Should patients get a choice of anesthesia provider?

[flightnurse2MD]

Had an issue with a patient’s mother today in a Children’s Hospital. When she met the nurse anesthetist in preop, she demanded for a physician to do her daughter’s anesthetic for a relatively uncomplicated procedure. She wouldnt even budge for a resident or fellow. In the end, the attending manged the case. She wasn’t a VIP or anyone in the medical field. I don’t know if she really understood the differences in training between nurses and physicians. It got me thinking. Should we start asking patients who they want in the OR? Should it be part of the preop evaluation along with asking if they ate after midnight or took their lisinopril?

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[nimbus]

Had an issue with a patient’s mother today in a Children’s Hospital. When she met the nurse anesthetist in preop, she demanded for a physician to do her daughter’s anesthetic for a relatively uncomplicated procedure. She wouldnt even budge for a resident or fellow. In the end, the attending manged the case. She wasn’t a VIP or anyone in the medical field. I don’t know if she really understood the differences in training between nurses and physicians. It got me thinking. Should we start asking patients who they want in the OR? Should it be part of the preop evaluation along with asking if they ate after midnight or took their lisinopril?

Smart mom. If you have inside knowledge it's more a matter of knowing who to avoid. But if you have no inside information what she did is reasonable. But I wouldn't make that part of a preop. Any reasonable person would ask for an experienced attending with a great reputation. That would be a scheduling nightmare. Don't go asking for problems.

 

[Maverikk]

Yep, if it was my kid I would want a pedi anesthesiologist doing the case regardless of what they had

 

[dhb]

Me too although an appriopriately surpervised resident or fellow would be fine in a teaching hospital.

 

[flightnurse2MD]

Smart mom. If you have inside knowledge it's more a matter of knowing who to avoid. But if you have no inside information what she did is reasonable. But I wouldn't make that part of a preop. Any reasonable person would ask for an experienced attending with a great reputation. That would be a scheduling nightmare. Don't go asking for problems.

Especially in the rural hospitals where there isn’t an anesthesiologist for miles.

 

[Aether2000]

Unfortunately it is not practical in most hospitals given they have a bevy of AAs/CRNAs employed at a 4:1 ratio to physicians. Such a request for physician coverage of anesthesia should be discussed with the surgeon in advance, since there remain some hospitals and anesthesiology groups that are all physician, and perhaps the surgeon could book at those hospitals or facilities. The patient attempting to make this request in advance through the anesthesiology group may not be possible since they do not know how to access the group or a person in the group that could make this happen. A last minute request on arrival for surgery for such specialist personal treatment may not be practical given daily schedules are already set, and it is not always easy or possible to make the changes to accommodate.

 

[deleted171991]

Had an issue with a patient’s mother today in a Children’s Hospital. When she met the nurse anesthetist in preop, she demanded for a physician to do her daughter’s anesthetic for a relatively uncomplicated procedure. She wouldnt even budge for a resident or fellow. In the end, the attending manged the case. She wasn’t a VIP or anyone in the medical field. I don’t know if she really understood the differences in training between nurses and physicians. It got me thinking. Should we start asking patients who they want in the OR? Should it be part of the preop evaluation along with asking if they ate after midnight or took their lisinopril?

Explaining the local anesthesia team model to patients is part of the informed consent.

Never lie to a patient, even by omission. Don't ask whom they want, but answer all their questions truthfully. If docs don't check on their rooms during surgeries, don't imply that to patients. There is nothing worse than lying to a patient and then having a complication. Don't promise things that you know won't happen.

 

[pgg]

Of course patients have a choice.

I recently had a patient state that she didn’t want any students or residents to be involved in her care. She was a periop nurse (who worked at another institution). I started to explain that we were a teaching institution, that residents were licensed physicians, that I was ultimately responsible for all parts of her anesthetic care, and her response was words to the effect of “I’m the patient, it’s my choice” ...

She agreed my resident could care for her, after I told her that we couldn’t accommodate the request, and if she felt strongly about it, her choice came down to choosing another hospital for her surgery. I didn’t try to talk her into anything. I think when she realized that her actual choice in the matter involved rescheduling at another hospital, on another day, with another surgeon, with another block of time off from work, possibly at greater out-of-pocket expense ... she chose to back down.

So of course patients can choose. It’s our job to help them understand what their choices actually are.

 

[leaverus]

Had an issue with a patient’s mother today in a Children’s Hospital. When she met the nurse anesthetist in preop, she demanded for a physician to do her daughter’s anesthetic for a relatively uncomplicated procedure.

i'm confused. i assumed children's hospitals only used pediatric anesthesiologists?? and if that's case what's the point of also utilizing crnas who don't get any specialized pediatric training as far as I know.

Yep, if it was my kid I would want a pedi anesthesiologist doing the case regardless of what they had

a pedi trained person for routine surgeries on otherwise healthy kids? that's ridiculous; understandable perhaps, but still totally ridiculous.

 

[2Fast2Des]

i'm confused. i assumed children's hospitals only used pediatric anesthesiologists?? and if that's case what's the point of also utilizing crnas who don't get any specialized pediatric training as far as I know.

a pedi trained person for routine surgeries on otherwise healthy kids? that's ridiculous; understandable perhaps, but still totally ridiculous.

Wouldn't you want your child to have the best possible care regardless of the degree of surgery? Or is a CRNA who has no peds specialty training just as good?

 

[narcusprince]

Pgg
This doesn't make sense if it's where I think you are. You could have put the resident in another room and done the case yourself. In a civillian model yes this would be hard to accommodate.

Of course patients have a choice.

I recently had a patient state that she didn’t want any students or residents to be involved in her care. She was a periop nurse (who worked at another institution). I started to explain that we were a teaching institution, that residents were licensed physicians, that I was ultimately responsible for all parts of her anesthetic care, and her response was words to the effect of “I’m the patient, it’s my choice” ...

She agreed my resident could care for her, after I told her that we couldn’t accommodate the request, and if she felt strongly about it, her choice came down to choosing another hospital for her surgery. I didn’t try to talk her into anything. I think when she realized that her actual choice in the matter involved rescheduling at another hospital, on another day, with another surgeon, with another block of time off from work, possibly at greater out-of-pocket expense ... she chose to back down.

So of course patients can choose. It’s our job to help them understand what their choices actually are.

 

[Man o War]

I've had 2 pediatric surgeons tell me they insist on pediatric trained anesthesiologists, so I didn't have to make a choice. One said that's just the way their hospital wants it, and the other said that's what he would want for his kids, so he doesn't accept less for his patients. The third surgery, I knew the surgeon and knew there was a care team model at that hospital. I told him I didn't want a nurse doing my kid's anesthesia and he took care of it with the anesthesia group.

 

[leaverus]

Wouldn't you want your child to have the best possible care regardless of the degree of surgery? Or is a CRNA who has no peds specialty training just as good?

I thought u meant vs a non-pedi MD/DO. crna shouldnt even enter the picture in my mind; tho I know crnas routinely take care of kids throughout the country

 

[flightnurse2MD]

I thought u meant vs a non-pedi MD/DO. crna shouldnt even enter the picture in my mind; tho I know crnas routinely take care of kids throughout the country

There are nurse anesthetists in our department that do routine pediatric cases. They are very good and are quick to call if things get out of hand.

 

[leaverus]

There are nurse anesthetists in our department that do routine pediatric cases. They are very good and are quick to call if things get out of hand.

Really?! i had no idea. Oh wait, i seem to recall writing somewhere in this thread that "crnas routinely take care of kids throughout the country". let me do a search and see if i can find that post for you.

 

[pgg]

Pgg
This doesn't make sense if it's where I think you are. You could have put the resident in another room and done the case yourself. In a civillian model yes this would be hard to accommodate.

I couldn't accommodate the request because my self respect wouldn't permit me to.

Also, policy, but that was secondary.

Priority #1 is safe care and priority #2 is resident education. I don't throw #2 under the bus because #1 is possible if I send the resident out for ice cream and do the case by myself. I bottom-line sign the chart but it's the resident's case; I'm just there to make sure it goes safely, and maybe retape the tube or make sure they dress the a-line correctly (CHG Tegaderm + two small Tegaderms in case you're wondering).

 

[drmwvr]

Interesting...I wonder if some patients and/or their families are as interested/informed in the competency of their surgeons...it seems as though family/patient expertise in perioperative management ends with anesthesia and takes for granted the good faith and skill of our surgery colleagues. What a mess....

 

[Precedexed Out]

If every patient requested a physician to do the anesthesia, it would be impossible. Same concept if every patient demanded to only see a physician and no NPs or PAs. Difficult situation, but how can one physician supervising 4 nurse anesthetists be pulled to do a case. This would mess up the logistics of the surgical flow, especially on the day of the case.

 

[Noyac]

There are nurse anesthetists in our department that do routine pediatric cases. They are very good and are quick to call if things get out of hand.

Makes me think, why do things need to get out of hand?

 

[Noyac]

If every patient requested a physician to do the anesthesia, it would be impossible. Same concept if every patient demanded to only see a physician and no NPs or PAs. Difficult situation, but how can one physician supervising 4 nurse anesthetists be pulled to do a case. This would mess up the logistics of the surgical flow, especially on the day of the case.

No, this would mess up the income of said physician. Some of us talk a big game but when it comes to finances we ignore the philosophy we are so quick to claim. Basically, they will claim superior knowledge and care to the crna all the up,to the point that they are asked to do a case. Then they say, it isn’t possible.

 

[Noyac]

Pgg
This doesn't make sense if it's where I think you are. You could have put the resident in another room and done the case yourself. In a civillian model yes this would be hard to accommodate.

See my previous post.

 

[Precedexed Out]

No, this would mess up the income of said physician. Some of us talk a big game but when it comes to finances we ignore the philosophy we are so quick to claim. Basically, they will claim superior knowledge and care to the crna all the up,to the point that they are asked to do a case. Then they say, it isn’t possible.

I don't understand how every surgery could be completed if there were no nurse anesthetists. There are way more surgical cases than anesthesiologists to do them.

I entirely agree some anesthesiologists will avoid doing their own case at all costs.

 

[2Fast2Des]

I don't understand how every surgery could be completed if there were no nurse anesthetists. There are way more surgical cases than anesthesiologists to do them.

I entirely agree some anesthesiologists will avoid doing their own case at all costs.

As a resident I find it quite puzzling that people who spent time specializing in a craft (providing safe and great anesthesia) in the operating room, be so against sitting a case. How does one claim superiority when they can't do a machine check, set up a room, or know how to set up an infusion. Some don't even know how to chart on our EMR except for signing in.

 

[Precedexed Out]

As a resident I find it quite puzzling that people who spent time specializing in a craft (providing safe and great anesthesia) in the operating room, be so against sitting a case. How does one claim superiority when they can't do a machine check, set up a room, or know how to set up an infusion. Some don't even know how to chart on our EMR except for signing in.

Agree entirely. Doing ones own cases every once in a while helps maintain skills and knowledge. IMO, the anesthesiologists should always know everything, that is what makes them doctor.

 

[Man o War]

There are nurse anesthetists in our department that do routine pediatric cases. They are very good and are quick to call if things get out of hand.

That is DEFINITELY not the case everywhere. Both the "very good" part and the "quick to call" part. The out of hand part, all the time.

 

[nimbus]

Pgg
This doesn't make sense if it's where I think you are. You could have put the resident in another room and done the case yourself. In a civillian model yes this would be hard to accommodate.

If every patient requested a physician to do the anesthesia, it would be impossible. Same concept if every patient demanded to only see a physician and no NPs or PAs. Difficult situation, but how can one physician supervising 4 nurse anesthetists be pulled to do a case. This would mess up the logistics of the surgical flow, especially on the day of the case.

In my city we have a children's hospital where >95% of all pediatric cases are done. There you will get one of 2 options.

1. Rockstar cream of the crop pediatric anesthesiologist alone.

2. Rockstar cream of the crop pediatric anesthesiologist working 1:1 with a resident.

It's a civilian model where it works very well and it is absolutely not impossible. It is done all day every day in some places. I am an insider and I'd have no qualms about letting any one of them take care of my child. They have a highly desireable, fair practice that attracts the best doctors, many of them triple and some quadruple boarded, practicing the right way.

 

[nimbus]

As a resident I find it quite puzzling that people who spent time specializing in a craft (providing safe and great anesthesia) in the operating room, be so against sitting a case. How does one claim superiority when they can't do a machine check, set up a room, or know how to set up an infusion. Some don't even know how to chart on our EMR except for signing in.

That's pathetic.

 

[nimbus]

Agree entirely. Doing ones own cases every once in a while helps maintain skills and knowledge. IMO, the anesthesiologists should always know everything, that is what makes them doctor.

Maintaining your skills is a pretty low bar. Very sad to me. To me anesthesia is like playing music or a sport. You can work at it for a lifetime and you will still not be perfect. But a lot of the joy comes from continuously working to improve and refine your craft.

 

[IlDestriero]

I couldn't accommodate the request because my self respect wouldn't permit me to.

Also, policy, but that was secondary.

Priority #1 is safe care and priority #2 is resident education. I don't throw #2 under the bus because #1 is possible if I send the resident out for ice cream and do the case by myself. I bottom-line sign the chart but it's the resident's case; I'm just there to make sure it goes safely, and maybe retape the tube or make sure they dress the a-line correctly (CHG Tegaderm + two small Tegaderms in case you're wondering).

We accommodate these kinds of requests. Education is pillar 2 of 3 of academic medicine. Pillar 1 is superior clinical care, which includes patient and family satisfaction.
If I told a patient to reschedule at another hospital, I would expect to have a complaint filed within the hour, the chair to know by the end of the day after risk management and the top brass heard about it, and I'd be packing my bags by the morning. Though I'm sure I could "take emergency leave" and just not come back. I'm not a big enough deal to get a sabbatical.
I am curious though about what the policy that you refer to actually says and if the patients have notification of it in advance, or even any access to it if they knew to look for it. It can't just be something like special requests can't be accommodated on the DOS as you implied she'd have to go elsewhere to get Attending only care.
Things must be very different now than when I was in. We were 1:1, outside of call and the labor deck, all the time and had surplus people pushing paper around their desks trying to look productive.


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Il Destriero

 

[pgg]

We accommodate these kinds of requests. Education is pillar 2 of 3 of academic medicine. Pillar 1 is superior clinical care, which includes patient and family satisfaction.

Uninformed whims of patients and families can influence unimportant aspects of care in the name of “customer service”, sure, if it doesn’t disrupt other patients’ care.

But surely you draw the line somewhere with regard to patient demands?

You accommodate a patient who says no students, trainees, or residents of any kind. OK.

Would you accommodate a patient who wanted a board certified attending (board eligible wasn’t good enough)?

What if he wanted one who was participating in MOCA, not some lazy old fart cruising with a non-expiring cert?

What if he wanted an attending with 10 years of experience? 15? 20?

What if he wanted the dept chair to do it solo?

What if he wanted a male anesthesiologist?

A white anesthesiologist?

You think a surgeon wouldn’t refuse a patient who said “you and only you can touch any instrument that touches my body”? That he’d send his resident, fellow, PA, and surgical tech away? Why is it wrong for anesthesiologists to make the same stand when it comes to members of their team?

Of course we can and should draw a line somewhere when it comes to ignorant and/or inappropriate patient demands.

I draw the line before they get to say that a licensed physician under my direct supervision can’t be in the room.

If I was in PP or working someplace where the billing for each case was critical, and/or my stand irritated/offended some rainmaker surgeon, I’d bend some. But I’m not, I don’t have to, and I don’t.

If I told a patient to reschedule at another hospital, I would expect to have a complaint filed within the hour, the chair to know by the end of the day after risk management and the top brass heard about it, and I'd be packing my bags by the morning.

Heh, you obviously must choose your words with politeness and tact. “We can’t accommodate that request here” has a totally different flavor than “get out, go to St. Otherhospital across town”.

Is your hospital admin and risk management going to ensure that no trainee in the pharmacy touches the meds for this patient before they go to the ward? That no student nurse assistant draws blood in the PACU? That no pathology lab tech in training handles her biopsy specimen?

I am curious though about what the policy that you refer to actually says and if the patients have notification of it in advance, or even any access to it if they knew to look for it. It can't just be something like special requests can't be accommodated on the DOS as you implied she'd have to go elsewhere to get Attending only care.

It could likely be arranged, if done well in advance, if the patient insisted. But they’d have to accept the possibility of a longer wait.

If the patient was a staff member and wanted to limit the number of friends/colleagues that were in the room, that is certainly reasonable.

Bottom line, if a patient really insists on an experience totally devoid of any trainees, they’re in a tough spot. They can choose to go to a non-teaching hospital, but that only ensures that none of the doctors are trainees.

 

[Precedexed Out]

Maintaining your skills is a pretty low bar. Very sad to me. To me anesthesia is like playing music or a sport. You can work at it for a lifetime and you will still not be perfect. But a lot of the joy comes from continuously working to improve and refine your craft.

Yes, so if one doesn't do a case for 5 years those skills will deteriorate. At one of my rotations, there was an obese attending who sat in the back corner of the room during induction. He didn't seem to be paying much attention and this was a CA-1 within the first few months of the year. If something had gone wrong, I'm not sure he had the physical stamina or skills to intervene in a beneficial way.

 

[IlDestriero]

It just strikes me as odd that you could have accommodated a reasonable patient request without any real hassle at all and chose to say no. Are you not 1:1 anymore?
Surgeons do accommodate those requests as well. They're infrequent. If the surgeon needs an assistant, that's different, however they can do all the real work themselves.


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Il Destriero

 

[parcus]

It just strikes me as odd that you could have accommodated a reasonable patient request without any real hassle at all and chose to say no. Are you not 1:1 anymore?
Surgeons do accommodate those requests as well. They're infrequent. If the surgeon needs an assistant, that's different, however they can do all the real work themselves.


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Il Destriero

Sounds like there is a real hassle to me. Besides, there is the futility of care ethic principle that kind of applies here.

 

[pgg]

It just strikes me as odd that you could have accommodated a reasonable patient request without any real hassle at all and chose to say no. Are you not 1:1 anymore?
Surgeons do accommodate those requests as well. They're infrequent. If the surgeon needs an assistant, that's different, however they can do all the real work themselves.

We're still 1:1, which makes it even more inappropriate and nonsensical for a patient to refuse to allow a trainee to be there. I even explained to the patient that I would be continuously present (usually I leave the room for at least part of the case when 1:1 as the residents don't need me hovering all the time but I did offer this concession). I told her I would intervene or personally perform any task that was beyond the ability of the resident to do safely, and that I was ultimately responsible for every part of her anesthetic care, start to finish.

I don't know if it was that reassurance that convinced her to change her mind, or if she did the math and decided it wasn't worth rescheduling or going elsewhere.

And no, it would've been no hassle to me, but it would've been a hassle to the resident, who'd taken the time to do the preop work ... set up the OR ... conjure a plan ... call me the day before to discuss it ... even called the patient the day before (because our program requires that). This demand was sprung on us in preop. I'm a nice guy, but I have a line and this is it.

 

[IlDestriero]

Sounds like there is a real hassle to me. Besides, there is the futility of care ethic principle that kind of applies here.

Did you reply to the right thread? How does the "futility of care ethic principle" apply to doing your own case at the request of the patient instead of letting a trainee do it?
What's the hassle? Actually doing a case yourself? The only one who might be inconvenienced is the resident that prepped for the case and didn't do it. Which isn't exactly a super uncommon thing, cases get cancelled or moved for convenience often. I do my own cases all the time, I wouldn't care either way. Though when supervising I'm almost always 2:1 so I would have had to shuffle things around a little to arrange coverage in my other room. That's not a significant problem at my place, perhaps nearly impossible at others until the end of the day.


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Il Destriero

 

[parcus]

Did you reply to the right thread? How does the "futility of care ethic principle" apply to doing your own case at the request of the patient instead of letting a trainee do it?
What's the hassle? Actually doing a case yourself? The only one who might be inconvenienced is the resident that prepped for the case and didn't do it. Which isn't exactly a super uncommon thing, cases get cancelled or moved for convenience often. I do my own cases all the time, I wouldn't care either way. Though when supervising I'm almost always 2:1 so I would have had to shuffle things around a little to arrange coverage in my other room. That's not a significant problem at my place, perhaps nearly impossible at others until the end of the day.


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Il Destriero

It is a futile request that has the potential to impose extra costs (depending on the place, as you mentioned), but I admit I'm stretching things a little too much here. That said, probably the best solution is to just bulge in most places as you risk annoying the patient for too little of an annoyance.

 

[mmag]

Same payment from the insurance company and copay whether it's an unsupervised nurse anesthetist, supervised nurse anesthetist, or physician anesthesiologist. I'd want the best and most qualified. If patients end up choosing to go to a hospital with what they want, maybe it'll mean even more jobs for anesthesiologists because of increased demand.

 

[apoondoc]

I can't believe this is even a discussion.
The patient deserves a board-certified, fellowship-trained anesthesiologist, if that is her request. End of story. She will certainly understand if it causes a scheduling inconvenience. Funny enough, it's not going to cost her a dime more.
Shame on the rest of you tools who can't tell the difference between a physician anesthesiologist and a nurse anesthetist. Maybe those of you who work in the care team model suck so bad that there is no difference, but that's the subject of another story.
Would you fault her if she wanted a cardiologist reading her father's ECG? Or a radiologist reading an X-ray? Or an OB-GYN delivering a grandchild? Or a pediatrician treating her child? FFS, that is exactly the sort of patient we, as doctors, want: the kind that respects our training and doesn't want a mid-level masquerading as a physician. And you act like she's acting too much, or the demand will subject the OR schedule to an inconvenience, or that "Four hands/Two Eyes" are equivalent or even better than having a dedicated physician anesthesiologist in the room at all times? Bloody Hell, I don't even know where to begin.
And to the guy who is afraid of his job if he does what's right: are you sure you want the job that won't let you do the right thing? I would consider being kicked out of that job a badge of GD honor. We are not hiring, but I would create a job opening to bring that guy on board tomorrow. There is no shortage of "top tier" education and training. There is, sadly, a real shortage of physicians who are willing to stand up in defense of the patient. That's the guy I want as a partner, not some tool who is worried about the hospital's bottom line, the surgeon's ego or his schedule.

 

[Modanq]

Regardless of the logistics, staffing, and feasibility based on surgical volume - we should continue to applaud and support patients that know there is a difference between Physicians and Nurse Anesthetists.
Blurring the lines between MDs and nurses occurs partly because we have done a poor job marketing and letting the public know that there is a difference in quality. Quality by nurses equals intubating and using gas. Quality by MDs is to know when to cancel a case, when to not cancel a case, what pre-op testing needs to be done, what pre-op workup can be skipped, what induction to choose, how should you manage the airway, doing blocks, managing emergencies, should the patient be discharged home or do they need to go to the ICU.

 

[jwk]

Like it or not, there are hospitals and anesthesia departments where these types of requests can be problematic. Private practice groups in particular, especially those that function in an ACT mode, may not have the flexibility to accommodate MD-only requests on the day of surgery. Like many practices, we run very lean - every single anesthesiologist and anesthetist has specific assignments on any given day. We can handle these requests when planned for in advance - doing so on the day of surgery would be difficult to say the least. It's not a question of who is best or most appropriate. It's a logistical issue plain and simple.

And BTW, this topic has been hashed and rehashed a number of times on SDN - the only difference here is it's a pediatric case.

 

[Noyac]

Like it or not, there are hospitals and anesthesia departments where these types of requests can be problematic. Private practice groups in particular, especially those that function in an ACT mode, may not have the flexibility to accommodate MD-only requests on the day of surgery. Like many practices, we run very lean - every single anesthesiologist and anesthetist has specific assignments on any given day. We can handle these requests when planned for in advance - doing so on the day of surgery would be difficult to say the least. It's not a question of who is best or most appropriate. It's a logistical issue plain and simple.

And BTW, this topic has been hashed and rehashed a number of times on SDN - the only difference here is it's a pediatric case.

Just because this topic has been hashed out doesn’t mean it isn’t relevant. This topic needs to be addressed more in my opinion.

 

[anbuitachi]

Not sure i completely agree with this one. While i agree with choosing MD over CRNA due to the large differences in fundamental and advanced training, it seems like some of these posts have moved onto a general vs specialty selection. I think the right thing to do is to assign the appropriate person to the case. While everyone wants the best and most qualified (and it is certainly fine to ask for it), patients are not the best at determining need. It'd be a waste of resources to supply a overqualified person to a simple case. I think that is why in medicine there is the referral model. You go to your PCP first and if the PCP determines that a specialist would be best for the patient, then he/she gets referred to one. Should all patients be allowed to simply go to a rheumatologist for every knee pain they get? I mean obviously if you have rheumatologists sitting around left and right sure, but that's probably not the case in most groups.

At our hospital if the patient wasnt OK with resident/fellow, and wanted attending only, then we tell them it's a teaching hospital

 

[jwk]

Just because this topic has been hashed out doesn’t mean it isn’t relevant. This topic needs to be addressed more in my opinion.

I have no issue with a patient requesting a physician anesthesiologist. I'm simply pointing out that there are logistical problems inherent in those requests in some practices. My guess would be that it's easier to accommodate in an an academic environment than private practice.

As far as pediatric anesthesia cases specifically - these types of cases by their very nature are "team" cases. I can do an adult anesthetic start to finish without the involvement of another person (illegal in my case, but just for argument's sake). That is not the case with a pediatric case, because someone else is going to have to do something with that patient. I can't manage their airway and start the IV by myself. Someone else will have to start the IV, or hold the mask (poor choice). In a care team environment, there will always be two anesthesia professionals involved. In many of our rapid fire ENT cases, there are two in the room the entire time, because it's virtually impossible for a single person to do everything (airway, IV, drugs, charting, etc.) during the actual case time. So even if it's a board-certified MD-provided pediatric anesthetic, somebody else will have to be involved - nurse, resident, anesthetist, another MD, whatever.

 

[nimbus]

As a general rule, within whatever network they are in, patients can choose their doctors. I don’t see why anesthesia is any different. It’s like going to a primary care office and asking to see the doctor instead of the NP. Is this any different?

When I was a resident, our chairman had a series of procedures for a bad knee. In each instance he hand picked an attending to take care of him solo. Why shouldn’t everyone have that option if it is their preference?

 

[pgg]

When I was a resident, our chairman had a series of procedures for a bad knee. In each instance he hand picked an attending to take care of him solo. Why shouldn’t everyone have that option if it is their preference?

There’s an additional element: that patient was a staff member. The issue here isn’t simply one of competence, safety, or quality of care, but also privacy. It’s entirely reasonable for staff members to want to minimize the number of colleagues, superiors, or subordinates involved in their health care.

 

[narcusprince]

Pgg,
For once I disagree with you. I would have done the case solo. The resident will understand one day they will be an attending and grant the same. It really upsets me that due to some schedule randomness that our patients could have a crna or physician. This is not setting a standard of care.

 

[Twiggidy]

I wonder how often a surgeon is told by a patient “I dont want a resident on the case” and I wonder how often the surgeons accommodate

Full disclosure, this happeneded to me in training when I preoped a patient who was chewing gum and I told her her case may be delay. She demanded an attending do the case and I was switched to another room. (actually i think she demanded another anesthesiologist) anywell, they didnt delay her, it was a potential LMA case that turned into an intubation, and then I did some stupid case and went home afterward

i lost respect for my attendings at that point because i realized they didnt stick up for their residents in order to save face. i think i was either late CA2 or CA3 at the time

 

[zero0]

Smart mom. If you have inside knowledge it's more a matter of knowing who to avoid. But if you have no inside information what she did is reasonable. But I wouldn't make that part of a preop. Any reasonable person would ask for an experienced attending with a great reputation. That would be a scheduling nightmare. Don't go asking for problems.

Why not check with patients well in advance then if they would prefer a physician or nurse? I think we all know who'd they pick and that ultimately it would be impossible to accommodate everyone's request. Depending on demand it may even become necessary to replace all CRNAs with physicians to meet the patients' needs Who knows, maybe if it seemed like patients appreciated physician anesthesiologists at the hospital we'd even be given some, gasp, leverage?! Come to think of it, this seems like an innocuous way to tip the odds in our favor. I would even suggest politely bringing it up to the administration that you're tired of last-minute scheduling conflicts arising and that it would be good to check with patients in advance of scheduling their surgery. They will of course prefer anesthesiologist overwhelmingly and help feed the cause. Patients get to decide on their care. We show everyone anesthesiologists aren't nurses. Everyone wins.

 

[deleted171991]

At our hospital if the patient wasnt OK with resident/fellow, and wanted attending only, then we tell them it's a teaching hospital

Good luck with that! Those times are going away. Even teaching hospitals can't afford to lose customers anymore, especially those with commercial insurance. For example, my specialist knows that I am not there to chat with his fellow, hence he sees me alone. I think that's perfectly normal. The fellow could sit in and listen, as far as I am concerned, but I don't care about him more than I care about the furniture.

 

[Psai]

Good luck with that! Those times are going away. Even teaching hospitals can't afford to lose customers anymore, especially those with commercial insurance. For example, my specialist knows that I am not there to chat with his fellow, hence he sees me alone. I think that's perfectly normal. The fellow could sit in and listen, as far as I am concerned, but I don't care about him more than I care about the furniture.

Then your doctor dies and there are no good ones left because divas like you refused to help them train. I guess you could see the np from then on, I heard they are just as great if not better.