The pandemic we have experienced over the last 18 months will impact the future of anesthesia practice and our specialty's place in health care for years to come. Anesthesia practice will change, as it is influenced by many factors – and the opportunity to refine and redefine our roles and responsibilities over the next decade must be undertaken.
As we prepare to cast our eyes to the future, Anesthesiology in 2030:
“In 2021, as the American health care system began to recover from the COVID pandemic, it was battered by a fourth COVID surge. The Delta variant was the most predominant and could infect both unvaccinated and vaccinated persons, who, in turn, can infect others. This represents a return to ‘square one’ with respect to transmission; however, the breakthrough infections among the vaccinated will hopefully remain mild. Numerous anesthesiologists are acknowledged as leaders as our specialty addresses the challenges COVID brings, and our specialty undertakes a reassessment of our role and scope of practice. Meanwhile, the continued fragmented government-level responses to the pandemic bode poorly for the potential of a crisp, unified response to stop, or even mitigate, another wave of COVID infections in the United States. After more than 18 months of ‘all hands on deck’ action, the health care delivery system is tired.”
With this backdrop, consider the following dystopian outcome scenario at the far end of the change spectrum, which we could experience from the pandemic's impact on anesthesiology and surgical care in 2030:
“An important discovery changed the face of anesthesia during a period of health care delivery crisis, which was fueled by a wholesale exodus of nurses and physicians from the workforce. When Google moved forcefully into health care, it bought IBM as a defense move to nullify any residual threat from IBM's Watson product. The merged data and technical teams of Google-Business Machines (Google-BM) uncovered that the observed physiologic variability during anesthesia that impacts outcomes is attributable to a newly discovered stress response. Google-BM then merged with Pfizer (to become G-B-P) as part of a strategy to corner the market on modulating this response. G-B-P developed an infused stress modulator given at induction that became standard of care, so the only real operating room challenges anesthesia personnel then faced after induction could all be mapped to the consequences of hemorrhage. Concomitantly, ‘robotic’ and minimally invasive surgery took over. In 2028, the first robotic, minimally invasive caesarian section was performed in just under 11 hours. When the Supreme Court ruled that monopolies are good for Americans, G-B-P acquired Intuitive Surgical and purchased hospitals across the country. Uber moved into self-driving surgical and procedural anesthesia as a vendor in G-B-P's wholly owned health factories. Fortunately, patients remain steadfastly difficult targets for autonomous robotic vascular cannulation systems, and health factories with affable, empathic anesthesia personnel to greet patients entering their perioperative systems continue to outscore competitors on HCAHPS.”
Implications of our current reality
Aspects of this far-fetched scenario could impact our practices, but historical trends suggest the state of anesthesia in 2030 is likely to be comfortingly similar to current anesthesia practices. In fact, over the last three decades, practice advances, new drugs, and new monitoring techniques have not changed the provider-patient relationship in a traditional procedural environment. Individuals or teams of clinicians use familiar drugs and devices to personally navigate patients through painful and physiologically stressful procedures in a highly regulated reimbursement environment largely based on billable time. The weighty frameworks of regulation and organized medicine around anesthesiology reimbursement are as strong a stabilizing force as the culture of personal attendance and vigilance in the care of the anesthesia patient. These forces, which include traditional fee-for-service payment models, seem almost insurmountable when considering the potential for true disruption of anesthesiology practice. Recently, the minimal impact on quality or costs of “alternative payment models” and incentive compensation proposals demonstrates that without significant reevaluation and assessment of every aspect of both clinical care and payment, it is plausible that anesthesiology in 2030 will be only incrementally changed from today. But there are factors that could alter this equation. Disruption could occur in at least two ways: from the origination and development of a “replacement technology” (disruptive innovation as described by Christenson) or from an overwhelming external force whose impact the specialty cannot avoid (as described by Grove in “Only the Paranoid Survive”). In both frameworks, “disruption” really means a fundamental change in the way things work in that industry, often resulting in the demise of the leading organizations. The disruption is often misused to describe things to which organizations such as industries and medical specialties must adapt, when it actually describes completely upending the specialty. Under that meaning, disruption is a concept industries and medical specialties seek to avoid.
The electronic health record and its impact on clinical care, or the impact of clinical guidelines that affect physician decision-making, and adoption of robotics in medicine are all examples of changes that possibly could be considered “innovations” and have affected clinical practice across medicine, though all are questionable in terms of their ability to catalyze a replacement of the status quo. However, anesthesiology specifically has been a target for disruptive innovation for some time. The Sedasys sedation system was a warning shot. The new approach to sedation delivery showed promise, and it was effective in its target application. It might have gained a foothold, but numerous factors contributed to its demise, including 1) the fact that it was priced like a general anesthetic but didn't come with the convenient user interface of an embodied anesthesiologist or CRNA, and 2) many practices that realized significant revenue from endoscopic procedure anesthetics vigorously defended the traditional practice model.
Sedasys failed because anesthesiology was not eager to cede procedure sedation territory – but the financial pressure favoring replacement via disruptive innovation remains. Medicare payments for anesthesia services are currently undervalued relative to payments to other specialties. Anesthesia practices cannot survive on professional fee-for-service clinical revenue alone, and provider scarcity has forced compensation increases. Consequently, many anesthesia practices are subsidized by contracting and employing health entities. Payors (who, in turn, represent employers) face spiraling health care costs and are pushing back against rising costs. They would likely welcome a disruptive replacement.
Turning to the potential for an overwhelming external force to disrupt anesthesiology, the ongoing impact of the COVID pandemic and its aftermath on health care workforce availability must be considered. Repeated COVID case surges and their impact on surgical care, critical care, and the workforce will have lingering effects. Delayed health care delivery now affects how hospitals and health systems operate, as it has challenged traditional bed capacity, resource allocation, and finance concepts. Scope-of-practice challenges continue to undermine anesthesiologists' and anesthesiologist assistants' collaborative relationship with certified registered nurse anesthetists (CRNAs) as part of the care team model. Simultaneously, the pressures and personal risks associated with COVID patients have taken a toll on all providers. Enough physicians and nurses could retire early and cause a notable health care workforce reduction.
The strong regulatory framework around payment, which has largely dictated the pragmatics of OR and procedural anesthesiology for three decades, is only as strong as the momentary decisions of regulators. A persistent inability to field a reasonably priced workforce could catalyze an enforced separation of anesthesiologists and CRNAs into wholly independent and non-overlapping (nor overlappable) provider groups. This could be effected by a rule-making change, not a legislative one. Prior experiences with the state-level physician supervision “opt-out” rule and the advancing effort to make CRNAs independent providers in the VA system are early indicators that this could realistically occur if not well guarded against.
A critical consideration is whether our profession is “between a rock and a hard place” or if this is the end of anesthesiology as we know it. The response is a resounding “NO”! The opportunities for the anesthesiology workforce and sustainable anesthesia practices allow us to confront the risks of disruption.
Where do we go from here?
How can we navigate anesthesiology to a favorable position in 2030? Over the next decade, anesthesiology needs to maintain a balance for all providers, as we have successfully done for many generations, between individual rights and societal obligations. Each member of a society has individual rights as a human and societal obligations as a citizen. Collective success as a society depends on most, or all, members voluntarily sublimating some of their individual rights in deference to society as a whole. In the middle part of the 20th century, Americans moved toward the “citizen” side of this pendulum arc, establishing programs like Social Security and Medicare to shore up a basic standard of living for all. For some time, the pendulum has swung in favor of individual rights and prerogatives, even at the expense of nearby and visible fellow citizens. This balance is also at work in anesthesiology.
To avoid a fundamental disruption, anesthesiologists recognize and help direct the forces favoring change. First, we must do whatever is necessary, collectively, to ensure that high-quality anesthesia care is available to all who need it, in the right setting, with the right resources and support at a reasonable and fair price. Any new models must also balance patient and health system needs with the personal and professional well-being of providers. Anesthesiologists have the ability, as a profession, to commit to fulfill these diverse obligations and reassess care models in a variety of new settings, utilize new technologies, and participate more broadly across the continuum of care.
Anesthesiologists have an added calling. Throughout the recent history of our specialty, the notion that pre- and postoperative care is bundled into the payment for intra-operative anesthesia has highlighted the tension between individualism and citizenship. The professional obligation to provide excellent preoperative consultation in advance of surgery, with focused attention on preoperative optimization, provides a level of service and participation beyond the intended routine preoperative visit. Effective preoperative assessment and management services better prepare high-risk patients for surgery, reduce costs, reduce readmissions, and optimize care. Similarly, the need to improve near- and long-term postoperative participation in optimizing outcomes through enhanced recovery programs is widely acknowledged. These programs extend our patient care beyond the “required” postoperative visit to identify any adverse anesthetic consequences. Some anesthesiologists protest the expectation to take on this broader role, but most recent trainees recognize it as part of the scope of anesthesia practice. A reevaluation of our specialty's perioperative role for anesthesiologists will address our collective, inescapable obligation and commitment to society from anesthesiologists, health systems, and payors to identify ways to pay for services based on value.
Equally important is the expectation that anesthesiologists become more engaged leaders, problem-solvers, calming voices, and organizers in the health care facilities that we collectively depend upon. To accomplish this, individual anesthesiologists must further participate as citizens in their hosting facilities, work collaboratively with colleagues and system leaders to evaluate what we do, and define new models of care that address patient needs without regard to whether we are directly compensated for these expanded roles. Successful civilizations navigate down the middle of the “human being” versus “citizen” pendulum arc. Our specialty's future success as a profession, given all the strong forces arrayed around us, depends on accepting broader roles and responsibilities, identifying barriers to quality and safety, and addressing them so that regulators do not undermine our efforts. These goals can be accomplished most successfully and meaningfully when done by those “on the front lines” rather than dictated by the C-suite or regulators.
Since at least the beginning of the last century in America, there has been an implicit contract between society and medicine. Patients, and society in general, expect us to be competent, provide evidence-based, high-quality care consistent with patient goals, demonstrate leadership within health care systems, provide expert advice and counsel to society on matters of health, and give primacy to the patient's interests. Conversely, medicine expects a high level of trust from society, the ability to self-regulate, to have adequate and socially responsible resources, and a reasonable level of remuneration. This social contract has slowly unraveled in recent years. A rededication to the basic principles upon which anesthesia practice was founded will create a bright future for anesthesiology, and the practice will continue to be rewarding.
“Collective success as a society depends on most, or all, members voluntarily sublimating some of their individual rights in deference to society as a whole. In the middle part of the 20th century, Americans moved toward the ‘citizen’ side of this pendulum arc, establishing programs like Social Security and Medicare to shore up a basic standard of living for all. For some time, the pendulum has swung in favor of individual rights and prerogatives, even at the expense of nearby and visible fellow citizens. This balance is also at work in anesthesiology.”
The U.S. prevailed in World War II, arguably the most important event of the past 100 years, foremost among all the Allies because of autonomous small-unit actions, frequently conducted by impromptu teams, and guided by the principles and overall objectives set out by their leaders (the Allied Chain of Command). Those citizen soldier teams were a sparkling example of that cultural principle by which our nation has succeeded since its founding and by which our specialty succeeds in its mission daily: in the OR, teams can form spontaneously, address a problem confidently and in a timely manner, guided by principles and acting with creativity, autonomy, and ownership, on their own. We can bring this culture out of the OR and into society at large. We are the creators of anesthesiology in 2030, and we can create anesthesiology's bright future.