Posts Tagged ‘Anesthesiology’

If you think about scope-of-practice creep at all, you may think immediately of the advocacy efforts so many physicians have made to preserve physician-led care and discourage independent practice by nurse anesthetists or physician assistants.

You may not have paid as much attention to the current momentum to grant independent practice to nurse practitioners, or NPs, nationwide.

In addition to the District of Columbia, 28 states allow NPs full practice authority to treat and prescribe without formal oversight. Half of these states grant NPs full practice authority as soon as they gain their licenses; the other half allow it after the NP practices with physician oversight for a period of time.

My home state, California, is one of the states that has always required physician oversight. Last fall, however, Governor Newsom signed a bill, Assembly Bill 890, that will allow NPs to practice independently after they have completed a three-year transition period, practicing under physician supervision.

That was when I started to worry.

Preop assessments that make us laugh or cry

No doubt everyone who practices anesthesiology or surgery has encountered preoperative medical assessments, H & Ps, or “clearance” notes that have been so far off the mark they’re laughable. I’m not just talking about the three-word “cleared for surgery” note scrawled on a prescription pad. I recall in particular:

A consultation at a VA hospital that “cleared” my cirrhotic patient with massive ascites and coagulopathy for his inguinal hernia repair under spinal anesthesia but not general.

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Is it time to unionize?

Remember the dark days of the pandemic in March and April, when the true risk of caring for COVID patients started to become clear?  Remember when you could be censured by a nursing supervisor or administrator for wearing a mask in public areas lest you frighten patients or visitors?

Right around then, a third-year resident at UCLA decided to wear a mask wherever he went in the hospital, as testing wasn’t readily available yet for patients, and visitors still had full access. Someone with a clipboard stopped him and said he couldn’t wear a mask in the hallways. The resident politely responded that yes, he could. Why? Because his union representative said so. The discussion ended there.

The resident enjoyed backup that his attendings lacked because all UCLA residents are members of the Committee on Interns and Residents/SEIU, a local of the Service Employees International Union (SEIU). This union represents more than 17,000 trainees in six states and the District of Columbia.

As CMS threatens further pay cuts for anesthesiology services and other third-party payers are likely to follow suit, many attending anesthesiologists are asking:  Why can’t we form a union? Alternatively, why can’t the ASA function like a union and negotiate on our behalf?

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Practice without fear

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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How are two-career households with children — let alone single-parent households — going to manage with daycare centers and schools closed, perhaps for a long time to come? What damage will this do to career progress and earning potential if one parent must cut back on work? Will childcare demands inevitably delay or derail partnership or academic promotion?

When I was a young mother — my two youngest children are only 17 months apart — life revolved around childcare arrangements. As newly fledged attendings, my husband and I both wanted to practice full time, and with the confidence of youth we assumed we could make it work. For a time, we had a live-in nanny. As the babies turned into children old enough for school, we still needed a full-time nanny for drop-off, pick-up, and the days when the kids were sick and needed to stay home. We accepted the fact that a third or more of our joint income would be spent on childcare and other support services so that we could both keep working as physicians and stay sane.

But what if there had been no school?

Today, it’s hard to fathom the impact that the COVID-19 pandemic is having on families trying to find solutions to their childcare needs with the closure of private and public schools alike. Who’s going to watch, let alone educate, the kids? A nanny, no matter how conscientious and loving, may not be a good educator. When one parent has to work less in order to supervise learning at home, often that job falls to the mother. What happens to her career?

The vicious downturn cycle

As of early July, the Census Bureau estimates that half of American adults live in households that lost job income this spring. Many anesthesiologists lost income too during the periods in March and April when elective surgery in many states went on hiatus to keep beds open for COVID-19 patients.

In California, the CSA surveyed members and found that 74% reported experiencing financial hardship this spring, with medium and small private practices faring worse than academic departments. There was no overall difference in perceived economic hardship between men and women in anesthesiology, though women reported being furloughed or given involuntary vacation more often than men: 41% vs. 26% of survey respondents.

When people lose their jobs or work remotely, demand for childcare services plummets. The National Association for the Education of Young Children reports that on average, enrollment in childcare centers is down by 67%. Many that were operating on a slim margin have already gone out of business. The centers that remain open to serve essential workers are facing huge additional expenses for staff, PPE, cleaning supplies, and duplicate equipment and toys to allow cleaning after each use. At least 40% of the remaining childcare centers are likely to go out of business unless significant government assistance arrives soon. People trying to return to work after lockdown — in anesthesiology or any other field — are having trouble finding high-quality early childcare.

“It’s much harder for me to find safe childcare to be able to work,” said one woman anesthesiologist in a private conversation. Another in academic practice commented, “It’s very stressful for the mom!” A third woman is worried because her current au pair leaves in August but the new one may not be able to enter the country due to the hold on visas.

Many of us assumed optimistically that the school closures of the spring would be short-lived, and that September would mark the end of “learning from home”. That doesn’t appear likely. California’s Governor Newsom announced on July 17 that most California public and private schools will not reopen when the academic year begins.

In some states, elite private schools have more latitude to reopen than public schools as they can afford to reduce class size and adapt to strict infection control regulations recommended by the CDC. But many private religious schools that serve less wealthy families were in financial trouble even before the full effect of the pandemic hit. The Roman Catholic Boston archdiocese, for example, has already shuttered 10% of its schools permanently. No one knows yet how many students actually will be able to return to school this fall.

Even if schools reopen where state government permits, it isn’t clear that teachers will agree to return to work. In a July 19 New York Times op-ed, a teacher wrote that she is willing to take a bullet for her students, but exposing herself and her family to COVID-19 would be like asking her to take that bullet home. “It isn’t fair to ask me to be part of a massive, unnecessary science experiment,” she wrote. “I am not a human research subject. I will not do it.”

In anesthesia, you can’t “phone it in”

What are women in anesthesiology going to do if schools don’t reopen? If your job is purely administrative, or you can run a preop clinic using telemedicine, you might be able to work remotely. But you can’t “phone it in” if your job is delivering anesthesia to humans.

“I don’t see how this school year is going to work,” said one woman anesthesiologist. “It’s a hot mess.”

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It’s early May in Los Angeles, and dystopian reality is here – storefronts boarded up; people (if they’re out at all) wearing sinister-looking black facemasks. Inside the hospital, everyone wears a mask all the time, no one gathers in clusters to chat, and even the tail-wagging therapy dogs must be sheltering at home because they’re nowhere to be seen.

One change I didn’t see coming was a metamorphosis in airway management.

Guidelines developed for the intubation of COVID-19 patients are evolving into the new normal whether a patient is infected or not. This is even more remarkable since anesthesiologists consider ourselves experts in airway management, and many of us (how can I put this kindly?) hold firmly to our opinions. Who would have thought old habits could change? But airway management this year is different and scarier. Remember when we didn’t think of it as hazardous duty?

Who still “tests” the airway?

Consider the question of whether to “test the airway” before giving any neuromuscular blocker (NMB) during a routine anesthesia induction. Some of us believe that it offers a measure of safety, because you can back out and wake the patient up if you can’t ventilate. Those (like me) who don’t do it quote studies that demonstrate more effective mask ventilation with larger tidal volumes after NMB, and point out that if you can’t ventilate, most people will give NMB anyway.

That controversy seems to have gone into hiding. Today, the guidelines for intubating a patient with proven or suspected COVID-19 recommend rapid-sequence induction (RSI) to reduce the risk of the patient coughing and spraying the area with aerosolized coronavirus. No one in that situation seems worried about testing the airway.

What about the patient who is asymptomatic, and has a recent negative COVID-19 test result? There is legitimate concern that the patient could still be in the early, asymptomatic stage of infection, and the incidence of false negative results from COVID-19 testing could be as high as 30%. By that logic, we should treat every patient as a PUI, and perform RSI on all comers. It would be interesting to survey anesthesia professionals and see how many now perform RSI as their default approach. Certainly, residents now ask me on nearly every case if the plan is RSI, and I hear from colleagues at other institutions that my experience isn’t unique.

What about extubation?

If we don’t want coughing on intubation in the era of COVID-19, logically we wouldn’t want it on extubation either. Awake extubation, especially in the hands of novices, can include an alarming display of coughing and struggling by the patient, accompanied by cries of “Open your eyes! Take a deep breath!” by the person at the head of the table. More coughing follows as the tube comes out. In contrast, a recent review article on the care of COVID-19 patients advises removing the endotracheal tube “as smoothly as is feasible”. For our colleagues in the United Kingdom who are accustomed to deep extubation, this is routine. In America, it isn’t.

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