NEVER ARGUE WITH AN ANAESTHETIEST

My friends in anaesthesia will tell you that I have never, in the last 35 years argued with them, whether they were junior to me, my batch mates or my seniors in medical college. Consequently, the atmosphere in my operating theatre is always congenial and jovial. It is not that I have not had my posted surgery postponed or even cancelled, but every time there was a reason, every time it was in the interest of the patient, and on most occasions I had a prejudice free mind to understand the reason.

I consider the anesthesiologist to be the leader of the medical staff in the theatre because (a) he knows the patient, as he also performed a pre-anesthetic consultation; (b) he is the internist who also anesthetizes a patient; (c) logically, he is sufficiently trained to handle any clinical complication occurring during the procedure without disturbing the "cruise flight" of the operation; (d) as so, he maintains the patient's hemodynamic and metabolic balance as well as a positive emotional atmosphere of the team; (e) fortunately, he is the first doctor to arrive and the last one to leave the operating room every other day.

Pleasing the surgeon by not disrupting the operating theatre schedule with a cancellation vs patient safety is a difficult choice and these days is driven more by economics than patient care. The tension that arises between the surgeon and the anaesthetiest is "an elephant in the room." There's not a lot of direct research on the surgeon-anesthesiologist dyad, but talk to either one of them and you'll recognize it. I am of the firm opinion that the surgeon-anesthesiologist relationships far from being strained, should be such that they do collaborate well to the greatest advantage of the patient. Though everyone in the operating theatre agrees that non-hierarchical, collaborative leadership is the gold standard, executing this kind of cooperation is difficult in practice.

It is the surgeon's responsibility always to pre-screen his or her patient ideally two weeks before the procedure. As a plastic surgeon, who primarily does a lot of trauma, I am truly appreciative of my anaesthesia colleagues. Trauma cases and other emergency cases come to the operating theatre all the time where no pre-op evaluation is possible and the vast majority of those anesthetics are successful.  If the surgeons and anesthesiologists work together, most surgeons will see their colleagues doing their best to keep their patients safe during induction and maintenance of anesthesia which is a tremendously stressful procedure.  Not all surgeons do unfortunately and some surgeons either do not appreciate what the anesthesiologists are trying to do for them and their patients, or they are too big of control freaks to allow someone else to tell them they can't proceed as they wish.

Just the other day I was sipping coffee in the surgeon’s lounge when I overheard this less than cordial conversation. The surgeon had a high risk patient scheduled He knew the man's history because he kept telling the anaesthetiest "But, he has a normal ejection fraction!” over and over again.  Finally when the anaesthetist had enough of that she snapped, "Sir that just tells me he's not in failure.  It doesn't tell me he won't have an MI on the table."  Surprisingly the surgeon’s response was, "That's not my concern!".  Had I not been so flabbergasted by his response, I might have had something snappier to say than what the anaesthetist did “we are cancelling his case until the man was seen by a cardiologist.” 

While the job of surgeons is far more glamourous as he / she is the one whom the patient approaches, and gives all the credit of success, they should never forget that they are just the display window of a very big team and it is on the efficiency of this team that their success depends. Also worth remembering is that just as the success is attributed to him so is the failure. Having said that nobody should go into anesthesiology with the expectation that life will be full of recognition and applause; that satisfaction usually has to come from within.  Mutual respect that is earned by years of working effectively together builds good professional, collegial working relationships. 

The relationship between the anesthesiologist and the surgeon is like dance partners. We each need to know the other's steps or we will trip and fall.   Saying 'No.' to a surgeon who wants to take an unprepared sick patient into the OR for an elective case is a heck of a lot easier than saying 'No.' to a family member asking the anesthesiologist if their loved one will be coming home from the hospital.

Effective team communication is critical in health care, yet no curriculum exists to teach it. Naturalistic research has revealed systematic patterns of tension and profession-specific interpretation of operating room team communication.

I have never argued with my anesthesia colleagues concerning cancellation. Firstly, the medicolegal exposure is obvious. But secondly, why take risks for elective procedures? Isn’t that what prudent medical decision making is all about? Aren’t we always balancing risk VS reward with every decision, every script? It seems morally, strategically, and legally stupid to put convenience over patient welfare.