I bumped into one of my partners in the Recovery Room. She appeared quite exasperated and peeved. I asked her what's wrong. She said she just had an argument with her surgeon when she cancelled one of his cases. The patient was scheduled for an elective shoulder arthroscopy in the beach chair position. He had multiple medical problems and was seen by a multitude of consultants for preop clearance.
Among the patient's many medical conditions, he complained of ataxia. A carotid duplex showed carotid stenosis. The consultant's note simply said the patient needs to have this addressed before his shoulder surgery but to go ahead and do a gentle intubation to prevent neck extension if the surgery was felt to be urgent. Nowhere in the consult was there a mention to cancel the surgery until the carotid artery stenosis was corrected. My friend was perplexed. She called up the consultant to ask about this unhelpful consult. The doctor told her that the surgeon was very aggressive and refused to listen to his verbal recommendation to cancel the case. Therefore he only wrote in the precautions and left it up to the anesthesiologist to cancel if she felt strongly about it.
Well she did feel strongly about the patient's safety. The surgeon would want deliberate hypotension with systolic blood pressures in the 90's during the procedure. Hypotension combined with carotid stenosis and the patient's symptoms of ataxia spelled c-a-n-c-e-l for her. She talked to the surgeon, who was furious. He pointed to all the preop clearance notes he had gotten for the patient, none of which recommended cancellation. The patient was likewise unhappy. He had taken time off from work to have his surgery done and made arrangements for after-surgery care. He wanted an immediate second opinion, which was impractical for this nonemergent operation. My partner stood her ground and cancelled the case.
Ultimately anesthesiologists have to worry about one thing only, and that is the patient's health and safety. Preop clearance notes can be worthless. If an aggressive surgeon does not like a conservative consultant, he'll refer all his future cases to somebody else who will approve his cases. It is up to the anesthesiologist to be the gatekeeper into the operating room and stop any elective surgeries that can cause serious harm to the patient. That is why surgeons hate anesthesiologists.