As technology explodes and our patients become more complex…it’s apparent to me that although the scope of our practice is changing, we can’t and shouldn’t be pushed into changing the principles of our practice just because there is economic and political pressure to do so.
We have to separate the important stuff (patient centricity, procedural awareness, safety, physiological risk benefit analysis, etc.) from the dogma (we’ve always done it like THIS and scheduled it like THAT in the OR) We have to protect ourselves from the economic constraints/pressures of health care and parent institutions: for us to be more productive with less information and less support. It seems to me that the best way to do this is for anesthesiologists and interventional medical/radiology proceduralists to align themselves. We have to try to make this happen.
Here’s a simple illustration:
In my place almost 80% of our NORA patients come to procedure with NO H&P…and most of the time the proceduralist has never seen them. No one has even written a note affirming the appropriateness of the patient for the booked procedure: an internist, oncologist or other (PA or NP) booked it from somewhere far way through some electronic instant access system. The hospital likes this: more patients more revenue. We are asked to “evaluate” the patient before we even have accurate info….would this ever happen in the OR??? NO. When I was a resident we had no preop clinic…we did a lot of same day pre-ops and 20% of the patients were cancelled. It was bad for the patients and it was a reckless financial “non-strategy” for the OR…we CANNOT go through that phase again with NORA…we know it doesn’t work.
Our medical and radiology colleagues have not experienced this with us, we have to educate them. We need the infrastructure to support a Pre-op/Pre-procedural evaluation phase before we (anesthesiologists) are even involved as physicians. Who should pay for this?? If someone wants to pay me my rate for performing H&Ps, and waste my anesthesiology skills that’s fine but it’s a waste of money and already scare resources. H&Ps are easily included as administrative/nursing/PA functions.
There is, however, no substitute for a proceduralist’s evaluation. Give me an H&P with properly acquired (not the patient’s recollection) medical information AND a proceduralists statement that the procedure is appropriate and I will anesthetize the patient and make sure they tolerate the procedure…no matter how low their EF, how bad their lungs or how miserable their airway is. That’s my expertise…Would we send someone to the OR without a surgical opinion being rendered?? NO…This is not DOGMA this is PRINCIPLE…our NORA patients are sicker than the OR patients sometimes…and the procedures more complex and more demanding from a technical standpoint. Why are we overlooking these necessary steps??
Is it the pressure of the almighty buck…and is it real…or to hospitals and insurance companies overstate their “poverty”…of course infrastructure costs money. Facility fees are often “secret” and we cannot write an ROI without complete data…but what’s the cost of a missed co-morbidity or an inappropriate procedure or an unanticipated complication? An extra preop nurse or anesthesia tech is peanuts compared to the cost of bad outcomes. Thoughts??