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June 2000
Volume 64 |
Number 6
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VENTILATIONS
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| Deus Ex Machina
(Presumed) |
Greek and Roman playwrights frequently created plots so complex
and fatalistic that they were hard-pressed to develop a suitable
happy ending. The protagonist was often taken to the brink of
destruction only to be rescued by a god who literally swept across
the stage on a rope to cast off the evil incantations. This drama
style, called "deus ex machina," or "god from the machine," is
reflected in many fairy-tales.
Scholars of Greco-Roman literature interpret "deus ex machina"
as representing a greater philosophical concept, one of hierarchical
manipulation of humans by whimsical gods and humankind's inability
to rise above their control. Conversely, cultures ascribing to
this predestination concept turned to another commonly known practice
of "carpe diem," or "seize the day," live life to its fullest
each day, for one cannot change fate.
The current practice of anesthesiology can draw many parallels
with these two classical philosophical notions. Indeed the threat
of clinical burnout with an attempt to espouse "carpe diem," in
hopes that "deus ex machina" will be anesthesiology's salvation,
seems to be the prevailing dream. Let us look at a typical practice.
The alarm sounds at 5:15 a.m. -- the start of the anesthesiologist's
workday. At 7 a.m., the morning's patients are anesthetized. Breaks
are then given, the next set of patients arrive in the holding
area, lunch breaks are provided, preoperative assessment clinics
are staffed, acute pain rounds are conducted, postoperative visits
are performed, add-on emergencies are addressed and first-, second-
or third-call duties are completed.
Afterward, the car pulls into the garage at 7 p.m. -- three
hours left before bedtime to eat, interact with family, self-educate,
pay bills ... and relax. The process will repeat itself again
tomorrow.
Many physicians appear to be working harder, often casting aside
innovation in technique, collegial dialogue, unessential yet satisfying
professional interests and, at times, even safe practice. Fatigue
and despair predominate the doctor's emotions and cannot be assuaged
with increased salary alone. Restoration of a balanced lifestyle
allowing for career satisfaction, adequate family time and requisite
stress reduction (rejuvenation) becomes the brass ring to grasp
when one is on this clinical merry-go-round. This scenario is
a perfect opportunity for the lounge-lizard naysayers and doomsday
prophets to prognosticate the futility of participating in the
reformation of a sensible anesthetic practice. Subsequently, they
infuse an atmosphere of nihilism, hopelessness and helplessness
remedied only by adopting a "carpe diem" mentality. Not surprisingly,
an increasing number of anesthesiologists are thinking with a
"me," not "we," mentality. As a result, physicians are reluctant
to train residents, give lectures, lobby, participate in hospital
activities and contribute to the common professional good. They
prefer to focus on e-trade activities with the goal of early retirement.
How sad for our specialty, and what a waste of clinical talent!
But down swings "deus ex machina"! The god of good fortune rushes
in to save these overworked, underappreciated, clinically depressed
yet high-wage-earning anesthesiologists. At this point, you may
wonder how I find a silver lining in the storm clouds of changing
practice, managed care and government "muscle flexing." Read on
to learn what favorable trends and imminent opportunities I see
through rose-colored glasses.
Three key issues are evolving that appear to be working to our
benefit with respect to better practice conditions: shifting personnel
demographics, increasing practice opportunities and changing practice
patterns. Our ability to view these challenges as opportunities
rather than obstacles will determine our level of success in maintaining
the current safe practice of anesthesiology.
Shifting Personnel Demographics
The trend in anesthesia personnel numbers appears to favor physician
anesthesiologists. First, anesthesiology is becoming popular again
with medical school graduates. Our ability to sustain this positive
shift rests on our daily attitudes when in the presence of potential
future anesthesiology residents. Second, nurse anesthetists appear
to be an aging population. Since about 37 percent do not have
bachelor's degrees, one can assume that four out of 10 nurses
are senior-level practitioners. Moreover, the rise in popularity
of critical care nurse practitioners who compete for the same
pool of critical care nurses, and the reduced numbers of people
entering nursing, makes wholesale increases in nurse anesthetist
ranks unlikely. Thus the threat of nurse anesthetist dominance
in the operating room may be improbable, but operating room care
team levels will certainly be threatened! Third, the rising interest
in anesthesiology assistants' utilization may increase care team
ranks. Finally, exploring new opportunities for the burgeoning
oversupply of primary care physicians, such as conceptualizing
restricted anesthesia-training skills, may help us meet any unanticipated
and sustained shortfall in care team members.
Increasing Practice Opportunities
It is anticipated that out of the 40 million anesthetics administered
yearly, 10 million will be given in offices. Policy changes in
pain practices and reimbursements have rapidly expanded these
markets' needs for qualified providers. Anesthesiologist-intensivists
are still in high demand nationwide. The demand for off-site practice
opportunities in physicians' offices and ambulatory surgical center
directorships have yet to peak. Taken together with their respective
subspecialties, it appears that anesthesiology offers as much
diversity in practice interests as does surgery or internal medicine.
It is no wonder that medical students are embracing anesthesiology
once again.
Changing Practice Patterns
As the ranks of traditional operating room-based anesthesiologists
diffuse into ambulatory, office-based, critical care or pain management
practices, one may see fatigue, burnout, apathy and despair develop
in those physicians working harder and longer to complete the
daily operating room schedule. Greater cooperation among all practicing
anesthesiologists is necessary to prevent CEOs and surgeons from
seeking alternative anesthetic care or legislative resolution.
We must not overpromise to provide safe physician-directed anesthetic
care only to ultimately underdeliver this expected level because
of self-interest, pride or perceived disenfranchisement. All anesthesiologists,
regardless of their primary area of interest, must work harmoniously
during personnel shortages to deliver our unique medical care.
Anesthesiology then will emerge as the respected leader of the
various areas of medical practice so important to the public's
well-being.
The Solution Is Among Us
More than 2,000 years ago, the citizens of antiquity relied
on divine intervention to solve life's problems. Today, anesthesiologists
faced with practice challenges are continually informed about
their paths toward resolution. However, without heeding the admonitions
of ASA leadership or working proactively as an effective team,
contemporary anesthesiologists are flirting with "divine legislation"
to resolve their dilemma.
Beware the "legislatio ex machina," for the magic can be unpredictable.
-- M.J.L.
"Restoration of a balanced lifestyle allowing for career
satisfaction, adequate family time and requisite stress reduction
(rejuvenation) becomes the brass ring to grasp when one is on this
clinical merry-go-round. "
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