Do You Have to be “Slick” in Private Practice?

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One of the most commonly discussed topics with anesthesia residents – for me, at least – is whether being slick as an anesthesiologist is important in order to thrive in private practice.  Most residents think that they need to be slick in order to do well in private practice. While there is some truth to this line of thinking, I think this mentality can potentially do more harm than good.  Rather than asking whether you should be slick, you should ask yourself what cost you’re willing to pay to be perceived as slick.  Icarus wanted to fly close to the sun without asking the cost of doing so, and he ended up in the Underworld.  Not a good place to be, if you ask me.

For the sake of this post, let’s define the word “slick.”  I feel that this term gets used by a lot of people, but what do I mean? To me, being slick as an anesthesiologist means being able to do things quickly either because you can do procedures fast or think on your feet quickly. Being slick can also mean that you’re less likely to delay cases or cancel them all together. As you can see, on its own, the term is a good thing.  However, if the desire to be slick meets production pressure, the result can potentially be detrimental to optimal patient care, and you might be putting yourself at an increased professional liability risk.  David Gaba et al. – in a 1994 article in Anesthesiology – defined the term “production pressures” as the “overt or covert pressures and incentives on personnel to place production, not safety, as their primary priority.”

Let’s say you’re a newly-hired anesthesiologist at a respected private practice group. You put pressure on yourself to keep up with the pace of the operating room schedule, and you don’t want to dodge or cancel cases.  As a matter of fact, you might even have the desire to impress others and try to be slick.  By being slick, you are a new hire who does procedures fast, keeps up with the flow of the surgical schedule, and does not cancel cases.  Most of the time, this will work out fine because you have a pretty good margin of error.  But if you believe in the law of large numbers, then something has to give when desire to be slick meets production pressure; if you do enough cases, you’ll eventually make a mistake if you routinely focus on being slick.

Let me share a case with you.  It’s was a case that was handled by Norcal, a large malpractice insurance company, and featured in one of their monthly newsletter called, ClaimsRx.

The patient, a 420-pound, 40-year-old male, was scheduled to undergo laparoscopic gastric banding at a surgery center on a Friday, but because of scheduling problems, the case was moved to a Saturday.  On Saturdays, the surgery center scheduled only one anesthesiologist and no anesthesiology technicians.  On this particular Saturday, the scheduled anesthesiologist was recently hired.

In addition to being morbidly obese, the patient had diabetes, hypertension, and OSA.  During the pre-procedure anesthetic evaluation, the patient informed the anesthesiologist that he had undergone a liposuction procedure in the recent past, and that there had been no anesthesia problems.  Because of the patient’s pre-existing conditions, the anesthesiologist assigned an ASA score of three.  The anesthesiologist obtained an informed consent for general anesthesia.

The patient was taken to the operating room, where in addition to the surgeon and anesthesiologist, a scrub nurse and a circulating nurse were present.  The difficult-airway cart was outside the operating room in the hallway.  After the monitors were placed, the patient received pre oxygenation through a facemask.  The anesthesiologist attempted a rapid-sequence intubation, but because of the patient’s size, had difficulty moving the patient’s head to get good position and visualization.  When the anesthesiologist passed the laryngoscope, one of the patient’s teeth became loose and his gums began to bleed.  The blood covered the oro-pharynx.  The anesthesiologist suctioned the blood, but still could not see the vocal cords.  Within a minute of the onset of bleeding, the oxygen saturations dropped to 80%.  The anesthesiologist was able to place an LMA, and the saturations slowly increased from a low of 70% to 90%.  The anesthesiologist placed an ET tube into a fiber optic scope and passed it down the LMA.  After an initial increase, the oxygen saturation dropped again, indicating that the ET tube was not in the right place.  At this point, the anesthesiologist and the surgeon agreed to cancel the surgery.

The anesthesiologist removed the ET tube, leaving the LMA in place because of the damage to the tooth.  He turned off all the gases and thereafter gave flumazenil to reverse the Versed and wake the patient.  The patient began to wake and resumed breathing on his own; however, he quickly became very agitated – kicking, flailing, and pulling at the LMA.  The anesthesiologist removed the LMA and placed a non-rebreather facemask, but the patient’s agitation continued.  He pulled off his monitors and facemask, causing the tubing to become disconnected from the oxygen source.  Because of the patient’s size, the surgical team was unable to restrain him adequately.  After struggling for a few minutes, the patient slowly became less agitated, and the team was able to reconnect the oxygen and monitors.  They then discovered he had no pulse.  Chest compressions were started and the LMA was placed.  The patient returned to sinus rhythm with a normal blood pressure and saturations.

Unfortunately, the patient had suffered an anoxic brain injury.  He was later found to be unresponsive to pain and his pupils were sluggish.  As recovery was deemed doubtful, the family decided to withdraw life support and the patient expired.

The family filed a medical liability lawsuit against all of the providers involved in the decedent’s care.  Because of lack of standard of care support, the case settled.

So what did the anesthesiologist say about the case?

Although the anesthesiologist recognized prior to surgery that the intubation could be challenging given the patient’s comorbidities, he felt that he could accomplish it safely.  In retrospect, however, the anesthesiologist acknowledged that because of the absence of additional anesthesiologists or anesthesia technicians and the fact that the surgery was not urgent, he should have insisted on postponing the surgery

The anesthesiologist was a recent hire, and he wanted to appear capable and make a good impression.  Despite the challenging circumstances, he did not want his colleagues to think he had “dodged the case.”  He was aware that this patient had already been rescheduled and knew that it would be an inconvenience to the patient and other members of the team if the procedure had to be rescheduled again.  He also knew that rescheduling would result in a loss of income for the surgery center and the surgeon, and he did not want to be held responsible for those losses.  All of these issues contributed to his decision to continue with the surgery.

And the experts – what did they say about the case?

Experts felt that the pre-anesthetic evaluation was adequate, but not ideal.  Had it been performed earlier, providers might have been able to plan more appropriately for the patient.  For example, the ability of the surgical team’s ability to restrain the patient physically might have been taken into consideration.  When he needed to be physically restrained, the team struggled to accomplish this in a timely manner.  Also, the anesthesiologist later noted that many of the problems he encountered with the patient could have been alleviated through the assistance of another anesthesiologist.

Experts were also critical of his lack of preparation.  In this case, the anesthesiologist did not have the specialized intubation equipment prepared for immediate use and had left the difficult-airway cart in the hallway.  He felt part of his inability to respond to the emergency was his unfamiliarity with the operating room.

Sound like something that could happen to you?  Certainly does.  It could very well have happened to me.  And it’s always easy to say – after the fact – that he should’ve postponed the surgery.  But when you are a new hire, the desire to impress the group does come into play and it is this mentality that I believe in dangerous.  Being slick is not a bad thing, but when it occupies a better part of your mind, I believe it could be detrimental.  I understand the anesthesiologist’s desire to proceed with the surgery in the above scenario, and I certainly feel for the anesthesiologist, but I think that his desire to be accepted by his private practice group played a large part in his wanting to proceed.  This is a good lesson for you because you’ll be starting on your own eventually and face similar situations; you must learn to prioritize patient safety over production in an acceptable manner.   You certainly can’t postpone every potentially challenging cases, but you must understand your work environment and make the appropriate choices efficiently on behalf of your patients.

Don’t fly too close to the sun; think twice before you want to slick for slickness sake.

So what can you do?

1) When it comes to speed in an anesthesiology practice, as long as you are in the meaty part of the bell-shaped curve, I believe that you will do fine.  Don’t try to shoot for that area to the right in the bell curve for the sake of being slick.  I don’t think that you will end up thriving in private practice because you are slick, but rather because you’re efficient and free of major mishaps.  In my experience the selection process in private practice is such that you will probably be asked to leave if something really bad happens (like the above scenario), but you probably won’t be asked to leave if you’re on the slower side.  Speed will come for most you if you just try to do your due diligence.  As you adapt to a new environment and get more comfortable, you’ll get more efficient, and as a result, quicker.  Focusing on delivering good care to the patients in an efficient manner is where the money is, and before you know it, you’ll notice yourself becoming quicker.

2) Don’t be afraid to ask for help.  When I was in private practice, I’ve had very experienced anesthesiologists ask for help multiple times, as have I.  For example, when I was the in-house OB call person, I remember being called by the trauma call person to help with an intubation of a boy with epiglottitis.  Everything went fine, and in retrospect he didn’t need anyone’s help, but you don’t know that when you’re getting ready for a case.  The experience highlighted the importance of being humble before a potentially dangerous clinical scenario; someone preoccupied with being slick might not have done the same.

And by the way, when a case like the one above settles, the medical malpractice insurance company must report the payment to the National Practitioner Data Bank and the State Licensing Board within 30 days of payment.  This means that the adverse event follows the anesthesiologist even though it didn’t go to court.  How does it follow the anesthesiologist?  Because a hospital must query the National Practitioner Data Bank when a physician applies for privileges, the information about any settlement will be there for all to see. This is a very steep price to pay for wanting to be slick. Don’t fly too close to the sun; think twice before you want to slick for slickness sake.

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