I remember the first time I saw the BIS (bispectral index) brain monitors (developed to display “depth” of anesthesia in an effort to avoid awareness episodes) displayed at an anesthesia meeting. The sales representative was explaining to a bunch of wide-eyed young residents how indispensable this new device was. “Soon, doing an anesthetic without this monitor will be considered malpractice,” he said. He then made the mistake of asking me (the old timer…I’m not really that old but I had been in private practice for about 15 years when this incident occurred) what I had to say. “If I need that machine to determine whether someone’s asleep or not, you don’t want me doing your anesthetic.” “Might be a great training tool, though.” Not a good sales day.
These brain wave monitors, relied on to determine the depth of anesthesia, essentially became “standard of care.” By that I mean that an anesthetic awareness complication in the absence of one of these monitors was basically indefensible. This was only for a short time, however, as big hospitals, quick to embrace this technology (partly because they could bill big bucks for the disposable probes on the forehead) saw the device as an anesthetic rationing tool. Anesthesiologists all over the United States turned their anesthetic gases down based on the feedback given them by this new device. Hospitals saw this as a way to save money on anesthetic gases, pressuring the anesthesiologists to practice stingy anesthesia. The results? Radical increases in the number of awareness episodes. BIS went pretty much down the toilet. They are trying to make a comeback hoping that memories are short.
Anesthesia journals are now full of articles about the performance of regional anesthesia with ultrasound. For you non-doctors reading this, regional anesthesia is just what you think it is: anesthetizing a region of the body, not your whole body. This is accomplished by placing needles in the vicinity of nerves or groups of nerves and applying local anesthetic in these locations to render an entire arm or leg “numb,” for instance. Ultrasound guided regional anesthesia is the latest craze. Articles are now appearing that state that regional anesthesia performed without the benefit of ultrasound guidance is basically malpractice. Here we go again. Hospitals are all over this as….you guessed it….they can bill a bunch of money for it! My blogs are becoming predictable aren’t they?
I took a course in medical school called “anatomy.” This is the course where they teach us about the structure of the human body. I use this knowledge to ascertain where to stick needles into people when administering regional anesthesia. That I don’t require ultrasound guidance is perhaps an indication that I use the anatomical knowledge provided by medical school professors. Those that have declared ultrasound guidance as indispensable should have paid more attention in class, I think. As a training tool, ultrasound guidance is cool. As a mandated or required tool, I think that this is BIS deja vu.
The clinical skills of some physicians dwarf those of others. No tests are needed for some savvy clinicians to come up with the right diagnosis. Few to no bells and whistles seem to be required for some surgeons to achieve perfect results. Technology has its place. As an anesthesiologist, I know this is true. It is, however, no substitute for the art of clinical diagnosis and treatment. The greed of the big hospitals (they charge big bucks for all of this garbage) has brought us unnecessary technology that has stifled physician’s clinical skills and has actually harmed patients. As the current medical racket crumbles and patients are increasingly paying for the care they receive (rather than insurance companies) these clinical skills will be in great demand, just as they were for centuries. Many of the bells and whistles will vaporize when patients realize they are paying for fluff, the vast majority of which contributes nothing to their outcome or wellbeing.
G. Keith Smith, M.D.