‘Happy Juice’ 2023

“Here comes your margarita!” I hear the familiar words through the thin walls of the cubicle in the preoperative area as I talk to my patient on the other side of the cubicle. Their conversation then turned to, “It’s never too early for a drink” and “It’s 5 o’clock somewhere.” The theme is recurrent and uncomfortable. Sometimes it is, “Here is your cocktail” or “This is your happy juice.” I have even heard on occasion a nurse introducing the anesthesiologist to the patient with, “Here comes your bartender.” I ask myself, are we promoting ourselves as bartenders? Is this the lasting impression we want to leave with our patients and our colleagues about our profession?

Light humor with our patients during the preoperative period can help allay their anxiety and may distract them from worries during the stressful time of surgery. After all, relieving anxiety is an integral part of our patient care. Easy conversations that promote confidence and trust are essential. Nevertheless, we should consider our choice of words. Does the talk of “giving a cocktail” undermine our professional role and decrease respect? Is this consistent with our role as the health care provider who guides patients through the perioperative period, monitors every breath and heartbeat to keep patients safe during invasive surgery, and gently guides their return to consciousness while providing reassurance and pain relief? Does this help patients understand that anesthesiologists are lynchpins in complex surgery, critical care, pain management, palliative medicine, health care sustainability, and patient safety? Highly trained physicians devoting endless hours to patient care are not bartenders.

ASA has worked for decades to improve the public perception and image of the anesthesiologist. Extensive education, rigorous training, and our ubiquitous role in all aspects of procedural health care are not obvious to the public. According to ASA’s Facebook page, six out of 10 Americans are unaware that anesthesiologists are physicians. Even fewer are aware that anesthesiologists save lives when emergencies arise (asamonitor.pub/3IJCRPj). Perhaps, thanks to this effort, the percentage of people who believe that anesthesiologists are physicians appears to have steadily improved over the years, and recent data show that only a small number of patients do not think that we are physicians. We must evolve in the public consciousness from being “just a gas man” as portrayed in an episode of “Grey’s Anatomy” by Dr. Miranda Bailey to being a physician anesthesiologist specializing in anesthesia, pain management, perioperative, and critical care medicine.

There is a certain urgency to this effort, as our roles may get blurred from the recent efforts by nurse anesthesia providers calling themselves nurse “anesthesiologists.” The American Association of “Nurse Anesthesiology” (scorn quotes added with intent) has invested substantial resources challenging arguments of better safety and outcomes when anesthesiologists are either the sole providers or are supervising anesthesiologists (asamonitor.pub/3hmEGlW; asamonitor.pub/3QK1nlg). They note that certified registered nurse anesthetists (CRNAs) provide safe, high-quality, and cost-effective anesthesia. They highlight their clinical experience and education prior to getting their CRNA certification.

However, the training CRNAs receive pales in comparison to the eight or more years of post-high school education required of all physicians, followed by a minimum of four years of post-MD training that is required of actual anesthesiologists (i.e., physicians who practice anesthesiology, not nurses who provide anesthesia services). Many CRNA programs now have an additional year of education and students are awarded doctorate degrees, which may be provided through online study. By 2025, all new graduates are mandated to have a doctoral degree (asamonitor.pub/3GC92h9). This CRNA doctoral degree is being used to further muddy the field with CRNAs who have earned a doctoral degree referring to themselves as “doctors.” This egregious practice intentionally blurs the line between highly trained medical doctors who have necessarily demonstrated academic rigor throughout their education to earn their MD degree, and those whose training focused exclusively on providing patient care and earned a doctoral degree through a far less rigorous process. This is not to disparage the training and skills of our CRNA colleagues, who are often exceptionally capable health care providers. Additionally, their “doctoral” training may involve some elements of research related to nurse anesthesia. However, they are not medical doctors. They have not graduated from rigorous anesthesiology residencies, where broad skills are ensured by meeting ACGME requirements for certification. They are not anesthesiologists. If patients are introduced to CRNAs as “doctors,” and we present ourselves as bartenders, no wonder our patients are confused.

We must move forward by educating our patients about our profession at every opportunity that we encounter. We should be role models and teach our trainees to do the same and conduct ourselves in a dignified and professional manner. I do not believe that an internist would describe their prescription for a sleeping medication as “a nightly cocktail.” I believe that we should conduct ourselves with equal dignity.

My personal approach is to emphasize that the medication I am administering will help my patients relax. It will decrease their anxiety. A kindly but completely factual explanation also avoids the allusion to alcohol, which may be highly inappropriate in nondrinkers or those with strong cultural approbations regarding alcohol consumption.

Until the time that we are seen by patients and our colleagues as highly trained and exceptionally skilled physicians who take care of the patient as a whole and not someone who just “pushes drugs,” we must choose our words wisely. We often have just a few minutes to establish patient rapport. A smile, a kind demeanor, a clear explanation of what to expect stated in simple language, gentle reassurance that we will keep the patient safe throughout the procedure, and carefully listening to the patient and answering concerns will convey to our patients that they are in the skilled hands of an exceptional physician.