Wednesday, October 13, 2010

You Expect Me To Examine My Patients? I'm An Anesthesiologist.

Do anesthesiologists perform physical exams? And is it necessary? These questions came up when I read a really interesting article about Dr. Abraham Verghese in The New York Times. This Indian born doctor's mission is to reintroduce the art of the physical to Stanford's medical students. In an era when no patients make it out of the emergency room without a CT scan, the idea of actually examining a patient seems quaint and antiquated.

We anesthesiologists are probably the worst physicians at doing an H+P (except maybe pathologists). In fact, I rarely see anesthesiologists with a stethoscope around their necks. The difference for anesthesiologists is that by the time the patient makes it to preop, the patient has had at least one, and frequently multiple H+P's in the chart. Besides the primary care doctor's, there's a physical by the surgeon and probably physicals by the cardiologist, nephrologist, ID, pulmonologist, etc.. What could anesthesiologists possibly add to the patient's workup that was missed by all these subspecialists' probing exams? Sure if the patient shows up orthopneic, wheezing, with an O2 sat of 91% on 6L face mask I might dust off my stethoscope and listen to the chest. But if the patient is a young healthy adult for outpatient surgery, do you expect me to do an independent H+P that will be substantially different from what's already in the chart? I'm more likely to browse through the history, glance at the labs, and wheel the patient to the OR than to slow down the turnover time by percussing the chest and palpating the belly for virtually zero gain in patient safety.

Anesthesiologists are probably one of the guiltiest physicians for demanding multiple lab tests be performed in place of the physical exam. Does it make sense to order an ECG on an otherwise healthy 56 year old even if the guidelines are anybody over 50 gets an ECG before receiving an anesthetic? Do surgeons reflexively order CBC, Chem 7, PT/PTT on young healthy patients because they fear their case will be cancelled by the anesthesiologist if everything is not in the chart? Is it logical that chest x-rays are frequently ordered and not seen by anybody just so the surgeon can tell the anesthesiologist that a CXR was completed?

Yes there is the rare occasion where I discovered a poorly controlled atrial fibrillation taching away at 135 beats per minute in preop.  But more often than not this will be found by the nurse during her preop documentation. The combination of a surgeon's history and the nurse's examinations appear to be sufficient for most anesthesiologists to proceed with a case without physically examining a patient. Sloppy? Yes. Dangerous? Probably not. However, as Dr. Verghese points out in the article, the laying of hands on the patient forms a sacred bond between physician and patient. When anesthesiologists skip this crucial step, it reinforces in the public's mind that we aren't really doctors.  Thus we are reduced to little more than stereotypes like "gasmen" or "gas passers". Or, horrors, nurse anesthetists.

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