ASA January 2003 Newsletter

SAAC/AAPD: Academic Anesthesiology Chairs and Program Directors Working Together With ASA

Steven J. Barker, Ph.D., M.D., President
Association of Anesthesiology Program Directors

SAAC and AAPD are two organizations in one: the Society of Academic Anesthesiology Chairs and the Association of Anesthesiology Program Directors. SAAC is the body of department chairs from all academic institutions that have separate departments of anesthesiology. AAPD consists of the program directors from all Accreditation Council for Graduate Medical Education (ACGME)-accredited anesthesiology residency programs. In most institutions, the anesthesiology department chair also is the program director — hence, most chairs are members of both SAAC and AAPD.

The annual meeting of SAAC/AAPD is regularly attended by about 90 percent of the members. At the 2002 three-day meeting, we presented and discussed the latest information on key issues facing anesthesiology departments today. In this article, I will describe some of those issues, which should be of interest to all anesthesiologists.

Our most recent meeting occurred in San Francisco, California, on November 8-10, 2002. Some of us endured an adventure in getting to San Francisco on the night of “the worst first-of-season storm in decades,” including unscheduled overnight vacations in places like Sacramento, California, and Las Vegas, Nevada. Nevertheless, the meeting attendance was outstanding as was the enthusiasm for tackling today’s toughest problems. Here are a few that we discussed.

Anesthesiology Workforce: Ever since the infamous “Abt Study” of 1994, we have been leery of statistics that supposedly tell us how many anesthesiologists we should train. As you recall, that study grossly underestimated future needs for anesthesiologists and may have contributed to the current and future physician shortage in our specialty. Partly as a result of this study and similar propaganda, medical students in the late 1990s avoided anesthesiology in favor of primary care specialties and national residency output dropped by half. Now that we are again attracting the best medical students in large numbers, we must continually ask ourselves, “what is the right number?” SAAC/AAPD analyzes and discusses this issue thoroughly every year. Alan W. Grogono, M.D., emeritus Chair of Anesthesiology at Tulane University, maintains a detailed, accurate database of past and present anesthesiology resident numbers, and is available at <www.grogono.com/nrmp/index.html>. Dr. Grogono has shown that our residency output seems to be leveling off at about 1,400 graduates per year. Is this an appropriate number, or will it lead to a continued shortage in the future? None of us believes that 1,400 per year will ever lead to a surplus of anesthesiologists. SAAC/AAPD needs additional input, particularly from ASA members, to accurately predict and respond to future workforce needs.

Scope of Practice: During the past 10 years, there has been a gradual trend toward the performance of “deep sedation” and general anesthesia in locations outside of the operating suite. These procedures are usually performed by nonanesthesiologists. For example, emergency medicine physicians commonly induce general anesthesia with etomidate and succinylcholine to facilitate endotracheal intubation, most often without the involvement of an anesthesiologist. This practice raises several important questions.
1) If anesthesiologists are in the hospital, when should they be called as consultants on such procedures?
2) What are the training and skill levels of the various providers who are doing this, and is a “single standard of care” represented as mandated by the Joint Commission on Accreditation of Healthcare Organizations (JCAHO)?
3) How can the anesthesiology department help ensure that these providers are adequately trained and have sufficient experience in such procedures?
4) How should the anesthesiology department be involved in quality assurance for general anesthesia, deep sedation and airway management performed by other providers? JCAHO requires that the anesthesiology department shall be responsible for all anesthesiology quality assurance throughout the hospital.

The answers to these questions are not entirely obvious, and SAAC/AAPD will work closely with ASA (including the Committee on Patient Safety) to resolve these issues.

Reimbursement: Professional fees reimbursement has been a constant concern for SAAC/AAPD, particularly since Medicare and the Centers for Medicare & Medicaid Services (CMS) effectively cut our payments by half in the early 1990s by paying a 50-percent conversion factor when one faculty member supervises two residents. (If you think Medicare payments are low at $17 per unit, how would you like $8.50?) Working with ASA, we will make every effort to help CMS see the error in this decision, evidenced by its present and future impact upon academic anesthesiology. I hope you saw the November President’s Update from ASA President James E. Cottrell, M.D., informing us that the U.S. Senate will not act to prevent the current CMS plan for an additional 4.4-percent Medicare cut in February. Reimbursement for government-sponsored health care will be an issue for all anesthesiologists for the foreseeable future.

Productivity: The measurement of anesthesiologist clinical productivity and its comparison with valid benchmarks has been a priority for SAAC/AAPD in the past several years. We began by using a crude comparison of departmental relative value unit output with Medical Group Management Association practice benchmarks and found that academic anesthesiology departments appear quite strong when compared with other academic clinical specialties (Barker SJ. Anesth Analg. 2001; 93:294-300). To take the next step of comparing different anesthesiology departments, or even comparing faculty members within a department, we need more accurate measures of actual effort. Amr E. Abouleish M.D., University of Texas, Galveston, has developed several new metrics of clinical productivity and has used these to make useful comparisons between departments. The results of his work were presented at the most recent SAAC/AAPD Annual Meeting and are now in press (Anesthesia & Analgesia).

Safety and Quality of Care: Anesthesiology is widely recognized as the medical specialty that has made the greatest progress in monitoring and improving patient safety during the past three decades. Roger A. Johns, M.D., Chair of Anesthesiology, Johns Hopkins, moderated a session on the latest developments in patient safety and quality of care. The relationships between treatment errors and systems design were explored in detail; for example, by studying the multiple steps between physician order of a medication and delivery to the patient. One useful conclusion was that “every system is perfectly designed to achieve the results that it does.” Unfortunately, these may not be the results that we originally wanted.

Other topics of discussion at the recent SAAC/AAPD meeting included proposed changes in the anesthesiology residency curriculum, recruiting and developing quality faculty members and methods of satisfying new ACGME requirements for resident competency.

Some of the officers of SAAC/AAPD enjoyed a useful and informative lunch meeting with the ASA Executive Committee. In recent years, the communications and collaboration between ASA and SAAC/AAPD have improved significantly and this will work to the benefit of both organizations. As much as I dislike tired clichés, this is truly a “win-win” situation. The membership of SAAC/AAPD looks forward to working closely with ASA on our many common issues.

Steven J. Barker, Ph.D., M.D., is Professor and Head, Department of Anesthesiology, University of Arizona College of Medicine, Tucson, Arizona.

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