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In Response

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, MS

doi: 10.1213/ANE.0000000000000957
Letters to the Editor: Letter to the Editor
Free

Department of Anesthesiology, University of Minnesota Medical School, Minneapolis, Minnesota, prielipp@umn.edu

Department of Anesthesiology, Twin Cities Hospital of Niceville, Niceville, Florida

Department of Anesthesiology, 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, Vanderbilt University School of Medicine, Nashville, Tennessee

Department of Anesthesia/Critical Care Services, NorthShore HealthSystem, University of Chicago Pritzker School of Medicine, Chicago, Illinois

Department of Anesthesia and Perioperative Care and Medicine, UCSF School of Medicine, San Francisco, California

We acknowledge the consternation of Lydon1 and respect his opinion about our recent publication on the “Future of Anesthesiology.”2 However, we must clarify that we are not promoting any specific care model but rather are encouraging an overall reassessment of the total value proposition of current anesthesia practice and education as we endeavor to address patient safety, quality, and ensure patient access in the evolving healthcare markets. We would like to clarify these additional components of our recommendations:

  1. First, we are not advocating for independent practice for certified registered nurse anesthetists, any other advanced practice registered nurses, or anesthesiologist assistants. At the same time, we must acknowledge that 24 states, the District of Columbia, and the Commonwealth of Northern Mariana Islands already allow independent certified registered nurse anesthetist practice (in some cases even including pain management).3 The rationale for independent nursing practice is generally justified based on assumed lower cost and improved access. Although these reasons for expanding practice for nonphysicians working without medical supervision may not be justifiable, we also recognize that Lydon’s hope for robust and convincing outcome data will likely never be realized. We agree that physician supervision and physical presence for all critical portions of each case and immediate availability to manage emergent issues are important elements of anesthesia care. We may not have formal studies to document the higher quality and safety of the supervised model of care, but we agree that physician oversight is important for our patients. At the same time, we may need to identify other issues that support the value of continued physician supervision, including the implementation of new models of care, use of technology, and other methods to ensure ongoing assessment and immediate availability based on clinical needs both within and outside the traditional operating room environment.
  2. Second, and in part to address the issues outlined earlier, we believe that coverage ratios should be flexible, dynamic, and predicated on the complexity of the patient, the operation, and the environment. We viscerally believe that, “anesthesia is the practice of medicine,” but we are also sufficiently realistic that we can envision one anesthesiologist supervising 10 (or more) endoscopy suites at the same time and in a safe manner using more creative and innovative ways to provide supervision, guidance, and ensure immediate availability of a qualified physician. In other circumstances, the coverage might be 1:2 to 1:4, depending on the clinical demands, anesthetic circumstances, and experience of the anesthesia care team. Of course, for the most clinically demanding patients, personal physician-delivered anesthesia care will continue to be the most appropriate model of care.
  3. We are not suggesting that our proposed multifaceted model delivers better quality than do the current ratios nor do we accept a priori that it delivers a lower quality. We are suggesting that there might be a better societal value proposition that balances quality and cost. Current Medicare reimbursement rates for anesthesia services—“the 30% problem”—has been and continues to be a drag on the profession. Despite massive advocacy and years of lobbying efforts, this rate is little changed. To move forward effectively, and in an economically viable way, necessitates some disruption of the status quo. The ability to provide appropriate care at lower cost must be a goal and must also be done without compromising safety or quality of care to any of our patients.
  4. Nothing in our proposal undermines the importance of physician supervision of anesthesia providers, but we are unaware of any unequivocal or unbiased data to suggest substantially different outcomes while an anesthesiologist with concurrency ratios of 1:2, 1:3, or 1:4 medically directs anesthesia providers. Indeed, there are some data to suggest that the anesthesia care team might be safer than physician-only delivered care.4 A profound question we pose is how far can, and should, one extrapolate these observations while exploring future options and as we consider alternative staffing options?
  5. We must also recognize that our ability to provide safe anesthesia has been greatly enhanced over the past 3 decades. Safer drugs, better monitoring, instant communication, better preoperative screening, and less invasive surgical techniques all contribute to reduced complications and improved outcomes. These improvements in care and outcomes allow us to reevaluate our staffing practices while maintaining the commitment to high quality and safe anesthesia care.
  6. We also draw a parallel to the intensive care unit, where we and other anesthesia-trained intensivists simultaneously care for 12 to 20 critically ill patients using a variety of physician extenders deployed based on the needs of various patients—from registered nurses to advanced practice registered nurses to physician assistants to physician trainees. Perhaps, there are some lessons learned from this model of supervision that can be extrapolated to other clinical environments without undermining the importance of physician supervision.
  7. Technology can and must facilitate oversight in new and innovative ways—and a number of new models should be explored. For instance, we again note the parallel innovation of the tele- or “electronic”-intensive care unit, telemedicine, and novel ways to deliver procedural sedation.5
  8. We also want to acknowledge the impact of changing payment strategies on anesthesia practice. Payment models such as bundled payments, value-based purchasing, and accountable care organizations will become the norm and surely will not financially support current fees for anesthesia services. Thus, this payment evolution will require further reassessment of our current value proposition to optimize care while controlling costs.
  9. Ultimately, the most important challenge we face is to confront our current resistance to accept the changing environment. As the Princeton economist Uwe Reinhardt said recently, “The doctors are fighting a losing battle. The nurses are like insurgents. They are occasionally beaten back, but they’ll win in the long run. They have economics and common sense on their side.”6 We do not have to unconditionally accept this perspective but must define and evaluate alternative approaches to patient care to effectively counter the argument.

In the meantime, we can either wait for change to be imposed on us or we can actively redefine our new future.7 So, in the parlance of the day, “Yes, really!”

Richard C. Prielipp, MD, MBA, FCCM

Department of Anesthesiology

University of Minnesota Medical School

Minneapolis, Minnesota

prielipp@umn.edu

Robert C. Morell, MD

Department of Anesthesiology

Twin Cities Hospital of Niceville

Niceville, Florida

Douglas B. Coursin, MD, FCCP

Department of Anesthesiology

University of Wisconsin School of Medicine and Public Health

Madison, Wisconsin

Sorin J. Brull, MD, FCARCSI (Hon)

Department of Anesthesiology

Mayo Clinic College of Medicine

Jacksonville, Florida

Steven J. Barker, PhD, MD

Department of Anesthesiology

University of Arizona

Tucson, Arizona

Mark J. Rice, MD

Department of Anesthesiology

Vanderbilt University School of Medicine

Nashville, Tennessee

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

Department of Anesthesia/Critical Care Services

NorthShore HealthSystem

University of Chicago Pritzker School of Medicine

Chicago, Illinois

Neal H. Cohen, MD, MS

Department of Anesthesia and

Perioperative Care and Medicine

UCSF School of Medicine

San Francisco, California

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REFERENCES

1. Lydon JC. The future of physician anesthesiologists. Anesth Analg. 2015;121:1679–80
2. 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
3. CRNA Independent Practice Map. Available at: https://www.ncsbn.org/5404.htm. Accessed May 30, 2014
4. Abenstein JP, Warner MA. Anesthesia providers, patient outcomes, and costs. Anesth Analg. 1996;82:1273–83
5. New Machine Could One-Day Replace Anesthesiologists. May 11, 2015 The Washington Post Available at: http://www.washingtonpost.com/business/economy/new-machine-could-one-day-replace-anesthesiologists/2015/05/11/92e8a42c-f424-11e4-b2f3-af5479e6bbdd_story.html. Accessed May 30, 2015
6. Doctoring, Without the Doctor. May 25, 2015 The New York Times Available at: http://www.nytimes.com/2015/05/26/health/rural-nebraska-offers-stark-view-of-nursing-autonomy-debate.html?_r=0. Accessed May 30, 2015
7. Kain ZN, Fitch JC, Kirsch JR, Mets B, Pearl RG. Future of anesthesiology is perioperative medicine: a call for action. Anesthesiology. 2015;122:1192–5
© 2015 International Anesthesia Research Society