Skip to content
  • About
  • Contact
  • Contribute
  • Book
  • Careers
  • Podcast
  • Recommended
  • Speaking
  • All
  • Physician
  • Practice
  • Policy
  • Finance
  • Conditions
  • .edu
  • Patient
  • Meds
  • Tech
  • Social
  • Video
    • All
    • Physician
    • Practice
    • Policy
    • Finance
    • Conditions
    • .edu
    • Patient
    • Meds
    • Tech
    • Social
    • Video
    • About
    • Contact
    • Contribute
    • Book
    • Careers
    • Podcast
    • Recommended
    • Speaking

I don’t care what your cardiologist says

Stephen Freiberg, MD
Physician
July 5, 2020
3K Shares
Share
Tweet
Share

Yeah.

I said it.

As an anesthesiologist, especially as a cardiothoracic anesthesiologist, there are few things I am more interested in than how well or how poorly your heart functions and why.  And a cardiologist can help me obtain a lot of vital information in that regard.  But there several things a cardiologist cannot, and I argue, should not do, when it comes to the perioperative care of patients.

First, a cardiologist’s assessment of anesthetic risk or prediction of perioperative complication, means nothing to me. Or rather, it is no different than the risk level that I can determine for myself. I will receive cardiologist letters that say, “This patient is at moderate risk for perioperative complication.”  In fact, it usually says the patient is at moderate risk.

How does a cardiologist determine risk?  Typically, or at least hopefully, by using a validated risk calculator such as the Revised Cardiac Risk Index (RCRI) or the  American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) Surgical Risk Calculator.

You know who is intimately familiar with these calculators and the data they are based on?

This guy.

You know who is perfectly capable of using the online calculators if I’m genuinely interested in knowing a numerical prediction of a patient’s potential complication?

This guy.

You know who else has also developed something of a Spidey-Sense for patients I’m concerned about, no matter what they look like on paper, or what a risk calculator might say?

You get the idea.

I don’t need to be told about risk.  I know and understand it. You know who does need to be told?  The patient!  And the surgeon!  That way, when I tell either party about my assessment of the risk, it doesn’t seem like the first time they’ve ever been told.

Second, please do not recommend a type of anesthesia.

Respectfully, you have no idea what you’re talking about.

People tend to assume that sedation or “twilight anesthesia” is safer than general anesthesia.  That’s not necessarily true. I’ve even had cardiologists recommend spinal anesthesia. I guarantee that a cardiologist has very little insight into the potential and complex hemodynamic effects of spinal anesthesia. Or at least, a cardiologist does not know them as well as I do. Especially when in the same recommendation, he or she has insisted that the patient not stop their clopidogrel.   Active use of this medication is an absolute contraindication to spinal anesthesia. So forgive me for not following your recommendation that could leave the patient neurologically devastated and me pleading for mercy before the board of medicine or civil court.

Anesthesiologists spend the entirety of our training learning how to develop the best and safest anesthetic plans for our patients. Please spare us your best guess recommendation on anesthesia type. We will typically ignore it, and it only leads to confusion when we have to explain to a patient why we are going to do something different than what his or her cardiologist (who they may have known for 20 years) recommends.

Lastly, please DO NOT make recommendations about which anesthetic medications to give.

I know propofol can cause hypotension. I know it has negative inotropic effects. I’ve answered more test questions about propofol than questions about my own personal demographics.  And I’ve probably even gotten more of them right.

Also ask yourself, how many times have you held a syringe of propofol, connected it to an IV, and personally administered it. Even if that number is more than zero, I am confident that it is fewer than the number of times that I personally did just that in my first year of residency alone. Probably less than I did in my first month.  And as such, in addition to knowing exact weight-based dosing, I have a certain gestalt for the effect that 1, 2, or 10 cc’s of that drug will produce.

But what I really suspect many cardiologists don’t understand is the fundamental logistical difference in how anesthesia care is delivered.

I don’t blame them. The way anesthesiologists deliver care is completely different than how people who train via the route of internal medicine do. Which is the route cardiologists go by definition.

On the wards, and even to a certain, albeit slightly lesser extent in the ICU, it goes like this: the physician gets called to evaluate the patient for hypotension. The physician has to come to the bedside. Then, conduct a physical exam and analyze the vital signs, and make a management decision. They might decide to administer a vasopressor medication, such as norepinephrine.  Typically this will be by starting an infusion.  Then, the team has to wait for the pharmacy to prepare and deliver the medication.  Then, the nursing staff prime the medication into tubing, load it onto a pump, program the pump, and start an infusion. A few minutes after the infusion is started, hopefully an improvement in blood pressure is seen. If not, and the clinician wants to deliver another intervention, many of the same steps will need to be repeated.

Now let’s move to the operating room.

The patient is suddenly hypotensive. I open my drawer, draw up a medication (in the unlikely event I don’t already have it prepared), and deliver it as a bolus into an IV line. I will see a clinical effect in seconds, and in those seconds, I am already further analyzing why the patient was hypotensive. I’m also already planning my subsequent second, third, and fourth interventions if the first didn’t work. This is a cornerstone and catchphrase of anesthesiology: “Simultaneously diagnose and treat.”

Do you see the difference?

It’s not that I’m smarter or better … just wired and trained to think and act differently.  As such, the way I choose to deliver certain medications in various dosages, and the way I choose to augment or offset the effects of a given drug, cannot be understood from reading a textbook.

Telling me what drugs to give, would be little different than if I told you what stent to put in the coronary artery.

Now, I’ve bashed on you cardiologists enough.

There are ways that you are invaluable. Among them being obtaining and interpreting the diagnostic tests that are crucial in my being able to deliver safe anesthesia.  And the role that you play that is most critical, specific to the perioperative period, is optimizing your patients’ chronic medical conditions.  Making sure their blood pressure is at goal.  Fine-tuning their heart failure or pulmonary hypertension medications to maximize their functional capacity. Recommending and performing coronary revascularization if it is, in fact, indicated.  That is what makes you all the superstars.

I know your hearts are in the right place (pun intended).  And I strongly believe the team-based approach to care is the best approach.

So please, bring all of your expertise. But I’ll bring the propofol.

Stephen Freiberg is an anesthesiologist who blogs at The DADesthesiologist.

Image credit: Shutterstock.com

Prev

4 resolutions for a new academic year

July 5, 2020 Kevin 3
…
Next

9 tips for new pediatric residents

July 5, 2020 Kevin 0
…

Tagged as: Cardiology, Surgery

Post navigation

< Previous Post
4 resolutions for a new academic year
Next Post >
9 tips for new pediatric residents

More by Stephen Freiberg, MD

  • The time when our health care dollars are worth every penny

    Stephen Freiberg, MD
  • Why this anesthesiologist rarely cancels surgeries

    Stephen Freiberg, MD
  • I’m the best anesthesiologist there is

    Stephen Freiberg, MD

Related Posts

  • Why health care replaced physician care

    Michael Weiss, MD
  • How social media can help or hurt your health care career

    Health eCareers
  • More physician responsibility for patient care

    Michael R. McGuire
  • Can the Maternal CARE Act fail moms? 

    Sonal Patel, MD
  • Health care needs more physician CEOs

    Alexi Nazem, MD
  • Denying payment for emergency care: a physician defends insurers

    Michael Kirsch, MD

More in Physician

  • The hidden gems of health care: Unlocking the potential of narrative medicine

    Dr. Najat Fadlallah
  • The dark side of immortality: What if we could live forever?

    Ketan Desai, MD, PhD
  • It’s time for C-suite to contract directly with physicians for part-time work

    Aaron Morgenstein, MD & Corinne Sundar Rao, MD
  • From rural communities to underserved populations: How telemedicine is bridging health care gaps

    Harvey Castro, MD, MBA
  • From solidarity to co-liberation: Understanding the journey towards ending oppression

    Maiysha Clairborne, MD
  • Finding peace through surrender: a personal exploration

    Dympna Weil, MD
  • Most Popular

  • Past Week

    • The real cause of America’s opioid crisis: Doctors are not to blame

      Richard A. Lawhern, PhD | Meds
    • Healing the damaged nurse-physician dynamic

      Angel J. Mena, MD and Ali Morin, MSN, RN | Policy
    • The struggle to fill emergency medicine residency spots: Exploring the factors behind the unfilled match

      Katrina Gipson, MD, MPH | Physician
    • Breaking the stigma: Addressing the struggles of physicians

      Jean Antonucci, MD | Physician
    • Beyond the disease: the power of empathy in health care

      Nana Dadzie Ghansah, MD | Physician
    • Deaths of despair: an urgent call for a collective response to the crisis in U.S. life expectancy

      Mohammed Umer Waris, MD | Policy
  • Past 6 Months

    • The hidden dangers of the Nebraska Heartbeat Act

      Meghan Sheehan, MD | Policy
    • The real cause of America’s opioid crisis: Doctors are not to blame

      Richard A. Lawhern, PhD | Meds
    • Nobody wants this job. Should physicians stick around?

      Katie Klingberg, MD | Physician
    • The fight for reproductive health: Why medication abortion matters

      Catherine Hennessey, MD | Physician
    • The vital importance of climate change education in medical schools

      Helen Kim, MD | Policy
    • Resetting the doctor-patient relationship: Navigating the challenges of modern primary care

      Jeffrey H. Millstein, MD | Physician
  • Recent Posts

    • Why it’s time to question medical traditions [PODCAST]

      The Podcast by KevinMD | Podcast
    • The hidden gems of health care: Unlocking the potential of narrative medicine

      Dr. Najat Fadlallah | Physician
    • The realities of immigrant health care served hot from America’s melting pot

      Stella Cho | Policy
    • The dark side of immortality: What if we could live forever?

      Ketan Desai, MD, PhD | Physician
    • Lazarus: the dead man brought back to life

      William Lynes, MD | Conditions
    • Revolutionizing COPD management with virtual care solutions [PODCAST]

      The Podcast by KevinMD | Podcast

Subscribe to KevinMD and never miss a story!

Get free updates delivered free to your inbox.


Find jobs at
Careers by KevinMD.com

Search thousands of physician, PA, NP, and CRNA jobs now.

Learn more

View 11 Comments >

Founded in 2004 by Kevin Pho, MD, KevinMD.com is the web’s leading platform where physicians, advanced practitioners, nurses, medical students, and patients share their insight and tell their stories.

Social

  • Like on Facebook
  • Follow on Twitter
  • Connect on Linkedin
  • Subscribe on Youtube
  • Instagram

CME Spotlights

From MedPage Today

Latest News

  • Doc Moms, Mind the Gap -- $3M Earning Difference by Sex
  • Clinical Note Writing App Powered by GPT-4 Set to Debut This Year
  • Helping Patients Get Fit -- One Walk at a Time
  • TB Cases Rebound to Near Pre-Pandemic Levels, CDC Data Show
  • Marginalized Groups May Benefit More From Decreasing Air Pollution

Meeting Coverage

  • Switch to IL-23 Blocker Yields Deep Responses in Recalcitrant Plaque Psoriasis
  • Biomarkers of Response With Enfortumab Vedotin in Advanced Urothelial Cancer
  • At-Home Topical Therapy for Molluscum Contagiosum Gets High Marks
  • Outlook for Itchy Prurigo Nodularis Continues to Improve With IL-31 Antagonist
  • AAAAI President Shares Highlights From the 2023 Meeting
  • Most Popular

  • Past Week

    • The real cause of America’s opioid crisis: Doctors are not to blame

      Richard A. Lawhern, PhD | Meds
    • Healing the damaged nurse-physician dynamic

      Angel J. Mena, MD and Ali Morin, MSN, RN | Policy
    • The struggle to fill emergency medicine residency spots: Exploring the factors behind the unfilled match

      Katrina Gipson, MD, MPH | Physician
    • Breaking the stigma: Addressing the struggles of physicians

      Jean Antonucci, MD | Physician
    • Beyond the disease: the power of empathy in health care

      Nana Dadzie Ghansah, MD | Physician
    • Deaths of despair: an urgent call for a collective response to the crisis in U.S. life expectancy

      Mohammed Umer Waris, MD | Policy
  • Past 6 Months

    • The hidden dangers of the Nebraska Heartbeat Act

      Meghan Sheehan, MD | Policy
    • The real cause of America’s opioid crisis: Doctors are not to blame

      Richard A. Lawhern, PhD | Meds
    • Nobody wants this job. Should physicians stick around?

      Katie Klingberg, MD | Physician
    • The fight for reproductive health: Why medication abortion matters

      Catherine Hennessey, MD | Physician
    • The vital importance of climate change education in medical schools

      Helen Kim, MD | Policy
    • Resetting the doctor-patient relationship: Navigating the challenges of modern primary care

      Jeffrey H. Millstein, MD | Physician
  • Recent Posts

    • Why it’s time to question medical traditions [PODCAST]

      The Podcast by KevinMD | Podcast
    • The hidden gems of health care: Unlocking the potential of narrative medicine

      Dr. Najat Fadlallah | Physician
    • The realities of immigrant health care served hot from America’s melting pot

      Stella Cho | Policy
    • The dark side of immortality: What if we could live forever?

      Ketan Desai, MD, PhD | Physician
    • Lazarus: the dead man brought back to life

      William Lynes, MD | Conditions
    • Revolutionizing COPD management with virtual care solutions [PODCAST]

      The Podcast by KevinMD | Podcast

MedPage Today Professional

An Everyday Health Property Medpage Today iMedicalApps
  • Terms of Use | Disclaimer
  • Privacy Policy
  • DMCA Policy
All Content © KevinMD, LLC
Site by Outthink Group

I don’t care what your cardiologist says
11 comments

Comments are moderated before they are published. Please read the comment policy.

Loading Comments...