Early in my private practice career, I had an old partner who did outrageous things. Monitors? Maybe. I'd give him relief, and shudder at what I found for vital signs when I hooked the patient up. He didn't bother much with preo-op interviews; he'd just look at patients in the OR while he was drawing up the pentothal and sux. I'd tut tut to myself, having just come from my University Post where I had played the role of encyclopedia anesthetica for my department; you know, the guy that knows all the literature and (in those days) kept multiple file drawers full of carefully catalogued articles. All departments have a guy like that. Since I had been almost immediately placed on the local QA committee, I self-righteously waited for the ineveitable consequences of his apparent inattention. There was only one hitch.
He never got in trouble. Not once. I practiced with him for years, and never once had a case fall out in QA. Oh yeah; he chipped a patient's tooth once, and as was the custom back then, he bought the patient a crown. End of story.
Now this was a guy who had given anesthetics for pediatric cardiac surgery in the era when perfusion consisted of hooking up baby to mom's iliacs and using mom as the heart-lung machine. That was long before pulse oximeters and gas monitors (think about doing a pediatric heart case without a pulse ox!) In the era "when ships were wood and men were steel," I guess he was a bosun. Towards the end of his career, I asked him why he never got in trouble. He thought for a while, then said something like, "well, I just look at 'em, and if it looks like I can't kill 'em, I just put them to sleep." Enigmatic.
Back in training, we all did a rotation with a group of private practice guys in a community hospital. One day we were doing a case; a lumbar laminectomy or the like, and as a conversation starter, I told my attending about some or another study I had found in Anesthesiology the night before on aspects of just such a case. He asked me how many patients in the study and I told him, whereupon he kindly informed me that by his reckoning, he had done at least three times that many in his twenty years of practice. End of conversation.
It's now twenty five years later, and I still reflect on that day. By my own reckoning, I've done North of 20000 cases, at least 18000 of them myself, not supervising.
I understand those men a lot better now than I did at the time. I still do a careful preop evaluation, but it's a lot different than it was; like Bob Seger said, I know "what to leave in, what to leave out."
I figured out Swan Ganz catheters weren't generally doing my patients a whole lot of good long before the Canadian study demonstrated that. It's too bad because they were a lot of fun.
I still read the literature, but not with the same rapture I had opening my journal each month when I was a pup. A lot of the time, what I read doesn't pass the "sniff test" of more than two decades of practice. For instance, perioperative MI's. Pretty darn rare out here in practice land. Maybe that's because triple-A cross-clamp times are typically about 15 minutes. I just don't know.
Occasionally, though, there'll be something that makes me say to myself, "now why didn"t I see that?" or, as often, "I knew that." Those are thrilling moments in the dry business of literature reading, and like the straight 300 yard drive in golf, (I am a psycho-motor nincompoop) the intermittent irregular positive reinforcement is a strong behavioral stimulus to keep reading.
I like messy review articles, and airy-fairy stuff. A couple of years back, there was a review article in Anesthesiology on Cardiopulmonary bypass and SIRS: fun! And Hameroff's latest Article on Anesthesia and Consciousness. Cool.
I'm pretty sure that my continued interest in the anesthesia literature doesn't directly translate into lives saved and morbidity averted; my best partners, and the guys I would let anesthetize my kids aren't big anesthesia readers, but they're great clinicians.
On the other hand, I find that general medical knowledge is pretty handy to have around the OR. And, with the scarcity of internists these days, general medical knowledge is getting to be distressingly rare; it's increasingly a do-it-yourself world.
Oh yes, the title of this post comes from a saying attributed to a long retired partner of my practice, gone before I got here twenty years ago. By some reports, it was first said by Will Rogers. Good judgment comes from experience, and experience comes from bad judgment.