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Anaesthesiology
The Practice of Anesthesiology
Built from Barash Clinical Anesthesia, 9th Edition
What’s inside
12 sections · 193 slides
Overview
- What this topic covers
From Ether to a Recognised Specialty
- William T. G. Morton, a dentist, gave ether at Massachusetts General Hospital on 16 October 1846. That single day changed the whole course of surgery. People had tried for centuries to blunt surgical pain; nothing worked reliably before this. At first anesthetists were little more than technicians. Most early progress came from chemists and other scientists, not from anesthetists. Longer, more complex operations then created a need for real anesthesia professionals.
- Milestones in the founding of the specialty
- In 1940 the American Medical Association recognised a Section on Anesthesiology. The society changed its name one last time to the American Society of Anesthesiologists (ASA). The new name marked out those formally trained to give anesthesia. The American Board of Anesthesiology (ABA) is the body that certifies individual doctors. The ASA is the professional society; the ABA is the certifying board. Two different jobs.
- Dr Ralph Waters set up the first anesthesiology residency at the University of Wisconsin in 1927. His trainees went on to found and lead many other US training programs. Numbers grew slowly at first; World War II changed that sharply. By 1948 there were 214 accredited US anesthesia residencies. Programs peaked at 296 in 1964, then fell away. From 2017 to 2022 the count rose 22%; by 2022, 159 programs and over 6,000 residents.
- Recognition as a specialty also meant a fight for fair pay. In the mid-1950s Dr Joseph Falling of California proposed a way to calculate anesthesia fees. His method scored the complexity of the procedure, the skill needed and the time taken. He called it the 'Anesthetic Value Unit'. The ASA adopted it in 1962; today it is the Relative Value Guide (RVG). Many societies, insurers and regulators still accept this fee schedule.
- Anesthesia first reached the battlefield in the Mexican-American War, just after Morton's work. Its use for wounded soldiers became steadily more common with each conflict. Lessons were often forgotten between wars, then relearned in the next. World War II brought the first systematic studies of trauma care, in the Mediterranean theatre. Surgery moved from mostly amputations to wound control, forerunner of damage control surgery.
- Anesthesia providers watched how anesthetics behaved in badly injured patients. From that came knowledge on managing hypovolemic shock (shock from blood loss). Airway management and controlled ventilation both advanced in wartime. So did transfusion medicine and intravenous anesthetics. Regional anesthesia, triage and transport of trauma victims also improved. Anesthesia delivery equipment was refined under battlefield pressure.
- Anesthesiology was the first specialty to build a systematic approach to patient safety. Fast-changing technology plus a sense of high anesthesia deaths galvanised the field. In 1984 ASA President Ellison C. Pierce set up a Patient Safety and Risk Management committee. In 1985 the Anesthesia Patient Safety Foundation (APSF) was founded as an independent non-profit. Its vision: 'no one shall be harmed by anesthetic care'. The AMA and others later launched the National Patient Safety Foundation on the APSF model.
- Events that shaped the anesthesia patient safety movement
- A diverse, inclusive workforce is vital to the specialty's future, and much work remains. In 2021 over half of US medical students were women, but only a third of anesthesia residents. The gap is wider in academic anesthesia. In 2015 women were about 14% of academic anesthesia chairs and 6.9% of full professors. Black, Hispanic and Native American physicians remain underrepresented in anesthesiology.
- Diverse teams are more productive and more innovative. They promote wellness and help recruit and retain the best talent. Concordance = the team's make-up mirrors the patient population it serves. With concordance, individual and population health outcomes improve, as does access to care. A diverse workforce also drives research into conditions that hit minorities hardest.
The Scope of Modern Practice
- Practice has moved far beyond its traditional reach, in both place and type of patient. The expansion covers geography, complexity and scope. That has created opportunities and challenges together. The growing number and variety of subspecialty fellowships reflect this wider scope. Some fellowships lead to an ABA subspecialty certificate; many do not.
- Subspecialty fellowships and available ABA certification examinations
- Subspecialty fellowships and available ABA certification examinations (continued)
- They care for patients having coronary bypass, valve repair, and congenital heart repair. Also heart and lung transplants, cardiac assist devices and ECMO (an external heart-lung machine). Their expertise covers advanced lung surgery, tracheal procedures and thoracic aorta surgery. They follow patients through the whole perioperative course. They may offer neuraxial or regional blocks for postoperative pain, and provide critical care. The field evolves with robotic surgery and endovascular repair of structural heart lesions.
- Transesophageal echocardiography (TEE) = an ultrasound probe in the gullet, imaging the heart. TEE is now an essential part of modern cardiac surgery. Cardiac anesthesiologists can be certified in basic or advanced TEE. Basic certification recognises proficiency in TEE monitoring during any anesthetic. Advanced certification requires full diagnostic proficiency in interventional cardiac procedures.
- Even healthy children have distinct anatomy and physiology. Immature organs and metabolic pathways change how they respond to anesthetic drugs. Most anesthetic drugs have narrow therapeutic windows, so dosing must be precise. Different airway anatomy and cardiopulmonary physiology make intubation harder in neonates. They also desaturate (lose blood oxygen) faster than adults.
- One of the newest fields in the specialty. The original agents were inhaled vapours like ether and chloroform, plus meperidine and morphine. Modern neuraxial techniques (spinal and epidural) are safer and work better. They relieve labour pain and provide anesthesia for cesarean delivery. Most anesthesiologists should manage a healthy mother and baby. Fellowship-trained experts are called for older, sicker pregnant patients.
- Obstetric anesthesiologists have a key role in high US maternal morbidity and mortality. The American College of Obstetrics and Gynecology issued a statement on levels of care. It advocates risk-based maternal levels of care within health systems. Hospitals giving subspecialty obstetric care should have a fellowship-trained director. Regional perinatal centres should always have fellowship-trained obstetric anesthesiologists.
- One route is an anesthesiology residency followed by a critical care fellowship. The critical care anesthesiologist combines residency skills with intensive care training. That mix gives a broader array of services than other critical care specialists can offer. They are specialists in perioperative care of critically ill surgical patients. They usually work in an intensive care unit within a multidisciplinary team.
- Expertise in all aspects of life support, including assist devices and ECMO. Airway management, ventilator management and invasive monitoring. Point-of-care ultrasound (POCUS) - bedside scanning to answer a clinical question fast. Central venous access, nutritional support, antimicrobial and renal replacement therapies. Pain management and sedation. Deep understanding of rehabilitation needs, and compassionate, ethical end-of-life care.
- The quest to relieve surgical pain gave birth to anesthesiology in the first place. As the specialty matured, anesthesiologists took their skills to pain beyond the operating room. The ACGME accredited the first pain medicine programs in 1992. The ABA gave the first subspecialty certification examination one year later. Neurology, physical medicine and psychiatry trainees may also enter pain medicine. All currently accredited pain fellowships are affiliated with anesthesiology.
- Pain medicine began with a focus on regional anesthesia techniques. Today's practitioners are also experts in drug therapy, physical therapy and psychology. Some implant spinal cord stimulators and intrathecal infusion pumps. Others offer percutaneous spinal stabilisation techniques. Most work in outpatient settings with chronic pain syndromes and cancer-related pain. They keep long-term relationships with patients, like other medical specialties.
- The central nervous system is the most complex and least understood part of the body. Neurologic surgery keeps getting more complex: stereotactic surgery and awake craniotomies. That drove some anesthesiologists to specialise in neuroanesthesia and neurocritical care. They care for stroke, brain injury and status epilepticus (a seizure that will not stop). Also inflammatory and infectious disease, spinal cord pathology and nervous system tumours. The goal is better survival and better functional recovery.
- Trauma is the leading cause of death under age 45, and third overall in the United States. Trauma care needs local and regional emergency services linked to hospital teams. The anesthesiologist is a fundamental member of any trauma service. Trauma anesthesiologists are often cross-trained in critical care. They are experts in hemorrhagic shock and in devastating injuries. They also lead in emergency management and transfusion medicine.
- Liver transplants are among today's most complicated operations. Transplant anesthesiologists manage coagulopathy - blood that will not clot properly. They also handle acid-base derangement, multiorgan failure and massive transfusion. They are skilled in vascular access and invasive monitoring. They care for multiorgan transplants and complex hepatobiliary surgery. Many sit on transplant selection committees and give pre- and postoperative care.
- Economics and minimally invasive techniques push more procedures out of the hospital. More than half of US anesthetics are now for ambulatory or 23-hour stay procedures. Patients who once stayed several days now go home on the day of surgery. That includes cardiac interventions and total joint replacements. All anesthesiologists care for ambulatory patients and must adjust their techniques.
- Many invasive procedures now happen outside the traditional operating suite. Patients undergo complex catheter-based, endoscopic and image-guided techniques. These are often offered to older, sicker patients who could not tolerate open surgery. Successful interventions mean faster recovery, fewer ICU admissions, shorter stays. Anesthesia staff now work in radiology suites, MRI scanners, cath labs and endoscopy centres. Non-operating room anesthesia (NORA) is growing faster than operating room anesthesia.
- Newer areas of anesthesiology practice
- A developing specialty aiming to improve health outcomes of surgical patients. It starts at the preparation stage and runs right through recovery. Specialists build and apply evidence-based clinical pathways. The pathways aim to reduce risk and improve functional recovery. Fellowships should give experience in clinical leadership, quality improvement and research.
- A subspecialty approved by the ABMS under the American Board of Preventive Medicine. Open to diplomates of any ABMS board, including anesthesiology. The first certification examination was offered in 2012. Clinical informaticians analyse and manage data, and study and refine workflows. They design clinical support aids and lead acquisition of information systems. That includes the electronic health record (EHR) needed to support the organisation.
- The specialty rests on three pillars: teaching, clinical care and research. For decades several barriers have limited anesthesiology research. There is too little money to support new researchers. There is a shortage of research mentors. External funding for space, resources and protected non-clinical time is very hard to find. Fewer than 60 of the 159 US residency programs currently hold NIH research funding.
The Value of Anesthesiologists
- The US spends a much larger share of its gross domestic product on medical services than peers. Despite that, it ranks last among developed countries on access to medical care. It also ranks last on administrative efficiency, health care equity and outcomes. The 'Triple Aim' has become a useful framework for this problem.
- The Triple Aim of health care
- Anesthesiologists are uniquely placed to reach triple aim and value goals. Perioperative care today is fragmented, which raises cost, risk and adverse outcomes. The ASA introduced the perioperative surgical home (PSH) to fix that fragmentation. In the PSH the patient's care is coordinated by a physician-led, interdisciplinary team. Goals: better operational efficiency, less resource use, shorter stays, fewer readmissions. Also fewer complications, lower mortality and a better patient experience of care.
- The perioperative surgical home model
- In 2014 the University of California Irvine showed the PSH was feasible. They published their experience with total joint arthroplasty patients. Later work showed the PSH can shorten hospital stay. It also cut admissions to skilled nursing facilities. A financial analysis found the PSH was linked to lower direct hospital costs. Since 2014 hundreds of publications have reported clinical and financial benefits.
- In the 1990s Professor Henrik Kehlet, a surgeon in Copenhagen, argued for multimodal pathways. Multimodal = several small interventions combined, not one big one. Those ideas became the foundation of enhanced recovery after surgery (ERAS) protocols. ERAS protocols are evidence-informed pathways that standardise perioperative care. Standardising means every patient gets the same proven steps, not one doctor's habit.
- Well-implemented ERAS protocols shorten hospital stays. They are also linked to decreased costs and fewer complications. ERAS can be built into PSH models to address all three triple aim goals. Published ERAS protocols now cover bariatric, breast, plastic, cardiac and colorectal surgery. Also esophageal, head and neck, hepatic, gynecologic, neurologic and obstetric surgery. And orthopedic, pancreatic, thoracic and urologic surgery.
- Practice standards, guidelines and advisories
- A key ASA contribution is developing, approving and disseminating practice parameters. The ASA Committee on Standards and Practice Parameters supervises creation and revision. The ASA House of Delegates then reviews and approves them. Parameters are reviewed periodically as medical knowledge evolves. They are a framework, not a unique indicator of appropriate care. Deviation may be right if the facts show the care met the physician's duty to the patient.
- Anesthesiologists are well placed to lead the management of surgical services. The specialty has a strong commitment to patient safety and quality improvement. As natural inhabitants of the operating room, they see how limited and expensive it is. These skills help improve OR efficiency and productivity. They can also evaluate operational and financial performance. Anesthesiologists can contribute to OR design and construction, which shape efficiency.
- Good OR management comes from personal leadership skills and experience. Emotional intelligence - reading and managing feelings in a team - is one such skill. Extra training in finance (budgeting, balance statements) adds to this. So do legal knowledge and stronger negotiation skills. These roles now extend well beyond the operating room. Anesthesiologists serve as hospital CEO, chief medical officer and chief operating officer.
- With more than 55,000 members the ASA is the largest anesthesiology association in the world. It provides educational content, sets practice parameters and supports research. It also engages actively in political advocacy. It educates members, legislators and the public on reimbursement and scope of practice. Other issues include drug shortages and, most recently, physician wellness. State component societies play the same role under the ASA umbrella.
Accreditation, Training and Certification
- The Accreditation Council for Graduate Medical Education (ACGME) was founded in 1981. It accredits US residency and fellowship programs and the institutions that sponsor them. Accreditation is voluntary and is earned by meeting published common program requirements. The ACGME has recently expanded overseas through an international arm. Besides core residencies, it accredits 10 anesthesiology subspecialties. There are 159 US programs, about 1,774 first-year and over 6,000 active residents.
- Doctors finishing an accredited anesthesiology residency become eligible for ABA certification. Board certification is a way to demonstrate expertise. It is voluntary, but state boards, facilities and the public treat it as a quality standard. Most health care facilities and states require board eligibility or certification. That requirement applies to credentialing and licensing.
- The staged initial certification examinations
- Those who trained before 30 June 2016 took a written part 1 and then an oral part 2. Those graduating after 2016 must pass staged BASIC, ADVANCED and APPLIED examinations. The APPLIED examination has two components. One is the traditional standardised oral examination (SOE). The other is the objective structured clinical examination (OSCE) - stations with set tasks.
- The ABA also offers written examinations for several subspecialty certificates. These cover critical care medicine, pain medicine, and hospice and palliative care medicine. Also sleep medicine, pediatric anesthesiology and neurocritical care medicine. The ABA recently added the Anesthesiology Special Purpose Examination (ASPEX). ASPEX proves a diplomate passed a secure knowledge examination in the last 10 years. Some state medical licences require exactly that proof.
- The ABMS asked boards to show that the standard set at certification is maintained. The ABA created Maintenance of Certification in Anesthesiology (MOCA) for this. MOCA focuses on lifelong learning and quality patient care. Maintain an unrestricted medical licence in the United States or Canada. Earn 250 CME credits and 50 quality improvement points every 10 years. Complete 125 MOCA-minute questions every calendar year.
- The MOCA minute replaced the old requirement to pass a written recertification examination. It gives the diplomate an interactive lifelong learning platform. The platform allows self-assessment and new knowledge while fulfilling MOCA requirements. New ABMS standards take effect in 2024. From then the ABA must renew certification every 5 years instead of every 10.
Financial Aspects of Anesthesia Practice
- Medicine is a service industry: physicians provide services and expect payment. Who pays, how they pay and how much they pay are in constant flux. Billing involves residents, nurse anesthetists (CRNAs) and anesthesiologist assistants (CAAs). Government programs (Medicare, Medicaid) pay low rates for anesthesia care. Private insurers have used new balance-billing limits to cut reimbursement unilaterally. Anesthesia groups are responding to both pressures at once.
- Every medical encounter has a reason (the diagnosis) and a procedure (what was done). Diagnoses are standardised in the international classification of diseases (ICD). The ICD grew from mid-19th century efforts to build a common language for health data. It is now a global tool for epidemiology and health management, kept by the WHO. US providers use ICD-10, with 14,400 codes; released 1992, adopted in the US in 2015. ICD-11 has 55,000 codes, released January 2022, with US implementation planned for 2025.
- Medical services are categorised by current procedural terminology (CPT) codes. The CPT code set is developed, owned and maintained by the American Medical Association. It gives one nomenclature for medical, surgical, radiology, laboratory and anesthesia services. There are CPT codes for more than 10,000 medical services. In 2021 there were 329 changes: 206 additions, 54 deletions and 69 revisions. CMS uses the same system, calling it the Healthcare Common Procedures Coding System (HCPCS).
- Common coding acronyms and their uses
- The two programs are Title XVIII and Title XIX of the Social Security Act. President Lyndon B. Johnson signed them into law on 30 July 1965. Medicare first covered Americans aged 65 and over receiving federal retirement benefits. It now covers almost all residents aged 65+, some younger disabled people, and renal failure. Medicaid gives states funds to insure low-income families and those needing long-term care. About 41% of the US population - over 144 million people - are covered by the two programs.
- Medicare payments were originally based on customary, reasonable and prevailing charges. This CRP system lacked standardisation across doctors and places. Different specialties were paid different amounts for the same service. It could not control the growth of Medicare spending. Those failures led to a new, resource-based system.
- Customary, reasonable and prevailing definitions
- The resource-based relative value system (RBRVS) was built to standardise payment. It assigns relative value units (RVUs) to each service or procedure. RVUs are based on the resources, or 'work', needed to provide that service. Think of an RVU as a token for effort; the token's cash value is set separately. RVUs are assigned to each CPT code.
- The three components of a relative value unit
- RVUs are reviewed and often adjusted by CMS. Input comes from the AMA's Specialty Society Relative Value Scale Update Committee (RUC). Payment = the RVU value of the service times a conversion factor (CF). The CF is the dollar value of a single RVU. Congress sets the CF for government-paid services. For commercial care, the CF comes from contracts between providers and insurers.
- The three parts of an operating room anesthesia bill
- Anesthesiologists do not control how long any given surgery takes. For that reason the ASA has consistently advocated for time-based payment, successfully. Base units and modifiers are set by the ASA and published in the Relative Value Guide. The ASA also publishes CROSSWALK, linking anesthesia RVG codes to the right CPT code. Every OR anesthesia bill needs a diagnosis, a matching procedure code and an ASA code.
- ASA physical status modifiers and base unit assignments
- ASA physical status modifiers and base unit assignments (continued)
- ASA physical status describes how sick the patient is before surgery. ASA I and II add no base units. ASA III adds 1 base unit, ASA IV adds 2 and ASA V adds 3. ASA VI is a declared brain-dead organ donor and adds 0 units. So sicker patients earn more units, because they take more work.
- Qualifying circumstances CPT codes and base unit assignments
- Representative anesthesia invoices
- There are exceptions to the standard base-plus-time methodology. The commonest is billing for epidural labour analgesia. No universally accepted method exists for charging labour analgesia time. The RVG says charges should reflect the cost, intensity and time involved. Approaches: base units plus time to delivery with a cap; or base plus one unit per hour. Others use incremental time bands (0-2 hours, 2-6 hours) or a single flat fee.
- Billing rules for blocks and injections
- Representative anesthesia procedures and their relative value units
- Actual reimbursement, especially by Medicare and Medicaid, is constantly revised. The Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) is the latest attempt. It aims to ensure quality care while controlling growth in US health spending. MACRA rewards clinicians for quality, outcomes and value, not volume. Providers must join one of two payment tracks. Either the merit-based incentive payments program (MIPS) or an Alternative Payment Model.
- MIPS lets providers or groups earn up to 100 points across four quality-related categories. Those above a set performance threshold receive a payment increase of up to 9%. Those below the goal see a payment decrease of up to 9%. In 2022 the threshold for a positive adjustment was 75 points. Scoring below 75 in 2022 means a negative adjustment in 2024; exactly 75 is neutral. Scoring 89 points or above earns an 'exceptional bonus'.
- Merit-based incentive payments program performance categories
- APMs try to reward quality, cost-efficiency and effectiveness. They do this with bundled payments for a condition, care episode or patient population. The 2016 comprehensive care for joint replacement (CJR) model was the first episode bundle. The CJR model has been implemented in 67 geographic regions. Advanced APMs let clinicians earn more by taking on some risk for patient outcomes. Advanced APM practices can get lump-sum bonuses and larger Medicare increases than MIPS.
- Ever more US health care dollars flow through APMs. Yet evidence that value-based purchasing improves quality or cuts cost is sparse. Value-based systems may not capture true clinical status or social determinants of health. Scoring may therefore be biased against physicians caring for many underserved patients. In 2021 most health care providers were still paid for volume, not value.
- Details will keep evolving, but the basics of anesthesia coding will stay the same. Every encounter needs a diagnosis code and a procedure code with a matching anesthesia code. Operating room anesthesia also needs an anesthesia start time and an end time. These codes must exactly match the codes the proceduralist submits. Close attention gets you paid promptly and protects you in an audit.
- Most US anesthetics are given personally by a physician anesthesiologist. Others are given by a non-physician provider - a CRNA or CAA - in an anesthesia care team. 'Medical direction' and 'medical supervision' have specific technical meanings here. So does 'without medical direction of a physician'. These terms decide how the care is coded, billed and reimbursed. Medical direction = an anesthesiologist directing one to four qualified anesthesia providers.
- The seven elements of medical direction
- To bill for medical direction, CMS requires the anesthesiologist to meet seven criteria. The physician must document performing the preanesthetic examination and evaluation. They must document that they provided indicated post-anesthesia care. They must document being present during some portion of anesthesia monitoring. They must document presence during the most demanding parts, including induction. Failure to document each element can bring penalties under the False Claims Act.
- Services an anesthesiologist can perform without breaking the medical direction rules
- The three main types of anesthesia provider
- CMS requires a CRNA to be supervised by the operating practitioner or an available physician. But CMS lets individual states opt out of that supervision requirement. In 2022, 30 states had opted out. CAAs work only under the medical direction of an anesthesiologist, within the care team. Seventeen states currently license CAAs to administer anesthesia.
- Medical direction ratios and payment modifiers
- Medicare requires each claim to carry a modifier showing the number and type of providers. With the AA modifier - personally performed - the physician is paid 100% of the allowable. Under medical direction, both physician and CRNA/CAA bill, using QK, QX or QY. Medicare then pays the physician 50% and the CRNA/CAA the other 50%. The QZ modifier means the CRNA was neither supervised nor medically directed. Billing under QZ, the CRNA receives 100% of the allowable payment.
- The AD modifier means medical supervision of more than four qualified providers. With AD, Medicare pays only three base units plus time. It pays four base units if the anesthesiologist was present for induction. The CRNA is still paid 50% of the total allowable amount. CAAs cannot bill under QZ, and a supervising anesthesiologist cannot use AD with a CAA. Even under QZ, the anesthesiologist would likely still be held medically responsible.
- Commercial versus Medicare conversion factors
- In 2016-2017 commercial charged CFs ranged from $104 to $231 per ASA unit. The 2022 Medicare CF was under 33% of the median commercial CF. The gap comes from trying to fit anesthesia time into the RBRVS billing method. The anesthesia unit was set at $13.68 for 1992, the first RBRVS year. That was a 29% cut from the 1991 Medicare CF. It was also about 40% of the prevailing commercial CF at the time.
- Commercial anesthesia conversion factors by region
- Medicare payment for anesthesia compared with other specialties
- Despite vigorous ASA lobbying, the Medicare CF continues to lag the commercial CF. Practices with many Medicare and Medicaid patients cannot cover costs from collections alone. In response, many anesthesia practices now rely on hospital subsidies. From 2002 to 2014 the share of California hospitals paying anesthesia groups rose 52% to 69%. The median subsidy was $1,295,369 in 2018 US dollars. Other estimates suggest 85% to 95% of hospitals provide anesthesia subsidies.
- Commercial insurers often set reimbursement as a percentage of the Medicare allowable. For most physicians 110% of Medicare is fair and reasonable. But because the anesthesia Medicare CF is so low, rates pegged to it fall short. Insurers have still pushed anesthesia providers for lower rates. Sometimes no agreement is reached and the anesthesia group falls 'out-of-network'. The surgeon and facility may stay in-network, so the patient gets a surprise anesthesia bill.
- Many states had already regulated balance billing for out-of-network services. In December 2020 Congress passed the No Surprises Act within a wider appropriations Act. The Act bans balance billing by out-of-network anesthesiologists. If an out-of-network payment seems inadequate, the physician may use dispute resolution. An independent arbiter picks either the insurer's rate or the physician's rate. One factor the arbiter may weigh is the insurer's qualifying payment amount (QPA).
- Many societies, including the ASA, fear the QPA mechanism can be gamed. Insurers could drive reimbursement down by offering progressively lower in-network rates. In November 2021 Blue Cross Blue Shield of North Carolina demanded a 15% rate cut. An informal 2021 survey found 50% to 70% of practices had a unilateral cut or termination. Similar laws in California, Florida and New York were followed by big reimbursement falls.
- Anesthesiologists were long well paid by direct payments from patients and insurers. Over 20 years, government underpayment has threatened many groups' financial stability. Groups now lean more heavily on hospital and facility subsidies. The No Surprises Act is likely to reduce reimbursement further. Morewood and colleagues predict a shift from insurer contracts to direct hospital contracts. In that model anesthesiologists supply service lines, procedural teams and surgical homes.
Quality and Safety
- The 1846 ether demonstration revolutionised surgical care. A short time later came the first death attributed to anesthesia. For the next century, anesthesia deaths remained distressingly common. Beecher and Todd estimated that from 1948 to 1952 anesthetics killed more Americans than polio. Access to care then expanded fast with Medicare and Medicaid. Continued harm brought rising malpractice actions and rapidly rising insurance costs.
- In 1982 a television programme, 'The Deep Sleep: 6,000 Will Die or Suffer Brain Damage', aired. It added public pressure to the existing malpractice crisis. That accelerated ASA efforts on patient safety. ASA President Ellison C. Pierce, Jr spearheaded the response. Actions included founding the Closed Claims Project and the APSF. The ASA also approved its Basic Standards for Intraoperative Monitoring.
- The ASA and the University of Washington at Seattle started the project in 1984. A 'closed claim' is a malpractice case that has finished, so the whole record can be studied. It analyses closed claims to find trends in anesthesia-related patient safety. By 1999 the project had reviewed 4,000 claims; by 2011, almost 9,000. It has produced more than 60 peer-reviewed publications. Topics span airway management, obstetric anesthesia, chronic pain and monitored care.
- Closed Claims data helped promote pulse oximetry and end-tidal carbon dioxide monitoring. It guided development of the ASA difficult airway algorithm. Reviews improved understanding of rare but serious events like postoperative visual loss. In the 1970s, 64% of claims involved permanent or disabling injury or death. That fell to 41% by the 1990s; death and brain damage were still 35% from 1990 to 2007. Claims for nerve injuries and for acute and chronic pain management have increased.
- The APSF was founded in 1985: 'no patient shall be harmed by anesthesia'. In 1996 the AMA and partners founded the National Patient Safety Foundation on that model. The movement was acknowledged in the 1999 Institute of Medicine report 'To Err is Human'. It also made the front page of the Wall Street Journal in 2005. Recent work highlights communication during adverse events. It also highlights rising claims from non-operating room locations.
- Fall in anesthesia-related mortality
- Technology was one driver: pulse oximetry and capnography. Pulse oximetry = a finger clip reading blood oxygen continuously. Capnography = measuring exhaled carbon dioxide, confirming the tube and the breathing. Research, education and advocacy were the other drivers. Together they took mortality from 64 per 100,000 to about 0.5 per 100,000.
- Because the mortality gains are so large, the quality focus has moved on. It has shifted from the single anesthetic to the entire perioperative period. Timely prophylactic antibiotics significantly reduce postoperative wound infection. Careful hand hygiene and disinfecting the anesthesia workstation may lower infection risk. That applies both during cases and between them.
- Postoperative cognitive decline is a current top APSF safety priority. Opioid-related harm is another. The National Anesthesia Clinical Outcomes Registry (NACOR) collects national outcome data. So does the Multicenter Perioperative Outcomes Group (MPOG). These registries help understand postoperative kidney and myocardial injury.
- Definitions of safety culture terms
- Many safety goals have measurable numbers; others are about human interaction. One APSF priority is helping departments build and keep a 'culture of safety'. Another is improving teamwork through collegial communication and collaboration. These goals are fundamental but very hard to establish and even harder to measure. National bodies can only define the culture and encourage departments to create it. Hospitals, departments and their leaders must do the actual implementing.
- Production-focused
- Focusing only on efficiency and productivity can squeeze out patient safety. High-reliability organisations (HROs) recognise that humans are imperfect. They also recognise that people work in imperfect settings. HROs use human factors engineering to optimise systems and processes. Human factors engineering = designing the work so the easy way is the safe way. Central to this are psychological safety and just culture.
- Committed leadership and well-designed systems are crucial to a robust safety culture. But individual clinicians are key stakeholders who must be engaged. Leaders must build easy-to-use reporting systems for nonroutine events. Leaders must praise, not punish, those who report, and give feedback on changes made. Individual clinicians must recognise why reporting matters - and actually report.
Regulation of Anesthesia Services
- The regulatory bodies governing anesthesia practice
- CMS conditions of participation define and regulate all anesthesia services in a facility. Anesthetic services must be organised under a qualified doctor of medicine or osteopathy. The anesthesia director oversees all anesthesia and moderate sedation in the facility. That covers anesthesia care providers and non-anesthesia providers alike. The director owns all anesthesia policies, staffing and quality alignment. The director also sets minimum qualifications for those giving moderate sedation.
- Organisation of hospital anesthesia services
- Must be done by someone qualified to give anesthesia, within 48 hours before induction. Review the medical and anesthetic history, medications and allergies. Interview plus a focused examination covering at least airway, cardiac and pulmonary systems. Document the ASA physical status. Identify potential anesthesia problems and contraindications; order and review any tests. Document the plan - technique, drugs, extra procedures - and the risk-benefit discussion.
- Required for all general, regional and monitored anesthesia care cases. Patient name and medical record number, plus names of all anesthesia care team members. An accurate report of every drug given: name, dose, route and time. Anesthetic technique, patient position, vascular access and airways used. Intravenous fluids and blood products where applicable. Vital signs on a time grid per ASA standards, plus all complications and their management.
- Done by a qualified provider once the patient can participate or is back at baseline. Assess airway patency, respiratory function and cardiac function. Assess mental status and temperature. Assess pain, nausea and vomiting, and hydration status. Must be completed within 48 hours of transfer to the recovery area or ICU. Facilities must meet the conditions of participation to be paid by Medicare and Medicaid.
- The Joint Commission (TJC) is an independent, not-for-profit organisation founded in 1951. It sets standards for and accredits hospitals and many other health care facilities. Each accredited hospital is surveyed every 3 years. Surveyors check compliance with both CMS and TJC standards. The aim is to confirm the care given is safe, efficient and effective. TJC also certifies 'Centers of Excellence' in areas like cardiovascular medicine and stroke.
- National Patient Safety Goals
- National Patient Safety Goals (continued)
- National Patient Safety Goals (continued)
- National Patient Safety Goals (continued)
- Health matters are deeply personal, and clinicians have a duty to protect privacy. The Health Insurance Portability and Accountability Act (HIPAA) of 1996 addresses this. It mandates standards preventing personal health information (PHI) spreading without consent. The law defines PHI and codifies when it may be shared. Rules apply to insurers, facilities, pharmacies and individual providers. HIPAA keeps adapting to changes in biomedical innovation, public health and informatics.
- How a HIPAA complaint is investigated
- Possible HIPAA violations may be investigated by the Federal Office of Civil Rights. The Department of Justice may also investigate. Violators can face severe professional consequences. They can also face financial penalties or criminal charges. Organisations are separately subject to state rules, usually via a Public Health department. At times state authorities act on behalf of CMS.
- Anesthesiology is unique among medical specialties. The work involves complex machines, invasive procedures and potent medications. Only anesthesia providers prescribe, prepare and give potentially lethal drugs themselves. That happens without direct involvement of a pharmacist or another provider. So CMS, TJC and state surveyors watch anesthesia departments closely. Deep knowledge of and careful compliance with the rules avoids citations and penalties.
Departmental Support and Infrastructure
- Modern anesthesia practice spans the whole continuum of health care. Services run in operating rooms, obstetric units, interventional and radiology suites. Also intensive care units, endoscopy units and pain clinics. Also free-standing ambulatory centres and doctors' offices. Each location needs its own equipment, drugs and support.
- Technicians ensure anesthetising locations and equipment are clean, stocked and ready. They manage supply inventory with the facility's materials management staff. Depending on regulation and training they may do quality control and point-of-care testing. They may set up and operate cell-saver devices, which recycle the patient's own blood. They may perform disinfection or sterilisation of reusable equipment.
- Support services behind an anesthesia department
- Every department needs a close relationship with its IT and EHR departments. Anesthesia information management systems (AIMS) are electronic anesthesia records. AIMS should interface with all anesthesia delivery systems and monitoring equipment. Ideally AIMS is fully integrated into the facility-wide electronic health record. That gives decision support and streamlines workflow, freeing clinicians from charting. AIMS must be supported by readily available, knowledgeable staff.
- Pharmacy support is instrumental to safe anesthesia practice. Pharmacists are an excellent source of knowledge and advice. They can help design and implement clinical pathways and protocols such as ERAS. They help develop order sets, analyse new medications and plan for drug shortages. They can work with IT to build warnings and contraindications into the EHR and AIMS. They can also collaborate on research projects.
Employment, Careers and Personal Wellbeing
- Future supply and demand depend on changes in health care coverage. An ageing population raises demand for surgery and therefore anesthesia. The rising number of women in the physician workforce affects supply patterns. Increasing cost pressures push practices to change staffing models. Shifting modes of health care delivery move work between settings. Predicting future employment prospects, however, is a fraught exercise.
- A 1983 report predicted a shortfall of 2,700 anesthesiologists by 1990. The 1994 Abt Report, commissioned by the ASA, predicted a gross oversupply instead. US graduates choosing anesthesiology fell from 1,609 in 1992 to a nadir of 493 in 1997. Trainee numbers rebounded, but the US still had a significant shortage in 2004. Later reports suggested an ongoing shortage in 2007 but a small surplus in 2013. So forecasts have repeatedly been wrong in both directions.
- Relative growth in physician supply by specialty
- Since 2013 the US supply of anesthesiologists has steadily increased. Between 2016 and 2020 the number of US anesthesiologists grew by 9%. That growth outpaced other specialties. Regional differences do exist within the country. Current reports suggest continued growth in both supply and demand.
- Growth in anesthesiologists and nurse anesthetists over a decade
- Monthly trends in internet job postings for anesthesia providers
- Subspecialty-trained anesthesiologists will likely stay in high demand. But prospects may vary a lot between subspecialties. A 2018 analysis predicted pediatric anesthesiologists rising 5.4 to 7.4 per 100,000 children. Average inpatient pediatric cases per specialist would fall from 262 to 191 per year by 2035. That may make purely pediatric jobs harder for new graduates to find. In contrast, ACOG maternal levels of care should raise demand for obstetric fellows.
- Your first practice is important, but is unlikely to be your last. Up to 70% of physicians leave their first position within 5 years. Your personal network of friends, colleagues, family and alumni can introduce employers. Websites such as Gaswork.com and the Anesthesiology Career Center post active listings. Journal advertisements and recruitment agencies offer other routes.
- Where do you want to practise - coast, city, suburb or rural? Academic or private practice? Full-time or part-time? Independent contractor, partner or employee? Will you do your own cases, or supervise CRNAs or CAAs? Will you teach residents, and what kind of cases will you do? Will you have non-clinical duties, and what research support exists?
- Base salary and retirement benefits, including any employer contribution. When you qualify for those contributions and when you are vested. Whether health insurance is provided, and how much vacation and sick time. Sign-on bonus, its terms, and whether a moving stipend exists. How much continuing medical education (CME) money is provided per year. For partnership tracks: how long, is there a buy-in, and are there partner classes?
- Whatever the job, read and understand your contract carefully. A local health care attorney or a national service can help review it. Watch for a noncompete clause - it can limit where you work if you leave. Job offers are negotiable, even when some items such as base salary are fixed. A recruitment agent can negotiate for you; negotiating for yourself is also acceptable. Many resources exist to help refine negotiation skills.
- Wellness and burnout prevention have become much-discussed topics. The COVID-19 pandemic heightened attention to both. Burnout first appeared in ICD-10 as 'problems related to life management difficulty'. ICD-11 defines burnout as an occupational phenomenon from chronic workplace stress. It is a work syndrome, not a medical diagnosis of the person.
- The three dimensions of burnout
- Being a young physician is a risk factor. So is being female, and having children. Residents suffer higher rates than medical students or those who finished training. Some studies report midcareer physicians have the highest rates of all. That is linked to longer hours, higher call burden and more emotional exhaustion. Late-career physicians report less burnout, thought to be a 'survivor effect'.
- Long work hours increase burnout risk. So does the number of nights on call per week. Unclear job expectations add to the risk. A workplace culture that promotes bullying is another factor. Personality traits such as neuroticism and anxiety are associated with higher rates. So is the use of negative coping strategies.
- Systems-based strategies
- Preventing burnout requires a multitiered approach. Truly effective prevention and treatment strategies are yet to be identified. Institutions should promote a culture of equity and wellness. Work-hour flexibility may increase job satisfaction and prevent burnout. Individual strategies can help, but are unlikely to succeed in isolation.
- Financial stress can be a major contributor to burnout. Many medical students graduate with staggering amounts of debt. Some anesthesiologists delay saving for retirement for decades. In that environment all physicians need a basic understanding of personal finance. The three core topics are debt, savings and protecting assets.
- Core areas of personal financial planning
- Attending college and medical school is expensive. In 2021 about 73% of medical students graduated owing money. Their mean debt was $203,062. Almost 20% owed $300,000 or more. Managing this debt needs careful planning and knowledge of the options.
- Medical student education costs, debt and loan repayment
- Medical student education costs, debt and loan repayment (continued)
- Both the federal government and private organisations offer student loans. Federal loans often carry lower interest rates than private loans. They also offer flexible repayment and loan-forgiveness options. Income-driven repayment (IDR) plans base monthly payments on your income. Public Service Loan Forgiveness may apply to government or not-for-profit employees. Private loans have fewer deferral options, but can sometimes be cheaper.
- Compound interest is a mechanism by which an individual can amass wealth. Compounding means the interest itself earns interest, so growth accelerates. But compound interest requires time. Saving for retirement should start on your first day of work. Medical graduates often start saving years after their fellow college graduates. Residency delays it further, so anesthesiologists must be even more financially savvy.
- Learning to budget requires diligence. Newly graduated practitioners frequently spend too much of their increased income. Consider your debt burden and total yearly expenses, now and in retirement. Consider how many years you plan to work before retiring. Then decide how much to allocate to debt repayment and to retirement savings. A simple rule suggests saving at least 20% of gross salary to retire comfortably.
- Common vehicles include the IRA, 401(k), 403(b) and 457(b) accounts. These are funded with 'pretax' dollars, deducted before income tax is paid. You then pay income tax as you withdraw money in retirement. Roth accounts are funded with 'post-tax' dollars and withdrawals are tax free. Consider a Roth when your current tax rate is lower than the expected retirement rate. Employers often match contributions - take full advantage of that free money.
- Most savings should be invested in something other than a savings account. Target funds shift money from stocks to bonds as the target date nears. They are simple but charge higher management fees and give no control over assets. A mutual fund pools money from many investors to buy stocks, bonds and short-term debt. Its holdings are called the portfolio; each share is part ownership of the fund.
- Active funds
- Disability insurance pays a percentage of income if illness or injury stops you working. As many as one in seven physicians has to use disability insurance. Policies usually exclude preexisting conditions, so buy while young and healthy. Many carriers offer trainee discounts with the option to add cover as salary rises. Group policies from employers or societies are cheaper and suit preexisting conditions. Individual policies are 'portable' - they belong to you regardless of where you work.
- A life insurance policy pays money if you die. That money supports partners, children and others who rely on your income. Whole, variable and universal life policies blend insurance with investing. They are more expensive than term-life insurance. A term policy insures your life for a set number of years, usually 30, at a fixed premium. The premium is based on your age at the time of purchase.
- Also called professional liability insurance. It protects physicians against lawsuits over acts and omissions during patient care. Policies are often in millions, described as, for example, $2 million/$4 million. The first number is cover per case; the second is the total the insurer could pay per year. For most physicians the employer selects and pays for the malpractice insurer.
- Claims-made
The Future of the Specialty
- The 2015 Lancet Commission on Global Surgery highlighted disparities in surgical access. Low- and middle-income countries (LMICs) are worst affected. A major deficiency is the lack of trained anesthesia providers. Global health organisations have shifted away from short-term 'mission' trips. The focus is now on education and training programs for clinicians living in LMICs. The goal is sustainable capacity in the local health care system.
- First is simple altruism - the belief every patient deserves safe anesthesia care. Global health education also gives professional benefit. You teach others, but you also learn a very different practice perspective. Cross-cultural work enriches one's own life. Local, national and international organisations all provide routes to take part.
- Climate change is a global reality. Health care produces 5% to 8% of global greenhouse gas emissions. National and international anesthesia societies have begun to address this. Inhaled anesthetics, including nitrous oxide, are potent greenhouse gases. They account for about 3% of the total health care climate footprint. They make up to 50% of the climate impact of surgical care.
- Atmospheric lifetime = how long the gas keeps trapping heat before it breaks down. Sevoflurane's atmospheric lifetime ranges from 1 to 5 years. Nitrous oxide persists for 114 years. So the choice of agent has consequences that last far beyond the case. The next figure lists the greenhouse gas figures for common agents.
- Greenhouse gas emissions of common inhaled anesthetics
- US hospitals produce over 5 million tons of waste each year. An estimated 20% to 30% of that waste is produced in the operating room. Single-use plastics make up about one quarter of this damaging waste. These include face masks, breathing circuits and intravenous tubing. Up to 60% of the waste is recyclable. The mantra 'reduce, reuse, recycle' is a useful framework for the problem.
- Weighing the carbon footprint of anesthetic options
- Artificial intelligence (AI) is the study of algorithms that let machines solve and decide. Machine learning is a tool helping drive the development of AI. Machine learning = the program improves from examples rather than fixed rules. AI and machine learning will likely have significant future impact on anesthesia care. Several areas of anesthesia-related AI research are already active.
- Current areas of anesthesia AI research
- AI can provide a staggering amount of information. What to do with the data, and when and how to act, are still largely unknown. An algorithm is only as accurate as its inputs. Reliable inputs are hard to get in complex patients and dynamic surgical situations. In a specialty where mistakes can be deadly, machine learning must be perfect. A further risk is 'deskilling' of clinicians as practice relies on automated processes.
Summary and Key Points
- Organisation, self-regulation and standards mark the shift from trade to profession. Anesthesiology was fully recognised in 1941 when ABMS approved the ABA as independent. The growing number and variety of subspecialty fellowships reflect a widening scope. The ASA introduced the perioperative surgical home to reach triple aim and value goals. Well-implemented ERAS protocols shorten stays, cut costs and reduce complications. ERAS built into PSH models may give the best results of all.
- Anesthesiologists are well placed for senior leadership roles beyond the operating room. ABA certification demonstrates expertise; accredited residency graduates are eligible. Recertification runs through MOCA, moving to a 5-year cycle from 2024. Reimbursement needs a diagnosis code, a procedure code and a matching anesthesia code. Operating room anesthesia also needs an anesthesia start time and end time. Low government payment plus balance-billing limits push groups onto hospital subsidies.
- Anesthesiology was first to build a systematic approach to patient safety. The result was a dramatic fall in anesthesia-related mortality. Focus has shifted to morbidity: wound infection, cognitive decline and opioid harm. Leaders must promote psychological safety, but individual clinicians are key too. Regulatory surveyors scrutinise anesthesia departments closely, so compliance matters. A well-organised department needs varied support staff and services to work safely.
- Current trends suggest continued growth in supply of and demand for anesthesiologists. Clinicians continue to report high levels of burnout. A multipronged approach is needed to mitigate burnout and promote wellness. All physicians need a basic understanding of personal finance. That means debt management, saving for retirement and protecting assets. If you use a financial advisor, understand how they are paid - it shapes their advice.
- Anesthesiology today is stronger than ever, with subspecialties across the care continuum. The specialty no longer confines itself to the operating theatre. It must keep expanding its influence beyond the surgical act itself. It must relieve all types of pain while reducing the role of opioids. It should collaborate on ERAS protocols and lead perioperative surgical homes. And it must care for its most precious resource - its own people.
- References
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- Barash, Cullen, and Stoelting's Clinical Anesthesia, 9th Edition