Escajeda D: Letter to the Editor; The Unmentionable Subject. The Internet Journal of Anesthesiology 1998; Vol2N2: http://www.ispub.com/journals/IJA/Vol2N2/subletter.htm ; Published April 1, 1998; Last Updated April 1, 1998.

I recently have come to a personal conclusion, and I am interested in knowing if others might be of a similar mind.

In a field such as anesthesiology, we, as people, accept a responsibility that is quite unique in medicine, when you think even a moment about it. An anesthesiologist or anesthetist can cause complications ranging to severe morbidity or even death, in nearly every patient encounter in daily practice. However, by its very nature, what we do is rarely, if ever, primarily therapeutic.

Furthermore,when such catastrophes occur, we are almost never in a position to mitigate the damage done ourselves. This deprives us of the opportunity, at least, for some minor "redemption." Unlike the surgeon who can reexplore, the anesthesiologist has "one shot" only, and invariably, when complications occur, other specialties have to be relied upon to step in and "save the day" (if that is possible.) Short of the occasional blood patch, there is little if anything that the anesthetist can directly do to impact the outcome of a patient's anesthetic complications once they occur.

In summary, then, anesthesiology is a practice which has no direct therapeutic benefit, in which the severity (if not number) of potential complications is disproportionately large, and where the practitioner has no virtually control of the outcome of the complications once they occur. In the aftermath of a complication, the first advice we receive from colleagues is usually to contact our malpractice company, and the first instruction we receive from them is the hardest to accept: do not talk about this to anyone. Could there be a more difficult mandate for a distraught practitioner faced with catastrophe than to isolate himself from communicating with others concerning what happened, much less the attendant emotions they are experiencing?

The vaunted "peer-review process" or "quality review committees" in place in many institutions are hardly more realistic in their recognition of the emotional distress of a practitioner living through a major complication. The case is most likely dispassionately dissected in order to determine "severity level" and to determine if "sanctions" are in order. In the meanwhile, the individual is told, in so many words, "stay tuned", while his or her career is on hold.

Even partners and other colleagues may unwittingly distance themselves from the physician at this point. After all, the complication "doesn't look good for the group; the less said the better." An unspoken superstition in medicine is that once one has a complication, it is a contagious condition. Too much talk about complications, and you are likely to experience one yourself. Furthermore, they may have no more resources to offer the individual in crisis than the individual already has himself: "Life After a Patient Has Complications" is not, after all, a course found in many educational institutions' curricula.

As a community of anesthesiologists and anesthetists, we know all of the foregoing already. And we make assumptions. We assume that the individual knows, after all, what they are getting into when they enter the field. We assume that some complications are unavoidable no matter how diligent the care. And we assume that every individual must rely on his or her own personal resources to pick up the pieces when their practice leads to a major complication. And the final assumption we make is that when a complication does occur, it will be happen to someone else.

The only thing these assumptions do is to ignore the problem: practitioners come to fear complications even more because once they realize once they do have a major complication, they will be essentially be on their own.

And yet, virtually all full time practitioners of anesthesia either have had a major complications in their career, or will someday. (The remainder just haven't been paying attention!) And we have all seen previously enthusiastic and dedicated practitioners age before our eyes in the months following an unexpected catastrophe.

I am sure that the mere stress of dealing with a major complication shortens lifespan, and perhaps alters forever the quality of the life remaining through diminished self-esteem. As a result, we have seen marriages fail, careers ended by drugs and alcohol, and lives cut short by suicide.

There must be a better way to provide an organized support mechanism whereby peers can seek the encouragement and support they so sorely need if they are unable to find it in their own environment. In this age of technology, many people are using the internet to chat anonymously about virtually nothing much of the time. Would this not be a perfect medium for something other than "chat"? Where anyone with a modem could talk with others who are either facing or have faced career crises and support each other without fear? I feel the ability to reach out to others in this way would be a lifeline for many people who have nowhere else to go to discuss their feelings after a disaster, or who have encountered some of the "brick walls" already discussed. What is the potential? Would it not be at least better than the options available now?

If anything here strikes a chord, please email me at denverguy@msn.com . In the meanwhile, be safe, and if you can't be safe despite your best efforts, be lucky!

Sincerely,

Dan Escajeda, MD

The Internet Journal of Anesthesiology