Douglas R. Bacon, M.D., Editor

These Are the Good Old Days

s I write these words, I have just returned from the ASA Annual Meeting in Las Vegas. Still ringing in my ears are the words of the Emery A. Rovenstine Memorial Lecturer, Jerome H. Modell, M.D., and of our now Immediate Past President Roger W. Litwiller, M.D. Both addressed, in different venues and to different audiences, the future of anesthesiology — and, curiously, a biblical verse found in Joel 2:28: “And it shall come to pass … your sons and your daughters shall prophesy, your old men shall dream dreams, and your young men shall see visions” applies equally to both of their comments on our shared future.

Sitting in the Rovenstine Lecture, I heard a very distinguished emeritus professor deliver what amounted to a “living” eulogy for our specialty. Dr. Modell ended with an emotional final plea for involvement of the assembled anesthesiologists to rescue our specialty, to return it to the good old days the speaker had experienced in the 1960s, ’70s and ’80s. Yet I must very respectfully disagree with his comments. For in my view, these are the best days that the specialty has experienced, and there are better days ahead.

The cynical among the NEWSLETTER readership will no doubt wonder what is in the Minnesota water, and more important, if we are willing to export it. Perhaps, the logic will go, the Mayo Clinic may be the only medical institute in the country unaffected by the recent changes in health care. But nothing could be further from the truth. Change affects all of us, and there is no real safe haven from transformations in our profession. What is important is how we face the challenges that are presented to our specialty.

In the 1960s, the number of medical school graduates going into anesthesiology had greatly decreased. Programs were unable to fill the available training slots, and programs were in jeopardy of closing. Does any of this sound similar to what was happening in the 1990s? ASA and the specialty responded by first studying the causes of the problem and finding solutions. One situation was the student preceptorship program, whereby a student spent eight weeks in the operating room on anesthesia service during the summer for $800. A number of very prominent anesthesiologists, myself included, were introduced and “converted” to anesthesiology as our life’s work. Sadly the program ended in the mid-1980s.

Reimbursement remains a prominent issue in anesthesiology. In the 1920s and ’30s, an anesthesiologist was either paid by the surgeon or collected a fee as a percentage of the surgeon’s fee. Quite commonly this fee was $5 on a $50 surgical fee. Fast forward again to the 1960s, and anesthesiology led the way with the development of the Relative Value Guide (RVG). Eventually other specialties adopted this method of calculating reimbursement for services rendered. The Federal Trade Commission (FTC) felt that the RVG violated antitrust regulations. All specialties except anesthesiology knuckled under to the pressure brought by the FTC. Anesthesiology and ASA stood alone in 1978 against the might of the federal government. Yet ASA stepped up to the plate and won the lawsuit, allowing the RVG to be used. Ultimately the RVG was adopted by the federal government as the preferred billing methodology.

At the ASA 2004 Annual Meeting, there was much discussion about academic centers not surviving long into the 21st century. The reasons are multifactorial, but without a change in reimbursement, thus placing them on a more sound financial footing, resident training and research are endangered. This is not the first challenge that academic centers have endured, though. When Ralph M. Waters, M.D., set up the “first” department of anesthesiology at the University of Wisconsin-Madison in 1927, he faced a variety of challenges, including how to pay his trainees. The advent of the post-World War II boom in residency training “made” anesthesiology as a specialty. Research, however, remained difficult to fund. Emanuel M. Papper, M.D., Ph.D., working with the National Institutes of Health (NIH), helped to make sure that there would be funds available for anesthesiology research in the mid-1960s.

During the mid-1980s, there was a need noted for funding of junior researchers to help support them so that they could become competitive for NIH funding. The Foundation for Anesthesia Education and Research (FAER) was founded to address this problem. In almost 20 years, close to 500 investigators have been supported, and many of these recipients are among the very best researchers in anesthesiology today.

Addressing the House of Delegates, Dr. Litwiller challenged the specialty to support academic anesthesiology in a number of ways. Most interestingly he repeated the words of Dr. Modell, urging the gift of 0.5 percent of an anesthesiologists’ income be donated to support research endeavors. If this money were forthcoming, FAER would be inundated; a problem the foundation would solve with great relish.

Do we need to “save” anesthesiology? I would argue no more than we needed to in the 1950s, ’60s, ’70s, ’80s or ’90s. No matter what time period is examined historically, there have been challenges to which our specialty has had to respond. Oftentimes these have been opportunities to redefine anesthesiology.

Our prophets must “see” into the future to help us understand the implications of the issues before us. The more senior among us must dream of new ways to lead the specialty. The younger must have vision of what anesthesiology can be — and have the strength of conviction to see that vision through for the betterment of the specialty. We already have too many people outside of anesthesiology ready to deliver our eulogy. Let us not do it to ourselves.

— D.R.B.

return to top