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Tag: Karen S. Sibert

Scope of Practice: Playing at the Top of My License?

flying cadeuciiThe Institute of Medicine in 2010 famously recommended that nurses should be encouraged to practice “to the full extent of their education and training.”Often, you’ll hear people advocate that every healthcare worker should “practice at the top of their license”.

What this concept is supposed to mean, I think, is that anyone with clinical skills should use them effectively and not spend time on tasks that can be done by someone with fewer skills, presumably at lower cost.

So I would like to know, please, when I’ll get to practice at the top of my license?

As a physician who specializes in anesthesiology at a big-city medical center, I take care of critically ill patients all the time.

Yet I spend a lot of time performing tasks that could be done by someone with far less training.

Though I’m no industrial engineer, I did an informal “workflow analysis” on my activities the other morning before my first patient entered the operating room to have surgery.

I arrived in the operating room at 6:45 a.m., which is not what most people would consider a civilized hour, but I had a lot to do before we could begin surgery at 7:15.

First, I looked around for a suction canister, attached it to the anesthesia machine, and hooked up suction tubing. This is a very important piece of equipment, as it may be necessary to suction secretions from a patient’s airway. It should take only moments to set up a functioning suction canister, but if one isn’t available in the operating room, you have to leave the room and scrounge for it elsewhere in a storage cabinet or case cart.

This isn’t an activity that requires an MD degree. An eight-year-old child could do it competently after being shown once.

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A Doctor’s Guide to Botched Executions

lockett execution chamber
I give what could be lethal injections for a living.

That’s right. Nearly every day I give someone an injection of midazolam, vecuronium, and an IV solution containing potassium chloride–the three drugs in the “cocktail” that was supposed to kill convicted murderer Clayton Lockett quickly and humanely in Oklahoma.

Here’s the difference between an executioner and me. I use those medications as they are intended to be used, giving anesthesia to my patients, because I’m a physician who specializes in anesthesiology. Midazolam produces sedation and amnesia, vecuronium temporarily paralyzes muscles, and the right amount of potassium chloride is essential for normal heart function. These drugs could be deadly if I didn’t intervene.

My job is to rescue the patient with life support measures, and then to reverse the drugs’ effects when surgery is over. The “rescue” part is critical. When Michael Jackson stopped breathing and Dr. Conrad Murray didn’t rescue him in time, propofol–another anesthesia medication–turned into an inadvertently lethal injection.

When anesthesia medications are used in an execution, of course, no one steps in to rescue the inmate. This gives new meaning to the term “drug abuse”. In my opinion, the whole concept of lethal injection is a perversion of the fundamental ethics of practicing medicine.

Not for amateurs

Though lethal injection is supposed to be more humane than the electric chair or the gas chamber, often it doesn’t work as planned. Mr. Lockett died on April 29 after the injection of midazolam, vecuronium, and potassium chloride into his system. It is unclear from media reports how much of which drug he actually received. Apparently, prison staff had difficulty finding a vein.

The drugs were injected, they thought, into the large femoral vein in Mr. Lockett’s groin, which should have killed him within moments.

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The Problem of Pain: When Best Medical Advice Doesn’t Equal Patient Satisfaction


The problem of pain, from the viewpoint of British novelist and theologian C. S. Lewis, is how to reconcile the reality of suffering with belief in a just and benevolent God.

The American physician’s problem with pain is less cosmic and more concrete. For physicians today in nearly every specialty, the problem of pain is how to treat it responsibly, stay on the good side of the Drug Enforcement Administration (DEA), and still score high marks in patient satisfaction surveys.

If a physician recommends conservative treatment measures for pain–such as ibuprofen and physical therapy–the patient may be unhappy with the treatment plan. If the physician prescribes controlled drugs too readily, he or she may come under fire for irresponsible prescription practices that addict patients to powerful pain medications such as Vicodin and OxyContin.

Consider this recent article in The New Republic:Drug Dealers Aren’t to Blame for the Heroin Boom. Doctors Are.” The writer, Graeme Wood, faults his dentist for prescribing hydrocodone to relieve pain after his wisdom tooth extraction.

As further evidence of her misdeeds, he says, first she “knocked me out with propofol–the same drug that killed Michael Jackson.” Wood uses his experience–which sounds as though it went smoothly, controlled his pain, and fixed his problem–to bolster his argument that doctors indiscriminately hand out pain medications and are entirely to blame for patient addiction.

But what happens to doctors who try not to prescribe narcotics for every complaint of pain, or antibiotics for every viral upper respiratory infection? They’re likely to run afoul of patient satisfaction surveys. Many hospitals and clinics now send a satisfaction questionnaire to every patient who sees a doctor, visits an emergency room, or is admitted to a hospital.

The results are often referred to as Press Ganey scores, named for the company that is the leading purveyor of patient satisfaction surveys. Today these scores wield alarming power over physician incentive pay, promotion, and contract renewal.

Now hospital payments are at risk too.

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