I’m an anesthesiologist, and I like to tell stories. This one is true. If you wonder how much the anesthesia scene has changed significantly over the past four decades, check out this narrative:
In 1986 I was in my second and final year of anesthesia residency training at Stanford, and I was looking for a job. The entire program was 24 months long in those days. We were all due to graduate from the residency on the 30th of June, and in the middle of the second year it was routine to begin searching for a full time job to begin in July. I heard about an opening with a busy private practice anesthesia group in Southern California. I contacted the group via telephone, mailed them my resume, and they invited me to travel to their hospital for an interview. I was excited. The prospect of a full time private practice job was enticing.
When I arrived at their hospital, I donned scrubs and was ushered from operating room to operating room to meet 15 or 20 attending anesthesiologists while they worked. The hospital was stylish and clean, the medical personnel were friendly, and the anesthesia work looked familiar, with no significant differences from what I’d seen during my training.
A month later they invited me back to the second step of their vetting process—an oral board-type exam where I was questioned by ten members of their group. They told me their exam would be “more difficult than the American Board of Anesthesiology oral exam.” The actual exam room was an imposing setting, with ten partners in the group sitting around a semicircular table with me at the center. Their questions were difficult. One I still remember was “a 3-year-old child is hit in the eye by a rock thrown from a lawnmower. His eye is open and bleeding, he is screaming, and he just ate a McDonalds Happy Meal 30 minutes earlier. How will you anesthetize him for his eye surgery?” This open eye-full stomach case was a classic anesthetic exam question meant to make an examinee squirm. The child has no intravenous (IV) line yet, and because he is scared and in pain he won’t let you start an IV, so the option of an IV induction of general anesthesia is not available. Doing an inhalation induction of general anesthesia by mask is contraindicated because the child has a full stomach and is at risk of vomiting his cheeseburger into his airway. I’d read a lot from my anesthesia textbooks at that point, and I passed their exam. Then I was invited to the last step of their vetting process, which was the performance of 20 anesthetics during one week at their hospital while they observed and evaluated my skills.
This is where the story gets more interesting, because I was not a fully trained anesthesiologist yet. It was March of my second year of residency. I had only completed 20 months of the total program, and I still had 3½ months of education remaining. I shared this fact with their group, and also told them I hadn’t yet completed my month of pediatric anesthesia training, which was scheduled for June. I’d performed approximately 20 pediatric anesthetics during other rotations, but I was relatively inexperienced anesthetizing children. This was pertinent, because this Southern California anesthesia group staffed a nearby children’s hospital. I was reassured my incomplete pediatric training to date would not be a problem. “Don’t worry,” they said. “We’ll be in the operating room with you.”
“What about malpractice insurance?” I asked, knowing my malpractice insurance in my residency only covered me at my training sites near Stanford.
“You’ll have to get your own malpractice insurance,” they said. “You can’t go bare.”
I made a few phone calls, and one of the two main malpractice insurance companies in California agreed to insure me, even though I was still not yet board-eligible in anesthesiology.
We scheduled my tryout to occur during a vacation I had pending in late March. I drove to Southern California to begin my tryout. Was I nervous? Very much so. I arrived at their hospital on a Monday morning. I’d prepared my strategy for the week. I decided to stick with a common anesthetic regimen I’d used frequently at Stanford: IV Versed, followed by IV pentothal, fentanyl, and vecuronium for induction, followed by oxygen, isoflurane, and nitrous oxide for maintenance anesthesia for all general anesthesia cases. Propofol was not yet available, nor were sevoflurane, rocuronium, or laryngeal mask airways.
The first four days of the week flew by. My anesthetic recipe worked fine, and by my own assessment I was passing with flying colors. The group introduced me to the dollars and cents of anesthesia billing and business practice. In residency you learn nothing about the economics of private practice. I was handed a tablet of blank anesthesia bills to fill out for each case. The group’s arrangement with me was that I was to keep all the income I earned for performing those 20 cases. The attendings in this private anesthesia group explained the concept of “anesthesia units” to me. Each scheduled anesthetic had a startup value from 3 to 20 anesthesia units, depending on how complex the surgery was. For example, a finger surgery earned 3 startup units and coronary bypass surgery earned 20 startup units. Each 15 minutes of anesthesia time earned one additional unit. On day #1 I administered a spinal anesthetic for a woman having a Cesarean section. The startup unit value for the Cesarean section was 7 units, and the anesthetic time was 90 minutes (6 units), for a total bill of 13 units.
“How much is a unit worth?” I asked.
“Whatever the payor pays you,” I was told. “For a fully insured patient we bill $38 a unit, so you’ll get paid $494 for this case. For a Medi-Cal patient, you’ll collect about 1/5 of that fee.”
I was shocked. Four hundred ninety-four dollars was my approximate salary for a week as a resident. The earning potential of an anesthesiologist became apparent to me, and my enthusiasm grew. All I had to do was finish impressing my potential employers during these 20 cases and I’d have a strong chance of securing a high-paying job.
On Thursday night my dreamworld darkened. My first scheduled patient on Friday morning was a premature baby scheduled for an exploratory abdominal surgery. The patient was in the Neonatal Intensive Care Unit (NICU) on a breathing tube and a ventilator, with IVs in her left foot and right hand. The infant was born one week earlier, at a gestation of 34 weeks, i.e. 6 weeks premature. The infant weighed 2 kilograms, or about 4.4 pounds. When I saw the patient in the NICU Thursday evening, I knew I was in over my head. I’d never worked on a patient this tiny, and I wasn’t sure how to manage the anesthetic. I tried to telephone one of my pediatric anesthesia attendings at Stanford for advice, but I couldn’t reach him. The sun went down and my anxiety escalated. My primary concern was no longer whether I’d get the job, but rather whether I was safe to anesthetize this kitten-sized patient in the morning.
I didn’t sleep a minute all night.
Prior to the surgery the next morning, I walked up to the chief of the anesthesia group and told him the truth: Because I’d yet to do my month of pediatric anesthesia training, I was not comfortable doing this neonatal anesthetic. He received my remarks with a stern face, and told me someone else would do the case. I finished out that day doing easy adult orthopedic surgery cases, but I felt like a failure. The week finished, I turned in my billing records to the administrators in their main office, and drove back to Northern California. I knew I’d done the right thing—I knew I had no business doing that 34-week-old baby’s anesthetic with my incomplete training, but I felt badly.
One week later I received a letter from the private practice group which read, “We believe you would fit in best at some other practice than ours. Thank you for your interest in working for us.”
I crumpled the letter into a ball and tossed it in the garbage. My next problem surfaced the following day when I received a bill from the malpractice insurance company. This posed a dilemma. Did I need that private practice insurance anymore? The private practice malpractice policy was for “claims made,” meaning this policy had to be valid when a malpractice claim was made, not when the actual anesthetic was done. Should I keep paying for this insurance coverage in case one of those 20 patients in Southern California sued me in the next year? My anxiety returned, and I felt I had no one to ask for advice regarding this odd set of circumstances. Cancelling the malpractice policy meant accepting the risk of being sued without coverage. I thought back to my 20 cases, and found it difficult to image anything had gone wrong enough to run the risk of a malpractice lawsuit. I rolled the dice, and tore up the bill. I’d go bare and gamble that no lawsuit was pending.
Three months later I received another envelope from the Southern California anesthesia group. This one contained a check for what they’d collected from my 20 anesthetics. The sum was equal to 5 months of my Stanford resident salary. This was a happy coda to an emotional rollercoaster.
In June I completed my month of pediatric anesthesia training at Oakland Children’s Hospital, and gained the experience and skills I didn’t have in my Southern California tryout.
Could this drama happen today? No, for several reasons. It’s difficult to imagine any hospital or surgery center would grant temporary medical staff privileges to someone who had not finished their training. At the surgery center in Palo Alto where I’m Medical Director, candidates for medical staff membership and clinical privileges must not only be board-eligible, but they must also be board-certified in their specialty. And it’s unlikely a 21stCentury malpractice insurer would issue coverage for an anesthesia practitioner who was incompletely trained. And in present times most anesthesiologists covering neonatal anesthesia in a children’s hospital will have completed not just their residency, but also a subspecialty fellowship in pediatric anesthesia. Beginning in 1989, anesthesia residencies in the United States were expanded from two years to three years (post-internship). At the 20th month mark in residency, when I was performing my “private practice tryout,” current anesthesia trainees would be barely half-finished with their 36-month residency.
Retelling this tale still makes me shake my head in disbelief. It was an anesthesia story—an anesthesia story like no other.
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