Attitudes: Surgeon and Anesthesiologist

Let me preface this post by saying I have a great deal of respect for surgeons and anesthesiologists. I entertained thoughts about both specialties and believe I would have made a great surgeon, but having decided to go to the other side of the blood-brain-barrier I have to make some effort to respond to these comments seen over at Dino's blog:

Hey you want that lab, you order it and deal with the result before you screw up the surgery schedule for everyone including the patient! I wonder how many anesthesiologist's are only children (I had to reply to this comment with the surgeon temper tantrum - children indeed)?

To this day I remain dumbfounded at how an anesthesiologist can walk into a room cold, review some pertinent facts on a patient and decide that administration of anesthesia won't be problem.

Having done a couple anesthesia months allowed me to see a little into the surgeon-anesthesiologist contest that constantly occurs, often behind the smoke and mirrors of surgical holding areas where patients sit anxiously awaiting. Most patients probably don’t even think about the anesthesiologist until they meet them right before they head back for surgery. Their surgeon is often the only doctor that they’ll remember from the entire event – unless something goes wrong and they try to sue everyone – but they don’t realize that the interplay between their surgery happening and staying alive during the case is often held in the hands of the “Gasman” and not the surgeon.

You see the anesthesiologist is often considered the “internist of the OR”. They check out patients the night before if they’re inpatients or review their history prior to the first meeting in order to optimize their anesthetic plan. This is done in order to understand what direction to take, what drugs to be wary of, whether another induction agent should be used over “white magic”, the medical illnesses a patient has that might need more attention in the OR, or if there are conditions that need to be evaluated further prior to anesthesia being delivered.

They are responsible for keeping the patient alive, not the surgeon (despite surgeons notoriety for saving people’s lives), and there are sometimes tests that have to be performed or evaluations done before surgery can commence to reduce morbidity or mortality. The problem that many surgeons have, at least from what I’ve seen, is the seemingly arbitrary demands that an anesthesiologist may have for a patient evaluation.

Well, it's a little more complicated than these two surgeons assume. Let's consider a 35 year old patient who is scheduled for an elective procedure related to gallstones. In the H&P the surgeon notes a congenital abnormality of the spine, but does not follow up more. The anesthesiologist reviews the abnormality the night before when they receive their case assignments, realizes that the location involves the cervical spine with potential for disasterous outcomes during intubation, and sees that the last check on the C-spine was over 2 years ago.

Had an anesthesiologist been able to see the patient in their preop clinic they could have anticipated the demand more than a surgeon concerned more about the chole and had a C-spine evaluation performed. However, because this outpatient surgery center or hospital doesn't require this before surgery the anesthesiologist often times only has the night before to be even aware of the cases scheduled and must attempt to obtain labs and other tests the day of surgery. The surgeon, however, sees only a delay and the lazy gasman as the cause.

This situation can be extremely frustrating to all involved, with the surgeon wondering how anyone can cancel or delay a case when only “seeing the patient for the first time and only for 5 minutes”, the patient is upset, hungry, and bewildered as to the delay, and the anesthesiologist wonders why in the hell this patient wasn’t properly preop’d as he's scapegoated by all involved.
Some surgeons call anesthesiologists lazy bums because of the belief that they sit and read or simply “watch the surgeon work”. There are some surgeons who believe, honestly, that they can administer anesthetics and operate at the same time. What they don’t understand is the fact that if it appears this way, then the anesthesiologist is doing their job well.

A patient who is tolerating anesthesia and has a rather stable operations is not just an everyday occurrence as many people believe – it requires diligence, understanding of complex physiology and pharmacology, and the training to maneuver through complications seemingly with ease. Just as an anesthesiologist shouldn't pretend to know how to perform surgery a surgeon shouldn't assume they know how to deliver anesthesia.

I’ve seen it go bad, though, when the patient crashes, things are going wrong, and the surgeons look wide-eyed as the anesthesiologist attempts to combat the grip of the reaper - sometimes after a completely uneventful operation. At these times the surgeons may offer advice, but more often than not they stand back and watch. Many times these events were unexpected, but occasionally there are hints that were overlooked in the original H&P that could have steered the anesthesiologist on a different course to avoid complications.

This has lead some hospitals to require preop evaluations by both the surgeon and anesthesiologist, since they often have differing needs and questions prior to surgery and this maximizes good outcomes. However, at least at the academic settings I've been involved, the cases are not listed until the late afternoon or early evening, are subject to change and add-ons, and often leave the anesthesiologist in the dark if the patient didn't get an anesthestic evaluation.

Of course both fields are necessary for surgery to take place and it would behoove all involved that the two fields work together. Yet, more often than not, surgeons consider anesthesiologists as part of their OR team, and therefore beneath them while some anesthesiologists refuse to cater to this demeaning attitude and believe that they are the primary since they manage the patient while the surgeon “fixes a problem”. Both lines of thought are, of course, erroneous, but continue to persist.

What I have seen, though, is that there are residents in anesthesia who jumped ship from other specialties. Often times a surgical intern or second year resident realizes their folly in entering surgery and comes to the other side. More often than not I saw people coming to anesthesia rather than abandoning it for greener fields which speaks volumes of a specialty. I actually think that there's a lot of bitterness on the surgeons part - for whatever reasons - that leads to some of their attitudes.

The reason for writing this, in part and beyond the comments read at Dino's, is because of a couple of my friends stuck to general surgery as their residency of choice while I went another way. Sometimes they’ll poke fun at my decision with the occasional “did the patient get antibiotics?” or “table up, please!” commands while we're hanging out. I often will reply “I’ll do it when I’m damn good and ready!" or "whatever, you don’t order me around!” Of course this is all done in fun, but hopefully this isn’t a sign for our attitudes later in our careers – that would be just sad.