Douglas R. Bacon, M.D., Editor

Changing the Status Quo

t could have been a very depressing end to a wonderful meeting. The last panel on the scientific program centered on the future of anesthesiology. Leading physicians from pain medicine and critical care outlined both the historical roots of their practice and clearly delineated the challenges before our specialty if we wish to continue to embrace these subspecialists within our medical family. The third speaker rose to address the issues current to those who have a more traditional operating room or procedural-based practice. Blunt and frank, the panel’s presentation to that point was not the traditional “the future of anesthesiology is rosy with just a few bumps along the road” but rather a starker reality with the many difficult decisions and challenges before anesthesiology that must be solved if the specialty will continue to exist into the latter half of the 21st century.

The final speaker rose to deliver his talk “The Future of Anesthesiology — Are We Dropping the Ball?” A nationally known anesthesiologist who has served the specialty in many different, important leadership roles on every level — local, regional, national and international—delivered the message that, in essence, everyone is talking about the future, but no one is doing anything about it. While the tone could have been downbeat and depressing, it was not. Like the crisp, cold Minnesota winter night, when the temperature drops to -20 degrees Fahrenheit, the snow crunches underfoot, the stars in the night sky seem so close that it is almost possible to reach up and touch them, and the stillness and quiet allow for calm reflection, this talk was a call to those in the audience to analyze the status quo. In light of what we know today, is change necessary? If so, the speaker asked, who will lead the charge and make the necessary change a reality?

To whom should anesthesiology turn to assess and perhaps change the status quo? There are several potential “players” in leadership roles that potentially could transform the direction of the specialty. The forum can be either large in number, or the anesthesiology section of a larger, more powerful organization; either such group can make a difference. The problem is twofold. First, what is the proper direction for the specialty to take? Decisions made today will impact anesthesiology for decades to come, and to make the “wrong” decision could doom the specialty. Second, which organization, which committee, should champion the decision, and how can this be kept from being lost in the inevitable criticism that comes with any controversial decision? How can anesthesiologists decide which is a legitimate concern and what is simply trepidation about such a decision since, in the short run, financial and practice implications appear to negatively affect the physician?

The first and obvious choice is ASA. Our great Society maintains several forums for the consideration of the status quo in anesthesiology. The House of Delegates remains the best voice of the “people” of the specialty. Each committee reports its activities of the year to the House, and each report is considered and potentially commented upon in a reference committee. Our elected officers address the House each year, with both the president and the president-elect speaking to the issues they see before anesthesiology. Oftentimes they recommend solutions that are debated and acted upon by the House. It is democracy in action and in the finest traditions of the United States.

There is, though, a handicap to democracy. A small, vocal minority can stop the Society from moving forward on an issue. Even worse, a crushing defeat of the minority can lead to animosity that cripples the effectiveness of the organization. Additionally our Society relies upon volunteers to make it work. From committee membership to top leadership positions, time and talent are given to the future of anesthesiology without thought of compensation. For many it is simply an honor to serve, to give back to the specialty that has given them so many advantages. Yet volunteers are volunteers and cannot be hired or fired based on performance as would happen in a business. Leadership is a quality that is sought after, yet the ability to move a large organization may take more than just one leader or more than one year. Thus there may be significant handicaps to ASA changing the face of American anesthesiology quickly.

The American Board of Anesthesiology (ABA) is another logical organization with the ability to change the direction and ultimately the future of anesthesiology. By setting the criteria to become a board-certified specialist — a credential that has become increasingly important to hospitals, malpractice insurers and third-party payers — ABA has the ability to change the face of anesthesiology. The board does report to a higher authority, the American Board of Medical Specialties (ABMS), but it has the “power” to effect substantial change. If Ronald D. Miller, M.D., is correct in his assessment of the future,* if indeed the future of anesthesiology lies with an increased responsibility for the intensive care of patients and perhaps outpatient pain management, then there needs to be a restructuring of how we train residents.

ABA can mandate that change so long as the members of the board are willing to endure the firestorm that will accompany such a far-reaching, radical decision. It would be difficult, although possible, to challenge an ABA proposal to require an additional six months or a year of critical care medicine in the anesthesiology residency through the ABMS approval process, should ABA make that decision. Likewise the board could authorize a year of research with a scholarly project, similar to a thesis, as criteria for successfully finishing an approved fellowship. This would clearly enhance the intellectual and investigative nature of the fellowship program. New innovations could potentially come from these projects, and the ultimate outcome would be enhanced patient care. In the end, it is up to the ABA directors to make this decision and to begin the process of communicating their rationale within organized anesthesiology and listen to the inevitable criticism. It is incumbent upon the rest of the specialty to interact with ABA (especially the ABA directors) to understand the reasons behind the decisions and to build consensus about the best way to implement the new directives that will allow anesthesiology to grow and change into that which it needs to be in the latter half of the 21st century.

The Residency Review Committee (RRC) also has the potential to change the flavor of American anesthesiology. The RRC attempted to make a change several years ago, and the conflagration of protest markedly modified and weakened the intent of the proposed changes. The RRC is responsible to the Accreditation Council for Graduate Medical Education (ACGME). Thus RRC decisions can be appealed, similar to ABA decisions. Effective lobbying by programs who could not survive a mandated internship drove the protest. Quite simply, since the number of residency slots in the country has been fixed by the federal government, the addition of a mandated, first postgraduate year would have caused many programs to decrease the number of residents in the operating room significantly. An alternative, finding funding for “new” residency slots, remains problematic as many departments already function under a deficit — in many instances greatly contributed to by the prejudicial Centers for Medicare & Medicaid Services anesthesiology teaching rule. While the RRC ultimately increased the duration of the critical care rotation, added more pain medicine experience and a month of perioperative medicine, little else was done to mold the future of the specialty. The RRC, though, could make a bold move concerning fellowships and require a scholarly project in RRC-approved training as well, and perhaps this is the first step in moving fellowship beyond simply clinical expertise and increasing the intellectual position of our subspecialties.

The comfort of the status quo can be deceptive. As a long-time ice hockey fan, there was an “unwritten” rule that in the third period of a playoff or close game, no penalties would be called no matter how grievous the infraction. The thought was that the referees should not affect the outcome of the game. My contention has always been that by not calling the penalty for an obvious offense, the referees were affecting the outcome just as if they had made the call. Since the lockout two years ago, the National Hockey League and its referees have called penalties in the third period and in overtime just as they call them in the first period. The status quo — “letting the players decide the outcome of the game” — was accepted as the norm, but it was not in the best interests of professional ice hockey.

The point of the final panelist was that we have spoken enough about the future and the need for change. We, as a specialty, need to act, to make a conscious decision about where anesthesiology is going that will allow our practice to survive into the latter half of this century. A wrong decision can have severe consequences. No decision, a maintaining of the status quo, could even be worse. Healthy debate, followed by closing ranks to support our leaders’ decisions, will ensure an equal place for anesthesiology with all medical specialties. Will you be part of the solution or part of the problem?

— D.R.B.

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