Archive for the ‘Anesthesiology’ Category

Once again, it’s Physician Anesthesiologists Week, and it’s a great time to celebrate our specialty’s many successes and accomplishments.

But we’re wasting an opportunity if we don’t also take this week to consider the state of the specialty today, and what it could or should mean to be a physician anesthesiologist 20 or 30 years from now.

There is no question that a seismic shift is underway in healthcare. Look at how many private anesthesiology groups have been bought out by—or lost contracts to—large groups and corporations; look at how many hospitals have gone bankrupt or been absorbed into large integrated health systems. Mergers like CVS with Aetna are likely to redefine care delivery networks. Where does a physician anesthesiologist fit into this new world?

An even better question to ask is this: Is your group or practice running pretty much as it did 20 years ago? If so, then my guess is that you are in for a rude awakening sometime soon. One of two scenarios may be in play:  either your leadership is running out the clock until retirement and in no mood to change, or your leadership hasn’t yet been able to convince your group that it can no longer practice in the same expensive, antiquated model. As one academic chair said ruefully, at a recent meeting, “They’re like frogs being slowly boiled. They just don’t feel what’s happening.”

The perspective beyond the ramparts

As CSA President, I’ve had the opportunity recently to attend two remarkable meetings:  the ASA’s Strategic Dialogue Summit, which took place on January 18-19 in Chicago, and the CSA’s Winter Meeting January 22-26 in Maui. The planners of both meetings took the forward-thinking step of inviting people from outside the walls of the ASA and of traditional academic anesthesiology. They weren’t just telling the attendees—and each other—what they wanted to hear.

The ASA Strategic Dialogue Summit was organized by Immediate Past President Jeff Plagenhoef, MD, FASA, and President James Grant, MD, MBA, FASA. It brought together more than 40 anesthesiologists from private, corporate, and academic practice, both ASA loyalists and outsiders. Some of us who were there practice clinical anesthesia every day; others haven’t touched an anesthesia machine in years.

The meeting gave us an opportunity to speak candidly about the specialty of anesthesiology:

What threatens the specialty?

Are current payment models stifling progress, and what can be done?

How will new technologies make us obsolete or help us work smarter?

Are we training too many anesthesiologists, or should we train more?

How should training be revised to meet the needs of the future?

What disruptive innovations are just over the horizon?

The participants can’t say more than that at present, as we are considering the next steps that the process should take:  whether and when to engage different demographic groups of anesthesiologists in the dialogue, and involve outside stakeholders (such as third-party payers, patient advocate groups, healthcare administrators, and other physician specialties).

Beyond the Strategic Dialogue Summit, these questions should be considered by all of us, as we think about our profession and where we are going from here.

How trauma surgery reinvented itself

A prominent surgeon, Gregory Jurkovich, MD, FACS, of the University of California at Davis, gave a fascinating talk at the CSA Winter Meeting on how the specialty of trauma surgery has reinvented itself over the past 20 years in response to a crisis.

Back in 2001, the US faced a critical shortage of surgeons who were willing to take trauma call for emergency departments, Dr. Jurkovich explained. The cases often occurred at night and on weekends, and the pay didn’t begin to match the work involved. Younger surgeons going into practice no longer considered emergency call a duty as previous generations had done. Emergency departments became severely overcrowded, and the harm to patients from delays in care turned into a national scandal.

The leaders in surgery had to face facts. The profession of surgery as it existed in 2001 wasn’t delivering the best possible care to trauma and other emergency surgical patients, Dr. Jurkovich said. Not all general surgeons or orthopedic surgeons, let alone sub-specialists, were willing to assume care of emergency cases, and a surgeon who rarely sees trauma cases probably shouldn’t be managing them anyway.

A new Committee on the Future of Trauma Surgery, with broad representation from surgical boards and subspecialties, convened in 2003. The committee members decided that they didn’t want to let the specialty of trauma surgery die out, and they didn’t want to turn all non-operative care over to non-surgeons or hospitalists.

They decided to create a new specialty, which would serve emergency patients better, offer an attractive career and lifestyle, and stand as a valuable specialty in its own right. The new specialty would provide critical care training as well as operative training in trauma and other acute emergencies.

The new specialty came to be called “Acute Care Surgery”, and it has been a resounding success, Dr. Jurkovich said. It consists of a two-year fellowship after general surgery, combining trauma care, general surgery, and surgical critical care, and there are now 25 fellowship programs. Graduates work for academic and private hospitals alike, typically on a salary plus stipend basis. Their practices may include routine emergency cases (appendectomy, bowel obstruction) along with trauma cases, and acute-care surgeons admit and make rounds on surgical intensive care patients. Their round-the-clock availability helps avoid dangerous operative delays.

The shift-based work appeals to younger surgeons who seek a more predictable schedule, Dr. Jurkovich said. He pointed out generational challenges which affect surgery and every other specialty today, with more women entering medical school than ever before, more interest in a “balanced” lifestyle, and less interest in general practice than in subspecialty “niches”.

What lessons can we learn?

If the specialty of anesthesiology needs to reinvent itself—redesign what we do and how we do it—it isn’t too late if we start now. The exact solutions and details of implementation will vary by location and practice setting. But inaction, and futile attempts to defend the status quo, are the biggest threats.

For the past several years, I’ve had the privilege of traveling and speaking with anesthesiologists from a wide variety of practice settings, during my work as a CSA officer, a delegate to the ASA, and now as CSA President. The problems and the fears are evident; many anesthesiologists feel as though we are being squeezed in an ever-tightening vise of production pressure and cost constraints. The question is how to break free.

Here are my crystal ball’s top three best-case predictions—those of you who are in practice 20 or 30 years from now will have a chance to see how right or wrong they turn out to be!

The training of anesthesiologists will break the mold of today’s iron-fisted control by the ACGME, the RRC, and the match system.

We’ll no longer insist that every program train every resident with exactly the same cookie-cutter requirements. Residency and fellowship programs will develop and excel along different lines. Some will focus on scientific research, some on the economics and operational management of healthcare, and others on the clinical management of patients and teams in procedural settings. Cross-training with other specialties will expand, and anesthesiology’s influence will expand accordingly.

You’ll never hear the question, “But how will we get paid for it?”

If a peri-procedural service needs to be delivered, anesthesiologists will figure out how to do it safely and efficiently, without being hobbled by fee-for-service constraints. New care models will involve sedation nurses, ICU nurses, pharmacists, and other staffers—in addition to anesthesiologist assistants and nurse anesthetists—under the direction of anesthesiologists across the continuum of every episode of care that includes an interventional procedure. The current rigid supervision ratios and definitions will no longer apply.

Technology will redefine delivery of care.

Operating suites will have command centers where multiple rooms can be viewed and monitored simultaneously. Physician anesthesiologists will no longer spend disproportionate amounts of time performing nursing and pharmacy tasks: injecting drugs into IV lines, or mixing antibiotics. Better drug delivery systems, with feedback loops and decision support, will replace minute-to-minute manual fine-tuning. As we work smarter, the desires of upcoming generations for predictable schedules AND career satisfaction can be fulfilled.

If we face the future squarely, and make changes now that set our specialty up to survive and thrive, we can bring the joy back to the practice of anesthesiology. Then we’ll have good reason to celebrate Physician Anesthesiologists Week for many years to come.

 

When you tell anyone in healthcare that “sedation” to the point of coma is given in dentists’ and oral surgeons’ offices every day, without a separate anesthesia professional present to give the medications and monitor the patient, the response often is disbelief.

“But they can’t do that,” I’ve been told more than once.

Yes, they can. Physicians are NOT allowed to do a procedure and provide sedation or general anesthesia at the same time – whether it’s surgery or a GI endoscopy. But dental practice grew up under a completely different regulatory and legal structure, with state dental boards that are separate from medical boards.

In many states, dentists can give oral “conscious” sedation with nitrous oxide after taking a weekend course, aided only by a dental assistant with a high school diploma and no medical or nursing background. Deaths have occurred when they gave repeated sedative doses to the point that patients stopped breathing either during or after their procedures.

Oral surgeons receive a few months of education in anesthesia during the course of their residency training. They are legally able to give moderate sedation, deep sedation or general anesthesia in their offices to patients of any age, without any other qualified anesthesia professional or a registered nurse present. This is known as the “single operator-anesthetist” model, which the oral surgeons passionately defend, as it enables them to bill for anesthesia and sedation as well as oral surgery services.

Typically, oral surgeons and dentists alike argue that they are giving only sedation – as opposed to general anesthesia – if there is no breathing tube in place, regardless of whether the patient is drowsy, lightly asleep, or comatose.

The death of Caleb Sears

Against this backdrop of minimal regulation and infrequent office inspections, a healthy six-year-old child named Caleb Sears presented in 2015 for extraction of an embedded tooth. Caleb received a combination of powerful medications – including ketamine, midazolam, propofol, and fentanyl – from his oral surgeon in northern California, and stopped breathing. The oral surgeon failed to ventilate or intubate Caleb, breaking several of his front teeth in the process, and Caleb didn’t survive.

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The real surprise – to me, at least – came more than halfway through Dr. Atul Gawande’s keynote address at the opening session of the American Society of Anesthesiologists’ annual meeting in Boston.

Much of his talk on October 21 celebrated the virtues of checklists and teamwork, topics that have turned into best-selling books for the well-known surgeon and professor of public health. “We are trained, hired, and rewarded to be cowboys, but it’s pit crews we need,” he said.

Then Dr. Gawande posed this question to the packed room: “What are the outcomes that matter?”

He answered his own question somberly. “The most unsafe operation is the operation that shouldn’t be done,” Dr. Gawande said. “Does the operation serve the patient’s goals or not?”

“We’ve all been there,” he continued. “Taking people to the operating room and wondering what we’re doing.”

Those are comments I’ve heard from anesthesiologists many times before, but I never thought I’d hear them from a surgeon.

Flogging the dead

For any of us who practice anesthesiology in a major hospital – doing cardiac, thoracic, or liver cases, for instance – there are days when all our efforts are spent on behalf of a patient whose health is unsalvageable. “Flogging the dead” is a phrase sometimes used to describe prolonged and futile care in the operating room or ICU.

Sometimes aggressive interventions are driven by a family that wants “everything” done, because in their innocence the family members have no idea how terrible and dehumanizing the process of postponing death can be.

In other circumstances, however, the decision of whether to do surgery is driven by the mission and the financial motivation of the health system to provide care. If care doesn’t occur, if the surgery isn’t done, no one gets paid.

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No, I’m not talking about putting fentanyl into my own veins — a remarkably bad idea. I’m questioning the habitual, reflex use of fentanyl, a synthetic opioid, in clinical anesthesiology practice.

I’ve been teaching clinical anesthesiology, supervising residents and medical students, in the operating rooms of academic hospitals for the past 18 years. Anesthesiology residents often ask if I “like” fentanyl, wanting to know if we’ll plan to use it in an upcoming case. My response always is, “I don’t have emotional relationships with drugs. They are tools in our toolbox, to be used as appropriate.”

But I will say that my enthusiasm for using fentanyl in the operating room, as a component of routine, non-cardiac anesthesia, has rapidly waned. In fact, I think it has been months since I’ve given a patient fentanyl at all.

Here’s why.

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(This post chronicles the recent Los Angeles visit of ASA President Jeff Plagenhoef, MD, and his Grand Rounds presentation at USC. It originally appeared on the website of the California Society of Anesthesiologists. Above, Surgeon General Jerome Adams, MD, MPH, left, with Dr. Plagenhoef.)

“Who kicked whom off the anesthesia care team?” asked ASA President Jeff Plagenhoef, MD, FASA. Which professional association refuses to work amicably with the other, he inquired of his audience at the University of Southern California on September 15, as he delivered a powerful Grand Rounds address to the Department of Anesthesiology.

In his talk, “Professional Citizenship:  Responsibilities Shared by All Anesthesiologists”, Dr. Plagenhoef emphasized that physician anesthesiologists and the American Society of Anesthesiologists (ASA) fully support nurse anesthesia practice within the physician-led anesthesia care team. In his practice as Chair of the Department of Anesthesiology at Baylor Scott and White Hillcrest Medical Center in Waco, Texas, Dr. Plagenhoef works with nurse anesthetists and with certified anesthesiologist assistants (CAAs).

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