Author’s Note: This is the text of the Leffingwell Honorary Lecture delivered at the annual meeting of the California Society of Anesthesiologists on April 9, 2022. Slides are available on request.

It is truly an honor to be here, and I want to thank Dr. Ronald Pearl and the California Society of Anesthesiologists for your kind invitation to speak.  I was quite surprised to receive it.  I’m neither a department chair nor an eminent researcher.  I find the concept of being a “thought leader” or an “influencer” frankly horrifying. Physicians aren’t sheep, and we don’t need to be led to think.

What I am is a well-trained writer. I owe that to my college professors and my editors at the Wall Street Journal, who were pitiless with their red pencils and equally quick to point out poor writing, or sloppy thinking, or both.

Since I never wanted to become a department chair, or a politician, or ASA President, I haven’t hesitated to say what I think about the sad state of healthcare – or really, anything else. I mean, if no one disagrees with you, have you said anything worth hearing?

Alexandr Solzenitsyn was right: “Truth seldom is pleasant; it is almost invariably bitter.” You may not agree with some or any of the ideas I’m going to talk about today, but if that’s the case, I hope you’ll be inspired to come up with better ones! I’m going to zero in on some of the hard truths about our profession and offer some thoughts about what we can and perhaps should do going forward.

Now I’ve never for a moment regretted becoming a doctor. I wanted to be a doctor since I was a kid and read a book my father gave me, published in 1960, called “All About Great Medical Discoveries.”  It had a horrifying and yet fascinating chapter about how terrible surgery was before anesthesia was invented, and how anesthesia made modern surgery possible.

In the 40 years – yes, 40 years — since I graduated from medical school, I’ve never regretted going into anesthesiology. It’s a wonderful field. We have the honor of being with patients and safeguarding them through some of the most critical moments in their lives.

There are amazing young people entering our field, I’m happy to say, so from that point of view, the future is promising.  In this year’s match, I believe there was only ONE unfilled position. But there are storms and riptides threatening our profession, and that is why we need – urgently – to rethink, redesign, and reimagine the practice of anesthesiology.

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Today’s noteworthy definitions, not new but often ignored:

1. Unintended consequences: The principle stating that an intervention in a complex system tends to create unanticipated and often undesirable outcomes.

2. Good intentions: The paving stones of the road to hell.

In anesthesiology, these precepts should be kept firmly in mind in our attempts to improve “quality”. Anyone who speaks out against measures that are taken under the banner of improving “quality of care” or “patient safety” risks coming across as reckless, heartless, or both. Yet the pursuit of “quality” in healthcare has a track record of implementing changes and policies that haven’t been subjected to any rigorous scientific study, in effect “prioritizing action over evidence.”

Quantitative neuromuscular monitoring

In anesthesiology, we love our gadgets. We especially like gadgets that generate numerical values we can track. It’s no wonder that quantitative nerve stimulators measuring thumb movement via acceleromyography are gaining in popularity. They give us a ratio of neuromuscular recovery that we can document and trumpet as evidence of high-quality care, blessed by the Anesthesia Patient Safety Foundation (APSF) in its most recent recommendations for patient monitoring.

A recent review article in Anesthesiology concluded that “the use of quantitative monitoring may reduce the risk of hypoxemic events and episodes of airway obstruction in the PACU, decrease the need for postoperative reintubation, and attenuate the incidence of postoperative pulmonary complications.”

Note the use of hedging verbs such as “may” and “attenuate”. The authors, Drs. Murphy and Brull, are not claiming that the use of quantitative nerve stimulators should be considered an absolute standard of care or a guarantee of improved outcomes. That’s because they are scientists and understand the hazards of confusing association with causation.

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This article, with advice for residents about the future of anesthesiology, was published first in the October 2020 issue of Anesthesiology News

You may be weary of being told that our profession is facing a time of unprecedented threat – from third-party payers, from the government, from non-physician practitioners. You’ve heard it so often that your brain is tuning it out. Is the threat level exaggerated for dramatic effect? Is it better just to go on with your day and not think about it at all?

That would be a mistake. The real question is:  How should we deal with the upcoming “market adjustment” that almost certainly will result in lower anesthesiologist compensation? In the face of gloomy reality checks, how can we promote pride in our profession and recruit the best medical students? How can we continue research that will reduce risk and improve outcomes? How do we avoid becoming irrelevant or extinct, like Kodak, Xerox, Sears, and now Hertz? It’s time to face the future.

The threats are real

Unfortunately, the “unprecedented threat” claim is all too real. Department chairs everywhere  worry that they will not be able to maintain the compensation rates that anesthesiologists have enjoyed up to now. Why?

The Medicare Trust Fund is expected to become insolvent as soon as 2024. The chair of the Medicare Payment Advisory Commission (MedPAC), Michael Chernew, PhD, recently commented, “We are very dedicated to finding payment models to promote efficient delivery of care.” No one could possibly think this will mean anything other than lower payments to physicians.

Scope-of-practice expansion is gaining ground. On March 30, CMS issued an array of “temporary” waivers and new rules, waiving the requirement that a nurse anesthetist must work under the supervision of a physician. How likely are these new rules to be reversed under a new administration, whether Republican or Democratic? Whether or not you live in an “opt-out” state may not matter in the near future.

Hospitals were in trouble even before the COVID-19 pandemic. Many have gone bankrupt; others are merging with larger health systems. At present, around 80% of hospitals subsidize their anesthesiology departments to the tune of millions of dollars each year. Realistically, can these subsidies continue? Probably not. Will hospital administrators seriously consider cheaper staffing models for delivering anesthesia care? Probably yes.

Make yourself indispensable

First, it would be wise to assume that a downward “market adjustment” to anesthesiologist compensation is coming. Plan for it now. Stop yourself from spending to the full extent of your income, and put away all you can in a tax-deferred retirement account.

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A true allergic reaction is one of the most terrifying events in medicine. A child or adult who is highly allergic to bee stings or peanuts, for instance, can die within minutes without a life-saving epinephrine injection.

But one of the most commonly reported allergies — to penicillin — often isn’t a true allergy at all. The urgent question that faces physicians every day in emergency rooms and operating rooms is this:  How can we know whether or not the patient is truly allergic to penicillin, and what should we give when antibiotic treatment is indicated?

It’s time for us to stop making these decisions out of fear, and look squarely at the evidence. Withholding the right antibiotic may be exactly the wrong thing to do for our patients. Here’s why.

Can’t we just prescribe a different antibiotic?

When we hear that patients are “PCN-allergic”, we’ve been trained from our first days as medical students to avoid every drug in the penicillin family. We’re also taught to avoid antibiotics called “cephalosporins”, which include common medications like Keflex. This is because penicillin and cephalosporin molecules have some structural features in common, raising the odds that a patient allergic to one may also be allergic to the other.

What does it matter? Can’t physicians just prescribe a different antibiotic?

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For several years now, I’ve been the social media curmudgeon in medicine. In a 2011 New York Times op-ed titled “Don’t Quit This Day Job”, I argued that working part-time or leaving medicine goes against our obligation to patients and to the American taxpayers who subsidize graduate medical education to the tune of $15 billion per year.

But today, eight years after the passage of the Affordable Care Act, I’m more sympathetic to the physicians who are giving up on medicine by cutting back on their work hours or leaving the profession altogether. Experts cite all kinds of reasons for the malaise in American medicine:  burnout, user-unfriendly electronic health records, declining pay, loss of autonomy. I think the real root cause lies in our country’s worsening anti-intellectualism.

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