A
Novel Thought?
Hospital turns toward service
Response prepared to national medical errors report
ROSENSTOCK: What happened six years ago was that financial payment to anesthesiologists dropped so groups tightened up and, for about two years, residents had a little trouble getting jobs. But there are only so many hours in a day, and soon people began rehiring. It's true that people get paid a bit less now.
Q: Lynn, do you work with residents?
ROSENSTOCK: Our group doesn't - that's the choice of the department. But we do work with medical students and some of the podiatry residents.
Q: What sort of medical students choose anesthesiology?
PEARL: Most of the people who go into anesthesia like the acute high intensity. Contrary to a stereotype, I think most of us do like dealing with people but you have to compress the whole lengthy encounter of trust building, etc., into five or 10 minutes with patients before surgery.
KRANE: Actually, anesthesiologists have to have very good people skills. Yes, there may be a few people who go into anesthesia because they think they don't need to communicate, but those people are usually weeded out of programs pretty rapidly. Besides the need for establishing rapid patient rapport, we're members of a team in the operating room and must get along with surgeons, other physicians and a large number of staff people. Other qualities? We tend not to enjoy deferred gratification. We're very goal-oriented: identify a problem, act on it, know within seconds or minutes whether or not your action was appropriate. If it wasn't, you change to a backup plan. The whole process is over in two hours and, hopefully, you've attained your goal.
ROSENSTOCK: We have a defined period of time to work in. There is a start and a finish, unlike the open-ended experience an internist often must deal with. And the other thing that is true of anesthesiologists - and that is absolutely critical - is that you need to be able to change gears from first gear to fifth instantly.
Q: How are anesthesiologists different from surgeons?
ROSENSTOCK: I think we're more fusion people. We like medicine more than surgeons do and we relate to surgery more readily than internists might.
Q: You are in charge of the operation, are you not?
ROSENSTOCK: Yes, and I think most surgeons realize that. Certainly we do and the nurses do. When something critical happens we start orchestrating things more and more - we need to take care of the whole patient while the surgeon concentrates on the procedure.
KRANE: One of the things that I try to teach the residents is the care and feeding of the surgeon. What surgeons want to be able to do and what they deserve to be able to do is focus on the operation. Overall, a good anesthesiologist needs to bring confidence to the room.
Q: Does Stanford use nurse anesthesists?
ROSENSTOCK: There have been some in the past in ancillary areas, such as supervising anesthesia techs.
Q: With easier-to-use anesthetics, would it not be easier for nurse anesthesists, surgeons or other specialists to administer anesthesia?
KRANE: I don't think the drugs are easier to administer, but often times have a faster onset or offset which in our hands make them more titratable. Although some of our newer drugs have a large margin of safety - especially some of the inhalation agents - many others have a smaller margin of safety because they have an easier ability to cross over from not enough to too much.
Q: But aren't at least some of the agents now regularly being used by non-anesthesiologists?
KRANE: Yes, that is occurring some places but it's highly controversial, and it's certainly not endorsed by the manufacturers.
PEARL: I think those of us who do anesthesia on a daily basis find that there are always unexpected occurrences that we need to react to. I feel confident that we will manage the things that come up. These, I think, do require the entire range of knowledge and skills which as anesthesiologists we're taught through training.
KRANE: Right now the estimated mortality rate for healthy patients undergoing elective anesthesia is approximately 1 in 250,000. Even a moderate increase in that rate would be hard to track statistically, so evaluating subtle differences in quality or performance among categories of professionals is difficult.
Q: What is your department's relationship with the critical care units?
PEARL: The American Board of Anesthesiology requires that every anesthesia resident spend two months in intensive care during their residencies. They frequently spend more. It's essentially the only timed requirement. And we provide clinical care in the ICUs here.
KRANE: A lot of the care we provide in the operating room is similar to what we do in a critical care unit. If an ICU patient is taken to the OR for surgery, the anesthesiologist has to continue all of the treatment modalities. If a patient requires critical care, it often begins in the OR. That's why anesthesiologists like to refer to themselves as perioperative physicians.
Q: Do you work in outpatient settings?
ROSENSTOCK: We work in outpatient surgery centers and some of the people in our group are doing office-based anesthesia, which is one of the new up-and-coming fields. This includes going to dental offices to give anesthesia for pediatrics, going to dermatologist and plastic surgeon offices. There has been a lot of bad publicity about the risks of office-based anesthesia. When our anesthesiologists work in the office setting, they make certain that they comply with the standards and regulations of California law. Our anesthesiologists ensure a very high level of service and make sure that procedures are very safely done. Some patients initially deemed to be candidates for office-based procedures are not medically suitable, and they have their procedures done at Stanford Hospital instead.
Q: What trends are important to your field clinically?
PEARL: Laryngeal mask airway (LMA) allows us to avoid placing intratracheal breathing tubes in a large number of patients. This has tremendous benefits clinically. It helps us manage an airway better and more effectively. It's widely used except in thoracic and abdominal cases, where we need to isolate the lungs from the G.I. tract, or in long complicated cases.
Q: Research?
KRANE: It's really interesting that after 154 years since the first use of ether we still don't know how the drugs put people to sleep. But we're getting closer. Faculty members Edward Bertaccini [assistant professor] and Jim Trudell [associate professor of chemistry in anesthesia] are looking at this issue, including molecular mechanisms of anesthesia. Another research trend is the application of molecular biology to anesthetic problems. Probably the best example of that in a laboratory is Dr. [assistant professor Rona G.] Giffard's laboratory looking at brain ischemia and how we can intervene. Molecular biology techniques are also being used to understand general anesthetic techniques. Dave Clark [acting assistant professor] at the VA is working on opiates. That's all in the same category of understanding how these agents work and how we become tolerant to them.
ROSENSTOCK: Understanding narcotics is important for postoperative management as well as in chronic pain management.
PEARL: In the area of pain there are truly new drugs and new techniques to allow us to treat chronic pain patients in ways that just have not existed before. Clinically there is always research on better drugs and in the ICU we are always looking at answers to specific problems such as sepsis and respiratory failure. Simulation, led by David Gaba and his group at the VA, is important in both education and research. Simulators have changed training.
Q: How?
PEARL: In July, new residents basically spend their first day on the simulator where we'll be able to show them realistically what an operating room is like and also give them the experience of dealing with common problems such as low blood pressure, etc.
ROSENSTOCK: But we can use the simulator throughout our whole lives. I've been a couple of times. The thing that it does so wonderfully is it simulates the very unusual disasters that we face in anesthesia. We have to be prepared to handle situations such as malignant hyperthermia, but you probably will never see such a case. Or what do you do when the electricity goes out? We have protocols for these issues which we read every year, but do we really remember them? I think the scenarios are realistic. And they always come up with something you didn't think about.
KRANE: You suspend reality pretty quickly. You need to in order to be fully prepared in the incredibly fast-moving OR anesthesia environment.
Q: Isn't it unusual to have three groups providing services in the same institution?
PEARL: Yes. I don't know of another medical center where this occurs. It stems from the agreement between Stanford and Palo Alto more than 30 years ago, which created a joint university-community hospital. The arrangement creates some efficiency challenges, including multiple on-call lists and coordinating separate block scheduling. One of the most significant challenges in the university service is building a service that's large enough to make sure we have a critical mass of physicians to cover all of the subspecialty areas as well as routine services.
Q: Does the "town-gown" paradigm make for better practice?
PEARL: We are as good as any academic medical center because, quite frankly, we have to match the service levels expected in private practice. At most academic medical centers the entire anesthesiology service is captive.
KRANE: I think in general, relationships in a private practice setting tend to be more collegial than in a university practice because people are more financially beholden to their colleagues for success. In private practice, if an anesthesiologist acts contentiously, then the surgeons will stop using that anesthesiologist. In a university setting, if you act disrespectfully toward other people, you still get your paycheck. I think having the private practice people in our operating rooms sets a tone of high service. Conversely, I think private practice anesthesiologists gain from being part of this state-of-the-art environment. The private practice people come to the university conferences, and there is an intellectual give-and-take in the operating room. We have a symbiotic relationship that takes the edge off what otherwise might be competition.
ROSENSTOCK: I definitely feel that our slightly different experiences and philosophies bring out the best in each other.
PEARL: I'd like to add that Lynn's group (AA) and the Palo Alto Clinic are very much part of our department - actively participating in our conferences, our quality assurance process and most department matters.
ROSENSTOCK: There is more of this interaction now than in the past, and we appreciate that. There have been times when relations at the top level were not very friendly, although at the bottom level the relationships have always been friendly. One of the things that helps make the relationship cordial is that we help each other out when the emergencies and workload swings become greater than any of us have been able to staff for.
KRANE: There is a lot of cross-fertilization. For example, we reimburse Palo Alto Medical Clinic for the time we get help from Charles Wang, who works every Monday as part of our pediatric anesthesia team. He completed a fellowship at UCSF and went to PA Clinic last year. Mark Singleton, who's in private practice in San Jose, comes and volunteers a day a month with us. He is a superb clinician and I think the residents really enjoy working with him. These individuals bring a valuable perspective to the educational arena and are valuable contacts for residents as they begin to think about jobs in the future.
Q: How do things stand with the downtown surgical center?
ROSENSTOCK: It's scheduled to open in May. We should have similar block scheduling as we do here.
Q: Is block scheduling working well?
ROSENSTOCK: Operating room time is something we all feel strongly about. We'd all like to have more operating room time. The blocks are revised every year. But the Surgicenter will give us four extra operating rooms, and that should help.
Q: Other than colorful hats, what's special about pediatric anesthesiology?
KRANE: The social interaction is quite different. We must allay the fear and anxiety not just of the child - which is enormous - but of the parent also. When we do a good job, I think that's what parents remember most about the whole hospital experience - at least according to a lot of the letters that I receive. Secondly, a child's smaller size creates some technical challenges, including rapidly occurring medical events and a smaller margin for discretion or error.
Q: Are there any special features of your pediatric program?
KRANE: The majority of our children who are undergoing chest, abdominal, orthopedic or certain other surgeries receive a regional anesthetic in addition to a general. In adults, I believe the percentage is substantially less than 50 percent. We would virtually never think of doing a thoracic operation in a child without a thoracic epidural line in place to provide two or three days of postoperative analgesia. I think we're much more aggressive with regional anesthesia and pain management postoperatively than most other places.
Q: Why is this not used on the adult service?
PEARL: We actually are significantly expanding our use of regional anesthesia for adults. This may have not been done in the past, perhaps, because of the belief that pain in adults is easier to manage psychologically. And frankly, adult anesthesiologists have generally not been taught regional anesthesia well. I think also on the adult side we have more pressure to get cases rapidly turned over. However, I think in the past year we have found ways to combine both regional and general anesthesia effectively to minimize the time between finishing one case and beginning another, most notably by adding an additional attending physician and resident to concentrate on regional anesthesia. In some cases we use only regional anesthesia, which offers a number of benefits, including time efficiency and reduction of potential adverse effects.
Q: Adverse effects? Isn't anesthesia improving continually?
KRANE: Yes. The drugs available in the past 10 years have improved enormously. They have fewer side effects, are much more rapid in their offset and have a much larger margin of safety as well. By the way, it's unfortunate that there is less drug development going on now, perhaps because the drugs have become so good but also because drug companies may see economic challenges to drug development.
PEARL: I think there have been two big improvements. Safety, as Elliott mentioned, is central. At this point there is no significant mortality, and probably very little morbidity related to anesthesia for almost everyone. So we are able to operate on much, much sicker patients much more safely. That's related to the development of better drugs, better monitoring and even better anesthesiologists. Side effects such as nausea, vomiting or feeling hung-over are minimized. The new drugs also wear off much faster so we are able to get patients out of the operating room, out of the recovery unit and feeling better in a way that we couldn't have 10 to 20 years ago.
KRANE: Of the 5 to 10 drugs typically administered to each patient, only two of them were available 10 years ago.
Q: Are there any particular drugs you can name that have made a major difference?
KRANE: Propofol [Diprivan] is the drug that most people would point to. It has at least two major properties. One, is it's much shorter acting than the other drugs. Second, its side effect profile is very different. Propofol actually counteracts nausea and has been used for that treatment.
Q: Are the payors happy about these shorter-acting drugs with fewer side effects?
KRANE: That's hard to determine because the new drugs are expensive. The hospitals and the HMOs put a great deal of pressure on the anesthesia department to limit drug costs. So for example, using pentothal to put someone to sleep is a fraction of the cost of using propofol - $2 vs. about $20 a dose. It's difficult to demonstrate to a payor or even the hospital the benefits of having a patient wake up feeling good. And there's probably not a significant difference on how quickly patients get out of the recovery room and back on the street. So there isn't a large savings difference. But to the individuals using or receiving the drugs there is an enormous difference.
PEARL: The department working with the pharmacy has spent a lot of effort to responsibly control costs and to figure out when some of the more expensive drugs have benefits that are worthwhile and in what settings they don't.
Q: Are young doctors interested in anesthesiology careers?
PEARL: About five years ago there was a perceived excess of anesthesiologists, and I think medical students were counseled by deans and advisors nationally not to apply for anesthesia residencies. Applications plummeted to less than a quarter of where they had been. It resulted in the closure of many residencies although I think the strongest programs survived. But the demand, despite expectations, markedly increased. We've found that surgery has not gone away and that managed care has sometimes deferred but not reduced the volume of service. Surgery volume is actually increasing and groups are trying extremely hard to hire anesthesiologists. Anesthesiology training is desired by students and training program applications have quadrupled in the past two years. We had about 250 applications for 15 positions this year, and the same trend is occurring nationally. We are seeing an increase in both the quality and quantity of students interested in anesthesia. But there is a five-year lead time, so for the next five years we're anticipating a major shortage of good anesthesiologists.
