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Dialogue on the Future of Anesthesiology

Prielipp, Richard C. MD, MBA, FCCM*; Morell, Robert C. MD; Coursin, Douglas B. MD, FCCP; Brull, Sorin J. MD, FCARCSI (Hon)§; Barker, Steven J. PhD, MD; Rice, Mark J. MD; Vender, Jeffery S. MD, FCCM, FCCP, MBA#**; Cohen, Neal H. MD, MPH, MS††; Warner, Mark A. MD‡‡; Apfelbaum, Jeffrey L. MD§§

doi: 10.1213/ANE.0000000000000698
The Open Mind: The Open Mind

From the *Department of Anesthesiology, University of Minnesota School of Medicine, Minneapolis, Minnesota; Department of Anesthesiology, Twin Cities Hospital of Niceville, Niceville, Florida; Departments of Anesthesiology and Medicine, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin; §Department of Anesthesiology, Mayo Clinic College of Medicine, Jacksonville, Florida; Department of Anesthesiology, University of Arizona, Tucson, Arizona; Department of Anesthesiology, University of Florida College of Medicine, Gainesville, Florida; #Department of Anesthesia/Critical Care Services, NorthShore HealthSystem, Chicago, Illinois; **University of Chicago Pritzker School of Medicine, Chicago, Illinois; ††Department of Anesthesia and Perioperative Care and Medicine, University of California–San Francisco School of Medicine, San Francisco, California; ‡‡Department of Anesthesiology, Mayo Clinic, Rochester, Minnesota; and §§Department of Anesthesia and Critical Care, University of Chicago, Chicago, Illinois.

Accepted for publication January 22, 2015.

Funding: None.

Conflict of Interest: See Disclosures at the end of the article.

Reprints will not be available from the authors.

Address correspondence to Richard C. Prielipp, MD, MBA, FCCM, Department of Anesthesiology, B515 Mayo Medical Building, MMC 294, 420 Delaware St. SE, Minneapolis, MN 55455. Address e-mail to prielipp@umn.edu.

We are the authors of the paired “The Open Mind” articles in this month’s issue of Anesthesia & Analgesia.1,2 Eight issues emerged in the process of reviewing each other’s submissions. This article captures our dialogue around these issues during peer review.

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1. EMBRACING CHANGE

Prielipp et al.: The commentary by Warner and Apfelbaum2 seems to imply that we are against change. We most assuredly are not. We are advocating for change. It is the direction, scope, velocity, and magnitude of change that we would like all anesthesiologists to consider. We also advocate for a thoughtful and comprehensive assessment of the opportunities and implications for the specialty in a timely manner to position anesthesiology for a leadership role in health care in the future.

Warner and Apfelbaum: We agree that Prielipp et al.1 are advocating for change. We disagree on their recommended pace of change. As noted in our reply,2 the specialty is not broken. Indeed, the specialty of anesthesiology is currently quite successful. This gives us time to pilot and test potential practice changes. We are skeptical that major changes can occur by 2020 as Prielipp et al. recommend. It took 8 years to implement modest changes in residency training and incorporate more perioperative experiences. It took another 3 years to introduce the concept of the perioperative surgical home. Major changes as recommended by Prielipp et al. are unlikely to be implemented in the next 5 years.

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2. PERIOPERATIVE SURGICAL HOME DEVELOPMENT TIME

Prielipp et al.: The duration of development of a project does not intrinsically guarantee its validity or quality. Warner and Apfelbaum2 note that the American Society of Anesthesiologists (ASA), American Board of Anesthesiology, and the Accreditation Council for Graduate Medical Education have been working on the concept of the perioperative surgical home for 14 years. While we applaud this effort, the length of time invested does not make them correct nor our perspective incorrect. More significantly, it is important for us to assess why it has taken ≥14 years for the concepts defined within the perioperative surgical home to be adopted by anesthesiologists if we are to successfully expand practices beyond the traditional roles in perioperative care.

Warner and Apfelbaum: The beauty of a prolonged development period is that the key stakeholders (anesthesiologists, surgeons, nurses, administrators, and regulatory agencies) have time to review and comment on a proposal such as the concept of the perioperative surgical home. There is an advantage of having the luxury of time to consider, modify, implement, and test new concepts.

As we enter the second half of this decade, the progressive implementation of long-anticipated shared payment mechanisms such as bundled payments and Accountable Care Organizations now generates the financial impetus to trigger anesthesiologists to look carefully at various perioperative surgical home models and determine whether any might be advantageous or in some cases essential in their local environments.

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3. DISRUPTIVE INNOVATION

Prielipp et al.: We question whether the perioperative surgical home is a sufficiently disruptive innovation to produce higher quality at lower costs. As currently envisioned, the perioperative surgical home appears to be a reassignment of roles currently filled by surgeons, hospitalists, and others, including advanced practice nurses and physician assistants. The perioperative surgical home would transition a few members of the current anesthesia community to the role of a “perioperative physician.” This is likely a more expensive alternative than that currently in place and will likely be limited to a few leading academic medical centers or very large private practice institutions. A truly disruptive innovation must be more than taking charge of selected orthopedic, colorectal, or urology surgical patients and managing their pain while providing the kind of perioperative care that many of us have been delivering for years.

Warner and Apfelbaum: Medicine in general, and perioperative care specifically, has become increasingly fragmented during the past several decades. As has been thoroughly described in the literature, the perioperative surgical home goes well beyond management of postoperative pain. Sustained improvement through advances in monitoring, medication, and process standardization will result in modest incremental reductions in complications and expense. We believe (as do others who write in this specific volume of the journal)3–10 that the concept of the perioperative surgical home is different, even disruptive, and will have a much greater impact on patient outcomes and cost-effectiveness of perioperative care.

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4. FUNDING

Prielipp et al.: Support of anesthesiology (and all other approved residencies) graduate medical education training positions has been and continues to be capped by Medicare funding. Thus, departments and hospitals are already paying for large numbers of resident and fellow positions. Moreover, the extension of residency training could replace some fellowship time. Hence, if done correctly, this may not actually increase training duration or costs. Also, claims that “the authors fail to give readers thoughts on who would pay for the expansion of training”2 are disingenuous because there are no funding proposals in perioperative surgical home models. Hoping to get paid for “quality and access” is not a financial strategy.

Warner and Apfelbaum: It costs money to train residents, and the longer they train, the more it costs. Prielipp et al.1 recommend expanding residency training from 4 to 5 years. Yes, approximately one-third of current residents already spent an additional year in fellowship training. However, requiring the addition of a full year of training to the other two-thirds of residents will clearly be associated with additional expense in the form of an unfunded mandate. At this time, state and federal governments have not shown any inclination to increase funding for graduate medical education in nonprimary care specialties. Other funding support will be needed if mandatory training time expands by a year for all residents.

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5. DISTRIBUTION OF PROGRAM GRADUATES

Prielipp et al.: Regarding any hypothetical maldistribution of anesthesiology resident graduates, we note that 10 of the 35 programs (Table 3 in reference 1) with >1 million National Institutes of Health (NIH) dollars are in the midsection of the United States. Moreover, readers should recall that approximately 60% of the U.S. population resides east of the Mississippi River, and, similarly, 24 (68%) of the 35 listed NIH programs are east of that landmark. Our proposals would have no impact on the forces that dictate the current workforce distribution.

Warner and Apfelbaum: The majority of new anesthesiology residents in 2013 entered programs adjacent to the east and west coasts.a Programs in the remainder of the country tend to be smaller. Less than one-third of training programs have >$1 million dollars of annual NIH funding. Because Prielipp et al.1 suggest that there could be fewer training programs, primarily concentrated into those institutions that have greater research effort, it is likely that programs in the noncoastal parts of the country will be disproportionally affected by the potential contraction that they project. This may result in a maldistribution of anesthesiologists over time.

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6. SUBSPECIALTIES

Prielipp et al.: There is the assertion that anesthesiology has successfully developed pain medicine and critical care. If that were the case, why are we the only developed country where anesthesiologists are a minority of the workforce in critical care? Indeed, our footprint in critical care was much more significant in the past than it is today. In addition, anesthesiologists specializing in pain medicine have never seen more intense competition, which now includes a number of other medical specialties as well as nonphysician healthcare providers in some states.

Warner and Apfelbaum: We agree with Prielipp et al. that anesthesiology subspecialty practice in critical care and pain medicine competes with others.

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7. PRACTITIONER INPUT

Prielipp et al.: Although Drs. Warner and Apfelbaum2 credibly speak on behalf of a number of academic anesthesiologists and institutions, these groups are a minority of practicing anesthesiologists. We seek to hear all voices, including physicians who may currently be silent on these issues or who are not members of the ASA.

Warner and Apfelbaum: Ironically, although we practice in academic centers, we have both recently served as presidents of the ASA and, in that role, have heard from and represented all members, including the >80% who work in nonacademic practices large and small. The ASA House of Delegates, the majority of whom are private practitioners, has provided input into the development of the perioperative surgical home concept during the past decade and recently supported its further development by providing considerable funding of a perioperative surgical home learning collaborative. However, we agree with Prielipp et al. that ongoing input from all anesthesiologists and others who provide perioperative care is needed.

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8. NUMBER OF TRAINING PROGRAMS

Prielipp et al.: The Open Mind submission by Drs. Warner and Apfelbaum laments that we “. . . state that there will be a need for fewer anesthesiology graduates and training programs, presumably from the elimination of existing programs that they do not believe to be ‘highly resourced’ (e.g., those with <$1 million of NIH-funded research).”2 We made no such presumption. First, we recognize that the number of anesthesiology graduates now and in the future will be market-driven. The market may demand either fewer or more graduates. However, separately, we endorse the already established trend of limited research dollars being prioritized to centers with the best scholarly productivity because this academic competitiveness will drive future innovation.

Warner and Apfelbaum: Our views on the number of training programs and graduates are concordant.

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RECUSE NOTE

Dr. Sorin J. Brull is the Section Editor of Patient Safety for Anesthesia & Analgesia. The manuscript was handled by Dr. Steven Shafer, Editor-in-Chief for the Journal, and Dr. Brull was not involved in any way with the editorial process or decision.

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DISCLOSURES

Name: Richard C. Prielipp, MD, MBA, FCCM.

Contribution: This author created the concept, outline, and core content of the article and cowrote the manuscript.

Attestation: Richard C. Prielipp approved the final manuscript and attests to the integrity of the content in the original and referenced material.

Conflicts of Interest: Richard C. Prielipp is a member of the Executive Committee of Anesthesia Patient Safety Foundation and on the Board of Directors of that Foundation.

Name: Robert C. Morell, MD.

Contribution: This author helped create the concept, outline, and core content of the article and cowrote the manuscript.

Attestation: Robert C. Morell approved the final manuscript and attests to the integrity of the content in the original and referenced material.

Conflicts of Interest: This author has no conflicts of interest to declare.

Name: Douglas B. Coursin, MD, FCCP.

Contribution: This author helped create the concept, outline, and core content of the article and cowrote the manuscript.

Attestation: Douglas B. Coursin approved the final manuscript and attests to the integrity of the content in the original and referenced material.

Conflicts of Interest: Douglas B. Coursin is vested in Isomark, LLC, which is exploring a novel method to identify early life-threatening infection. This constitutes no cash value.

Name: Sorin J. Brull, MD, FCARCSI (Hon).

Contribution: This author helped create the concept, outline, and core content of the article and cowrote the manuscript.

Attestation: Sorin J. Brull approved the final manuscript and attests to the integrity of the content in the original and referenced material.

Conflicts of Interest: Sorin J. Brull is a member of the Executive Committee of Anesthesia Patient Safety Foundation (APSF) and is on the Board of Directors of APSF. Shareholder, ADBV, a medical device company with no connection to the contents or subject of this manuscript.

Name: Steven J. Barker, PhD, MD.

Contribution: This author helped create the concept, outline, and core content of the article and cowrote the manuscript.

Attestation: Steven J. Barker approved the final manuscript and attests to the integrity of the content in the original and referenced material.

Conflicts of Interest: This author has no conflicts of interest to declare.

Name: Mark J. Rice, MD.

Contribution: This author helped create the concept, outline, and core content of the article and cowrote the manuscript.

Attestation: Mark J. Rice approved the final manuscript and attests to the integrity of the content in the original and referenced material.

Conflicts of Interest: Mark J. Rice has served on several Roche Diabetes Care Advisory Boards.

Name: Jeffery S. Vender, MD, FCCM, FCCP, MBA.

Contribution: This author helped create the concept, outline, and core content of the article and cowrote the manuscript.

Attestation: Jeffery S. Vender approved the final manuscript and attests to the integrity of the content in the original and referenced material.

Conflicts of Interest: This author has no conflicts of interest to declare.

Name: Neal H. Cohen, MD, MPH, MS.

Contribution: This author helped create the concept, outline, and core content of the article and cowrote the manuscript.

Attestation: Neal H. Cohen approved the final manuscript and attests to the integrity of the content in the original and referenced material.

Conflicts of Interest: This author has no conflicts of interest to declare.

Name: Mark A. Warner, MD.

Contribution: This author helped prepare the manuscript.

Attestation: Mark A. Warner approved the final manuscript.

Conflicts of Interest: This author has no conflicts of interest to declare.

Name: Jeffrey L. Apfelbaum, MD.

Contribution: This author helped prepare the manuscript.

Attestation: Jeffrey L. Apfelbaum approved the final manuscript.

Conflicts of Interest: This author has no conflicts of interest to declare.

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FOOTNOTE

a ACGME Date Resources Book, 2013–2014, p. 116. Available at: https://www.acgme.org/acgmeweb/tabid/259/GraduateMedicalEducation/GraduateMedicalEducationDataResourceBook.aspx. Accessed March 1, 2015.
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REFERENCES

1. Prielipp RC, Morell RC, Coursin DB, Brull SJ, Barker SJ, Rice MJ, Vender JS, Cohen NH. The future of anesthesiology: should the perioperative surgical home redefine us? Anesth Analg. 2015;120:1142–8
2. Warner MA, Apfelbaum JL. The perioperative surgical home: a response to a presumed burning platform or a thoughtful expansion of anesthesiology? Anesth Analg. 2015;120:1149–51
3. Mariano ER, Walters TL, Kim TE, Kain ZN. Why the perioperative surgical home makes sense for Veterans Affairs health care. Anesth Analg. 2015;120:1163–6
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5. Kain ZN, Hwang J, Warner MA. Disruptive innovation and the specialty of anesthesiology: the case for the perioperative surgical home. Anesth Analg. 2015;120:1155–7
6. Goeddel LE, Porterfield JR Jr, Hall JD, Vetter TR. Ethical opportunities with the perioperative surgical home: disruptive innovation, patient-centered care, shared decision making, health literacy, and futility of care. Anesth Analg. 2015;120:1158–62
7. Shafer SL. Anesthesia & Analgesia’s 2015 collection on the perioperative surgical home. Anesth Analg. 2015;120:966–7
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© 2015 International Anesthesia Research Society