Expert: Ronald Levy, M.D. - 12/17/2009

Question
Background: I am an Army-trained Anesthesiologist, approx 2 years out of residency, practicing as the sole 'ologist with several CRNA's at a Army Community Hospital.  
Question: What have you done/recommend doing in situations in which a patient is obviously not optimized for surgery (blood glucose 320 on DOS) and the surgeon REFUSES to listen to reason, you have advised the patient it's not wise to proceed, but they want to anyway, you have no step-down or ICU in your hospital available. Pt's glucose have been elevated on orals only for several months & primary care has not done anything to help in the past (in terms of optimizing)?  

Answer
That's a loaded question because in private practice, you don't have the leverage you might have in an academic practice. In this particular case, an elevated glucose in a patient that is not spilling into the urine is not necessarily an indication to cancel surgery but it is not unusual for other cases to be more obvious. You are not obligated to provide anesthesia to a patient if you feel it is not safe. Conversely, if the surgeon can find another anesthesiologist, then you may have lost a "client". In the "eat what you kill" world of private practice, that will impact your pocket book. If you are the only anesthesiologist and several surgeons are not happy with you, they will go to hospital administration and have you replaced (since they bring in the patients, they have the clout).

My only advise is to calmly sit down with the surgeons and explain your concerns. If they refuse to listen, you may need to find another position.


Ronald Levy, MD
Professor of Anesthesiology
UTMB-Galveston