June 1997
Volume 61 |
Number 6
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PRESIDENT'S PAGE
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| Perioperative
Medicine or Perioperative Management? |
Phillip O. Bridenbaugh, M.D., President
Just one year ago, the ASA NEWSLETTER (May
1996) devoted a significant portion of its space to several
articles related to the expansion of the practice of anesthesiology
into the pre- and postsurgical areas of patient care. The term
most frequently applied to these practices is "perioperative
medicine." In his "President's Page" for that issue,
then President Norig Ellison, M.D., discussed the efforts of our
specialty over the past decade to better describe our practices
outside of the operating room through a variety of name changes.
He most wisely noted that "a name change without a change
in mission and respectability is merely window-dressing."
Our past extra-surgical activities that led to expanded name
changes were primarily in the areas of pain management and critical
care. These were natural extensions of patient care for the physicians
most suited to render that care. These activities are included
in the new concept of anesthesiologists as "perioperative
physicians."
Why Now?
What is the driving force that moves our specialty into this
arena of perioperative care? Beginning in this decade, politicians
and the public were made aware of the impossibility of sustaining
the increasing costs of health care into the new millennium. It
was destined to bankrupt the country. Health care reform became
the vehicle for a variety of governmental and marketplace efforts
to "take over" the practice of medicine. The conclusion
was (is?) that the only way to manage cost was to manage care.
The working hypothesis was simply, "Too many specialists
charging too much for too many unnecessary procedures." The
solution, also well-known to all, has been drastic reductions
in all three of the above excesses!
Unfortunately, these corrections as they related to anesthesiology
were not coordinated and began to occur simultaneously. Practicing
anesthesiologists reacted, most appropriately, by placing new
recruitment on hold and by becoming active players in helping
their hospitals become more efficient in the running of the perioperative
areas of preanesthesia screening, operating room management and
PACU turnover.
This activity coincided with much press coverage that the government
was going to force reductions in residency slots in most specialties
by 50 percent. The word of supply and demand in medicine is first
heard by medical students. Thanks to a few key articles in the
press, the "no jobs in anesthesiology" message was transmitted
to the students, and we now recruit 30 percent of the precrisis
numbers of American medical students into anesthesiology.
Once again, there seems to be an asynchrony in the supply-and-demand
side of anesthesiology. We must go forward together.
Several of the advocates for our role in perioperative medicine
cite the activities of radiology, where in the 20 years
after 1975, they progressed from being 90 percent involved in
reading films to 90 percent involvement in MRI, ultrasound, CAT
and interventional studies (all advanced technology unique to
their specialty, I might add). The conclusion from radiology has
been stated as "More radiology is done by more radiologists
to generate more good for society (?). Radiology has expanded
the size of its pie." That sounds good if the pie is to be
for the good of society! Unfortunately, I previously noted that
the financial pie is shrinking (too many for too much)!
I personally believe that anesthesiologists should take the lead
into the realm of "perioperative medicine" because it
must be value-driven to preserve the quality of care our
patients are currently getting. If we do not get involved, the
cost managers will sell out to the lowest bidder (nonphysician
practitioners).
Perioperative Medicine or Management?
In April, I was invited, as your President, to address the German
Society of Anaesthesiologists at its annual meeting. It is the
second largest anesthesia society, next to ASA, with approximately
14,000 practitioners. They are very active and very progressive.
The topic they asked me to discuss was "The Future of Anesthesiology,
Perioperative Medicine." In preparation for my talk, I realized
a need to remove this practice concept from the socioeconomic
cauldron of health care reform in the United States and deal with
it more objectively in an effort to determine its future in Germany
or anywhere else in the world.
The practice of medicine in any country is designed to serve
the health care needs of its people. The practice of anesthesiology
has, traditionally, provided pain relief for all surgical and
many obstetrical patients. Over the years, our practices have
expanded into critical care, acute and chronic pain management.
Not unlike the radiologists, advances in technology and pharmacology
have provided opportunities for anesthesiologists to expand their
medical practices into these areas.
For reasons not totally clear, however, we have not exploited
those opportunities to the maximum. A look at the numbers of fellowship
programs and their graduates would suggest a need to do better.
Similarly, our activities in "periobstetric" care are
minimal. These are areas of the practice of medicine and anesthesiology
that we as physicians have been trained to do, areas in which
we can be updated through continuing medical education programs
and, quite frankly, for which we are/should be reimbursed like
other physicians.
As noted, "health care delivery" has changed. (Is this
the same as the practice of medicine?) The emphasis on health
care, today, is wellness not illness, ambulatory or outpatient
care, home care and no care (?) but not inpatient care.
The hope is that this philosophy will prove to be cheaper and
more efficient without loss of quality.
In anticipation of or reaction to this trend, anesthesiologists
have realized a need to expand their activities into what had
been peripheral areas of our practice such as preoperative assessment
clinics as well as administrative and management responsibilities
of the operating suites and postanesthesia care units. Is this
perioperative medicine, or is it perioperative management? Are
these activities for which anesthesiologists have been specially
trained and for which we receive continuing management
education? Are these areas for which we are reimbursed
proportionately to services rendered? Does our professional liability
insurance cover us if we commit errors in judgment?
Since it is obvious that the driving force for this expanded
anesthetic endeavor is cost-containment, it is important that
we understand the cost/risk and benefits of undertaking these
practice changes. One could, simplistically and cynically, note
that the risks are all on the anesthesiologists and that the benefits,
costs versus profits, go to the payers.
Anesthesiologists can and do provide value-based services by
defining: 1) appropriate preoperative testing and evaluation;
2) optimizing intraoperative management by appropriate selection
of drugs, techniques and monitors; and 3) by participating in
the recovery process. It should be noted, as published, that the
most important determination of cost is still personnel salaries.
Salaries are paid independent of the presence or absence of patients.
Decreasing the time patients spend in a facility can reduce cost
only if personnel perform other money-making activities in this
same time period.
How Should Our Specialty Proceed?
ASA represents 22,806 active members. Should we start a "top
down" campaign at the national level, encouraging our members
to take the lead in defining and collecting data to validate this
"subspecialty" area of medicine as best suited to anesthesiologists?
Should our anesthesiology programs be required to include more
cardiology, pulmonology and general medicine in our training so
we are better qualified to declare our patients safe for anesthesia
and surgery?
Or, should we adopt a supportive "from the bottom
up" position where we encourage all ASA members to be aware
of perioperative opportunities and to become more involved as
their skills, practices and local circumstances allow? Many
anesthesiologists are already active in most areas of perioperative
medicine, i.e., pain management, obstetric anesthesia and
critical care. My sense is fewer private groups are actively involved
in the less remunerative areas of perioperative management.
The risk/benefit ratio would support such a practice.
Which Path Will We Take?
I believe we should combine our forces at the national, state
and local levels. We should, as a specialty, take the lead in
providing public service and value-based medicine in good conscience
to our patients. Only by sharing information, data and experience
can we convince hospital administrations, payers and, most importantly,
our fellow physicians that we have medicine at heart. We should
be careful of becoming hospital-employed managers with conflicts
of loyalty; but rather, we should contract with hospitals where
efficient management is an essential part of value-based anesthesia
care throughout the entire patient experience. This is a complete
package that no other physician or nonphysician group can offer.
We must be wary, however, of overselling our practice. If we
are going to have 50+ percent fewer anesthesiologists in the next
decade, we must prioritize our practices to preserve those essential
parts of perioperative medicine we are most qualified to do.
There will be interesting times ahead!
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