In Reply:--Waun states that management of patient-controlled analgesia (PCA) by anesthesiologists fragments perioperative care and increases cost. Our contentions are merely that PCA may not be markedly safer or less complicated to manage than epidural analgesia and that the best-qualified personnel should manage PCA therapy. The application of multidisciplinary expertise of different physician and allied health providers, using an integrated teamwork approach, is one of the great advances of modern medicine and does not necessarily imply a fragmented and uncoordinated approach to patient care.

There is no reason why highly motivated surgeons cannot learn to manage PCA well, but in practice, they are less likely to be either as knowledgeable or as available to patients on the hospital wards as their anesthesiologist colleagues. In addition, any labor-intensive service, such as a very busy PCA service, is unlikely to arouse adequate interest from extremely busy health-care practitioners unless there is reasonable reimbursement for it. We wish this were not true, but it is. Too much of our medical care is driven by economics. We would like to be able to improve postoperative pain management solely on the basis of appeals to our colleagues for "empathetic and compassionate relief of postoperative pain"; it is unfortunate that improving reimbursement will be much more effective.

David C. Mackey, M.D., Consultant in Anesthesiology and Medicine, Department of Anesthesiology and Critical Care Medicine, Mayo Clinic Jacksonville, 4500 San Pablo Road, Jacksonville, Florida 32224–1865.

M. Kathleen Ebener, R.N., M.S.N., Clinical Research Nurse, St. Luke's Hospital, 4205 Belford Road, Jacksonville, Florida 32216–5898.