In Reply:-I have great respect for the leadership Dr. Ellison has contributed to our specialty. We have all benefited from his knowledge and experience. I have no doubt that his reluctance to accept the message in my editorial [1] reflects the opinion of many anesthesiologists. I welcome the criticism and hope the result will be a continued constructive debate.

Although Dr. Ellison disagrees with my historical interpretation of the development of the Anesthesia Care Team (ACT) concept, we do agree that the ACT concept permitted the knowledge and skills of the anesthesiologist to be available to more patients by means of physician extenders. Evidently my suggestion that the ACT concept added value to our services is inferred by Dr. Ellison to mean that I advocate “that the direct administration of anesthesia by physicians is history!” I neither stated, nor suggested, such a position in my editorial. I remain a staunch defender of direct physician administration and supervision of anesthesia as the primary contribution of our specialty to patient safety in the operating room. What I advocate in the editorial is that anesthesiologists must now add value to their core service (direct administration and supervision of anesthesia) to maintain their fair share of healthcare dollars.

I would like to call particular attention to Dr. Ellison's position that he does “not concur” with my assertion that we are presently perceived as far too expensive for the limited services we render. Although I fully appreciate that Dr. Ellison does not agree with that perception, I find it perplexing that he denies such a perception exists. All one has to do is read the recent literature [2,3] or discuss the matter with a hospital administrator or managed care executive to be convinced that the perception not only exists, but is pervasive. As I stated in my editorial, “the validity of the perception is irrelevant!” In my opinion, denial that the perception exists is unjustifiable. I support thoughtful and informed positions [4,5] that encourage us to gain a realistic understanding of what is happening around us and to become informed advocates for our profession and patient safety.

Finally, my suggestion that we must add value to our basic service is neither a disservice to those who practice anesthesiology nor a denigration of the value of direct administration of anesthesia by physicians. Rather, it is a wake-up call that there is an abrupt presence of new economic pressures that are harsh and unforgiving. We must recognize and understand these phenomena to properly evaluate our response. No matter how much we disagree with what is happening, we must consider how others perceive us and realistically evaluate our position. To do less dooms us to failure.

Barry A. Shapiro, M.D.

James E. Eckenhoff Professor and Chair; Department of Anesthesiology; Northwestern University Medical School; Chicago, Illinois 60611

(Accepted for publication July 29, 1997.)

Shapiro BA: Why must the practice of anesthesiology change? It's economics, doctor! Anesthesiology 1997; 86:1020-2.
Bierstein K: Hospital consulting firm advocates greater autonomy for nurse anesthetists. ASA Newsletter 1997; 61(3):27-8.
Cromwell J: Health professions substitutions. A case study of anesthesia. In A. S. Health Workforce Power, Politics and Policy. Washington, DC, Association of Academic Health Centers, 1996, pp 219-28.
Longnecker DE: Navigation in uncharted waters: Is anesthesiology on course for the 21st Century? Anesthesiology 1997; 86:736-42.
Vaughan RW: It's ours to choose or ours to lose. ASA Newsletter 1997; 61(7):26-8.