A better pathway to acute care

When patients need acute interventional care, coordinating the transitions away from and back to primary care is a challenge. The common pathway for these patients, no matter what their diagnosis, is an encounter with anesthesiology. But it often happens too late in the process. If we’re involved earlier, physician anesthesiologists can help reduce procedure risk, control costs, and improve the long-term health of this high-risk, high-spend population.                    

The numbers haven’t changed significantly in several years—only five percent of the U.S. population consumes a full 50 percent of annual health care spending, and just one percent is responsible for nearly 23 percent of spending.

Within the top 10 percent of high spenders, most (nearly 80 percent) are age 45 or older. About 42 percent are persistent high consumers year after year, while the majority requires high spending only on an occasional basis. These episodes of high health care consumption often involve surgery or other invasive procedures in the older patient population.

The experience of undergoing surgery inevitably disrupts a patient’s normal routine of care, even if the surgery is a common elective procedure such as a total joint replacement. Too often, the primary care physician may be unaware that the patient has actually undergone surgery.

Even if the patient’s primary physicians are informed of the plan for elective surgery, they may be left out of the loop regarding discharge planning, the need for post-acute care and rehabilitation, and any changes made to the patient’s medication and diet regimen. Lapses in care and deterioration of chronic medical conditions may result, with the frail, older patient population clearly at highest risk.

Why we should rethink current practices

Within every community population, a subset of patients will be in need of procedural care at any point in time. This care may involve an operation. Or it may involve a substantial, invasive procedure for diagnosis or treatment, such as ablation of cardiac arrhythmia, ERCP (endoscopic retrograde cholangiopancreatography), or insertion of an endovascular stent.

The common pathway for this entire population subset, regardless of the diagnosis or any other factors, is an encounter with anesthesiology before, during, and after the procedure. Today, that encounter often begins way too late in the process.

Read the Full Article

2 COMMENTS

As always, you are an incredible writer and clearly passionate about this subject. I always get a little nervous when I hear doctors talking about population health instead of individual patient health, "quality" measures in medicine, and bending cost curves in medicine. The baby boomers are aging and their health care costs are high and going to get higher. I realize that the government and other third party payers are concerned about those costs. However, my oath was to my patients and not ...Read More

Art Boudreaux

Great article Karen!

Read All 2 COMMENTS

Nothing brings out the mama lioness in me more than seeing one of my cubs not being treated as well as I think it should be.

Recently I had the unusual experience of accompanying my oldest daughter into an unfamiliar hospital for a minor surgical procedure. Now this daughter isn’t exactly a cub — she’s a full-fledged adult, with a master’s degree in health care administration, a husband, and two small boys of her own.

But as I watched the OR team prepare her for surgery, I started to feel like an odd combination of a mama lioness and a secret shopper. To the staff members who came in and out of the hospital’s preoperative area, it was clear that I was simply the family member in the corner, and they probably figured I had little clue about what was transpiring. Meanwhile, I was taking in every detail. Some tasks were performed excellently — others, not so much.

The hospital where her surgery took place is a small community hospital on Long Island. It enjoys a location where Jerry Seinfeld, Christie Brinkley, and other wealthy New Yorkers maintain lavish homes for weekend and summer holidays.

My daughter was instructed to arrive at 6:30 a.m. Her procedure involved an initial stop in radiology, to be followed by the actual surgery. As a veteran of hospital life, I questioned whether radiology even opened that early, but we had no way of checking. So we left her house at 5:25, driving carefully on dark, icy roads with fresh snow, and lining up for a 5:40 a.m. ferry ride from her home town so that we could arrive at the hospital by 6:30.

The good news — a valet met us at the hospital door and whisked away the car, so we had only a moment to savor the 20-degree weather and the harsh wind that made it feel colder. My daughter was promptly escorted to a private room to change clothes.

Hurry up and wait

A nurse gave her an insulated paper gown with two openings to connect it to a wall-mounted forced air warming unit. This, I thought, was a wonderful thing. Where I’ve worked, we had forced air warming blankets in the ORs but the hospital wouldn’t spend the money to put them in the preoperative areas. I thought of Tina Fey, playing an immigrant from Albania in a Saturday Night Live spoof of the HBO series “Girls”, and imagined her saying, “In my country, we do not have such things.” Within minutes, my daughter’s gown was hooked up to the warmer and she was feeling much cozier.

Then we waited.

Read the Full Article

7 COMMENTS

I'm glad that some parts to that day were positive - i.e. quick out of the cold due to the valet, the warming unit, and that the surgery went well. I had surgery in December and they gave me one of those warming units to use in pre-op - it was wonderful. I have had interactions with a few medical professionals in my lifetime in which I have had similar experiences. I have never figured out if they were just having a rough day or ...Read More

bradjohnsnow

Karen: Wait until you are actually the patient, as I have been frequently in recent years. "Modern Medicine" is terrifying for someone who actually knows a better time - far closer to the quality offered by Lucy in Peanuts than that taught by Sir William Osler!(Except the charges are more like Tiffany than like even Sir William's charges.) It's already too late to fix it, Karen! Which gives rise to the question: "Is it better to be like your daughter and not to know how ...Read More

Read All 7 COMMENTS

Short-selling private practice

Today, January 29, is a remarkable day for me. I’m officially leaving private practice after almost 18 years, to return to academic medicine with a faculty position in a highly regarded California department of anesthesiology.

Why would I do that?

There are many positive reasons. I believe in the teaching mission of academic medicine:  to train the anesthesiologists of the future, and the scientists who will advance medical care. I enjoy teaching. The years I’ve spent at the head of the operating room table, anesthetizing patients every day, have given me a great deal of hands-on experience (and at least some wisdom) that I’m happy to pass along to the next generation.

But the other, more pragmatic reason is this. I’ve lost confidence in the ability of private-practice anesthesiology in California to survive in its prevalent form — physician-only, personally provided anesthesiology care.

MD-only:  A viable model?

California is an outlier among all other states in its ratio of physicians to non-physicians in the practice of clinical anesthesia. Nationally, there are slightly more non-physicians — including nurse anesthetists (about 47,000) and anesthesiologist assistants (about 1,700) — than physician anesthesiologists (about 46,000) in the workforce, according to 2015 National Provider Identifier (NPI) data.

But in California, there are about 5,500 physician anesthesiologists and only 1,500 nurse anesthetists in the workforce, while anesthesiologist assistants can’t yet be licensed here at all. Though some other states, chiefly in the western half of the U.S., also have more physicians than nurses in the anesthesia workforce, none tops California’s ratio of more than 3.5 to 1.

It’s hard to see how such a physician-skewed model of anesthesia care can continue to be financially viable, no matter how much affection I have for it. I genuinely love safeguarding my patients through anesthesia for complex surgical procedures, from beginning to end. But there’s no way that it makes sense for many of the tasks involved to be performed directly by a physician. If the Institute of Medicine advocates for nurses to practice “to the full extent of their education and training” in order to provide cost-effective care, it stands to reason that physicians ought to work at the top of their licenses too.

Many of the daily tasks involved in MD-only, personally-provided anesthesia care could and should be delegated to nurses, pharmacists, and technicians. Easy examples include starting IVs, drawing up medications, labeling syringes, and monitoring a patient’s blood pressure. Surgeons don’t perform these tasks during surgery, intensive care physicians don’t perform them in ICUs, and hospitalists don’t perform them on the inpatient wards. And we haven’t even mentioned other routine tasks such as changing the suction tubing on the anesthesia machine between cases — a duty that is well within the skill set of the OR clean-up crew. It makes no fiscal sense, in our cost-conscious time, for physicians to be performing these tasks personally.

Read the Full Article

2 COMMENTS

karen

Dear Dr. Tse, Advice? Read everything you can find about the business of anesthesia. One excellent common-sense online source is Tony Mira's Anesthesia Business Consultants' quarterly communique. Go to meetings such as the ASA's Practice Management, and get familiar with the concepts of the Perioperative Surgical Home. If a private practice you're looking at doesn't seem to be keeping up with the times, be wary. Smart practices are working closely with their hospitals and extending their footprint outside the OR. Since this website is strictly ...Read More

Brian

Congratulations on this transition in your career and for sharing your forecast on the climate of California's anesthesia marketplace. What advice would you have for a current resident who plans to stay and practice in California to prepare for this? We will spend years in the role of being supervised, but upon graduating will likely be in a role of having to supervise others. Also, which institution will you be joining? Thanks!

Read All 2 COMMENTS

Is it always wrong for a surgeon to book cases that will be done in two operating rooms during the same timeframe?

If you’ve paid much attention to the overheated commentary on social media since the Boston Globe published its investigative report, “Clash in the name of care“, you might easily conclude that the surgeon who runs two rooms ought to be drawn and quartered, or at least stripped of his or her medical license.

John Mandrola, MD, a Kentucky cardiologist who I’ll bet doesn’t spend a lot of time in operating rooms, weighed in on Medscape with a post called “The Wrongness of a Doctor Being in Two Places at Once“, accusing surgeons of hubris and greed.

Respectfully, I disagree.

The Globe’s story tells the dramatic tale of how a prominent surgeon at Massachusetts General Hospital often scheduled two difficult spine operations at the same time. According to the Globe’s reporters, the surgeon typically moved back and forth between two operating rooms, performing key parts of each procedure but delegating some of the work to residents or fellows in training.

On one particular day, a complex case ended with a tragic outcome. The patient, a 41-year-old man, sustained spinal cord injury at the level of his neck, leaving him permanently unable to move his arms or legs. Another prominent MGH surgeon leaked details of the case to the press, and was summarily fired.

Of course, I have no special access to information about what goes on at the MGH, and can’t comment on the specific cases highlighted in the Globe’s report. But I’ve been giving anesthesia for a long time in first-class hospitals. On countless occasions, I’ve seen surgeons run two rooms, and have administered anesthesia to a patient in one of them.

Have I ever seen a patient come to harm because the surgeon scheduled concurrent cases?  No.

Have I ever been annoyed because a surgeon delayed the start of my patient’s case because of the demands of the case in the other room? Yes, but I always agreed with the decision to delay, and the wisdom behind it. If the surgeon is at a critical portion of the first case, we have no business starting the second case until the surgeon gives the go-ahead.

Have I ever been thankful that the surgeon had two rooms? Yes indeed. Here’s why.

Read the Full Article

5 COMMENTS

Karen: see you tomorrow at 11 am on the show. This is excellent stuff!

Bob Ruxin

Karen-- I shared this post with a good friend and her adult daughter who recently had complex surgery at MGH and is scheduled for another one in March. We had just discussed the article and I tried to argue there might be good reason for double booking. Your inside perspective makes the case much more persuasively. I suspect not only your medical, but your journalistic credentials trump those of the Globe reporters and editors.

Read All 5 COMMENTS

I admit, I was taken aback at the headline in the Houston Press:

GOING UNDER:  WHAT CAN HAPPEN IF YOUR ANESTHESIOLOGIST LEAVES THE ROOM DURING AN OPERATION

The curious reader is bound to wonder why the anesthesiologist would leave the operating room in the first place.

Of course, reporter Dianna Wray explains that in many hospitals, one physician anesthesiologist often supervises multiple cases staffed by nurse anesthetists. This model of care is called the “anesthesia care team“, and has a very long record of safe practice in nearly all major hospitals in the United States. Typically, the anesthesiologist makes rounds from one operating room to the next, checking on each case frequently, just as an internal medicine physician would round on patients in the hospital who are being monitored by their nurses.

Ms. Wray’s article narrates in detail what happened in several anesthesia cases where things went horribly wrong. She points out that the patients and families were not aware that the anesthesiologist would not be present during the entire case.

Complications can develop with patients on the ward, in the intensive care unit, or in the OR. In any medical setting, the nurse’s job is to recognize the problem in time to call for help, so that the physician can respond and the patient can be treated successfully. Sometimes, the call for help may not come in time for successful resuscitation. The results can be tragic — cardiac arrest, brain damage, even death. Hospitals track “Failure to Rescue” events that cause adverse patient outcomes as a Joint Commission and CMS standard for measuring quality in nursing care.

The fact is — anesthesia is dangerous. We have made huge strides in developing safer drugs and better monitoring techniques. But going under anesthesia — losing consciousness from the drugs we give — is really the same thing as inducing coma. Most anesthesia drugs have the potential to depress breathing, lower blood pressure, and decrease the function of the heart. Even regional anesthesia, using proven techniques such as spinal and epidural blocks, can cause major complications.

I can verify that even the most routine procedure — under sedation, regional block, or general anesthesia — has the potential to evolve into a crisis. Some days are completely routine, and some days I find I need every scrap of medical knowledge and experience I can bring to the problems my patients face.

Read the Full Article

7 COMMENTS

RMAU

“Our program is one of the oldest and longest running programs in the country, and over those years there has always been a culture of encouraging leadership development,” Rieker said. “We want our students to do something more than just provide anesthesia, such as stay on the path of leadership, embody professionalism and advocacy for the profession, and recognize their role as more than just serving patients in the hospital.”

Johnsnow

Dr. Sibert has a marvelous talent for translating "Medicaleeze" into "Everydaypeopleeze". Again herein proven. I hope she is planning to collect her writings into a book for "The Public". For the record: The status of CRNAs in the U. S. Armed Forces was accomplished by a series of command decisions by non-medical line officers. It was based on apparent cost, shortage of anesthesia physicians, and an inherent conflict between line officers and physicians of any specialty. There was never any consideration of the wisdom or a ...Read More

Read All 7 COMMENTS

X
¤