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July 1999
Volume 63 |
Number 7
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VENTILATIONS
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| ... Of Dinosaurs,
Dodos and Anesthesia Personnel |
Walking through the Museum of Natural History in New York some
time in the near future, you may come upon an exhibit in the Hall
of Extinct Species that shows the "anesthesia care team" in action.
This supervisory arrangement may no longer exist, not because
of the current acrimonious relationship between the American Society
of Anesthesiologists (ASA) and American Association of Nurse Anesthetists
members, but due to lack of personnel. The current health care
evolution is challenging the existence of anesthesia providers
regardless of degree status. Let us examine some of the issues
that may influence this unintentional extinction.
First, anesthetic care has never been safer. Administrators,
surgeons, payers, politicians and the public take it for granted
that this safety will not deteriorate. Moreover, they pay little
attention to the maintenance required for proper functioning.
Even a Mercedes Benz will malfunction if not properly serviced.
Thus, cries of physician shortages and lack of nurse anesthesia
students fall upon deaf ears. Conversely, legislation altering
practice patterns, poor intersociety relationships and witch hunting
by governments for "improper billing" procedures further destabilize
recruitment into both physician and nursing ranks alike.
Second, specialization depletes the number of traditional anesthesia
care providers. The rapid rise of pain management clinics, multidisciplinary
critical care groups and office-based private anesthetic practices
siphon off qualified personnel from practicing hospital-based
perioperative and anesthetic care. More anesthesiologists are
opting to practice pain management exclusively, detached from
a group practice so as to avoid surgical anesthesia coverage.
The same case can be made for critical care anesthesiologists
who now wish to concentrate solely on ICU management issues. You
may have seen the picture of the anesthesiologist riding the subway
with suitcases of anesthesia equipment to his appointed office-based
anesthetic case.1 This type of anesthetic care offers
untapped opportunities for the solo practitioner who wants to
rely only on his or her clinical skills, bill and collect for
one's self and eliminate the fatigue associated with cardiac,
trauma, obstetrical or general surgical on-call duties. Even nurse
anesthetists must worry about filling their schools with critical
care-trained students, often a prerequisite for acceptance. Those
engaged in critical care nursing now have the option to either
become nurse anesthetists or critical care nurse practitioners,
a rapidly expanding field.
Third, the infrastructure of the traditional anesthesiology
practice paradigms appears to be cracking, not at the national
or state levels but in the local communities. Threats of hospital
or group consolidations, reduced reimbursement, retroactive Medicare/Medicaid
billing fraud investigations, withdrawal of resident financial
support, retrenchment of academic time, verbal assaults by other
specialty groups, deteriorating anesthesiology-nurse anesthesia
relationships, increased liability exposure and changing practice
patterns have made almost all anesthesiologists insecure to some
degree. Even though we know our profession is essential and that
our supply is relatively diminishing, our daily practices change
with every new piece of legislation or malpractice lawsuit making
us perpetually dysphoric.
In the next three to five years, we should have the last laugh,
if this dismantling of health care were, indeed, a laughing matter.
Our need for physician anesthesiologists and even nonphysician
anesthesia personnel will intensify since there is no indication
that surgery will lessen markedly. For those who have lived through
previous anesthesia personnel shortages, however, laughter is
not the prevailing emotion. Days can be long, relief scarce, on-calls
frequent and vacations limited. "Body snatching" of personnel
among groups intensifies, and complaints from surgeons and administrators
increase in decibels.
The solution: stick together, strategize, synergize and economize.
The worst course of action is to take the "me first approach,"
because it may only assure that you will be the last person to
suffer a catastrophe prematurely. It is now time to recruit new
physicians, participate in local, state and national societal
activities and forecast what changes need to be made in our current
practice modes. For those anesthesiologists engaged in pain management,
critical care or office-based anesthesia, resist the temptation
of canceling memberships to traditional anesthesiology societies.
Look closely at the politics and composition of your smaller specialty
societies that ostensibly represent your practice interest better
than ASA or your state society. In my experience, when the chips
are down, physicians flock to their primary specialty for strength
and influence in policy-making decisions. Otherwise, you may find
that your interests are not of the majority opinion but those
of a neurologist, psychologist or surgeon.
Eventually, health care in the United States will find the proper
balance between access to care and quality of care, between physician
care and non-physician care and between costs for physician education
and appropriate physician reimbursement. We happen to be in the
transition phase. The actions we take today will either shape
the future practice of our specialty or cascade it into extinction.
Reference:
- Zuger A. Surgeons Leaving the O.R. for the Office. The
New York Times. May 18, 1999:D1, D4.
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