THE PERIOPERATIVE SURGICAL HOME HAS EXISTED FOR YEARS

the anesthesia consultant

Physician anesthesiologist at Stanford at Associated Anesthesiologists Medical Group
Richard Novak, MD is a Stanford physician board-certified in anesthesiology and internal medicine.Dr. Novak is an Adjunct Clinical Professor in the Department of Anesthesiology, Perioperative and Pain Medicine at Stanford University, the Medical Director at Waverley Surgery Center in Palo Alto, California, and a member of the Associated Anesthesiologists Medical Group in Palo Alto, California.
email rjnov@yahoo.com
phone 650-465-5997

The American Society of Anesthesiologists is supporting an expansion of the role of anesthesiologists in the delivery of perioperative care in hospitals. This proposed model is called the Perioperative Surgical Home. The American Society of Anesthesiologists defines the Perioperative Surgical Home as “a patient centered, innovative model of delivering health care during the entire patient surgical/procedural experience; from the time of the decision for surgery until the patient has recovered and returned to the care of his or her Patient Centered Medical Home or primary care provider.”

 

It’s a sound idea, and it resembles a model that’s existed for decades outside the hospital. In an outpatient surgery center the Perioperative Surgical Home concept is carried out by an anesthesiologist who is the Medical Director. I can speak to this, as I’ve been the Medical Director at a busy surgery center only minutes from Stanford University in downtown Palo Alto, for the past 12 years.

A surgery center Medical Director is responsible for:

  • All preoperative matters, including preoperative medical assessment of patients, scheduling of block times, surgical cases, anesthesia assignments, and creation of protocols,
  • All intraoperative matters, including quality issues, efficiency and turnover of cases, and the economics of running a profitable set of operating rooms, and
  • All postoperative matters, including overseeing Post Anesthesia Care Unit (PACU) nursing care, post anesthesia medical decisions, and supervision of post-discharge follow up with patients.

All medical problems including complications, hospital transfers, and patient complaints, are routed through the anesthesiologist Medical Director.

A key difference between a surgery center and a hospital is scale. A busy hospital has dozens of operating rooms, hundreds of surgeries per day, and hundreds of inpatient beds. No one Medical Director can oversee all of this every day—it takes a team. At Stanford University Medical Center the anesthesia department is known as the Department of Anesthesia, Perioperative and Pain Medicine. The word “Perioperative” is appropriate, because anesthesia practice involves medical care before, during, and after surgery. A team of anesthesiologists is uniquely qualified to oversee preoperative assessment, intraoperative management, and post-operative pain control and medical care in the hospital setting, just as the solitary Medical Director does in a surgery center setting.

A second key difference between a surgery center and a hospital is that medical care is more complex in a hospital. Patients are sicker, invasive surgeries disturb physiology to a greater degree, and patients stay overnight after surgery, often with significant pain control or intensive care requirements. Again, a team of physicians from a Department of Anesthesia, Perioperative and Pain Medicine is best suited to supervise management of these problems.

The greatest hurdle to instituting the Perioperative Surgical Home model is pre-existing economic reality. In a hospital, other departments such as surgery, internal medicine, radiology, cardiology, pulmonology, and nursing are intimately involved in the perioperative management of surgery patients. Each of these departments has staff, a budget, income, and incentives related to maintaining their current role. Surgeons intake patients through their preoperative clinics, and may regard themselves as captains of the ship for all medical care on their own patients. Internal medicine doctors are called on for preoperative medical clearance on patients, and thus compete with anesthesia preoperative clinics. The internal medicine department includes hospitalists, inpatient doctors who may be involved in the post-operative management of inpatients. Invasive radiologists perform multiple non-invasive surgical procedures. Like their surgical colleagues, they may see themselves as decision makers for all medical care on their own patients. Cardiologists manage coronary care units and intensive care units in some hospitals, and may feel threatened by anesthesiologists intent on taking over their territory. Pulmonologists manage coronary care units and intensive care units in some hospitals, and may feel threatened by anesthesiologists intent on taking over their territory. Nurses are involved in all phases of perioperative care. If the chain of command among physicians changes, nurses must be willing partners of and participants with such change.

Why has the anesthesiology leadership role of a Medical Director evolved naturally at surgery centers while the Perioperative Surgical Home idea has to be sold to hospitals? At surgery centers the competing financial incentives of surgeons, internal medicine doctors, radiologists, pulmonologists, cardiologists, and nurses are minimal. In a freestanding surgery center, surgeons want to be able to depart for their offices following procedures, and welcome the skills that anesthesiologists bring to managing any medical complications that arise. Internal medicine doctors have no significant on-site role in surgery centers, although they are helpful office consultants for the anesthesiologist/Medical Director in assembling preoperative clearance for outpatients. Radiologists have no significant on-site role at most surgery centers—if they do perform invasive radiology procedures on outpatients, they too welcome the skills that anesthesiologists bring to managing medical complications that arise. Because there are no intensive care units at a surgery center, there is no role for pulmonary or cardiology specialists. Nursing leadership at a surgery center works hand-in-hand with the Medical Director to assure optimal nursing care of all patients.

Hospital administrators anticipate penetration of the Accountable Care Organization (ACO) model for payment of medical care by insurers. In the ACO model, a medical center receives a predetermined bundled payment for each surgical procedure. The hospital and all specialties caring for that patient negotiate what percentage of that ACO payment each will receive. A Perioperative Surgical Home may or may not simplify this task. You can bet anesthesiologists see the Perioperative Surgical Home as a means to increase their piece of the pie. Ideally the Perioperative Surgical Home will be a means to streamline medical care, decrease costs, and increase profit for the hospital and all departments. Anesthesiologists are rightly concerned that if they don’t take the lead in this process, some other specialty will.

Establishing the Perioperative Surgical Home is an excellent opportunity for anesthesiologists to facilitate patient care in multiple aspects of hospital medicine. To make this dream a reality across multiple medical centers, anesthesiology leadership must demonstrate excellent public relations skills to convince administrators and chairpeople of the multiple other specialties. I expect data on outcomes improvement or cost-control to be slow and inadequate to proactively provoke this change. It will take significant lobbying, convincing, and promoting. Change will require a leap of faith for a hospital, and such change will only be accomplished by anesthesia leadership that captures the confidence of the hospital CEO and the chairs of multiple other departments.

I’m impressed by the adoption of the Perioperative Surgical Home at the University of California at Irvine. I’ve listened to Zev Kain, MD, Professor and Chairman of the Department of Anesthesia and Perioperative Medicine lecture, and I’ve met him personally. He’s the prototype of the charismatic, intelligent, and convincing physician needed to convince others that the Perioperative Surgical Home is the model of the future.(http://www.anesthesiology.uci.edu/clinical_surgicalhome.shtml)

I expect the transition to the Perioperative Surgical Home to occur more easily in university or HMO hospitals than in community hospitals. It will be easier for academic or HMO chairmen to assign new roles to salaried physicians than it will be for community hospitals to control the behavior of multiple private physicians.

Anesthesiologists were leaders in improving perioperative safety by the discovery and adoption of pulse oximetry and end-tidal carbon dioxide monitoring. Can anesthesiologists lead the way again by championing the adoption of Perioperative Surgical Home on a wide scale? Time will tell. Is the Perioperative Surgical Home an optimal way to take care of surgical patients before, during, and after surgeries? I believe it is, just as the Medical Director is a successful model of how an anesthesiologist can optimally lead an outpatient surgery center. Those lobbying for the Perioperative Surgical Home would be wise to examine the successful role of anesthesiologist Medical Directors who’ve led outpatient surgery centers for years. The stakes are high. As intraoperative care becomes safer and the role of nurse anesthesia in the United States threatens to expand, it’s imperative that physician anesthesiologists assert their expertise outside the operating room.

 

The most popular posts for laypeople on The Anesthesia Consultant include:

How Long Will It Take To Wake Up From General Anesthesia?

Why Did Take Me So Long To Wake From General Anesthesia?

Will I Have a Breathing Tube During Anesthesia?

What Are the Common Anesthesia Medications?

How Safe is Anesthesia in the 21st Century?

Will I Be Nauseated After General Anesthesia?

What Are the Anesthesia Risks For Children?

 

The most popular posts for anesthesia professionals on The Anesthesia Consultant  include:

10 Trends for the Future of Anesthesia

Should You Cancel Anesthesia for a Potassium Level of 3.6?

12 Important Things to Know as You Near the End of Your Anesthesia Training

Should You Cancel Surgery For a Blood Pressure = 178/108?

Advice For Passing the Anesthesia Oral Board Exams

What Personal Characteristics are Necessary to Become a Successful Anesthesiologist?

 

 

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Published in September 2017:  The second edition of THE DOCTOR AND MR. DYLAN, Dr. Novak’s debut novel, a medical-legal mystery which blends the science and practice of anesthesiology with unforgettable characters, a page-turning plot, and the legacy of Nobel Prize winner Bob Dylan.

KIRKUS REVIEW

In this debut thriller, tragedies strike an anesthesiologist as he tries to start a new life with his son.

Dr. Nico Antone, an anesthesiologist at Stanford University, is married to Alexandra, a high-powered real estate agent obsessed with money. Their son, Johnny, an 11th-grader with immense potential, struggles to get the grades he’ll need to attend an Ivy League college. After a screaming match with Alexandra, Nico moves himself and Johnny from Palo Alto, California, to his frozen childhood home of Hibbing, Minnesota. The move should help Johnny improve his grades and thus seem more attractive to universities, but Nico loves the freedom from his wife, too. Hibbing also happens to be the hometown of music icon Bob Dylan. Joining the hospital staff, Nico runs afoul of a grouchy nurse anesthetist calling himself Bobby Dylan, who plays Dylan songs twice a week in a bar called Heaven’s Door. As Nico and Johnny settle in, their lives turn around; they even start dating the gorgeous mother/daughter pair of Lena and Echo Johnson. However, when Johnny accidentally impregnates Echo, the lives of the Hibbing transplants start to implode. In true page-turner fashion, first-time novelist Novak gets started by killing soulless Alexandra, which accelerates the downfall of his underdog protagonist now accused of murder. Dialogue is pitch-perfect, and the insults hurled between Nico and his wife are as hilarious as they are hurtful: “Are you my husband, Nico? Or my dependent?” The author’s medical expertise proves central to the plot, and there are a few grisly moments, as when “dark blood percolated” from a patient’s nostrils “like coffee grounds.” Bob Dylan details add quirkiness to what might otherwise be a chilly revenge tale; we’re told, for instance, that Dylan taught “every singer with a less-than-perfect voice…how to sneer and twist off syllables.” Courtroom scenes toward the end crackle with energy, though one scene involving a snowmobile ties up a certain plot thread too neatly. By the end, Nico has rolled with a great many punches.

Nuanced characterization and crafty details help this debut soar.

Click on the image below to reach the Amazon link to The Doctor and Mr. Dylan:

41wlRoWITkL

Learn more about Rick Novak’s fiction writing at ricknovak.com by clicking on the picture below:  

DSC04882_edited

 

 

HOW TO SCREEN OUTPATIENTS PRIOR TO SURGERY

the anesthesia consultant

Physician anesthesiologist at Stanford at Associated Anesthesiologists Medical Group
Richard Novak, MD is a Stanford physician board-certified in anesthesiology and internal medicine.Dr. Novak is an Adjunct Clinical Professor in the Department of Anesthesiology, Perioperative and Pain Medicine at Stanford University, the Medical Director at Waverley Surgery Center in Palo Alto, California, and a member of the Associated Anesthesiologists Medical Group in Palo Alto, California.
email rjnov@yahoo.com
phone 650-465-5997

Screening prior to outpatient surgery is important. Over 70% of elective surgeries in the United States are ambulatory or outpatient surgeries, in which the patient goes home the same day as the procedure. There are increasing numbers of surgical patients who are elderly, obese, have sleep apnea, or who have multiple medical problems. How do we decide which 70% of surgical candidates are appropriate for outpatient surgery, and which are not?

For the past 16 years I’ve been the Medical Director at a busy Ambulatory Surgery Center (ASC) in Palo Alto, California. ASC Medical Directors are perioperative physicians, responsible for the preoperative, intraoperative, and postoperative management of ambulatory surgery patients. Our surgery center is freestanding, distanced one mile from Stanford University Hospital. The hospital-based technologies of laboratory testing, a blood bank, an ICU, arterial blood gas measurement, and full radiology diagnostics are not available on site. It’s important that patient selection for a freestanding surgery center is precise and safe.

The topic of Ambulatory Anesthesia is well reviewed in the textbook Miller’s Anesthesia, 7th Edition, 2009, Chapter 78, Ambulatory (Outpatient) Anesthesia. With the information in this chapter as a foundation, the following 7 points are guidelines I recommend in the preoperative consultation and selection of appropriate outpatient surgery patients:

  1. The most important factor in deciding if a surgical case is appropriate is not how many medical problems the patient has, but rather the magnitude of the surgical procedure. A patient may have morbid obesity, sleep apnea, and a past history of congestive heart failure, but still safely undergo a non-invasive procedure such as cataract surgery. Conversely, if the patient is healthy, but the scheduled surgery is an invasive procedure such as resection of a mass in the liver, that surgery needs to be done in a hospital.
  2. Because of #1, an ASC will schedule noninvasive procedures such as arthroscopies, head and neck procedures, eye surgeries, minor gynecology and general surgery procedures, gastroenterology endoscopies, plastic surgeries, and dental surgeries. What all these scheduled procedures have in common is that the surgeries (a) will not disrupt the postoperative physiology in a major way, and (b) will not cause excessive pain requires inpatient intravenous narcotics.
  3. One must screen patients preoperatively to identify individuals who have serious medical problems. Our facility uses a comprehensive preoperative telephone interview performed by a medical assistant, two days prior to surgery. The interview documents age, height, weight, Body Mass Index, complete review of systems, list of allergies, and prescription drug history. All information is entered in the patient’s medical record at that time.
  4. Each surgeon’s office assists in the preoperative screening. For all patients who have (a) age over 65, (b) obstructive sleep apnea, (c) cardiac disease or arrhythmia history, (d) significant lung disease, (e) shortness of breath or chest pain, (f) renal failure or hepatic failure, (g) insulin dependent diabetes, or (h) significant neurological abnormality, the surgery office is required to obtain medical clearance from the patient’s Primary Care Provider (PCP).    This PCP clearance note concludes with two questions: 1) Does the patient require any further diagnostic testing prior to the scheduled surgery? And 2) Does the patient require any further therapeutic measures prior to the scheduled surgery?
  5. For each patient identified with significant medical problems, the Medical Director must review the chart and the Primary Care Provider note, and confirm that the patient is an appropriate candidate for the outpatient surgery. The Medical Director may telephone the patient for a more detailed history if indicated. On rare occasions, the Medical Director may arrange to meet and examine the patient prior to the surgical date.
  6. Medical judgment is required, as some ASA III patients with significant comorbidities are candidates for trivial outpatient procedures such as gastroenterology endoscopy or removal of a neuroma from a finger, but are inappropriate candidates for a shoulder arthroscopy or any procedure that requires general endotracheal anesthesia.
  7. What about laboratory testing? Per Miller’s Anesthesia, 7th Edition, 2009, Chapter 78, few preoperative lab tests are indicated prior to most ambulatory surgery. We require a recent ECG for patients with a history of hypertension, cardiac disease, or for any patient over 65 years in age. If this ECG is not included with the Primary Care Provider consultation note, we perform the ECG on site in the preoperative area of our ASC, at no charge to the patient. All diabetic patients have a fasting glucose test done prior to surgery. No electrolytes, hematocrit, renal function tests, or hepatic tests are required on any patient unless that patient’s history indicates a specific reason to mandate those tests.

Utilizing this system, cancellations on the day of surgery are infrequent—well below 1% of the scheduled procedures. The expense of and inconvenience of an Anesthesia Preoperative Clinic are eliminated.

What sort of cases are not approved? Here are examples from my practice regarding patients/procedures who are/are not appropriate for surgery at a freestanding ambulatory surgery center:

  1. A 45-year-old patient with moderately severe obstructive sleep apnea (OSA) is scheduled for a UPPP (uvulopalatalpharyngoplasty). DECISION: NOT APPROPRIATE. Reference: American Society of Anesthesiologist Practice Guidelines of the Perioperative Management of Patients with OSA (https://www.asahq.org/coveo.aspx?q=osa). For airway and palate surgery on an OSA patient, the patient is best observed in a medical facility post-surgery. For any surgery this painful in an OSA patient, the patient will require significant narcotics, which place him at risk for apnea and airway obstruction post-surgery.
  2. A morbidly obese male (Body Mass Index = 40) is scheduled for a shoulder arthroscopy and rotator cuff repair. DECISION: NOT APPROPRIATE. Obesity is not an automatic exclusion criterion for outpatient surgery. Whether to cancel the case or not depends on the nature of the surgery. A shoulder repair often requires significant postoperative narcotics. The intersection of morbid obesity and a painful surgery means it’s best to do the case in a hospital. One could argue that this patient could be done with an interscalene block for postoperative analgesia and then discharged home, but I don’t support this decision. If the block is difficult or ineffective, the anesthesiologist has a morbidly obese patient requiring significant doses of narcotics, and who is scheduled to be discharged home. If this surgery had been a knee arthroscopy and medial meniscectomy it could be an appropriate outpatient surgery, because meniscectomy patients have minimal pain postoperatively.
  3. An 18-year-old male with a positive family history of Malignant Hyperthermia is scheduled for a tympanoplasty. DECISION: APPROPRIATE. A trigger-free general total-intravenous anesthetic with propofol and remifenantil can be given just as safely in an ASC as in a hospital.
  4. A 50-year-old 70-kilogram male with a known difficult airway (ankylosing spondylitis) is scheduled for endoscopic sinus surgery. DECISION: APPROPRIATE. In our ASC, for safety reasons, we have advanced airway equipment including a video laryngoscope and a fiberoptic laryngoscope. If a patient needs an awake intubation, we are prepared to do this safely. This case would be scheduled with a second anesthesiologist available to assist the primary anesthesia attending in securing the airway.
  5. An 80-year-old woman with shortness of breath on exertion is scheduled for a bunionectomy. DECISION: NOT APPROPRIATE. Although foot surgery is not a major invasive procedure, any patient with shortness of breath is inappropriate for ASC surgery. The nature of the dyspnea needs to be determined and remedied prior to surgery or anesthesia of any sort.
  6. A 6-year-old female born without an ear is scheduled for a 9-hour ear graft and reconstruction. DECISION: APPROPRIATE. With modern general anesthetic techniques utilizing sevoflurane and propofol, patients awake promptly. Even after long anesthetics, if the surgery is not painful, patients are usually discharged in stable condition within 60-90 minutes.

There are infinite combinations of patient comorbidities and types of surgeries. The decision regarding which scheduled procedures are appropriate and which are not is both an art and a science. The role of an anesthesiologist/Medical Director as the perioperative physician making these decisions is invaluable.

 

The most popular posts for laypeople on The Anesthesia Consultant include:

How Long Will It Take To Wake Up From General Anesthesia?

Why Did Take Me So Long To Wake From General Anesthesia?

Will I Have a Breathing Tube During Anesthesia?

What Are the Common Anesthesia Medications?

How Safe is Anesthesia in the 21st Century?

Will I Be Nauseated After General Anesthesia?

What Are the Anesthesia Risks For Children?

 

The most popular posts for anesthesia professionals on The Anesthesia Consultant  include:

10 Trends for the Future of Anesthesia

Should You Cancel Anesthesia for a Potassium Level of 3.6?

12 Important Things to Know as You Near the End of Your Anesthesia Training

Should You Cancel Surgery For a Blood Pressure = 178/108?

Advice For Passing the Anesthesia Oral Board Exams

What Personal Characteristics are Necessary to Become a Successful Anesthesiologist?

 

 

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Published in September 2017:  The second edition of THE DOCTOR AND MR. DYLAN, Dr. Novak’s debut novel, a medical-legal mystery which blends the science and practice of anesthesiology with unforgettable characters, a page-turning plot, and the legacy of Nobel Prize winner Bob Dylan.

KIRKUS REVIEW

In this debut thriller, tragedies strike an anesthesiologist as he tries to start a new life with his son.

Dr. Nico Antone, an anesthesiologist at Stanford University, is married to Alexandra, a high-powered real estate agent obsessed with money. Their son, Johnny, an 11th-grader with immense potential, struggles to get the grades he’ll need to attend an Ivy League college. After a screaming match with Alexandra, Nico moves himself and Johnny from Palo Alto, California, to his frozen childhood home of Hibbing, Minnesota. The move should help Johnny improve his grades and thus seem more attractive to universities, but Nico loves the freedom from his wife, too. Hibbing also happens to be the hometown of music icon Bob Dylan. Joining the hospital staff, Nico runs afoul of a grouchy nurse anesthetist calling himself Bobby Dylan, who plays Dylan songs twice a week in a bar called Heaven’s Door. As Nico and Johnny settle in, their lives turn around; they even start dating the gorgeous mother/daughter pair of Lena and Echo Johnson. However, when Johnny accidentally impregnates Echo, the lives of the Hibbing transplants start to implode. In true page-turner fashion, first-time novelist Novak gets started by killing soulless Alexandra, which accelerates the downfall of his underdog protagonist now accused of murder. Dialogue is pitch-perfect, and the insults hurled between Nico and his wife are as hilarious as they are hurtful: “Are you my husband, Nico? Or my dependent?” The author’s medical expertise proves central to the plot, and there are a few grisly moments, as when “dark blood percolated” from a patient’s nostrils “like coffee grounds.” Bob Dylan details add quirkiness to what might otherwise be a chilly revenge tale; we’re told, for instance, that Dylan taught “every singer with a less-than-perfect voice…how to sneer and twist off syllables.” Courtroom scenes toward the end crackle with energy, though one scene involving a snowmobile ties up a certain plot thread too neatly. By the end, Nico has rolled with a great many punches.

Nuanced characterization and crafty details help this debut soar.

Click on the image below to reach the Amazon link to The Doctor and Mr. Dylan:

41wlRoWITkL

Learn more about Rick Novak’s fiction writing at ricknovak.com by clicking on the picture below:  

DSC04882_edited

 

 

WHY DOES ANYONE DECIDE THEY WANT TO BECOME AN ANESTHESIOLOGIST?

the anesthesia consultant

Physician anesthesiologist at Stanford at Associated Anesthesiologists Medical Group
Richard Novak, MD is a Stanford physician board-certified in anesthesiology and internal medicine.Dr. Novak is an Adjunct Clinical Professor in the Department of Anesthesiology, Perioperative and Pain Medicine at Stanford University, the Medical Director at Waverley Surgery Center in Palo Alto, California, and a member of the Associated Anesthesiologists Medical Group in Palo Alto, California.
email rjnov@yahoo.com
phone 650-465-5997

A question anesthesiologists are commonly asked is, “Why did you want to become an anesthesiologist?”

Let’s assume a young man or woman has the discipline and intellect to attend medical school. Once that individual gains their M.D. degree, they will choose a specialty from a long line-up that includes multiple surgical specialties (general surgery, orthopedics, urology, neurosurgery, cardiac surgery, ophthalmology, plastic surgery, ear-nose-and-throat surgery), internal medicine, pediatrics, family practice, dermatology, radiology, invasive radiology, radiation oncology, allergy-immunology, emergency medicine, and anesthesiology.

Why choose anesthesiology? I offer up a list of the reasons individuals like myself chose this specialty:

  1. Anesthesiologists do acute care rather than clinic care or chronic care. Some doctors enjoy sitting in a clinic 40+ hours a week, talking to and listening to patients. Other doctors prefer acute care, where more exciting things happen moment to moment. It’s true that surgeons do acute care in the operating room, but most surgeons spend an equal amount of time in clinic, seeing patients before and after scheduled surgical procedures. Chronic care in clinics can be emotionally taxing. Ordering diagnostic studies and prescribing a variety of pills suits certain M.D.’s, but acute care in operating rooms and intensive care units is more stimulating. It’s exciting controlling a patient’s airway, breathing, and circulation. It’s exciting having a patient’s life in your hands. Time flies.
  2. Patients like and respect their anesthesiologist, and that feels good. Maybe it’s because we are about to take each patient’s life into our hands, but during those minutes prior to surgery, patients treat anesthesiologists very well. I tend to learn more about my patients’ personal lives, hobbies, and social history in those 10 minutes of conversation prior to surgery than I ever did in my internal medicine clinic.
  3. An anesthesiologist’s patients are unconscious the majority of time. Some anesthesiologists are attracted the this aspect. An unconscious patient is not complaining. In contrast, try to imagine a 50-hour-a-week clinic practice as an internal medicine doctor, in which every one of your patients has a list of medical problems they are eager to tell you about.
  4. There is tremendous variety in anesthesia practice. We take care of patients ranging in ages from newborns to 100-year-olds. We anesthetize patients for heart surgery, brain surgery, abdominal or chest surgeries, bone and joint surgeries, cosmetic surgery, eye surgery, urological surgery, trauma surgery, and organ transplantation surgery. Every mother for Cesarean section has an anesthetist, as do mothers for many vaginal deliveries for childbirth. Anesthesiologists run intensive care units and anesthesiologists are medical directors of operating rooms as well as pain clinics.
  5. Anesthesiologists work with a lot of cool gadgets and advanced technology. The modern anesthesia workstation is full of computers and computerized devices we use to monitor patients. The modern anesthesia workstation has parallels to a commercial aircraft cockpit.
  6. Lifestyle. We work hard, but if an anesthesiologist chooses to take a month off, he or she can be easily replaced during the absence. It’s very hard for an office doctor to take extended time away from their patients. Many patients will find a alternate doctor during a one month absence if the original physician is unavailable. This aspect of anesthesia is particularly attractive to some female physicians who have dual roles as mother and physician, and choose to work less than full-time as an anesthesiologist so they can attend to their children and family.
  7. Anesthesia is a procedural specialty. We work with our hands inserting IV’s, breathing tubes, central venous IV catheters, arterial catheters, spinal blocks, epidural blocks, and peripheral nerve blocks as needed. It’s fun to do these procedures. Historically, procedural specialties have been higher paid than non=procedural specialties.

What about problematic issues with a career in anesthesia? There are a few:

  1. We work hard. Surgical schedules commonly begin at 7:30 a.m., and anesthesiologists have to arrive well before that time to prepare equipment, evaluate the first patient, and get that patient asleep before any surgery can commence. After years of this, my internal alarm clock tends to wake me at 6:00 a.m. even on weekends.
  2. Crazy hours. Every emergency surgery—every automobile accident, gunshot wound, heart transplant, or urgent Cesarean section at 3 a.m. needs an anesthetist. Working around the clock can wear you out.
  3. The stakes are high if you make a serious mistake. In a clinic setting, an M.D. may commit malpractice by failing to recognize that a patient’s vague chest pain is really a heart attack, or an M.D. may fail to order or to check on an important lab test, leading to a missed diagnosis. But in an operating room, the malpractice risks to an anesthesiologist are dire. A failure in properly insert a breathing tube can lead to brain death in minutes. This level of tension isn’t for everyone. Some doctors are not emotionally suited for anesthesia practice.
  4. In the future, anesthesia doctors may gradually lose market share of their practice to nurse anesthetists. You can peruse other columns in this blog where I’ve discussed this issue.
  5. Anesthesiologists don’t bring any patients to a medical center. In medical politics, this can be problematic. Anesthesiologists have limited power in some negotiations, because we can be seen as service providers rather than as a source of new patient referrals for a hospital. Some hospital administrators see an anesthetist as easily replaced by the next anesthetist who walks through the door, or who offers to work for a lower wage.

The positive aspects of anesthesiology far outweigh these negatives.

Akin to the Dos Equis commercial that describes “The Most Interesting Man in the World,” I’d describe the profession of anesthesiology as “The Most Interesting Job in the World.”

And when you love your job, you’ll never work a day in your life.

 

The most popular posts for laypeople on The Anesthesia Consultant include:

How Long Will It Take To Wake Up From General Anesthesia?

Why Did Take Me So Long To Wake From General Anesthesia?

Will I Have a Breathing Tube During Anesthesia?

What Are the Common Anesthesia Medications?

How Safe is Anesthesia in the 21st Century?

Will I Be Nauseated After General Anesthesia?

What Are the Anesthesia Risks For Children?

 

The most popular posts for anesthesia professionals on The Anesthesia Consultant  include:

10 Trends for the Future of Anesthesia

Should You Cancel Anesthesia for a Potassium Level of 3.6?

12 Important Things to Know as You Near the End of Your Anesthesia Training

Should You Cancel Surgery For a Blood Pressure = 178/108?

Advice For Passing the Anesthesia Oral Board Exams

What Personal Characteristics are Necessary to Become a Successful Anesthesiologist?

 

 

LEARN MORE ABOUT RICK NOVAK’S FICTION WRITING AT RICK NOVAK.COM BY CLICKING ON THE PICTURE BELOW:

DSC04882_edited

 

 

the anesthesia consultant

Physician anesthesiologist at Stanford at Associated Anesthesiologists Medical Group
Richard Novak, MD is a Stanford physician board-certified in anesthesiology and internal medicine.Dr. Novak is an Adjunct Clinical Professor in the Department of Anesthesiology, Perioperative and Pain Medicine at Stanford University, the Medical Director at Waverley Surgery Center in Palo Alto, California, and a member of the Associated Anesthesiologists Medical Group in Palo Alto, California.
email rjnov@yahoo.com
phone 650-465-5997

Dr. Novak intubating a patient using a McGrath 5 videolaryngoscope in the operating room. Full story available at Outpatient Surgery Magazine.

Cover story, Magazine article on techniques of starting IV's

 

Vascular Access Made Easy

Time-tested tips for locating veins and starting IVs.

Categories:

—ALL SMILES The best IV starts are the ones patients don’t remember.

Talented surgeons, a staff full of Florence Nightingales and Starbucks in the waiting room won’t matter much to patients if they’re stuck more than pincushions during IV starts. It’s true: Patients who’ve been poked and prodded multiple times in pre-op will remember that experience long after they leave your facility, no matter how successful their surgeries. Make sure patients never complain about IVs again with these 6 proven steps for first-stick-success, which I’ve developed from starting more than 20,000 lines throughout my career.

 

The most popular posts for laypeople on The Anesthesia Consultant include:

How Long Will It Take To Wake Up From General Anesthesia?

Why Did Take Me So Long To Wake From General Anesthesia?

Will I Have a Breathing Tube During Anesthesia?

What Are the Common Anesthesia Medications?

How Safe is Anesthesia in the 21st Century?

Will I Be Nauseated After General Anesthesia?

What Are the Anesthesia Risks For Children?

 

The most popular posts for anesthesia professionals on The Anesthesia Consultant  include:

10 Trends for the Future of Anesthesia

Should You Cancel Anesthesia for a Potassium Level of 3.6?

12 Important Things to Know as You Near the End of Your Anesthesia Training

Should You Cancel Surgery For a Blood Pressure = 178/108?

Advice For Passing the Anesthesia Oral Board Exams

What Personal Characteristics are Necessary to Become a Successful Anesthesiologist?

 

 

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Published in September 2017:  The second edition of THE DOCTOR AND MR. DYLAN, Dr. Novak’s debut novel, a medical-legal mystery which blends the science and practice of anesthesiology with unforgettable characters, a page-turning plot, and the legacy of Nobel Prize winner Bob Dylan.

KIRKUS REVIEW

In this debut thriller, tragedies strike an anesthesiologist as he tries to start a new life with his son.

Dr. Nico Antone, an anesthesiologist at Stanford University, is married to Alexandra, a high-powered real estate agent obsessed with money. Their son, Johnny, an 11th-grader with immense potential, struggles to get the grades he’ll need to attend an Ivy League college. After a screaming match with Alexandra, Nico moves himself and Johnny from Palo Alto, California, to his frozen childhood home of Hibbing, Minnesota. The move should help Johnny improve his grades and thus seem more attractive to universities, but Nico loves the freedom from his wife, too. Hibbing also happens to be the hometown of music icon Bob Dylan. Joining the hospital staff, Nico runs afoul of a grouchy nurse anesthetist calling himself Bobby Dylan, who plays Dylan songs twice a week in a bar called Heaven’s Door. As Nico and Johnny settle in, their lives turn around; they even start dating the gorgeous mother/daughter pair of Lena and Echo Johnson. However, when Johnny accidentally impregnates Echo, the lives of the Hibbing transplants start to implode. In true page-turner fashion, first-time novelist Novak gets started by killing soulless Alexandra, which accelerates the downfall of his underdog protagonist now accused of murder. Dialogue is pitch-perfect, and the insults hurled between Nico and his wife are as hilarious as they are hurtful: “Are you my husband, Nico? Or my dependent?” The author’s medical expertise proves central to the plot, and there are a few grisly moments, as when “dark blood percolated” from a patient’s nostrils “like coffee grounds.” Bob Dylan details add quirkiness to what might otherwise be a chilly revenge tale; we’re told, for instance, that Dylan taught “every singer with a less-than-perfect voice…how to sneer and twist off syllables.” Courtroom scenes toward the end crackle with energy, though one scene involving a snowmobile ties up a certain plot thread too neatly. By the end, Nico has rolled with a great many punches.

Nuanced characterization and crafty details help this debut soar.

Click on the image below to reach the Amazon link to The Doctor and Mr. Dylan:

41wlRoWITkL

Learn more about Rick Novak’s fiction writing at ricknovak.com by clicking on the picture below:  

DSC04882_edited

 

 

COVER STORY, OUTPATIENT SURGERY ARTICLE ON TECHNIQUES FOR STARTING DIFFICULT IV’S

ROBOT ANESTHESIA

the anesthesia consultant

Physician anesthesiologist at Stanford at Associated Anesthesiologists Medical Group
Richard Novak, MD is a Stanford physician board-certified in anesthesiology and internal medicine.Dr. Novak is an Adjunct Clinical Professor in the Department of Anesthesiology, Perioperative and Pain Medicine at Stanford University, the Medical Director at Waverley Surgery Center in Palo Alto, California, and a member of the Associated Anesthesiologists Medical Group in Palo Alto, California.
email rjnov@yahoo.com
phone 650-465-5997

Will robots replace anesthesiologists? I am the Medical Director of a surgery center in California that does 5,000 gastroenterology endoscopies per year.  In 2013 a national marketing firm contacted me to seek my opinion regarding an automated device to infuse propofol. The device was envisioned as a tool for gastroenterologist/nursing teams to use to administer propofol safely for endoscopy procedures on ASA class I – II patients.

 

The marketing firm could not reveal the name of the device, but I believe it was probably the SEDASYS®-Computer-Assisted Personalized Sedation System, developed by the Ethicon Endo-Surgery, Inc., a division of Johnson and Johnson.  The SEDASYS System is a computer-assisted personalized sedation system integrating propofol delivery with patient monitoring. The system incorporates standard ASA monitors, including end-tidal CO2, into an automated propofol infusion device.

The SEDASYS system is marketed as a device to provide conscious sedation.  It will not provide deep sedation or general anesthesia.

Based on pharmacokinetic algorithms, the SEDASYS infuses an initial dose of propofol (typically 30- 50 mg in young patients, or a smaller dose in older patients) over 3 minutes, and then begins a maintenance infusion of propofol at a pre-programmed rate (usually 50 mcg/kg/min).  If the monitors detect signs of over- sedation, e.g. falling oxygen saturation, depressed respiratory rate, or a failure of the end-tidal CO2 curve, the propofol infusion is stopped automatically.  In addition, the machine talks to the patient, and at intervals asks the patient to squeeze a hand-held gripper device.  If the patient is non-responsive and does not squeeze, the propofol infusion is automatically stopped.

As of February, 2013, the SEDASYS system was not FDA approved. On May 3, 2013, Ethicon Endo-Surgery, Inc. announced that the Food and Drug Administration (FDA) granted Premarket Approval for the SEDASYS® system, a computer-assisted personalized sedation system.  SEDASYS® is indicated “for the intravenous administration of 1 percent (10 milligrams/milliliters) propofol injectable emulsion for the initiation and maintenance of minimal to moderate sedation, as identified by the American Society of Anesthesiologists Continuum of Depth of Sedation, in adult patients (American Society of Anesthesiologists physical status I or II) undergoing colonoscopy and esophagoduodenoscopy procedures.”  News reports indicate that SEDASYS® is expected to be introduced on a limited basis beginning in 2014.

Steve Shaffer, M.D., Ph.D., Stanford Adjunct Professor, editor-in-chief of Anesthesia & Analgesia, and Professor of Anesthesiology at Columbia University, worked with Ethicon since 2003 on the design, development and testing of the SEDASYS System both as an investigator and as chair of the company’s anesthesia advisory panel.

Dr. Shafer has been quoted as saying, “The SEDASYS provides an opportunity for anesthesiologists to set up ultra-high throughput gastrointestinal endoscopy services, improve patient safety, patient satisfaction, endoscopist satisfaction and reduce the cost per procedure.” (Gastroenterology and Endoscopy News, November 2010, 61:11)

In Ethicon’s pivotal study supporting SEDASYS, 1,000 ASA class I to III adults had routine colonoscopy or esophagogastroduodenoscopy, and were randomized to either sedation with the SEDASYS System (SED) or sedation with each site’s current standard of care (CSC) i.e. benzodiazepine/opioid combination.  The reference for this study is Gastrointest Endosc. 2011 Apr;73(4):765-72. Computer-assisted personalized sedation for upper endoscopy and colonoscopy: a comparative, multicenter randomized study. Pambianco DJ, Vargo JJ, Pruitt RE, Hardi R, Martin JF.

In this study, 496 patients were randomized to SED and 504 were randomized to CSC. The area under the curve of oxygen desaturation was significantly lower for SED (23.6 s·%) than for CSC (88.0 s·%; P = .028), providing evidence that SEDASYS provided less over-sedation than current standard of care with benzodiazepine/opioid.  SEDASYS patients were significantly more satisfied than CSC patients (P = .007). Clinician satisfaction was greater with SED than with CSC (P < .001). SED patients recovered faster than CSC patients (P < .001). The incidence of adverse events was 5.8% in the SED group and 8.7% in the CSC group.

Donald E. Martin, MD, associate dean for administration at Pennsylvania State Hershey College of Medicine and chair of the Section on Clinical Care at the American Society of Anesthesiologists (ASA), expressed concerns about the safety of the device.  Dr. Martin (Gastroenterology and Endoscopy News, November 2010, 61:11) was quoted as saying, “SEDASYS is requested to provide minimal to moderate sedation and yet the device is designed to administer propofol in doses known to produce general anesthesia.”

Dr. Martin added that studies to date have shown that some patients who had  propofol administered by SEDASYS experienced unconsciousness or respiratory depression (Digestion 2010;82:127-129, Maurer WG, Philip BK.). In the largest prospective, randomized trial evaluating the safety of the device compared with the current standard of care, five patients (1%) experienced general anesthesia with SEDASYS. The ASA also voiced concern that SEDASYS could be used in conditions that do not comply with the black box warning in the propofol label, namely that propofol “should be administered only by persons trained in the administration of general anesthesia and not involved in the conduct of the surgical/diagnostic procedure.”

Anesthetists, emergency room doctors, and trauma helicopter nurses are trained in the administration of general anesthesia. Gastroenterologists and endoscopy nurses are almost never experts in airway management.  For this reason, propofol anesthetics for endoscopy are currently the domain of anesthesiologists and nurse anesthetists.

In my phone conversation regarding the automated propofol-infusion system, I told the marketing company’s representative that in my opinion a machine that infused propofol without an airway expert present could be unsafe.  The marketing consultant responded that in parts of the Northeastern United States, including New York City, many GI endoscopies are done with the assistance of an anesthesia provider administering propofol.  If SEDASYS were to be approved, the devices could replace anesthesiologists.

In the current fee-for-service model of anesthesia billing, anesthesiologists and CRNA’s bill insurance companies or Medicare for their professional time.  If machines replace anesthesiologists and CRNA’s, the anesthesia team cannot send a fee-for-service bill for professional time.  The marketing consultant foresaw that with the advent of ObamaCare and Accountable Care Organizations, if a health care organization is paid a global fee to take care of a population rather than being paid a fee-for-service sum, then perhaps the cheapest way to administer propofol sedation for GI endoscopy would be to replace anesthesia providers with SEDASYS machines.

A planned strategy is to have gastroenterologists complete an educational course that would educate them on several issues.  Key elements of the course would be: 1) anesthesiologists are required if deep sedation is required, 2) SEDASYS is not appropriate if the patient is ASA 3 or 4 or has severe medical problems, 3) SEDASYS is not appropriate if the patient has risk factors such as morbid obesity, difficult airway, or sleep apnea, and 4) airway skills are to be taught in the simulation portion of the training.  Specific skills are chin life, jaw thrust, oral airway use, nasal airway use, and bag-mask ventilation.  Endotracheal intubation and LMA insertion are not to be part of the class.  If the endoscopist cannot complete the procedure with moderate sedation, the procedure is to be cancelled and rescheduled with an anesthesia provider giving deep IV sedation.

Some anesthesiologists are concerned about being pushed out of their jobs by nurse anesthetists.  It may be that some anesthesiologists will be pushed out of their jobs by machines.

I’ve been told that the marketing plan for SEDASYS is for the manufacturer to give the machine to a busy medical facility, and to only charge for the disposable items needed for each case. The disposable items would cost $50 per case. In our surgery center, where we do 5,000 cases per year, this would be an added cost of $25,000 per year. There would be no significant savings, because we do no use anesthesiologists for most gastroenterology sedation.

There have been other forays into robotic anesthesia, including:

1) The Kepler Intubation System (KIS) intubating robot, designed to utilized video laryngoscopy and a robotic arm to place an endotracheal tube (Curr Opin Anaesthesiol. 2012 Oct 25. Robotic anesthesia: not the realm of science fiction any more. Hemmerling TM, Terrasini N. Departments of Anesthesia, McGill University),

2) The McSleepy intravenous sedation machine, designed to administer propofol, narcotic, and muscle relaxant to patients to control hypnosis, analgesia, and muscle relaxation. (Curr Opin Anaesthesiol. 2012 Dec;25(6):736-42. Robotic anesthesia: not the realm of science fiction any more. Hemmerling TM, Terrasini N.)

3) The use of the DaVinci surgical robot to perform regional anesthetic blockade. (Anesth Analg. 2010 Sep;111(3):813-6. Epub 2010 Jun 25. Technical communication: robot-assisted regional anesthesia: a simulated demonstration. Tighe PJ, Badiyan SJ, Luria I, Boezaart AP, Parekattil S.).

4) The use of the Magellan robot to place peripheral nerve blocks (Anesthesiology News, 2012, 38:8)

Each of these applications may someday lead to the performance of anesthesia by an anesthesiologist at geographical distance from the patient.  In an era where 17% of the Gross National Product of the United States is already being spent on health care, one can question the logic of building expensive technology to perform routine tasks like I.V. sedation, endotracheal intubation, or regional block placement.  The new inventions are futuristic and interesting, but a DaVinci surgical robot costs $1.8 million, and who knows what any of these anesthesia robots would sell for?  The devices seem more inflationary than helpful at this point.

Will robots replace anesthesiologists?  Inventors are edging in that direction.  I would watch the peer-reviewed anesthesia journals for data that validates the utility and safety of any of these futuristic advances.

It will be a long time before anyone invents a machine or a robot that can perform mask ventilation.  SEDASYS is designed for conscious sedation, not deep sedation or general anesthesia.  Anyone or anything that administers general anesthesia without expertise in mask ventilation and all facets of airway management is courting disaster.

NOTE: In March of 2016, Johnson & Johnson announced that they were going to stop selling the SEDASYS system due to slow sales and company-wide cost cutting. The concept of Robot Anesthesia will have to wait for some future development, if ever, if it is to ever become an important part of the marketplace.

 

The most popular posts for laypeople on The Anesthesia Consultant include:

How Long Will It Take To Wake Up From General Anesthesia?

Why Did Take Me So Long To Wake From General Anesthesia?

Will I Have a Breathing Tube During Anesthesia?

What Are the Common Anesthesia Medications?

How Safe is Anesthesia in the 21st Century?

Will I Be Nauseated After General Anesthesia?

What Are the Anesthesia Risks For Children?

 

The most popular posts for anesthesia professionals on The Anesthesia Consultant  include:

10 Trends for the Future of Anesthesia

Should You Cancel Anesthesia for a Potassium Level of 3.6?

12 Important Things to Know as You Near the End of Your Anesthesia Training

Should You Cancel Surgery For a Blood Pressure = 178/108?

Advice For Passing the Anesthesia Oral Board Exams

What Personal Characteristics are Necessary to Become a Successful Anesthesiologist?

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Published in September 2017:  The second edition of THE DOCTOR AND MR. DYLAN, Dr. Novak’s debut novel, a medical-legal mystery which blends the science and practice of anesthesiology with unforgettable characters, a page-turning plot, and the legacy of Nobel Prize winner Bob Dylan.

KIRKUS REVIEW

In this debut thriller, tragedies strike an anesthesiologist as he tries to start a new life with his son.

Dr. Nico Antone, an anesthesiologist at Stanford University, is married to Alexandra, a high-powered real estate agent obsessed with money. Their son, Johnny, an 11th-grader with immense potential, struggles to get the grades he’ll need to attend an Ivy League college. After a screaming match with Alexandra, Nico moves himself and Johnny from Palo Alto, California, to his frozen childhood home of Hibbing, Minnesota. The move should help Johnny improve his grades and thus seem more attractive to universities, but Nico loves the freedom from his wife, too. Hibbing also happens to be the hometown of music icon Bob Dylan. Joining the hospital staff, Nico runs afoul of a grouchy nurse anesthetist calling himself Bobby Dylan, who plays Dylan songs twice a week in a bar called Heaven’s Door. As Nico and Johnny settle in, their lives turn around; they even start dating the gorgeous mother/daughter pair of Lena and Echo Johnson. However, when Johnny accidentally impregnates Echo, the lives of the Hibbing transplants start to implode. In true page-turner fashion, first-time novelist Novak gets started by killing soulless Alexandra, which accelerates the downfall of his underdog protagonist now accused of murder. Dialogue is pitch-perfect, and the insults hurled between Nico and his wife are as hilarious as they are hurtful: “Are you my husband, Nico? Or my dependent?” The author’s medical expertise proves central to the plot, and there are a few grisly moments, as when “dark blood percolated” from a patient’s nostrils “like coffee grounds.” Bob Dylan details add quirkiness to what might otherwise be a chilly revenge tale; we’re told, for instance, that Dylan taught “every singer with a less-than-perfect voice…how to sneer and twist off syllables.” Courtroom scenes toward the end crackle with energy, though one scene involving a snowmobile ties up a certain plot thread too neatly. By the end, Nico has rolled with a great many punches.

Nuanced characterization and crafty details help this debut soar.

Click on the image below to reach the Amazon link to The Doctor and Mr. Dylan:

41wlRoWITkL

Learn more about Rick Novak’s fiction writing at ricknovak.com by clicking on the picture below:  

DSC04882_edited

 

 

HOW DOES A SURGERY CENTER INVESTIGATE IF A SURGEON IS PRACTICING BELOW THE STANDARD OF CARE?

the anesthesia consultant

Physician anesthesiologist at Stanford at Associated Anesthesiologists Medical Group
Richard Novak, MD is a Stanford physician board-certified in anesthesiology and internal medicine.Dr. Novak is an Adjunct Clinical Professor in the Department of Anesthesiology, Perioperative and Pain Medicine at Stanford University, the Medical Director at Waverley Surgery Center in Palo Alto, California, and a member of the Associated Anesthesiologists Medical Group in Palo Alto, California.
email rjnov@yahoo.com
phone 650-465-5997

Clinical Case for Discussion:    You are the Medical Director of a freestanding surgery center.  A surgeon at the facility has a serious perioperative complication which leads to a bad outcome.  You believe that his management was below the standard of care.  What do you do?

Discussion:    You put on your best Dirty Harry sneer and say, “Punk, we don’t want your kind in these parts no more.”  Then you wake up from your daydream, and deal with the reality of an unpleasant responsibility.  Playing policeman with your surgical colleague’s privileges is not on any anesthesiologist’s Top Ten list.

There is a growing trend of surgical cases moving away from hospitals to freestanding facilities.   Each of these outposts must have medical leadership.  Anesthesiologists are ideally suited for Medical Director jobs, because of their training and expertise in perioperative patient care.  In addition, duties include quality assurance (QA) monitoring, setting policies and procedures, preoperative consultation regarding appropriateness of particular patients for the facility, and medical staff credentialing.

The phrase “Standard of Care” is defined as “the level at which an ordinary, prudent professional having the same training and experience in good standing in a same or similar community would practice under the same or similar circumstances.”  When a physician is suspected of practicing below the standard of care, the facility he or she is practicing at may initiate an investigation of his or her clinical practice.  In addition, if there was an adverse patient outcome, the medical malpractice system may initiate legal action to investigate the physician’s role in the adverse outcome.

This column will discuss only the investigation of the physician by the medical facility, and will not address the workings of the medical malpractice system.

When an adverse patient outcome occurs, the QA system at a surgery center begins with telephone calls to the Medical Director to inform him or her of the event, followed by written incident reports to document the details of what occurred.  The Medical Director is responsible for screening for:

(1) errors in the system which contributed to the patient’s outcome,

(2) errors in judgment, or

(3) practice below the standard of care.

Goals are to:

a)  improve any system problem which lead to the complication,

b)  identify  educational opportunities to prevent future incidents, and

c) identify if an individual may have practiced below the standard of care.  The medical-legal system defines standard of care as what a reasonably competent practitioner of that specialty would do in the same setting.

What will you do as Medical Director if after careful review of the medical records and incident reports, you believe the surgeon’s management was below the standard of care?   Each facility you work at, including a hospital or any surgery center, has a document called the Medical Staff Bylaws.  Most physicians throw their copy into a file cabinet and never read it.  In a case like we are examining today, the Bylaws are the road map for what to do next.  A typical Bylaw pathway might be as follows:   (Reference:  Bylaws of the Waverley Surgery Center in Palo Alto, California.)

(1) Investigation.  The QA committee, with representatives of all specialties, reviews the case.   (At  different institutions, this committee may have  a different name,  such as the Medical Advisory Committee, or the Medical Care Evaluation Committee.)   They may appoint an Ad Hoc Investigation Committee of relevant specialties to gather facts and circumstances.  The Investigation Committee will report back to the QA committee with their consensus.

(2) Interview.  The physician is interviewed by the QA committee.

(3) Actions.  The QA committee may:   a) take no action,  b) issue a warning,  c) recommend a term of probation,  d) recommend a reduction or suspension of privileges, or  e) recommend suspension or revoking of medical staff membership.

(4) Request for a hearing.  The physician may appeal and request a hearing following suspension or revoking of privileges.  An Ad Hoc Hearing Committee composed of unbiased members of the medical staff not previously involved in the investigation is chosen.  The physician is physically present for the hearing, and may have an attorney present.  The meeting is tape recorded, and all evidence is heard.  The majority decision of the Hearing Committee is usually final.  A system for appeals exists.

(5) Any suspension or revocation of privileges must be reported to the Medical Board of California, and the National Practitioner Data Bank.  Being reported to these two is a very big deal.  In the surgeon’s future, every application to every hospital or surgery center, and every medical license renewal would have to include this information.

Despite the obvious perks of stretch limousines, penthouse suites, and groupies,  the Medical Director job comes with some serious responsibilities.  Investigating another physician’s practice is difficult, time-consuming, and can be emotionally taxing for everyone involved.  Ignoring potentially substandard care is a mistake, however, that can result in further mishaps and the possibility of further patient harm in the future.

Dirty Harry exists for doctors too, but it is a system, not an individual, that does the dirty work. The Quality Assurance investigative system is a chore and and obligation for a Medical Director, but it’s an important and essential chore.

 

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Published in September 2017:  The second edition of THE DOCTOR AND MR. DYLAN, Dr. Novak’s debut novel, a medical-legal mystery which blends the science and practice of anesthesiology with unforgettable characters, a page-turning plot, and the legacy of Nobel Prize winner Bob Dylan.

KIRKUS REVIEW

In this debut thriller, tragedies strike an anesthesiologist as he tries to start a new life with his son.

Dr. Nico Antone, an anesthesiologist at Stanford University, is married to Alexandra, a high-powered real estate agent obsessed with money. Their son, Johnny, an 11th-grader with immense potential, struggles to get the grades he’ll need to attend an Ivy League college. After a screaming match with Alexandra, Nico moves himself and Johnny from Palo Alto, California, to his frozen childhood home of Hibbing, Minnesota. The move should help Johnny improve his grades and thus seem more attractive to universities, but Nico loves the freedom from his wife, too. Hibbing also happens to be the hometown of music icon Bob Dylan. Joining the hospital staff, Nico runs afoul of a grouchy nurse anesthetist calling himself Bobby Dylan, who plays Dylan songs twice a week in a bar called Heaven’s Door. As Nico and Johnny settle in, their lives turn around; they even start dating the gorgeous mother/daughter pair of Lena and Echo Johnson. However, when Johnny accidentally impregnates Echo, the lives of the Hibbing transplants start to implode. In true page-turner fashion, first-time novelist Novak gets started by killing soulless Alexandra, which accelerates the downfall of his underdog protagonist now accused of murder. Dialogue is pitch-perfect, and the insults hurled between Nico and his wife are as hilarious as they are hurtful: “Are you my husband, Nico? Or my dependent?” The author’s medical expertise proves central to the plot, and there are a few grisly moments, as when “dark blood percolated” from a patient’s nostrils “like coffee grounds.” Bob Dylan details add quirkiness to what might otherwise be a chilly revenge tale; we’re told, for instance, that Dylan taught “every singer with a less-than-perfect voice…how to sneer and twist off syllables.” Courtroom scenes toward the end crackle with energy, though one scene involving a snowmobile ties up a certain plot thread too neatly. By the end, Nico has rolled with a great many punches.

Nuanced characterization and crafty details help this debut soar.

Click on the image below to reach the Amazon link to The Doctor and Mr. Dylan:

41wlRoWITkL

Learn more about Rick Novak’s fiction writing at ricknovak.com by clicking on the picture below:  

DSC04882_edited

 

 

Out-of-Network Surgery Centers and the Anesthesiologist

the anesthesia consultant

Physician anesthesiologist at Stanford at Associated Anesthesiologists Medical Group
Richard Novak, MD is a Stanford physician board-certified in anesthesiology and internal medicine.Dr. Novak is an Adjunct Clinical Professor in the Department of Anesthesiology, Perioperative and Pain Medicine at Stanford University, the Medical Director at Waverley Surgery Center in Palo Alto, California, and a member of the Associated Anesthesiologists Medical Group in Palo Alto, California.
email rjnov@yahoo.com
phone 650-465-5997

Clinical Case for Discussion:

You’re planning a career in private practice anesthesia following your residency. One night during a dream, a wizened man with a long white beard speaks to you and says, “Beware of lateral spread, and the OON model….” He retreats into a swirling fog, and you wake up in a cold sweat. What was he talking about, and why should you care?

Discussion:

Whatever model of anesthesia practice you are employed in, your income will depend on two things: how many hours you spend giving anesthetics, and how much you are paid per hour. In a sense operating room anesthesia providers are like taxi cab drivers—the more rides we give, the more fares we collect. The busier your surgeons are, the busier you will be. If your surgeons operate from 7:30 a.m. until 3:30 p.m., you will be earning money for 8 hours, minus break times between cases. If your surgeons operate from 7:30 a.m. until noon, your income may be halved.

Ideally your anesthesia group will employ n anesthesiologists, working in n rooms, for 8 hours in each room. What if the number of operating rooms your group covers each day increases to n+5, but the total number of surgeries stays constant? This is happening in the surgical/anesthesia world today for several reasons. We call this phenomenon “lateral spread,” and it refers to the same surgical volume spreading out over more operating rooms, all starting at the same 7:30 a.m. time, yet now finishing hours earlier.

Reasons behind lateral spread include: (1) Surgeons prefer to operate at 7:30 a.m. when they are not following another surgeon, and therefore will not to be delayed. They can schedule their afternoon as clinic or personal time, instead of waiting to do their first case at an undependable later time slot; (2) Some busy surgeons like to run their cases concurrently in two operating rooms, so that they can operate in the second room while the first room is turning over between cases. This enables them to do more cases in less time; and (3) Many surgeons are opening their own operating rooms in freestanding surgery centers or in their offices, which gives them the advantages of controlling their own operating room schedule and environment, and the opportunity to make extra income from owning and billing for the operating room.

This last point, the extra income from owning a share in the operating room, has become a significant business issue in the current surgical/anesthetic world outside academia. By owning an operating room and then referring cases to that operating room, it’s possible for a surgical specialist to augment their surgical income significantly.

Note: It’s unusual for anesthesiologists to own the surgery center and enjoy this same advantage. Why? Because the surgeon has patients to refer to the surgery center, and most surgeons see no advantage in diluting their income by sharing it with anesthesiologists who do not refer any patients to the surgery center. (An exception to this is an anesthesiologist who is a pain specialist, and who refers his or her patients to the surgery center, thus bringing value and money to the surgery center.) A surgery center may employ an anesthesiologist as a Medical Director, and may allow a small ownership share in the surgery center to the anesthesiologist for this role. In full disclosure, I am the Medical Director of Waverley Surgery Center in downtown Palo Alto.

Waverley Surgery Center is contracted with all major insurance plans, but some surgery centers remain out-of-network (OON) with insurers. Why remain out of network? Let’s look at an example. Let’s say a patient’s health insurance pays 80% of a usual-and-customary rate for contracted physicians and health care facilities, and pays only 50% to out-of network physicians and facilities. But what if the OON facility chooses to charge a markedly inflated charge to out-of-network patients? For example, what if the facility charges $35,000 for a surgical procedure when the in-network, contracted rate is $6000? What if the insurance company then pays the facility 50% of the $35,000, or $17,500?

What if the OON facility waives the patient’s co-payment, and waives the balance of the bill not paid by the insurance company? The patient is not upset, and the facility receives a larger payment than if they were contracted with the insurance companies. It is not unusual to see out-of-network reimbursement be as much as five times higher than contracted reimbursement rates. Insurance companies have filed litigation against out-of-network ambulatory surgery centers, attempting to recover a substantial portion of the OON fees on a number of theories, including that a) the waiver of the co-pay is fraudulent, and b) waiving the co-pay is illegal interference with the contract between the patient and the payor. (www.surgistrategies.com/articles/2008/12/2009-outlook-ambulatory-surgery-centers.aspx December 18, 2008).

In 2009 HealthNet of New Jersey sued Wayne (N.J.) Surgical Center, claiming that the center engaged in fraud when it waived patients’ coinsurance payments so they would use the facility. An Appellate Court rejected HealthNet’s claim, and sided with the surgery center (www.ama-assn.org/amednews/2009/12/07/gvsc1207.htm).

Will insurance companies eventually cease to pay higher levels to OON facilities? Will the government and courts move to outlaw this practice in some way? Perhaps, but for now the playing field includes OON surgery centers making healthy profits. And the increased income from owning surgery centers provides a powerful monetary incentive for surgeons to move as many cases as possible from hospitals into these surgery centers.

Lateral spread to multiple freestanding locations complicates anesthesia scheduling and manpower. The surgical schedule may require n anesthesiologists at 7:30 a.m. for certain days, n + 3 anesthesiologists for other days, and n – 3 anesthesiologists on still other days. If the group hires n + 3 fulltime anesthesia partners, then on certain days they may have 3 to 6 more anesthesiologists than they have rooms. No cases = no income for the day, which makes people unhappy. If the group hires n – 3 fulltime anesthesia partners, then on some days they may be 3 to 6 anesthesiologists short at 7:30 a.m. How does a group handle this problem? It helps to have flexibility, i.e. individuals whose job description is to be available 5 days a week but are guaranteed only to work 3 out of 5 days. It helps to have relationships with other anesthesia groups, so that when your group is short on manpower, the other group(s) may have extra anesthesiologists to lend for a day.

My advice: Be thankful for your free time those days when you’re finished at noon, and be thankful for copious income on the days when you’re working until 7 p.m. You’ll have plenty of both kinds of days.

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Published in September 2017:  The second edition of THE DOCTOR AND MR. DYLAN, Dr. Novak’s debut novel, a medical-legal mystery which blends the science and practice of anesthesiology with unforgettable characters, a page-turning plot, and the legacy of Nobel Prize winner Bob Dylan.

KIRKUS REVIEW

In this debut thriller, tragedies strike an anesthesiologist as he tries to start a new life with his son.

Dr. Nico Antone, an anesthesiologist at Stanford University, is married to Alexandra, a high-powered real estate agent obsessed with money. Their son, Johnny, an 11th-grader with immense potential, struggles to get the grades he’ll need to attend an Ivy League college. After a screaming match with Alexandra, Nico moves himself and Johnny from Palo Alto, California, to his frozen childhood home of Hibbing, Minnesota. The move should help Johnny improve his grades and thus seem more attractive to universities, but Nico loves the freedom from his wife, too. Hibbing also happens to be the hometown of music icon Bob Dylan. Joining the hospital staff, Nico runs afoul of a grouchy nurse anesthetist calling himself Bobby Dylan, who plays Dylan songs twice a week in a bar called Heaven’s Door. As Nico and Johnny settle in, their lives turn around; they even start dating the gorgeous mother/daughter pair of Lena and Echo Johnson. However, when Johnny accidentally impregnates Echo, the lives of the Hibbing transplants start to implode. In true page-turner fashion, first-time novelist Novak gets started by killing soulless Alexandra, which accelerates the downfall of his underdog protagonist now accused of murder. Dialogue is pitch-perfect, and the insults hurled between Nico and his wife are as hilarious as they are hurtful: “Are you my husband, Nico? Or my dependent?” The author’s medical expertise proves central to the plot, and there are a few grisly moments, as when “dark blood percolated” from a patient’s nostrils “like coffee grounds.” Bob Dylan details add quirkiness to what might otherwise be a chilly revenge tale; we’re told, for instance, that Dylan taught “every singer with a less-than-perfect voice…how to sneer and twist off syllables.” Courtroom scenes toward the end crackle with energy, though one scene involving a snowmobile ties up a certain plot thread too neatly. By the end, Nico has rolled with a great many punches.

Nuanced characterization and crafty details help this debut soar.

Click on the image below to reach the Amazon link to The Doctor and Mr. Dylan:

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Learn more about Rick Novak’s fiction writing at ricknovak.com by clicking on the picture below:  

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