To the Editor:-Dr. Orkin's editorial view on rural realities adds one more contribution to his long list of epidemiology studies on anesthesia practice. However, the editorial commentary on the distribution of anesthesia personnel in rural areas did not reflect reality in a number of points. Although we applaud Dr. Orkin's attempt to identify the factors influencing the numbers of anesthesiologists and nurses anesthetists who work in underserviced area, the author admits that the data were obtained from an annual survey conducted by the American Hospital Association and answered by hospital administrators.
We relocated to the Florida panhandle in 1989 and have lived in Walton County, which has about 31,000 inhabitants. Because of our interest in rural hospital services and management, we are also well informed of the anesthesia-related situations and the hospitals' statistics for other adjacent rural counties, such as Washington, Holmes, Gulf, Franklin, and Jackson, which have one hospital each with a small bed capacity Table 1.
The ratio of anesthesiologists to 100,000 population in northwest Florida is erroneous, as far as the shaded areas shown in Dr. Orkin's Figure 1are concerned. There is one anesthesiologist in Walton County and one nurse anesthetist; other hospitals have one nurse anesthetist each covering between 20-40 cases per month, except for in Franklin County, which has four CRNAs providing anesthesia coverage for about 90 cases per month. Dr. Orkin's map is an incorrect representation of anesthesiologists per 100,000 population in this part of the country. By incorporating two non-rural counties such as Okaloosa County with 14 anesthesiologists and Bay County with 9 anesthesiologists, all the adjacent rural counties shown in Figure 1appear to have 7 anesthesiologists per 100,000, when in fact there are only 2.
We have been aware of anesthesiologists wanting to practice in these hospitals; however, administrators have not only been uninterested, but at times they have been openly hostile. The reason is economics because even with only 30-40 cases per month, by employing a CRNA for about 60,000-70,000 dollars per year, they actually profit more by billing for the medications, supplies, equipment and for the professional fee. Therefore, hospitals are not eager to have anesthesiologists.
Finally, case reviews and analysis of pre- and postoperative complications and deaths are seldom conducted in a proper manner, making quality assurance a family affair. Deaths and complications are not discussed and go unreported, and because litigation is scarce in this location, the AHA statistics do not reflect reality as far as morbidity is concerned. The reports describing no anesthesia-related deaths in these hospitals is a myth because there are powerful reasons to cover them up.
Nevertheless, anesthesiologists should consider going into rural areas not expecting a certain number of cases set up for them, nor a guaranteed income, but with the mission to join the community and build practice as any other specialist would do based on professionalism, availability, and competence. Incorporation of Pain Management, for example, could help to establish their own base of patients for whom they will be providing medical care and making treatment decisions. Hopefully then, emancipation from “consultant only” stigma may elevate the spirits of some anesthesiologists.
J. Antonio Aldrete, M.D.
Professor; Department of Anesthesiology; University of South Florida; Tampa, Florida
Valentina T. Aldrete, D.D.S., M.S.H.A.
Chief Executive Officer; Sunshine Medical Center; Destin, Florida
(Accepted for publication July 9, 1998.)