual will be unlikely to respond to requests for a behavior change, constructive criticism, and the like, and a formal write-up may be necessary.

I try not to do knee-jerk write-ups because I think adversarial solutions / automatic antagonism can be far less productive, and perhaps even harmful in the long-term, than open, dispassionate conversation (provided the other party is willing, of course).

I try to give people the benefit of the doubt and see if they will respond to pleas for respecting patient safety above all. It's what I hope people would do for me. Every situation is informed by individual details that I think warrant a case-by-case approach. I'm not hesitant about reporting cases for which formal review appears to be the appropriate avenue by which to arrive at meaningful change.

Unknown said...

Came across your blog via Universal Hub.

RB-- I've also been a patient at Faulkner and can not say enough GOOD things about my anesthesia experience there. I've had 11 surgeries, my last 3 there and I never knew that is what it is supposed to be like. I woke up feeling brilliant! No tears, no head ache and no vomiting.

Great blog! I look forward to reading more.


I have come across some brilliant anaethetists.
Only twice have I experienced a not so nice time, and it was in the same time period.
The first Anaethetist paralized my right leg after a spinal. He was really nice though, and he cared.
I have recovered from that. It was the surgeon who covered for him and decided to lie about the whole thing. She was covering her own back though as she had made a huge boo boo.
I have respect for great medics who know their stuff, even if they are grumpy and rude. If they are good at their job I can get past the "rude".
However if they are grumpy rude, and botching operations consistently, blame the patient, attack nurses and other medics, and cover up their botch ups, then I find it hard to move past that.

You appear to have empathy, a great understanding of your patients and their safety, that would make you great at what you do.

Bruce said...

Dear Dr. T,

I try to remember it is a team effort...one that requires great care on both sides of the ether screen.

In my world, we have lots of very interesting airways. Sometimes, waiting for the anesthesiology trainee to find the larynx, get the tube in, and complete the set-up can be excruciating! Still, I realize that the experience will make them a better practicing airway expert when he/she completes training.

Would love to work with you someday!

K. said...

Wow the sad part is that the arrogant behavior you are describing is not uncommon...
Good for you for standing up for yourself. I think people like that are used to having people cower around them.

T. said...

Sarah - thanks for coming! I'm so glad you had a good experience at Faulkner too.

Kirst - I hope I can keep growing into the ideals I set for myself. Thanks for reading and encouraging!

Bruce - I would be SO honored to work with you. I think you're extraordinary!

Kirti - thanks for being "one of the good ones!" It was always great to be on a team with you.

Resident Anesthesiologist Guy (RAG) said...

In my institution we have a system where we can report such interactions and clear deviances from standard of care. I know that I'd likely want to report an interaction akin to what you described, especially when I felt that the patient's health was placed in jeopardy. I've been in the ORs this month, delivering the anesthetics, and have felt the good and bad from surgeons/ staff/ etc. You have to develop exceptionally thick skin to do this job sometimes. I'm still building my layers.

T. said...

RAG - I've been at a disadvantage in many ways by the unfortunate thinness of my "skin." Residency was quite stressful and painful at times because of it. But being "the sensitive type" has also helped me a great deal in terms of trying to understand and show compassion for what patients are going through.

Instead of being impervious to external noxious stimuli like an anesthetized patient (which has never really worked for me), I've had to develop something else entirely: a new way of seeing myself and of seeing those who abuse/demean/disdain others.

I'll give you an example. Once when I was a resident, I was giving anesthesia for a thoracic case during which the patient's blood pressure was just all. over. the place. "Alpine Skiing Anesthesia," my attending called it. Patient was high, patient was low, up, down, up, down, and I was chasing it with various drugs the whole case. At one point the surgeon noticed an egregiously low reading and started yelling at me. "How long has the pressure been like that? Get your attending in here! This is totally inappropriate!" My attending came in, stood and watched what I was doing, and did nothing. He didn't even budge. He just left after a while. Why? Because I was doing everything he would have done if he had been in my sorry position. The patient was just really sick and really tough.

Later apparently the thoracic surgeon went to the head of the thoracic anesthesia division to complain about me. The head guy caught up with me on the way to the parking garage and told me the surgeon had spoken to him. I explained what happened from my point of view, briefly, then said, "I would be COMPLETELY comfortable if you went back and reviewed the computer record of the vital signs, in detail, and the written record of all the interventions I tried to make."

"Well, as a matter of fact, I don't want you to feel I've been spying, but I already did that. And I did see it was a tough chase - Alpine Anesthesia."


"You know...the surgeon wasn't trying to make trouble for you."

"I understand. She cared about her patient. I do too. That puts us ultimately on the same side."

He looked surprised. "It's big of you to see it that way."

Not really. It was just the truth.

That's my coping mechanism, I guess - I try to see the ultimate good intention underneath all the yelling and frustration and anger.

I just wasn't able to see it in Banshee's case.

Suldog said...

Thank you very much for the in-depth answers!

Lisa Johnson said...

I love that you bring up these issues and get people talking. And maybe even change their actions. Your post might be the thing that makes someone change the way they operate today. Bravo!

Anonymous said...

The surgeons actions were completely out of line and deserve official discipline. The decisions as described seem to be more focused on saving time than on a positive pt outcome, as the MD was rushed.

Anonymous said...

Why can't the surgeon be reported and disciplined accordingly? This is more covering for each other - and the main reason malpractice in the U.S. exists. If something had gone wrong the ranks would have closed around this surgeon, protecting her.

It's a sticky thing. Tattling. I suppose it invites reprisal and a never-ending spiral of recrimination. But, really, there must be some sort of disciplinary action. This time, the patient recovered - but what about the next time? The surgeon might learn from this particular - non-lethal experience and prevent her from a similar action in the future that might have a less favorable outcome.

What a b1+¢h.

T. said...

Only the individuals directly involved know the full story and can determine the best alternatives.

Please don't make assumptions about what has and has not been done to address this issue.

jb said...

Comments from a surgeon:
1. Your depiction of Dr Banshee is unfortunately totally believable- all of us who work in the OR have seen behavior like this, although we have heard only one side of the story, and before getting out the pitchforks we should get the surgeon’s take on the situation. We are in a very stressful profession, and if this behavior is an isolated instance, then it can perhaps be forgiven (but not forgotten). If this is a common occurrence (as the nurse told you), then Dr Banshee will have to learn to behave or be banished from the OR.
2. I know that you don’t mean to be condescending or a wise-guy, but your depiction of the “GOOD” surgeon wears thin. Your depiction described traits of a surgeon that you as an anesthesiologist understandably deem to be easy to work with, but please remember that your involvement with the patient lasts a matter of hours, while we have worked with patients and sometimes families for weeks or months. Ideally the patient would be in the best possible condition for the operation, but sometimes we have to work with folks who absolutely need an operation but don’t have the (financial, social, psychological) resources to be absolutely optimized. I’m not talking about the bleeding trauma patient here, but about the frail patient with a heart murmur for whom getting to multiple appointments for the cardiac eval will be a true hardship, and the likelihood that something significant and correctable will be found is minimal. Some in your specialty approach the complex patient like a board exam question- what does the examiner want me to do and say, rather than what can I do to help this patient get through the operation? It is generally the less experienced ‘ologists that act in this fashion. The more experienced ones tend to accept the patients as they come and do the best they can with what they have to work with. Believe me, as a surgeon, I do that all the time- everyone knows that quitting smoking and losing 20 lbs will greatly increase the safety of most operative procedures, but very few patients are willing to do what is necessary to do that.
3. I understand that you are protecting the best interest of the patient, and that it’s far easier for you to just go on with the case and hope for the best, rather than put up with the consequences of delaying or cancelling the operation. You have every right to expect that true problems will result in a delay, but expecting a busy surgeon to not act exasperated under these circumstances is expecting a bit much.
4. Don’t get me wrong- I’m what you would call a GOOD surgeon. When the patient gets bradycardic from my yanking on the guts, I stop the yanking until the atropine or Robinul (or whatever) kicks in. I’m also one of the few surgeons in my hospital who refuses to do a trach on the ICU bed because exposure is not optimal and if either one of us gets into trouble, it’s the patient who may not get out of trouble. There is generally little or no tension in my OR- the ‘ologists tell me that they are glad it’s me doing the case rather than Dr. X because I don’t act out, and I get the cases done with a minimum of fuss, and I’m actually social friends with a couple of the ‘ologists at my hospital.
5. Thanks for your blog- it’s well written and enjoyable to read.

T. said...

Dear Dr. JB -

Thank you for your thoughtful comments! I'd like to respond:

1) I totally agree, hence my rather long-winded response to Suldog above.

2) Please know that I understand completely how annoying my venting about the "GOOD" surgeon must have been to surgeons. I can only hope that you and other readers read such a rant in its context, namely, a blog used specifically by its author for such venting from time to time, and authored by someone who has left one place of work filled with much-missed, "good" surgeons and who is now observing more immature behavior from a few that intensifies that homesickness. After a day like that I daydream that I am back at St. Boonie's, where people were mostly professional, competent, and even gracious. It was a special community.

3) I can understand the displeasure caused by delays - we can be insanely busy too - but if an anesthesiologist has spotted something that actually means the patient winds up better protected, then exasperation seems to me a bit selfish. Displeasure at the SITUATION I can totally understand; exasperation at an anesthesiologist REASONABLY advocating for patient safety (your point about the rigid, board-obsessed anesthesiologist is well-taken) strikes me as a more personal response. But I hear you about it being too much to ask to expect no negative feelings at all - I guess I just meant to say, there are productive, classy ways of expressing such disappointment, and inferior ways, which I have seen a little too much of lately.

4) Thank you for being one of the good guys! Your thoughtfulness comes across even in this out-of-O.R. forum.

5) Thanks for stopping by to read and leave such good food for thought. If only we could consistently have gracious dialogue over tough issues in the O.R.! :)

Anonymous said...

This is exactly the kind of information I would want, as a patient, to make an informed decision about which surgeon to choose for my procedure. And, it's exactly the kind of information the general public will never know. Secrecy, lies, covering for each other - protecting our territory. No wonder medicine has lost so much respect.

Øystein said...

I didn't get to read this until now. Indeed an appaling example of the behavior of any medical professional.

I've seen my share of "snapping" between surgeons and anesthesiologists, but mostly they seem to work, as you say, as one team.

Anonymous said...

Anesthesiologist looking over the drape during a a major abdominal cancer operation "Oh, this is a bowel resection case?"

Anonymous said...

Nothing inspires more confidence in your anesthesiologist than finding them asleep on the other side of the drape.

T. said...

Anonymous Ones - I shouldn't be laughing, but I have to admit, it's an LOL moment for me. Touche - I do realize it goes both ways! :)

Anonymous said...

We certainly need good CRNAs. It's one of the few fields where demand seems to still outweigh supply. Sites like http://www.unitedanesthesia.com/ show evidence that every state is still looking for qualified CRNAs (and willing to pay for them too). Hardly something that every industry can claim right now.