Friday, June 22, 2007

June 22, 2007 - You Takes Your Chances

Dr. De La Luz (my pulmonologist) and I have been playing telephone tag for a couple of days. Late this afternoon, he calls back. I begin by telling him there was “some confusion” in Same-Day Surgery, when I was there the other morning (see yesterday’s blog entry). He corrects me immediately: let’s call it “commotion,” he says, not confusion.

OK, I say. Fair enough. We’ll call it commotion. (He’s sensitive about undermining his colleagues, evidently – which speaks well of him.)

I explain what happened: how the anesthesiologist basically overruled his recommendation that I use a BiPAP machine to keep my airway open during the colonoscopy. Turns out, Dr. De La Luz heard something about it that very morning. He didn’t actually talk to the anesthesiologist, but to one of the respiratory technicians, who evidently called him while the debate (“commotion”?) was going on.

As I talk with him, it becomes clear that there’s an established hierarchy of authority in the hospital, with each specialist having absolute sway over his or her own little area. When it comes to the choice of anesthesia techniques, the anesthesiologist reigns supreme. That means Dr. De La Luz’s suggestion that I use a BiPAP machine during my procedure is just that: a suggestion.

I can understand that. The anesthesiologists do know their narrow, little area of medicine better than anyone else. The only thing is, as a pulmonologist, Dr. De La Luz knows far more about obstructive sleep apnea than most other doctors. It was clear to me, from Dr. B’s unfamiliarity with BiPAP machines, that he’s considerably less well-informed about sleep apnea. Yet, because of the established pecking-order, Dr. De La Luz isn’t about to challenge him.

Anesthesia is a little, self-contained principality within the larger medical world. It’s like walking from Rome into St. Peter’s Square, thereby crossing the border into Vatican City. In that rarefied atmosphere, the ordinary rules no longer apply.

Having learned this, I can’t say it gives me a great deal of confidence. Anesthesiology is one of the few medical fields where patients don’t get to choose their doctors (pathology is another one). You pays your money and you takes your chances, as they say. Whichever doctor you get is the luck of the draw.

That means patients can be put in the position, as I was, of having our longtime physician’s professional judgment overruled by some seeming newcomer we’ve never met before. That unfamiliar doctor’s word is law. To me, that’s scary. What accountability is there, for those who rule over these self-contained medical principalities? With other medical specialties, one can make the case that market forces will eventually cull out the bad apples, as patients avoid doctors with bad reputations. With anesthesiologists, who rarely have any repeat customers, an awful lot of patients could experience unnecessary pain before anyone catches on and starts flagging a doctor as less than competent.

I’m not saying anything like that about Dr. B, the anesthesiologist I had the other day. After all the commotion, he did a fine job of keeping me comfortable during the colonoscopy. I can’t say the same about the nameless anesthesiologists who watched over me my last two times in the operating room – they evidently didn’t pay sufficient attention to my sleep apnea. The problem is, having had bad experiences on the operating table in the past, you want to take proactive steps to prevent that happening again. The “pay your money and take your chances” system of assigning anesthesiologists – which effectively bars those doctors from talking to their patients until moments before their surgeries – stymies any attempt of patients to advocate for themselves.

I think the system needs to be changed. Why can’t patients meet with their anesthesiologists at the same time they come in for their pre-admission testing? That way, they could share their medical histories far enough in advance that the doctor wouldn’t have to make snap judgments about which techniques to use – and, the patients would be looking upon a familiar face the morning of their surgery, rather than some stranger.

Most medical specialties have caught up with the fact that it’s a new world out there: patients are better-informed about health care than ever before, and want to participate in their own care decisions. It’s about time anesthesiologists got with the program.


Christopher Bettin, Senior Director of Communications, AANA said...

Speaking for the American Association of Certified Registered Nurse Anesthetists (AANA), a preoperative interview with your anesthesia provider is a standard of care within the anesthesia specialty. This confidential discussion with the Certified Registered Nurse Anesthetist or anesthesiologist prior to surgery provides information vital to your care and essential to effective communication.

On the American Association of Nurse Anesthetists (AANA) website (; click on For Patients, and then All About Anesthesia) you will find a questionnaire you can fill out and bring along to the preoperative interview. Information supplied by the questionnaire assists your anesthesia provider in doing the interview thoroughly and efficiently.

If you haven’t had the opportunity to meet your anesthesia provider (for a preoperative interview) prior to the day of surgery, you should have your preoperative interview just before your surgery. At this time, your anesthesia provider will review your medical chart with you in order to better understand your medical condition and needs.

Certainly, it was and still is within your rights as a patient to request a preoperative interview, especially if you have any condition -- in your case apnea -- which is likely to affect the administration or effects of anesthesia and your recovery from it.

Similarly, if you know of an anesthesia provider whose services you’d prefer to use who works in that hospital you can arrange in advance to use that individual’s services rather than accepting “the luck of the draw.” Keep in mind, however, that some insurance providers require that you utilize healthcare professionals within your own network.

Carlos ("Carl") said...

These are enviable standards, but they are not always followed. Yes, I received a pre-surgery interview with the anesthesiologist, but it was the morning of the surgery. I called ahead, a day or two before, and tried to raise my concerns earlier, but I was told - by the hospital staff member who answered the phone - that this would not be possible, because they wouldn't know until the morning of the surgery who the anesthesiologist would be.

If these are indeed professional standards for anesthesiologists, then it would seem to me the hospital is violating them, in maintaining a policy that makes it effectively impossible for a patient to speak with an anesthesiologist earlier than the morning of the surgery.