Saturday, September 17, 2011

Overpaid Porters

Cataract surgery when I was in medical school was a 2 hour surgery under general anaesthetic with a 7 day recovery in hospital. Anyone who operates on eyes of course deserves to be well paid and ophthalmologists were even in those days. This blog by the is not a complaint about ophthalmology although I could probably rant about that for a while.

Cataract surgery is now a 15 minute procedure done under topical anaesthetic. The ophthalmologist still gets the same fee in inflation adjusted dollars which I promised above not to complain about.

When I arrived in my current city, cataracts were done under retro or peribulbar block with the anaesthesiologist providing the block. We had a nice deal in those days where the anaesthesiologist got a minimum of one third of the surgeon's fee which is a nice chunk of change for a day's work. That's why they were known as retro-dollar blocks. I never learned to do them where I trained and as I tell anybody who asks, "there are some places even I won't stick a needle.". Fortunately we were in a revenue sharing group and there was no reason for me to learn to do them. Times changed, some cataracts were farmed out to private clinics and the rest of them centralized in another hospital. Because a small group of individuals were in the process of cornering the market on cataracts, the province's anaesthesiologists actually voluntarily reduced the fee and the extra money went to other areas.

The joke among ophthalmologists in that era was that while they were capable of doing the blocks themselves, if the anaesthesiologist wasn't present, who was going to push the stretchers in and out of the OR?

Several years later I did a locum in a hospital in another province that still did cataracts. The fee schedule in that province was such that you couldn't make large amounts of money so I actually got to do the list. This list was entirely under topical. The ophthalmologist explained how to do the topical. For 8 hours I put in various eye drops and lidocaine jelly into seniors' eyes and pushed them in and out of the OR. It was a pleasant day, I felt like a bit of slut getting paid to do it and I joked with the nurses that I was just an overpaid porter.

Somewhat apropos as our department recently started doing endoscopy sedations. We started this gradually and just this month made the leap to full-time coverage of endoscopy. Sedating endocopies is an interesting process with the older patients, intensely stimulating parts of the procedure followed by less stimulating times, the high turnovers and the shared airways.

One of the gastroenterologists typifies the old joke about the definition of a colonoscope (a long black tube with an asshole at each end). This fellow has enthusiastically been using propofol for the past few years. He claims have done this uneventfully for years although the first thing I noticed when I first work in endo was how good the nurses were at bagging patients. He did agree to having us sedate his patients. This goodwill lasted about one session after which he "fired" our department, sending off a poison pen letter accusing us of all kinds of unsafe practices. One of his parting shots called us "just overpaid porters". What was worse for me, was the loud and vocal opposition from a small number of department members who believed that sedating a patient was an abuse of their considerable skills. Our GI friend didn't help much here.

The problem of course with anaesthesia is that we make it look so easy. This leads to things like GI, ER and sundry other specialists merrily sedating patients everywhere in the hospital. Drugs like propofol which have a large margin of safety are even more dangerous if only for the false sense of security they give the doctors. One thing I have learned over the years is that a good general anaesthetic is better than a bad sedation. We now have some short acting options which enable us to more safely sedate patients. The "more safely" is as I mentioned as safer or easier also means less respected or less feared. As site chief for anaesthesiology I feel I am responsible for all anaesthetics given in the hospital including those given by non-anes.

There is as I am becoming aware, a turf war in the US between endoscopists who believe they can safely sedate patients while looking up their bum and anaesthesiologists who say they can't. There is a little self-interest in both. In a private system it is cheaper for the patient or the insurer not to have an anaesthesiologist. At the same time endoscopy sedation offers employment for anaesthesiologists and generally a pleasant decently paid day. Our health region recently wanted to trial a servo system that would enable endoscopists to 'safely' sedate patients. They wanted anaesthesiologist to participate in the trials which we politely declined. There are of course studies both pro and con which largely depend on the bias of the person who ordered the study.

As we get better sedatives there are a lot of cases we currently do under general which could be done with local and sedation. Turf is an issue here. The operating room is "our house". If say, a surgeon wants to do some or all of his cases under local, this can be a loss of income. We can stay in the room "monitoring" and portering the patient or we can cool our heels at home or in the lounge. In eastern Canada where I first worked and trained, local cases were almost exclusively done in a local room where surgeons worked while nurses gave sedation. Occasionally we got a stat call to the local room but it usually worked out okay.

I like to think that by sedating patients I can achieve a perfect balance between comfort and safety. One of my mentors as a resident used to lecture me and the difference between being a professional and a technician. When one tries to get the best possible outcome for the patient you are being a professional. If you just show up and squirt in a little propofol, you are being a technician. I hope I am being that I am not just another overpaid porter.

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