Thursday, November 21, 2013

The ABA Made Me Do It

The American Society of Anesthesiologists recently published a list of procedures and practices that they feel have been overly used and abused. Among the items that the organization advises doctors to minimize is the compulsion to draw routine blood tests on young healthy patients, blood transfusions for patients who are young and hemodynamically stable, and the use of cardiac stress tests or pulmonary artery catheterization in low risk patients for procedures that will produce minimal cardiac disturbances.

This all sounds pretty commonsensical. I've had many conversations with our surgeons who insist on getting a full preop workup on young patients prior to a relatively benign operation. Just the other night, I received a young patient from the ER for a laparoscopic appendectomy. He was less than 40 years old. His H+P consisted of "No previous medical history" and "No previous surgical history". Yet the ER had drawn a complete metabolic panel, coag studies, and performed an ECG. Why do surgeons continue to request all these tests when it's so obvious that most are unnecessary and a waste of money?

The simple answer is that surgeons hate to have their cases delayed or cancelled because the anesthesiologist wants one more test before clearing the patient for a procedure. By painful and frustrating experience, almost all surgeons become habituated to overtesting their patients just so they can be sure that the anesthesiologist doesn't have any excuses to cancel a case and ruin everybody's day.

This leads to the question of why some anesthesiologists want so many studies before they will take a patient to the operating room. While I don't have direct knowledge of why some people do what they do, I submit that a fundamental reason for this action is because we were all horribly traumatized by the American Board of Anesthesiology during our oral examinations prior to receiving our board certification. Virtually every anesthesiologist remembers the horror story of that experience. You study for months at a time, spend thousands of dollars on board prep courses, then fly to a city far away to get grilled by four distinguished strangers for nearly one hour straight on esoteric subjects you hope you will never encounter in real life.

As part of this examination, you are asked by the executioners, er I mean examiners, what kind of lab work you want before allowing a patient into the operating room to continue the exam scenario. Almost automatically we all want to have every blood work and cardiac exam possible. It is so much easier to get every lab done before taking the patient to the OR than to discover that you missed a crucial piece of information once the patient goes under the knife. Heaven forbid that the patient starts bleeding out on the OR table because you didn't think the patient needed a PT/PTT and it turned out she has a Factor XI deficiency. Now you're stuck with an unstable patient in the OR with no clue as to why the patient is oozing from every cut surface in the body, and most likely you also didn't bother getting a Type and Cross to the blood bank too. FAIL.

You'll have nobody to blame but yourself if on the physical exam in another hypothetical preop you hear a heart murmur and the patient says he's had mitral valve prolapse for years but is asymptomatic and you don't do anything about it. Then during surgery the patient becomes unstable because in reality he has severe mitral regurgitation and pulmonary hypertension. At that point you are scrambling to save your skin by calling for an emergency TEE instead having an echo done before surgery and hoping you still have a rat's ass of a chance of passing this exam, which you probably don't.

What about all the expenses and potential complications of performing so many tests on patients who most likely don't need them? Well, in these simulations, cost is never a factor. You may have to justify the need for a test based on your examinations, but money is never an excuse. As a matter of fact, if you omit a test because you say the cost doesn't justify the benefits, you will unerringly be led down a path where you absolutely should have performed that preop test but now it's too late and the patient died on the table. And it will be ALL YOUR FAULT, you penny pinching board failing loser.

So it is understandable why some anesthesiologists continue to be haunted by the what ifs in their daily practice. After being scarred for life by the ABA, it just makes sense that most anesthesiologists will want multiple preop tests performed with little regard for necessity. It is simply better to be safe than sorry. If anybody complains about the expense, tell them to take it up with the ABA.

1 comment:

  1. Your analysis is reasonable, as far as it goes, and would explain a lot of defensive behavior on the part of anesthesiologists in their daily practice. The problem is that there are many jobs and professions where the rigors of formal training must be laid aside in deference to the practical knowledge generated by real life, day-to-day experiences. The public doesn't want doctors to be practicing out of a textbook. And no one wants their death-row lawyer sounding like Prof. Kingsfield when a scrappy pro who "knows the ropes" is needed. Cut the apron strings; you're on your own now!