Gabriel M. Gurman, MD
I practiced anaesthesiology for almost six decades. Interesting enough, only in the last years have I had the time to think more about this profession, which became my second nature and the goal of my principal activity, starting with my youth years and up to this very moment.
For a long time I saw anaesthesiology as a multifaceted speciality, a notion more related to what we call in the last decades perioperative medicine. Once upon a time a narrow profession, mainly restricted to operating room (OR) activity, anaesthesiology became in the last part of the 20th century a speciality oriented towards many aspects of patient care. As I had the occasion to emphasize not only once in my previous editorials, about one-third of our daily activity takes place outside the OR, from pre-hospital care to critical care, pain management, and sedation for patients in need of invasive diagnostic and therapeutic procedures.
This subject is far from being new, and this is why I see no reason to go back to this essential aspect of our daily routine. But in the last period of time I dedicated a good part of my thoughts to a completely different angle regarding not the profession itself but our own professional existence.
I asked myself a very simple question: What would be the pattern of a successful anaesthesiologist? To get a decent answer to this question I searched the pertinent sources and got an interesting list: solid clinical judgment, manual skills and ability, scientific approach, professional curiosity, leadership, ability to cope with changing situations, and to work as part of a team. For many of our readers this short list is more than obvious and it is not my intention to elaborate. But my thoughts went further to the next question: What kind of ‘character’ are we supposed to ‘play’ almost every single day? Surprisingly or not, I reached the conclusion that during our routine activity we are asked to play more than one role, besides that classical one, that of being part of the mechanism of patient management! Here are some of those roles we, the anaesthesiologists, are supposed to fulfil during our professional career.
Recently I had the opportunity to present a rather original idea, comparing the anaesthesiologist with a backstage director of a show or movie. This comparison has its origin from the simple and universal fact that the vast majority of the public and hospital patients have a very (if at all!) slight idea about the role of the anaesthesiologist as a vital part of the process that is supposed to assure the patient’s safety and his/her wellbeing during surgical (and often nonsurgical) treatment. Very much like the backstage director, the anaesthesiologist remains hidden from view and the appreciation of the patient and his/her family. But, in fact, we are in charge with everything: we prepare the ‘show’, we take care of the ‘settings’, we are responsible for the ‘subject’, and, often, we are obliged to instruct the ‘actors’ in order to prevent unwanted events.
Interesting enough, this is exactly what an anonymous writer published in the prestigious British newspaper The Guardian last year: ‘You have to get used to being invisible as an anaesthetist. A large percentage of the public had no idea that we are medically qualified … Patients always remember the name of their surgeon, never that of the anaesthetist.’
True, a careful observer would easily remark a gradual, positive progress regarding public opinion about the place of the anaesthesiologist in the management of the patient’s medical condition, but much more is to be done in order to reach a satisfactory situation from this point of view.
Also we are asked, quite often, to play the role of a psychologist. Some studies show that reducing the preoperative anxiety could contribute to the postoperative analgesia. It means that one of our specific tasks is to ease the preoperative stage, by trying to explain to the patient everything related to his/her condition and assure about the smooth perioperative course we are preparing for each of them.
We, believe it or not, must sometimes use our amateur psychologist gifts to ease the charged atmosphere of the OR, trying to calm the situation, taking care not only once of the surgeon’s mood. But more than this, sitting down every single day with a critical care patient’s family, we need a psychological approach, trying to understand who exactly are the people in front of us, what they expect from the treatment, and the degree of their ability to understand the patient’s condition and cope, sometimes, with bad news.
Since the basic request for progress is the continuous professional curiosity, the anaesthesiologist is also a researcher. Even today, in the era of modern medicine, surrounded by excellent equipment, very efficient drugs, and a large series of bedside laboratory and imaging investigations, our daily activity presents the clinician with a lot of unanswered questions. The solution is, in most of the cases, careful and well-organized studies, with the aim of finding things and clinical processes not yet enough known and understood. Some of us find the time to go to experimental laboratories and try to find the solutions to clinical problems by testing them on animals. Few anaesthesiologists go to fundamental aspects of medicine, like molecular biology, and provide the necessary theoretical basis for clinical progress.
We, like any other medical specialty, but sometimes more than others, are teachers. We teach everybody, laymen (for instance the technique of cardiopulmonary resuscitation), students, residents, young specialists, and last but not least the paramedical professions, nursing, physiotherapy, etc. Anaesthesiology was the first medical profession in Europe that created, more than ten years ago, a school for ‘teaching the teacher’, which curriculum included all the ‘secrets’ of a good teaching system and the successful presentation of a lecture. We teach our ‘pupils’ the art of keeping the audience’s attention vivid, by using various methods, among them the technique of stand-up presentation! So, all of a sudden, we become actors, obliged to present the details of a lecture in a manner that would prevent boredom and postprandial sleep.
Unlike many other medical fields, anaesthesiology demands a good and deep knowledge regarding the technology of the medical equipment. I am not aware of any other medical profession which felt the need to edit textbooks on subjects like physics, as we did, decades ago, for the anaesthesiologist! We also need to be gifted technicians in order to uncover, on the spot, technical errors and find immediate alternative solutions. In many countries the anaesthesiologist covers the function of the heart-lung machine technician. The transoesophageal echocardiography, a technology which in the last decade became part of the everyday monitoring equipment, demands a profound level of technical knowledge for understanding the rather cumbersome images.
The anaesthesiologist is too often an organizer of the workplace. In many hospitals, all over the continent, our colleagues are directors of operating theatres, and succeed to cope with the various demands of every single surgical specialty. They are asked to prepare the necessary background for taking care of serious emergencies which demand life-saving surgical procedures. Today the ORs are considered in many corners of our world as ‘factories of money’, the production pressure is sometimes very heavy, and only a skilled organizer could solve the daily problems created by this aspect of our daily activity.
We are also supposed to be good managers. Anaesthesia stopped being a cheap way of treating patients. A good part of any hospital budget goes to anaesthesia equipment, expensive drugs, and manpower. Some 1% of the USA gross national product (GNP) is spent for critical care. New legislation in many countries stipulates a limited number of hours spent by a physician in the hospital. In other words, more MD positions are necessary in order to cover the daily requirements of a busy anaesthesia department. Today a good chief of department is not only that person with the greatest knowledge and the best manual skills, but also he or she who would be able to face the increasing demands by carefully calculating the resources and saving budget anytime and anywhere possible. In many hospitals a negative budgetary balance is not accepted anymore and the blame in any case falls on the director/manager.
Finally, today the need for a broad understanding of medicolegal problems becomes obvious and the anaesthesiologist is faced with the new burden, that of trying to possess as much as possible of a lawyer’s knowledge. The number of medicolegal litigations is continuously increasing and our profession occupies a top place in the list of medical fields with the highest liability. Some of us, true not many, feeling the daily malpractice pressure, decided to start a new career, by graduating law school. Most of them do not quit their medical practice, but they are more than helpful in the process of risk management in cases connected to their primary profession.
I am aware of the fact that most of the points mentioned above are very well known to our readers. My intention was just to put together all those aspects that create a clear contrast with the ‘classical’ view of Anaesthesiology as a narrow profession, limited to patient management and almost to no other field of interest. I do hope that I succeeded in presenting the modern anaesthesiologist as a professional with a large perception of his/her duties, a physician involved in many aspects of medical activities, all of them needing experience, an open mind, and healthy judgment. But above anything, we stay human, we save lives, we are connected to our patients and substantially contribute to their wellbeing.
All of the above should represent a true source of arguments in the permanent struggle to bring as many as possible young colleagues to our profession. The today the anaesthesiologist is far away from the ‘gas man’ description, he/she is involved in many aspects of healthcare and deserves the appreciation of peers and public at large.
Yes, appreciation and not glory. But as a very nice cartoon says: ‘Anaesthesiologists have been born in order that the surgeons could have their heroes, too!’