| |
July 1997
Volume 61 |
Number 7
|
| |
|
| It's Ours to Choose
or Ours to Lose |
Robert W. Vaughan, M.D.
I read with interest but not surprise the excellent ASA
NEWSLETTER analysis by Karin Bierstein concerning Charles
Peterson Associates.1It was only
a matter of time before money-driven consultants would read Cromwell's
case study of anesthesia as a substitution model.2
As an economist, Cromwell describes anesthesia as a traditional
nursing function. He details how nurse anesthetists are excellent,
"almost perfect" substitutes for anesthesiologists,
seemingly unbiased by previous clinical outcomes knowledge regarding
risks and mortality. With a perceived glut of specialists and
anesthesiology as the "poster child" for physician oversupply,
front page headlines in The Wall Street Journal and American
Medical News feature us as a "specialty in trouble".3,4
Why are we even talking about "almost perfect" substitutes
for physicians anyway? What has happened since 1993-94 to produce
such radical proposals?
After the well-publicized Clinton Health Plan of 1993, the concept
of managed care exploded across the United States to represent
the only answer to health care reform. Today's managed care is
really managed cost. Free-market economic forces have been
unleashed to accelerate changes based on the economic incentives
of corporate America. The socially amoral rules of competition
prevail unencumbered by the 50-plus-year-old culture of a traditional
cottage industry (U.S. medicine), patient choice or preferential
community referral patterns developed by fee-for-service medicine.5
Cost containment at any price suddenly became the driving force
of health care reform. Consequently, U.S. health care began to
evolve as just another commodity bought at the lowest price in
the marketplace, not unlike shopping at Wal-Mart. Thus, Charles
Peterson Associates, without reviewing clinical outcomes data,
markets a health care staffing model to exclude anesthesiologists
from comprehensive anesthesia services. He would stratify patients
on the basis of age, ASA physical status and complexity of care
to exclude hands-on physician anesthesia care just to reduce staffing
costs.
But for the patient, safety remains the issue. Americans expect
to receive the safest, lowest risk anesthesia care for each and
every episode of care. How ironic that to meet patient and physician
expectations, many of our staffing practices actually assign cases
that increase our unit personnel cost by including fellowship
trained anesthesiologists with additional subspecialty expertise.
We continue to champion safer clinical outcomes when our
unit costs are increased. Perhaps Cromwell's "almost perfect
substitute" may just beget "but not quite!"
What can each community and academic practice anesthesiologist
do today to communicate the value of anesthesiologist services
to patients, surgeons and hospital administrators? We must first
reframe the dialogue beyond cost only. What value can anesthesiologists
add to each patient care episode? Do you think safer clinical
outcomes by a multiskilled team would matter to patients? You
bet! In addition, the "specialist boom" of anesthesiologists
has already enormously benefited American society. Today, anesthesiology
finds itself mired in a crisis of success. Perioperative
mortality associated with anesthesia and operation has markedly
decreased from 1:1,500 in 1950 to 1:250,000 today despite more
complex surgical procedures performed on sicker patients.6
Recently, Silber et. al. analyzed factors that contribute
to mortality (death rates), complications (adverse event rates)
and failure to rescue (resuscitate) after operation.7
Death rate and failure to rescue from complications were inversely
related to the proportion of Board-certified anesthesiologists
on the anesthesia provider staff of each hospital studied. Said
in a positive way for patient outcomes, as the number of Board-certified
anesthesiologists on each medical staff increased, death rates
decreased. These data by nonanesthesiologists (an internist and
pediatrician) support the societal value of Board-certified anesthesiologists
in the delivery of anesthesia care. The "physician boom"
of anesthesiologists so impugned in the media has improved clinical
outcomes and decreased patient risks for operations. Moreover,
in order to study and measure anesthesia risks, anesthesiologists
established and in 1985 funded their own international foundation
to focus on improved safety in anesthesia care. Just recently
in October 1996, the American Medical Association patterned its
new medical foundation for risk management after the enormously
successful anesthesiology model. The AMA, representing all physicians,
plans to focus intently on reducing untoward events associated
with all clinical care, not just anesthesia and operations.8
After so much progress toward enhanced patient safety, physicians
cannot allow a commodity mentality focus for U.S. health care.
Nevertheless, managed care continues to reduce the demand for
all medical specialists. As hospitals have consolidated, the job
market has tightened for each anesthesia provider.5
As is human nature, the pendulum of supply and demand has overcorrected
due to the sheer momentum of negative publicity regarding anesthesiology.
Unfortunately the adverse publicity by news media has been reinforced
by some physician colleagues, some of whom occupy leadership positions
in teaching hospitals and academic medical centers. Academic anesthesiologists
carry the additional responsibility of clarifying the value of
anesthesiology by word and deed for medical students.
But good news is out there. Today more than 90 percent of the
surgical procedures performed annually in the United States occur
at facilities where anesthetics are either personally administrated
by an anesthesiologist (physician only) or the anesthesia care
team is medically directed by an anesthesiologist.9
When nurse anesthetists work without medical direction by an anesthesiologist,
the setting is rural, the hospital averages less than 100 beds,
and fewer than four operations occur per day.10
As one would predict, such operative procedures are less complex,
shorter in duration and performed on much healthier patients.10
Despite these simpler operations performed on healthy patients,
risks for adverse outcomes are increased when a Board-certified
anesthesiologist is not a member of the hospital medical staff.7
Trust me, patient survival will be perceived as "value-added"
by all patients and especially the aging Baby Boomers. This group
cares a lot about enhanced lifestyles and quality of life. When
anesthesiologists can add product quality and enhanced service
to clinical care, cost containment alone does not sell. By reframing
societal benefits beyond cost, anesthesiology becomes a luxury
item in the marketplace, not just another commodity.
Finally, do your hospital administrators and even other physicians
understand the fallacy in Mr. Peterson's consulting claims
and Cromwell's "almost perfect substitute" argument?
Have you told administrative colleagues repeatedly that anesthesia
is safer in 1997 because of research, education and comprehensive
medical practice that has reduced perioperative mortality associated
with anesthesia and operation from 1:1,500 in 1950 to 1:250,000
today? Do you recall that safety in anesthesia has been accomplished
despite more complex procedures performed on sicker patients?6
Suppose we look beyond anesthesia to compare purchasing habits
of the population. How many Americans would embrace lower value
services by booking routine airline flights in (forecasted) fair
weather but without knowledgeable and experienced pilots because
it's cheaper? What about being cared for in ICUs without
immediately available hands-on care by multiskilled teams, including
critical care physicians, or undergoing routine surgical procedures
in healthy patients without a physician as the surgeon? All these
high-risk, often unpredictable experiences require the presence
of a professional who is educated and trained from a unique body
of knowledge to improve outcomes for the public good. Review our
specialty's 50-year journey from a technical service to what patients
now enjoy: the application of clinical scholarship underpinned
by scientifically sound, research-based clinical information.
Anesthesiology has become a legitimate medical profession because
of the continuous creation of new knowledge and the clinically
safe application of that scholarship. Please do not keep such
incredible good news to yourself; tell everybody!
Bottom line: What can you do immediately after recalling the
above information? Begin immediately serving as a vocal advocate
for anesthesia safety plus contribute professional citizenship
to your hospital, medical staff and community. Ask yourself how
many anesthesiologists chair committees on your medical staff
or recruit money to elect knowledgeable political representatives
locally and nationally. Ask yourself, "How can I help my
local hospital outreach programs?" Such new, innovative efforts
can serve each community with comprehensive perioperative anesthesia
services and enhanced pain management. Also, I question whether
health system and hospital leaders really want to pay anesthesiologists'
professional liability rates plus be held to ASA national standards
of practice. I wonder what would happen with Patterson's staffing
suggestions and Cromwell's proposed cost savings when just one
anesthesia bad outcome is featured on page one of The Wall
Street Journal or "60 Minutes"?
Finally, run, do not walk to the nearest medical library. Read
and reread the articles by Cromwell,2
Abenstein,6 Silber,7
Longnecker,11 Reves12
and our recent workforce overview.5
Become a conversant advocate for safer anesthesia. But be a realist.
You need to take responsibility for action as a community physician.
Remember always that ignorance is not a contraindication to action!
Your silence can cost lives in your community. Some listeners
will challenge you by saying that the rhetoric about the role
of the anesthesiologist in safe care is just "physician bragging."
Born and raised in Dallas, I am reminded of a Texas saying that
offers an alternative point of view: "It ain't bragging if
you can do it!" Today, the future of anesthesiology is certainly
ours to choose or ours to lose. What's your preferred future?
References:
- Bierstein K. Hospital consulting firm
advocates greater autonomy for nurse anesthetists. ASA NEWSLETTER.
1997; 61(3):27-28.
- Cromwell J. Health professions substitutions.
A case study of anesthesia. In: U.S. Health Workforce Power,
Politics and Policy. Association of Academic Health Centers,
Washington, DC, 1996:219-228.
- Anders G. Once hot specialty, anesthesiology
cools as insurers scale back. Washington, DC. The Wall Street
Journal. March 17, 1995:1.
- Mitka M. Market driven match - Most US grads choose primary
care. American Medical News. 1996; 39(14):1,7.
- Vaughan RW, Vaughan MS. Using anesthesiology
as a model for change. The Physician Executive. 1997;
23(2):4-12.
- Abenstein AP, Warner MA. Anesthesia providers,
patient outcomes, and costs. Anesth Analg. 1996; 82:
1273-1283.
- Silber JH, Williams SV, Krakauer H, Schwartz
JS. Hospital and patient characteristics associated with death
after surgery. Med Care. 1992; 30:615-629.
- USA Today. Reducing untoward events.
Oct. 14, 1996:A1.
- Rosenbach ML, Cromwell JA. When do anesthesiologists
delegate? Med Care. 1989; 27:453-465.
- Rosenbach ML, Cromwell JA. A profile of
anesthesia practice patterns. Health Aff. (Millwood)
1988; 7:118-131.
- Longnecker DE. Navigation in uncharted
waters: Is anesthesiology on course for the 21st
century? Anesthesiology. 1997; 86:736-742.
- Reves JG, Rogers MC, Smith LR. Resident
workforce in a time of U.S. health care system transition. Anesthesiology.
1996; 84:700-711.
Robert W. Vaughan, M.D., is Professor
and former Chair of the Department of Anesthesiology, University
of North Carolina School of Medicine, Chapel Hill, North Carolina.
E-mail the author.
return to top
|