What can we expect in the next 10 years of anesthesiology? I’m writing this in January 2016. God willing, we’ll all be alive and well to reread this in 2026, and find out how many of these predictions came true.
I’m writing this from the perspective of a busy clinician who has worked as an anesthesiologist in California in both private practice and at a major university hospital for over 30 years. I see 10 trends for the future of anesthesiology as:
- Lower income (as adjusted for inflation). There will be multiple causes for this: a) An aging population, with the significantly lower pay for attending to Medicare patients, b) Obamacare and other governmental payment cuts, c) Bundled insurance payments to hospitals, requiring anesthesiologists to negotiate for every nickel of that payment due to them, and d) Corporate anesthesia (see #9 below).
- More care team anesthesia and more Certified Nurse Anesthetists (CRNAs). Hospital systems will have increased incentives to perform anesthetics with cheaper labor. Rather than physician anesthesiologists personally performing anesthesia, expect to see CRNAs supervised by physician anesthesiologists in an anesthesia care team, or in some states, CRNAs working alone.
- There will be a paucity of new drugs to change the practice of operating room anesthesia. A few years ago I had a conversation with Don Stanski, MD, PhD, former Chairman of Anesthesiology at Stanford and now a leading pharmaceutical company executive, regarding new anesthetic drugs in the pipeline. Dr. Stanski’s reply was something along the line of, “There are almost no new anesthetic drugs in development. The ones we currently have work very well, and the research and development cost in bring an additional idea to market is high. Don’t expect much change in the coming years.” Consider sugammadex, a new drug for the reversal of neuromuscular blockade, recently approved by the Food and Drug Administration. The drug is more effective in reversing a rocuronium or vecuronium block than is neostigmine, but the cost is high. The acquisition cost of the smallest available vial of sugammadex is over $90, far exceeding the cost of neostigmine. In certain instances, faster reversal by sugammadex will be critically important, but for routine cases the cost is prohibitive. This trend of fewer new anesthesia drugs isn’t only a futuristic phenomenon. In my current private practice, I see my colleagues using the same medications that they used 25 years ago: propofol, sevoflurane, rocuronium, fentanyl, and ondansetron.
- An aging population, an increased volume of surgery, and an increased demand for anesthesia personnel. As the baby boomers age, there will be an increased number of surgeries on older, sicker patients. Anesthesia personnel will be in great demand.
- Anesthesiology will become more and more a shift-work job. A generation ago an anesthesiologist started a case and finished that case. An on-call anesthesiologist came to work at 7 a.m., took 24-hour call, and finished their last case as the sun came up the next morning. Certain instances of this model may persist, but as more anesthesiologist become corporate employees, expect more anesthesia practitioners working 8-hour or 12-hour shifts, just like employees in other jobs.
- Increased interest in the specialty of anesthesiology amongst medical students. Although several items on my list may seem discouraging, take heart, because the career of anesthesiology will remain extremely popular. Why? Because the other fields of medicine have problems, too. Bigger problems. Many future doctors will shun the primary care fields of family practice, internal medicine, and pediatrics. The primary care fields offer long days in clinics, dealing with a new patient every 10 – 15 minutes, and they suffer from low pay. Because of the higher reimbursement in procedural specialties, careers in surgery, anesthesia, cardiology, and invasive radiology will always be popular.
- Expect improved safety statistics regarding anesthesia mortality and morbidity. Anesthesia has never been safer. See “How Safe is Anesthesia in the 21st Century?” Expect further improvements in monitors, protocols, education, and the analysis of Big Data that will make anesthesia safer than ever.
- There will still be a non-zero incidence of anesthesia-related fatalities. There will still be disasters, particularly airway disasters. Some anesthesia clinical situations will always remain extremely difficult and challenging, and human error will not be eradicated.
- Large national corporations will continue buying up private anesthesia practices, perhaps eliminating the current model in which groups cover one hospital or one city alone. In the last three months, Sheridan, the physician services division of AmSurg, Corp has purchased the 60-physician, 140-anesthetist Northside Anesthesiology Consultants in Atlanta, and the 240-physician Valley Anesthesiologists & Pain Consultants in Phoenix. In these purchases, senior board members and partners receive seven-digit checks to sell their practice, then all physicians in the practice’s future labor for a discounted wage, perhaps as low as 50% of the prior income. If this trend becomes widespread, this subset of the anesthesia workforce will become low paid practitioners, while the purchasing corporations will make significant profits for their stockholders.
- Continued fascination with anesthesia practice, a discipline which makes all surgical treatments and cures feasible. Without anesthesia, there can be no major surgical procedures. Medical care without major surgical procedures is unthinkable. Whether as anesthesia providers, as patients requiring surgery, or just as observers of the process, we will all continue to value and marvel at the field of anesthesia.
Published in September 2017: The second edition of THE DOCTOR AND MR. DYLAN, Dr. Novak’s debut novel, a medical-legal mystery which blends the science and practice of anesthesiology with unforgettable characters, a page-turning plot, and the legacy of Nobel Prize winner Bob Dylan.
In this debut thriller, tragedies strike an anesthesiologist as he tries to start a new life with his son.
Dr. Nico Antone, an anesthesiologist at Stanford University, is married to Alexandra, a high-powered real estate agent obsessed with money. Their son, Johnny, an 11th-grader with immense potential, struggles to get the grades he’ll need to attend an Ivy League college. After a screaming match with Alexandra, Nico moves himself and Johnny from Palo Alto, California, to his frozen childhood home of Hibbing, Minnesota. The move should help Johnny improve his grades and thus seem more attractive to universities, but Nico loves the freedom from his wife, too. Hibbing also happens to be the hometown of music icon Bob Dylan. Joining the hospital staff, Nico runs afoul of a grouchy nurse anesthetist calling himself Bobby Dylan, who plays Dylan songs twice a week in a bar called Heaven’s Door. As Nico and Johnny settle in, their lives turn around; they even start dating the gorgeous mother/daughter pair of Lena and Echo Johnson. However, when Johnny accidentally impregnates Echo, the lives of the Hibbing transplants start to implode. In true page-turner fashion, first-time novelist Novak gets started by killing soulless Alexandra, which accelerates the downfall of his underdog protagonist now accused of murder. Dialogue is pitch-perfect, and the insults hurled between Nico and his wife are as hilarious as they are hurtful: “Are you my husband, Nico? Or my dependent?” The author’s medical expertise proves central to the plot, and there are a few grisly moments, as when “dark blood percolated” from a patient’s nostrils “like coffee grounds.” Bob Dylan details add quirkiness to what might otherwise be a chilly revenge tale; we’re told, for instance, that Dylan taught “every singer with a less-than-perfect voice…how to sneer and twist off syllables.” Courtroom scenes toward the end crackle with energy, though one scene involving a snowmobile ties up a certain plot thread too neatly. By the end, Nico has rolled with a great many punches.
Nuanced characterization and crafty details help this debut soar.
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