ASA January 2003 Newsletter

This address was delivered by 2002 ASA President-Elect James E. Cottrell, M.D., to the ASA House of Delegates on October 13, 2002, in Orlando, Florida.

Last summer I got a call from the White House. Richard Tubb, M.D., Physician to the President, reached me on a cell phone while I was waiting in a garage to pick up my car. He wanted to know what anesthetic would allow President Bush to make important decisions within two hours of a colonoscopy. I gave Dr. Tubb my opinion — and The New York Times ran a column reporting that “an expert” recommended propofol!

This story is not an advertisement for propofol, and I realize that I did not give a more expert answer than any of you would have given. My point here is to remind you that well-informed people are aware of issues in anesthesia, and they are anxious about having their central nervous system disarmed by powerful drugs — drugs that they don’t really understand. People basically understand what the surgeon or the gastroenterologist is going to do to them, but they understand less about anesthesia … and they want an expert. Uncle Sam Wants You … and so does Uncle Fred and Brother Bill and Aunt Sally.

They want you for two good reasons: one old good reason and one new good reason. The old reason is that nobody wants to die, and for routine procedures, patients face a greater risk from anesthesia than they do from surgery.¹ The new reason is concern about a more subtle outcome. Patients are worried about their minds. They are worried about postoperative cognitive dysfunction, or POCD.

Anesthesia Related Mortality: Stable Rate = Safety Up
Let’s deal with the old fear first. Fourteen years ago, my take on the literature was about right: 1 to 2 anesthesia-related deaths per 20,000 anesthetics.” ² However, overextension of an article also published in 1989 initiated some overenthusiasm. Limiting patient outcome information to the database of a malpractice insurance carrier, Eichhorn found five intraoperative deaths judged to have been entirely due to anesthesia.³ The denominator was 1,001,000 ASA physical status (PS) 1 and 2 patients, yielding a death rate of 1 per 200,200.

Unfortunately, subsequent confusion of nomenclature (anesthesia-related versus anesthesia alone), extension of the study’s implication to the actual incidence of mortality (not just closed claims) and extension to all surgical patients (not just the healthiest) led to reports of an anesthesia-related mortality rate of 1 in 200,000 to 300,000 surgical patients. Somewhere between wishing this were true, hoping it was true and wanting it to be true, some irrational exuberance was inspired.

The claim of an order-of-magnitude decrease in anesthesia-related mortality over the past two decades was challenged by Lagasse in the December 2002 issue of Anesthesiology,⁴ and his article raises as many questions as it answers.⁵ Lagasse’s extensive literature review failed to support a dramatic decrease in anesthesia-related deaths since 1960, and analysis of his own data on 184,472 ASA PS 1-5 patients across two hospitals revealed an anesthesia-related mortality rate of 1 per 13,000 anesthetics.

It is almost surely the case that the emperor’s new clothes are not so regal as some were led to believe, but it is equally certain that he is not naked. My guess is that The emperor is wearing scrubs — a noble uniform — and that as Lagassse conjectures: “[I]mprovements in medical technology have led to increased anesthetic management of older patients with significantly more concurrent disease… [and] the risk of death in these complex patients increases exponentially, as does the risk of death in which human error by an anesthesiologist is deemed contributory.” In other words, anesthesia safety has improved substantially, as evidenced by the realization that we are anesthetizing far more frail patients without allowing an increase in anesthesia-related death rates.

Nevertheless, our ASA PS 3-5 patients’ apprehensions about being anesthetized are not unfounded. We owe Dr. Lagasse a debt of gratitude for reminding us of that reality and for putting forth a challenge that should inspire more and better research.

The risk of death notwithstanding, even our ASA PS 1-2 patients are worried about a far more probable consequence of anesthesia, and research done by anesthesiologists indicates that their concern is justified.^6,7 POCD presents a challenge that we are just beginning to appreciate. We must continue to define this problem and devise ways to prevent and decrease it — perhaps by cerebral preconditioning with certain anesthetic drugs and techniques.

New Directions: ASACCPM?
To borrow from the Rev. Jesse Jackson’s speech on progress in civil rights: “It’s movin’ time. From the Courthouse to the State House, from the State House to The White House, it’s movin’ time.” And for us, from preoperative evaluation to postoperative outcome, whether the issue is anesthesia-related mortality or POCD, it’s still movin’ time.

So how are we doing? We’re moving! Science and education are the foundation of progress in anesthesiology and we are strengthening that foundation every day. Grants to departments of anesthesiology from the National Institutes of Health (NIH) have increased 57 percent in the past five years [Table 1], and research has blossomed in many academic departments [Table 2]. From cardiac preconditioning to cerebral preconditioning, from a reinvigorated focus on anesthesia-related morbidity and mortality to genetic determinants of behavioral characteristics of chronic pain patients, we’re moving.

Nevertheless, there is cause for concern. Submissions from American authors to our journal, Anesthesiology, have decreased in recent years. Applications for Foundation for Anesthesia Education and Research (FAER) grants have also fallen off [see related article on page 2]. In some ways more disturbing, applications for fellowships in pain medicine and critical care have decreased significantly [Table 3].

Perhaps it is time for ASA to become the American Society of Anesthesiology, Critical Care and Pain Medicine (ASACCPM). This is a pressing issue about our future. Remember that the best acute pain managers make the best chronic pain managers, and the best intraoperative caregivers make the best postoperative and critical care providers. It’s movin’ time… and these subspecialties are where we need to move.

Where else have we gone, and where do we need to go? The Administrative Council has made reimbursement our top priority for the coming year. ASA Washington Office staff members, including Mike Scott, Karin Bierstein, Diane Turpin and Manuel Bonilla, are doing a great job. Uncle Sam has learned to respect us. Truth sometimes gets trampled in the short run, but it does well in the long run. The truth that anesthesia requires anesthesiologists is being delivered via the high road, and it will be received.

Meanwhile, our workforce is growing [Table 4]. The most recent match indicates that 94 percent of positions offered were filled. Medical schools in the United States supplied 88 percent of those positions. Each year I have focused on departments that recruit the largest number of students into anesthesiology. This year the leaders are again Jeffrey Katz, M.B., at the University of Texas-Houston, and Robert K. Stoelting, M.D., at Indiana University in Indianapolis. We congratulate both of them.

To further stimulate progress in anesthesiology, ASA will institute a Presidential Scholar Award. It will be offered to anesthesiologists who have made substantial research accomplishments within their first seven years of practice. Submissions will be judged by our Committee on Research, and the award will be presented each year before the Emery A. Rovenstine Memorial Lecture at the ASA Annual Meeting. Allow me to take this opportunity to call for nominations for the Presidential Scholar Award [see related article on page 2].

After next year’s Rovenstine lecture, FAER will sponsor a plenary session, “A Celebration of Research,” chaired by Michael M. Todd, M.D., where award recipients will present overviews of their work while the rest of us eat lunch and listen. Following the plenary session, a FAER panel will convene, and four hours of continuous science updates will be available to all registrants.

Another ASA task force will review opportunities for keeping our annual meetings new and invigorating. Do we need more official subspecialty input? Should we have more plenary sessions? Should each subspecialty summarize, at a closing session, progress presented during the meeting? Should we have more distinguished, early-morning sessions with scientists, politicians or industry? All of these possibilities are in the offing, and we look forward to your input.

Let me conclude on a personal note. Last spring Jeffrey L. Apfelbaum, M.D., asked whether, in consideration of my crowded schedule, I wanted to forego giving a Refresher Course Lecture at the ASA 2002 Annual Meeting. I was tempted to take this opportunity to lighten my load, but I remembered what Alice said in Wonderland: “Here you have to run as fast as you can just to stay in the same place.” Because it’s movin’ time, we all need to run as fast as we can.

It is a privilege to be an anesthesiologist, and it is our responsibility to the wonderful people who trained us to continue their legacy, to be educators, to improve upon and pass on what they gave to us. Each of you has multiple responsibilities… delivering the best care to our patients, finding new and better techniques for doing our job, and sharing knowledge and experience with colleagues, young and old. We all need to do as much as we can do and still do everything well. That is what I mean by taking the high road to our destination.

We need to shine by being who we are. Anesthesiologists are doctors who keep patients alive while surgeons do things that would otherwise kill them.1 In the clinic, in the classroom and in the organization of our professional society, we need to maintain our emphasis on research and patient outcome. That is what makes us indispensable.

Science and education are not auxiliary aspects of our profession — they distinguish us within the anesthesia care team. Our unique ability to advance our field will enable us to meet current challenges to our supervisory responsibilities and, in the end, prevail.

References:

1. Cottrell JE. Against putting people to sleep. Surgical Rounds. 1989; October:81-82.

2. Cottrell JE. Patient safety — do the fears match the facts? ASA Newsl. 1995; 59(11):6-7.

3. Eichhorn JH. Prevention of intraoperative anesthesia accidents and related severe injury through safety monitoring. Anesthesiology. 1989; 70(4):572-577.

4. Lagasse RS. Anesthesia safety: Model or myth? Anesthesiology. 2002; 97:1609-1617.

5. Cooper JB, Gaba D. No myth: Anesthesia is a model for addressing patient safety (editorial). Anesthesiology. 2002; 97:1335-1337.

6. Moller JT, Cluitmans P, Rasmussen LS, et al. Long-term postoperative dysfunction in the elderly: ISPOCD 1 study. Lancet. 1998; 351:857-861.

7. Newman MF, Kirchner JL, Phillips-Bute B, et al. Longitudinal assessment of neurocognitive function after coronary artery bypass surgery, N Engl J Med. 2001; 344:395-402.

James E. Cottrell, M.D., is Professor and Chair, Department of Anesthesiology, and Senior Associate Dean for Clinical Practice, State University of New York Health Sciences Center at Brooklyn, New York. He is ASA President for 2003.

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