Anesthesia Providers, Patient Outcomes, and Costs

To the Editor: The article by Abenstein and Warner on anesthesia providers, patient outcomes, and costs (Anesth Analg 1996;82:1273-83) will no doubt generate considerable editorial controversy. I would like to add my comments. It is interesting that there exist no data within the last 20 years concerning patient outcome as a function of anesthesia provider. Much has changed in anesthetic practice in 20 years, not only from the standpoint of medical and technical factors, but also in terms of the distribution of providers, the types of patients and surgeries encountered by these providers, and the organizational nature of these practices. It is not at all clear that the results of Forrest's study [1] would be replicated in the practice settings of the current era. The authors make a number of conjectures considering potential advantages of the care team environment in terms of patient safety. I believe that these conjectures on the inherent psychological superiority of teams are superficial and ignore substantial bodies of research on the cognitive and social psychology of teams. The authors state that "the combined talents and observational skills of this team may allow them to synergistically utilize available knowledge and observations to make appropriate patient care decisions." This is certainly true of the ideal care team, but we do not know how many teams actually fulfill this ideal promise. Teams carry with them the potential for poor function as well as ideal function. Poor communication, lack of leadership, failure to use all available information, and inability to distribute workload effectively have all been observed in a variety of team situations including in anesthesiology [2-5]. Two pairs of eyes and hands are often better than one pair, but they are also sometimes worse. Also, the authors consider only the "anesthesia care team" and not the whole operating room team. In fact, my laboratory now refers to the operating room "team" as being made up of several independent "crews," of which the anesthesia crew is but one [5]. Patient outcome is almost certainly related to the performance of the overall team, not just to that of one of the crews. There are no data concerning the team interaction, communication, and vulnerability to surgical production pressure of anesthesiologists, nurse anesthetists, or care teams. The care team is not necessarily stronger than other provider models (particularly anesthesiologist only) in these aspects of good patient care. Furthermore, the authors state that, in care team settings, "when a problem occurs with an individual patient … more than one physician and more than one nurse or other provider are rapidly available to assist with the care of that patient. These dynamics illustrate the rapid response that an anesthesia care team model can mount to a crisis, and it may be the key to improved patient outcomes." Rapid mobilization of skilled help in a crisis is crucial [6], yet the care team model in anesthesiology does not guarantee the availability of skilled help. One provider must always stay with each anesthetized patient. When relatively few anesthesiologists supervise many CRNAs, help may not be forthcoming if the anesthesiologists are already busy. If mobilization of help is a specific goal of a surgical suite, the issue needs to be addressed directly, that is, by ensuring that skilled personnel who are not already occupied with critical patient care activities are always available. The care team as it is organized in most surgical settings may not be any better at this than are other organizational systems (for example, an anesthesiologist-only system that has an extra anesthesiologist on site for such contingencies). Finally, mobilization of help is only one of many factors that are needed to ensure appropriate crisis management in anesthesiology [6]. There is no guarantee that care teams, with their mix of providers having different skills and training, will work optimally in responding to crisis situations, especially in the absence of specialized training in crisis management techniques [7]. In summary, although the data, information, and analyses provided by the authors are interesting and provocative, I strongly disagree with their nearly unqualified statement that "the anesthesia care team and hybrid practices appear to be the safest methods of delivering anesthesia care. This safety may be due, in part, to the rapid availability of physicians, especially during medical crises." The question of how best to organize anesthesia care (or any other type of medical care) for achieving maximum patient safety has not yet been thoroughly examined. It is inappropriate to make claims such as those made by the authors based on such a paucity of data and analysis. David M. Gaba, MD Department of Anesthesia Stanford University School of Medicine Veterans Affairs Palo Alto Health Care System Palo Alto, CA 94304