The Once and Future Kingdom of Anesthesiology

by
  • Chow, Harrison, MD
| Jul 28, 2013

“Mr. Abrahams, I can find you another 2 steps.”

— Actor Ian Holm as Olympic sprint coach, Sam Mussabini, in the 1982 movie, “Chariots of Fire."

The night is a different place altogether in a hospital. Sometimes if I’m in the hospital late, stuck on call, I’ll just wander the halls chatting with people, catching up under the ubiquitous fluorescent lighting, which acts as my sunlight. The hospital at night is a relatively quiet and deserted place: administrators, patient families and the majority of physicians have long since gone home. It is often also a relaxed environment and a quiet time for me to think.

Recently I was awoken at about midnight while on OB call for a routine labor epidural placement. After the epidural I got the all-too-frequent call about a “central line” in the ICU. While chatting with the team and putting in the line, another nurse came by to ask if I would help with the extubation next door. I abandoned all hope of sleep.

At some point in the hospital graveyard shift, the word got out – “there’s an anesthesiologist up and helping out!” That night, as I worked all through the hospital, putting in IVs, central and arterial lines, monitoring extubations and intubations, helping with sedation, altering pain orders and putting in the occasional epidural, I was left with a prevailing thought: With so much need and so many areas to share expertise, an anesthesiologist is never really unemployed in the hospital.

The next day, I thought about the economic impact of my overnight shift. In each instance, I helped patient care, but also I advanced each patient through his or her hospitalization, and in many cases probably saved a hospital day (if not a life). I made somebody some money out there, but this was largely unpaid work for me.

As an anesthesiologist, if I am the expert of ABCAA (airway, breathing, circulation, anesthesia and analgesia), why am I just tasked with the OR anesthesia? The simple answer is OR anesthesia is what I am primarily paid for. However, having an anesthesiologist available outside the OR throughout the hospital creates an ecology of anesthesia practice, which benefits patients both in and out of the OR — and larger benefits are sustained.

In a prior time, a different anesthesia practice existed where anesthesiologists managed all of hospital ABCAA. In what is described by old-timers as the “Golden Age of Anesthesia” (1960s and early 1970s), the anesthesiologists who largely founded the field were paid to cover the ABCAA functions of a hospital. The hospital and the operating room were a more dangerous place – our more modern monitoring, ventilators, drug delivery systems and anesthetics were in the process of being developed and invented.

The anesthesiologists in that era, made their skills available throughout the hospital, managing some of the most critical parts of hospital patient care. Survival was the driving metric then: As far as safety and suffering, ABCAA was the primary focus of patient care, placing anesthesiologists in the center of the action, with the hospital as their kingdom.

Today, the field of anesthesia is largely confined to operating/procedure room anesthesia, mostly because of a dis-coordinated payment structure. There is a lot of evidence that a new payment model may be created from either Accountable Care Organizations (ACOs) or changes in Medicare Parts A and B. This would change current payment methodology for anesthesiologists. One of the models I have heard about would lump hospital and physician payments together with the goal of reducing high intensity care and procedures.

This lumped hospital-physician compensation scheme, in the form of say an ACO, would break “quality” compensation measures into pre-hospital, intra-hospital and post-hospital epochs of care. In plain English, physicians would be financially incentivized to minimize hospital admissions (perform gatekeeper functions), length-of-stay, and re-admission in such an ACO structure.

Should that altered-payment-model day ever come – and I believe it will –  anesthesiologists will have a giant opportunity to influence hospital care in general, and hospital length-of-stay more specifically. I also suspect, however, that we would all take a pay cut, but at least I would get paid to carry out and oversee the range of do (or better yet manage) the ABCAA hospital jaunts that I currently perform without compensation.

In the 1982 Oscar-winning movie, “Chariots of Fire,” the British sprinter champion, Harold Abrahams, having lost a 100-meter race against future Olympic competitors, hires a famous sprint coach, Sam Mussabini, who promises him he can find “2 steps” in the race.

It strikes me that the 100-meter dash can be thought of as a throughput. In industrial language, a throughput describes a process consisting of a series of coordinated steps to move as efficiently as possible toward an outcome. A throughput analysis for the 100-meter dash, as described Sam Mussabini, would consist of a simple series of 40-50 running steps. A throughput in a patient’s care could consist of any range of steps, but would still strive to move efficiently toward a desired, positive outcome as a coordinated process.

What difference does 2 steps make in a competitive race or in a patient’s hospital stay? A typical operating profit margin for a hospital is 4-6%, or about 2 steps in a 100-meter dash. When hospital systems incentivize inpatient “efficiency,” whether through ACOs or some other payment model, anesthesiologists will have the opportunity to once again rule. This time, however, anesthesiologists will be managing more diverse and sophisticated processes and teams, deeply tied to hospital or health system profitability. In short, getting patients through the hospital as safely and quickly as possible, just like the old days.

Hospitals and ACOs need to know, your Anesthesia Department can find you 2 steps.  Nobody can do it better.

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See a re-enactment of Harold Abrahams’ 100-meter dash on YouTube, from the movie Chariots of Fire.

Dr. Chow is a frequent contributor to CSA Online First.  Currently he is in private practice and is the incoming Chair for the Department of Anesthesia at Good Samaritan Hospital, San Jose.  He also holds an adjunct community faculty position at Stanford School of Medicine and has a masters degree in Health Services Research in addition to his medical degree from Stanford.

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