Applicant Question
You said in your intro talk to the applicant group yesterday that residency training needs to prepare the anesthesiologist to be able to practice 20-30 yrs from now. What do you see for the future for anesthesia?
Response
Another good but difficult question! I suppose the main skill we need to impart to residents is the desire and tools for life long learning. When I was a resident in 1991-94, I thought i had to do every type of case before i graduated and get competent with every technqiue. It turns out that you keep learning after you finish training — this is true even more so in the future.
Some predictions:
Clinical
—20 yrs from now, consumer genomics means that before surgery we will test the patient’s saliva for DNA to tell us which pts are most likely to respond well to drugs, and have less side-effects. As a result, suggestions about drug choice based on DNA profiling will be provided to anesthetist, along with other decision support to help the anesthesiologist deliver the best care possible.
—Computer imaging measurements of craniofacial dimensions will be done routinely preop and the optimal insertion depth of endotracheal tube will be provided to the anesthesiologist.
—Just like the fields of anesthesia/surgery have eliminated catastrophic intraoperative events (e.g., death from esophageal intubation), in 10 yrs no patient will suffer from severe pain after surgery, or even from nausea/vomiting. A combination of analgesics will be used, and include long acting (several days) local anesthetics for peripheral nerve blockade that affect only sensory fibers so that motor function will be maintained! Non-opioid analgesic cocktails will include agents such as iv acetaminophen, and other yet unknown compounds.
Economics
—20 yrs from now, physicians in the US will spend an increasing percentage of their time supervising other (less expensive) personnel
—Increased computer automation of preoperative assessments, order entry, patient education, case and staff scheduling (no need for scheduler coordinator person) will free up MD time for providing more hands-on-care to complex cases.
—IT costs will increase for healthcare from current 1-2%! to the same 15% of operating expenditures as in other industries
—Hospitals and health networks will transition from consolidating locally, to nationally, to take advantage of economies of scale. Such advantages in pricing may squeeze out the smaller competitors in the market, at the risk of further limiting access to care.
—The numbers of physicians per capita in the US will continue to remain so low that non-physician providers will grow. Recruitment of foreign medical graduates will be ever more competitive as global need for expert care increases.
—The bottleneck to getting surgery done will be in order from greatest to least: surgeon > anesthesiologist > nurse anesthetist > capital > nurses.
—Value of anesthesia care will replace volume of care (billed anesthesia base units/time) as Medicare’s primary reimbursement incentive. We will get paid X dollars for an anesthetic. Groups/practices will invest resources to monitor and track patients to show value(=quality/cost)
Residency
—20 yrs from now, Medicare will no longer pay for residents, so the hospital or the department will have to foot their salaries (service model)
—Or, Medicare will start pegging reimbursement to promises by trainees to enter certain sub-specialties that have inadequate numbers of providers, or to promises by resident to practice for some period of time in underserved areas
—Or, residents will pay tuition for the training opportunity to become specialists, and the resident will customize their training by selectively choosing from a menu of cases and rotations. Residents wil be more like medical students in this model.
—Anesthesia Residency will not be 4 yrs, but of variable length based on meeting pre-determined milestones/requirements. If you are really good and show you have the required skills, attitudes, and knowledge you could finish in 3.5 yrs for example, and if not it could take some people more than 4 yrs to meet the milestones expected!