Criticare - A special feature on Anaesthesiology

Interpersonal relationship between surgeon and anaesthetist

Dr Sateesh R Gupte

Relationship between surgeon and anaesthetist has a long history since anaesthesia was discovered in 1846 and has of necessity, endured ever since. The requirements then of surgery were very basic. A quick painless surgery for removal of a limb, tumors, abscesses were the foremost surgical operations. One of the assistants working with the surgeon would pour ether or chloroform on Schimelbush mask held on the face and that was anaesthesia. Then some vaporizers and apparatuses to administer anaesthesia started appearing and the art of anaesthesia began.

The understanding of human physiology converted this art slowly into a fledgling science. With this improvement, surgical fraternity became bolder and devised major and demanding operations for the benefit of the patients, which gave a vital thrust to anaesthesia. The simultaneous progress in pharmacological, physical chemical and electronic research improved the science of anaesthesia. With this there was a need train physicians as anaesthetist, who had to know all the aspects of human body, its functioning, action of different drugs like sedatives, painkillers, muscle relaxants and volatile anaesthesia agents.

A need for a full-fledged training and post-graduate qualification was obvious and soon became available in this branch. Till this happened, the anaesthetist was one of the surgeon’s assistant who administered the anaesthetic. With specialised training and a well developed science, anaesthetist started getting importance and respect from his colleagues. The transition from a surgeon’s assistant to an independent specialist was prolonged. Along with his routine work, the anaesthetist took care of the very sick patients in intensive care units and now for more than sixty years it is accepted as a discipline which has revolutionised medicine in general and surgery in particular.

After anaesthesia became accepted as a speciality, anaesthetist’s relationship with the surgeon took some time to change from an assistant to an equable to of the surgeon. The transition was gradual but changed faster with every new generation and as of today they are equal partners who respect each others knowledge and ability. As the patient first consults the surgeon, he is indeed the primary doctor of the patient and the anaesthetist is consulted by the surgeon for his services. The surgeon selects his anaesthetist based on his confidence, knowledge, ability, association and rapport. In this pattern of the private practice, ultimately it the prerogative of the surgeon to choose the anaesthetist as patients rarely ask for ananaesthetist however in the current scenario patients now request and do ask who will be anaesthetist for their surgery. It is not always correct or wise to call an entirely new person when a surgeon has not worked with him in a tandem. Many super speciality surgeries have their finer requirements, and also every surgeon is used to certain finer details in anaesthetic procedures which the newer person might not know, and one has to develop a rapport with each other to work as a team. Confidence develops between these two doctors by woriing together for long times, and this is the basis of the smoothness with which they work as a team. The two could have a relationship which is entirely professional, where two professionals approve each others method of working, their ability, temperament, good interpersonal relationship, and professional friendship. Respect for knowledge and each other’s integrity and ability are very important for a lasting relationship. It is indeed a human relationship between two professional individuals, with a resolve to work together. If there develops a bond of friendship in this relationship, which is often the case, it is the best situation as friendship removes all barriers and helps to cement the relationship further. I would any day prefer this to only a professional relationship, but for this you have to choose like-minded people and also have to be lucky. In this pattern of practice as the surgeon is the primary care doctor who selects the anaesthetist, the surgeon should be magnanimous to make sure that the anaesthetist should be made to feel his importance in a given case and a successful outcome is equally dependant and based on both the surgeon and the anaesthetist as equal partners. The anaesthetist has to reciprocate his surgical friends trust and magnanimity, with the same amount of understanding, loyalty, sincerity, friendship and ofcourse professional excellence. This will make a delicate relationship solid and lasting. Relations between surgeon and anaesthetist could be purely professional and could go on for years but can also become fragile. I personally prefer a relationship which has an element of friendship and does not exist only for material considerations.

Ethics and professional integrity and excellence, mutual faith and trust are the hallmarks of lasting relationship. The patient comes to the surgeon, he takes it upon himself to cure him of his problems. The surgeon puts all his might to make the patient better and the anaesthetist has to compliment him with equal sincerity. Leave aside negligence but a casual attitude towards the safety of the patient is unacceptable. In every branch of clinical medicine and so also in anaesthesia, one has to realize for all times that eternal vigilance is required at all times. Professional ability, quick decisions and actions in emergencies and a desire to do one’s best, is expected of every doctor. I remember two quotations in one of our books, one says, “first of all do no harm” and the other “eternal vigilance is the price for safety”, how apt these are for younger anaesthetist to keep in his mind.

In private practice in the city of Mumbai and places around, when a patient consults a surgeon and should he need surgery, is told about the surgery needed and where it could be done. The surgeon quotes his fees depending upon the type of surgery, and the patients ability to afford. In addition to other considerations, the surgeon’s charges depend on his seniority, his busy practice, his name and fame in the field and the hospital and the type of room patient has chosen. The surgeon usually quotes the anaesthetist’s fees which are 1/3, 1/4 or 1/5th of the surgeon’s fees. This percentage is usually decided by the surgeon. These are variable, but should have a standard ratio which should be maintained uniformly at all work places. If this happens it will take away the chances of misunderstanding. The monetary transactions should be above board and should never be cause of discord between two doctors.

In government, municipal and other large hospitals where there is full time staff, both surgeon and anaesthetist are on salary basis, there is no monetary transactions involved between the doctors. In private and large corporate hospitals, for different variety of operations, surgeon’s fees are decided upon by the hospital authorities, and the anaesthetist usually get one-third of the total surgical fees. This avoids any conflict and should become a practice in all types of practice.

At the end, I would like to state that it is the prerogative of the surgeon to choose his anaesthetic colleague, and both maintain high ethical standards with transparency so that it can result in joy and happiness I would like to end this write-up with one famous quotation, which all of us should remember.

“Honour and shame from no condition rise, Act well thy part, and there your honour lies”

The writer is chief anaesthesiologist, Bombay Hospital.

Email: guptesr@bom7.vsnl.net.in