To the Editor:

I was intrigued by the use of the metaphor “Anesthesia's Low-Lying Fruit” by Orkin and Duncan1in their Editorial View entitled “Substrate for Healthcare Reform: Anesthesia's Low-Lying Fruit.” I believe that it refers to the absence of data showing a major benefit conferred by anesthesiologists providing sedation for colonoscopy compared with other personnel using older drugs. The study for which the editorial was written, Alharbi et al. ,2did not attempt to look for any benefits (or harms) from anesthesiologist involvement in colonoscopy. That study looked strictly at the demographics of the providers of sedation for outpatient colonoscopy. The absence of documented benefits presumably provides the low-lying fruit for healthcare benefit czars to pluck. Orkin and Duncan state that “Anesthesiologist involvement in colonoscopy sedation in the absence of medical indication... may be one vignette among myriad throughout United States health care in which low-benefit services and procedures result in disproportionate expenditures.”

One place to start looking for benefits (or harms), rather than making assumptions from untested hypotheses, might be to ask the patients. Could a randomized controlled trial that compared midazolam and narcotic administered by registered nurses to the addition of propofol to that drug regimen by an anesthesiologist be performed? If such a trial included patient satisfaction as an outcome benefit, I will wager it would be higher with propofol. As would gastroenterologist and nursing personnel satisfaction because of increased throughput in the facility and less struggling with patients insufficiently sedated during the procedure who then sleep for hours afterward. I think only those who pay for anesthesiologists' services might be less satisfied.

To carry Orkin and Duncan's metaphor along further, to save money, why not instead prune anesthesia services from cataract surgery performed with topical anesthesia? That procedure seems to me to be less stressful than teeth cleaning by a dental hygienist. Cataract-induced discomfort is far under that of a colonoscopy. Or, as one patient told me: “I've had more painful haircuts than that cataract operation.”

Crouse Hospital, Syracuse, New York.


Orkin F, Duncan P: Substrate for healthcare reform: Anesthesia's low-lying fruit. Anesthesiology 2009; 111:697–8
Alharbi O, Rabeneck L, Paszat LF, Wijeysundera DN, Sutradhar R, Yun I, Vinden CM, Tinmouth J: A population-based analysis of outpatient colonoscopy in adults assisted by an anesthesiologist. Anesthesiology 2009; 111:734–40