Douglas R. Bacon, M.D., Editor

Paradigms

ecently I received the following letter to the editor. My ensuing editorial is not a personal attack on the letter’s author, but rather it is a response to points raised that I have heard from ASA members for a considerable period of time. The purpose here is to refute the arguments and provoke a professional discussion. Thus while the author has given permission to publish his name, I have withheld it.

I found the ASA task force vision of the “Anesthesiologist of the Future” very disturbing. Serious mistakes have already been made involving mode and scope of practice and now “leadership” appears ready to make another. The CRNA problem and its amplification by the manpower shortage are two current examples of miscalculations. A flawed decision-making process that lacks meaningful input from mainstream clinical anesthesia providers is in large part responsible. Leadership role players tend to come from academia, never experience significant mainstream immersion and are atypical representatives of the specialty. This limits their viewpoint and increases their fallibility.

A case in point is the leadership fostered perpetuation of the totally illogical “Anesthesia Care Team” mode. If it requires two professionals to accomplish safe induction and intubation and two to bring off emergence, extubation and post extubation airway management, there is something seriously wrong with training. If anesthesia administration is the practice of medicine, why doesn’t every patient deserve a physician for the entire procedure, not just physicians, their families, relatives and dignitaries? This mistake is compounded by the fact that the genie is out of the bottle.

Our leaders are now hoping to carve out of surgical therapeutics something called “perioperative medicine.” This denies the reality that except for those who come into anesthesiology from internal medicine and perhaps family practice, anesthesiologists will not possess the qualifications to provide this care. Furthermore, anesthesiology attracts individuals who desire short-term doctor-patient relationships. This bias is not going to generate a lot of recruits interested in turning the anesthesia component over to a nurse while they practice internal medicine for the unknown duration of the patient’s confinement.

The name of our specialty is ANESTHESIOLOGY, with the interventional component of pain management a logical extension of what anesthesiology training encompasses. We chose anesthesiology to provide ANESTHESIA care; to make surgery, obstetrics and diagnostic and therapeutic procedures painless, safe and free of emotional stress. Moreover, we did not sign on to master the discipline and then have our skills decay over the years by watching a technician perform what we have been trained to do better.

Task force projections on the rate and degree of technological change that will alter the way anesthesia is administered are purely speculative. Cure for cancer was “just around the corner” in 1940. More than 60 years later, with few exceptions, we are still searching. Yet the task force is advocating, and “15-20 programs are ready to begin,” the production by 2025 of a provider who practices “perioperative medicine” (a form of internal medicine better provided by hospitalists), only supervises anesthesia and will be an expert in neither. The anesthesia provider will be a nonphysician. Despite what CRNAs and politicians say, I want my anesthesia administered by a physician.

Most of us who chose the specialty did so to learn and provide O.R. anesthesia. I submit that will continue to be the case as long as leadership does not change the name of the specialty. Meantime, we would be better served by concentrating energy and resources on reclaiming lost turf, shoring up our acknowledged boundaries and turning out more physician providers.

Aside from the many inaccuracies, I found this letter particularly disturbing. Anesthesiology is far more than the mechanical administration of anesthetics; it requires the insight of a physician for preoperative assessment, a matching of the anesthetic to the patient’s conditions and postoperative management of the acute recovery phase from the anesthetic and conquering of the patient’s surgical pain. There are many changes occurring in the operating room practice of anesthesiology, and we are faced with either adapting or being dictated to by forces outside our control and possibly having our role in the care of the patient greatly reduced or eliminated.

The first misguided belief, and the one easiest to deal with, is that the majority of ASA leadership comes from academia. The vast preponderance of leaders in ASA — and by that I mean committee chairs, directors, alternate directors and officers, as a start — are volunteers and work in areas in which they have interest. ASA has no control over who will step up to help with the important work that moves the Society forward. Academics tend to flock toward research and education, areas of anesthesiology that are of great interest to them, while private practitioners look toward practice and reimbursement issues. The senior leaders, if the recent past is any indication, are a nice balance among the various groups in anesthesia. Past presidents Roger W. Litwiller, M.D., and Eugene P. Sinclair, M.D., have spent their entire careers in private practice. Our current President, Orin F. Guidry, M.D., was in private practice for many years before moving to a hybrid practice at the Ochsner Clinic in New Orleans. President-Elect Mark J. Lema, M.D., Ph.D., and First Vice-President Jeffrey L. Apfelbaum, M.D., are both from academic institutions. Many of the remaining ASA officers and leaders are in private practice. Similar concerns over representation at ASA have been voiced by subspecialty groups. Yet the important point to remember is that ASA is only as strong as the people who volunteer their time, talents and money to make the organization run. In my estimation, if there is a problem with under-representation of any group or subspecialty at ASA, it is because someone did not come forward to do the work.

The second of my concerns with this letter is harder to dissect. For at least the past century, there have been many strong voices advocating the “one patient, one anesthetic, one anesthesiologist” mantra. This paradigm has been talked about and fought over on many different levels. In the distant past, the 1920s and ’30s, Francis Hoefer McMechan, M.D., pushed the American Medical Association (AMA) so hard on this point that AMA almost disavowed anesthesia within the confines of the organization. At another point, the Federal Trade Commission became involved, believing that this mantra restricted other anesthetic providers with the ability to practice, and ASA agreed to a cease-and-desist order that centered on restraint of trade.¹

In 1939 an opportunity arose whereby the American Board of Anesthesiology (ABA) would assume responsibility for the certification of nurse anesthetists.² Surgeons brought the anesthesiologists and nurses together, for ABA was a sub-board of the American Board of Surgery at the time. What has always fascinated me was that the anesthesiologists present wanted nothing to do with the process. These early anesthesiologists were concerned that if they certified the nurse anesthetists, it would be a license for surgeons to use them exclusively. The potential to regulate the specialty was foreign to them — and only through the retrospectascope can the potential good be seen.

In the mid 1990s, there was an “oversupply” of anesthesiologists, and many individuals and groups studied the problem. The net result was a decrease in the number of residency positions. This was in response to the concern that compensation for services would decrease. At the same time, newly graduated residents were being unfairly exploited and expected to work unreasonably long hours for wages less than many nurse anesthetists made. If we truly believed in the mantra of one anesthesiologist for each operation, if this were the ambition of all anesthesiologists, would we not have reacted differently?

Canada, the United Kingdom and much of Europe have used physician anesthesia exclusively. Yet these nations are under increasing pressure to bring physician extenders into the O.R. The last two issues of the European Society of Anaesthesiology Newsletter have contained articles and letters dealing with these issues. In private conversation, there is much fear that the system will become “like the U.S.” and the contributions of anesthesiologists will be missed. Faced with the inability of their respective systems to provide enough anesthesiologists to cover the anesthetizing locations, however, alternatives are being sought. At the moment, in the United Kingdom, basic science graduates who are having difficulty finding jobs are being trained to give anesthetics. While physicians abroad may feel differently, administrators — and remember, the vast majority of European nations have a socialized, federally funded health care delivery system — see the need to expand services economically, and they feel that physicians are not the most logical alternative.

Can the number of physicians being trained in anesthesiology significantly increase? The unfortunate answer is no because a majority of the funding for residency positions comes from the federal government. Trying to increase the numbers of anesthesiologists to meet the demand means lobbying for support for the new positions. Unless an academic department or its parent institution is very well funded and willing to support the cost of a residency line, it is impossible to increase the number of training positions and thereby increase the number of anesthesiologists.

In a special supplement to the journal The Hospitalist, Geno Merli, M.D., wrote an editorial whereby he expressed the opinion that the best physician to care for the perioperative patient was not a surgeon (or an anesthesiologist) but a hospitalist — an internist who practices only in the hospital environment.³ While internists may be experts on chronic disease states, they have limited understanding, in my experience, of the complex interactions of surgical manipulations, anesthetic agents and chronic disease. In reading the articles in this particular issue, anesthesiology, or an anesthesiologist, is rarely mentioned and then often as an afterthought or as part of a list of providers involved in operative patient care. In the same issue, Amir K. Jaffer, M.D., and Daniel J. Brotman, M.D., argue that preoperative care is the proper setting for hospitalists to expand their practice.⁴

Rather than turfing preoperative and postoperative care to the internists, anesthesiologists ought to be as aggressive in caring for their patients in these settings as they are in the operating room. The chair of my residency program always taught that the anesthesiologist and the surgeon make the decision about when the patient needs or ought to come to the operating room, not an internist. He abhorred the term “medical clearance” because it took the decision-making process out of the most qualified hands, those of the anesthesiologists and surgeons, and let the internists dictate practice. Anesthesiologists have better insight into the problems patients encounter in the surgical process, and we need to act as we were trained.

Will a hospitalist ever master perioperative pain medicine, or will they “steal” the techniques we have developed — such as femoral nerve catheter insertion, for total knee arthroplasty analgesia, in a manner similar to what many interventional radiologists have done with blocks for chronic painful conditions — and only call on anesthesiologists when they cannot manage to care for the patient adequately? Dealing effectively and aggressively with postoperative pain has the potential to decrease length of stay significantly. Already many regional anesthesiologists have focused on the immediate postoperative period; is it such a stretch to manage other more routine health issues in a very short-stay environment?

I do not advocate anesthesiology becoming involved in long-term care, but the acute stay in the hospital can be part of our care. Perhaps the role for the hospitalist is in the care of the very complex surgical patient in consultation with anesthesiologists, not the other way around!

The third issue with this letter, like many letters I have recently received, is that it criticized the concept brought forth by the ASA Task Force on Future Paradigms of Anesthesia Practice. I would argue with the changes in O.R. technology being similar to the cure for cancer. There are plenty of examples of how the technology of surgery is rapidly changing. Coronary artery bypass grafting (CABG) cases have decreased by at least one-third nationally over the last few years due to the increased use of drug-eluting stents by cardiologists. At the cutting-edge of interventional cardiology are left main angioplasty, valvuloplasty and ascending aortic aneurism repair.5 Vascular surgery, especially repair of abdominal aortic aneurisms, has radically changed with the introduction of percutaneous stents; and the acuity of the anesthetic management has concurrently changed with some patients having the procedure under regional anesthesia alone and oftentimes with less invasive hemodynamic monitoring.

At the ASA 2005 Annual Meeting this past October in Atlanta, the Emery A. Rovenstine Memorial Lecturer, Mark A. Warner, M.D., presented some of the anesthetic implications of the next generation of minimally invasive surgery using elements of nanotechnology. His example was transgastric appendectomy. These patients require either deep sedation or a “light” general anesthetic, leave the hospital the day of surgery and return to normal activities within hours. Since his lecture, several cholecystectomies have been done transgastricly. The future of surgery, and consequently anesthesiology, is less and less invasive. Therefore anesthesiologists will face less complicated anesthetics in the operating room of the future. What does this mean for our specialty?

There is the unfounded belief that less acute anesthetics, with less invasive monitoring, is an invitation to decrease the number of anesthesiologists. While articles written by nurse anesthetists and some anesthesiologists attempt to delineate when the anesthesiologist’s role should be limited, the health policy literature is more disturbing. A Johns Hopkins University Press product, the Journal of Health, Politics, Policy and Law, published an article which stated that anesthesiologists were a barrier to low-cost health care.⁶ The Lansdale Public Policy Fellowship, whereby an anesthesiologist spends a year in Washington, D.C., studying public policy and government, is so critically important to our specialty in fighting this trash.

When I decided to become an anesthesiologist, the intense, short-term patient care was attractive to me. Twenty years ago, at the start of my residency, most, if not all, patients were hospitalized the night before surgery; all had a CBC, a set of electrolytes and liver function tests. Twenty years later, I work on occasion in a preoperative assessment clinic, and less than 5 percent of the patients I care for are admitted to the hospital 24 hours before surgery. The scope was a tool for the gynecologic surgeons almost exclusively, yet today there is no organ, or body part, save perhaps the brain, that is safe from its use in surgical diagnosis and treatment. Anesthetics in the radiology suite were rare, as were any anesthetics outside the O.R., but have now become the norm.

Is it such a stretch to see that 15 years down the road, as my career in anesthesiology draws to a close, that many of the major operations of today, done laparoscopically, will be done utilizing nanotechnology? Witnessing that CABG cases are declining rapidly, being replaced by a procedure done under sedation without, by and large, an anesthesiologist or a nurse anesthetist present, is it so hard to believe that our beloved O.R. practice will undergo a radical change that will most likely involve simplification in the next 20 years? If anesthesiology is to survive, we need to change with the conditions, to adapt and to seek new opportunities. Failure to do so will force us to go the direction of the dinosaurs.

Is it not better to be a Morganucodon* than Tyrannosaurs Rex? Which would you choose for our beloved specialty? Only by making your voice heard, by participating in the work of ASA, by donating time and perhaps money, can we influence our future. Anesthesiology needs you now more than ever. Will YOU come forward and help lead, or will you sit in a comfortable armchair, decry the state of the specialty and criticize those who try to guide us? Only YOU can decide — and to begin the process, I welcome your comments.

— D.R.B.

References:
1. Smith BE. The 1980s: A decade of change. In: Bacon DR, Lema MJ, McGoldrick KE. (eds.) The American Society of Anesthesiologists: A Century of Challenges and Progress. Wood Library-Museum of Anesthesiology Press. 2005:174.
2. Bacon DR. A curious moment: The proposal to certify nurse anesthetists by the American Board of Anesthesiology. J Clin Anesth. 1996; 8:614-619.
3. Merli GJ. The hospitalist as perioperative expert: An emerging paradigm. The Hospitalist special supplement of Perioperative Care. 2004; 8(6):4.
4. Jaffer AK, Brotman DJ. Preoperative care: An opportunity to expand and diversify the hospitalist’s portfolio. The Hospitalist special supplement of Perioperative Care. 2004; 8(6):57-59.
5. Burkle CM, Nuttall GA, Rihal CS. Cardiopulmonary bypass support for percutaneous coronary interventions: What the anesthesiologist needs to know. J Cardiothorac Vasc Anesth. 2005; 19(4):501-504.
6. Cromwell J. Barriers to achieving a cost-effective workforce mix: Lessons from anesthesiology. Journal of Health, Politics, Policy and Law. 1999; 24(6):1331-1361.

* The Morganucdon was one of the first mammals alive at the time of the dinosaurs.




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