Barbarians at the Gate
2009; Lippincott Williams & Wilkins; Volume: 109; Issue: 3 Linguagem: Inglês
10.1213/ane.0b013e3181af803e
ISSN1526-7598
Autores Tópico(s)Hemodynamic Monitoring and Therapy
ResumoAnesthesiology is at a crossroads. In some settings compensation outstrips revenue, supported by stipends to anesthesia groups from hospitals. At the same time, the number of anesthesiologists relative to demand seems to be declining. According to a draft report by the RAND corporation, there is an imminent shortage of anesthesiologists,1 and this will certainly exert further upward pressure on compensation. Meanwhile, government payers are signaling that reimbursements must decline. What will be the outcome of this developing conflict? In this issue of Anesthesia & Analgesia, Kheterpal et al.2 report the results of their most recent survey of workforce and finances in academic anesthesiology programs. Their notable findings are a continuing desire to hire more anesthesiologists into academic practice and another increase in the subsidy from hospitals to anesthesia groups (now $109,000/year per faculty full-time equivalent [FTE]) simply to maintain the status quo in terms of filled faculty positions. The figure represents the difference between revenue per faculty FTE generated by the department and the cost per faculty FTE borne by these same academic departments. One might worry that this subsidy represents the salary support required to keep the departments staffed, although the data of Kheterpal et al. do not prove causation. However, this dismal state of affairs is distressing for obvious reasons; academic departments train the residents who are our future. Academic anesthesia departments do virtually all of the research in anesthesiology, and they provide much of the care for complex cases. In the continuing gap between compensation and revenue, one can discern a concealed but fundamental challenge to anesthesiology, namely a disruptive change that could upend the foundational expectations about how anesthesia care is provided in the United States and perhaps elsewhere. To understand this potential threat, one must understand the notion of the disruptive innovation. Disruptive innovation was described in terms of products and the companies that make and buy them by Clayton Christensen in "The Innovator's Dilemma."3 However, the construct also applies to medical specialties and the services they provide. Generally stated, any product has a range of users who need differing degrees of performance from the product. This is certainly true in anesthesiology, where cardiac surgeons, for example, need more capabilities from their anesthesiologists than surgeons who specialize in minor outpatient procedures. Companies that make the most capable, reliable (i.e., high performance) products meet the needs of the high-end users who demand the most from such products. Such high-end customers are willing to pay high margins for performance, and thus are the company's best customers. Successful companies improve their products by responding to the needs of their high-end customers and seeking the most profitable opportunities. Figure 1 demonstrates, in graphic terms, the general relationship between the performance demanded from products by high-end users and the capabilities achieved by the makers of such products. Required performance of a product, technology (or medical specialty) is shown as two parallel lines on Figure 1. The upper line indicates the capability and performance required to meet the needs of the most demanding users. The lower line represents the capabilities required to meet the most basic needs of the users of a given product. The shaded zone between the lines represents the continuum between the minimum necessary and the highest required performance.Figure 1.: Relationship between the performance demanded from products by high-end users and the capabilities achieved by the makers of such products. Adapted from Ref. 3, with permission from Harper Collins Harvard Business School Press.Through diligence in attending to customer needs and investment in research, products almost always evolve as fast as or a little faster than the needs of the most demanding customers. Or, from a different perspective, there will always emerge a customer who can use all of the available capability in the best example of a product and will be willing to pay high margins. Companies aggressively pursue improved capabilities in their products to meet the needs of their best customers, illustrated by the top pointed line in Figure 1. They do this by pursuing a course of sustaining innovation, wherein the product's capabilities steadily improve, but still the core product itself continues to resemble the original on the dimensions of performance that the vast majority of users care about. Reflection on the history of technological, educational, and scientific development in anesthesiology indicates that the specialty has been on a steady course of sustaining innovation since its inception. At the other end of the continuum, low-end users are often problematic for makers of high-end products. If there is more than one potential supplier of products who meet low-end customers' needs, then all of the suppliers must compete on price, and profit margins must be low. In other words, for these low-end users, the product is simply a commodity for which the key distinction is price, rather than performance. Certainly, commodity users are not willing to pay a premium for increased capabilities that they do not need. Protecting their own financial interests, commodity customers are always on the lookout for a way to get their needs met for a lower cost. Occasionally, a new, different technology appears in the market that just meets the needs of the commodity users of the original technology. If the price is right, the low-end users will switch to the new, less capable technology. Initially, everyone is happy, including the purveyors of the original product. The new technology cannot compete at the high or even the middle end of the market, so it is not an obvious threat. Getting rid of the low-end commodity customers frees the industry leaders to focus on best meeting the needs of its high margin, high-end user customers. Over time, performance of new technology improves as it follows its own path of sustaining innovation, illustrated by the lower pointed solid line in Figure 1. If the price continues to be right, the new technology or product begins to take customers from the industry leader as its own capabilities inevitably improve. Eventually, the new technology captures the entire market. To see how this analogy might apply to anesthesiology, consider the two curves in Figure 1 to be the skills and knowledge required to give anesthesia for liver transplantation (top curve) and laparoscopic cholecystectomy (bottom curve). I chose these examples because they happen to be the two procedures that I do frequently, and so considering these may lessen the offense that could be given by presuming to establish more general hierarchies of difficulty in anesthesia practice. Through improved technology, training, and education, including subspecialty fellowships, the field of anesthesiology readily produces graduates who, as a group, are more than capable of handling the toughest liver transplant cases and for whom the laparoscopic cholecystectomy is mere child's play. What do we have to worry about? In advising would-be disruptive innovators where to look for opportunities, Christenson suggests looking for "jobs to be done" that are not currently well covered by current solutions. The Kodak FunSaver Camera is given as an example: at a time when film photography was being replaced by increasingly capable digital cameras, no one expected these buy-at-the-drugstore disposable cameras to be very successful. However, they provided a cheap way to take snapshots at a moment's notice, after which the user just dropped the whole thing off to be developed. The job to be done was on-demand photography. The FunSaver was a step on the pathway to the true disruptive innovation that allows on-demand, anytime snapshots: the digital camera that is ubiquitously present in the equally ubiquitous mobile phone. Analogously, there are numerous "jobs to be done" wherein patients have procedures entailing some form of discomfort or physiologic perturbation, for which anesthesiologists are not a perfect fit. This is not to say that anesthesiologists cannot do these cases, but rather that the multispecialty, fellowship-trained anesthesiologist is not analogous to the FunSaver or the phone camera. We are completely capable of performing these cases, but we bring too large a "tail" of complexity, equipment, expectations, and, above all, cost. Low-end consumers of anesthesia services regard the ability to safely produce a deeply sedated or anesthetized patient who is happy at the end of the procedure as a commodity, where the key differentiators—compensation and fit with the procedure area workflow—boil down to cost. The current commodity users of anesthesia services are ready for a solution that better meets their needs, and the products, technologies, and services that could provide this solution are already visible, albeit faintly. Consider the case of fospropofol. The initial marketing plan for this drug was as an alternative to propofol that could be administered by nonanesthesiologists for use during uncomfortable diagnostic and therapeutic procedures. Reasoning that the active agent would have the same risk profile as IV propofol, the American Society of Anesthesiologists encouraged the Food and Drug Administration to apply the same warning requiring administration by clinicians with expertise in airway management (i.e., anesthesiologists) as is found on the label for propofol.* This was probably the right position to take in the current environment, given the capabilities of alternative practitioners, devices, etc., for managing the airway in accidentally oversedated patients. But the important lesson is that proceduralists want to have a drug such as fospropofol that they could use without an anesthesiologist. Some aspect of current anesthesiology practice and management of the procedural suite is not meeting the needs of the proceduralists. There are unmet needs for anesthesia care in the segments of the market that are not commonly regarded as central customers of anesthesia services. Other potentially disruptive technologies have been demonstrated. For example, Bispectral Index-mediated closed loop control of isoflurane4 or propofol5–7 provides better performance on some metrics than human operators. Similar demonstrations of closed loop control for muscle relaxants have been published.8 Web searching the term "McSleepy" reveals some eye-opening text, images, and video. Others are developing automated methods to alert clinicians of developing hemodynamic perturbations.9 None of the developers of these technologies is proposing that they replace the anesthesiologist in the operating room (OR). That suggestion will come from the financial stakeholders in anesthesia care. Anesthesiologists are expensive. The total annual cost of an academic anesthesiologist reported by Kheterpal et al. is $605,000. Academic programs are unable to generate enough revenue to cover this compensation, in part because academic surgical cases are long and ORs are not optimally utilized.10,11 An increase in the number of anesthetizing locations over the past decade means that the relative number of available providers decreases, and compensation must increase to ensure service. Of course, this scenario also motivates a search for less expensive alternatives. Current trends in anesthesiology employment and education do not bode well for efforts to control costs. Because of the down economy with less hiring by practices, recent graduates are flocking to fellowships, furthering the process of subspecialization. This increases the trainees' capabilities, with an attendant increase in the compensation they can command as a benefit of subspecialty certification. If the RAND forecasts prove accurate, these highly qualified individuals will be negotiating compensation amid a scarcity of providers. The field of anesthesiology is aggressively moving upmarket. Although this seems financially exciting for anesthesiologists, it amplifies the pressure for the users of more basic (or "commodity") anesthesia services to find an alternative source of anesthesia care for their patients. If a less expensive, albeit less capable but still sufficient, alternative becomes available, will commodity users of anesthesia care pay extra for the super-capable product? Experiences from other industries say no. Ongoing rising cost of the available high-end product will motivate the search for lower cost alternatives and whet the payers' appetites for implementation. "Less expensive" does not mean certified registered nurse anesthetists, who are comparable with anesthesiologists in many ways, including cost, but rather a nonanesthesiologist alternative way to provide what is essentially anesthesia care. One does not need to look very far to see potential replacements. Critical care nurses are essentially providing anesthesia when they transport an intubated, ventilated, sedated, and pressor-dependent patient from the intensive care unit for a diagnostic procedure, for example. There are also the technological developments mentioned earlier. The very number of such emerging new technologies, pharmaceuticals, and proposed alternatives to anesthesiologists as providers should sound the alarm that there is something wrong with the way the specialty currently serves its commodity users. Instead, all parties appear happy to find ways for anesthesiologists to get out of the commodity end of the market. This is a big mistake for anesthesiologists. Business history has countless examples of companies that abandoned a low-yield market sector to a disruptive technology only to be knocked off completely some years later by the very same "low-end" innovation. The problem is that the seemingly limited performance technology, product or service will inevitably become more capable. It will only be a matter of time before McSleepy can handle maintenance for basic general anesthetics and then more complex ones. The continuing move upmarket is painting anesthesiology into a corner. If an alternative care model or technology that allows nonanesthesiologists to produce anesthetized patients gains acceptance, the specialty of anesthesiology will face a choice: contract the boundaries of our practice, leaving behind the simpler cases, or find ways to compete more effectively for the lower end of the anesthesia market. This is an opportunity to leverage technology to become more efficient in our use of personnel and their intellect. Seizing this opportunity implies that we should regard technologies, such as anesthesia information management systems, decision support tools, closed-loop control for drug administration, as well as new care team models as the topics of enthusiastic research and development. Choosing this course moves OR and procedure room anesthesiology closer to the model used in intensive care units, where anesthesiologists assure that care is provided, but only personally provide care when their unique skills cannot be replaced. It is tempting to raise the objection that the practice of medicine is not subject to the same kinds of market forces and disruption that sent silver-halide film to join the dinosaurs, and this is to a limited degree true. State regulations, the label warnings on anesthetic drugs, liability risk, and hospital policies all provide inertia that slows the rate of change in who and what can provide anesthesia to the point that change is almost imperceptible. However, with sufficient incentive to alter the status quo plus a little luck, anesthesiologists' protected status can be altered by the stroke of a pen, as evidenced by the gubernatorial opt-out provision from physician supervision of nurse anesthetists, published in 2001. Cost, protectionism, and unmet needs provide the incentive for change. The considered position taken by the specialty over innovations such as fospropofol could be seen as protectionist or obstructive. Embracing new technologies as something that enables anesthesiologists to do more with fewer people sends a completely different message than does opposing technological development. Kheterpal et al.2 publish a simple observation, but one that should trouble us. Compensation and hospital support to anesthesiology departments cannot continue to increase forever in the face of determination to reduce health care costs. But there is not much history of high-end producers voluntarily decreasing the price of their flagship product. Instead, the product is replaced by an upstart. How to avoid this fate is not completely clear. Anesthesiologists should strive to be facilitators of patient care and patient flow in all environments. When departments receive support from hospitals, the reasons for giving the support should be explicitly agreed upon, and the work to be done specified so that the value in exchange to cost is widely understood.12 Anesthesiologists can perform many nonclinical value-added activities that benefit the hospital and its patients. Just as it is appropriate for these to be compensated, so too should departments that receive subsidies be visible throughout the facility performing these important nonclinical organizational and leadership functions. Figure 1 should always be in our minds. New technologies, some of them disruptive, will always continue to appear and challenge our status quo. Occasionally, these can apparently be beaten back. In 2005, a robot called Penelope worked as the scrub technician during a live surgery on a patient at New York Presbyterian Hospital.† The robot functioned without an operator, recognizing the instruments optically and responding to voice commands. This event provoked one trade publication to run the headline "Controversial robotic arm tested" on its front page.13 The new technology was received rather coolly by OR personnel. Fast forward to 2009 and one finds the device now positioned for use in the central sterilization area, where its optical instrument recognition, counting accuracy, speed, and unbeatable duty cycle are to be used in instrument picking, counting, and kit packing. This clever strategy gives the robot a place in the workflow to grow and develop along its sustaining pathway. Eventually it will make it into the OR.
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