MSA The Ventilator Fall 2014 by Hillary

IN THIS ISSUE:

PATIENT SAFETY AND QUALITY IMPROVEMENTS: ASPIRE AND MHA KEYSTONE SURGERY: PAIN INITIATIVE

Can You Ever Have Too Much of a Good Thing? We all know that data helps us make better, more-educated decisions. But collecting large amounts of data is ineffective without the proper tools to display those insights. Without understanding the context of a specific metric, it can be easily misunderstood and misrepresented. Physicians and managers alike require a smooth transition from the clinical, administrative and operational data sets to better understand the true message that the data is trying to tell.

Make the Data Work for You F1RSTAnalytics is the ultimate in technical sophistication. It offers data prowess, providing the data to aid in operating your anesthesia practice as an effective clinical organization and successful business. The information you need, provided in a way you can use it.

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President Frederick Campbell, M.D. Cedar President-Elect John LaGorio, M.D. Norton Shores Secretary-Treasurer Michael Danic, D.O. Redford Immediate Past President Sam Talsma, M.D. Ann Arbor Communications/Public Relations Committee Ali Jaffer, M.D. Dominic Monterosso, D.O.

TAB LE OF C O NT ENT S P R E S I D E N T’ S M E SSAGE ................................................................. 4 DIRECTOR’S REPORT............................................................................ 6 ASPIRE A NEW OPPORTUNITY FOR QUALITY IMPROVEMENT...............8 CA LE N D A R O F E V E N TS..................................................9 M H A KE Y S TO N E SURGE RY: PAI N I N I TI ATI VE ...................... 1 0 THE NUMBER OF ANESTHESIOLOGISTS BEING TRAINED....................... 12

Managing Editor Hillary Walilko Contact for advertising information: Hillary Walilko MSA 120 N. Washington Sq., Suite 110A Lansing, MI 48933 Phone: 517.346.5088 Fax: 517.371.1170 email: walilko.h@gcsionline.com The Ventilator is published four times annually by GCSI Association Services. It is funded by the Michigan Society of Anesthesiologists and with advertising revenues. The Michigan Society of Anesthesiologists is a nonprofit, statewide organization. No part of this publication may be reproduced without permission of the publisher and MSA. All article submissions will be considered for publication and accepted at the approval of the Editor and the Communications/Public Relations Committee. We reserve the right to edit submissions for accuracy, clarity, and length.

Fall 2014

MSA PARTNERS WITH ASA TO COLLECT DUES..................................... 14 ASA LEGISLATIVE CONFERENCE – RESIDENT EXPERIENCE...................... 16 MSA EDUCATION AND RESEARCH ENDOWMENT FUND..................... 17

LEGISLATIVE CORNER ........................................................................ 18

MSAPAC REPORT .............................................................................. 19

INDEX TO ADVERTISERS Anesthesia Business Consultants....................................... IFC Destination CME.....................................................................7 Lifetime Income Sales Associate, LLC ...................................5 Paragon Service.................................................................... 15

PRESIDENT’S MESSAGE

Frederick Campbell M.D. President

How Safe Is This Airplane? How can we see our patients arrive safely?

he safety of modern anesthesia is commonly compared to that of commercial airline flight. Many of us may have used the simple analogy with our patients, “It’s similar to getting on an airliner. You understand the underlying risk of flying but millions of people travel safely every day.” Is this an accurate comparison? If not, are we doing the public and the complexity of our specialty a disservice by its use? The Institute of Medicine wrote in its 1999 report, To Err is Human, “... anesthesiology has successfully reduced anesthesia mortality rates from two deaths per 10,000 anesthetics administered, to one death per 200,000 to 300,000 anesthetics administered.” Robert Lagasse differed in his 2002 study of anesthesia outcomes in two New York hospitals citing a rate of anesthesia-related death of one in approximately 13,000 anesthetics (Anesthesiology 2002). In contrast, a review of 78 major commercial aircraft accidents world-wide over a 20 year period concludes the odds of being killed on a single airline flight in that period was one in 4.7 million (OAG Aviation and PlaneCrashInfo. com accident database, 1993-2012). In the United States, NTSB data (commercial carriers

operating under 14 CFR 121) reveals there were 1,417 passenger fatalities out of 13.4 billion passenger enplanements in the decade 20032012, the resulting death rate being one in 9.4 million (www. ntsb.gov/data/aviation_stats). If one is to compare sliding onto an operating table with buckling into a seat for an airline flight in the United States, our patients are 30 to 700 times safer in flight. In this issue of the Ventilator are two articles about anesthesia safety and quality initiatives in Michigan. Roy Soto, M.D. writes about the Michigan Hospital Association’s Keystone: Surgery collaborative and the perioperative patient safety projects in which it is engaged or is planning. The MHA Keystone: Surgery collaborative develops tools that hospitals may employ to prevent surgical complications and improve outcomes. Sachin Kheterpal, M.D. and Nirav Shah, M.D. describe the Anesthesia Performance Improvement and Reporting Exchange (ASPIRE), an outgrowth of the Michigan Surgical Quality Collaborative (MSQC). Drs. Kheterpal and Shah have years of experience managing database research in the MultiCenter Perioperative Outcomes Group (MPOG). ASPIRE provides a payer-funded

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collaborative quality initiative in which participating Michigan hospitals can compare their anesthesia processes and outcomes with others in the state, and from which “best practices” may be inferred. Many MSA member anesthesiologists are already participating in these collaborative safety and quality initiatives either through their hospital affiliation or as individual contributors. This is commended and enthusiastically encouraged. The Michigan Society of Anesthesiologists, as an organization, can also collaborate with MHA Keystone: Surgery and ASPIRE. These safety and quality collaboratives provide an opportunity for MSA to put its values into action, to promote participation and contribution by our members, to provide venues for dissemination of Keystone tools and ASPIRE process and outcome information, and to be recognized for its contributions to surgical and anesthesia safety in Michigan. Toward these ends, MSA is forming the Safety and Quality Collaborative Liaison Committee. It is anticipated that committee members will represent MSA serving on advisory groups, contributing to collaborative projects, and communicating quality and outcome information to the MSA membership. Opportunities to speak and publish can result. If you have an interest in participating on this developing committee with other MSA members, please send a message to me either directly or through the MSA administrative office walilko.h@gcsionline.com. I look forward to hearing from you! The MSA faces repeated legislative challenges to physician supervision of anesthesia in Michigan and the anesthesia care team practice model. As we confront these efforts our focus on patient safety and improved outcomes must be transparent and pervade our advocacy. Our message for physician-led perioperative care resonates even more strongly when we couple our advocacy with organizational and individual actions that demonstrate our commitment to our

Fall 2014

patients’ safety and the quality of their clinical experience. Our legislators must know that surgical anesthesia, as well as interventional pain management, have to evolve further to achieve the safety record of commercial air travel. MSA and its members are working to maintain the level of safety our specialty has achieved to date and to reduce complications and improve outcomes in the future. No one is yet advocating the captain be taken out of the cockpit. It’s certainly not time to take the physician out of the anesthesia care team!

DIRECTOR’S REPORT

Tell your Story and Raise Awareness Through ASA’s When Seconds Count™ Endeavor Kenneth Elmassian D.O. ASA Director, Michigan Chairman, ASA Committee on Communications

hink back to a time when you solved a problem during a critical moment. A routine surgery goes wrong. An emergency occurs in the O.R. Your patient is dying on the table. You use your education and training to properly evaluate the situation, diagnose what is happening and intervene and rescue that patient who needs you right at that moment. That is your When Seconds Count™ story. We know that when seconds count, physician anesthesiologists save lives. Now we need the general public, legislators, hospital administrators and journalists to know it too. The American Society of Anesthesiologists® (ASA®) launched the educational endeavor When Seconds Count…Physician Anesthesiologists Save Lives™ in September 2013 to advocate for patientcentered, physician-led anesthesia care. The endeavor takes a proactive approach to raise awareness of the critical role of physician anesthesiologists by using powerful, tested messaging based on extensive research. ASA engaged a message testing firm to determine perceptions of physician anesthesiologists and found that a majority of the public and many policymakers are unaware that anesthesiologists are physicians. Even fewer know how physician anesthesiologists save lives before, during and after surgery. And yet, when it comes to administering anesthesia or responding to medical emergencies during surgery, people overwhelmingly prefer a physician. Based on the research, When Seconds Count™ messaging emphasizes the medical education and training of physician anesthesiologists that provides patients with the highest-quality and safest care. The endeavor has grown significantly since 2013, and has expanded to include a number of resources for ASA members, such as the www.asahq.org/WhenSecondsCount website, the Member Toolkit, physician anesthesiologist and patient video stories, and the When Seconds Count™ Leadership Spokesperson Training Program (LSTP).

Look out for opportunities to attend LSTP through your state component society and at ASA meetings where you’ll learn more about the educational endeavor and how to craft your personal close-call story. The endeavor provides tools for members, but has also been in the national spotlight this year. When Seconds Count™ appeared in USA Today’s Patient Safety insert, featuring the importance of physician anesthesiologists and ASA’s ongoing dedication to advancing patient safety. Patient Stephanie Arnold told the story of when she lay dead on the operating table and her physician anesthesiologists saved her life with a quick diagnosis of an amniotic fluid embolism. Her story was featured on CBS Chicago, and was in When Seconds Count™ advertisements in the National Journal, Politico.com and Washington, D.C. local radio station WTOP. ASA members also shared Stephanie’s story – and their own When Seconds Count™ stories – with legislators during Capitol Hill visits at ASA’s 2014 Legislative Conference. You will find a growing number of patient and physician close-call stories on the When Seconds Count™ website, and the endeavor is featured often on ASA social media. The act of storytelling has been around for hundreds of thousands of years, and it’s not going anywhere. We can share stories in so many ways now, from a Facebook post to a quick email, a handwritten letter or an oldfashioned, in-person conversation. Be an advocate for the specialty of anesthesiology and ensure that every patient has the chance to receive safe, physician-led care. Help us communicate the value of your role as a physician anesthesiologist by telling your story using tested, proven messaging. No one is going to tell it for you. For more information or help in crafting your personal story, please contact Theresa Hill, director of public relations (t.hill@ asahq.org), or Natalie Cammarata, public relations associate (n.cammarata@asahq.org).

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Provided by:

The Ritz-Carlton Grand Cayman January 28-31, 2015

This activity has been approved for AMA PRA Category 1 credit.TM

ACTIVITY MEDICAL DIRECTORS John E. Ellis, MD University of Pennsylvania

Brian Ginsberg, MB BCh Duke University Medical Center FACULTY

David Lubarsky, MD, MBA University of Miami

Girish Joshi, MD, FFARSCI UT Southwestern Medical Center

Sachin Kheterpal, MD, MBA University of Michigan

Eric Jacobsohn, MD, MHPE University of Manitoba

Vivek Moitra, MD Columbia University

John Fiadjoe, MD The Childrenâ&#x20AC;&#x2122;s Hospital of Philadelphia

www.destinationCME.com Fall 2014

ASPIRE

A New Opportunity for Quality Improvement

Sachin Kheterpal M.D. BA, sachinkh@med.umich.edu Nirav Shah M.D. nirshah@med.umich.edu

“R

eimbursement rates,” “preauthorization,” “coverage.” When most anesthesiologists consider their relationship with their primary payer, they are likely to focus on these phrases. However, a novel partnership between anesthesiologists and Blue Cross Blue Shield of Michigan (BCBSM) hopes to change these phrases to include “partner”, “advocate”, and “catalyst.” Building upon the mature infrastructure of the BCBSM Value Partnership portfolio (www. bcbsm.com/providers/value-partnerships/valuepartnerships-overview.html) and the Michigan Surgical Quality Collaborative (MSQC, www.msqc. org), anesthesiologists in the state of Michigan are embarking on a quality improvement journey that breaks down historical competitive barriers across payers, hospitals, surgeons, and anesthesiologists. The Collaborative Quality Initiatives (CQI) funded by the BCBSM Value Partnerships program have transformed the payer-provider relationship in Michigan. The CQIs enable motivated physicians and hospitals to assess variation in practice, identify local/regional best practices, and measure process adherence and patient outcomes. By funding the majority of data collection costs, BCBSM overcomes one of the greatest obstacles to widespread benchmarking and QI. More importantly, BCBSM does not request access to the data itself, creating the honest, “safe” environment needed

for meaningful self-assessment and practice improvement. Since 2004, the MSQC has used data collection and analysis as the foundation of peer-to-peer communication, collaborative benchmarking, and best practice implementation among general, vascular, and gynecologic surgeons. MSQC uses a robust skilled surgical clinical quality reviewer (SCQR), typically an RN, to abstract data from the medical record for selected patients. By including not only risk-adjusted outcomes, but also process of care measures, the MSQC dataset creates insight into variation in care and outcomes. With more than 66 hospitals participating currently, the “crowd-sourcing” of optimal care patterns is a potent accelerator of change. Given the impact of anesthesiology interventions on long-term postoperative outcomes, length of stay, and costs, a natural evolution of the MSQC has been to expand the data collection and collaboration efforts to include the anesthesiology provider and process. Since 2013, SCQR nurses have manually extracted specific intraoperative variables related to anesthesiology processes of care, such as use of peripheral nerve blockade, glycemic management, vasopressor administration, and fluid administration. Early analyses of these data have revealed the wide variation that affects nearly all clinical processes without robust prospective evidence or third party metrics. However, these data are limited in quality and detail because they are manually extracted from anesthesia records, many of them paper-based. In addition, despite the volumes of data available for discussion, engagement of anesthesiologists at quarterly QI meeting has been limited. As a result, BCBSM is funding the creation of an Anesthesiology CQI to collect more detailed anesthesiology process of care data and engage anesthesiologists in data-driven clinical collaboration. The CQI will fund a coordinating

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center, housed at the University of Michigan and led by anesthesiologists. In addition, the CQI will defray the costs of data collection. For hospitals and ambulatory surgery centers that use an electronic health record (EHR), we will be implementing the existing Multicenter Perioperative Outcomes Group (MPOG) infrastructure. Founded in 2008 as a research consortium, MPOG membership has expanded the use of perioperative data from EHRs to include not only research, but also QI use case scenarios. Detailed preoperative and intraoperative medication, physiologic, and staff data are aggregated across geographically and clinically diverse hospitals. More than 2.5 million operations across 17 medical centers have already been aggregated at the University of Michigan Coordinating Center for MPOG. These data are used to develop peer-reviewed publications to identify variations in care and optimal care patterns. Over the last year, MPOG developers have developed a benchmarking and provider feedback infrastructure based upon EHR data. CQI funds will be used to expand this infrastructure to hospitals in the Michigan. For those hospitals that still used paper based records, we will manually collect preoperative and intraoperative data, modeled after MSQC data collection approach. The goal of the Anesthesiology CQI is to integrate surgeon and anesthesiologist perspectives to improve patient care using data as the foundation of collaboration. Existing risk-adjusted preoperative and postoperative outcome data collected by MSQC SCQRs will be integrated with anesthesiology data collected by the Anesthesiology CQI. In year 1, a grass-roots Anesthesiology CQI measures committee will identify process measures that are based upon data that can be collected with high quality and reliability across participating hospitals; reflect peer reviewed publications

establishing an impact on patient outcomes and costs; demonstrate wide variation across providers and facilities; are under the control of the anesthesiologist and surgeon; and are reasonable targets for practice change in real-world clinical practice. Where possible, we will leverage national standards developed by the ASA, the Anesthesia Quality Institute, and subspecialty societies to remain consistent with national recommendations. This Anesthesiology CQI will serve as a model of collaboration across hospitals, anesthesiologists and surgeons within the state of Michigan. Using cost-effective EHR interfaces from MPOG and complementary manual data collection methodologies established by MSQC, we will use data as the foundation for collaboration between surgeons and anesthesiologists. The visionary financial and organizational commitment from BCBSM reveals the possibilities when payers and providers come to the table for the shared goal of improving patient outcomes. After much thought and discussion, we recently agreed that the name of this CQI will be ASPIRE (Anesthesiology Performance Improvement and Reporting Exchange). It captures both in spirit and description our values and optimism about this amazing opportunity. We hope that the MSA membership is just as excited as we are. Please contact us for more information on joining – we are ready to get to work.

References

Kheterpal S. Random clinical decisions: identifying variation in perioperative care. Anesthesiology 2012;116:3-5. Kheterpal S. Clinical research using an information system: the multicenter perioperative outcomes group. Anesthesiol Clin 2011;29:377-88.

CALENDAR OF EVENTS

2014 October 27 – 31

November 7-15

American Board of Anesthesiology Examinations

Healing the Children - Volunteer Opportunity

Chicago, IL

Cucuta, Colombia

November 8 – 9

ASA AQM Quality Meeting Schaumburg, IL Fall 2014

MHA Keystone Surgery:

Pain Initiative Roy Soto, M.D.

he Surgery collaborative of MHA Keystone was founded to improve the perioperative care of Michigan patients. Since 2003, the MHA Keystone Center has supported and guided Michigan hospitals in identifying best practices and pioneering patient safety interventions that have reduced infections and medical errors. I was invited to discuss Enhanced Recovery protocols and implementation strategies with the MHA Keystone: Surgery leadership in 2013. Following these discussions it was decided that pain would be the primary focus of the collaborative for 2014. Utilizing guidance from the Anesthesia Patient Safety Foundation and the Joint Commission as well as initiatives developed by other state medical societies, a multi-step program was developed as described below: 1) Gap Analysis: Using a tool developed by the Minnesota Hospital Association as a guide, an opioid safety Gap Analysis tool was sent to participating hospitals to determine compliance with “best practices” in pain management. The tool is not meant to be a call for change, per se, but rather is being used to identify areas of strength and weakness throughout the state. Areas of focus include risk assessment, risk prevention, therapeutic measures, and education. Initial results have proven interesting, with indications that many ‘standard’ practices are not being followed by all. For instance, 25% of reporting hospitals do not screen for OSA in patients receiving opioids, and 45% do not include presence of OSA in standard nursing handover reports. The tool is distributed for completion every six months, and the hope is that improved education and data sharing will improve best practice compliance over time. 2) Michigan Opioid Safety Score (MOSS): Simple visual analog scores for pain can result in opioid overdose and do not appropriately consider patient risk when used solely for medication dosing. In conjunction with national pain leaders, a new pain score (the “MOSS”) was developed. Points are assigned for risk factors (obesity, duration of anesthesia, coexisting disease, concomitant sedative use), sedation score, and respiratory rate to generate an overall risk score. If risk is considered to be low, additional opioids can be given. If high, opioids should be reduced or stopped and appropriate consultation should be obtained. Initial experience has shown that the MOSS can improve patient safety and increase nursing empowerment and satisfaction.

MHA: MICHIGAN HEALTH AND HOSPITAL ASSOCIATION Established in 1919, the MHA represents the interests of its member hospitals and health systems (every community hospital in the state) in both the legislative and regulatory arenas and supports their efforts to provide quality, cost-effective and accessible care. MHA KEYSTONE CENTER: The MHA Keystone Center is a 501c3 organization under the MHA Health Foundation, a division separate from MHA advocacy. It is funded through grants from CMS, BCBSM, the CDC, and AHRQ as well as by its member hospitals. Keystone has a separate board of directors comprised of hospitals, organized medicine (including MSMS & MOA), patient representatives, long-term care centers, and the employer community. The MHA Keystone Center operates collaborative projects focused on care transitions, catheter-associated urinary tract infections, emergency rooms, intensive care units, obstetrics, safe care, sepsis and surgery. MHA KEYSTONE SURGERY: The Keystone Surgery collaborative focuses on improving the perioperative care of Michigan patients. Areas of focus past and present include surgical-site infections, preventing defects in care (including wrong-site surgery and retained foreign objects), eliminating mislabeled specimens and improving the safety and teamwork climate, and perioperative optimization and standardization (pain management and glycemic control). HEN: HOSPITAL ENGAGEMENT NETWORK Twenty-six Hospital Engagement Networks were formed by CMS in 2012 as part of the Partnership for Patients campaign to reduce harm and improve the quality and safety of healthcare. The MHA Keystone Center HEN works with hospitals to identify, share, and implement best practices aimed at reducing the number of adverse drug events, catheter-associated urinary tract infections, central-line-associated bloodstream infections, injuries from falls and immobility, obstetrical adverse events, pressure ulcers, surgical-site infections, venous thromboembolisms, ventilator-associated pneumonia and preventable readmissions.

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3) Patient and family education materials: Patient centered education materials have been developed to aid patients in understanding their pain. Typical patient materials stop at “you should have no pain, let us know how we can help.” The MHA Keystone tool stresses that 4/10 pain is normal after surgery, eliminating all pain will result in unwanted side effects, and that patients should discuss pain duration, intensity, and type prior to the surgical procedure. 4) Sample pain order sets: Perioperative order sets are being developed to aid surgeons, nurses, and anesthesiologists to maximize the use of multimodal analgesics (beyond the typical ketorolac and acetaminophen) and minimize opioid risk. 5) Process and outcomes measures: Participating hospitals are required to submit the following data every three months, and individual and state-wide reports are made available as data is collected: a. MHA Derived measures (numerator/denominator) i. Percent of patients readmitted within 30d/total number surgical procedures ii. HCAHPS question 13: satisfaction with pain treatment b. Process Measures (numerator/denominator) i. Number of surgical patients receiving opioids/total number surgical procedures ii. Number of patients evaluated with MOSS/total number surgical procedures c. Outcome Measures(numerator/denominator) i. Number of surgical patients receiving naloxone/number of surgical patients receiving opioids ii. Number of Rapid Response Team opioid calls/number of surgical patients receiving opioids All MHA Keystone hospitals were invited to participate, and those interested were required to create an internal improvement team/committee to guide the hospital’s participation in this initiative. Each team was encouraged to have, at a minimum, the following roles committed to the project: • • • • • • • •

Director of surgical services Physician champion (surgeon or anesthesiologist; preferably both) Anesthesia champion Pharmacy contact Surgical services nursing leader Quality improvement and/or risk management representative Data contact (responsible for data collection and/or submission to the MHA Keystone Center) Senior executive sponsor

The teams require a “pain champion”, and anesthesiologists were encouraged to fill this role. The goal was, and continues to be, improvement in perioperative pain control with reductions in opioid use and opioid related morbidity and mortality. Educational programs are ongoing, and MSA leadership has been invited to participate in the project, with hopes of cobranding patient materials and increasing anesthesiologist involvement at the hospital and state level. Improving safety, quality, and satisfaction of our surgical patients should be the goal of every anesthesiologist, and pain control represents the “low hanging fruit” of process improvement. For more information I encourage you to contact Michelle Norcross, project manager for MHA Keystone: Surgery, at mnorcross@mha.org. Fall 2014

The Number of Anesthesiologists Being Trained:

Too Many, Too Few, or Just About Right Kevin K. Tremper, Ph.D., M.D.

or over 20 years the American Society of Anesthesiologists has been trying to determine whether we are producing too many or too few anesthesiologists. Up until the early 1990s there had been a persistent shortage of anesthesiologists from the inception of the field. For example, when the Department of Anesthesiology at the University of Michigan was founded in 1948, the chair, Robert B. Sweet, MD, found there were few trained anesthesiologist available. The surgery chair, Dr. Frederick Coller, told Bob Sweet that he had a relationship with Saint Bartholomew’s training program in London, England, who sent recently trained surgeons for a year of experience in Ann Arbor. He contacted the chair of surgery at Saint Bartholomew’s to see if there were any young anesthesiologists who might want to come to Michigan for a year of experience. In 1954, Dr. Thomas Boulton (who ultimately became chair at Oxford) came to Ann Arbor with his wife, supported by a scholarship from Senator Fulbright. When he returned to England he recommended to others that they do the same. This visiting faculty program from the United Kingdom has continued ever since and has many times filled the gap in the availability of anesthesiologists at the University of Michigan. When I started my anesthesia training at UCLA in 1980, there were approximately 800 graduates nationally. It was during the 1980s that the field of Anesthesiology was “discovered” by U.S. medical students. The interest progressively increased so that each class was approximately 100 residents larger than the previous year. This continued until 1995 when the graduating class nationally was 1800 (Figure 1). There was a drop in graduates in 1988 due to the increase in residency training from internship plus two years to internship plus three years in 1985. This progressive increase in graduating class size started to be concerning to the ASA and in 1992 they commissioned a workforce study, the results of which were presented in 1994.1 At this time the resident class size had leveled off to somewhere between 1700-1800 per year. This report was presented at a very interesting time in U.S. healthcare because the first Clinton Administration had vowed to change healthcare in “100 days” with the assistance of Hillary Clinton. The theory was that if people received more/better primary care then they would need less expensive care later.

There were also some areas of the country changing from traditional insurance to capitated/managed care payment programs where the primary care providers and insurance plans would benefit from not providing care as opposed to the fee-for-service model. This new model of care started in San Diego and was predicted to sweep the country, providing a disincentive for expensive procedures such as elective surgery. Simultaneously, the federal government recommended that medical schools should encourage 55% of their graduates to go into the primary care fields because there would be a greater need for primary care and a lesser need for subspecialties. Deans across the country were encouraging students not only to go into primary care, but also discouraging them to go into specialties.2 For some reason, anesthesiology appeared to be the poster child for the field that would be virtually unemployable given the predicted shrinking number of elective surgeries. To top it off there was a front page article in the Wall Street Journal titled, “Once a Hot Specialty, Anesthesiology Cools as Insurers Scale Back.” This article chronicled the plight of a graduate from UCSF’s anesthesiology residency program who could not find a job in San Francisco doing cardiac anesthesia.3 All of these forces came together in the 1996 NRMP match. The graduating resident class of 1996 was approximately 1750 and the match class into Anesthesiology was 143. It was as though a neutron bomb had hit the field. Although this class of 143 grew to over 800 by the PG2/CA1 year with interns and residents from other fields electing to go into Anesthesiology, it was still less than half the size of the previous years. Because of the length of the training program, the class matching in 1996 was the class graduating in the year 2000, which was the smallest class in nearly 20 years (Figure 1). As many of you remember, in the early 2000s there was a dramatic shortage of anesthesiologists nationwide and within a few years interest in anesthesiology dramatically rebounded.4,5 Why were medical students so swayed by the predicted difficult employment picture and not by their interest in our phenomenal field of applied physiology? This was principally due to a progressive increase in medical student education costs and debt at graduation. The average debt of a Michigan student is over $200,000, so any student facing the prospect of a difficult employment market

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and huge and growing debt would clearly go where they felt they would be most employable. Here we are in the year 2014 where again the ASA has twice more commissioned manpower surveys, this time by the RAND Corporation.6 The results of the survey reported in 2011 demonstrated a smaller shortage of anesthesiologists, and the one that will be reported this year will again demonstrate a smaller shortage. All of these studies have a variety of provisions in their model which could make their prediction vary considerably. There are the usual discussions of CRNA numbers, supervision ratios, and independent practice; now, they have added to that the gender change with more women in the field who may require some time off to have children, which will reduce their availability for OR work. In addition there has been a dramatic increase in interest for pain management and critical care over the past decade. With 300 fellows in pain management and approaching 140 each year in critical care, we can subtract about 300 from the graduating class available for operating room anesthesia. We are left with roughly 1300 per year added to the OR workforce. Due to the fluctuating stock market and its subsequent effect on retirement accounts, many anesthesiologists have delayed full retirement and opted for part-time work. Now looking at the national picture, the demographics of the nation are aging and surgical procedures increase with age, which has resulted in a continued increase in the number of surgical and medical procedures each year. So where does that place us in the next 10 to 20 years with respect to the number of practitioners in our field, too many, too few, or just about right? I would suggest that we will have a significant shortage for the simple reason of arithmetic. As I stated earlier in this article, when I graduated in the early 1980s there were roughly 800 graduates per year and by the 1990s there were 1800 graduates per year. Move that number forward to the 2000-teens and early 2020s where all of those graduates from the 1980s are now approaching and passing retirement age. If you assume that there will be roughly 1300 OR practitioners graduating per year and at some point the 1600, 1700, and 1800 practitioners per year age out by retiring, going part-time, or otherwise leaving clinical practice, we will face a situation within the next five to ten years, that, for the first time in our nation’s history the number of anesthesiologists practicing in the country will start to shrink and will continue to do so for the next five or more years. This is just “doing the math.” Historically, a rough rule of thumb for the number of anesthesiologists per population has been 1:10,000 population. This is a very crude estimate but there are approximately 35,000 anesthesiologists and there are approximately 318,000,000 people in the U.S. In Michigan there are about 900 anesthesiologists and 9,000,000 in population. Fall 2014

Currently, the University of Michigan has the largest training program in the nation having a total of 144 interns, residents and fellows and a graduating residency class of 30 per year. The state’s production has been fairly steady with a decrease with the closure of the Providence and Sinai programs 20 years ago and an increase with the addition of the Beaumont program three year ago. Overall, with the aging population, our current graduation rate of approximately 65 graduates per year is probably about the number needed to maintain the current number of practitioners. This assumes that most of the graduates stay in the State of Michigan. At the University of Michigan, nearly half our graduates leave the state, returning to where they grew up or to warmer weather. Therefore, all in all I think we are heading into a slow but progressive shortage of anesthesiologists unless there are unforeseen technologic or pharmacologic genome changes. Time will tell.

References

1. American Society of Anesthesiologists. Estimation of Physician Work Force Requirements in Anesthesiology. Abt Associates, Inc, Bethesda, Md; 1994. 2. Tremper KK, Barker SJ, Gelman S, Reves JG, Saubermann AJ, et al. A Demographic, Service, and Financial Survey of Anesthesia Training Programs in the United States. Anesth Analg 2003; 96:1432-46. 3. Anders G. Once a Hot Specialty, Anesthesiology Cools as Insurers Scale Back. Wall Street Journal, 17, March, 1995. 4. Kheterpal S, Shanks A, Morris M, Tremper KK. Workforce and Finances of the United States Anesthesiology Training Programs: 2009-2010. Anesth Analg, 2011; 112:1480-1486. 5. Schubert A, Eckhout GV, Ngo AL, Tremper KK, Peterson MD. Status of the anesthesia workforce in 2011: evolution during the last decade and future outlook. Anesth Analg. 2012; Aug; 115(2):407-27. 6. Rand Corporation. Is there a shortage of anesthesia providers in the United States? Available at: http//www. rand.org/pubs/research_briefs/2010/RAND_RB9541.pdf

MSA Partners with ASA to Collect Dues

he Michigan Society of Anesthesiologists (MSA) and the American Society of Anesthesiologists (ASA) will be providing unified dues billing to all members in 2015. The ASA annual membership renewal invoice will now include MSA dues. This service provides several benefits to MSA and MSA members including: • Convenient single invoice to pay both ASA and MSA dues • Ensures uninterrupted benefits and member access in both organizations • Easy online payments • New applicants joining ASA join MSA at the same time • Reduced overhead expenses for MSA • Reduced staff time on billing and collections for MSA

The renewal invoices for membership year January – December 2015 will be available for online payment in early November, with printed invoices mailed in December. Printed and email communications for ASA and MSA membership renewal will primarily come from ASA. All existing MSA and ASA group invoices will continue. Questions can be directed to Hillary Walilko, MSA Administrative Direcotr at walilko.h@gcsionline.com or Rachel Rusch, Component Services Manager, American Society of Anesthesiologists at r.rusch@asahq.org.

ASA is not increasing dues for 2015. Your combined invoice will reflect the following rates Benefit Type Active Affiliate Resident

ASA Amount

MSA Amount

Total Amount

$665.00 $335.00 $25.00

$300.00 $125.00 $5.00

$965.00 $460.00 $30.00

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New & Refurbished Anesthesia Equipment

New VideoStylet Only $499 each

Refurbished Cardiocap/5 $3,500-$7,500

Refurbished Aestiva/5 $14,900-$19,900

Refurbished Fabius GS $15,900-$19,900

800-448-0814

Fall 2014

Refurbished Mindray Spectrum $2,950-$4,500 w/ EtCO2

New Mindray A3/A5 $27,000-$35,000

New Mindray DPM6 & DPM7 $7,860-$15,995

Refurbished Avance $25,900-$32,900

Paragon Service www.ParagonService.com

SimpleBlend O2 & Air Mixer $845-$1,145

New&Refurbished Paragon SC430 $12,900-$18,900

Fax 734-429-3197

ASA Legislative Conference – Resident Experiences

he annual ASA Legislative Conference in Washington D.C. is the setting for a different type of education for anesthesiology residents. This year five residents, representing each residency program in Michigan, attended the conference. This annual conference is an educational experience for all anesthesiologists, as it provides an update on political and policy issues that concern our specialty. Representative Andy Harris, the first anesthesiologist elected to congress, presented an eye-opening lecture and Larry Sabato added a side of humor to his predictions for future political nominations. We were also able to participate in an invaluable small group session simulating effective communication with the media. Most importantly, we were able to bring concerns about issues such as scope of practice in the VA health system, as well as, rural pass through legislation to the attention of Senator Stabenow and Representative Mike Rogers. The meetings with policy makers demonstrated the importance of maintaining relationships between congressmen and practicing physician anesthesiologists. The ASA Legislative Conference provided the perfect stage to draw attention to the issues facing current and future practicing anesthesiologists. Lindsay Straight, CA-2 Beaumont

y initial exposure to the field of medicine was in the realm of advocacy. Working with a local adolescent homeless shelter, coordinating their medical care

and immunizations, I learned that when there is a cause you are passionate about you have to get involved personally. My experience this year at the ASA Legislative Conference was no different. It was refreshing to see so many other like-minded people, an experience you seldom get from a residency program whose focus is to educate future anesthesiologists, not necessarily to ensure that future. The topics addressed, including the hot button issue surrounding the VA handbook on nursing independent practice, helped give me context surrounding the arguments, and my ability to respond appropriately to criticism from opposing sides. We also had the opportunity to meet with our state representatives, allowing them to hear our concerns on the future of our field. Seeing our Michigan Society of Anesthesiology leaders speak with such conviction and having our politicians captivated really opened my eyes to power that we all have. The interactions that day will never be forgotten. I think above all though, making the connections and friendships I did on this trip made all the difference. To know that there are other residents who have the same mindset, and now with a similar vantage point, really put everything in perspective. This conference solidified my commitment to the future of our field. The only way physician anesthesiologists will become unnecessary is if we allow that to happen – something I plan to prevent from transpiring. Zev Davidovich, CA-3 University of Michigan

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The Michigan Society of Anesthesiologists Education and Research Endowment Fund Robert L. Snyder, D.O.

he 2003 Annual meeting of the Michigan Society of Anesthesiologists showcased the 1st Annual Resident Poster Session for our society. Through the hard work and visionary leadership of Drs. David Dull, Rosalie Tocco-Bradley and Maria Zestos the exhibits were very successful. The benefit of a large resident turnout at the MSA Annual Meeting was apparent to the Board of Directors and a strategy to fund the resident research presentations was developed. I served as Secretary-Treasurer during the implementation of this program and recall the society’s budget was very tight. With the blessing of the Board of Directors, I took on the task to see how funding of the resident posters could be accomplished. An endowed fund for this purpose would not be subject to possible budget cuts in future years and would secure funds for ongoing support of resident research in Michigan. After researching the U.S. tax codes and how they applied to our organization and resident grants, it became apparent that the best solution was to use the tax status of a Community Development Fund as the investment vehicle for our endowed fund. Living in Midland and knowing about the numerous funds the Midland Area Community Foundation (MACF) manages, I researched the possibility of using this vehicle. The MSA Board selected the MACF to carry out the purpose of the Fund through investment and reinvestment because of its favorable tax status, investment experience, policies, and low administrative costs. As an organization, MSA committed $5,000 to initiate the Fund in January 2005. Donations that are made to the Fund are tax deductible on the federal level. Unfortunately, the community foundation tax credit from the State of Michigan is no longer available for your donations. Through individual donations and investments our Fund has grown to over $20,000 in less than 10 years of existence. To date the spendable balance in the Fund is just

Fall 2014

over $1,500. Each year $600 is awarded in educational grants for the Resident Poster Session at the MSA Annual Meeting. In 2011, the MSA Board transferred $1,700 from the Fund to cover poster awards for the following three years. The fund is achieving its primary goal of providing awards/grants in support of education and research by resident physicians in anesthesiology programs (M.D. and D.O.) in the state of Michigan. By encouraging education and research, the fund promotes enhanced patient safety for Michigan citizens undergoing anesthesia and surgery. It is hopeful that recipients of the endowment awards might be influenced positively to stay and practice in Michigan and to continue their research interests, thereby raising the level of anesthesia care to the citizens of Michigan. The Fund could achieve much more if MSA member donations were available to grow its asset base. You are encouraged to visit the MACF’s website at http:// www.midlandfoundation.com/ and click on the link to funds to view our statement of purpose. Donations can be made to the Fund via checks, credit cards, donation of stock, charitable remainder trusts, or estate planning. MACF’s website is secured for credit card processing and is very easy to use. The contributions are private unless the individual directs the Foundation to notify MSA of a memorial or “in honor of” donation. MSA leaders have received a great deal of positive feedback over the years from resident physicians and their Program Directors for our Resident Poster Session at the Annual Scientific Session. The MSA Education and Research Endowment Fund is intended to support the Poster Session and other possible research and educational activities for the residents without an outlay from MSA’s annual budget. I encourage you to support the Fund when making your decisions on charitable donations. Your generosity to the MSA Education and Research Endowment Fund will benefit our patients, our practices, and our society. Thank you.

LEGISLATIVE CORNER

Election Lawmakers were in session again for several weeks, following the August Primary. However, during most of October through early November, there is only one legislative session day scheduled as lawmakers continue to be primarily focused on the 2014 election. State Senators are running in the new reapportionment maps, based on the 2010 census, for the first time. We are also seeing a few Senators and Representatives not returning for reelection, either because of retirement, term limits or to run for another office. Consequently, there are ten open seats in the Senate, which will largely be filled by current members of the State House of Representatives or former members. The House has 41 open seats which will be filled with new faces for the 2015-16 session. Your MSA and GCSI team have been working hard to get to know the candidates for state office. This grassroots strategy is critical as we see new lawmakers coming to Lansing to set policy on issues that affect anesthesiology. It is important to educate these individuals early on about the practice of anesthesiology and discuss some of the topics supported and opposed by MSA physicians. Also, don’t forget to get out and vote in the General Election on November 4th! Although much of the activity in Lansing has been slower as lawmakers have focused much of their attention on the fall election, your team at GSCI and the MSA continue to work behind the scenes in order to remain prepared to work on the variety of issues the Legislature may tackle when they return for the lame duck session in November. In addition, we are preparing for the new lawmakers by strategizing on the MSA legislative agenda for 2015 when the new session will be in full swing. We also want to note that with the start of the 201516 session, we will see a number of changes to the policy committees relevant to anesthesiologists, including House and Senate Health Policy and Insurance Committees due to the election. We will work to educate all new committee members about anesthesiology, including the importance of physician supervision for patient safety, as well as other issues of importance to your specialty and medicine in general. There are at least two physicians running for the Michigan House – John Bizon in the

Legislative Corner is a regular feature, written by Nell Kuhnmuench and Marcia Hune, Governmental Consultant Services, Inc.

62nd District to replace term-limited Rep. Kate Segal (D-Battle Creek) and Ned Canfield in the 84th District, which is currently held by term-limited Rep. Terry Brown (D-Pigeon). We will provide a comprehensive election update and summary to the MSA in future editions of “The Ventilator”. In the meantime, if members have questions, please do not hesitate to contact either of us at kuhnmuench.n@gcsionline.com or hune.m@gcsionline.com.

Legislation Removing Physician Supervision of Nurse Anesthetists One of the major bills we continue to monitor and oppose is legislation removing the physician supervision requirement for nurse anesthetists. Currently, Senate Bill 180 has been introduced by Sen. Mike Green (R-Mayville) and referred to the Senate Health Policy Committee. The bill amends the Public Health Code to expand the definition of the “practice of nursing” to include “the administration of anesthesia by a registered professional nurse who holds a specialty certification as a nurse anesthetist”. This would, in effect, remove the requirement of physician supervision of nurse anesthetists. We continue to believe that Rep. Frank Foster (R-Pellston) could still introduce companion legislation, or possibly an amendment to another bill, to remove physician supervision of nurse anesthetists. GCSI continues to reach out to members of the House Health Policy Committee to let lawmakers know of MSA opposition to either stand-alone legislation or an amendment on the issue. It is worth noting that Representative Foster was the only incumbent to lose in his primary election, and may not focus on introducing this

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Legislative Corner Con. controversial bill in his remaining few months in office. However, your GCSI team will remain vigilant. When Senate Bill 180 was up in Senate Health Policy Committee for testimony last fall, several senators on the committee expressed concern over the idea of removing physician supervision at the risk of patient safety. While Senate Bill 180 was not reported by the committee, and although Rep. Foster has not yet introduced a similar version in the House, MSA members are encouraged to continue outreach to your representatives and senators about the patient safety concerns that would result from removing physician supervision of nurse anesthetists. In the meantime, GCSI and your MSA Legislative Committee will continue to work hard in advocating on behalf of anesthesiologists and physician supervision in regard to this legislation.

Legislation to Expand the Scope of Certain Advanced Practice Nurses Another bill that could move during the lame duck session later this year is Senate Bill 2, sponsored by Sen. Mark Jansen (R-Grand Rapids), which

provides for an expansion of scope for certain advanced practice registered nurses (APRNs), including certified nurse midwives, certified nurse practitioners, and clinical nurse specialistscertified. The bill has passed the full Senate and is currently before the House Health Policy Committee. The House Health Policy Committee held a hearing for testimony only on Senate Bill 2 in September. Among other things, Senate Bill 2 would authorize a licensed APRN to prescribe and administer nonscheduled prescription drugs and Schedule 2 through 5 controlled substances if he or she met certain criteria and greatly expand their unsupervised scope. We continue to monitor for action on SB 2 in the House Health Policy Committee, and remain vigilant for any efforts to include nurse anesthetists in this bill during lame duck session. However, after the recent hearing, Rep. Gail Haines (R-Waterford) has created a workgroup on the overall issue of rural access to healthcare, and does not appear interested in moving SB 2 without a compromise reached in this workgroup. GCSI continues to work diligently to be the eyes, ears, and representatives of the Michigan Society of Anesthesiologists in Lansing, as we advocate for policies that ensure the safety of patients.

MSAPAC REPORT David M. Krhovsky, M.D. dkrhovsky1@gmail.com

y report for this i s s u e of The Ventilator will be brief. As I write this, there is about a month to go in the MSAPAC fiscal year. Overall contributions are down a bit, with the number of donors down as well. Interestingly, the amount given per donor has increased. This means, of course, that fewer members are carrying the burden that all MSA members should be sharing. It is important to keep in mind that the challenges

Fall 2014

facing our specialty are not becoming less, as the legislative report elsewhere in The Ventilator will make quite apparent. PAC funds are vital in our efforts to educate legislators and support those who understand and agree with our views on these issues. As anesthesiologists, we are all stakeholders here. To those who have given, I extend my sincerest thanks. To those who have not, please give. Donâ&#x20AC;&#x2122;t let a minority lift the load that we all should be helping to lift. Any amount you feel you can afford will be most welcome. It is the right thing for our specialty and for our patients!

PRESORT STD U.S. POSTAGE

PAID

LANSING, MI PERMIT NO. 234

120 N. Washington Sq., Suite 110A Lansing, MI 48933 Phone: 517.346.5088 Fax: 517.371.1170

MSA - PAC Critical issues affecting your practice will be decided by the State Legislature. Your contribution is needed more than ever! Enclosed, find my contribution for o $500 o $250 o $150 Name ______________________________________________________________________________________ Address_____________________________________________________________________________________ Phone Number ____________________________________Personal Check__________ payable to MSA-PAC N O C ORP OR ATE C H E C KS Visa/Mastercard____________________________________________ Expiration Date________/_________ Cardholderâ&#x20AC;&#x2122;s Signature______________________________________ Forward your contribution to: 120 N. Washington Sq., Suite 110A, Lansing, MI 48933 Contributions to MSA-PAC are not tax deductible as business expenses or charitable contributions.