Tuesday, May 18, 2010

Gastroenterologists and Anesthesiologists--Can't We Just Get Along

A couple of days ago, I mentioned the antagonism shown to Dr. Alexander Hannenberg, president of the ASA, during his presentation at the DDW.  He was trying to lay out his reasoning for why anesthesiologists alone should provide propofol sedation during GI endoscopy.  This naturally didn't sit well in a room filled with hundreds of gastroenterologists. I feel that this animosity is more motivated by money than any legitimate medical reason.  So let me present some logical reasons why anesthesiologists and the use of propofol should be used in every endoscopic procedure.

Improved patient compliance.  Patients' worst fears and the reason many avoid needed endoscopic screening are the perceived pain felt during the procedure.  They hear horror stories about how uncomfortable the procedure is from friends or recall bad memories of previous endoscopies.  But once they've experienced a screening with propofol sedation, many are effusive with praise.  When they wake up, they can't even believe the procedure is already finished.  They have no further hesitation for future endoscopies and highly recommend to their friends and family the virtues of propofol sedation.  Thus more procedures and money for the gastroenterologists.

Improved examination.  When the patient is well sedated with propofol by an anesthesiologist, the patient has minimal movement compared to a versed/fentanyl moderate sedation.  The gastroenterologist is free to take his time to examine the GI tract thoroughly at his leisure instead of telling three people to hold the patient down before he falls out of bed.  A better examination leads to a better reputation which leads to more referrals, which again means more money for gastroenterologists.

The gastroenterologist can concentrate on his exam.  Two sets of eyes watching the patient during a procedure is better than one.  Sure a nurse can give the sedation and chart the vital signs and assist the doctor and monitor the patient's airway for impending obstruction.  But isn't it safer to have another physician who is a trained expert in all those activities in the room?  If the patients loses his airway and codes, guess who is going to get sued? The sedation nurse and the gastroenterologist.  And the nurse's lawyer will punt the responsibility to the MD in charge of the room.  If an anesthesiologist was present the GI doc's lawyers could legitimately say that the airway is not his concern and is the onus of the anesthesiologist and we would agree. Why does an endoscopist want to risk a malpractice lawsuit from a patient that becomes hypoxic and possibly get an MI, stroke, or even dies on the table when there are plenty of anesthesiologists willing to help out to prevent such a tragedy? Fewer lawsuits, more money.

As you can see, there are plenty of monetary incentives for GI docs to use anesthesiologists in the endoscopy suite.  There are now papers that document increased satisfaction from patients and endoscopists with propofol sedation.  In this era of evidence based medicine, the gastroenterologists should abandon their traditional ambivalence and embrace anesthesiologist-administered propofol for endoscopy.

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