Douglas R. Bacon, M.D., Editor

Hey, Anesthesia!

t happened one night as I was leaving the O.B. suite to help emerge a patient in the main operating rooms. “Hey, anesthesia!” the nurse called after me, “we need an epidural in room eight.” I had spent the greater portion of my night in the O.B. suite, and I had covered there regularly over the past several years. Yet on this night, at 2 a.m., the nurse could not tell me from the resident assigned to cover the obstetrical floor who had placed all manner of regional anesthesia that day. Why are we the generic “hey, anesthesia” when we prominently wear our nametags day after day? What is required for us to be recognized as a professional within the operating room?

Having worked in surgical anesthesia for almost 20 years, I have never heard anyone refer to a surgeon, or a surgical resident, as “hey, surgery.” The same is true of all the operative specialties, although it would be fun to hear “hey, otolaryngology!” just once. Are we really such faceless providers to our colleagues, both physician and nurse, that we are thought of as a nameless entity? What does this say about our specialty? Moreover, what does it say about our status as physicians?

A Vision
I read with great interest in last month’s ASA NEWSLETTER the article by Ronald D. Miller, M.D., longstanding chair of the Department of Anesthesiology at the University of California-San Francisco. His look into the near future of our specialty fascinated me. The take-home message for me was the fact that many of the groups interviewed viewed our specialty as the logical choice to run the perioperative experience for patients. Moreover, it was felt that anesthesiologists were the physicians of choice to be hospitalists — caring for those sick inpatients throughout the continuum of care. Remember, of course, that the hospital of the future would largely be critical care-oriented with a much greater ratio of intensive care unit beds to floor beds than currently is the norm.

Reading the article, I found myself in agreement with the idea that anesthesiologists should expand their role. In the hospital of the future, we would be positioned to be what has been talked about for decades, true perioperative physicians. Finally, anesthesiologists would be recognized for the unique contribution they make to patient care, and rather than constantly worrying about the number of operating rooms that can be run or who will cover the obstetrical suite, a whole host of possibilities, given the flexible nature of our specialties’ training, took hold. Could we do this? Of course the specialty could, especially if there were physicians of vision leading this change.

Reality
Reality in early 21st century academic anesthesiology is quite different. In the early 1990s, when the workforce crisis first struck, there was a shift of personnel into the operating rooms. Coupled with the Medicare teaching rule, which limits anesthesiologists to half the Medicare reimbursement fee when supervising two resident rooms simultaneously, departments were hard-pressed to keep the operating rooms running and be fiscally sound. Unfortunately, as a service department, keeping the operating rooms running was the priority, and in some instances, places of learning such as the Veterans Affairs (VA) hospitals had their residents pulled back to the main university hospital, and the VA’s resident positions were left unfilled.

This crisis led to the naming of individuals as chairs in some institutions who were primarily operating room managers. It satisfied the need to keep the operating rooms and other anesthetizing locations going. Yet what these folks lacked were the intangibles that a tenured professor brings to the leadership of a department. Most important is the vision of where the specialty is headed in that particular institution — across the nation and occasionally the world. What these tenured professors have in vision, however, they may lack in fiscal management. The ASA Certificate in Business Administration program is one way to address this problem.

My residency program chair once was heard to say that he was “the most unacademic academic chair in anesthesiology.” He was a successful chair, graduating residents who were skilled anesthesiologists, yet my program did not have the benefits that a well-connected, internationally known chair would have brought. We had no American Board of Anesthesiology examiners on faculty, no Association of University Anesthesiologists members and no National Institutes of Health (NIH)-funded research until well after my graduation, and both were recruited to the department. Since a vision of where anesthesiology was headed nationally was lacking and contacts with outside institutions through the reputation of the chair were lost, the program was somewhat isolated from mainstream anesthesiology.

Even today anesthesiology remains an expensive proposition. Receipts from patient care activities often do not adequately cover expenses for the services the institution or hospital require. Thus, in academia especially, anesthesiology has gone from a source of income to requiring a stipend to meet expenses. A good fiscal manager by definition looks to the bottom line today and in the near future and often does not look to the horizon. Reading the reports of the Foundation for Anesthesia Education and Research over the past decade, it becomes clear that anesthesiology research, per capita, is not adequately represented in NIH funding, but also that while slowly recovering, anesthesiology research is not and will not become in the foreseeable future the force that it needs to be if the specialty is to grow and prosper significantly. It seems as if anesthesiology is caught in a quandary — if we cannot produce academically qualified tenured professors, how can we convince deans and search committees of the need for a strong department of anesthesiology in the institution? How will we ever begin the transformation so enticingly laid before us by Dr. Miller? The question most likely is not “Will the specialty step up to Dr. Miller’s challenge?” but rather, “Can it?”

Widgets
Another concern that often leads to the “hey, anesthesia” problem is our willingness, in supervisory practices, to hand over cases to our colleagues. While not every anesthesiologist supports or practices in this mode, it is done frequently. When the surgical providers do not know who is giving the anesthetic, despite all the best practices, or when a case has been handed off so many times that the in-room provider is no longer sure who is the supervisor, anesthesiologists appear to be interchangeable widgets. One of the greatest challenges for every anesthesiologist occurs when he/she first steps into a new hospital and joins the practice for the first time. Getting to know the likes and dislikes of the surgeons, the flow of the operating room and how each individual in the surgical team communicates takes time. Trust is earned, not given by degree or title. I would argue that to eliminate “hey, anesthesia” requires a change in practice to some extent, rather than a diatribe against an offensive phrase.

Vision Meets Reality
Is Dr. Miller’s vision of the future viable? Obviously the possibility of making anesthesiologists the specialist for hospitalized patients — in addition to our already various duties to administer anesthesia all over the hospital and, in many instances, outside of it — strains our credulity. Currently there are not enough anesthesiologists to fill the offered positions, and there are not enough residency positions to keep up with the current demand without increasing the number of residency training positions in the United States. Who will pay for this training? The federal government, at best, seems reluctant to foot the bill, and at the worst, is downright hostile. Would caring for patients in such settings as the intensive care unit, where reimbursement has been traditionally lower than the operating room practice, mean that the average anesthesiologist’s salary will decrease in buying power if not actual dollars in the coming years? Is this a small sacrifice to pay to ensure the growth and development of anesthesiology for the rest of the century?

In many ways, the recent Residency Review Committee proposal to ensure all postgraduate years of training were under the direction of the academic anesthesiology department responsible for the three-year anesthesiology residency training was a step toward Dr. Miller’s vision. Yet for many reasons this proposal met with great opposition. To some it seemed like an unfunded mandate — from where would the money for the additional postgraduate year one (PGY-1) positions come? The federal government, which funds most postgraduate training, did not volunteer. Enlightened deans and their institutions seemed willing to shoulder part or all of the cost in order to maintain the flow of excellent interns, but not all deans or institutions are enlightened on this issue or have the resources to help. Should PGY-2, 3 and 4 slots be reduced to make sufficient PGY-1 positions available? This would decrease the number of available anesthesiologists even further each year, making an attractive job market for the graduating physician and a dismal one for employers. Could academic anesthesiology withstand another such blow?

Visionary Leaders Needed
Most of the questions I have raised do not have a ready answer. Yet it is the answers to those questions that will determine what happens to our specialty. Are we destined to become something beyond our current definition and three main areas of practice—the operating room, pain clinic and intensive care unit, or shall we remain the faceless practitioner at the head of the table, one indistinguishable from the other? Hey, anesthesia! ought to be eliminated from the vocabulary of every member of the teams with which we toil, out of the respect that is engendered by the work we do.

Let us make it our mission, as ASA enters its second century, to change our faceless image. It is the most important work we will ever do.

— D.R.B.

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