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Do you remember ‘supply and demand’?

Weiss, Mark S.

Current Opinion in Anesthesiology: August 2019 - Volume 32 - Issue 4 - p 488–489
doi: 10.1097/ACO.0000000000000748

Department of Anesthesioloy and Critical Care, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA

Correspondence to Mark S. Weiss, MD, Assistant Professor of Anesthesiology and Critical Care, Director, Inpatient Endoscopy Anesthesia, Department of Anesthesioloy and Critical Care, Hospital of the University of Pennsylvania, 6th Floor Building, 3400 Spruce Street, Philadelphia, PA 19104, USA. Tel: +1 215 687 9069; e-mail:

Did you take an Intro to Econ course when you were an undergrad in college? You spent hours in that big hall listening to a semester's worth of lectures. Well, what do you remember? Supply and demand? Opportunity costs? Perhaps an obscure graph?

Okay, maybe you did not take Econ, but most surely you took freshman biology as a premedical student. What do you remember from that? Meiosis and mitosis? Do you remember which one is which? Did you remember to make those squiggly lines when you drew the mitochondria?

If you are reading the wonderful and varied articles in this nonoperating room anesthesia (NORA) edition of Current Opinion in Anesthesia, you will get a lot of the particulars of what you need to know to proceed. But, unless you spend a lot of time in a NORA suite and you do this every day, in a few years, or weeks even, you may have the same retention from these articles as that lecture you heard in in that cavernous auditorium about some obscure (to me!) economic theory. So, after your readings, what do you need to retain from all of this? In other words, what is the ‘supply and demand’ of NORA?

There are three supply and demand things that you need to know about NORA cases.

The first supply and demand thing you need to know about NORA is that NORA is growing. In any lecture, presentation, or paper, the same ubiquitous graph is shown. I will present it here as well:

Why is NORA experiencing this tremendous growth? What are the forces and trends that are behind the continuous rise in the numbers and types of cases that fall under our growing subspecialty? ‘Tectonic plates’, unstoppable forces that slowly, inevitably bring big changes to our world, are an apt analogy. There are three ‘tectonic plates’ underlying NORA growth.

The first ‘tectonic plate’: We are treating an older, sicker patient population. As this segment of society grows, they come to us not only with greater comorbidities, but also greater expectations regarding procedural results, pain control, and time.

The second ‘tectonic plate’: improved technologies in imaging, optics, and instruments have expanded our abilities to access and treat a larger and expanding group of diseases.

The third ‘tectonic plate’: economic factors that will drive growth in NORA. Bundling, shared revenue, and value delivering better outcomes with lower hospital and resource utilization will drive the market to our treatment suite. To illustrate the three tectonic plates working together, I present to you Grandma. In the not too distant past if Grandma needed her cranial aneurysm repaired, she would be subjected to a very long, invasive, high-risk craniotomy. After her craniotomy, her several days in the neuro-ICU, and a few weeks in the rehab hospital, she would be allowed to finally go home. When she did finally arrive, it seemed familiar but we all knew that she was never really the same again. Today, Grannny will spend the morning in the invasive neuroradiology suite. Instead of a brutal craniotomy, the aneurysm will be coiled from access through her groin. She will be discharged the next day, intact, and come home complaining how bad the food is at the hospital.

The second thing you need to know about NORA is that NORA growth is limited only by our imagination. New and innovative procedures, such as Natural Orifice Transluminal Endoscopic Surgery (NOTES), better equipment and technology will, probably sooner than we realize, allow us to do more and different procedures with wider access to treat and cure diseases that are now beyond the scope of care, cheaper, and using fewer resources.

The third thing you need to know about NORA is that NORA needs standards and guidelines in practice and teaching. This is slowly happening through teaching courses mandated by the ACGME, societal groups through the ASA, such as the Association of Anesthesia Clinical Directors (AACD), and publications, such as the Current Opinion in Anesthesia. Together these outlets will enable us to deliver consistently excellent care to the patients whose lives have been entrusted to us.

There are three supply and demand main points. There are three ‘tectonic plates’ behind the growth of NORA. Now, I will be happy if you come away and remembered these three pearls for survival in the NORA suite.

NORA pearl 1: airway/airway/airway. Often in the NORA suite, the airway is shared, the patient is in an abnormal position or physically difficult to reach, and the room is darkened. Vigilant monitoring is essential.

NORA pearl 2: communicate, communicate, communicate. Discuss potential care issues in a morning ‘time out’. Discuss any issues that arise in real time with the proceduralists and nurses in the room. Do not silo information, but rather share what you know with your care team.

NORA pearl 3: do not go fast, just be efficient. The key to moving a NORA room is not speed, but efficiency. Rushing leads to cutting corners, and that has the potential to lead to mistakes. Plan ahead, but take time appropriately to thoughtfully resolve any patient issue that may arise.

Finally, a bonus pearl: a good anesthesiologist manages people as well as airways. This is never more important than in the NORA suite.

The issues and topics covered in this edition of the Current Opinion in Anesthesia are as broad as the NORA itself. Some topics selected were chosen to reflect the need for improved education, standardization or safety in NORA. Other topics were selected to provide updates in the evolution of treatment in administering these cases, or because of the economic issues in NORA that affect our income as well as patient care. The results of these criteria provide a series of articles focusing on different and important aspects of NORA. This issue of Current Opinion in Anesthesia begins with a needed discussion on the requirements to ensure quality and standardization in the teaching of our residents. There is a compelling NORA safety lecture review of how to apply the safety lessons learned from the National Transportation and Safety Board (NTSB) to NORA safety. The is an interesting article on how efficient changes to staffing models can improve both patient satisfaction as well as our economic bottom line. This edition features an article on the POEM procedure from its country of origin. Clinically, this issue takes another look and evolving endovascular treatment of acute ischemic stroke. Finally, there are several different looks at and comparisons of practice regarding airway managements, MAC versus general anesthesia, and comparative gastrointestinal practices in the Unites States and Great Britain.

It takes many contributors in multiple programs from different countries, as well as administrators and editors, to make this edition possible, and I would like to thank each one of them for their time, ideas, effort and patience. Thank you. I am grateful to Dr Paul Barash, Professor Emeritus of Anesthesiology at Yale University, and my former Chairman, for giving me the opportunity to again edit this edition of the Current Opinion in Anesthesiology. I am fortunate to have done this project with Ciaran Finn at Wolters Kluwer, for his encouragement and advice with this project was invaluable. And, as always, I am deeply thankful to my family, and to the families of our contributors, for their patience and understanding of the commitment of time that this project took to complete. ‘See you around campus.

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The author wishes to thank Drs Linda J. Greff, Norman Randolph, and Jason Walls for their patience and proofreading skills as well as their friendship and support.

The author wishes to Ciaran Finn for helping in many ways, large and small, in this endeavor.

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Financial support and sponsorship


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Conflicts of interest

There are no conflicts of interest.

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