Posts Tagged ‘Disruptive innovation’

Nurses argue that they can perform many hands-on tasks of anesthesia care just as well as we can. So why are we still doing those tasks?

As we orient our brand-new, fresh-faced CA-1 residents to the operating room each year, I ask this question. Has anyone explained to them that much of what they’ll need to learn in the first couple of months is how to be a nurse?

We watch them struggle to draw up propofol into a syringe without spraying white foam all over themselves. We emphasize the critical difference between a surgeon’s order of 5000 units of heparin to be given SQ or IV. We teach residents how to inject medications into line ports using sterile technique, how to label a syringe correctly, and how to chart IV fluids and urine output.

Is this why they went to medical school?

Before a mob assembles with torches and pitchforks, let me be clear: there is much more to learn beyond these nursing and pharmacy tasks on the road to becoming a qualified anesthesiologist. But why are we still doing these tasks when other physicians don’t do likewise?

Do our intensivist colleagues mix up and inject antibiotics? Do our cardiology colleagues load infusion pumps with potassium or magnesium drips? Of course not. That would be a waste of their time and education.

It’s time to redesign anesthesia care delivery. We should be charting the course, not executing every change of sail. We should be performing the diagnostic and intellectual work of physicians all the time, not just some of the time. If we don’t, we shouldn’t be surprised if we continue to lose control over the future of our profession. It’s way too expensive to pay a physician to do the tasks of a nurse.

How did we get here?

Let’s look all the way back to the second half of the 19th century, when the use of ether, chloroform, and nitrous oxide for surgical anesthesia spread rapidly. During the American Civil War, according to medical historian Shauna Devine, PhD, “Union records show that of more than 80,000 operations performed during the war, only 254 were done without some kind of anesthetic.” Most often, the anesthetic was chloroform. “The practice was for the operating physician’s assistant to place the chloroform on a piece of cotton or towel, which had been fashioned into a cone, and then placed over the patient’s nose and mouth, preferably in the open air.”(1)

Nurses or surgical assistants gave many of these anesthetics; most American physicians weren’t interested. One notable exception in the early 20th century was Ralph Waters, MD. He described his experience starting general practice in Sioux City, Iowa, in 1913:

“A few more or less full-time surgeons, who were looked upon as specialists, employed nurses to administer ether in the mornings at hospitals and act as office nurses in the afternoons. A majority of us, ‘occasional’ surgeons, depended upon each other to act as anesthetist as occasions demanded, or sometimes we ‘borrowed’ the nurse-technician of one of our more glamorous surgical colleagues.”(2)

Outcomes were variable and sometimes tragic. A true scientist, Dr. Waters devoted the rest of his career to anesthesiology, joined the faculty of the new medical school at the University of Wisconsin in 1927, and founded the first anesthesiology residency program. However, the model of anesthesia care delivery as the practice of nursing by then was well established in America. It took decades for academic anesthesiology programs to proliferate in the U.S., but the model in America continued to be one person at the bedside, giving medications and monitoring the patient – and that person could be either a physician or a nurse.

Practicing at the top of my license?

In a fascinating ASA Monitor article a few years ago, authors Marc Steurer, MD, DESA, and Michael Ganter, MD, DESA, examined differences in the delivery of anesthesia care in the U.S. compared with Europe. Among the chief disparities:

1. “Most European countries mandate two professionals to provide anesthesia (physician and assistant, e.g., certified registered anesthesia nurse): this means that an anesthesiologist and an assistant are both present during all critical events of the anesthesia (e.g., induction and emergence). In contrast, in the U.S., the anesthesia physician may provide anesthesia alone without a trained assistant.”

2. “In most western European countries, the clinical anesthesiologist is more longitudinally involved in patient care…Not only do anesthesiologists govern the prehospital portion of emergency medicine, but also once the intrahospital care begins. Together with the primary team, an anesthesiologist is usually involved in the care of the most ill medical and surgical patients in the hospital. Also in those settings, the anesthesiologist stays with the patient for the entire critical period and provides a very helpful continuum of care. In Europe there is also a heavy involvement of anesthesiologists in both medical and surgical ICUs. Additionally, operation room (O.R.) management, preoperative and pain clinics as well as services for palliative care have been a mainstay for even small anesthesia departments for a long time. This contrasts to most U.S. practices, where anesthesiologists have predominantly focused on the intraoperative and critical care period. The broader and more longitudinal scope of practice positions European colleagues well for the development of the field.”(3)

Very interesting. These European anesthesiologists are functioning as physicians.

As an American anesthesiologist, on the other hand, I am not practicing anywhere near the top of my license much of the time. There’s satisfaction in seeing all my syringes neatly labeled and lined up in a row, but is that how I should be using my time, energy, and education? Checking the circuit and filling the vaporizer? Our residents are expected to fetch their patients in the preop holding area and – single-handedly – push the gurneys down the hall to the operating rooms, no matter how large the patient or how small the resident. No doubt they feel that their average $200,000 in medical school debt is worth it in job satisfaction, and that being a physician is all they hoped it would be.

The ICU model of care

We need to do a total restructure of procedural care to function along the same lines as ICU care, where physicians direct the care of multiple patients. Pharmacists and registered nurses – sedation nurses and critical care nurses – could be involved as part of a cost-effective bedside care team, flexing the composition of the team to the complexity of the case. Cardiologists, GI and ER physicians supervise RNs giving sedation; why don’t we?

With today’s technologies, it’s possible to monitor multiple sites at the same time. I don’t have to stay tethered to my patient with a plastic earpiece and a length of IV tubing to listen for breath sounds. (Raise your hand if you’re old enough to remember those days.) Physicians who specialize in anesthesiology can be freed up to do actual physician work, putting our medical diagnostic skills to use and functioning as team leaders, not as pawns on the OR chessboard interchangeable with nurse anesthetists in the view of too many hospital administrators.

As American healthcare moves away from fee-for-service payment into a model of giving total care to populations, which appears inevitable, we have an opportunity to redesign anesthesiology. We don’t have to be bound by 1:4 ratios and other arbitrary rules tied to submitting bills for specific services to third-party payers.

We can figure out how to provide the right care to each patient at lower cost. We can allow anesthesiologists to function as doctors of medicine all the time, not just when there’s a crisis or when we’re not busy doing bedside nursing tasks in the operating room.

To me, that sounds like a far better job description.

              (Author’s note: This commentary was first published online in Anesthesiology News on September 8, 2021.)

___________________________________________

1. Devine S. Chloroform and the American Civil War: The art of practice and the science of medicine. PBS: Mercy Street Blog; online publication Feb 22, 2016. Accessed June 13, 2021.

2. Gillespie N. Ralph Milton Waters: A brief biography. British Journal of Anaesthesia: Vol 21 Issue 4, April 1949; 197-214. https://doi.org/10.1093/bja/21.4.197

3. Steurer M, Ganter M. Comparison and contrast of anesthesia practice in Europe and the U.S. ASA Monitor: December 2015, Vol 79; 18-20.

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.

Read the Full Article

Elegy for giant conventions

ANESTHESIOLOGY 2019 may have been the last old-school, convention-size, professional meeting I will ever attend. I could be wrong, but it may mark the end of an era. Disruptive change to the convention business model was inevitable, though hastened by COVID-19. On June 5, ASA leadership announced that the 2020 annual meeting will be virtual — for the first time, but perhaps not the last. Does this news herald disaster or opportunity?

When I was a resident attending my first ASA annual meeting, the huge convention center struck me as the mother lode of anesthesiology knowledge, with lectures and workshops that couldn’t be found anywhere else. Today, I wonder why I would travel across the country to attend a refresher course lecture in a freezing-cold meeting room, when I can watch similar content on YouTube or VuMedi for free, in comfort?

Professional associations could take this moment to move decisively into the video/podcast market. Speakers could record their own lectures, pro-con debates, and panel discussions, and societies like ASA and CSA could post all the content on proprietary video and podcast channels for members to access year-round. Think of the money we could save in travel and the cost of renting convention centers. Giant conventions at the ASA level are limited to only a few cities, most of which wouldn’t be my choice to visit.

The future of exhibit halls?

Corporate interest in buying exhibit space at anesthesiology meetings was fading fast, even before COVID-19. Why pay to send people and equipment to exhibit halls when mergers and acquisitions have centralized all the purchasing power? As recently as ten years ago, many anesthesiologists were able to influence which laryngoscopes or epidural kits their departments would order. Today, people who negotiate purchasing contracts typically work in the central offices of health systems, not in operating rooms. Today, most of us can do little more than complain about our inadequate stock of video laryngoscopes or the maddening electronic health record we’re compelled to use.

Read the Full Article

Tech entrepreneur Josh Linkner gave the keynote speech at this year’s ASA annual meeting in San Francisco, delivering a rousing talk designed to leave the audience inspired with a can-do attitude and new hope for the survival of anesthesiology as a profession.

It should be a good talk; Mr. Linkner clearly has given it plenty of times. According to national speakers’ bureaus, the 48-year-old “innovation and creativity speaker” and “New York Times bestselling author” charges from $30,000 to $50,000 a pop for his keynote addresses, and guarantees a “fast-moving and entertaining” experience for listeners with “real takeaway value.”

So what did we get for our money?

We learned from Mr. Linkner about five “big ideas” that he believes are the keys to driving innovation in any field:

Every barrier can be penetrated

Video killed the radio star

Change the rules to get the jewels

Seek the unexpected

Fall seven times. Stand eight.

Read the Full Article

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.”

Read the Full Article

X
¤