Mark J. Lema, M.D., Ph.D. Editor

The New Medical Ecosystem: Will Anesthesiology Thrive?

The current medical care paradigm across the world began in the 1800s when doctors developed an independent general practice system. These “personal corporations” were like silos standing alone and disconnected from any meaningful professional interactions. Secret formulas were jealously guarded in an effort to build and maintain a private practice (e.g., Dr. Pepper, Coca-Cola and Carter’s Liver Pills). Apart from major clinics and academic medical centers, doctor relationships were mostly adversarial and, at times, hostile (the ether story!).

In the 20th century, medical practice began to coalesce with the rise of group practices and medical centers. Medical advancements and the expansion of professional journals facilitated dissemination of information on current practices. Doctors connected the silos largely within their own areas of medical disciplines, and subspecialties were born. Today each specialist surely holds memberships in his or her own professional societies and quite possibly is a member of subspecialty societies (cardiac, pediatric, obstetrics, regional, etc.). Some subspecialties have even become so multidisciplinary that no single specialty society can claim exclusivity (endoscopy, critical care, pain, etc.). Finally newer specialties have evolved such as invasive radiology, pain medicine, hospitalists and emergency medicine. These disciplines raised the bar of clinical performance expectations, effectively making the nonspecialist who dabbled in these areas on a part-time basis obsolete.

Anyone following the course of medical practice in the United States since 1980 can see a clear metamorphosis from the fee-for-service, cost-plus billing, secret society nomenclature and hang-out-the-shingle arrangements to our care-restrictive, practice-perfectly-on-a-budget, megagroup system. There are few silos left, and medicine seems very interdependent on specialist consultations. Moreover the popular press, more knowledgeable patients and, of course, Internet surfing have dramatically altered the doctor/patient relationship.

This change in attitude regarding the delivery of medical care by business, government and the public has resulted in a number of substantive alterations in health care delivery. Of note, minimally invasive procedures by surgeons and nonsurgeons have altered hospital-based practices, especially for anesthesiologists.

I work in what might be considered one of the last bastions of classical surgical practice, the cancer hospital. Yesterday four procedures lasted between eight and 18 hours. Despite these traditional long surgeries, we are witnessing the rapid expansion of off-site procedures and minimally invasive surgery. Some surgeries that required nasal intubations, spinal anesthesia and cardiorespiratory clearance can now be performed with conscious sedation by trained nonanesthesia nurses. Moreover our daily techniques are in jeopardy of being relegated to midazolam, fentanyl, propofol and oxygen delivery.

Another paradigm change has occurred in emergency rooms and intensive care units where nonanesthesiologist physicians are intubating, using laryngeal mask airways (LMAs), providing propofol anesthesia for emergency deliveries and using anesthetic drugs for sedation and immobility. Hospitalists are performing roles that anesthesiologists could have filled as the perioperative specialist. Their presence is of special concern since most hospitalized patients are now critically ill or surgical candidates. These areas were voluntarily relinquished as we retrenched back into the operating room milieu largely due to staffing and reimbursement issues.

Pain medicine is evolving to the extent that most practicing anesthesiologists would be lost if they had to provide one week’s coverage of that service. The use of X-ray-guided procedures, parallax views, percutaneous neurosurgical techniques and newer analgesic agents has made the casual pain specialist practicing blind epidural steroid injections, trigger-point therapy and morphine prescribing all but obsolete.

It seems to me that anesthesia may be at a crossroads. We need more personnel; no one will dispute it. But how will anesthesia be practiced in 20 years, and what kind of people should we be training? Consider these changes in the last five years that have made anesthesia safer and even easier — propofol, remifentanil, desflurane, sevoflurane, rocuronium, LMAs, rapid-response pulse oximetry, noninvasive hemodynamic monitoring and minimally invasive procedures. While both organized anesthesiology and nurse anesthesia have been engaged in a death grip regarding independent practice issues, other nurses, pediatricians, intensivists and emergency physicians are chipping away at the very foundation of both anesthetic practices. Anesthesiologists and nurse anesthetists should be concerned about this outside professional intrusiveness, which may be passed off as simply another “turf” issue by government and payers.

How safe have we become, and what importance does society now place on having a board-certified anesthesiologist or certified registered nurse anesthetist provide sedation for their minimally invasive procedure? It is all about perception and affordability. Politicians and the public are largely ignorant about the subtle risks of anesthesia in this setting, but they are not stupid. If both specialties continue to relinquish procedures to nonanesthesia specialists, our workforce shortage may quickly dissipate. We cannot rely on the public wanting the safest care at any cost. We cannot rely on the media covering 88 deaths occurring separately across the United States due to dumbing down of health care as they would cover an airplane crash killing the same number of people. Society, business and government will either unknowingly or quietly attribute these “losses” to the cost of doing business. Since hospital deaths can end up in lawsuits, the real cause of death, i.e., substandard care due to shortages, will be hidden by defense attorneys blaming demise to the patient’s condition. I doubt that the defendant physician will refute that line of defense in the hopes of stirring up public sentiment for better health care.

ASA is currently working to avert any erosion of the practice of anesthesiology by rebuilding the ranks of critical care anesthesiologists and seeking to serve as the umbrella society for pain medicine specialists. Each practicing anesthesiologist, however, must decide how he or she will practice and whether supporting nonsurgical anesthesia activities is healthy for our survival. Each anesthesiologist must let ASA committee chairs, state directors and ASA officers know what concerns are critical to the practice not only of anesthesiology but of perioperative medicine, critical care and pain medicine.

Will anesthesia ever become so safe and so reliable that anesthesia-trained personnel become obsolete? I do not believe so, but the evidence to date is suggesting that anyone with minimal training can use our lethal drugs, but in nontoxic doses, while not knowing how to resuscitate. Ironically, the safer we become, the more expendable we may be regarded. One wonders why society still wants the airline industry to use two pilots when it is 15-20 times safer than anesthesia.

Perception is everything.

Editor’s Note: Don’t miss my last installment of “Ventilations” in the December 2003 issue.

– M.J.L.

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