BMJ  2003;327:79-80 (12 July), doi:10.1136/bmj.327.7406.79

Paper

Should same anaesthetist do preoperative anaesthetic visit and give subsequent anaesthetic? Questionnaire survey of anaesthetists

¹ Ospedale Generale Provinciale, 55100 Lucca, Italy, ² Laboratorio di Epidemiologia Clinica, Istituto di Ricerche Farmacologiche "Mario Negri," 24020 Ranica (Bergamo), Italy

Introduction

The preoperative anaesthetic visit is done to assess the patient's fitness for surgery, to discuss the most appropriate anaesthetic technique, to reassure the patient, to obtain informed consent, and to prescribe premedicant drugs. Patients used to be visited by the doctor who later anaesthetised them,¹ but the preoperative visit and the subsequent anaesthetic are now seldom done by the same anaesthetist.² Patients would rather be anaesthetised by the doctor who saw them,³ but anaesthetists' opinions are unexplored.

Participants, methods, and results

In June 2002 we sent a questionnaire containing two scenarios to anaesthetists belonging to the Gruppo italiano per la Valutazione degli interventi in Terapia Intensiva (GiViTI), a research network of Italian anaesthesia and intensive care units founded in 1991 to promote research and improve clinical practice. In scenario A, "one patient, one anaesthetist," patients are anaesthetised by the anaesthetist who visited them. In scenario B, "one patient, two anaesthetists," one anaesthetist visits a patient and another physician administers the anaesthetic. We asked anaesthetists which scenario is used in their institution, which one they preferred, and to pick from a list (drawn up by a panel of senior anaesthetists, see box) at least one reason for their choice. Assuming 50% preferences for both choices (worst scenario for estimating sample size), we needed 170 respondents to give a width of 15% for the 95% confidence interval of the percentage of preferences.

Reasons for choosing each scenario Reasons for preferring scenario A (one patient, one anaesthetist) Because in case of litigation, how will responsibilities be attributed to the two anaesthetists involved? (136 answers; 69% of respondents) Because preoperative tests and drugs are best ordered by the anaesthetist who gives the anaesthetic (126; 64%) Because anaesthetists should never visit a patient thinking "who cares, it's not me who will give the anaesthetic" (101; 51%) To avoid the second anaesthetist cancelling an operation for a patient he or she deems unfit but who was judged fit by the first anaesthetist (82; 41%) Because you can't be expected to anaesthetise a patient you think is unfit for surgery, just because another anaesthetist judged him or her fit (59; 30%) Because it's the anaesthetist who gives the anaesthetic who should choose the anaesthetic technique (40; 20%) Because otherwise you are working at a surgical assembly line (36; 18%) Because otherwise no patient-doctor relationship is possible (33; 17%) Because the person who gets the patient's informed consent should give the anaesthetic (30; 15%) Because patients prefer being visited and anaesthetised by the same doctor (10; 5%) Reasons for preferring scenario B (one patient, two anaesthetists) Because it's easier to organise (17; 9%) Because it forces anaesthetists in a department to adopt uniform preoperative criteria (16; 8%) Because each patient is seen by two anaesthetists (6; 3%) Because it allows sharing of responsibility in case of mishaps (1; 0.5%)

Within a month 198/262 (76%) anaesthetists from 99 departments replied. Respondents had a mean age of 45 (SD 7; range 26-62) years and a mean seniority of 15 (8; 0-33) years; 194 (98%) anaesthetists worked in public hospitals. In all, 161 anaesthetists (81.3%; 95% confidence interval 75.3% to 86.1%) preferred scenario A, 20 (10.1%; 6.6% to 15.1%) preferred B (reasons are shown in the box), and 17 (8.6%; 5.4% to 13.3%) had no preference. Of respondents who chose scenario A, 145/161 (90%) picked fewer than six reasons for their choice (range 1-9). Eighty nine departments out of 99 (89.9%; 82.4% to 94.4%) used scenario B, and 10 (10.1%; 5.6% to 17.6%) used A.

Comment

The scheme "one patient, two anaesthetists," enforced in nine tenths of the departments, is preferred by only one tenth of anaesthetists. The vast majority of anaesthetists (like patients³) prefer the scenario "one patient, one anaesthetist."

Preoperative assessment in Italy is always done by medical anaesthetists but seldom by the one who will administer the anaesthetic. A decade ago it was "accepted as an integral part of the practice of high quality anaesthesia that patients are visited by the anaesthetist who will subsequently anaesthetise them: indeed such a practice is considered as a marker of quality."⁴ Anaesthetic standards in the United Kingdom state that "the anaesthetist will normally visit the patient both pre and postoperatively. Unless in emergency or unusual circumstances this is a requirement of the specialty. Ideally this should be carried out by the anaesthetist who is to administer the anaesthetic. Where this cannot be undertaken the anaesthetist should detail in the case notes the reason for the omission."⁵

A high response rate (76%) and sending questionnaires to predetermined researchers excludes self selection bias. If non-responders would have chosen scenario B, A would still have been preferred by a large majority (161 (61%) v 84 (32%) out of 262). Our results reflect the opinions of anaesthetists interested in research.

Among reasons given for preferring scenario A no single pattern prevailed—the combination of reasons chosen most often was chosen by 7% of respondents. This excludes wish bias (the questionnaire pushing respondents in the direction they believe would please the investigators). The single reason cited most in favour of A was the medicolegal one (69%), and the reason given least often was following the patient's preference (5%). Does this reflect anaesthetists' current concerns? Reasons given for supporting scenario B were non-clinical: easier organisation and uniformity within departments.

The policy "one patient, two anaesthetists," adopted by most Italian anaesthetic departments, clashes with professional standards and with the opinion of anaesthetists and patients. Why is clinical practice so far from ideal? Is the same happening in other countries and in other disciplines? Current preoperative assessment in Italy is judged by most anaesthetists doing it and patients undergoing it to be done by the wrong anaesthetist.

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We thank Marta Cattaneo for her invaluable help.

Contributors: BS and GB designed the study. GB coordinated the study and did the statistical analysis. Both authors wrote the paper and are guarantors for the study.

Funding: Mario Negri Institute, Ranica (Bergamo), Italy.

Competing interests: None declared.

References

1. Egbert LD, Battit GB, Turdoff H, Beccher HK. The value of the pre-operative visit by the anaesthetist: a study of doctor-patient rapport. JAMA 1963;188: 87-9.
2. Roizen ME. More preoperative assessment by physician and less by laboratory tests. N Engl J Med 2000;342: 204-5.[Free Full Text]
3. Simini B. Pre-operative visits by anaesthetists. Anaesthesia 2001;56: 591.[Medline]
4. Nightingale JJ, Lack JA, Stubbing JF, Reed J. The pre-operative visit: its value to the patient and the anaesthetist. Anaesthesia 1992;47: 801-3.[Medline]
5. Royal College of Anaesthetists. Guidelines for the provision of anaesthetic services. Oxford: Hall, 1999: 8.

(Accepted April 10, 2003)

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