Authors: Andrew Kadar, MD, Christine Doyle, MD, FASA, Rita Agarwal, MD, FAAP
Below, please find summaries of three presentations made at the recently concluded ANESTHESIOLOGY 2017, the annual meeting of the American Society of Anesthesiologists, which also serves as an international platform showcasing issues and innovations in our shared practice of anesthesiology. These summaries were prepared by three CSA leaders and selected based on their relevance to our specialty and potential impact to your practice.
Saturday, October 21 – Ellison C. Pierce Lecture: “Anesthesia Patient Safety: Closing the Gap Between Perception and Reality,” Robert Stoelting, MD
Review by Andrew Kadar, MD
The real challenge for improving patient safety depends not on identifying the risk or finding a solution, but from “closing the loop,” namely implementing that solution. Dr. Robert K. Stoelting emphasized that repeatedly during his Ellison C. Pierce Lecture, delivered on Saturday, October 21 at the 2017 ASA Annual Meeting.
Dr. Stoelting, who succeeded Ellison Pierce, MD, as president of the Anesthesia Patient Safety Foundation (ASPF), started his presentation by recounting the events that led to the founding of the organization. It took a “perfect storm” consisting of three elements. The first was a public perception of the danger of anesthesia stoked by media stories, particularly sensational ones such as an ABC’s 20/20 program aired in 1982 entitled “The Deep Sleep: 6000 Will Die or Suffer Brain Damage.” This coincided with the malpractice liability crisis caused by rapidly rising premiums. Finally, and crucially, a leader stepped forth to implement a solution. That leader, Dr. Pierce, first established a committee of the ASA dedicated to patient safety. This led to the creation of the APSF and the Closed Claims Project.
As preposterous as it now seems in hindsight, not everyone at the time supported the formation of an organization with the stated objective of promoting patient safety. In particular, the president of the AMA at the time wrote to Dr. Pierce advising against founding such a group, arguing that doing so would lead the public to perceive a greater danger than actually existed.
After all, he stated, “anesthesia was so very safe already.” He wrote these comments before the routine use of end-tidal CO2 monitors and pulse oximeters, before the ASPF-promoted pin indexed gas cylinders. And before the use of connectors that allow only the correct anesthetics to be put in vaporizers. In spite of these warnings, Dr. Ellison persisted and the APSF was created.
ASPF has encouraged the widespread use of many “fail safe” devices to guard against human error, including anesthesia machines that don’t allow delivering gas mixtures with less than 21 percent oxygen. It has also become the model for other specialties, with anesthesia and the ASPF widely admired for leading the way in efforts to promote greater patient safety.
Dr. Stoelting then focused on ongoing projects promoted by the ASPF. These include ending the underutilization of neuromuscular blocking monitoring with nerve stimulators. We know that excessive neuromuscular blockade poses a problem – we have the means to guard against it. Anesthesiologists must “close the loop,” use the known solution to eliminate the problem.
The same goes for excessive levels of oxygen for procedures above the shoulder leading to fire hazards, inadequate monitoring of opioid induced respiratory depression in the recovery room, and distractions in the OR, from electronic records to personal devices and loud music. We know that each of these poses a hazard and how to reduce it. What we need, and what the ASPF advocates for, is that anesthesiologists “close the loop,” implement solutions, follow up to make sure those efforts are providing the expected improvements, and reassessing if they are not.
In his concluding remarks, Dr. Stoelting urged us to take the lead in closing these loops and continuing to improve patient outcome and recovery
Monday, October 23 – “Women and the Power of Negotiation,” Sara Laschever, from the Carnegie Mellon Leadership & Negotiation Academy for Women, along with ASA Members Cynthia Lien, MD, Laura Dew, MD, and Judith Semo, JD
Review by Christine Doyle, MD, FASA
Sara Laschever is the co-author of Women Don’t Ask and Ask For It (with Linda Babcock), and led off with an excellent presentation about some of the reasons that women don’t negotiate well, and the direct and indirect costs of not doing so. Most people tend to think solely of the financial ramifications of inadequate negotiation, however the indirect costs include missed opportunities, limited advancement and career progress, and lessened career satisfaction. There may even be stress-related health consequences.
While there may be a multitude reasons that women don’t or won’t negotiate, it is vital that women ask for more, more often, and be willing to be told no, without taking it personally. She offered some tools and tricks for the attendees. More information is available on her web page, or at the Carnegie Mellon Leadership & Negotiation Academy for Women.
Dr. Lien spoke about leadership in academic anesthesiology. She emphasized that diversity has been shown to improve complex problem solving among teams as well as in research. Corporations with women on the Board or as C-Suite leaders do better than corporations without women in those positions.
The proportion of women within academic medicine is fairly even, but changes as research and administrative duties are added to their responsibilities. This is not just related to the age or years in practice, but is more than likely related to child bearing and rearing.
Dr. Dew spoke about more general issues in leadership. She made the distinction between mentorship and sponsorship. A sponsor is someone who will recommend you to others, which may be more important in the long-run than mentorship. Opportunities for sponsorship are not always obvious. Many occur during social or sporting events, such as golf.
Traditionally, this is where women do not engage in the same way as many men do. She also brought up the concept of “he-peating” — when a woman suggests an idea and it’s ignored, but a man repeats your idea and everyone loves it.
Judith Semo, an attorney who specializes in contracts, spoke about negotiating both for yourself and for your group. She emphasized that it is important to come to any negotiation with a plan and background information (comparable contract rates or terms, value of special training, etc.).
Women are rarely just negotiating for the current situation – we are also laying the groundwork for the next negotiation and our future within the group/institution. In addition, we need to know when it’s time to walk away.
Overall, this was a well-designed presentation from the Ad Hoc Committee on Women in Anesthesia, with great messages and great presenters.
Monday, October 23 – “Point-Counterpoint: A Mandatory Pre-Operative Pregnancy Testing Policy in Adolescent Girls Violates Patients’ Rights,” Paul Yost, MD, and Mark Singleton, MD
Review by Rita Agarwal, MD, FAAP
Dr. Yost started this panel by joking that both he and Dr. Singleton were discussing a topic that did not affect them personally, however as the fathers of daughters and caring physicians, it was an important issue to consider. Both Drs. Yost and Singleton are former Presidents of the CSA and practicing pediatric anesthesiologists. They have been involved with ASA leadership and were instrumental in guiding the ASA’s Policy of mandatory pregnancy testing.
Dr. Yost believes that mandatory pregnancy testing is an important part of the pre-anesthetic evaluation. He reviewed the literature on potential teratogenesis with various anesthetics. He discussed the significance of the recent FDA warning on anesthesia neurotoxicity in infants and pregnant mothers, and the increased risk of anesthesia during pregnancy.
He argued that the reliability of teenagers is suspect, and they have a tendency to “bend” the truth. He asked how many of us ever lied to our parents when we had been teenagers, and the majority of the room raised their hands. While the incidence of positive pregnancy tests is rare, it does happen and could effect the decision to proceed with surgery or alter the conduct of the anesthetic. Dr. Yost argued that it is the right thing to do and an essential part of our pre-operative evaluation.
Dr. Singleton presented an equally compelling argument against the routine, and in particular, uninformed pregnancy testing done at many institutions. Since he works at a number of hospitals, he informally surveyed their practices and found a great deal of variability in what was discussed with the patient and the family. Responses ranged from a thoughtful and informed approach to “we just need you to pee in a cup.”
He challenged the audience to consider the case of the positive pregnancy test and the HIPAA protections afforded the now emancipated minor child. It is mandatory that support is in place to handle these events in a sensitive and private manner. He also discussed literature that showed no real teratogenic problems in clinical studies and that a good history has been shown to be as accurate as a urine test in detecting pregnancy.
He reviewed the incidence of false-positive and false-negative tests and the consequences of them. There was quite a lively discussion following the presentation with the audience sharing their own experiences and reviewing their policies and procedures.