Two For One Response, in the interest of conserving electrons:
galo,
Thank you. Well said.
I do want to apologize if my tone was not what it should be. Those of you who have read my few postings know that I try to stay out of personal attacks. Frankly never was good at it.
Ditto for me. Aatrek: I suppose my upbringing as the son of an English teacher and a Baptist preacher has informed my relationship with words and thoughts. I was always taught (even at subliminal levels) that inaccuracy of communication bespeaks inaccuracy of cognition. I realize, of course, that in a forum such as this, as in other blogs across the net, spelling is not considered an important issue, especially to the generations younger than myself. I apologize if my tone was excessively didactic; those of you who know me personally from daily work "in the trenches" know that I am like that with everyone...a "rough edge" which I hope to grind down during my next incarnation.
Back to the issue at hand:
Galo said:
Rob, many surgeons in the AF by the nature of the beast are doing some procedures (more than likely safely), that they may not be able to do on the outside unless they are in a more rural enviroment.
...which, IMHO, is all well and good if they are doing it in-country, with no other options available; it is harder for me as an anesthesiologist to rationalize when "rural medicine" is being practiced at a "Major" Military Medical Center (Travis, Andrews) which is a few minutes away from a truly world-class, tertiary civilian center which offers more than "rural medicine".
My experience has been that, if you are a hammer, the whole world looks like a nail. Surgeons in the military (yeah, I'm talking about you, S.) go ballistic when an anesthesiologist suggests referring sexy cases somewhere else. Example: severely symptomatic anterior mediastinal masses with objective evidence of airway and/or great vessel compression NEED to be done in a facility with fem-fem bypass available. It's simply standard of care; any plaintiff's lawyer could make a
res ipsa loquitur case by simply showing the algorithm from the seminal article on an overhead slide (reference on request). Much more important than legal considerations, however, are ethical ones. If a surgeon decides to ship out a complex/pediatric case, no anesthesiologist would EVER get in her face and SCREAM at her that we NEED to keep this case in house for MRB, Maximum Attending Benefit, or any other reason other than good patient care. Every single day, however, military anesthesiologists are faced with this situation: Do the wrong thing, according to textbooks of medicine, because I am telling you to; if you don't, I will get you in trouble with your Commander who, by the way, is 100% of the time a surgeon or a nurse without any surgical/anesthesiologic knowledge. In the civilian world, yes, this sometimes happens, but fear of lawsuits is a powerful moderating influence.
It also depends alot on what base you were at, and what ***** was supervising you. There is no question that the majority of basic chest cases in the country are done probably by general surgeons who were trained and are practicing to do it. As time goes, all that is changing, as the 80 hr work week bullS%$t decimates the ability to fully train surgeons, and many seek subspecialty fellowships
Well, as one "vascular/thoracic" surgeon from Keesler told the Chief Resident of Surgery at Travis: "The lung is kind of a three dimensional organ." I guess I count myself among the subset of humans who would rather get plastic surgery from plastic surgeons, urologic care (outside of vasectomy) from urologists, and thoracic surgery from BC thoracic surgeons. I guess I am just old fashioned. Of course, the military is training neurosurgical PAs at WRAMC (true fact); they can do the cranis on our IED-injured troops on the Iran FEBA in 2007...so I guess it can always get worse.
Like aatrek, flitesurgn, in our minds we are THE BEST SURGEON THERE IS. Frankly I would not want to think otherwise unless it comes to some procedure that I have never done, or done just a few of. That is the type of surgeon I would want operating on me.
Self-confidence is a key attribute of all invasive specialists (anesthesiologists included). However, there is a difference between knowing that one is competent and the M.Deity syndrome. Being 12 years out of residency, I find that the ability to admit what one does not know, and the ability to accept one's (and one's facility's) limitations, lies along a strict bell curve:
Stage 1 (left of bell curve): Right out of residency, most surgeons think they are Gods. "Give me a scalpel and/or a hammer, and I shall cure the world,"
to misquote Archimedes.
Stage 2 (middle of curve): After 5-10 years and several bad outcomes, many of which are caused, not by paucity of their own skills, but by bungling induced by a bad system which offers inadequately trained techs, nurses, anesthesia "providers", and support staff (rads, path, blood bank), they realize that it does not detract from the respect they get from colleagues if they refer selected cases out. Patient care improves.
Stage 3 (right of bell curve): 15 years out of residency, physicians who decide to stay in the military have lost touch with clinical medicine due to mandatory command assignments, where the ability to shuffle e-mail is rewarded 1000X more than the ability to suture. They look at all actions by members in Stage 2 in support of patient safety as direct insubordination to the Will of the Hierarchy: after all, if the Air Force didn't want vascular surgery to take place at Andrews, why did AFPC put 2 vascular surgerons (sic) on duty there? Hammer, Nail...
deru kui wa utareru: The stake that sticks up will be hammered down (my favorite Japanese proverb). Being supported by loud-mouthed, gung-ho members of Stage 1, they are able to bully and browbeat members of Stage 2 into either a) doing the wrong thing clinically for political reasons or b) falling on their swords by ruining their careers when they complain up the clinical chain of command (SGH, Consultants) about the illegal orders to commit malpractice that they are being given.
One other link regarding being "THE BEST SURGEON THERE IS", and, please, don't take it personally (I have spoken with you at length, and realize what a good person and surgeon you are):
http://www.sfgate.com/cgi-bin/article.cgi?file=/chronicle/archive/2000/01/18/MN73840.DTL
Relying on surgeons to request privileges and/or credentialling for operative interventions based on their own subjective determination of competence is fraught with danger. See the MII report from Travis in 1998 on my site. This applies to anesthesiologists as well. I have always scratched out neurolytic blocks (celiac plexus, etc.) on my credentialling forms, as I haven't done any since 1994 during residency. That requires a level of introspection and honest appraisal of personal
inability that is rare, in my experience, among physicians in general, and operative specialists in particular (including anesthesiologists). IMHO, this is one area where the dreaded term "metrics" may apply: I wouldn't want an anesthesiologist doing my neurolytic block if he/she hadn't done one in 12 years, and that one was under the watchful eye of his/her residency director and board-certified pain specialist. The system needs to change.
Aatrek wrote:
Just stating the facts. What bothers me, and most surgeons that I know, is when physicians and non-physicians that do not see the pt during their acute problem, through the problem, at the middle of the night, and see them after the problem sit there and make all the calls and have this attitude that they are the pts advocate.
Warning: Rhetorical Questions Ahead next 1.5 miles
Have you ever considered that this level of intimate involvement with you patients clouds your objectivity? Have you ever considered that the Dr.-Patient relationship you are able to build over days and weeks is one that anesthesiologists need to build over 5 minutes? Have you ever considered that being a "patient advocate" from an anesthesiologist's perspective means practicing our specialty as we see fit, based on our experience and judgment? Would you appreciate having an anesthesiologist literally SCREAM at you for doing a case laparoscopically rather than open because it would save time? Would you ask him where he did his surgical residency? Would you feel devalued and embittered if an anesthesiologist squadron commander dragged himself away from Outlook to waddle down from the command section to give you a Letter of Reprimand for trying your best to take care of your patient, according to your clinical judgment, and, by the way, the latest consensus of the medical literature?
Have you considered that one of the key roles of an anesthesiologists (or CRNA) is to act as the critical
advocatus Diaboli at the critical moment in a patient's life: Yes, they need their gall bladder out, BUT the sodium is 125, AND it is not an E-mergency, so perhaps the wisest course is to optimize the patient medically prior to your operative intervention? Yes, the patient needs surgery, but our facility has proven it can no longer handle the preop/intraop/postop continuum of management of this kind of surgery (AAAs, peds trauma, MRI on posturing patients with increased ICP, etc.), so is not the wisest course of action to transfer the patient expeditiously to a hospital with a higher level of care than the military is willing to pay for in its own devolved "medical centers"? Walk a mile in my mocs, Mr. Major Dr., and you will see how hard it is to be on the other side of the proverbial "blood-brain" surgical drape barrier. When a patient dies on the O.R. table due to Airway, Breathing, or Circulation issues, who will be hammered by the MII, slammed by JCAHO, sued by the family, and haunted by the memory forever: the surgeon doing a "routine" case (e.g., eyeballs), or the anesthesiologist who violated standards of care codified in textbooks due to political pressure to do a case against his/her better judgment? "It's just an eyeball"-- tell that to the gentleman who is now in the ground after his fatal cataract at Andrews. There
is such a thing as "minor" surgery; there is no such thing as "minor" anesthesia-- even MAC, as one of our journals wrote recently in a lead editorial, should stand for Maximum Anesthesiology Caution rather than Minimal Anesthesiology Care, given that there is no evidence that MAC has fewer complications than GA(
http://www.anesthesiology.org/pt/re/anes/fulltext.00000542-200602000-00002.htm)
Thus I do not need a nurse or a physician that goes home when their shift is done (again, no insults jus the facts) to tell me what I can and can not do.
No insults just the facts: The day you stop looking at dissenting opinions from anesthesiologist colleagues as "telling you what you can and cannot do", rather than what you "should or should not do", you will have learned. Anesthesiologists in the military go through sheer hell nearly every time they have to cancel a case; the civilian world could not survive the financial impact of forcing anesthesiologists to respond to countless Memoranda For Record every time a patient's anesthetic was postponed (I never cancel surgery-- you can do what you want-- just bring 4 large techs and 5 sets of earplugs). Beating your manly chest and standing up for your Alpha Male status on the pecking order of the hospital ("Me surgeon, you shut up") isn't the best thing for your patients, as you seem to be
starting to learn. We are not lazy shift workers. We are your physician colleagues. Treat us as such, and you will improve care for your patients.
Warning: Philosophical Opinions ahead, next 1 mile:
Next time you start to get into an argument with an anesthesiologist, take a big, deep, cleansing breath, and remember to focus on your power chakra (
manipura):
Fair Use Quote from:
http://www.kundalini-teacher.com/chakras/power.html
"Any sort of non-consensual power or control games, come from people with an inadequately functioning power chakra, trying to get their energy needs fed by vampirism. Any argument, if you look at it from an energy dynamic point of view, is a power chakra tug of war over life energy. It is a war over resources, people bombing each other with negative energy, and feeding on the life force of another.
Most everyone can feel (their) power chakra, but few realize that it is the power chakra response that they are feeling. How do you feel when you win an argument? How do you feel when you lose? Take a moment to think about it. Remember past events and the associated feelings, and notice where in your body the feelings -emotion or sensation- is located.
The feeling of triumph, or the feeling of loss is centered in the power chakra. In the belly, in the middle just below the ribs. Think of a time when someone praised you or gave you a really nice compliment. Think of a time when you felt very successful; think of a time when you felt failure. Remember, and feel. Where is the feeling located, in your body? Think of a time when someone criticised you, insulted you or demeaned you. Where is that feeling located?"
If we all interacted with each other using the heart chakra of empathy, what a calmer place the O.R.s of the world would be!
http://www.kundalini-teacher.com/chakras/empathy.html
Peace to all!
--
Rob
http://www.medicalcorpse.com
