The Imperfection of Becoming Perfect

“Practice makes perfect” the saying goes, and with medical procedures there is little doubt that practitioners and centres with a high use of particular procedures have higher success rates and fewer complications. In anaesthesiology complex regional blocks, intravascular catheterisation and airway techniques are procedures which require learning and ongoing use by the anaesthetist for skilful application.

Some skills are learnt and used readily in day today practice: mask ventilation, direct laryngoscopy and spinal anaesthesia. Other procedures are used less frequently but usually opportunities present often enough for the full time trainee of practitioner: these include epidural analgesia, central vein catheterisation and plexus block. The administration of new drugs also requires learning and practice; for example, remifentanil’s potency and fast onset and offset demand practice to gain familiarity. Then there are procedures which require skilful application and are expected to be within the capabilities of a specialist anaesthetist but are usually only rarely mandated, such as cricothyroidotomy and fiberoptic intubation (FOI). Cricothyroidotomy is never done unless mandated and training in this procedure is limited to mannequins and animals (which presents another and not unrelated ethical problem). Fibreoptic intubation, however, is a relatively non-invasive procedure in that it can be done without breaching epithelium. A very few practitioners may use this technique as their standard ay of intubation. Some may use it as their preferred means of securing nasal tracheal tubes. Most, I think, would use a flexible fiberoptic bronchoscope (FOB) only for the difficult airway in which intubation with direct laryngoscopy is, or is anticipated to be, impossible.

There is encouragement from some to practice FOI on patients having routine anaesthesia and surgery in whom direct laryngoscopy and intubation would be expected to be readily achieved. The equipment is readily available, the patient is anaesthetised and needs to be intubated; it seems a very good opportunity to practice an important skill. But is your patient there to be practised on?

The main argument for so doing is the “practice makes perfect” mantra; the real benefit will be for the future and as yet unknown patient with the difficult airway. Society will benefit from having doctors who have skills. Another argument if the practice occurs in a teaching hospital is that a teaching hospital is for teaching. These types of arguments follow a utilitarian ethic: the means of practising on patients justify the ends of having skilled doctors in the community. It was the argument in support of medical students performing pelvic examinations on anaesthetisted patients, but when this practice came under public and media scrutiny and criticism in the 1990s it subsequently became more onerously conducted; in particular, gynaecology patients are counselled and are to give consent before student examinations under anaesthesia. Intubation practice on recently deceased patients in emergency departments also has been criticised as a violation to the deceased being’s autonomy and at least one Australian state forbids it without the patient’s or a relative’s consent. These examples of a shift in teaching practice illustrate the current dominant view that individual patient autonomy is paramount. Autonomy is one of the principles of medical ethics, and it is difficult to dispute that practising a procedure on a patient without her knowledge or consent is a violation of her autonomy.

The other principles of medical ethics include beneficence, non-malificence, dignity and justice.

The beneficence in FOI is in safely securing an airway. However, the airway under general anaesthesia can collapse and flexible fiberoptic laryngoscopy can be difficult. A typical direct laryngoscopy and intubation is quickly accomplished; the beneficence from the standard approach is arguably greater.

Non-malificence is to avoid harm. Specifically for intubation it is to avoid mucosal trauma, arytenoid injury from the tracheal tube bevel, apnoea, haemodynamic disturbance or oesophageal intubation. Most of these complications can occur can occur with either means of intubation, but if a complication occurs practising FOI on a patient with an airway which would be readily intubated with direct laryngoscopy it would be more likely than not that harm resulted from the act of practising.

Dignity might be denied to a patient if there was a tendency to reserve practice to patients of lower socio-economic status or non-English speaking status. A test would be to ask if FOI practice would be undertaken on an unknowing staff member or other VIP having anaesthesia and surgery.

And perhaps justice would be breached if a later patient with a truly difficult airway was denied FOI because the bronchoscope that had been practised with was being cleaned or repaired when ir was really needed, or the opportunity cost takes away resources from other areas of healthcare.

By testing with the priniciples of medical ethics, I contend that the act of practicing FOI on unknowing anaesthetised patients is unethical. So how do anaesthetists learn and maintain the important skill of FOI?

The use of FOI should pass a test: it is a reasonable procedure for the clinical circumstances that would be supported by most medical peers? This means FOI will be probable be reserved for the anticipated difficult airway or certain types of surgery such as head and neck surgery. If the practitioner is accomplished in FOI and uses it as a standard means of intubation, FOI on patients without a difficult airway is not then unethical. Autonomy and dignity of the patient might be compromised if the FOB is used on a whim, be it for practice or for a challenge or “just to do something different”.



If the FOI is to be truly done for practice the patient must volunteer their altruism and give her fully informed consent, and the procedure must be done with due care and appropriate supervision. It is likely the obligation to gain consent will mean such requests are unlikely to be made and more likely to be denied if they are.

If departments or teachers or individual practitioners feel a need to teach, acquire or maintain the skill of FOI then high fidelity training mannequins and a practice FOB should be acquired and used.

In conclusion, the care and interests of the patient to hand are a doctor’s paramount concern. The patient is not for practice.