As a newly minted physician, you have defied the odds to gain entrance into a competitive medical school, pored laboriously over textbooks in the library to achieve high scores on the USMLE step examinations, matched into a residency program to further your training, and you have finally received that employment offer from the hospital of your choice! As ecstatic as this moment is, after nearly ten years of continuous work, the next decisions you make could greatly influence the next chapter of your life and career. These career-defining decisions are determined by one singular entity: the employment agreement.

The majority of early-career physicians have yet to negotiate a fair employment agreement, as their schooling and residency programs were likely based on a standardized package that did not differ among matriculants. However, the ability for an employment agreement to vary increases exponentially once you become a physician. How can you be certain that you are being fairly compensated for your hours worked? How do you determine how shifts are assigned to you? What about overtime and call time? Benefits? Each of these items is eminently important to consider before signing on the dotted line and agreeing to begin a career at a new institution. The following will discuss key considerations and best practices for early-stage physicians as they negotiate fair employment agreements with potential future employers.

It is first important to understand that employment agreements (also known colloquially as “offers” in the working world), will vary from workplace to workplace. There are distinct differences between employment agreements made with academic centers, private hospitals, private practices, and clinics. When deciding on a future employer, it is essential to conduct preliminary research utilizing public websites such as Salary.com or GlassDoor.com. Although there are nuanced considerations to be made between employment settings, there are certain factors that are relevant and non-negotiable for the physician to discuss before accepting an offer from any employer.

1. Clearly-defined, set hours^[1]

As an anesthesiologist, you must discuss the specific hours you will be working. Be sure to have this discussion prior to even considering getting an ID badge. The surgeries are long, and there may be ward responsibilities in addition to your scheduled shifts. You should therefore be clear on exactly when you are expected to be working, and how soon you will be notified in advance of each shift.

2. Compensation — salaried or hourly?^[2]

This section of the employment agreement is relatively self-explanatory. Will you be compensated on a salaried or hourly basis? The answer will likely depend on the type of institution you are working for. The HR department at an academic hospital, for example, may prefer physicians to be salaried so they can also commit to academic duties during the work week. However, in a typical hospital or private practice, hours may be tracked more rigorously, and you may be compensated only for the hours you have worked.

3. Medical malpractice protection^[3]

In the modern world of medicine where lawsuits are always a possibility, physicians are at risk for being held liable without adequate legal protections. While hospitals enact every possible safety measure to ensure safe, high-quality surgeries, some mistakes are inevitable. Your hospital or future employer should provide you with a contingency plan in the unlikely event of medical malpractice. Possible protections include insurance plans, set annual funds to be used towards any suits, or an on-site lawyer dedicated to malpractice suits.

To our new physicians — congratulations! You are embarking on an enriching and fulfilling career. Before you charge forth into the world of medicine, be sure to sit down and carefully consider and negotiate each employment agreement. By doing so, you can help ensure that you are well-protected, well-supported, and have the necessary tools at your disposal to succeed as a healthcare practitioner!

Reference:

^[1]Kraft, J. “The Final Hurdle: A Physician’s Guide to Negotiating a Fair Employment Agreement”. Department of Anesthesiology and Critical Care Medicine, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania. Aug 2017.

^[2] Oliver, E. “10 statistics on anesthesiologist compensation, benefits.” Becker’s ASC Review. April 2018.

^[3] Tan, SY. “Medical Malpractice: Understanding the Law, Managing the Risk”. Hackensack, New Jersey, World Scientific Publishing Company, 2006.

In recent years, the Association of American Medical Colleges has prioritized empathy as a critical skill for physicians to employ in their practice, detailing that by the end of medical school, students will “value the importance of curiosity, empathy, and respect in patient care”.^[1] Inherent in empathy is the art of listening, that is, that physicians have the ability to hear their patients’ concerns, empathize with the emotions behind the concerns, and respond appropriately with reference to the patient’s state at that moment in their care journey. Anesthesiologists and Certified Registered Nurse Anesthetists (CRNAs) are particularly well aligned with initiatives in listening and empathy. Patients may harbor anxiety about the onset of surgery, particularly if they have not yet undergone a procedure that required anesthesia. While the surgeons will assuage fears about the procedure, it is the duty of the anesthesiologist to speak with the patient regarding the anesthesia itself. As anesthesia consultants and providers, anesthesiologists and CRNAs are in a critical role for quality of care. During this interaction, it is crucial for the anesthesiologist, or CRNA, to employ empathetic listening.

In addition to the humanistic benefits of listening, recent literature now suggests that listening to the patient may improve quality of care with regards to anesthesia. In Anesthesiology, Dr. Fleisher asserts that patient expectations towards care have changed, and patients now expect physicians to be receptive towards listening to patient concerns^[2]. To achieve this aim, anesthesiologists should align with an institutional code of conduct that places the patient at the center of the listening paradigm. In this fashion, the anesthesiologist is guided to ask certain questions about the patient’s journey to the institution, his/her experience thus far, and expectations for his/her future health. This article underscores the importance of practitioner listening for high patient-reported outcomes, metrics which are increasingly important for hospital efficacy initiatives.

Along with strengthening the patient-provider relationship, practitioner listening is also crucial for increasing the patient’s comfortability with the treatment that will be administered through surgery. If the patient is satisfied by the explanations of anesthesia given by the practitioner, and has their questions listened to and responded to, the patient is more likely to be receptive to moving forward with treatment^[3]. Moreover, the patient will leave their surgery with a favorable perspective of their anesthesiology provider imprinted in their memories, which is a benefit for post-operative patient satisfaction surveys that may be administered.

Based on the theory that physician listening directly correlates with patient satisfaction, a selection of healthcare scholars have proposed physician empathy as a cornerstone for patient satisfaction, to then be utilized to calculate fees in a pay-for-performance payment plan.^[4] The American Society of Anesthesiologists, in particular, has a proposal in place to justify patient satisfaction as a legitimate basis for determining physician compensation, noting that a viable question to ask the patient is, “To what degree was the anesthesia team willing to listen to your questions?”. While the ability to include patient satisfaction as a metric for compensation and, accordingly, patient reimbursement, may differ per institution, the presence of such a mechanism exemplifies the importance of patient listening for quality of care.

In sum, the literature favors the philosophy that providers may improve anesthesia quality by listening to their patients. Furthermore, as healthcare professionals, anesthesiologists and CRNAs are critical to the delivery of empathetic, compassionate care — utilizing listening as a tool to achieve the aim of increased outcomes for all patients.

^[1] AAMC. “Cultural Competence Education.” Association of American Medical Colleges, 2005, www.aamc.org/download/54338/data/.

^[2] Fleisher, Lee A. “Quality Anesthesia: Medicine Measures, Patients Decide.” Anesthesiology, 2018, p. 1., doi:10.1097/aln.0000000000002455.

^[3] Morrissey, Candice. “Patient Feedback in Anesthesiology Matters.” NEJM Catalyst, 2 Aug. 2017, catalyst.nejm.org/patient-feedback-anesthesiology-matters/.

^[4] Anesthesia Quality Institute. Patient Satisfaction and Experience with Anesthesia. 2017. www.aqihq.org.

Academicians estimate that by 2020, approximately 84% of United States academic anesthesiology departments will have implemented an anesthesia information management system, or AIMS . AIMS are a form of electronic health records that function in two parts. First, AIMS automatically integrate the patient’s vital signs from the many monitors present throughout the surgery to the broader electronic medical record (EMR). Second, AIMS streamline anesthesia electronic medical record production. AIMS is significant because not only does it allow for digitization of medical records, but it can also serve as a cornerstone of patient safety.

Predominantly, AIMS contribute to patient safety by placing the patient at the center of data integration. Historically, operating rooms (ORs) staff were tasked with monitoring the patient’s vital signs manually, where an anesthesia provider periodically verified the monitors to ensure that the patient’s respiratory rate, blood oxygen level, and so forth were at the standard level. As technology advanced, monitors developed the function to auditorily alert the anesthesia provider and OR team when the patient’s’ vital signs were abnormal. However, AIMS take this principle one step further by combining all vital sign monitoring streams into one continuous analysis, thereby mitigating unnecessary alerts to only filter through that data most relevant to the patient’s safety . Furthermore, AIMS can also take into consideration drug-drug interactions, patient allergies, and drug metabolization threshold levels, variables that heavily impact the patient in the perioperative period.

AIMS enhance patient safety because they minimize the margin of human error. In the typical anesthesia and operating room episode, the surgeon and anesthesiologist are tasked with submitting post-operative reports after completion of the surgery. For both providers, these reports are often required to be detail-oriented and accurate. Given the providers’ busy schedules and other responsibilities, it can be time consuming to provide such reports. Lack of time to submit a complete report, combined with fatigue and sleep deprivation, could lead in certain cases to omitting clinical information relevant to the patient’s care — information that could explain unfavorable surgical outcomes or be important for determining a cause of ailment . As opposed to allowing for human error to potentially affect patient safety, AIMS automatically track all clinical information as related to anesthesia during the OR episode and combines it into a legible, comprehensive document. In such a way, records reflect an objective, measured evaluation of the OR episode.

Over the next ten years, EMRs will continue to develop to match the needs of an evolving healthcare system. AIMS are key to such developments. As highly sophisticated vehicles of measuring anesthesia care, AIMS are crucial to promoting patient safety by maximizing data collection, medication dose management, and patient vital signs. By managing the data, AIMS allow anesthesiologists and staff such as Certified Registered Nurse Anesthetists (CRNAs) to focus on their duties of caring for the patient throughout surgery and ensuring a seamless perioperative experience. Henceforth, AIMS, as an integral part of the anesthesia professional experience, will increase in importance as a valuable tool for emphasizing patient safety across the care continuum.

References:

Stol IS, Ehrenfeld JM, Epstein RH. Technology diffusion of anesthesia information management systems in to academic anesthesia departments in the United States. Anesth Analg 2014;118:644-50.

Ehrenfeld, Jesse M., and Mohamed A. Rehman. “Anesthesia Information Management Systems: A Review of Functionality and Installation Considerations.” Journal of Clinical Monitoring and Computing 25.1 (2011): 71–79. PMC. Web. 1 Oct. 2018.

Marian, Anil A., et al. “The Influence of the Type and Design of the Anesthesia Record on ASA Physical Status Scores in Surgical Patients: Paper Records vs. Electronic Anesthesia Records.” BMC Medical Informatics and Decision Making, 2 Mar. 2016, doi.org/10.1186/s12911-016-0267-6.

This year, Rhode Island Hospital made headlines when they were reported for four cases of patient misidentification, all of which resulted in unnecessary and incorrect medical care. In three cases, patients received imaging and/or diagnostic tests that were intended for another patient — actions which carry moderate risk but could be determined to be relatively neutral. However, in the fourth and most impactful case, a patient underwent an incorrect operation on the non-designated part of the spine, a shocking medical error which will have ramifications throughout the patient’s life. Rhode Island Hospital has made both financial and operative investments to ensure that such errors will not occur again. However, such a case demonstrates that the issue of patient misidentification is still frequent in the United States healthcare sector, even in largely industrialized and sophisticated hospital systems. Particularly in the anesthesiology and surgical fields, addressing patient misidentification is crucial for effective, appropriate, and ethical patient care.

Patient identification refers to the confirmation that an individual is both (a) the person whom they claim to be and (b) receiving the services that are intended for the person whom they claim to be. If both conditions are not met in the healthcare setting, then this is considered a breach of patient identification and could imply both legal and medical ramifications for the health system. According to the World Health Organization, the major healthcare fields in which patient misidentification is most likely to occur are drug administration, phlebotomy, blood transfusions, and surgical interventions. Inherent to anesthesiology is, of course, drug administration and surgical interventions, rendering patient misidentification as a core issue to the field.

Therefore, what specific interventions can anesthesiology and surgical practices make to avoid patient misidentification? In the age of an increasing emphasis on patient safety, there are many options at both the provider and practice level. At the practice management level, standards of practice should be related to all providers, from anesthesiologists to Certified Registered Nurse Anesthetists (CRNAs) to operating room nurses. Policies could include two corroborating patient identifiers as proof of identity, physical markers with the identity of the patient place on the patient at all time during stay, multiple verbal verifications, or dedicated time during the procedure to verify patient identity and site of surgery, for example. In addition, policies must be enforced at the practice management level. Although anesthesia professionals are often highly booked, it must be a strategic priority of the operating room manager or chief of department to enforce standards of practice as related to patient identification, whether that means providing a team member or volunteer that is responsible for the task of patient identification or providing in-service ongoing training to practitioners to ensure education is up to the current standard.

In light of technological advancements, more sophisticated options for patient identification are entering the sphere of conversation. Several companies have come forth with advanced biometric identification solutions, such as matching the individual to the identity by utilizing palm-vein technology, thumb scans, two-step secure verification, or facial analysis techniques. While such technologies may be expensive at first to integrate into each hospital system’s electronic medical records (EMR) system, they will likely prove to be the next generation method of securely verifying a patient’s identification.

In and out of the operating room, patient identification is critical for delivery of patient care, particularly in the anesthesia. By strengthening pillars of standards of practice and integrating novel biometric technologies, anesthesia providers as well as anesthesia management organizations, can ensure that hospital and health systems move forward in delivering enhanced care for patients.

References:

^[1] Miller, G. Wayne. “R.I. Hospital Enters Consent Agreement after 4 Patient Errors in 4 Weeks.” Providence Journal, Providencejournal.com, 9 June 2018, www.providencejournal.com/news/20180608/ri-hospital-enters-consent-agreement-after-4-patient-errors-in-4-weeks.

^[2] World Health Organization, et al. “Patient Safety Solutions.” World Health Organization, 2007, www.who.int/patientsafety/solutions/patientsafety/PS-Solution2.pdf.

^[3] AST Education and Professional Standards Committee. “Standards of Practice for Patient Identification, Correct Surgery Site and Correct Surgical Procedure.” Association of Surgical Technologists, Oct. 2006, www.ast.org.

^[4] Wood, Megan. “How Biometric Identification Enhances Patient Safety and the Hospital’s Bottom Line.” Becker’s Hospital Review, Dec. 2017, www.beckershospitalreview.com/cybersecurity/how-biometric-identification-enhances-patient-safety-and-the-hospital-s-bottom-line.html.

Americans spend over $27 billion yearly on herbal supplements, botanicals, and other alternative medicines. Many are unaware of the potency and potential side effects of these agents, which are not subject to federal regulation. Some supplements may cause electrolyte disturbances, anticoagulation effects, interactions with other medications, or interaction with anesthetic agents. Moreover, not only do patients often not disclose the supplements they are taking to their anesthesia providers, providers may be unaware of the implications of these herbal supplements on their anesthetic.

A brief review of some common herbs and supplements that may have anesthetic implications is presented below. However, the list of available supplements patients take is so vast, it is difficult to cover them all. The anesthesia provider should address with the patient if she/he is using herbal supplements, and to make an effort to determine if any potentially serious side effects could arise from their continued use perioperatively. While it is generally safe to advise patients to discontinue herbals one or two weeks prior to surgery, it may be dangerous to abruptly stop some agents. These may require tapering or continuation during the perioperative period.

Supplements known to increase the risk of bleeding include garlic (inhibits platelet aggregation), ginkgo (inhibits platelet activating factor), ginseng (inhibits platelet aggregation; also decreases blood glucose), saw palmetto (unknown mechanism), black cohosh (NSAID-like properties), chamomile (contains phytocoumarins which have an additive effect with warfarin), feverfew (inhibits platelet aggregation and has additive effects with antiplatelet drugs and warfarin), fish oil (dose-dependent), and vitamin E (can also affect blood pressure).

Herbals that increase clotting risk include coenzyme Q10 (through a decreased response to warfarin), goldenseal (opposes effects of warfarin and heparin), and St John’s Wort (reduces blood levels of warfarin).

Other supplements also have different effects. Ephedra (Ma-Huang) may interact with blood pressure medications and cause tachycardia and hypertension. Kava can increase the effect of anesthesia and has been implicated in liver dysfunction in rare cases. Valerian can prolong the effects of some types of anesthesia. Abrupt discontinuation of this agent may cause benzodiazepine-like withdrawal symptoms.

Further resources for information on supplements include www.naturaldatabase.com and www.fda.gov (which reports adverse events). While sometimes time-consuming (some patients may be taking ten or more supplements), it is good to at the very least, to have an open discussion with patients regarding the use and potential side effects of the medications they are taking, whether prescription or alternative.

References:

http://www.asahq.org/lifeline/anesthesia%20topics/herbal%20supplements%20and%20anesthesia

https://www.asahq.org/whensecondscount/wp-content/uploads/2017/10/asa_supplements-anesthesia_final.pdf

https://www.openanesthesia.org/aba_herbal_supplements/