(1) Competence in the fundamental elements necessary for the safe delivery of anesthesia, including both technical and non technical aspects
(2) Assumes responsibility for the care of individual patients and as such contributes to the well being of society in general
(3) As a profession anesthesiologists have the right to train, admit, discipline and dismiss its members for failure to sustain competence or observe the duties and responsibilities
(4) Exhibits the following humanistic qualities including: altruism, accountability, excellence, duty, honor and integrity, and respect for others
For anesthesiology professionalism, at a minimum, implies competence in the knowledge of anesthesia. The basic curricular elements considered necessary for certification in anesthesiology are defined by the American Board of Anesthesiology (ABA) and the Accreditation Council for Graduate Medical Education (ACGME) . A board-certified anesthesiologist is a physician who has completed specialized post graduate training in anesthesiology and exhibited an acceptable depth of knowledge in a written and oral examination. The standards for certification examinations are set by the ABA and are constantly reviewed and updated to reflect advances within the field and its specialties.
While the anesthesia profession has a responsibility for the care of individual patients and towards society in general, the care and well being of the patient must take primacy over other considerations. In a busy operating room environment, it can be difficult to put the patient’s needs first, above those of oneself, the surgeon or the schedule, but it is necessary to fulfill the anesthesiologist’s professional obligation to the patient. Anesthesiologists have long been recognized as leaders in patient safety, and in 1985 the American Society of Anesthesiologists (ASA) was the first medical society to create a foundation dedicated to patient safety. The Anesthesia Patient Safety Foundation (APSF) was established to raise awareness within the profession and dedicate resources to improve the understanding of safe anesthetic practice. Since that time the ASA and APSF have sponsored numerous research projects and helped to establish guidelines and recommendations that have significantly improved patient safety over the last 20 years. Anesthesiologists have also been instrumental in the advancement of the electronic medical record, team training, and medical simulation. These are examples of how anesthesiologists can fulfill their professional obligations to patients and society in general through active participation with the society and its related organizations.
Anesthesiologists belong to a profession, and as such accept the responsibility to train, admit, discipline, and dismiss its members for failure to sustain competence or observe the expected duties and responsibilities. As indicated above, the public trusts that through education and training an anesthesiologist will have acquired a level of clinical competence and technical expertise matched by intellectual understanding of the needs of the patient preparing for surgery, in the intensive care unit, in labor and delivery or for the patient in pain.
In addition to ensuring competence, as professionals, anesthesiologists are also obligated to ensure the safety of fellow practitioners and their patients. Besides offering national comprehensive educational programs on substance abuse, many state societies have established programs to assist and treat individuals with substance abuse or other professional behavioral issues. State societies work closely with state licensing boards to ensure the development of fair and safe regulations for patients and practicing physicians.
Finally, for individual anesthesiologists professionalism also implies the presence of humanistic qualities that are central to the physician in the role of healer. These key elements of professionalism include: altruism, accountability, excellence, duty, honor and integrity, and respect for others. The basic need for these traits does not differ for anesthesiologists compared to other physicians from other specialties.
“The Etiquette of Medicine”
Another aspect of professionalism that deserves attention is simply put: manners matter! The impression that daily behaviors make on patients and other healthcare providers cannot be underestimated. One author eloquently described the value of “etiquette based medicine”, emphasizing the importance of basic manners and appearance. He points out that it is often these very simple actions that will leave the most lasting impression upon the patient and their family members. The importance of etiquette in medicine is very applicable to anesthesiologists, who often have limited, but intense interactions with patients and other healthcare workers. A modified checklist for behavior is displayed in Table 30.2.
Table 30.2
Etiquette-based anesthesia introductions
(1) Verify with the nurse and the patient that now is an appropriate time to begin the anesthetic interview and preparation |
(2) Introduce yourself – as a physician. First names can come later |
(3) Look the patient in the eye and shake hands. Introduce yourself to family members – ask their relationship, do not make assumptions |
(4) Briefly explain your role within the anesthesia team (i.e. a student or resident), name the attending if applicable |
(5) Verify with the patient the surgery that will be occurring |
(6) Begin your discussion regarding the administration of anesthesia |
For most patients, surgery is a relatively unique event, and one that is surrounded by significant anxiety and trepidation. The way an anesthesiologist approaches his or her patient before surgery will reflect the professionalism of the individual physician and the profession in general. For example, when a patient arrives at the hospital holding area nursing students, as well as residents from multiple specialties and various levels of training. In the flurry of activity that ensues, the patient can easily lose track of all the providers. Therefore, it is imperative that anesthesiologists take a few moments to clearly introduce themselves and clarify their role within the anesthesia care team.
Safety and Teamwork
Many students are first attracted to the field of anesthesiology because of the excitement of the operating room and the appeal of the hands-on technical aspects of the field. It is often only later that students begin to appreciate the central – the non-technical – role played by the anesthesiologist during the patient’s operative course. The development of superb communication skills is critical for the anesthesiologist, who will need to be able to speak effectively with patients and multiple healthcare providers, including surgeons, nurses, technicians, and other specialists. In some instances effective communication may prevent significant patient harm.
In 1999, the Institute of Medicine (IOM) published a report indicating that 44,000–98,000 patients die in the United States each year due to errors by medical personnel. This placed medical error as the leading cause of accidental death in the country, and sent shock waves through the medical community. Similar data were later published from other countries around the world. More recently, the IOM estimated that there is an average of one medication error per patient per day in hospitalized patients. A growing body of research has now demonstrated that hundreds of thousands of patients are harmed each year due to error, at a cost of hundreds of billions of dollars. The causes of medical error are complex and multi-factorial, but poor communication is the single factor that has consistently been cited as the most common cause of error.
Failure to effectively communicate, to accurately transfer information from one team member to another, is common. In studies performed in the operating room, one author found that about 30 % of clinical communication events fail to meet their intended goal. Although not specific to anesthesiology, it is easy to see how important “ closed loop communication” could be in a busy operating room.
While it is clear that poor communication is a leading contributor to medical error and adverse events, much less is known about why communication failures continue to occur. One of the most vulnerable times for loss of information is during the hand-off of patient care from one provider to another, and this has been shown to be the most common time that communication errors lead to patient harm. Contributing factors include differences in communication style, poor or no hand-off structure, and production pressure. Other common causes of communication failure are shown in Table 30.3.
