John P. Abenstein, M.S.E.E., M.D.

Prognostications can be difficult – particularly if they are about the future.

— Author unknown

ne of the most hotly debated issues at this year’s ASA Annual Meeting was how the Society should address deep sedation conducted by nonanesthesiologists. Most anesthesiologists believe this practice is unacceptable. In spite of concerns voiced by anesthesiologists, however, more and more procedures are being conducted under sedation (i.e., a level of sedation that renders a patient essentially insensible to pain) administered by physicians and nurses who lack training in anesthesia. A simple Medline search of the keywords “deep sedation complications” reveals many papers advocating that deep sedation performed by nonanesthesiologists (usually emergency medicine and gastroenterology physicians) is safe. How could the American medical system reach this point where anesthetics (once thought to be too dangerous for anyone to administer other than those with extensive training and experience) are being administered by physicians and nurses with little or no training in anesthesia?

Most likely the reasons for this broad and disturbing change in practice are multifactorial. Most important is the fact that anesthesia, and by extension I.V. sedation, is now presumed to be very safe. No matter how one defines anesthesia-related mortality, it is now remarkably lower than it was 50 years ago. This improvement in outcome means that many physicians have never seen an anesthesia-related death. Unfortunately this fact leads to the conclusion that the anesthetic agents that anesthesiologists are trained to use are easy to administer and safe to use by anyone with prescriptive authority.

Another issue, however, comes into play and is eloquently summarized in a recent editorial in the American Journal of Gastroenterology:

“The provision of sedation for procedures and tests is labor intensive and, for the foreseeable future, requires human resources far and above those which can be met by individuals whose primary training was in anesthesia care.”¹

Clearly part of the problem is that demand for anesthesia services is greater than what can be delivered by anesthesiologists. Patients increasingly expect deep sedation or anesthesia for uncomfortable procedures. Since patients require medical care whether we are available or not, their physicians will find other ways to relieve pain during procedures. The absence of an anesthesiologist in these circumstances (due to excess demand or, more cynically, economic motivation) places the proceduralist in the role of performing the procedure as well as directing the anesthesia/sedation.

This situation will only get worse because of the confluence of four demographic trends. First, the baby boom generation will begin to enter the Medicare system in just four short years and will be making increasing demands for medical care. Second, the American population as a whole is rapidly expanding, due mostly to immigration. Third, the output of our medical schools is, at best, flat, and there is little interest in significantly expanding the number and/or size of our medical schools. Finally, medical care is changing, and therapeutic interventions are no longer concentrated in the operating suite but are spreading throughout our facilities. These trends are occurring simultaneously and will lead to a discontinuity in the American medical system broadly and will have particularly significant consequences to anesthesiology specifically. One of the consequences of these changes is that demands for anesthesia services will rise substantially while the number of available clinicians will remain flat.

The medical specialty of anesthesiology can respond to this in a number of ways. We could continue to practice as we have in the past. We would accept the fact that those patients for whom we are able to care will receive the benefit of physician anesthesia. Patients receiving anesthesia or I.V. sedation from nonanesthesiologists is an unfortunate state of affairs, but there is little we can do about it other than encourage our medical colleagues to improve their practice standards. Our practice “sphere of influence” may shrink as a consequence, but we would continue to deliver high-quality medical care to those lucky enough to receive it. Another potential avenue would be to significantly expand the use of physician extenders (e.g., anesthesiologist assistants, nurses, respiratory therapists, etc.), increase the number of concurrent anesthetics we cover and, in effect, decrease our involvement on a per-patient basis. This option would allow us to maintain or even increase our share of the anesthesia/sedation market but at the cost of diluting the contribution of anesthesiologists to the care of individual patients. I think it is fair to say that many anesthesiologists may not be happy with some of the challenges associated with the utilization of physician extenders. These are just two examples of many possible responses to the increasing imbalance of supply and demand for anesthesia and sedation services.

When one thinks about how we have delivered anesthesia care over the last century, it begins to resemble how craftsmen operated prior to the industrial revolution. We deliver care one patient at a time, customize the anesthetic on a per-patient basis and then assign at least one clinician to each patient. In spite of advances in medical knowledge, pharmacology and technology, our delivery model has remained essentially the same for many decades. Is it possible, with a change in practice model, to increase the involvement of anesthesiologists while decreasing the labor intensity of anesthesia care?

A future model for anesthesia care potentially could make use of information technology, including robotics, architectural redesign of procedural suites and allied health professionals to allow anesthesiologists to care for more patients, achieve better outcomes and decrease costs. Already today, critical care physicians are using the real-time output of physiologic monitors and mechanical ventilators that are processed by a computer which identifies early sepsis and adult respiratory distress syndrome, allowing for much earlier interventions. Could similar developments provide electronically presented information (in contrast to date) to anesthesiologists so they can safely monitor and intervene on four, six or more patients simultaneously? Is it possible to develop medical robotics that can deliver different I.V. fluids (e.g., crystalloids, colloids, blood products) and medications without a human spiking a bag or pushing a syringe? How about systems that could raise or lower the depth of anesthesia or degree of muscle relaxation via closed loop control? It may even be possible that systems could be developed, possibly with the use of ultrasound guidance, to automatically cannulate arteries, veins or even the airway. Can our specialty move from one clinician per patient to a practice that has anesthesiologists in a control cockpit directing other anesthesiologists to patient bedsides for necessary direct interventions and supported by still other anesthesiologists in preoperative and postoperative areas? Can we, via the use of appropriate technology, lower costs by decreasing the number of clinicians required to deliver anesthesia services, offering lower fees with improved quality of care?

This vision of the future obviously requires the development of a broad range of new technology that must be designed and validated prior to clinical use. More importantly it would require that our specialty radically change its approach to patient care. While I am not advocating for this specific, technology-based approach, I do believe that the impending demographically driven discontinuity in medicine demands that anesthesiologists proactively formulate solutions. Our medical facilities, colleagues and, most importantly, our patients will decide which solution(s) are best, but it is clear that the status quo will not hold. The future is upon us, and we will either embrace these changes or be swept aside by them.


Reference:
1. Bailey PL, Zuccaro G. Sedation for endoscopic procedures: Not as simple as it seems. Am J Gastroenterol. 2006; 101:2008-2010.

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