The Elephant in the Operating Room: The Surgeon-Anesthesiologist Relationship

Donavyn Coffey

December 19, 2019

Anesthesiologist Evgeny Tkachenko, MD, had a routine day ahead of him at the clinic where he works in Moscow: two surgeries, one of them elective. The anesthesia for the elective surgery, an aesthetic procedure, should have been straightforward; the 40-year-old female patient was just back from hiking Kilimanjaro, and her blood tests were fine.

Then she made a passing comment, one that, in retrospect, likely saved her life — but not before it put anesthesiologist, surgeon, and patient at odds.

The woman said she had experienced a single instance of shortness of breath since her last visit, lasting about 15 minutes. When Tkachenko rested the stethoscope on her chest, he could hear only one lung. There was nothing from the other.

An X-ray suggested pneumothorax, but a CT confirmed a giant bullae. If the giant bullae had ruptured during anesthesia induction and positive pressure ventilation, it could have led to pneumothorax, pneumopericardium, hypoxemia, and even death. Tkachenko immediately decided it was unacceptable to go ahead with the operation. He consulted a colleague to be sure, before breaking the news. Neither patient nor surgeon took it well.

"The operation was canceled on the morning of surgery. And yes, the surgeon was very upset. Also the patient was quite angry and didn't understand what's happened," Tkachenko posted on Medscape Consult, a crowdsourced social media platform in which clinicians share and discuss real cases. 

It took 4 hours after the decision to cancel for the team of physicians to convince the patient that she should be discharged and go see a thoracic surgeon. Although the surgeon seemed to understand Tkachenko's decision, it nonetheless left him in a frustrating predicament with an angry patient.

Several anesthesiologists from around the world commented on Tkachenko's Medscape Consult post, affirming his decision to cancel. Other commenters elaborated on the tension that can underlie the anesthesiologist-surgeon relationship. "Pleasing the surgeon by not disrupting the OR schedule with a cancellation vs patient safety is a difficult choice and these days is driven more by economics than patient care," one physician wrote.

The tension that arises between the two OR physicians is "an elephant in the room," said Jeffrey Cooper, PhD, a professor and health quality researcher at Harvard Medical School in Boston, Massachusetts. There's not a lot of direct research on the surgeon-anesthesiologist dyad, he told Medscape Medical News, but "talk to either one of them and you'll recognize it."

Not all surgeon-anesthesiologist relationships are strained, and when they do collaborate well it is a great advantage to the patient, Cooper said. But his qualitative research and that of others has found that even though everyone in the OR agrees that nonhierarchical, collaborative leadership is the gold standard, executing this kind of cooperation is difficult in practice.

When researchers asked 72 surgeons, anesthesiologists, and nurses to watch and respond to three videos depicting tension in the OR, each group viewed responsibility for starting and resolving the tension very differently, rating their own profession as having less responsibility than others, according to a 2005 study.

A 2002 study of nurses, surgeons, anesthesiologists, and trainees found that during tense conversations team members, especially novices, tend to simplify and distort the roles of others.

And training events were unsuccessful at increasing how often anesthesiologists speak up in the OR, according to a 2016 study. The most frequent hurdles to speaking up the study identified were "uncertainty about the issue, stereotypes of others on the team, familiarity with the individual, respect for experience, and the repercussion expected."

"I've been involved in situations where I wanted to cancel a case, and the surgeon did not agree with me," K. Gage Parr, MD, an anesthesiologist and professor at George Washington University Hospital in Washington, DC, told Medscape Medical News. "Sometimes it goes well. Sometimes it goes poorly. And I think it depends a lot on your working relationship with the surgeon."

"Most often the surgeon and anesthesiologist don't really know each other that well," said Richard Cahill, Esq, vice president at malpractice insurer The Doctors Company. It's becoming increasingly common in the United States, he said, for hospitals to contract independent anesthesiology groups rather than employ the physicians directly. In these situations, there's not time or opportunity to form a trusting relationship with the surgeon. He urged that, regardless of the relationship or either party's seniority, it's critical to communicate clearly and immediately for the sake of the patient.

Between 2013 and 2018, The Doctors Company found that "communication among providers" contributed to patient harm in 16% of the malpractice claims they closed. In other words, "if communications had been properly held, the damages would have been avoided," Cahill said. In these cases, the consequences can be catastrophic, including sanctions, revocation or suspension of license, and removal from one or more networks.

Conflict in any working relationship can't be avoided completely, said Cooper, but surgeons and anesthesiologists could do more to understand and trust one another for the sake of the patient. Ideally, Cooper writes, "Each would always start with an extension of the 'basic assumption' [of]: 'I believe that you are intelligent, competent, trying your hardest to do your best and seeking to improve, and acting in the best interest of the patient and the organization.'"

Parr suggested communicating in a way that's direct but not affronting to ego. Go out of your way to make it about the patient. Think professional, not personal. She added that the inevitable will happen. "You make the wrong decision sometimes, but you have to err on the side of safety because it's 'first do no harm.'"

The key to navigating the tension in Tkachenko's situation, he said, was calling for help. He immediately consulted a colleague, contacted the chief of anesthesiology who works at another branch of the hospital, and sent the scans to a trusted colleague in the United Kingdom. They all affirmed his decision. "After all that," he told Medscape Medical News, "the surgeon and patient, they have to agree."

Donavyn Coffey is a freelance journalist in New York City. She interned for Medscape in the fall of 2019.

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