Wow,
Where to begin. Dr Sibert sounds like a great and very smart MD, but come on, a generalist?? You have got to be kidding. I am an internist working as a hospitalist and even I don't consider myself a generalist anymore. I follow patients for days to weeks, not months to years like a true generalist does in practice. I work with a pretty good group of anesthesiologists and they are proceduralists first and thinkers second. I didn't say they are not intelligent but their time horizon in the care of patients in the hospital is hours to days.  Of course she is offended by the question from the medicine resident about the indication for an arterial line. This is a doctor early on in training, cut these young doctors some slack they are learning. Remember not that long ago we put PA catheters in just about every patient in the ICU and just assumed it was the right thing to do for management of vasopressors and fluids. As an experienced doctor working in a hospital with many different specialists I would not ask such a question (" why an art line?") of an anesthesiologist but I am not offended when one of my anesthesiology colleagues asks me about antibiotic selection in a severely septic patient in the ICU. As far as medical " clearance" that is a junk term that has no real significance to a medical doctor. None of my colleagues state things such as avoid hypotension and hypoxia in our recommendations for a patient about to undergo a surgical procedure.  We never recommend what anesthetic technique or anesthetic drug should be used.  We figure that is your area or expertise. We may ask you what INR is acceptable to you for a planned spinal ( planned by you not me) so we can correct the coumadin induced coagulopathy prior to surgery.  We may remind the anesthesia/surgical team that we would like to avoid excess volume due to the patient's cardiomyopathy with an ejection fraction of 30% and CKD stage IV so we can help get the patient off the vent post op without resorting to dialysis. Perhaps a trip outside the ivory tower would give you a different perspective of how medicine is practiced in the real world. Your anesthesiology colleagues  ( whom I have great respect for their knowledge and skills related to their field) in the real world are too busy putting in art lines, CVP's, intubating and ventilating patients and managing nurse anesthetists and passing gas on their own in the OR to spend much time thinking about or practicing medicine in the hospital. There is just way too much money to be made in the OR and in procedures to waste your time and energy thinking about how to manage complex medical patients.  By the way, I just have a few generalist questions for you:   could you tell me how often my wife should have mammography?, should I have my vitamin D level checked, how about my cholestero?l, heart disease runs in my family, should I be taking a daily ASA and how much ? and my brother is a smoker, should he be screened for a triple AAA? and how often?  Those are questions any good generalist should have an opinion ready on the tip of their tongue.

I love these specialists who think they are "keeping up" with internal medicine by reading through a patient's med list. Imagine being treated for hypertension by this doctor - sodium nitroprusside for bp of 142/94.

Are anesthesiologists the last true generalists?

That's a joke, right?

Dear Jason,

We don't request "medical clearance".  Surgeons typically request it as a form of insurance to make sure their cases don't get canceled.  When the patient has been seen in our system and has information on file, I don't need anyone else to summarize it for me.  However, many of our patients are referred to surgeons here from long distances away, and all we have to go on is faxed information in the chart.  At 6:45 in the morning, their primary care doctors' offices aren't open for us to call, and patients are no longer admitted the night before surgery except in rare instances.

So yes, we really do need a decent history on the patient in order to figure out how to take care of him.  We need documentation of what the patient's medical problems are, and what has been done to optimize his condition.  Some patients are good historians.  Others, even when they're intelligent, are not.  My own father, who's a very sharp 89-year-old, is part of a generation that never complains.  You're not going to get anything out of him except that he's feeling fine.

Let me guess:  are you a nurse anesthetist?  No matter; I hope an anesthesiologist is there to take care of you if you ever need surgery.

Best,

Karen Sibert

 there are a lot of absurdities and back-tracking popping up in your various statements now that you have been challenged by a bunch of "generalists":

you seem to imply that the "medical clearance" is not necessary and just a "form of insurance" ordered up by the surgeon; if that's the case, why are you even concerned about it?

if it is so important for you to know the medical history (which it is, since you will be putting tubes/lines/meds in every orifice the pt has), why don't you schedule a visit with the patient prior to "6:45 in the morning" on the day of surgery so you can talk to them? is it beneath you? or more likely you wouldn't get paid for it?

believe it or not, many of us undertrained "generalists" see multiple patients on a daily basis who are "not in our system" (not everyone has one yet!)  or "from long distances away", and yet we still manage to obtain meaningful information by using some basic tools: a telephone and  fax machine.
if you want to take some time off from passing gas to follow me around one day, i can give you a refresher course on how to use them.

 Do you still have pre-anesthesia clinics, or has that disappeared as well?

Wow,
Everybody is so serious!  This was intended as a bit tongue-in-cheek, as I thought would have been obvious from the reference to Dr. House.

But the point was this:  in tertiary care hospitals such as mine, where everybody is a super-specialist, I do feel sometimes as though the anesthesiologists are among the few people around who are "bilingual" in medicine and surgery.  Not a lot of family practice docs are prowling the halls at Cedars-Sinai.  Even our hospitalists are firmly positioned in the medical ICUs, while the surgeons run the SICU.  Yes, the ER docs know a lot about a lot of things, but they don't get out of the ER much.

The original title of this piece was "Bridging the disconnect between medicine and surgery", which was the real topic and is the way it appears in my blog.  The headline was changed by the editor.

The surgical ICU residents tell me they'd rather get report from me (or someone like me) than from the surgeon or the medical consultant because I can tell them the whole story:  what surgery was done, what's  wrong with the patient medically, and how to manage the vent and the pain control as well.

While we need more primary care doctors, that's not what the residency programs are turning out.  Even the anesthesiology residents are starting to do more fellowships, because that's what will get them a job.  The fellowship rate among internal medicine residents and surgery residents must be 80% or more.  As smaller hospitals are closing and hospital systems are consolidating, everybody is seeking a niche.

It will be interesting to see what happens over the next ten years or so.

Thanks to everyone for reading, and for your comments.

apennedpoint.com

Yep, some the readers seem to have missed the point! We are luckier in Australia, as all doctors must do at least 2 years in the hospital rotating though medicine, surgery, emergency medicine etc, before enrolling in specialist training. It means the internal physicians remember what it's like to have to the damn laparoscopic camera for hours, and the surgeons remember why patients are on beta blockers. In my opinion it allows specialists to be better doctors.

The problem is your premise.  You assume that all medicine = inpatient medicine, which is blatantly wrong.  Most medical care happens OUTSIDE a hospital/ICU/OR environment.

You say the ER doctors "never leave the ER" whereas I say that anesthetists "never leave the hospital" so therefore you are just as limited as they are in your experience/scope.

The main reason people take issue with you is your extreme hubris.

Man, so anesthesiologists don't know how to use telephones and fax machines?  That's some self-righteous vitriol down there.
Anesthesiologists aren't the last true generalists, we're the last true critical care generalists -- because that's what we are, intensivists.  Every day, I render my previously healthy 25-year-old lap chole patient defenseless and critically, critically ill by giving him midazolam so he can't remember me pushing propofol and burning his veins prior to paralyzing him with vecuronium, the latter two of which would literally kill him were I not to provide him with ventilatory support.   I can't claim that I remember all about ATP III levels for cholesterol treatment or when Grandma needs a colonoscopy or immunization dates or when proper fundal height of the uterus is reached, but I sure do know about pretty much everything else.

I'm a PGY-2 anesthesia resident who just studied for and took the anesthesia in-training exam on Saturday -- this is a test that is supposed to resemble my written anesthesia boards in a few years...it essentially covers our entire specialty, including the four major subspecialties of OB, ICU, pediatric anesthesia, and pain management.  

Questions on previous exams have asked about the critical care management of thousands of conditions, including obscure problems in pediatrics like Treacher-Collins syndrome, and more common things like DKA in a septic patient, placenta previas in OB, management of traumatic brain injury and increased intracranial pressure in neurosurgery, and acute management of hypertrophic cardiomyopathy in the cardiac OR.  While I've never anesthetized a patient for a liver transplant myself, I know nearly every step of the procedure and know when my surgical colleagues are likely to run into problems.  Same goes for a Fontan procedure, where the pediatric cardiac guys anastomose the right ventricle to the left atrium for any number of congenital malformations of the RV or pulmonary circulation.  

I challenge anyone to find one single physician other than an anesthesiologist who would ever be tested on as broad a range of critical care topics as those.  Good luck.

"I can't claim that I remember all about ATP III levels for cholesterol treatment or when Grandma needs a colonoscopy or immunization dates or when proper fundal height of the uterus is reached, but I sure do know about pretty much everything else."

By "everything else" you mean all of outpatient medicine.  You are aware that most medical care in this country is delivered in an outpatient setting, correct?  That means there is a shitload of info you have no clue about.

If you want to claim supremacy in the critical care world, thats fine.  But thats a small subsegment of medicine.  Quit pretending like you are the experts at everything, because you arent.

BTW, if your training is so in-depth and broad, why havent you guys been able to do studies showing your care is superior to CRNAs?  They are kicking your asses right now, and you guys just sit there and take it, bringing up gripes with all the bogus studies they do instead of running your own studies to prove how superior you are.  You guys are on a sinking ship.  I think another state just opted out of the supervision requirement for CRNAs.

 Again, Wow.
At the Hospital where I work the healthy 25 year old lap chole patients are managed by nurse anesthetists. I don't think they ever see a bonafide MD anesthesiologist ( unless of course it is required for billing purposes).  When I was in internal medicine training we never discussed  critically ill patients, or rare and obtuse medical illnesses. We were never tested on those rare illnesses on the boards either.  It was all about seasonal allergic rhinitis,  PAP smears, mammograms, and those little hemoccult cards.

I fear some may think you are not kidding.

I guess I should have ended my response with a LOL.

Except for the fact that we only treat females, Ob/Gyns have to span the medical/surgical gap, along with the unique situation of pregnancy, daily. My residency did not include a flex internship, so I find myself "behind the eight ball," occasionally, and call PCPs all the time to learn more about disease states I learned little about in med school or residency. I, for one, feel that I missed a lot not having a "true" intern year, but like you, I doubt it will return. Thank goodness, I don't mind opening books(yes, there are some things that change little over the years), reading articles, asking colleagues and taking CME credits in primary care subjects.  I do worry that many Drs. are ashamed to ask these questions, and  I wonder what happens to their patients in these situations, when gaps in knowledge could harm their patients. I don't have the answer, but agree that there is a need for both physicians and surgeons to bridge this gap. 

Actually, as an internist, I wouldn't mind  following Dr Sibert around for a day. Re ramping that kind of knowledge  always helps. And we all know that we are getting narrower and narrower in our fields. Hals of my job is getting the various specialist to talk to each other- or at least by proxy via me.Of note EMR is making this harder- now all notes are 4-5 pages, of which 2 are usually useful.
On the other hand, I am convinced that no one reads my clearances , except the last line "cleared for surgery" After enough experience, I call with the major points of management, tailored to the surgeon.Which is what the  that call from me, is about.  Even thought famous critical care guy at Big Institution has cleared that patient,(for surgery I was unaware of)  but now  the patient is telling me he is having SOB with exertion,that he told them about. His wife just dragged him in because now he is waking up with it-take the call. The surgery is scrubbed anyway,

To me, this is over the top.
Why can't specialists understand the narrow framework they work in, and also appreciate the work primary care docs provide in the outpatient setting?  I do appreciate what specialists can do.  Is it worth the 4-5 times what I make?  Why not a little respect back the other way? If specialists don't like the "medical clearance," and think they are so smart, why don't they do their own medical clearance? What from medical school have they forgotten?

that's the whole point: they don't care about your "clearance". it's just so if something goes wrong, there is another name to add onto the lawsuit - yours!

 Dear NewMexicoRam,

I have the utmost respect for primary care physicians.  What I'm describing are real life events dealing with internal medicine residents at a teaching hospital, and what I see is that too often they are disconnected from and ignorant about the procedures that their patients are having.  It is a problem with early specialization of training.

Of course I do my own medical clearance--that's what happens each time I agree to proceed with an anesthetic.  The concept of a medical "clearance" is actually a bit silly.  What we need from the history and physical is accurate information about the patient.  Please don't just tell me the patient has "CAD with stent".  I need to know what kind of stent and how long ago the stent was placed so I know if aspirin needs to be continued, and if the patient has had any recent symptoms or stress testing. 

Here's an actual "medical clearance" from a patient's chart:

“Pt is at low risk for surgery. Please avoid shifts in Blood Pressure and

Volume. As is true with all surgery the anesthesiologist should mind

the blood pressure as this will reduce any unknown cardiac risk the

patient may have. A profound anemia would add further risk, which

this patient has no evidence of. Should heavier than expected bleeding

occur, please keep Hct over 30 for further cardiac risk reduction.”

You can imagine how helpful that was.  For more about that patient's case, go to:

http://apennedpoint.com/gar...

I could go on!  But please don't think I devalue primary care.  That is the furthest thing from the truth, and I admire people who have the patience and dedication for it. 

All the best,

Karen Sibert

 actually, this is a great "clearance", because it shifts all the blame back onto you if something goes wrong...for example, if the crit goes below 30, the lawyer can set his sights on you...i am glad you posted this, i'll use it next time someone gets sent to me for "medical clearance"...

and by the way, what makes you so special that you can't find out what kind of stent someone has, or when it was placed...do we have some special spidy-sense that enables us  to find out that information that you don't have? i'm done with residency, so i'm not anyone's b---- anymore (unlike you, who are the surgeon's!).

Thanks for the direct reply.
Do you think I have time to spend all day at the hospital, learning about procedures that did not exist when I was in school and residency over 25 years ago?  I can't even use all the vacation time I'm alloted each year because my profit/loss statements say I will have to take a pay cut if I do take time off.  And I'm in the office from 6 AM to 7 PM every weekday, with 4 hours of that dealing with "paperwork" and dictating.
If you do a medical clearance, then why does the surgeon waste my time requesting one?  I personally think it's just for the "free" H & P they get out of it.  As a matter of fact, unless the surgeon has a specific question or need because of the patient's condition, most insurances, including Medicare, don't want to pay for a clearance, and doctors who bill one are technically, if they were ever audited, in violation of Medicare law.  It's  my belief that if a surgeon really thinks a medical clearance is necessary, they should ask a cardiologist or pulmonalogist to do it because those specialties will be able to assess nearly 100% of the potential complications that would arise during surgery, and they would be the ones called upon if something did go wrong.
Also, I work in a multi-specialty clinic.  How many times do I have to ask the patient what recent surgical procedures they had done, and try to sort it out as the FP, because the surgeon failed to put it properly into the electronic medical record, if they recorded anything at all?
I enjoy what I do, but the hassles, stagnant reimbursement, and increasing office costs, including malpractice costs, are rapidly taking the joy out of it.  Now I wish I had gone into dermatology instead
Again, thanks for the response.  I'm not arguing with you, but hope you can understand the frustrations from someone who works outside the ivory towers.

Oh, one more thing.  Did it ever occur to you that the physician in the clearance letter you described above, may have been a part of a malpractice suit because in the time the patient saw the internal med doc and then had the surgery, the patient developed a slow GI bleed, had a lower BP and Hct at the time of surgery, but nobody did anything and the patient had a bad outcome?  It seems to be a "cover my butt" statement, but in this case seems specific enough as to be a reaction out of previous experience, not an attempt to add verbage to a note.

My question stands. Are there no pre-anesthesia clinics any more?

They used to exist, I haven't paid attention lately. With the astronomically high income of anesthesiologists.....actually the same as my gross income in primary care, except I have overhead.....is it no longer possible to at least hire a nurse to gather the data, and a doc available to oversee the questionable findings?

Maybe they are, I don't know. The patient traveled to see the consultant, it should not be that big of a problem to visit the clinic.

Frankly, I think your article is arrogant.  The true generalist is a full spectrum Family Medicine doctor.  Try diagnosing some of the conditions you write about and then treat them, accompanying the patient as first assist in surgeries, caring for them at the bedside and then dealing with their depression from their illness after you see them in follow up.  Anesthesiologists the last true generalists, give me a break.  

I find it curious that you request "medical clearance" to gather information that is easily gathered by yourself.  Are you incapable of talking to the patient or looking up medical records?  

Lets get real for a sec.  You want these "medical clearances" because you want somebody to do your job for you.  Gas docs (who are easily replaced by CRNAs with much less training BTW) and surgeons want these "consults" to hand them a patient on a silver platter so they can spend 100% of their time in the OR doing cases and making more $$$$.

BTW Dr Sibert, how does it feel to know that your field is in the process of being phased out by CRNAs?  22 states and counting have opted out of the "supervision" requirement by physicians.  Good luck on your sinking ship.  Everybody knows that the surgeons are the reason the patient is there in the first place, gas docs are ancillary providers at best.

I have worked in both systems: The nurse anaesthetist system, and the anesthesiologist-only system. The anesthesiologist-only system is by far superior. Safer, more efficient, better for patients, and expected by the public. Another great reason to live and work in Australia!