“Proceduralists” Do Care!

From the 6/4/2021 newsletter

Perspective/Opinion

“Proceduralists” Do Care!

Harvey Woehlck, MD - Professor, Department of Anesthesiology

Dr. Woehlck reminds us that doctors whose main task is to perform procedures can break from their molds and have fulfilling roles as caring physicians, as well …

What does a caring academic proceduralist look like in today’s modern medical environment?  

We can imagine that the modern proceduralist descended from the surgeon of ancient times.  In the second century, the expression of “laudable pus” was a common procedure which, of course, required incision.  [Excuse the digression, but laudable pus was staph-related and often survivable with incision and drainage as the only treatment, as opposed to what we now call necrotizing fasciitis, which was uniformly fatal at the time.]  Amputations were described a century earlier, where lack of anesthetics required the proceduralist to be as fast as possible. 

in that era, caring may not have been a meaningful virtue; completing the amputation – and allowing the patient to survive – was meaningful.  Unfortunately, this may have selected for what we could today call a psychopathic trait in proceduralists of the preanesthetic era.  Just how could you have empathy when the goal was to amputate as quickly as possible?  

Nitrous oxide was synthesized in 1772, but was mostly used as a party curiosity, not for procedural pain relief.  Anesthetics like ether gradually increased in use from the 1840s to the present day, but “modern” pain relief is something we would recognize only in the twentieth century.  Prior to the era of anesthetics, lay literature, newspaper accounts, and battlefront stories from numerous wars and conflicts described eager but cruel doctors sliding down the slippery slope of brutality themselves, amputating, when possible, on the most minor of injuries as if to draw the biggest possible crowd as part of a spectacle. 

Flash forward to the present.  With a history like that, what does a caring academic proceduralist look like in today’s modern medical environment?  

High-tech procedural platforms require numerous people for support.  Housekeeping, instrument processing, lab services, anesthesia services, proceduralists and assistants, nurses, technicians, and more are part of the team.  Let’s not kid ourselves. All of these people and resources need to work together. They are expensive to operate and maintain.  We need to be mindful of RVUs created, payer mix, and the effect on dollars generated, turnaround times, expense units utilized (which includes choice of drugs and equipment). You wind up with a dizzying array of competing factors.  Add to that teaching of students, residents, fellows, and it’s amazing that we’re not reduced to robotic, unemotional, protocolized efficient machines in an environment devoid of empathy focusing on getting patients in and out faster and cheaper. Without efficiency, modern infrastructure could not exist.

And then, there’s caring and the patient’s best interests.  

Many people equate a caring physician with a good bedside manner. While that is important, some might argue that caring is secondary if the patient is asleep or sedated for the most critical part of one’s procedural interaction. As an anesthesiologist, the life-or-death part of most interactions with a patient occur when the patient is unaware. Stolid efficiency might be supportive of the infrastructure that allows us to provide an optimal level of care by today’s standards, but it doesn’t end there.  

The epitome of proceduralism transcends efficiency and a low complication rate. But it differs for patients receiving their definitive procedure versus those at the beginning of their diagnostic journey.  

What about the lost patient, trying to find the mountain pass to Erewhon?  I’d argue many nontraditional opportunities exist for caring, some of which could be hard to explain.  And notice that I used the word “argue” in there.  People who know me personally know that I am frequently contrary and argue a lot.  I pride myself on being one of those “competing factors.”  

Let me exemplify:

As a proceduralist – an anesthesiologist – I recently had a patient with a mundane problem having a common procedure, and I was part of the anesthesia team.  This is what Kikuko Tsumura might call an “easy job” for me.  Or what I imagine the late economic anthropologist David Graeber might have berated as a job where any interchangeable person with minimal competence sufficed.  

But I noticed the patient had multiple co-morbidities that didn’t substantially alter anesthetic care. Those anomalies happened to fit a pattern for a diagnosis that was neither listed nor treated by any of the dozen qualified healthcare providers he had seen in the prior six months. In addition to performing the dull, boring anesthetic, I took it upon myself to arrange some screening tests for this potential undiagnosed problem that would tie together the co-morbidities into a single diagnosis and change treatment 180 degrees.  

The test came back positive for what the textbooks call a “rare disease.”  After a referral and more procedures, the patient thanked me for figuring out, and finally solving, the underlying issue that caused years of suffering and, untreated, would have taken decades off of his life.

Why didn’t others find the problem?  Did we unknowingly allow ourselves to wear the mask of tunnel vision and be compartmentalized into that mechanical state of efficiency?  Was it production pressure?  Protocols?  A nebulous bureaucratic expectation that we maintain our defined roles?  

Many opportunities existed to look the other way and perform only up to minimum acceptable standards.  Breaking from this mold is what I call caring.  I am sure nobody would have noticed the difference had I only done the minimum.  For some, caring could mean providing emotional comfort, but for others, it may mean taking the extra time to solve a problem, even if it opens the uncomfortable door of crossing boundaries of specialties or roles, or advocating for the rare and unpopular.  

Tsumura might summarize this approach by arguing that caring encompasses the dignity of work.  Or becoming more invested and engaged as the job becomes increasingly routine or trivial, extracting from context nuances that defy description.

For me, in my procedural world of the unaware, caring transcends the routine and encompasses the intangible.

For further reading:

Kikuko Tsumura. There’s No Such Thing as an Easy Job. Bloomsburg Publishing, 2020.   ISBN: 9781526622242 To find the book, click this link.

David Graeber. Bullshit Jobs: A Theory. Simon & Schuster. 2018. ISBN: 9781501143342 To find the book, click this link. 

Harvey Woehlck, MD is a Professor of in the Department of Anesthesiology at MCW. In addition to multiple educational, clinical, and administrative responsibilities, Dr. Woehlck is an accomplished concert pianist.