1/5/2017 Anesthesiologistsarevictimsoftheirownsuccess

Anesthesiologistsarevictimsoftheirownsuccess
KARENS.SIBERT,MD| PHYSICIAN| APRIL18,2013

NewresearchjustoutinthejournalPsychologyandAgingsayspessimistslivelongerandhealthierlives.Ifthis
istrue,thencontemplatingthefutureofanesthesiologyoughttomakeusimmortal,becauseourprofessional
prospectsdontlookbright.Asweteachresidentstodowhatwevealwaysdone,shouldntweaskourselves
honestlyifweretrainingthemforafuturethatdoesntexist?

EspeciallyhereinCalifornia,itseemslikelythatourpredominantlyMDprovided,feeforservicepracticeof
anesthesiologywillnotsurviveindefinitely,andperhapsnotforlong.WecanblamethereelectionofPresident
ObamaandthepassageoftheAffordableCareActifwelike,buttherealityisthatmarketforceswere
eventuallygoingtocatchupwithuswhetherornotMittRomneywenttotheWhiteHouse.

Inaway,werethevictimsofourownsuccesswevemadeanesthesiasosafethateveryonethinkstheres
nothingtoit.Butthatsexactlythepoint.Technologyhasindeedmadeanesthesiamuchsafer.WhenIstarted
learninganesthesia,pulseoximetryandendtidalCO2monitoringwerenewtothemarket,unproven,and
scarce.Nowtheyreeverywhere.Wefearthedifficultairwaylessnowthatwehavevideolaryngoscopes
readilyathand.

Sincetechnologyissomuchbetter,whydosomanyofusstillbelievethateverycaserequiresthecostly
expertiseofaboardcertifiedanesthesiologist?Wecanmaketheargumentthatphysicianprovided
anesthesiacareissimplybetter,inthewaythata$75,000BMWisasuperiorproducttoa$15,000economy
car.Butinaworldofincreasingpressuretocontrolhealthcarecosts,peoplearewillingtoconsidercheaper
solutions,andthereinliesourrisk.

Medicineisntthefirstbusinesstobethreatenedbycostpressureandnewtechnology.Lookatwhat
happenedtovinylrecordswhenCDscameonthemarket,andwhathappenedtothedemandforCDswhen
iPodsanddigitaldownloadsappeared.WhocouldhaveimaginedthatthegiantEastmanKodakCompany
wouldcrumblewhendigitalphotographykilledthedemandforcamerafilm?Peoplecomplainedatfirstthat
thenewtechnologieslackedthesamesoundqualityorrichcolor,butastimepassedthemarketnolonger
cared.

ClaytonChristensen,aHarvardBusinessSchoolprofessor,usesthetermdisruptiveinnovationtodescribe
howcomplicated,expensiveproductsandservicesareeventuallyconvertedintosimpler,affordableones.In
arecentWallStreetJournalcolumn,Christensenandhiscoauthorsarguethataccountablecare
organizations,orACOs,cantmakeadentincostsbecausetheywontfundamentallydisruptandtransform
thedeliveryofAmericanhealthcare.Whilemanyanesthesiologistsagreedwiththatassessment,theywere
appalledbytheauthorsrecommendationthatpolicymakersconsiderchangingmanyanticompetitive
regulationsandlicensurestatutesthatpractitionershaveusedtoprotecttheirguilds.Theauthorspraised
Californiaforenablinghighlytrainednursestosubstituteforanesthesiologiststhelastthing
anesthesiologistswantedtohear.

HasCaliforniasoptoutchangedthemarketplace?

Intheyearssince2009,whenGovernorSchwarzeneggersignedtheoptoutletterthatfreedCalifornianurse
anesthetistsfromtheCMSrequirementforphysiciansupervision,manyofushaventseenhugechangesyet
inthedeliveryofanesthesiacare.MostCaliforniaanesthesiologistsstillprovidepersonalcare,onepatientata
time,andbelievetheirhospitals,surgeons,andpatientsaresatisfiedwiththestatusquo.

Butifyouthinkeverythingisfinewithyourhospitalbecauseyoutakegoodcareofyourpatients,youllheara
counterargumentfromDr.MichaelR.Hicks,ananesthesiologistandexecutivewhoheadsanesthesiaservices
forEmCare,anationalphysicianpracticemanagementfirm.Inanonlinearticle,DisruptionandtheTheoryof
theAnesthesiaBusiness,Dr.Hickswrote,NearlyeveryanesthesiapracticethatIhaveseenreplacedhas
hadsatisfiedpatients.Buttheincumbentgroupfelloutoffavorandlostitscontractbecauseitbecameoutof
touchwithitsenvironment,andsecureintheknowledge,erroneouslyso,thatthegroupandgroupmembers
areirreplaceable.

OnesouthernCaliforniaanesthesiologistwhocoordinatesanesthesiaservicesforseveralhospitalsrecently
hiredhisfirstnurseanesthetisttopracticeonherown,withoutanysupervision.Sheworksonaflexible
schedulewhenheneedstostaffanadditionaloperatingroomwithroutinecases.Hesquitepleasedwiththe

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qualityofherpracticeandherworkethic,asopposedtosomeyoungeranesthesiologistsheshiredwhoarrive
withasenseofentitlementandalistofdemands.Shesalotlesstrouble,theanesthesiologistsays.

AnecdotalevidencesuggeststhatanesthesiologistpayinCaliforniaisonadownwardtrajectory,perhaps
becauseemployersareawarethattheycouldhirenurseanesthetistsinstead,andarebolderaboutextending
lowoffers.Anacademicanesthesiologist,postingrecentlyonthephysicianonlywebsiteSermo,bemoaned
thefactthatanexcellentresidentacceptedajobofferforpaythatwasbarelyabovethatofanurse
anesthetist.AnesthesiologistswhowanttoworkindesirablelocationsliketheBayarea,workparttime,or
workinsurgerycenterswithnocallandnoweekends,appeartobewillingtoacceptpaythatnoonewould
haveconsideredcompetitivejustafewyearsago.

Understandingdisruptiveinnovation

Clearly,therearemajorfaultlinesbeneaththeanesthesiamarketplace.MuchaswemaydislikeProfessor
Christensenscommentaboutnurseanesthesia,perhapsweshouldhearmoreabouthistheoryofdisruptive
innovationbeforewecallforhisheadonapike.WithcoauthorJasonHwang,hewroteanelegantarticle
forHealthAffairsthatexaminesthetheorysimplicationsforhealthcare.

Thetraditionalbusinessmodelofhospitalsandphysicianpracticeshasbeenthesolutionshopaninstitution
createdtodiagnoseandsolvecomplex,unstructuredproblems,staffedbyexperts.Thisbusinessmodelstill
workswellforconsultingfirmsandlawfirms,forinstance.Inmedicine,thesolutionshopmodelevolvedinan
erawhenmedicalcareinvolvedminimaltechnologyandrelieduponthediagnosticintuitionandhandson
experienceofhighlyskilledphysicians.

Buttimeshavechanged.Twootherbusinessmodelsnowapplyaswelltothedeliveryofhealthcare:

1.Valueaddedbusinesses:Liketraditionalmanufacturingfirmsandrestaurants,thesebusinessestransform
resourcesintooutputsofgreatervalue.Theyfocusonprocessexcellenceandefficiencyinordertoproduce
highqualityproductsconsistentlyandatlowcost.

2.Facilitatedusernetworks:Thesebusinessesdelivervalueandmakemoneybyfacilitatingtheoperationofa
networkanditsusertransactions.Examplesaremutualinsurancecompanies,stockexchanges,andbanks.

AsChristensenandHwangviewAmericanhealthcare,thecurrentcrisiswasinevitableoncehospitalsand
physicianpracticesthatbeganashighlycompetentsolutionshopsstartedtochangehaphazardly.They
subsumedundertheirorganizationalumbrellasmanyactivitiesthatareperhapsbettersuitedtobusinesses
basedonvalueaddingprocessesorusernetworkmodels.Thelegacyinstitutionsofhealthcaredeliveryare
jumbledmixturesofmultiplebusinessmodelsstrugglingtodelivervalueoutofchaos,incorporating
indecipherablesystemsofcostaccounting,excessiveoverhead,pervasivecrosssubsidization,andan
unacceptableamountofvariabilityandmedicalerror.

Instead,theauthorssuggest,weshouldseparatethediagnosticandintellectualworkofphysicians(the
solutionshop)fromthevalueaddedprocessesofhealthcare.Inotherwords,itdoesntmakesenseforme,
asanexpensiveandhighlytrainedanesthesiologist,tochangethesuctioncanisterontheanesthesia
machine,pushthegurneydownthehall,andwatchtheventilatorduringalong,stablecase.Thosetasks
couldbedonebysomeoneelseatfarlesscost,someonewhowouldntbequalifiedtodecideifthepatientisin
optimalconditionforsurgeryortoformulatetheanestheticplan.Manyofthepredictable,routineprocessesof
anesthesiacaredontrequireanesthesiologistleveltraining.

Astheauthorsexplain,Whenthevalueaddingproceduresareorganizationallyseparatedfromtheworkof
solutionshops,theoverheadcostsofthevalueaddingprocesshospitalsandclinicscandelivercareatprices
thatare60%lowerthanthoseathospitalsandphysicianpracticesinwhichthebusinessmodelsofvalue
addingbusinessesandsolutionshopsareconflated.

Ifanything,thisapproachvaluesphysiciantimeandeducationmorehighly,pointingoutthatitisamistaketo
focusonreducingphysicianpay.Cuttingreimbursementinanattempttoforcethesolutionshopbusiness
modelsofhospitalsandphysicianpracticestosomehowfigureoutawaytobecomemoreefficientdoeslittleto
improvehealthcaredelivery,theauthorsconclude.Withlowerreimbursement,hospitalsandphysicians
struggleevenmoretofulfilltheirvaluepropositionsofprovidingcomplex,inherentlyexpensivemedicalcare,
andtheybecomeevenlessinclinedtohandoffworktovalueaddedprocessbusinesses.

Startingover:Stopsqueezingthebag
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Ifwecouldstartalloveragainanddeveloptheoptimalmodelfordeliveringanesthesiacare,whatwoulditlook
like?Ibetthatitwouldhavelittleincommonwithanesthesiapracticestoday.Ifweletgooftheideathat
squeezingthebaginpersonistheonlyanesthesiarelatedactivitythatdeservescompensation,thenaworld
ofpossibilitiesopensup.

Rightnow,therearethreemodelsofanesthesiacareintheU.S.:

1.Personallyprovidedcarebyananesthesiologist

2.Theanesthesiacareteammodelinwhichanesthesiologistssupervisenurseanesthetists,anesthesiologist
assistants,and/orresidents

3.Personallyprovidedcarebyanurseanesthetist.

Whenwelookatdeliveryofcareindifferentsettings,itbecomesclearhowmuchirrationalitythereistocurrent
practicepatterns.Whyisitroutineforacardiologistoragastroenterologisttosuperviseanursewhois
administeringsedation,butananesthesiologistonlysupervisesamuchmoreexpensivemidlevelanesthesia
practitionerorresident?WhyisitroutineforanICUnursetomonitorapatientwhoisintubatedandreceiving
medicationslikefentanyl,midazolam,andpropofol,butthesamenurseisntallowedtomonitorthesame
patientthemomenthecrossestheORthreshold?

Perhapsweneedtochangetheconversation,anddrawadistinctionbetweengivinganesthesiaand
monitoringpatients.

Considerthepatientswhoneedsedationinoutpatientsettings,cardiaccatheterizationlabs,and
gastroenterologysuites,forinstance.Envisionascenariowhereananesthesiologistsupervisesseveral
nurseswhoaretrainedtoadministersedation.Theanesthesiologisthasevaluatedthepatients,andis
capableofconvertinganycasetodeepsedationorgeneralanesthesiaiftheneedarises.Weimprovepatient
safetybyeliminatingthealltoocommoncrisiswhenthepatientundersedationgetsintotroubleandan
anesthesiologistmustbepagedstatfromelsewhereinthehospital.Weeliminatethechanceofhavingacase
canceledinmidstreambecausethepatientcantbeadequatelysedatedandanesthesiaisntavailable.We
providebetterservicetothehospitalbytakingresponsibilityforallthesecases,andtheproblemofscheduling
anesthesiaforoccasionalcasesdisappears.Potentialliabilitydecreasesforthehospitalaswellasthe
surgeonorproceduralist,andthecostisfarlessthanitwouldbewithananesthesiologistoramidlevel
anesthesiapractitionerassignedtoeverycase.

Nowconsiderpatientswhoarehavingproceduresperformedunderregionalblockwithsedation.Oncethe
anesthesiologisthasplacedtheblock,thepatienthasbeensedated,andvitalsignsarestable,istherereallya
compellingreasonwhyasedationnursecouldnotmonitorthepatientwiththeanesthesiologistimmediately
available?

Ofcourse,underthecurrentfeeforservicepaymentmodel,noneoftheseoptionsarefeasible.Underan
integratedcaremodel,however,thefacilitycouldofferareducedpricefortheentireprocedure,whichwould
includetheanesthesiologyandsedationservices.Weredefinethenursesrolesothatinsteadofproviding
anesthesiatheyaremonitoringpatientswhoareundertheanesthesiologistscare.

Wecanenvisionanintelligentlydesignedoperatingsuitewheretheappropriatelevelofcareisdeterminedfor
eachpatientafterevaluationbyananesthesiologist.Nursepractitionersorphysicianassistantswouldfacilitate
patientevaluationandthroughputinthepreoperativearea,andassistanesthesiologistsintheplacementof
regionalblocks.Aidesortechnicianswouldfacilitateroomturnover,settingupfreshcircuits,suction,and
airwayequipment.Staggeredcasestartswouldensurethatananesthesiologistispresentattheonsetof
eachcase,andthenwoulddelegatetotheappropriatelevelofcareformonitoring:asedationnurseora
criticalcarenurse,forinstance.Todaystechnologycanenableananesthesiologisttoviewoperatingrooms
andvitalsignmonitorsfromatabletcomputer,andrespondtoanychangeinpatientstatus.Anesthesiologists
wouldprovidepersonalcareforcomplexcasesorveryhighriskpatients,ormightsupervisearesidentora
midlevelanesthesiapractitioner.

Asradicalassuchaproposalsounds,itoffersanalternativevisionforredesigningthedeliveryofanesthesia
careandreducingcosts.Itwouldfreethehealthcaresystemfrombeingheldhostagebyexpensivemidlevel
anesthesiapractitionerswhobelievetheirtrainingmakesthemequivalenttophysicians.Iwouldrather
superviseanursewhounderstandsherboundaries,andsummonstheresponsiblephysicianappropriatelyfor
consultationandfurtherorders.
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Barrierstochange

Ourcolleaguesinemergencymedicine,gastroenterology,andpediatricssailintothedangerouswatersof
deepsedationwithhardlyaglanceback,whileanesthesiologistshesitatetomakeanychangeinpracticeto
adapttoanincreasinglycompetitiveenvironment.Untilanesthesiologistscometotermswiththefactthatthe
worldaroundusischangingrapidlyandourbusinesstheoryisfailing,thereislittlehopethatourspecialtywill
surviveasweknowit.Certainlyanyanesthesiologistislivinginadreamworldifhebelievesthathecaninfuse
propofoltoonepatientatatimeinaGIsuiteoroutpatientcenterforthenext20or30years,andcontinueto
enjoyahandsomesixfigureincome.

Californiaanesthesiologistsareunderstandablyreluctanttoembracetheanesthesiacareteammodelifthe
onlyoptionistoworkwithnurseanesthetists.TheAmericanAssociationofNurseAnesthetists(AANA)has
clearlyestablisheditselfasouropponent,andbelievesthatthereisnoneedforsupervisionbyorconsultation
withanesthesiologists.

TheCaliforniaSocietyofAnesthesiologistsstandsinsupportofstateregulationthatwouldenable
anesthesiologistassistants(AAs)topracticeinCalifornia.HiringAAswouldbeanexcellentoptionforany
groupseekingtomovetowardtheanesthesiacaremodel.Asopposedtonurseanesthetists,AAspractice
undertheauthorityofthestatemedicalboardandmustbesupervisedbyanesthesiologists.However,there
arenotnearlyenoughAAsinpracticeorintrainingtofilltheneedforcosteffectiveanesthesiaservices.

Soweneedtobreakthemoldandlookatdifferentwaysofprovidinganesthesiacare,takingadvantageofthe
technologythathasmadeanesthesiaremarkablysafe.Sadly,someofthemajorbarrierstoourprogress
comefromwithin.Leadersofanesthesiologygroupstendtobenearretirementage,andaremoreinterested
inprotectingthestatusquothaninleadingintothefuture.AsDr.HicksofEmCareputsit,Manyanesthesia
practices,likeothermedicalpracticesandphysiciansingeneral,equateleadershipwithlongevityandwisdom
withaccommodation.Theirresistancetochangeisdrivenbyadesiretomaintainpoliticalpowerand
maximizecurrentincome.

Evenourprofessionalsocietiesarefailingus,inDr.Hicksview.Unfortunately,frommyperspective,he
writes,manyleadersinanesthesiologyarepoorlyequippedforthisbroaderdiscussionandcontinuetoview
thecarewedeliver,andhowwedeliverit,throughthelensofhistory.Theseleadersareclingingtowhathas
workedorwhatisdesiredbyourprofessionoverwhatisneededoraffordablebythosewhoreceivecare,
benefitbyitsdelivery,orareresponsibleforitsfunding.

WehaveanopportunitynowtoacceptthefactthattheAffordableCareActisreality,andtouseitsprinciples
tocreatenewmodelsofanesthesiacare.TheACApromotesincreasingscopeofpractice,andwecan
capitalizeonthattomakebetteruseofnursesandphysicianassistantstoextendourreach.Wecan
encouragethemtoexpandtheircareerhorizonsandtoworkwithusintheoperatingroomsandprocedural
suites.Insteadofusinganearpiecetomonitortheheartrateandrespirationsofonepatient,wecanuse
technologytosupervisethemonitoringofmultiplepatients.Byreducingthenumberofanesthesiologists
neededinanygivensurgicalorproceduralsuite,wecanenabletheanesthesiologistsofthefuturetopractice
asthespecialiststheytrulywillbe.

IfIhaveanyadvicetogivetoresidentstoday,itwouldbethis:Gainallthespecialtyexpertiseyoucan.Doa
fellowshipseekoutthetoughcasesdifferentiateyourselffromamidlevelanesthesiapractitioner.Useyour
specialisteducationtoitsfullestextent,andlearntoworkwithotherclinicianstomanagethecasesthatdont
requireyourcontinuousexpertise.Theydontneedtoknowadvancedinterventionalpaintechniquesor
transesophagealechoinordertomonitorapatientwhoishavingakneearthroscopyoraninguinalhernia
repair.Youcansurvivethewindsofchangeifyourewellpreparedandflexible.Toomanyanesthesiologists
areindenial,andareirrationallyoptimisticthattheircurrentpracticeswillneverbeatrisk.Inanesthesia,asin
therestoflife,pessimistsmaybemorelikelytolearntosurvive.

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