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

Thinking Outside the Box

Humans often take comfort in following traditional activities and rote actions. In large part, it reduces the stress of methodically planning and performing unfamiliar tasks. It also reduces the likelihood of failure or catastrophe.

As anesthesiologists we are trained to perform a series of preparatory and medical tasks for patients undergoing anesthesia. Familiarity with these tasks quickens our response time, especially during emergency care. For routine cases, adequate and rapid preparation moves the daily operating room (O.R.) schedule more efficiently.

Despite a universal human desire to maintain the status quo and resist change, society advances by continuously assessing and improving its state of affairs. So, too, businesses must adapt to meet these rapid changes. If change is inevitable, how will we practice anesthesia 20 years from today? The answer lies in predicting both the internal and external forces that influence our practice. In this final editorial, I want to pose some questions that may need to be answered by us as we continue to define our specialty.

Anesthesia mode of practice
Will the anesthesia care team still be the predominant mode of practice? Will the ratio of nurses/residents to attending physicians change if society perceives anesthetic practice to be very safe? Will society demand physician-only care, or will nonphysician providers be perceived as suitable for routine procedures and surgeries? Will emergency room and intensive care unit physicians begin to routinely provide propofol/fentanyl/midazolam anesthesia to intubated patients bypassing the O.R.? Will nurse anesthetists actively compete for positions with anesthesiologist assistants and even physician assistants? How will the status of conscious sedation nurses expand, and will they be a threat to all anesthesia providers? Will offsite and office-based anesthesia be the predominant locations for our anesthetic practices, and how will that change our practice arrangements? Will physician anesthesiologists anesthetize only the sickest patients or those requiring emergency surgery, leaving the rest to others with less anesthesia training?

Expansion of our role as perioperative specialists
Will we ever be regarded by surgeons and internists as the “go-to” specialty for any and all perioperative issues? Will anesthesiologists predominate in non-O.R. activities such as critical care, pain medicine, hospitalist practice and even emergency medicine? How should we train today’s anesthesiology residents in preparation for perioperative and non-O.R. medicine? Can we reassign residents from the O.R.s in order to train them in non-O.R. areas? Will we be the leaders in promoting a coordinated perioperative analgesia program to reduce the incidence of postsurgical chronic pain syndromes?

Practices based on evidence not intuition
Will we ever abandon the ASA Physical Status Classification scale and develop an operative risk-assessment index that accurately predicts surgical outcomes? Will we develop a computerized national database for all anesthetics to show which techniques might be better for certain patients? Will regional anesthetics be abandoned for simpler general anesthetic techniques? Will regional techniques become popular due to their improved morbidity outcomes? What is the impact of our anesthetic practice on patients with respect to cognitive functioning, and how will it change what we do?

ASA and membership involvement
How will ASA restructure in order to represent all of the multiple diverse practices engaged in by its members? Will all subspecialty societies unify under the ASA umbrella for strength in representation, or will some remain as small, isolated interest groups? Will all members begin to understand the importance of public access to government officials and support the ASA Political Action Committee? Will all members understand the importance of our three foundations (the Anesthesia Patient Safety Foundation, Foundation for Anesthesia Education and Research and the Wood Library-Museum of Anesthesiology) in defining us as a respected medical specialty by supporting them? How will anesthesiology fare with respect to physician payment if a single-payer system is adopted? Will we physicians ever be able to develop new programs and best practices without the fear of lowered reimbursement or of siphoning care to other practitioners as we show improvement?

Many of these questions will require answers and proactive measures to turn the tide of events in our favor. We, as a professional society, must work in unison with those who we elect as our officers to move everyone forward. Remember that all boats rise with the tide. Our leaders are dedicated, altruistic and most capable. “Leaders,” however, can only lead those who wish to move forward. They cannot solve these issues if the majority of members are passive. You must be active in this process if you want change to benefit your practice.

It has been my distinct honor and pleasure serving as the ASA NEWSLETTER Editor for the last 72 issues. I have learned that we, as a group of specialists, are incredibly intelligent, stubbornly unique, prophetically insightful and subtly humorous. I thank all of you who wrote comments, especially those with dissenting opinions. The ability to have the counterargument expressed in print to the entire membership is a sign that our professional society is open, honest and strong.

I pass the stewardship of this NEWSLETTER into the capable hands of Douglas R. Bacon, M.D., at the Mayo Clinic in Rochester, Minnesota. I know that he will continue in the long tradition of editors who use this newsletter as a sounding board for issues that affect our practices. Finally I must thank Denise M. Jones, Philip S. Weintraub, Roy A. Winkler, Karen L. Yetsky and David A. Love for their invaluable and essential roles in making the NEWSLETTER into an overwhelming worldwide success.

Thus this “Ventilations” column will serve as my last gasp!

P.S. Be sure to see my bonus aphorisms at the end of the “Letters to the Editor” section on page 37 of this NEWSLETTER!

– M.J.L.

Fish Out of Water? The guide said turn left at the last pyramid and go 200 kilometers to get to the nearest fishing hole. — M.J.L.

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