Wednesday, January 4, 2012

Why Surgeons Don't Understand Anesthesiologists

We anesthesiologists consider ourselves men and women of science. We went through vigorous years of study in college, medical school, and residency training to earn the privilege of administering drugs that literally put patients into controlled states of coma. Yet anesthesia, like much of medicine, is really an art. No matter how many times one reads about Fa/Fi ratios, cerebral perfusion pressures, or GABA receptors, the skills required to be a successful anesthesiologist take years of clinical practice to develop.

Anesthesiologists in particular seem to be very individualistic in their methodology. While there are all sorts of guidelines to aid in treatment of ailments like acute MI, stroke, or diabetic ketoacidosis, there are few studies to prove that one mode of anesthesia is safer than another. In an editorial in the January 2012 issue of Anesthesiology, Dr. Sachin Kheterpal from the University of Michigan School of Medicine writes a very insightful view of anesthesiologists and why there is so little uniformity in our practices:

Although firmly rooted in science, the field of anesthesiology has had a bias toward the art of medicine. There is a strong individualism component to the practice of anesthesia, with providers spending long and lonely hours behind the surgical drape. Unlike surgeons and medical specialists who constantly direct a team of operating room and floor personnel, anesthesiologists are often a one-person team. This leads to clinical creativity and diversity, with a resulting abundance of epidural anesthesia "cocktails" and airway management techniques. Because the anesthesiologist is at the point of care making and executing second-to-second decisions, there is limited institutional oversight or checks and balances of anesthesiologist decisions. All in all, what our field lacks in randomized controlled trials, we make up in "random clinical decisions." Even during a single operation, the hemodynamic and pain management techniques may completely change as a result of provider handover.

Whenever I take over a case from another anesthesiologist, I rarely continue the exact same method of anesthesia. I may decide that I'd rather use sevoflurane instead of desflurane. The previous anesthesiologist may have used a combined technique of inhalational agents plus propofol infusion while I may feel to use only gas instead to provide anesthesia. I may lower the patient's tidal volume setting to decrease the peak airway pressure and increase the respiratory rate to maintain minute ventilation. Does that mean that I'm a better, or worse, anesthesiologist than my colleague? No.It just means there is more than one way to provide the same level of safety and care to the patient. Again, think of anesthesiology as an art. If you ask ten artists to paint a bowl of fruit, you'll get ten different paintings but they are all ultimately the same bowl of fruit. Same thing with anesthesia.. Ten different anesthesiologists will administer anesthesia ten different ways for the same case but the ultimate goal of patient safety still remains.

So to answer the question, "Why don't surgeons understand anesthesiologists?" the answer is that because there is no one correct way to give anesthesia. While one anesthesiologist may recoil at giving anesthesia to a patient with a potassium level of 5.8, another anesthesiologist will plunge right in.  Whereas one anesthesiologist will give propofol sedation to a morbidly obese patient with sleep apnea, another one will insist on first intubating the patient via awake fiberoptic. So it can be hard for surgeons to understand why they can bring a particular case to the O.R. one day then on another day a different anesthesiologist will insist on a preop medical clearance and stress echocardiogram. Like artists, we anesthesiologists have individual visions of constructing a work of art. But please bear with us; the ultimate goal is still the same: to ensure the safety of the patient as we guide them through their surgical procedure.


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