To the Editor:-Articles and editorials addressing the economics of anesthesia practice are rarely published in Anesthesiology. That makes the recent publication of four articles and two editorials in the May issue all the more unusual, and I applaud the Editorial Board for recognizing the realities forced on all physicians, whether by market forces or by managed care-inspired cost restraints. [1–6] As Shapiro points out in his editorial, Fisher and Macario place the articles in a perspective that challenges all anesthesiologists to examine the economics of their practice.
However, Shapiro's editorial also expresses opinions not acceptable to many anesthesiologists, and his interpretations of history is at variance with the facts as I know them. Although I agree with the basic tenet of his message that perioperative medicine is the future of our specialty, that does not mean that the direct administration of anesthesia by physicians is history! Further, I do not concur with his statement that we are perceived, “as far too expensive for the limited services (i.e., direct physician-administered anesthesia) we render.”
Shapiro's suggestion that the Anesthesia Care Team (ACT) developed in response to this perception and the replacement of “explosive and poorly controllable anesthetic agents in conjunction with limited monitoring capabilities” by better, safer agents and more sophisticated monitoring in the mid-1960s is not true. The ACT functioned much earlier in response to a shortage of trained anesthesiologists and permitted their knowledge and skills to be available to more patients by means of physician extenders.
Has the introduction of better agents and monitoring decreased the need for direct administration of anesthesia by physicians? Absolutely not! Rather, it has only permitted us to anesthetize sicker patients for more complex procedures safely. Radical cancer surgery, aggressive trauma surgery, and multiple organ transplants are examples of procedures that developed after the administration of anesthesia became safer. Direct administration of anesthesia to patients may have been the anesthesiologist's sole focus at one time. Today we have exported and greatly expanded our talents to acute and chronic pain management and to critical care. Preoperative preparation (as opposed to evaluation), efficient operating room (OR) management, and satisfaction of patient, surgeon, and hospital administrator are all areas that demand and deserve our attention as perioperative physicians.  The “added value” in these new areas is just that-added-and does not mean the demise of direct administration of anesthesia by physicians is history. To suggest otherwise does a disservice to the many anesthesiologists who practice in this manner and, frankly, denigrates their services.
Norig Ellison, M.D.
Department of Anesthesiology; University of Pennsylvania Medical Center; 3400 Spruce Street; Philadelphia, Pennsylvania 19104–4283
(Accepted for publication July 29, 1997.)