I have written a good amount about automation, the good, the bad and the ugly.  I have written about doctors and ancillary providers and physician extenders, also good, bad and ugly.  A recent comment on Karen Sibert’s excellent blog A Penned Point caught my eye as an amalgamation of these subjects.

This person wrote, and I hope he doesn’t mind my quoting him:

American anesthesiologists should focus much more on becoming true consultants and not simply be hands-on anesthesia providers. The latter arena shall be, in some future time be mostly staffed by technicians nurses … call them what you will. The finances will determine such.  Anesthesiologists should be supervising these workers, not competing with them directly for menial employment in a race to the bottom. Thus, physician anesthesia training should be expanded in depth scope and rigor.

Nice.   I agree.  Then I read the latest Atlantic Monthly, in which there is an article entitled “The Great Forgetting,” in which Nicholas Carr talks about how automation has taken away both menial tasks and, increasingly, less menial tasks, and our reliance on automation has made us less able to deal with reality when it hits us in the face.  Bear with me.  The quotes are related.

Here is what Mr. Carr says:

Many software programs take on the intellectual work — observing and sensing, analyzing and judging, even making decisions — that until recently was considered the preserve of humans.  That may leave the person operating the computer to play the role of high-tech clerk — entering data, monitoring outputs, and watching for failures.  Rather than opening new frontiers of thought and action, software ends up narrowing our focus.  We trade subtle, specialized talents for more routine, less distinctive ones.

Here is my point.  Anesthesia has become so safe, so well-monitored and so well-administered by various computers that it no longer takes subtle, specialized talents in all cases.  We are now doing the routine tasks of entering data and monitoring outputs.

While maybe not the “menial employment,” Dr. Sibert’s commenter claims, it still is work that no longer needs the rigorous training a physician brings (I emphasize that there are exceptions).

We doctors, as I’ve said a million times, should be doing the hard stuff.  The stuff no one else can do.  Imagine if the anesthesiologist was not just “anesthesia,” a replaceable person in the chair at the head of the bed, revolving with breaks and lunches.  What if the anesthesiologist was “The Anesthesiologist,” the one people turn to in a pinch, someone people look up to as an arbiter of truth and wisdom, the one people look to to do the difficult cases, the sickest patients, the most complicated anesthetics.

This would be a culture shift of the first magnitude, and it would start with training.  Anesthesia residents should not be treated as a warm body to put in a chair.  Endless days of podiatry and cataracts are not helpful.  Yes, emergencies can occur in these cases but a month or so in the first year should alert most decent residents to the hazards of remifentanil boluses and ankle blocks.

How many times have I looked at the OR schedule and seen a resident doing arthroscopies while a solo attending is doing a bronchoscopy or a shared-airway or a prone monitored anesthesia care (MAC) or a trauma.  Why?  If a program has residents it should be the first priority of everyone to get those residents into the hardest cases.   All the time.  They should be doing all the central access.  All the shared airways.  All the double lumen tubes.  All the open triple As and the gunshots and the ICU transfers on three pressors.  They should do awake fiberoptic intubations until they can do them in their sleep.

Physician anesthesiologists should be looked at with respect and awe as the person who can do what nobody else can do.  Right now we’re looked at as the guy in the chair reading the Wall Street Journal, or the guy in Gray’s Anatomy who falls asleep.   Let’s drop the turf wars and the fiscal concerns.  Let’s be real doctors.

Shirie Leng, a former nurse, is an anesthesiologist who blogs at medicine for real.