The Daily Dose • Thursday, May 20, 2021

How Anesthesiologists Can Be Leaders in Patient Care

Mark Arcario, MD, PhD

Lee A. Fleisher, MD, delivered a call to action on the governmental response to the SARS-CoV-2 pandemic and how this could or should influence leadership in anesthesiology during the “T.H. Seldon Memorial Lecture: the Future of the Specialty: How the Pandemic and Policy Changes Should Influence Our Leadership” on May 15 at the IARS 2021 Annual Meeting. Well versed in this topic, Dr. Fleisher is Professor of Anesthesiology, Critical Care, and Medicine at the University of Pennsylvania Perelman School of Medicine, and currently serving as the Chief Medical Officer and Director of the Center for Clinical Standards and Quality at the Center for Medicare and Medicaid Services.

Opening remarks, provided by Max Kelz, MD, PhD, Distinguished Professor of Anesthesiology and Critical Care at the University of Pennsylvania Perelman School of Medicine, set the context for the T.H. Seldon Memorial Lecture before introducing Dr. Fleisher. Dr. Kelz remembered the namesake of the lecture, Dr. Harry Seldon and his contributions to anesthesiology research, including serving as the Directing Editor of Anesthesia & Analgesia for over 20 years.

Beginning his lecture, Dr. Fleisher harkened back to the 47th Annual Rovenstine Lecture, specifically how Ronald Miller, MD, so eloquently described the mission of the field of anesthesiology as tripartite: patient care, education, and research. This formed the outline of his lecture as he would discuss the future of anesthesiology through the lens of each of these facets.

A familiar graph showing an ever-increasing share of gross domestic product being spent on healthcare was quickly supplanted by a figure showing a sharp and significant downturn in healthcare spending during the height of the global pandemic. Interestingly, healthcare spending has not yet returned to its prepandemic baseline, and Dr. Fleisher suggests that it will likely take years to get back to baseline, if it ever does. Part of this is the significant reduction in elective care and procedures, but also can be attributed somewhat to the rapid adoption of telehealth and “hospital at home” care.

However, this decrease in healthcare spending should be viewed as an opportunity for anesthesiologists to lead the way into alternative payment models that emphasize the value we add in care of the surgical patient, Dr. Fleisher urged. This ranges from proposals such as the perioperative surgical home, to optimize and improve outcomes for surgical patients, to enhanced recovery after surgery, to reduce opioid exposure, and to improve recovery times for surgical patients. Dr. Fleisher emphasized that anesthesiologists must proactively advance the field with new and innovative ways to be of value, lest the field get left behind in these new alternative payment models and fossilizes.

Of equal importance, Dr. Fleisher correctly pointed out that anesthesiologists, both as critical care physicians and pulmonary physiologists, played a large and visible role in coordinating and staffing the front lines of the ongoing epidemic. From devising alternative staffing models for catastrophic overutilization of healthcare resources to rapidly and efficiently determining how operating room and postanesthesia care unit resources could be mobilized in an emergency to help the sickest of sick patients, the fortitude and creativity of anesthesiologists was a bright spot in the early pandemic. Dr. Fleisher stressed that this is a perfect opportunity to seize in order to show the nation and world at-large, the capability of anesthesiologists and the expertise they provide, not only in surgical anesthesia, but in patient care as a whole.

Next, Dr. Fleisher turned his attention to education of the next generation of anesthesiologists. Many challenges exist in intergenerational education as anesthesiology trainees have been raised in a world of ever-increasing technology where new knowledge is created and disseminated daily. Mediocrity in anesthesiology training and practice for the younger generation, however, is something that is not an acceptable outcome, according to Dr. Fleisher. Therefore, new educational techniques and approaches must be adopted to cater to new learners, including less reliance on traditional lecture formats and more use of advanced technology methods with rapid feedback. Additionally, residency has traditionally been time- and case-based; molding experts in anesthesiology needs to move to a competency-based progression model. This will help us identify where trainees are struggling or succeeding and allow us to tailor educational efforts to each individual trainee, Dr. Fleisher explained.

Lastly, Dr. Fleisher pivoted to the future of anesthesiology research. Recent data have shown that in academic medicine, for every $1 of federal investment in medical research, universities generally have to contribute an additional 53 cents to fund their research missions. With decreasing reimbursement, how can this be sustained? Dr. Fleisher argues that anesthesiology departments need to emphasize more translational medicine that adds value to patient care. While basic science does play a critical role in advancing medicine, and by no means should be eliminated from the field, anesthesiology as a field is translational and so the research should reflect that.

Following this thought-provoking lecture, there was a robust discussion among attendees on the ideas presented. First, there was discussion on the “value-added” paradigm, specifically what is meant by that and what role patients have in this. Dr. Fleisher commented that as the field of medicine moves away from “fee-for-service” models, the mindset about what is success in medicine also needs to pivot. Using a perioperative example, he stated, instead of thinking “Was this surgery a success?”, the thought needs to be “Are you more functional following the surgery? Did we as physicians help you achieve your goal?” While there were too many questions to answer during the session, it was clear that the talk generated quite a bit of discussion. This topic should be a talking point for many anesthesiologists as we look to the future.