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A Unique View from the Head of the Operating Table

For many of us, the new year is a moment to reflect on opportunities for change in our own lives. Taking on a new exercise regimen or resolving to save more money are common and laudable goals, as many of us seek to be healthier and manage our finances more wisely. But many of us know that all too often, something that seems so simple may nonetheless be hard to attain.

And when it comes to change on a much bigger scale – making people healthier while saving money throughout the U.S. healthcare system – similar principles apply. What seems simple isn’t always so. Healthcare reform was passed last March, and debates continue surrounding difficult questions related to the utilization and costs of healthcare in the U.S.  And with the new year a whole new slate of healthcare reform changes have gone into effect. Perhaps one of the biggest areas of debate is a challenge faced by policy-makers, physicians, patients and families alike: how to deliver care (or receive it) that values the preferences of patients and their families while also controlling the rising costs in medicine?

A recent perspective published in the New England Journal of Medicine by Mark Neuman, MD, assistant professor of Anesthesiology and Critical Care at the University of Pennsylvania School of Medicine, offers new insights into this question from the standpoint of physician decision-making.

Dr. Neuman was prompted to write the perspective after he watched a popular YouTube animated video* where a surgeon and an anesthesiologist negotiate performing a surgery on a new patient. The snarky theme of the video – made humorous through adorable animated characters – struck a chord with Dr. Neuman and many others in the medical community.

I recently spoke with Dr. Neuman about his views on the issues from the head of the operating table…

Q. Why did you write this piece?

I chose to write this perspective as a way of exploring themes that have emerged both from my clinical work in taking care of surgical patients, and in my research on medical decision making at the University of Pennsylvania.

In my clinical practice, I find that physicians frequently are faced with challenges in counseling patients and families regarding treatment decisions where the potential for benefit may be equivocal or unknown.  The piece highlights some of the challenges physicians face in practice in making care recommendation, and the potential of these recommendations to influence both the quality and cost of care.

Q. It’s rare to hear anesthesiologists discussing surgical decision-making?  How has your work in the OR given you insight into the topics you discuss here?

A. As an anesthesiologist, I have had the opportunity to come into contact with patients receiving care in almost every part of the hospital, including the very youngest and the oldest old.

In all these settings, anesthesiologists manage acute and chronic medical conditions that have the potential to alter surgical outcomes, and offer consultation regarding factors that may influence the risks and benefits of a given procedure. These experiences offer anesthesiologists a unique viewpoint on decision-making regarding medical and surgical interventions, and create opportunities for anesthesiologists to improve the care delivered to individuals for whom the presence of advanced or complex concurrent illness complicates decision-making.

Q. What impact do you hope this perspective will have on healthcare and/or your colleagues in surgery?

A. My hope is that readers of this perspective will take away an understanding that efforts to improve the quality and cost of care for surgical patients will require an improvement in the way we assess the risks and benefits of a given surgical procedure for an individual patient.

In the examples I discuss in the article, limited prognoses for survival may alter the benefits that specific surgical interventions may offer. Increasing the degree to which information on prognosis is brought into health care decision represents an enormous challenge, as an individual patient’s prognosis can be difficult to assess with certainty. Nonetheless, working to improve the degree to which such information is incorporated into surgical decisions is an essential task in seeking to align the care we deliver with patient and family goals.

It’s safe to say that questions will linger and debates will run on over how to find the common-ground between what is medically possible and what is functionally best. But keeping an open dialogue between doctors, patients, and legislators will be the only way to work through these issues – so cheers to Dr. Neuman for adding to the dialogue.

*The YouTube video was not created by and has no affiliation to any Penn faculty members.

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Views expressed are those of the author or other attributed individual and do not necessarily represent the official opinion of the related Department(s), University of Pennsylvania Health System (Penn Medicine), or the University of Pennsylvania, unless explicitly stated with the authority to do so.

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