uturists generally agree that changes are occurring rapidly, and health care futurists that these changes will be major. Thus it is not surprising that many speakers at the 2007 Conference on Practice Management in Phoenix last January 26-28 focused on change and future anesthesia practices.

ASA President Mark J. Lema, M.D., Ph.D., presented the keynote conference address, “21st Century Anesthesiology — Preparing for the Future Paradigm.” He described how anesthesiology and health care are changing and prepared attendees for more. Affecting the anesthesia status quo are “dabblers” and “poachers,” clinicians who attempt deep sedation but administer general anesthesia, and who deliberately administer general anesthesia but without training. Both put patients at risk. For dabblers he included some endoscopists and cosmetic surgeons; for poachers he included some emergency physicians, intensivists and hospitalists. Contributing to the shortage of anesthesiologists is their increasing work outside operating suites, in preoperative clinics and for pain services.

Figure 1: Panelists on the “Future of Anesthesia Practice,” left to right, Dana E. Simpson, J.D., Robert E. Johnstone, M.D., Julian M. Goldman, M.D., Norman A. Cohen, M.D., and Ronald D. Miller, M.D.

Dr. Lema quoted studies that medical outsourcing will grow; traditional work relationships change; and new ethical, legal and quality standards will develop. Although controversial, he observed that to reduce costs, lesser-trained personnel might predominate the delivery of health care. Hospitals will become inpatient intensive care unit facilities, and reduced payments for services will change supervisory ratios and the ability of physicians to provide solo care. He opined that since the future of surgery is medicine, the future of anesthesiology should be perioperative medicine. ASA is now studying alternative payment methods, fighting to preserve anesthesia payments for endoscopic procedures, fighting to improve payments for resident-administered anesthesia and undertaking studies of outcomes and safety to demonstrate the high value of anesthesiologist-delivered care. Slides from Dr. Lema’s talk are available on the ASA Web site www.ASAhq.org/Washington/PM2007-01-DRLEMAUPDATE.pdf.

Ronald D. Miller, M.D., Chair of the Department of Anesthesia and Perioperative Care at the University of California at San Francisco, discussed the findings of the ASA Task Force on Future Paradigms for Anesthesia Practice in the year 2025. The task force concluded that tertiary care hospitals will evolve into predominantly periprocedural (including surgical) units, with a gradual decline in the number of overnight patients. Health delivery, biotechnology and pharmaceutical industries leaders, as well as government officials, felt that anesthesiologists should lead these periprocedural units, although many doubted anesthesiologists would. Find more information at www.ASAhq.org/Newsletters/2005/10-05/miller10_05.html#report.

Robert E. Johnstone, M.D., led off a panel on the future of anesthesia practices [Figure 1] by describing six major drivers of change. These included dissatisfaction with our current health care system; demands by the public for accountability; increasing demand, supply and costs for anesthesiologists; the evolution of clinical anesthesia; workforce demographics; and information technology. He cited numerous and disparate facts, e.g., 47 million uninsured Americans, a recent $20 million anesthesia malpractice judgment, 20 million Americans over age 65 by 2030, 13-percent increase in locum tenens physicians this year, more than 10 million cosmetic surgery procedures annually, and more than 2.7 billion Google Internet searches per month. Dr. Johnstone quoted physicist Neils Bohr: “Prediction is very difficult, especially about the future,” but offered six predictions, including a public database of surgeons and anesthesiologists with outcomes and benchmarks by 2011 and an anesthetic workforce of 100,000 in 2016.

Julian M. Goldman, M.D., Director of the Program on Interoperability at the Center for Integration of Medicine and Innovative Technology and the Massachusetts General Hospital and past president of the Society for Technology in Anesthesia, described the operating room of the future. It will be a technology-rich “integrated clinical environment” where sophisticated systems support the skills of clinicians. Surgeons, nurses and anesthesiologists will have information dashboards that enhance decision-making and reduce errors. Parallel processing will improve work efficiencies, and common standards for device integration will improve transfers throughout the perioperative process (see www.mdpnp.org and www.cimit.org/orfuture).

Dana E. Simpson, J.D., a health care attorney involved in anesthesiology, reviewed legal and political trends that are shaping anesthesia practice. He covered the growing acceptance of arbitrary regulatory formulas to cut physician reimbursements by politicians wanting to make budget cuts without taking heat from constituents. He predicted that anesthesiologists who embrace performance measures of quality and patient satisfaction will benefit from the tiered payments of pay-for-performance programs. He thought the future depended greatly on state-level legislative battles over out-of-network payments from managed care organizations as well as balance billing rules. Other battles would arise from the movement of cases to nonhospital settings, scope-of-practice regulations, limits on exclusive hospital contracts, hospital employment of anesthesiologists and the growth of national anesthesia groups.

Other speakers at the Conference on Practice Management described how the rise of hospital subsidies for anesthesia groups is changing their institutional relationships. Robert M. Johnson, M.B.A., vice-president of Business Development at Sheridan Healthcare, Sunrise, Florida, correlated the view of hospital administrators that providing anesthesia is an important business service to their use of anesthesia management companies. To thrive in the future, anesthesia practices will need to define their customer service better. Norman A. Cohen, M.D., described economic trends for anesthesiologists, and Mark A. Singleton, M.D., discussed part-time work arrangements. Syllabus chapters for conference speakers are available at www.ASAhq.org/news/news021907.htm.

Two speaker citations offered perspective. Paul Valery wrote, “The trouble with our times is that the future is not what it used to be.” John F. Kennedy said, “Change is the law of life. Those who look only to the past or present are certain to miss the future.”

Speakers added a quote from William Shakespeare: “Don’t shoot the messenger if you don’t like the message.”

Robert E. Johnstone, M.D., is Professor of Anesthesiology, West Virginia University, Morgantown, West Virginia. He is ASA Director for West Virginia.