Internet Experts and the Unbridgable Gap

In my day job as a board-certified anesthesiologist with 25 years’ experience, I’m frequently struck by the freedom with which patients, and families, feel they can tell me how to do my job. Thanks to the internet, everyone’s an expert — except when they aren’t, which applies to almost everyone, about almost everything. As one of my favorite writers, Kevin Williamson, puts it, “Everything is simple when you don’t know a f$%#king thing about it.”

I had a chance to marvel at this phenomenon again yesterday. A patient showed up to have a surgical procedure done. This is a straightforward procedure, the sort of case that would be assigned to a properly-supervised first-year anesthesiology trainee. But a “simple” anesthetic, nonetheless, still requires knowledge and training to do properly and safely.

The patient had had a previous, similar procedure done, and s/he and the family had extrapolated, wrongly, from that experience to the current one. They brought a laundry list of suggestions/demands for how we were to proceed. They had “researched” such things as the “right” antibiotic for the procedure; and which anesthetic medications and techniques would be “appropriate”. The patient insisted on not going “all the way to sleep” for the procedure, as s/he hadn’t last time. They wanted me to do things exactly the same way, using the same drugs and doses. That they were all lay-people, with no medical training other than the isolated factoids they had gleaned somewhere, didn’t seem to affect anyone’s perception of the situation.

Turned out that every single thing they mentioned was either dead wrong, or inapplicable to the specifics of this patient’s situation — as I knew might happen, and had tried to explain. I wound up having to deviate from the previous anesthetic plan, because though the surgery was similar, other circumstances had changed. This is the sort of nuance that training and experience confers, and which can’t be acquired by an untrained person with a Google search.

Like most physicians in this age of the almighty Patient Satisfaction Score, I feel compelled to at least appear to listen to the maunderings of patients and families. Making people mad on a regular basis by not acting like the help, and acceding automatically to their whims, can be bad for one’s career standing and income. And I always keep an ear cocked on the odd chance that a patient or family might offer something of actual use, perhaps portending problems ahead. Even a blind hog finds the occasional truffle. Separating wheat from chaff in the torrent of information offered by patients and families is itself an important skill that takes years to develop.

Where technically feasible and safe, I accommodate harmless requests. At other times I gently deflect, and try to explain why the request is wrong; most people, when offered actual expertise in an understandable form, see reason. Only on a few occasions have I had to flat-out refuse to comply with a patient’s wishes. In one instance, the patient declined my services, and ultimately one of my partners did the anesthetic — in exactly the manner I’d recommended — after inconveniencing everyone and him-/herself by a last-minute spurious cancellation at the threshold of the OR door.

I realize it’s unfashionable to say it, people, but you will never be able to know enough or to Google enough to dictate a safe anesthetic plan — or any other medical procedure, for that matter. I make no apology for this statement; every doctor I know believes it, even if he or she won’t say it forthrightly. When it comes to healthcare, you don’t know jack-sh%t, and won’t ever know it. “Expertise” comprises at least two factors: factual knowledge, and the judgment to apply it. First comes knowledge, later paralleled by hands-on training and more study to learn how to apply that knowledge. This process, starting with undergraduate sciences, followed by medical school and residency training, takes twelve to fifteen years. And you think you can second-guess such a person after an afternoon with Google? That’s laughable. Hate to break it to you — but there are actual experts in the world, and the gap between you and them is insurmountable.

It would be similarly absurd for me, an expert in my field, to tell a civil engineer, an expert in hers, how to design and build the viaduct I drive ever day to get to work. Yes, I might be able to study materials science and computer-aided design, and the physics of static and dynamic load-bearing, and maybe converse knowledgeably with her. But I’d never think of telling her how to design that bridge. She’d rightly disregard my “advice”, and would be within rights to throw me out of her office.

Yet patients and families do essentially the same thing just about daily when they encounter the healthcare system, and it’s beyond passing strange. I suppose it’s an expression of fear, and a manifestation of the urge to control the uncontrollable. Circumstances have forced you to put your life in a stranger’s hands in an immediate and up-close manner — just as you put your life in that civil engineer’s hands every time you drive over her viaduct.

That said, what are you to do? First thing, you need to plan ahead. Here’s something useful Google can do for you. Research the hospitals in your area. The “best” hospitals usually attract the “best” medical staff. Published ratings aren’t foolproof, but they are a place to start.

Everyone needs to develop a relationship with a primary-care doctor well ahead of any actual health crisis. Once you’ve found someone you trust, ask him or her which specialists s/he’d recommend. There’s a decent chance that, in your lifetime, you’ll need a general surgeon, an orthopedic surgeon, a cardiologist, or an oncologist. Ask your PC doctor who she’d recommend among those specialists.

All of us doctors know who the “good” people are. If you know any doctors, ask them to whom they’d send their own family members. You have to do this ahead of time. You’ll have no choice at all if you turn up at the ER with an acute surgical problem; you’re gonna get whoever’s on call for that surgical specialty. It’ll probably turn out fine, but wouldn’t you rather have some control over the situation? In a true emergency — surgery is required within six hours to prevent death or serious disability — there may not be time to arrange a transfer somewhere else, or you might be too sick to be moved.

Things are a bit different with anesthesiologists. Yours will be a solo individual or a member of a group that covers your hospital, and is often someone the surgeon works with regularly. For elective outpatient cases, an anesthesiologist likely won’t be assigned to you until the night before your procedure. For emergency cases, you’ll get whoever’s on call. Again, the better hospitals and better surgeons — who you’ll already have researched, right? — tend to work with the “better” anesthesiology groups. Ultimately, you’ll probably have no say in who does your anesthetic. If there’s time, it’s always possible to request a phone call from him or her; we get those requests and are glad to honor them.

I don’t mean to imply that I expect my patients to blindly accept whatever I tell them; and intelligent questions are always welcome. But, like it or not, you’re going to have to surrender some control, and make a leap of faith. That leap will be less frightening if you’ve done your homework in advance. The threshold of the OR is not the place for you to work out your problems with authority, or to pose as the smartest kid in the classroom. In a healthcare setting, you almost certainly are not. Try to make your peace with that.

Michael Sebastian @mikeseb