It’s time for anesthesiologists to be real doctors

I have written a good amount about automation, the good, the bad and the ugly.  I have written about doctors and ancillary providers and physician extenders, also good, bad and ugly.  A recent comment on Karen Sibert’s excellent blog A Penned Point caught my eye as an amalgamation of these subjects.

This person wrote, and I hope he doesn’t mind my quoting him:

American anesthesiologists should focus much more on becoming true consultants and not simply be hands-on anesthesia providers. The latter arena shall be, in some future time be mostly staffed by technicians nurses … call them what you will. The finances will determine such.  Anesthesiologists should be supervising these workers, not competing with them directly for menial employment in a race to the bottom. Thus, physician anesthesia training should be expanded in depth scope and rigor.

Nice.   I agree.  Then I read the latest Atlantic Monthly, in which there is an article entitled “The Great Forgetting,” in which Nicholas Carr talks about how automation has taken away both menial tasks and, increasingly, less menial tasks, and our reliance on automation has made us less able to deal with reality when it hits us in the face.  Bear with me.  The quotes are related.

Here is what Mr. Carr says:

Many software programs take on the intellectual work — observing and sensing, analyzing and judging, even making decisions — that until recently was considered the preserve of humans.  That may leave the person operating the computer to play the role of high-tech clerk — entering data, monitoring outputs, and watching for failures.  Rather than opening new frontiers of thought and action, software ends up narrowing our focus.  We trade subtle, specialized talents for more routine, less distinctive ones.

Here is my point.  Anesthesia has become so safe, so well-monitored and so well-administered by various computers that it no longer takes subtle, specialized talents in all cases.  We are now doing the routine tasks of entering data and monitoring outputs.

While maybe not the “menial employment,” Dr. Sibert’s commenter claims, it still is work that no longer needs the rigorous training a physician brings (I emphasize that there are exceptions).

We doctors, as I’ve said a million times, should be doing the hard stuff.  The stuff no one else can do.  Imagine if the anesthesiologist was not just “anesthesia,” a replaceable person in the chair at the head of the bed, revolving with breaks and lunches.  What if the anesthesiologist was “The Anesthesiologist,” the one people turn to in a pinch, someone people look up to as an arbiter of truth and wisdom, the one people look to to do the difficult cases, the sickest patients, the most complicated anesthetics.

This would be a culture shift of the first magnitude, and it would start with training.  Anesthesia residents should not be treated as a warm body to put in a chair.  Endless days of podiatry and cataracts are not helpful.  Yes, emergencies can occur in these cases but a month or so in the first year should alert most decent residents to the hazards of remifentanil boluses and ankle blocks.

How many times have I looked at the OR schedule and seen a resident doing arthroscopies while a solo attending is doing a bronchoscopy or a shared-airway or a prone monitored anesthesia care (MAC) or a trauma.  Why?  If a program has residents it should be the first priority of everyone to get those residents into the hardest cases.   All the time.  They should be doing all the central access.  All the shared airways.  All the double lumen tubes.  All the open triple As and the gunshots and the ICU transfers on three pressors.  They should do awake fiberoptic intubations until they can do them in their sleep.

Physician anesthesiologists should be looked at with respect and awe as the person who can do what nobody else can do.  Right now we’re looked at as the guy in the chair reading the Wall Street Journal, or the guy in Gray’s Anatomy who falls asleep.   Let’s drop the turf wars and the fiscal concerns.  Let’s be real doctors.

Shirie Leng, a former nurse, is an anesthesiologist who blogs at medicine for real.

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  • buzzkillerjsmith

    I agree that things are going that way. Less trained people are doing more of the work we docs used to do.

    This has happened in many fields before and will continue to happen. Sweatshop workers replaced tailors long ago.

    The problem here, for anesthesiologists if not for others who will do their work, is that there simply might not be much call for anesthesiologists in this new world. Perhaps the training programs should get smaller. Maybe folks who used to do anesthesia should become hospitalists or rheumatologists or general surgeons or whatever.

    I would not advise family medicine or general internal medicine because those are dying fields.

    • Zaphod

      Its possible, but the lack of physicians and enormous growth of the aging population is likely to keep everyone employed. Unless of course economic factors and policies combine in such a way that they can be cheaply and easily replaced.

    • Shirie Leng, MD

      Buzz, you agree with me! Yes there might be fewer anesthesiologists in the future. Maybe that’s OK. We sure could use some geriatricians and palliative care docs. And I don’t think IM is dying, although family practice might be. The IM guys will always have a job taking care of orthopedic surgeons’ patients! :)

      • buzzkillerjsmith

        I should have said outpatient general IM. Sorry.

  • Anthony D

    Good article a few years back.

    “Certified registered nurse anesthetists: out to replace MDs?”

    http://medcitynews.com/2010/09/certified-registered-nurse-anesthetists-out-to-replace-mds/

    • dontdoitagain

      Thanks Anthony D I missed that one. I detest crna’s.

      • NPPCP

        ?Detest? Such a strong word. So what is the “stronger” word you would use for criminals or pedophiles as opposed to well educated professionals caring for patients and providing for their families? All written with the utmost respect. These types of comments add zero to a conversation where commenting parties may strongly disagree.

        • Guest

          Out of curiosity, do you personally know any CRNAs? Have you worked with CRNAs?

          • NPPCP

            Noni , yes and yes. Many.

  • whoknows

    The answer is go into pain management. Follow the money.

    • Kristy Sokoloski

      There’s a problem with that though. There are Nurse Practitioners and Physician’s Assistants that also work in this specialty as well. And their colleagues are also going in to other specialties as well because of the “follow the money” routine that has been going on for the last number of years.

      • Shirie Leng, MD

        Yah. The money is part of the problem isn’t it?

  • Steven Reznick

    There was a time when anesthesiologists provided the postoperative care and respiratory care of all surgical patients for the first 24 hours post surgery. In our local hospitals anesthesia has successfully contracted to relinquish all responsibility as soon as the patient leaves the immediate post op care unit. Any problems.from that point on are handed off to the medical doctors on the case since in so many instances surgical specialists are now ” consultants” and just come in and operate and do post op wound care ( actually except for general surgery it is the PA’s and ARNP’s doing their post op care). As our baby boomers age and we have older more complicated patients with multisystem disease and multiple physicians the well trained anesthesiologist should be the immediate pre operative and post operative team leader. That includes the easy stuff which can become complicated in an instant and the anticipated hard stuff. My experience is that anesthesia has walked away from that task by choice and they certainly would be welcomed back warmly.

    • Shirie Leng, MD

      I agree Steve. In my hospital once the patient hits the PACU the anesthesiologist “covering” the unit doesn’t make a move without consulting/informing surgery, and most people never see their anesthesiologist again. Acute perioperative care has been given away.

  • NPPCP

    Rishi, It will all work out in the end. There will be plenty of work for all anesthesiology health care clinicians. :)

  • NPPCP

    So you underwent your surgery, the CRNA was the provider, there were no complications, and you were fine post operatively? I don’t see an issue with “demanding” an MDA – but you may have to go to a different facility. The CRNA might be your only “cheap substitute” (wow) in a particular setting. But you will always have the right to pack up and drive 5 miles or 500 hundred miles for an MDA. I really don’t see any issue with the way you feel. You relayed your point well except for the unnecessary nasty words about CRNAs. That really added nothing to this conversation in my opinion. :)

  • Tiredoc

    From my perspective, modern anesthesia is so far removed from intellectual medicine as to be unsalvagable. On several occasions, I have had to write letters to surgeons to explain how to anesthetize and provide appropriate post-operative care to my patients, bypassing anesthesia entirely.

    The practice of ending anesthesia care in post-op comes from a time of halothane anaesthesia, a time that is now passed. Current anesthesia relies on medications with significant interactions between pre-operative medication regimens and with significant post-operative metabolism. If the anaesthesiologist doesn’t round on the patients after they go to the floor, they don’t ever see their failures.

    The pain control movement of the last decade has left us worse than before. We have hordes of patients on high dose narcotic medications undergoing surgery with nary a practitioner with experience dealing with the consequences. We have CRNAs without a clue about narcotic tolerance and surgeons who never write anything higher than a Lortab trying to care for patients who take 120 mg of Methadone daily.

    Anything in medicine can be drilled down to an index card for 95% of the patients. It’s the other 5% that need someone with a brain. If you give all of the 95% to the brainless, there isn’t enough work to feed the brain, and it finds something else to do.

    • PoliticallyIncorrectMD

      I see, you are not only the expert in Palliative Care and Critical Care, but, also, Anesthesia. Perhaps I underestimated how broad the Physical Medicine training is. Or maybe you are overestimating your knowledge of other dusciplines just a bit.

      • Tiredoc

        For such an otherwise logical writer, you have a distressing tendency to resort to arguing from authority.

        Why do you think that palliative care and narcotic tolerance are separate disciplines? I can’t recall commenting on ICU care at all. In our prior discussion, I believe the explicit limitation of care to IV antibiotics and DNR status implied care on the ward more than the ICU, anyway.

        As to my actual point, I am not an anaesthesiologist or a surgeon. Our country consumes more hydrocodone than any other country in the world. Patients on chronic narcotic medications are a problem for every specialty.

        Your complaint about my post is precisely my point. If surgeons and anesthesiologista ere being properly trained, I wouldn’t need to write letters to tell them how to deal it. I can only send letters for planned surgeries, anyway.

    • querywoman

      Tiredoc, you have so much common sense it hurts.
      I wish you would expound on the evils of specialization in medical care. How did child medicine get separated from adult medicine?
      I see mostly specialists these days, who are all great docs and good people, but I am probably stable enough that a good GP could continue my care.
      I’ll keep seeing my specialists, but I have personal reason to believe that the smartest docs have the least training. A good GP, without board certification, with strong family doctors instincts is the best!

      • Tiredoc

        Pediatric patients have different physiology and pharmacological reactions than adults. The bedside skill set is different as well.

        As for the GP, residency training is compressed experience of a certain patient type. And independent GP will acquire the experience present in a residency, as long as they have a measure of humility and an eagerness to learn.

        The only caveat is that in this era of near-universal residencies, GPs are the misfits. This can be good in the sense of a willingness to ignore bad guidelines, or bad in the sense of ignoring good guidelines.

  • NPPCP

    Mingles, kind of reminds me of “mid-level” provider. Respectfully I know you see the comparison. MDA is not pleasant. Neither is the other. I only use those terms when others use terms I find offensive. We should all respect each other. Words and labels mean something as you have stated.

  • NPPCP

    “basic” is subject to interpretation. For you it would be basic. But I understand what you would personally like.

  • NPPCP

    Excellent!! I completely agree with you. Choice is a wonderful thing.

  • PoliticallyIncorrectMD

    Interesting! In any other skill / profession more training means more safety, less training means more limitations. Apparently not in Anesthesia.

    • Adam

      So you’re saying you have a credible research study that offers some evidence that CRNA’s are less safe than MD’s? Or you just have sarcasm? I
      actually don’t disagree with the intent of the article, its just not reality. Crnas and mda’s both provide the same service with the same results the only difference is the educational level.

      • PoliticallyIncorrectMD

        It wasn’t pure sarcasm. I also am not trying to downplay the role CRNAs play in providing safe and competent care. At the same time, the absence of evidence is not the evidence of absence. For example, there is no study suggesting you need any training to provide anesthesia, however you would agree with how absurd this premise is. Common sense dictates that better education provides (on average) better performance – why wouldn’t it? There is also “what if it was your grandma?” test I’ve learned in residency. If you could choose the provider for your loved one, who would you choose (all other things equal)?

  • Rachel Phillips

    CRNAs are not “posing” as doctors. It is a certified specialty for RNs under the supervision of an MDA. If an MDA does not feel comfortable supervising CRNAs then he/she should find another position. In today’s healthcare economy we have to look for cost-effective solutions but solutions, of course, that are safe and provide equal quality of care. The title does not make for quality… it is the individual’s attitude of responsibility and truly caring about the quality of their services. I’ve seen bad CRNAs and bad MDAs. I would have to trust that a hospital has provided enough supervision to the CRNA that if an emergency occurred, they have either trained the CRNA well or have an MDA immediately available. Again, leaving out the fact that MDAs want to preserve their billing costs, have physicians created an environment/regulations that supports their decisions regarding the number of CRNAs they supervise and the safety of that situation to patients?