Bigger Is Better, Even In Anesthesia

This is a cautionary for all anesthesia practices and residents evaluating anesthesia groups to join after graduation. Olean General Hospital in New York has just informed its anesthesia providers, Southern Tier Anesthesiologists, that it has decided to go with a different group for their anesthesia needs. Bye bye. And don't let the door hit you on the way out.

What's particularly galling is that STA had no conflicts with the hospital prior to them seeking proposals from others. STA members asked directly if there were any issues with their work and the hospital denied any work or personality conflicts. Ultimately the work contract was awarded to another anesthesia group out of Buffalo who were willing to work for less money.

STA had been OGH's exclusive anesthesia providers for 24 years. And OGH has been the exclusive hospital to STA for the last fifteen. Unfortunately they may just have been too small to compete with groups that are much larger and have economies of scale. STA only has six anesthesiologists and two CRNA's. Meanwhile, hospitals and insurance companies are merging at a furious pace. OGH is part of a much larger hospital group, Kaleida Health. When large corporations start running hospitals, loyalty takes a back seat to the bottom line.

For the anesthesiologists in STA, the future looks bleak. It's unclear if they will be absorbed by the Buffalo group if they are willing to work for less money. Otherwise, there are no other hospitals within an hour drive and the physicians will have to move away to find other jobs.

While it may be desirable to work in quaint small towns with Mayberry quality lifestyles, medicine isn't practiced like the 1950's anymore. Corporate medicine is creeping into even the smallest medical practices. I've had personal friends who thought they found the perfect anesthesia jobs after residency. Then one day, they show up for work and find out their hospital has negotiated with a different anesthesia group willing to work for less money. They were suddenly unemployed. Devastating.

In order to compete, doctors will need to team up or get run out of town by companies with billions of dollars in revenue and no compunction to fire staff at will if it helps their stock holders. I wish all the luck to the members of Southern Tier Anesthesiologists in their careers and hope they land somewhere that will provide a more stable job environment for themselves and their families.

The Fallacy Of The Universal Time Out

Scott Baker, MD

Is it possible to legislate away human error? It would appear not. Despite the best intentions of hundreds of bureaucratic agencies and thousands of rules governing every conceivable aspect of medical practice, plain old human error still rears its ugly head to make sensational news headlines about the latest grievous injury to a patient.

Last week, an Iowa woman sued her surgeon, Dr. Scott Baker of Sioux Falls, SD for removing the wrong body part. In 2016, Dena Knapp of Iowa was supposed to have an adrenal mass removed by Dr. Baker. Instead, the surgeon was notified by the pathology department afterwards that he had removed a kidney, not the adrenal. To make matters worse, Ms. Knapp states that the surgeon lied to her about the mistake and claimed he did not get all of the mass and needed a second operation, never informing her that he had accidentally removed a healthy kidney. She went to the Mayo Clinic for her second operation. Now she claims that her one remaining kidney is starting to fail and she is suffering from severe mental distress and pain.

Can you see the difference between the adrenals and the kidney?

This incident has so many open questions. It also points out the fallacy of imposing more and more rules on people in order to prevent human error. First of all, let's agree that the surgeon made a huge error in judgement when he somehow mistook a kidney for the adrenals and took the wrong one out, even if they are right next to each other. However, I'm curious about what the rest of the surgical team  was doing when the error took place? As part of the Universal Protocol required by the Joint Commission, every member of the team in the operating room had to confirm the correct patient, surgical procedure, and site of the procedure prior to the start of the operation.

So that begets the question, where was the rest of the OR staff when the kidney was being removed? Did the nurse or the surgical tech, who would have been right there to document the specimen being removed from the patient, not notice that they were being handed a kidney and not an adrenal? Was the surgeon's assistant not confident enough to tell Dr. Baker that he was resecting the wrong organ?

For that matter, what about the anesthesiologist in the case? We are an integral part of the surgical team and consider ourselves leaders in patient safety. That includes being an active participant in the Universal Time Out. Did the anesthesiologist not notice that the surgeon had removed the kidney by accident? Was anything said to the surgeon by anybody in the OR when the nephrectomy was taking place? So many unanswered questions that I'm sure will be aired out in court very soon.

This is just the latest medical malpractice case to make headlines since the practice of Universal Protocol was conceived in 2004. No matter how many rules are enacted, the best protection for the patient is one of the simplest--stay vigilant.

Don't Google Check Your Attending

Now is the season when medical students all over the country start doing away rotations in their desired fields hoping to gain experience and come away with a favorable letter of recommendation for their residency applications. We are currently trying to accommodate dozens of students each month who come and go through our hospital who are undergoing this ritual.

In general, most of the students are great to work with. They are eager to learn and still in awe of some of the amazing work we do in anesthesia. Many have little experience in our specialty other than what they see on TV or over the drapes during their surgery rotations. It's a pleasure to have them around.

But that doesn't mean that they are all easy to work with. We love it when they ask great smart questions about what they are seeing in the operating rooms. However I recently had one student who loved asking questions but then would quickly look up Google on his smartphone to double check the answer I gave him. This was beyond annoying.

If you just want to learn from Google, why bother going to a far away rotation to questions everything somebody is trying to teach? Sure maybe my own fragile ego may have something to do with my insecurity when I'm up against an omniscient presence like Google. But I don't like being told while I'm teaching that my MAC number for Sevoflurane was just a fraction of a decimal point different from that almighty search engine. I find it rude when I'm questioned about every nugget of wisdom I'm trying to impart on our future anesthesiologists while I'm in the process of doing so. It got to the point where I stopped teaching that particular student anything. Instead we just sat there and talked about his personal life and interests, which frankly he seemed far more receptive to than anesthesia.

Every anesthesia attending I discussed this situation with agreed that the student should be more tactful in how they question their instructors. Don't Google check your attending unless you're invited by them to look something up together as a shared learning experience. If you question something that was said, you can always look it up later and perhaps ask another attending about the discrepancy in information. But to constantly berate your teacher with the internet will quickly shut down the conversation and leave you poorer for it. And that's not why students spend thousands of dollars and months of their lives to gain experience to be smart physicians.

The Genius of Sting

I have been a fan of Sting since his Police days in the 1980's. Well, mostly early Sting music anyways. His later solo career works just became too mellow for me. So while driving home from work the other day, I was listening to the oldies station (God when did my favorite music migrate to the oldies station?) when they started playing Sting's "If I Ever Lose My Faith In You". I've heard it hundreds of times before but not recently. Then I suddenly caught these lyrics in the second verse.

Some would say I was a lost man in a lost world.

You could say I lost my faith in the people on TV.

You could say I'd lost my belief in politicians.

They all seemed like game show hosts to me.

What?! This song was released back in 1993. Yet the lyrics are so prescient of our current times and politics. In four simple lines he so perfectly encapsulates the present day controversies regarding fake news, Russian collusion, lost emails, special counsels, qualifications for higher office, etc.

Sting, wherever you are, you are truly a genius.