Perioperative Medicine: What does this actually entail for anesthesiologists?

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theblueswede

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I realize that nobody has all the answers with regard to the future of the practice of anesthesia, but "perioperative" is a buzzword that almost always shows up in the conversation as a possible area of expansion. I just can't figure out what this actually entails. What are some practical, day to day examples of what this could potentially look like in an anesthesiologist's practice 20 years from now?

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I realize that nobody has all the answers with regard to the future of the practice of anesthesia, but "perioperative" is a buzzword that almost always shows up in the conversation as a possible area of expansion. I just can't figure out what this actually entails. What are some practical, day to day examples of what this could potentially look like in an anesthesiologist's practice 20 years from now?

20 years? Can you do the day to day work for your chosen speciality? If not it may not be for you.

As you’ve pointed out, it’s a buzzword, as far as I know within this current medical system, it will be difficult to implement. As an internist, I would want to see my own patients before surgery. As an anesthesiologist, I don’t want to see my patient for three months (certainly don’t want to be responsible for any medical problems for three months after surgery). Not sure if you can see where this is going....

But in short, within the current system, Anesthesiologists see their patient on the day of surgery, for more complicated case, maybe preop clinic. Right after patient leave the pacu the patient is no longer “mine.” Sure I can implement ERAS or do a little more before to prep the patient for surgery and a little more after for speedier recovery. But those effect will be hard to measure, and as far as I know, most institutions will not pay me extra to do that work.

So set patient up for preop clinic, cardiology work up, ERAS pathway implementation, prevention of N/V, prevent prolong PACU/hospital stay, adequate pain control to shorten hospital stay. More esoteric things, blood product utilization, OR resources management, even testing for rare genetic susceptibility for drugs, diseases.

I am jaded.
 
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Nobody talks about the Periop Surgical Home anymore. Seems like the big wigs realized it didn't make sense.

There is a preop clinic with the intention of minimizing cancellations due to workup but cancellations still happen.
 
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it was and still is a stupid concept. Basically become the internist for surgeons and manage people's diabetes, HTN, pain stuff. If I liked doing rounds and bull**** paperwork all day I'd ****ing be an IM doc at least they have the chance of going GI and just scope peoples butts all day.
 
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My understanding is that as payment models shift to reimburse for episodes of care rather than doing procedures, anesthesiologists under a perioperative care model could stand to benefit by being more involved in the pre-op and post-op care in order to demand a higher piece of a fixed pie. Seems like just another zero-sum game to be played at the expense of clinicians and to the benefit of our administrative and political overlords. It never seemed convincing to me that this type of strategy would do much other than lead to a more work, less pay scenario. There is some potential benefit to having a great pre-op clinic that can identify issues in order to minimize same-day cancellations. This saves time and money for everyone involved. But perioperative surgical home opens up several potential turf wars with internists and surgeons. Given our inability to deal with RN encroachment, picking fights with other specialties seems like a recipe for failure to me.

Buzzwords and strategies like these do not change the feeling that the ship is sinking and we should all be picking the appropriate time and place to bail out and swim for shore. Situational awareness is a key skill to be a successful anesthesiologist.
 
My understanding is that as payment models shift to reimburse for episodes of care rather than doing procedures, anesthesiologists under a perioperative care model could stand to benefit by being more involved in the pre-op and post-op care in order to demand a higher piece of a fixed pie. Seems like just another zero-sum game to be played at the expense of clinicians and to the benefit of our administrative and political overlords. It never seemed convincing to me that this type of strategy would do much other than lead to a more work, less pay scenario. There is some potential benefit to having a great pre-op clinic that can identify issues in order to minimize same-day cancellations. This saves time and money for everyone involved. But perioperative surgical home opens up several potential turf wars with internists and surgeons. Given our inability to deal with RN encroachment, picking fights with other specialties seems like a recipe for failure to me.

Buzzwords and strategies like these do not change the feeling that the ship is sinking and we should all be picking the appropriate time and place to bail out and swim for shore. Situational awareness is a key skill to be a successful anesthesiologist.

Exactly how does one “bail out”. I’m an anesthesiologist in my 30’s. I have a wife, kids, and a mortgage. I have exactly zero other marketable skills that can earn close to my current income. Even if the market became so bad that we had salary parity with CRNA’s I would really have no choice but to keep working. I think most other docs are in the same boat. There is no “bail out”. We are at the mercy of the market.
 
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More work for less pay

Exactly - more work for less pay. More specifically it involves coming up with ERAS protocols, doing preop clinics, managing post op pain, and creating a bunch of graphs and charts - all to "add value". Note that adding value is code for doing stuff for free while others profit.

By the way, the ASA model for perioperative surgical home is:

Step 1: Create perioperative surgical home
Step 2:
Step 3: Profit


... doomed from the start!
 
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Nobody talks about the Periop Surgical Home anymore. Seems like the big wigs realized it didn't make sense.
You know, I actually hadn't realized now long its been since someone said that stupid "perioperative surgical home" near me. It's been ... a long time.

Maybe they really have given up on it. Maybe they read SDN? :)

Or maybe I'm just hanging out with better quality people these days who don't say dumb stuff.
 
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PSH was a consequence of Obamacare. As parts of the latter die, so does the former (hopefully).
 
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basically in 20 years if we dont increase lobbying, i think our profession will do very poorly. i think we'll get pushed into doing the toughest cases (very young kids , or very sick hearts), the rest will be done by nurses, likely independently. then what happens is we will have way too many anesthesiologists, and thus salaries will TANK due to over supply.

we already work long hours compared to other fields.. and our per hour salary is already not very good.

i think for this to change we must be more united like nurses unfortunately. they complain and complain, and strike and unionize and whatnot for their own benefit while doctors are being left in the dust. otherwise the guys/girls in suits will just keep on pushing the limits until you work ridiculous hours earning next to nothing. either that or we expand into some type of procedural field
 
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20 years? Can you do the day to day work for your chosen speciality? If not it may not be for you.

As you’ve pointed out, it’s a buzzword, as far as I know within this current medical system, it will be difficult to implement. As an internist, I would want to see my own patients before surgery. As an anesthesiologist, I don’t want to see my patient for three months (certainly don’t want to be responsible for any medical problems for three months after surgery). Not sure if you can see where this is going....

But in short, within the current system, Anesthesiologists see their patient on the day of surgery, for more complicated case, maybe preop clinic. Right after patient leave the pacu the patient is no longer “mine.” Sure I can implement ERAS or do a little more before to prep the patient for surgery and a little more after for speedier recovery. But those effect will be hard to measure, and as far as I know, most institutions will not pay me extra to do that work.

So set patient up for preop clinic, cardiology work up, ERAS pathway implementation, prevention of N/V, prevent prolong PACU/hospital stay, adequate pain control to shorten hospital stay. More esoteric things, blood product utilization, OR resources management, even testing for rare genetic susceptibility for drugs, diseases.

I am jaded.

Nobody talks about the Periop Surgical Home anymore. Seems like the big wigs realized it didn't make sense.

There is a preop clinic with the intention of minimizing cancellations due to workup but cancellations still happen.

https://www.anesthesiologynews.com/...true&dgid=&order=1&date=20190212&click=button

Don't write it off yet...this stupid idea is still alive and well

How is that new residents, graduates, etc. can see the nightmare this is going to be but those entrusted with protecting the specialty can't or won't? Just crazy
 
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https://www.anesthesiologynews.com/...true&dgid=&order=1&date=20190212&click=button

Don't write it off yet...this stupid idea is still alive and well

How is that new residents, graduates, etc. can see the nightmare this is going to be but those entrusted with protecting the specialty can't or won't? Just crazy
They are paid not to see it. Do you think lobbying happens only in Congress? ;)

What's the number 1 special interest group supporting the AS(s)A? The big corporations (AMCs and academia), not the anesthesiologist losers.
 
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Nobody talks about the Periop Surgical Home anymore. Seems like the big wigs realized it didn't make sense.

There is a preop clinic with the intention of minimizing cancellations due to workup but cancellations still happen.

problem i see is this:

1. things could change in the time frame between preop visit and day of surgery. rarely do I cancel cases d/t missed cardiopulmonary risk factors and need for further CV optimization. usually something else.

2. many patients don't want to take an extra day off to go to preop clinic to get blood work and evaluation performed.

3. most of the time seen by NP. they miss **** left and right.
 
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Don't write it off yet...this stupid idea is still alive and well

How is that new residents, graduates, etc. can see the nightmare this is going to be but those entrusted with protecting the specialty can't or won't? Just crazy

I see “values” in Periop Surgical home approach.

But so many questions, no good answers other than good sound bites.

1. Anesthesiologists aren’t paid to do this kind of work.
2. Most of the anesthesiologists wanted to take care of patients in OR, not the floor.
3. Even Anes/CC trained/boarded sometimes having difficulty being accepted as an equal to take care of “medical” problems in ICU. Are general anesthesiologists ready to pick a fight with IM for “hospitalist” jobs?
4. We have much more anesthesia trainings, therefore we have the depth over Midlevels. Now you’re saying you have more breadth and can take care of patients who historically have been taking care of by hospitalists? Are we going to make our trainings even longer? Shorten the anesthesia part, then how do you fight off CRNAs? Board periop fellowship? Where would these anesthesiologists work?
5. Why would IM let you take over this?
6. With ASA 1-2 patients, why would insurance company pay an periop hospitalist when historically they are under surgeons services?

Maybe it the ivory tower thinking? But like the other thread was discussing, some groups may have CRNA/NPs to man the preop clinic, if we don’t do it now, will that also be taking over?

Anyone has a crystal ball that can see into 20 years from now?
 
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https://www.anesthesiologynews.com/...true&dgid=&order=1&date=20190212&click=button

Don't write it off yet...this stupid idea is still alive and well

How is that new residents, graduates, etc. can see the nightmare this is going to be but those entrusted with protecting the specialty can't or won't? Just crazy


Interesting article but if the program was so great why would they discontinue it in 2017? Would love to get that story. Also the staffing seems like a great way to get at least 5 people to do the work of 1 or 2. And it didn’t mention what specifically anesthesiologists add that hospitalists don’t do.
 
Period surgical home I can see. But you couldn’t pay me enough to be a surgical hospitalist straight up - deal with dispo problems, potassium replacement calls and detoxing post op trauma patients? I went into this field for a reason, and it wasn’t to be a permanent intern.
 
The perioperative home stuff is a ruse to create more jobs for midlevels. I think these preop clinics are largely a waste of people’s time and money as well. I see an incredible number of unnecessary cardiology visits, TTEs, CXRs, stress tests, labs, etc done before routine cases. Preop testing has turned into a whole cottage industry of wasted healthcare spending. Who is canceling cases, anyway?

Are you having a heart attack on the day of surgery? No? Good, let’s proceed. There’s your preop clinic.
 
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Who is canceling cases, anyway?

Are you having a heart attack on the day of surgery? No? Good, let’s proceed. There’s your preop clinic.

Anesthesia. Of course it’s always anesthesia’s fault!

I’ve learned when the payer mix is poopoo, we don’t work as hard. When the population all have good insurance, we get pushed to do the cases when questionable..... capitalism at work?!
 
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Are you having a heart attack on the day of surgery? No? Good, let’s proceed. There’s your preop clinic.

A friend of mine actually did have a patient who was having an active MI on the day of an elective surgery. The surgeon apparently argued and complained because of the case being cancelled (even with an actual active MI occurring).
 
Are you having a heart attack on the day of surgery? No? Good, let’s proceed. There’s your preop clinic.

One of my last days in residency we had a patient with worsening unstable angina come for a shoulder scope, and the surgeon went into absolute orbit when I told him we had to cancel. Screamed at me and asked “can’t we just do this case and be a little worried about it?” Didn’t let up even as the patient was being loaded into the ambulance to go to the ER for further workup.

My academic attending was nowhere to be found and offered no assistance. Didn’t leave me with a good impression as I was leaving the place.
 
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Sounds awful, there are a lot of not great anesthesiologists out there.
i just do whatever i think is best for the patient. money never gets in the way of doing that in my opinion. if the surgeon wants to do a case when its obviously bad for the patient then im going to cancel. if the group refuse to back me up then i'll just pack my bags and find another place. there are some grey areas obviously where some may go and others may cancel but if you got active MI or unstable angina.. if not emergent then case cancelled
 
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Sounds awful, there are a lot of not great anesthesiologists out there.
i just do whatever i think is best for the patient. money never gets in the way of doing that in my opinion. if the surgeon wants to do a case when its obviously bad for the patient then im going to cancel. if the group refuse to back me up then i'll just pack my bags and find another place. there are some grey areas obviously where some may go and others may cancel but if you got active MI or unstable angina.. if not emergent then case cancelled

To expand on my other post as well. I really learned that when the patient population is affluent, then everyone else, surgeon, administration and even patient themselves feel entitled and give you a million reasons that you cannot cancel them.....

“How can you cancel me/them/customer/clients?” “I had to take time off from my job, I cannot take more time off, why didn’t YOU tell me that I had to be cleared?”
Compare to
“Oh, I need to come back another day? That’s fine, I have nothing else to do next Thursday anyway....”

Obviously I don’t make bank, but surgeons and partners are much easier to work with, because no one is getting paid by Medicaid or Medicare that the patients have.
 
To expand on my other post as well. I really learned that when the patient population is affluent, then everyone else, surgeon, administration and even patient themselves feel entitled and give you a million reasons that you cannot cancel them.....

“How can you cancel me/them/customer/clients?” “I had to take time off from my job, I cannot take more time off, why didn’t YOU tell me that I had to be cleared?”
Compare to
“Oh, I need to come back another day? That’s fine, I have nothing else to do next Thursday anyway....”

Obviously I don’t make bank, but surgeons and partners are much easier to work with, because no one is getting paid by Medicaid or Medicare that the patients have.

thats when you tell them you wont have to worry about taking more time off if you drop dead
 
thats when you tell them you wont have to worry about taking more time off if you drop dead

One in particular comes to mind, bp over 200/130.
“Really not safe to do it, Mrs. Smith. ”
“Oh it’s like that for weeks, I decided to stop one medication because blah blah, and didn’t take that little white one this morning....” “my daughter had to take off a day from work just for this....”

Affluent area partner: order some meds, and let her sit as second case, if less than 100, then just have to do it. It’s in your room.

Lower SE area partner: just cancel the case, if gyn wants to admit her to manage the bp, they can. She can be first add on tomorrow.
 
One in particular comes to mind, bp over 200/130.
“Really not safe to do it, Mrs. Smith. ”
“Oh it’s like that for weeks, I decided to stop one medication because blah blah, and didn’t take that little white one this morning....” “my daughter had to take off a day from work just for this....”

Affluent area partner: order some meds, and let her sit as second case, if less than 100, then just have to do it. It’s in your room.

Lower SE area partner: just cancel the case, if gyn wants to admit her to manage the bp, they can. She can be first add on tomorrow.

Is there really any difference between giving some labetalol (or nothing, just wait for prop) and doing that case ASAP vs giving PO meds and then first thing in the AM? It presumably takes weeks to establish new autoregulatory perfusion curves and correct the intrinsic aldosterone/catecholamine/ace derangements. I’ve mostly stopped canceling for severe range BP unless the pt is having a true HTN emergency (I.e. symptomatic headache, chest pain, end organ damage on labs etc)
 
One of my last days in residency we had a patient with worsening unstable angina come for a shoulder scope, and the surgeon went into absolute orbit when I told him we had to cancel. Screamed at me and asked “can’t we just do this case and be a little worried about it?” Didn’t let up even as the patient was being loaded into the ambulance to go to the ER for further workup.

My academic attending was nowhere to be found and offered no assistance. Didn’t leave me with a good impression as I was leaving the place.

Surgeon sounds like a big douche
 
The perioperative home stuff is a ruse to create more jobs for midlevels. I think these preop clinics are largely a waste of people’s time and money as well. I see an incredible number of unnecessary cardiology visits, TTEs, CXRs, stress tests, labs, etc done before routine cases. Preop testing has turned into a whole cottage industry of wasted healthcare spending. Who is canceling cases, anyway?

Are you having a heart attack on the day of surgery? No? Good, let’s proceed. There’s your preop clinic.
Perfect response GravelRider,

I worked with a board examiner a few years ago and he gave a w hole talk on if you are going to cancel a surgery, the patient needs to go the Emergency Room. Short of that, patient gets the anesthetic.
That was his criteria.
I agree surgical home is nuts. The lab ordering has gotten out of hand. that is what happens when you dont have a grasp as to what you are doing. You start ordering tests.
 
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Is there really any difference between giving some labetalol (or nothing, just wait for prop) and doing that case ASAP vs giving PO meds and then first thing in the AM? It presumably takes weeks to establish new autoregulatory perfusion curves and correct the intrinsic aldosterone/catecholamine/ace derangements. I’ve mostly stopped canceling for severe range BP unless the pt is having a true HTN emergency (I.e. symptomatic headache, chest pain, end organ damage on labs etc)

Probably not. Let’s say I drop the bp with prop and some catastrophic event happens. Or even worse, the CRNA or the resident dropped it 60/30s and unable to bring it back.

My feeling always is, if they can let it sit for weeks=noncompliant patient= no medical care for months=cannot be sure any other underlying medical problems. If not a true emergency case, why chance it?
 
Here’s an idea. Come up with a list of guidelines for surgeons. Then, tell them if the guidelines aren’t met, not only are we NOT doing your elective case, they won’t even receive “anesthesia pre-operative evaluation”. Make the surgeons and their staff jump through some hoops, so I don’t have to explain to the surgeon why their 350 lb diabetic COPD’er with 5 stents and an electric scooter for mobility, who hasn’t seen a cardiologist in 4 years, probably needs a cardiology clearance for their joint replacement surgery, to fix the knee they’ll never walk on...
 
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Here’s an idea. Come up with a list of guidelines for surgeons. Then, tell them if the guidelines aren’t met, not only are we NOT doing your elective case, they won’t even receive “anesthesia pre-operative evaluation”. Make the surgeons and their staff jump through some hoops, so I don’t have to explain to the surgeon why their 350 lb diabetic COPD’er with 5 stents and an electric scooter for mobility, who hasn’t seen a cardiologist in 4 years, probably needs a cardiology clearance for their joint replacement surgery, to fix the knee they’ll never walk on...

Since I am on the topic of affluent vs Low SE comparisons.
Can you imaging what kind of power that surgeons, especially Ortho, have over the hospital at a high volume affluent town? Ultimately us?
“I am going to bring my cases to the hospital across the town....“ those are the magic words that can really get a lot people canned.
 
Since I am on the topic of affluent vs Low SE comparisons.
Can you imaging what kind of power that surgeons, especially Ortho, have over the hospital at a high volume affluent town? Ultimately us?
“I am going to bring my cases to the hospital across the town....“ those are the magic words that can really get a lot people canned.

the question is do you want to work in an environment like that? where money is put before the patients health? i think for everyone, just have to draw the line somewhere. and i think thats when the department has to have your back.
 
the question is do you want to work in an environment like that? where money is put before the patients health? i think for everyone, just have to draw the line somewhere. and i think thats when the department has to have your back.
According to the older guys in my practice who remember the days of “eat what you kill” cancellations by anesthesia were extemely rare .......
 
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First of all, the "older guys" did not anesthetize anything older than like 70, back then. Then, the average BMI was lower than 25. Plus there were so many hoops to jump through preop, that only the most stable and optimized patients made it to the surgery. So, of course, there were no cancellations.

Nowadays, bean counters want us to anesthetize anybody, short of "a-systole". It's not their career on-line; the pilots (i.e. bosses) do not go down with the drones (i.e. us), so they don't care. All they care about are profits, and until the American people (i.e. juries) don't punish them, they will keep doing this.

I am looking forward to the first floor-runner convicted of malpractice because he ordered an underling to not cancel a surgery.
 
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We learn from experience which cases can be done without significant complications. No single case is ever worth a major complication. Smart surgeons know this and don’t push back.
 
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well back then they didnt have a pulse ox and were still using ether. these guidelines/studies probably didnt even exist
Umm no. My practice was eat what you kill up to 5 years ago. The point being was that you could cancel, but you had some skin in the game ( no case, no units = no pay for today)
 
Umm no. My practice was eat what you kill up to 5 years ago. The point being was that you could cancel, but you had some skin in the game ( no case, no units = no pay for today)

i dont think cancellations are that common, so even if you cancel you really shouldn't be losing that much
 
i dont think cancellations are that common, so even if you cancel you really shouldn't be losing that much
I would rather cancel and lose my income for those hours than hurt a patient. This is what (bad) surgeons don't get.
 
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I would rather cancel and lose my income for those hours than hurt a patient. This is what (bad) surgeons don't get.

I don't doubt it, FFP- but all humans respond to incentives and rewards. It's just how our brains are wired... So does it really make sense to set the system up in such a way that we're (subconsciously) rewarded for putting the patient at risk?
 
We should just drop this stupidity regarding optimizing patients for surgery. When was the last time someone showed up to holding with full and complete documentation of how all their comorbidities were clearly optimized by all their doctors?
 
While the surgical home is definitely a silly idea, perioperative medicine is still and will always be what we do.
We just do it within the frame of our normal patient encounter. We are not internists or primary care providers, so managing chronic medical problems including optimization for surgery is not our domain, that's the job of those other physicians.
Anesthesiology is a specialty that deals with acute care episodes and that's how it should remain. Our perioperative medicine practice should be focused on our ability to understand the whole clinical picture of the surgical patient and come up with a plan of action that is tailored to every patient's specific circumstances.
 
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