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May 1996
Volume 60 |
Number 5
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| The Anesthesiologist
and Office-Based Anesthesia Practice |
James A. Mihalcik, M.D.
Office-based anesthesia practice is the poor relation in the
family of anesthesia services. Often relegated to "moonlighting"
hospital-based physicians, it has been believed to be an easy
path to a fast buck and sure trouble if the department chair finds
out. Now it seems this diamond in the rough may be appreciated
for what it has to offer, namely low-cost health care. The anesthesiologist
as a perioperative physician can, indeed, have an impact on the
quality of this low-cost care.
The office anesthesiologist has an opportunity not only to be
a perioperative physician but the operating room director, an
anesthesia technician and a circulating nurse as well. This lack
of supplementary staffing eliminates many of the redundant safety
checks that are commonplace in a hospital setting; conversely,
it also breeds a sense of need. Hence, into this vacuum, the multidisciplinary
approach of a true perioperative physician is readily welcomed.
Our surgical colleagues, who grouse about "goldbricking"
anesthesiologists in a hospital setting when a point of preoperative
care is raised, realize that wasted time and canceled cases in
an office setting are shared by both surgeon and anesthesiologist.
They also realize that the consequences of even moderate postoperative
complications caused by poor perioperative management are exaggerated
in the office setting due to constraints on staffing and resources.
The balance that must be achieved between good preoperative preparation
and profit motive to get the case done is a delicate one. Neither
rigorous ivory-tower academic standards nor "damn the torpedoes"
bravado will yield satisfactory outcomes. It is an area in which
the art of medicine can still flourish. Unbridled by inflexible
committee-created protocols, the office anesthesiologist can bring
the full force of his or her training to bear and develop a custom
care plan to meet the divergent perioperative needs of the office
setting.
Market surveys predict some interesting developments for office-based
anesthesia. Although anticipated growth for hospital-based ambulatory
procedures through the year 2000 is flat or on a mild decline,
office-based anesthetics are expected to double in the same time
frame. The cost savings for the "bread and butter" hospital-based
ambulatory cases will not be lost on the descendants of health
maintenance organizations. It may not be outrageous to state that
just as "ambulatory" rapidly became mandatory because
of insurance fiscal pressures, "office surgery" may
soon be mandated by insurance plans for many patients undergoing
minor surgical procedures.
Before this growth burgeons, anesthesiologists are well-situated
to take a commanding role as administrative procedures and regulations
are insinuated into office surgery. The rapid rise of hospital-based
ambulatory procedures over the last several years, while driven
by economics, was achievable largely by the accommodation and
flexibility in anesthesia care. The same attention and innovation
applied to hospital ambulatory procedures need to be directed
toward the office setting.
This author knows of no training program in anesthesia that, as
a routine, offers exposure to anesthesia in an office setting.
This needs to change if we are truly forward-looking and wish
to prepare residents for all employment opportunities in our specialty.
Anesthesiology departments should look into offering office anesthesia
services on a routine basis. Much as "off the floor"
procedures such as angiograms and endoscopy are routinely staffed,
office services could hold a similar status.
As more complex procedures are contemplated for the office setting,
a better system for addressing complications that arise in office
procedures needs to be instituted. Much like major trauma cases
are rushed directly to predesignated trauma operating rooms, direct
admission to a hospital postanesthesia recovery room would save
time and improve communication. Obviously, the anesthesiologist
would be a central player in any such system.
The truth of the issue is clear. While the office setting is primed
for an expanded role of the anesthesiologist as a perioperative
physician, we have paid little attention to this field. Perhaps
we will be forced to pay attention, however, as office procedures
grow in market share. We can capitalize on this situation.
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