The origin of the title of my Leadership Perspective, for those of you unfamiliar with it, is a cartoon character named Pogo, dating back more than five decades. True historians may recognize it as a play on a famous quote by U.S. Navy Master Commandant Oliver Perry during the War of 1812, written in a letter to Major General William Henry Harrison: “We have met the enemy and they are ours.”
The origin of Pogo's quote was a poster that Pogo's cartoonist Walt Kelly made for Earth Day 1970, depicting Pogo in a wooded area, surrounded by litter strewn across the ground as far as the eye could see. The obvious message being that we are the source of many of our own problems.
As we assess the list of challenges facing physician-delivered and physician-led anesthesia care in the U.S., there is a component of “they are us” for at least one of the primary items on that list.
Some of you may not share my opinion, but I will go to my grave believing that the delivery of care in the supervisory model is inferior to a personally performing anesthesiologist or to a medically directing anesthesiologist practicing in the anesthesia care team. Supervision of nurse anesthetists in any alternative model that does not provide for the active engagement of the anesthesiologist in all aspects of peri-anesthetic care places the patient at increased risk of adverse events, from which they are less likely to be rescued (
Anesthesiology 2000;93:152-63).
Each of us is likely aware of one or more examples of a medical direction and/or personal performance anesthesia group being displaced by a supervisory model, in which a much smaller number of anesthesiologists becomes responsible for covering the anesthetizing locations. I recognize that there are instances in which a medically directing model has been displaced for reasons other than to realize the economic efficiencies of diluting the anesthesiologists' presence, due to lack of providers or reasons aside from a reduction in anesthesia labor costs. However, I am also well aware of a number of examples where economic considerations appear to be the primary, if not the sole, driver of this dramatic change in anesthesia coverage.
I recently spoke with the leadership of an anesthesiology corporation that had been providing anesthesia service at their hospital for 50 years. When they encountered challenges with recruitment and retention of members of their group, the hospital administration chose to issue a request for proposal (RFP) for their anesthesia services rather than collaborate with the currently contracted corporation to pursue opportunities to improve recruitment and retention. Even though they had been providing high-quality care with a high level of efficiency, frequently medically directing in 1:4 ratios, they were displaced for what would seem to be purely cost-cutting reasons.
In the above scenario, one could point fingers in any number of directions, such as the hospital administration or the inadequate reimbursement rate provided by government payers creating the significant growth in health system financial support required for anesthesia services. However, in virtually all instances like the above example, the leadership of the new provider groups espousing the “efficiencies” of reduced anesthesiologist engagement in patient care is composed of, in whole or in part, anesthesiologists. Truly, one of our greatest enemies, in this case, is
us.
To be clear, I am not referring to rural and underserved areas in which anesthesiologist-delivered anesthetics or medical direction in the anesthesia care team may simply not be feasible. However, the example above is a well-resourced suburb in which medical direction had been provided for decades.
The growing demand for anesthesiologists creates a new opportunity to set parameters on our service that may not have previously existed. I contend our patients and our specialty would both be well served if each anesthesiologist – particularly those who are decision-makers regarding the specifics of the care they will provide – acted in alignment with ASA's mission statement:
Advancing the Practice and Securing the Future.
If each of us, as physicians trained in the medical specialty of anesthesiology, resolved to prioritize quality over economics, providing the level of anesthesia care we would want for ourselves or for our family, we would not only ensure better perioperative care for our patients, we would take “us” off our enemies list.
