Practice without fear

25th October, 2020

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.

Anesthesiology residents today are well advised to specialize. Do a fellowship year or two. Pursue advanced training in clinical research if that’s what you enjoy. Consider working toward a PhD. There are other alternatives as well: advanced degrees such as a master’s in public health, business administration, or hospital administration. The days are over when it was enough to learn to deliver anesthesia competently in order to get a decent job. We need to do more to establish our value beyond simply putting patients to sleep and waking them up. Set yourself apart from midlevel practitioners, or you’ll find yourself classified as a “provider” – an equivalent pawn on the OR chessboard. Make your skillset unique, and your services indispensable to your hospital or your group.

Don’t be afraid to act like a physician

In a remarkable JAMA column written in 2012, Ezekiel Emanuel, MD, PhD, one of the architects of the Affordable Care Act, recommended shortening medical school to three years. His argument: less medical education would “enable physicians to use evidence more effectively to improve care; and enable physicians to become comfortable with group decision making, standardization of practices, task shifting to nonphysician providers, and outcomes measurement.”

Obviously, Dr. Emanuel’s advice is a trap. As a champion of protocols and cookie-cutter medicine, he wants physicians to be afraid to defy a care protocol even if they are convinced it would be in the individual patient’s best interest. Standardization of practice works best for a single procedure such as central line insertion, or a patient who has only one medical problem. What if your patient has more than one medical condition with conflicting protocols?

As Dr. David L. Sackett wrote in a landmark article in the British Journal of Medicine, the unthinking application of evidence-based medicine may make it a “dangerous innovation, perpetrated by the arrogant to serve cost-cutters and suppress clinical freedom.” Instead, what it should be is the integration of  “the proficiency and judgment that individual clinicians acquire through clinical experience and clinical practice” and “the best available external clinical evidence from systematic research.”

Best practice or “groupthink”?

Groupthink is defined as a phenomenon that occurs when a group of individuals reaches a consensus without critical reasoning or evaluation of the consequences or alternatives. Unfortunately, “any dissenters in the group who may attempt to introduce a rational argument are pressured to come around to the consensus and may even be censored.” This is exactly what can happen when adherence to clinical protocols becomes the benchmark of quality care.

Let’s look at a real-life example. In the 1990s we were told that every patient with any risk factor for coronary disease must receive perioperative beta-blockade, and compliance was measured as a quality indicator. Unfortunately, much of the evidence behind the recommendation was fraudulent. Upon further investigation, aggressive perioperative beta-blockade was associated with higher rates of hypotension and stroke in the POISE trial. The eminent lead author of many dubious articles cited as evidence for aggressive beta-blockade – Dr. Don Poldermans – eventually was fired from his leadership positions.

Many of us didn’t buy into the beta-blocker hype in the first place. I can remember documenting the administration of 1 mg of IV esmolol in non-cardiac cases so that the chart would be compliant with a nonsensical dictum mandating a beta-blocker. Time proved that resistance was the right call.

A similar argument can be made with regard to antibiotic administration. Too often, a vague history of penicillin allergy will lead the anesthesiologist to withhold cefazolin, the indicated antibiotic for prophylaxis in many cases, and give a drug with a far worse safety profile such as clindamycin or ciprofloxacin. Cefazolin, unique among the cephalosporin antibiotics, has no cross-reactivity with penicillin. Yet when questioned about the choice, the anesthesiologist’s reply may be: “Well, that’s what the surgeon wanted.” That attitude automatically establishes the surgeon as the boss, and may lead to a worse outcome for the patient. How is that acceptable?

Trust your instincts, and be kind

The feeling of powerlessness is thought to be a key factor leading to physician burnout. Fortunately, we are not powerless yet. Nothing is stopping us (at least today) from exerting the clinical decision-making ability we have as physicians. It’s best never to make a decision for fear of criticism after the fact. If the case goes badly, you’ll be criticized no matter what you did. When it goes well, you’ll know you made the right call, even if few others know about it or acknowledge it.

Be kind. Look, for example, at the protocols for enhanced recovery after surgery (ERAS). They often recommend withholding benzodiazepine premedication. But if your patient is facing surgery that may be disfiguring or disabling, giving a benzodiazepine may be the kindest thing you can do for that patient. Trust your instincts, and forget the protocol.

Patients in my personal experience have described prior awake fiberoptic intubations as “torture” and “like being water-boarded”. Was that necessary? Couldn’t adequate sedation have been provided? With today’s video laryngoscopy equipment, unless the patient has a full stomach and an unstable cervical spine, how often is awake fiberoptic intubation the only reasonable alternative? Consider the patient’s point of view.

When we are consciously kind to our patients, we feel better about ourselves as physicians and human beings. Understand the science behind care protocols, but never be afraid to individualize the care of the patient in front of us.

My top three predictions

Here is what I see in my crystal ball — those of you who are in practice 20 or 30 years from now will have a chance to see how right or wrong these optimistic, best-case predictions turn out to be.

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

We’ll no longer insist that every program train every resident with exactly the same cookie-cutter requirements. Academic residency and fellowship programs will develop different tracks and specialize 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 care teams. 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 clinical 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 every episode of care that includes an interventional procedure. The current rigid supervision ratios and definitions will no longer apply. There’s no point in disparaging “zone” models of OR coverage. Think of them as comparable to how intensive care units operate.

Technology will redefine delivery of care

Operating suites will have command centers where multiple rooms can be viewed and monitored simultaneously. 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 for success, we can bring the joy back to the practice of anesthesiology. The alternative isn’t pretty.

5 COMMENTS