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PubMed1994

A demonstration of validity for certification by the American Board of Anesthesiology.

PURPOSE: To investigate the validity of the certification process of the American Board of Anesthesiology. Specifically, does board certification in anesthesiology identify physicians judged to be clinically superior by evaluators who are not part of the certification process? METHOD: All 154 U.S. anesthesiology program directors (or faculty members they chose to represent them), unaware of the study's intent, were asked whether they would permit each of their residents completing training in 1991 to administer three increasingly complex anesthetic regimens to the directors themselves. This clinical skills rating was compared with the residents' performances in the certification process in 1992. A list of personal characteristics was also provided to the directors so they could identify reasons for less-than-optimal clinical skills ratings. A total of 1,310 residents participated in the certification process in 1992. RESULTS: A total of 146 programs responded. The directors would have accepted anesthetic care for all three increasingly complex operations from 828 (63.2%) of their own residents; for only the two less complex procedures, from 262 (20%); and for only the least complex procedure, from 127 (9.7%). In addition, 93 residents (7.1%) would not have been accepted to administer anesthesia to their directors for any of these operations. Certification success rates for these groups were 74.6%, 53.8%, 44.9%, and 49%, respectively (p < .00001). The personal characteristics believed important to the practice of anesthesiology were strongly linked to the clinical skills ratings; these included motivation, adaptability, clinical judgment, manual dexterity, several work habits, response to criticism, and handling of stressful situations. CONCLUSION: These data support validity for certification in anesthesiology and identify characteristics considered necessary for high-quality practice of the specialty.

Anesthesiology↗
PubMed2003

Labor costs incurred by anesthesiology groups because of operating rooms not being allocated and cases not being scheduled to maximize operating room efficiency.

UNLABELLED: Determination of operating room (OR) block allocation and case scheduling is often not based on maximizing OR efficiency, but rather on tradition and surgeon convenience. As a result, anesthesiology groups often incur additional labor costs. When negotiating financial support, heads of anesthesiology departments are often challenged to justify the subsidy necessary to offset these additional labor costs. In this study, we describe a method for calculating a statistically sound estimate of the excess labor costs incurred by an anesthesiology group because of inefficient OR allocation and case scheduling. OR information system and anesthesia staffing data for 1 yr were obtained from two university hospitals. Optimal OR allocation for each surgical service was determined by maximizing the efficiency of use of the OR staff. Hourly costs were converted to dollar amounts by using the nationwide median compensation for academic and private-practice anesthesia providers. Differences between actual costs and the optimal OR allocation were determined. For Hospital A, estimated annual excess labor costs were $1.6 million (95% confidence interval, $1.5-$1.7 million) and $2.0 million ($1.89-$2.05 million) when academic and private-practice compensation, respectively, was calculated. For Hospital B, excess labor costs were $1.0 million ($1.08-$1.17 million) and $1.4 million ($1.32-1.43 million) for academic and private-practice compensation, respectively. This study demonstrates a methodology for an anesthesiology group to estimate its excess labor costs. The group can then use these estimates when negotiating for subsidies with its hospital, medical school, or multispecialty medical group. IMPLICATIONS: We describe a new application for a previously reported statistical method to calculate operating room (OR) allocations to maximize OR efficiency. When optimal OR allocations and case scheduling are not implemented, the resulting increase in labor costs can be used in negotiations as a statistically sound estimate for the increased labor cost to the anesthesiology department.

Anesthesiology↗
PubMed2005

The prevalence and characteristics of incentive plans for clinical productivity among academic anesthesiology programs.

Performance-based compensation is encouraged in medical schools to improve faculty productivity. Medical specialties other than anesthesiology have used financial incentives for clinical work. The goal of this study was to determine the prevalence and the types of clinical incentive plans among academic anesthesiology departments. We performed an electronic survey of the members of the Society of Academic Anesthesiology Chairs and the Association of Anesthesiology Program Directors in the spring of 2003. The survey included questions about departmental size, presence of a clinical incentive plan, characteristics of existing incentive plans, primary quantifiers of productivity, and factors used to modify productivity measurements. An incentive plan was considered to be present if the department measured clinical productivity and varied compensation according to the measurements. The plans were grouped by the primary measure used into the following categories: None, Charges, Time, Shift, Late/Call (only late rooms and call), and Other. Eighty-eight (64%) of 138 programs responded to the survey, and 5 were excluded for incomplete data. Of the responding programs, 29% had no system, 30% used a Late/Call system, 20% used a Shift system, 11% used a Charges system, 6% used a Time system, and 3% fit in the Other category. Larger groups (>40 faculty members) had a significantly more frequent prevalence of incentive plans compared with smaller groups (<20 faculty members). Incentives were paid monthly or quarterly in 85% of the groups. In 90% of groups, incentive payments accounted for <25% of total compensation. Adjustments for operating room schedule supervisors, personally performed cases, day surgery preoperative clinics, pain-management services, and critical care services were included in less than half of the programs that reported incentive plans. Call and late room compensation was based on varied formulas. Sixty-nine percent of academic anesthesiology departments did not vary compensation according to clinical activity during regular hours. Most did vary payments on the basis of call and/or late rooms worked. Larger departments were more likely to use clinical incentive plans.

Academic Medical Centers↗
PubMed2005

Chemical dependency treatment outcomes of residents in anesthesiology: results of a survey.

Substance abuse is a potentially lethal occupational hazard confronting anesthesiology residents. We present the results of a survey sent to all United States anesthesiology training programs regarding experience with and outcomes of chemically dependent residents from 1991 to 2001. The response rate was 66%. Eighty percent reported experience with impaired residents and 19% reported at least one pretreatment fatality. Despite this familiarity, few programs required pre-employment drug testing or used substance abuse screening tools during interviews. The majority of impaired residents attempted reentry into anesthesiology after treatment. Only 46% of these were successful in completion of anesthesiology residency. Eventually, 40% of residents who underwent treatment and returned to medical training entered another specialty. The mortality rate for the remaining anesthesiology residents was 9%. Long-term outcome was reported for 93% of all treated residents. Of these, 56% were successful in some specialty of medicine at the end of the survey period. We hypothesize that specialty change afforded substantial improvement in the overall success rate and avoided significant mortality. Redirection of rehabilitated residents into lower-risk specialties may allow a larger number to achieve successful medical careers.

Anesthesiology↗
PubMed2001

The impact of longer-than-average anesthesia times on the billing of academic anesthesiology departments.

UNLABELLED: Academic anesthesiology departments provide clinical services for surgical procedures that have longer-than-average surgical times and correspondingly increased anesthesia times. We examined the financial impact of these longer times in three ways: 1) the estimated loss in revenue if billing were done on a flat-fee system by using industry-averaged anesthesia times; 2) the estimation of incremental operating room (OR) sites necessitated by longer anesthesia times; and 3) the estimated potential gain in billed units if the hours of productivity of current anesthesia time were applied to surgical cases of average duration. Health Care Financing Administration average times per anesthesia procedure code were used as industry averages. Billing data were collected from four academic anesthesiology departments for 1 yr. Each claim billed with ASA units was included except for obstetric anesthesia care. All clinical sites that do not bill with ASA units were excluded. Base units were determined for each anesthesia procedure code. The mean commercial conversion factor (US$45 per ASA unit) for reimbursement was used to estimate the impact in dollar amounts. In all four groups, anesthesia times exceeded the Health Care Financing Administration average. The loss per group in billed ASA units if a flat-fee billing system were used ranged from 18,194 to 31,079 units per group, representing a 5% to 15% decrease (estimated billing decrease of US$818,719 to US$1,398,536 per group). The number of excess OR sites necessitated by longer surgical and anesthesia times ranged from 1.95 to 4.57 OR sites per group. The potential gain in billed units if the hours of productivity of current anesthesia time were applied to surgical cases of average duration was estimated to be from 13,273 to 21,368 ASA units. Longer-than-average anesthesia and surgical times result in extra hours or additional OR sites to be staffed and loss of potential reimbursement for the four academic anesthesiology departments. A flat-fee system would adversely affect academic anesthesiology departments. IMPLICATIONS: We examined the economic impact of longer-than-average anesthesia times on four academic anesthesiology departments in three ways: the estimated loss in revenue under a flat-fee system, the excess operating room sites staffed, and the potential gain in revenue if the surgeries were of average length. These results should be considered both in productivity measurements and strategies for operating room management.

Accounting↗
PubMedDate not supplied

Ralph M. Waters and Swedish anesthesiology.

Swedish anesthesiology is greatly indebted to the preeminent American anesthesiologist, and first professor of anesthesiology in the world, Ralph M. Waters. It was in part because of the influence and teaching of this great pioneer that modern anesthesiology became firmly established in Sweden. Approximately 60 residents were trained by Dr. Waters. They later became chairmen of their own university departments of anesthesia and preached and practiced the Waters gospel of professionalism in academic anesthesiology. Among these were four Swedes: Olle Friberg, Eric Nilsson, Karl-Gustav Dhunér, and the author. Through these Swedish pioneers and their numerous disciples, Waters had a profound influence on the development of Swedish anesthesia. The author reports his personal memories from his contact with Ralph Waters.

Anesthesiology↗
PubMed1994

Kenneth K. Keown, MD: pioneer of cardiac anesthesiology.

In 1948, just 2 years out of his anesthesiology residency at Hahnemann Medical College and Hospital, Kenneth K. Keown, MD, was chosen as the anesthesiologist for the procedure that launched the era of intracardiac surgery--a mitral valves commissurotomy. Although surgery on stenotic mitral valves had met with some success as early as the 1920s, its application had lain dormant for some 25 years. In effect, Keown and Hahnemann's Chief of Thoracic Surgery, Charles P. Bailey, MD, who performed the daring operation, launched the acceptance of intracardiac procedures, showing that the heart could be invaded with a successful outcome. Keown and Bailey continued as a team through many innovative cardiac procedures, during which Keown wrote the first monograph on cardiac anesthesia in 1956. Keown was also an early innovator in perfecting methods of inducing hypothermia in cardiac surgery and is also renowned for his pioneering work in cardiac arrhythmias, using lidocaine to counteract fibrillation during cardiac surgery. In 1957, Keown returned to his home state of Missouri to build a department of anesthesiology at the University of Missouri School of Medicine. He advocated allowing only physicians trained in the specialty to administer anesthesia, and he believed firmly that anesthesiology should be a freestanding specialty separate from surgery. He also maintained a vigorous resident recruitment service. Keown held leadership positions in many medical organizations and, during a sabbatical from Missouri, served on the hospital ship Hope in Tunisia. He was Professor and Chief, and later Chairman, Section of Anesthesiology, at the University of Missouri Medical Center, and from 1969 until his death in 1985, he also served as the Center's Medical Director.

Anesthesiology↗
PubMed2000

The future of anesthesiology is perioperative medicine.

Anesthesiology faces many challenges in the years ahead. To meet these challenges, the author hypothesizes that perioperative medicine, which includes the spectrum of care from preoperative assessment to postoperative care, offers the best chance for the specialty to survive and prosper. The history of perioperative medicine is reviewed and a discussion of how such change will benefit anesthesiology is included. Implementation may be difficult and the author explores how a transition from traditional procedure-focused anesthesiology to a broader based specialty may be accomplished. The special needs of perioperative medicine and how they differ from anesthesiology are also presented.

Anesthesiology↗
PubMed2002

Training of residents in peripheral nerve blocks during anesthesiology residency.

STUDY OBJECTIVE: To survey American anesthesiology residency program directors to determine the availability and extent of training in peripheral nerve block techniques. DESIGN: Survey questionnaire was mailed and faxed to 132 American anesthesiology residency program directors and followed up 4 weeks later with another mailing to nonresponders. SETTING: University medical center. MEASUREMENTS AND MAIN RESULTS: Of the 132 American anesthesiology residency program directors surveyed, 69 (52%) responded. Of the responders, 40 (58%) offered a specific peripheral nerve block rotation. The rotation was of 1 month's duration in 61% of these programs. Formal instruction was administered during the rotation in 69%. The regional instruction approach consisted of a nerve stimulator (98%), paresthesia (75%), and transarterial (85%). Multimedia, mannequins, and cadaver dissection were used infrequently (13-25%). During the rotation, residents performed a variety of blocks, but the number of each block varied from 2 (supraclavicular) to 10 (axillary). These blocks were performed in the operating room in 48% of programs. Finally, in the programs with a specific peripheral nerve block rotation, residents were evaluated. CONCLUSIONS: Specific peripheral nerve block rotations are not always included in anesthesiology residents' curriculum. In addition, residents in programs with a specific nerve block rotation are exposed to a greater number of peripheral nerve block techniques than those who do not have such a rotation included in their curriculum.

Academic Medical Centers↗
PubMed1999

The relationship of cognitive, personality, and academic measures to anesthesiology resident clinical performance.

UNLABELLED: Cognitive skills (including vigilance), personality factors, and standardized academic test performance may be associated with clinical competence in anesthesiology to varying degrees. Sixty-seven anesthesiology residents in training at one center between 1993 and 1995 were administered the modified Vigil (For Thought, Ltd., Nashua, NH), the Paced Auditory Serial Addition Test, the California Personality Inventory, the State-Trait Anxiety Inventory, and five standardized academic performance tests. The clinical performance of anesthesiology residents was rated on a quarterly basis by a clinical competence committee. A growth curve model indicated that there was significant variability in clinical competence at the start of residency and a statistically significant improvement over time, and that the relative ranking of the residents remained stable over the course of training. Of 46 potential variables, 7 were associated (P < 0.10) with poor clinical performance; these were subjected to a multivariate test (Mantel-Haenszel). Cognitive variables predicting poor clinical performance were difficulty performing a rapid mental arithmetic test requiring divided attention and commission errors during complex visual target detection. Personality variables predicting poor clinical performance were introversion and flexibility. A predictive academic variable was poor anesthesia knowledge as measured by using two different tests during the first month of training. There were varying levels of independence among these variables. IMPLICATIONS: Early academic test performance and certain cognitive and personality tests were associated with the clinical performance of anesthesiology residents. The predictive value of these findings should be confirmed in a prospective, multicenter study.

Anesthesiology↗
PubMed1984

Factors affecting the choice of anesthesiology by medical students for specialty training.

To learn some of the reasons why anesthesiology as a specialty is not preferred by more graduating medical students and to determine the effects of various factors on their specialty choice, the authors studied the number of medical students who chose anesthesiology as a specialty after graduation and the quality of clerkships available in various departments. The study established that medical students do not find anesthesiology as attractive as other specialties and that several factors are related to the students' choice of anesthesiology. Most surprising was the negative effect of the presence of certified registered nurse anesthetists on the operating room floor. These results suggest the need for a thorough study of the use of nurse practitioners, physician's assistants, and nurse-clinicians, at least where teaching of medical students is taking place.

Anesthesiology↗
PubMed1993

Attitudes of anesthesiology residents toward critical care medicine training.

The number of anesthesiology residents pursuing critical care medicine (CCM) fellowship training has been decreasing in recent years. A significant number of training positions remain unfilled each year. Possible causes of this decline were evaluated by surveying residents regarding their attitudes toward practice and training in CCM. All 38 anesthesiology programs having accredited CCM fellowships were surveyed. Four of these and one program without CCM fellowships were used to develop the survey instrument. Four programs without CCM fellowships and 34 programs with CCM fellowships make up the survey group. Returned were 640 surveys from 37 (97%) programs accounting for over 30% of the possible residents. Resident interest in pursuing CCM training decreased as year of residency increased (P < 0.0001). Residents in programs with little patient care responsibility during intensive care unit (ICU) rotations expressed less interest in CCM training (P < 0.012). The administrative role of the anesthesiology department in the ICU also influenced resident interest (P < 0.014). Written responses to open-ended questions suggested resident concerns with the following: stress of chronic care, financial consequences of additional year of training, ICU call frequency and load, ICU role ambiguity, and shared decision-making in the ICU. A recurring question was, "Are there jobs (outside of academics) for anesthesiologist intensivists?" Most residents knew a CCM anesthesiologist they admired and knew that there were unfilled fellowship positions available. Defining the job market, improving curriculum and teaching, supporting deferment of student loans, and introducing residents and medical students to the ICU earlier may increase the interest in CCM practice among anesthesiology residents.

Anesthesiology↗
PubMed2006

Local anesthetic-induced cardiac toxicity: a survey of contemporary practice strategies among academic anesthesiology departments.

Though new local anesthetics (LA), effective test-dosing, and new regional anesthetic techniques may have improved the safety of regional anesthesia, the optimal management plan for LA-induced cardiac toxicity remains uncertain. Accordingly, we evaluated current approaches to LA cardiotoxicity among academic anesthesiology departments in the United States. A 19-question survey regarding regional anesthesia practices and approaches to LA cardiac toxicity was sent to the 135 academic anesthesiology departments listed by the Society of Academic Anesthesiology Chairs-Association of Anesthesiology Program Directors. Ninety-one anonymously completed questionnaires were returned, at a response rate of 67%. The respondents were categorized into groups according to the number of peripheral nerve blocks (PNBs) performed each month: >70 PNBs (38%), 51-70 PNBs (13%), 31-50 PNBs (20%), 11-30 PNBs (23%), and <10 PNBs (6%). Anesthesia practices administering >70 PNBs were 1.7-times more likely to use ropivacaine (NS), 3.9-times more likely to consider lipid emulsion infusions for resuscitation (P = 0.008), and equally as likely to have an established plan for use of invasive mechanical cardiopulmonary support in the event of LA cardiotoxicity (NS) than low-PNB volume centers. We conclude that there are differences in the management and preparedness for treatment of LA toxicity among institutions, but the safety implications of these differences are undetermined.

Academic Medical Centers↗
PubMed2003

[Transfusion problems in surgery and anesthesiology. The causes, consequences, prevention and treatment of perioperative anemia].

INTRODUCTION: The classical indication for blood transfusion is the correction of oxygen delivery failure, and the elimination of tissue ischaemia. Such indications in the surgical and anesthesiological practice are the acute haemorrhagic states (trauma, acute gastrointestinal bleeding, intraoperative hemorrhage), as well as diseases associated with chronic blood loss (occult bleeding caused by malignancies, and ulcerating processes etc.). The traditional surgical and anesthesiological viewpoint has adopted a remarkably liberal approach to the indication of blood transfusion, and a whole range of its subtle, medium-long term adverse effects has been taken into account only recently. The purpose of this review was to analyze the causes and pathophysiological consequences of perioperative anemia and blood loss, as well as to reconsider the proper indications of blood transfusion in the view of immunological sequela. The most recent data on the transfusion related immuno-depression and immunomodulation are summarized. The authors wish to provide clues for the definition of "transfusion trigger", in addition, methods available for the clinical practice to reduce blood demand and to restore oxygen transport capacity during surgical and anesthesiological interventions are revisited. Based on the review of the literature and the personal experience of the authors the practical recommendations concerning the administration of blood and blood products should be summarized as follows: 1. Blood transfusion is rarely indicated if the hemoglobin level is above 10 g/dl, and in fact always necessary if it is less than 6 g/dl, especially, if the anemia developed acutely. 2. The "transfusion trigger" is subject to continued debate, and whether a particular patient with intermediary (6-10 g/dl) Hb levels should be transfused or not must be assessed in the perspective of the potential complications initiated by the inadequate oxygenation. 3. If major co-morbidity (e.g. emphysema, ischaemic heart disease) is present, 10 g/dl Hb, in case of respirator dependency 12 g/dl Hb levels justify the administration of transfusion. If feasible, the beneficial effects of allogenous blood sparing methodologies should be utilized. CONCLUSIONS: Although the National Blood Supply Service is excellently organized in Hungary, the current clinical practice is not satisfactory. The use of up-to-date methods at the average surgical departments is suboptimal, and due to the lack of knowledge concerning the recent advances in immunology the clinicians are far too liberal in the indication of blood transfusion. The objective is to establish a modern surgical and anesthesiological transfusion practice based on the solid understanding of immunological facts, and to modernize the continued education, as well as to improve the financing of costly blood saving methodologies.

Anemia↗
PubMedDate not supplied

Women and specialty choice: why not anesthesiology?

The number of women in all medical specialties increased during the 1970s and 1980s. Anesthesiology residency programs experienced unprecedented growth from 1980 to 1986. We reviewed statistics published by the American Medical Association to investigate the relationship between the increase in female residents in all specialties compared to that for individual specialties including anesthesiology, pathology, surgery, pediatrics, obstetrics/gynecology, radiology, internal medicine, and psychiatry. We found an above average rate of growth for female residents in gynecology, pediatrics, and internal medicine; pathology, radiology, psychiatry, surgery, and anesthesiology showed a below average rate of growth. Studies have shown a correlation between gender and choice of specialty. Factors influencing the differences in choice and the decrease in the percentage of women choosing anesthesiology are unknown.

Anesthesiology↗
PubMed1997

Cost containment in anesthesiology: a survey of department activities.

STUDY OBJECTIVE: To survey cost containment activities in anesthesiology and to determine to what extent departments use cost policies and guidelines. DESIGN: Mail survey. SETTING: Academic and large nonacademic anesthesiology departments. MEASUREMENTS AND MAIN RESULTS: 147 responding departments answered 20 questions. 38% of surveys were returned. 90 responders identified themselves as academic departments and 57 responders as nonacademic. 73% of departments reported pressure from hospital administrators to reduce anesthesia costs. The most common cost-saving activity, used by 90% of departments, is improving operating room (OR) utilization. 53% of all departments have policies or guidelines to contain drug costs, while 48% of departments have these to contain other product costs. Departments reporting themselves as academic generally reported greater use of cost policies. CONCLUSIONS: Anesthesiology departments are experiencing pressure to reduce costs and the majority have cost policies and guidelines concerning utilization of ORs and anesthetic drugs. Academic anesthesiology departments may be experiencing more cost-containment pressure than nonacademic departments.

Academic Medical Centers↗
PubMed2003

Anesthesiological risk and endoscopic sphincterotomy in acute biliary pancreatitis.

INTRODUCTION: The rate of complications after endoscopic sphincterotomy (ES) is about 10%, and early complications have been reported in 20% of patients considered unfit for surgery. AIM: To evaluate the early and long-term results of endoscopic intervention in relation to the anesthesiological risk for 87 patients with acute biliary pancreatitis. METHODOLOGY: All patients underwent endoscopic retrograde cholangiopancreatography (ERCP) and were evaluated according to the American Society of Anesthesiology (ASA) criteria immediately before the operative procedure. Patients' ASA scores were as follows: 49.4%, ASA 2; 29.9%, ASA 3; and 20.7%, ASA 4. RESULTS: The severity of acute pancreatitis was positively related to the anesthesiological grade (p = 0.014). Six patients (6.9%) had complications related to the endoscopic procedure. There was no significant relationship between the frequency of biliopancreatic complications during the follow-up (23/84, 27.4%) and the ASA grade. The frequency of cholecystectomy was inversely related to the ASA grade (p = 0.003). Seven patients (8.3%) died during the follow-up period: multivariate analysis showed that the ASA grade (odds ratio [OR], 10.9; 95% confidence interval [CI], 1.2-96.6; p = 0.001) and age (OR, 1.1; 95% CI, 1.0-1.3; p = 0.037) were significantly related to survival. CONCLUSIONS: Endoscopic treatment is safe and effective in patients at high anesthesiological risk with acute pancreatitis, and survival is significantly related to the ASA grade.

Acute Disease↗
PubMedDate not supplied

[Evaluation and evolution of the scientific production by Spanish anesthesiology departments].

OBJECTIVES: To count the scientific publications coming from Spanish departments of anesthesiology and rank them by productivity using various bibliometric tools. To examine the evolution of productivity between 1992 and 2001. METHOD: Abstracts of articles from Spanish anesthesiology departments were located on Medline. Hospital departments were ranked by productivity based on number of publications. Other classifications were established based on the international impact of articles measured by "net" impact factor (IF) of the journals and "relative" IF (according to the category assigned by Journal Citation Reports [JCR]). The evolution of scientific productivity was analyzed by five-years periods. RESULTS: We located 644 entries for articles published in Spanish journals and 182 for articles in journals outside Spain. Ten departments of anesthesiology produced 68% of the articles in non-Spanish journals. Hospital Clinic i Provincial in Barcelona was the most productive (55 publications, 27 in foreign journals). Hospital del Mar published articles in journals with the highest IF (mean 2.63). When IF results were adjusted by JCR category, Hospital Clinic i Provincial had the best quantitative and qualitative indexes. Hospital Torrecardenas had the best evolution in scientific productivity in the last five years. CONCLUSION: The scientific productivity of Spanish anesthesiology departments has evolved favorably over the past 10 years, led by Hospital Clinic i Provincial.

Anesthesia Department, Hospital↗