N. Martin Giesecke, M.D., Associate Editor

Looking to the Past to Discern the Future

Readers may not have noticed a subtle change in the Editorial Board of the ASA NEWSLETTER. At last year’s House of Delegates meetings, the House approved the recommendation of the Editor, Douglas R. Bacon, M.D., to add two Associate Editors to the Editorial Board. Each of those two editors, Doris K. Cope, M.D., and N. Martin Giesecke, M.D., will contribute one editorial to the NEWSLETTER this year. This is the first of those editorials.

— D.R.B.

little more than 100 years ago, George Santayana wrote in his book, The Life of Reason, “Those who cannot remember the past are condemned to repeat it.” Perhaps a corollary to this is that by looking into the past, one may discern the future. Here, we will pursue this idea, and maybe we will find out whether or not it has an application to the practice of anesthesiology.

For my first example, I must be given a bit of latitude. At last year’s Annual Meeting, I was walking down one of the hilly streets of San Francisco. My destination was Moscone Center and one of the many continuing educational opportunities therein. My shoes were standard black leather penny loafers. Their heels had recently been replaced. The cobbler had convinced me to add a plastic heel guard to decrease the rate at which I wear down the heels of my shoes. These small, semilunar pieces of plastic may decrease the rate of heel wear, but they make the heel quite slippery. When walking on level ground on a non-slippery surface, such as dry concrete, it is easy to overcome the disadvantage of the slippery plastic heel protector. When walking downhill, where the back edge of the heel is the first part of the shoe to come into contact with the ground, it is a bit harder to control the slippage. This is especially true when the pavement on the downward incline is marble.

So there I was, walking downhill on the sidewalk, in front of one of the upscale shopping venues in the Union Square area, when my left heel hit a slab of marble pavement. What followed was not pretty - my left leg shot out in front of me at such a rate that the left knee hyperextended, and I heard, or rather felt through my bones, the distinct sound of popping cartilage. I did not lose stability in my left knee; however, it remained painful to walk on and bend. It was not surprising to find out that I had torn both the medial and lateral menisci of my left knee and that surgery would be required to correct the problem.

So how does this reveal that one might be able to see the future from looking at the past? And what does it have to do with the practice of anesthesiology? I’ll answer the second question first. Good knee function is integral to my ability to practice anesthesiology, to move from one location in the hospital to another. To be limited by a knee that is painful and stiff might mean a slower response from the O.R. office to the operating room where a resident or fellow has requested my presence, or from the O.R. to a code blue where a patient requires intubation. This is not to say that all anesthesiologists require two functional knees to practice. Rather, one dysfunctional knee has the capacity to make walking quite uncomfortable. Hurrying to a code becomes an impossibility.

The answer to the second question is that in my past, I had a hyperextension injury to my right knee. That injury, which occurred 12 years ago, was a ruptured anterior cruciate ligament. The reconstructive surgery and rehabilitation was significant. Nevertheless, at the time I was committed to regaining total function of that knee and would settle for nothing less. Within 18 months of the surgery to repair my right anterior cruciate ligament, I was back to fencing with an épée and taking long day hikes with my wife, Susan. So looking into the past told me that I would have good results from the surgery on my left knee. It also told me that I would be removing those plastic heel protectors from my shoes so that a similar injury would not occur again.

Back in the 1990s, the Society commissioned a study looking at workforce needs in the specialty of anesthesiology. This is the infamous “Abt Study,” named after Abt Associates of Cambridge, Massachusetts, the consultants who undertook the poll. The study was an appropriate attempt by the Society to document the need for anesthesiologists in light of suggested changes to national health care, which were coming from the Clinton White House. Unfortunately, the Abt Study was flawed for several reasons, not the least of which was the assumption that certified registered nurse anesthetists would be available to take over much of the anesthesia care of patients. The study’s finding was that there was an overabundance of anesthesiologists and that U.S. surgical volumes foreshadowed that no new anesthesiologists needed to be trained through 2010. This highly publicized result quickly led to a downturn in the number of medical students who applied to anesthesiology training programs. So not only was the result wrong - in reality there was and continues to be a relative shortage of anesthesiologists nationwide — but also the shortage of anesthesiologists was accentuated by the subsequent decrease in the number of graduates from anesthesiology residency programs.

What does a review of the Abt Study have to do with the future of anesthesiology? History has proven wrong the assumptions and findings of the study. Yet, anesthesiology is still dealing with the negative press it received as a result of the study. Though the number of anesthesiology residents has increased since then — reversing the trend of the mid-90s — we still have a long way to go to have an adequate supply of anesthesiologists. Thus, workforce needs were underestimated in the past, there was a shortage of anesthesiologists in the past, and there will continue to be a shortage of anesthesiologists in the future.

Another issue soon to come to the forefront is the current iteration of computer-directed administration of anesthetic medications. Closed-loop computer programs have been used to provide anesthetic infusions since at least as far back as the mid-1980s. Perhaps the most effective use has been in the administration of neuromuscular blockade. In that example, the administration of the medication is directly controlled via a feedback mechanism from a device that measures muscle strength after automatic firing of a nerve stimulator. There are many other computer-controlled medication administration devices; most are used in education or research.

A recent example of computer-controlled administration of anesthetics is that of an apparatus used to administer propofol sedation. At least one computer-assisted personalized sedation (CAPS) device is under trial at this time. It has been used primarily in the gastrointestinal endoscopy suite. The purported benefits of the CAPS are that it provides safe, tight control of sedation, giving the endoscopy team the confidence that a patient would be at an appropriate level of sedation for the entire endoscopic procedure. If approved, the device will allow a team of non-anesthesiologists the ability to give propofol sedation to patients having gastrointestinal endoscopic procedures. The issue at hand is patient safety. Does a small-scale pilot trial (24 patients, 12 of whom received colonoscopy and 12 of whom received esophagogastroduodenoscopy) demonstrate safety across the broad spectrum of patients who require endoscopy?

Reviewing the history of these devices shows that they have not replaced the anesthesiologist. Assume that approval for the CAPS is sought only for the endoscopy suite. There are too few anesthesiologists to provide our patient-saving vigilance and quality care to every patient undergoing an elective endoscopy, so it is unlikely that the CAPS will affect the way the majority of us practice. On the other hand, there are many of us who work with gastroenterologists, and CAPS may become a damper on that relationship. Will it spread into the operating room? The answer to that question is yes, it most likely will. However, in the arena of the operating room, CAPS will most likely be operated by an anesthesiologist.

Incursions into the scope of practice of the anesthesiologist are another issue to review in this manner. It was not long after the first public demonstration of ether anesthesia by William T.G. Morton that nurses began to administer anesthesia. Though the exact dates are uncertain, nurses began providing ether anesthesia as early as 1861, when they cared for wounded combatants in the early stages of the Civil War. This is a mere 15 years after Morton demonstrated ether at Massachusetts General Hospital. And it was with the Clinton Administration that Medicare offered the option for states to opt out of the medical direction of nurse anesthetists in the operating room. Several states have chosen this path. Even gastroenterologists, cardiologists and emergency physicians are currently using propofol. So, history tells us that there have been many and strong incursions into our scope of practice. The lessons learned are that we need to continue to strive for patient safety. There are many of who think what we do is so safe that anyone can to do it. We need to continue to show the benefit of our training and how significantly it differs from that of others.

As a final example, we can discuss the general decline in Medicare payment to anesthesiologists over the last 15 to 20 years. We all should be aware that in the early 1990s, Medicare payment to anesthesiologists dropped significantly. It was about that time that Medicare began to under-appreciate anesthesiology services. From 1989, when I first started practice, to 1991, my Medicare payments fell more than 50 percent. That was merely the beginning of the decline. Since the Balanced Budget Act of 1997, Medicare has used the sustainable growth rate (SGR) calculation to determine physician payments from Medicare Part B. The SGR formula has been flawed from the beginning, and nearly every year, organized medicine (including the American Medical Association and ASA) has fought Medicare to replace the SGR with a more appropriate method of physician payment. Indeed, we have also had to go to Congress nearly every year to counteract planned cuts in Medicare payment to physicians. And the inequities of Medicare payment to anesthesiology training programs may lead to their bankruptcy without significant outside support.

Our goals with Medicare are laudable; we are trying to preserve medical care options for our senior citizens as well as striving to continue training the country’s future anesthesiologists. And though for many years our success with Medicare was not as significant as many of us would have liked, recent history teaches us that ASA’s response to Medicare policies is well thought out and has been successful. At the end of 2007, the Centers for Medicare & Medicaid Services (CMS) finally recognized the gross underpayment for anesthesia services. For 2008, CMS announced a 32-percent increase in anesthesia work values. This increase roughly amounts to a 25-percent increase to the Medicare anesthesia conversion factor. Thus, the national unadjusted anesthesia conversion factor has risen to $19.97; this will provide anesthesiologists with an average of $16,500 more from Medicare this year. (For more information, see Ron Szabat’s column in the January 2008 ASA NEWSLETTER.) ASA was instrumental in these accomplishments. These changes came about as the culmination of a multi-year effort by ASA and its members to convince both the AMA/Specialty Society Relative Value Scale Update Committee and CMS of the importance of bringing equality into the anesthesiology payment equation. Perhaps this latest news on the Medicare front will be the beginning of the landslide that eventually leads to a complete renovation of the Medicare payment system, including the need to appropriately pay for services provided by anesthesiology residency training programs.

The reader has been presented with four examples looking at reviewing history in order to see direction in the days to come. Though history presents us with some sobering lessons, we can be optimistic in that we still have the opportunity to shape our collective future.

— N. Martin Giesecke, M.D.
Associate Editor

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