October 2002
Volume 66 |
Number 10
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PRO: Anesthesiology Group Practice
Versus Independent Pain Practitioners: Exclusive Contracts
Should Include Pain Medicine
Timothy R. Lubenow,
M.D.
Annual Meeting Subcommittee on Local Anesthesia and
Pain
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The extension of anesthesiology practice outside the operating
room (O.R.) includes the subspecialty of acute and chronic
pain medicine. The delivery of pain therapies for patients
with either acute or chronic pain is enhanced when the pain
medicine section is intimately connected with the O.R. anesthesiology
service so that the goals of optimum patient care are well
aligned between the pain service and anesthesiology service.
The advantages of this organizational approach are:
- More efficient patient care
- Better continuity of patient care between inpatient
and outpatient settings
- Enhanced ability of the surgeon to bring more challenging
cases to the O.R.
- Improved reputation of the anesthesiology department
Consideration of a clinical scenario familiar to anesthesiologists
will facilitate an understanding of these advantages. A
common problem is the chronically opioid-dependent patient
who presents for spinal fusion or other major surgery. Such
patients present challenging dilemmas because the routine
pain medication dosing paradigms for acute postsurgical
pain such as patient-controlled analgesia-intravenous (PCA-I.V.)
dosing of morphine are ineffective.
This scenario creates a difficult postoperative management
problem for the surgical service and even the anesthesiologist
without substantial pain management experience. Quite frequently,
these patients will request meperidine because of prior
use of this medication, and they will require much longer
doses that may produce toxic levels of the normeperidine
metabolite, which can compound the irritability and combativeness
seen with inadequate analgesia.
Optimally, these patients would be identified preoperatively
and referred to the pain medicine service for preoperative
evaluation and planning. At this juncture, there are several
approaches the pain medicine physician in consultation with
the surgeon may recommend and discuss with the patient.
One approach may be to utilize PCA-I.V. alone – with
the use of hydromorphone in combination with adjuvant medications
such as lorazepam and an early introduction of gabapentin
as soon as patient can take oral liquids. For surgical cases,
another alternative could be a single dose of preservative-free
morphine injected by the surgeon immediately prior to closure
or continuous epidural analgesia via a catheter placed by
the surgeon immediately prior to closure.
Whichever technique is used initially, the anesthesiologist/pain
physician managing the patient can then transition to a
potent systemic-release opiate medication within the first
several days in addition to other adjuvant medications to
augment analgesia such as a benzodiazepine, alpha-2 agonist,
anticonvulsant and often an antidepressant. Generally speaking,
the goal of earlier discharge can be achieved with appropriate
multidisciplinary pain medication prescription.
Following hospital discharge, pain management can be carried
on by the pain service anesthesiologist. Continuity of care
is assured when the same team of anesthesiologists see the
patient preoperatively and postoperatively. The pain service
anesthesiologist can wean the systemic opiate medication
over the next several months while the patient undergoes
physical therapy and rehabilitation. Ultimately, these patients
may require management by a qualified pain management practitioner
for an extended time frame.
The preceding clinical scenario serves to illustrate reasons
why anesthesiology group practice is preferable to independent
pain practice for delivery of pain management services.
If this same patient was to be managed by an outside pain
physician, whether an anesthesiologist or other physician
specialist, a consult would need to be initiated. Often
this need is not identified for several hours or even one
day postoperatively, triggering a consult request to be
initiated late in the evening on the day of surgery or on
the morning of the first postoperative day.
Independent pain practitioners, who are not an integral
part of the anesthesiology service, are frequently based
at another location such as an office, surgical center or
different hospital. Because of time and distance issues,
the independent practitioner may not be able to see the
patient until the next day, which is suboptimal for effective
pain control.
Anesthesiologists knowledgeable about acute and chronic
pain therapy, who are an integral part of the anesthesiology
department, are in general readily available. They can see
and evaluate patients quickly throughout the day and facilitate
patient care because of quick, on-site access. This promotes
continuity of care as well since the same anesthesiology
pain team who managed these patients during the hospitalization
can continue to see the patient postoperatively as an outpatient.
This situation ultimately enhances the ability of our surgical
colleagues to see more difficult or challenging cases that
require their technical skills. The surgeon will feel confident
that the anesthesiologist/pain physician will handle the
difficult medication issues both in the short-term and long-term,
and the surgeon also has ready access to discuss the patient
on a daily basis.
This arrangement elevates the reputation of the anesthesiology
department because it represents a high level of perioperative
care and provides easy access to pain management expertise
for the surgeon and opioid-tolerant patient who has complex
requirements in chronic pain.
Another component of pain medicine is the role that pain
medicine physicians have (similar to surgeons) with respect
to admitting patients for certain nerve block procedures,
and more invasive interventional pain therapies such as
intradiscal electrothermal anuloplasty or spinal cord stimulation.
When the pain practitioner is a primary member of the anesthesiology
department, that department gets the benefit (credit) for
increasing hospital clinical volume. The pain medicine anesthesiologist
also can provide services that attract patients to a surgical
center. There is an elevated amount of revenue that a hospital
derives from patient care attributable to the anesthesiology
department. This ultimately bestows on the anesthesiology
department a certain stature within the institution that
levels the playing field with our surgical colleagues relative
to generating patient caseload and revenue for the facility.
Another issue that evolves in the absence of an exclusive
contract for anesthesia and pain services relates to credentialing.
If an independent outside group that wishes to provide pain
services does not have the same training experience in certain
invasive procedures, the credentialing standards may need
to be reduced, which may alter the quality of patient care.
In addition, when pain medicine services are not part of
the anesthesiology department, scenarios can arise where
a facility grants pain physicians temporary privileges to
provide pain care, usually postoperative acute pain management.
This arrangement can potentially necessitate a less rigorous,
"fast tracking" credentialing process for hospitals
to provide timely provision of services when there is turnover
of independent practitioners.
Admittedly, there is potential for conflict and disagreement
between anesthesiologists who practice pain medicine and
those who practice anesthesia solely in the operating room.
These conflicts occur because of different perceptions about
the relative amount of work being performed, primarily because
the work product is different. Strong leadership is needed
from both the anesthesiology chair and the director of the
pain service to minimize conflict and resolve real or apparent
differences regarding equality of work product and other
issues of employment such as financial compensation, work
schedules and on-call commitments between these two groups
within the same department.
When this challenge in leadership is met, the benefits
of pain medicine services being intimately connected with
the primary anesthesiology department include increased
clinical volume and enhanced quality of care, which translate
to an elevation in status of both the pain service and anesthesiology
department.
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Timothy
R. Lubenow, M.D., is Associate Professor of Anesthesiology
and Director, Section of Pain Management, Rush-Presbyterian-St.
Luke's Medical Center, Chicago, Illinois. |
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