An Anesthesiologist Thinks Out Loud

Anyone who has read my work knows that articles like the one written in the New York Times on Sunday by Elisabeth Rosenthal will immediately get a response out of me.  If you haven’t read it, here’s the link.

Where do I start with this???  I’m going to let Ms. Rosenthal tell you about how many unnecessary colonoscopies we do.  I’ll let her tell you how much more it costs here than anywhere else.  I will address the anesthesia bit.  Let me tell you a little story.  When I was a baby anesthesiologist my hospital sent anesthesiologists “downstairs” to do anesthesia for GI procedures maybe once a week for a few hours.

This was in 2004 or so.  Now we send three board certified anesthesiologists to various GI units every day all day.  We do maybe 25 cases a day on average.  Now, some of this is due to the aggressive expansion of the advanced GI procedures unit as well as the addition of an outside private group that was recently folded into the greater hospital system.  It’s also because we’re there.  It’s no accident that as soon as we committed troops to the GI battle all of a sudden everybody needed anesthesia.

The NYT article uses Dierdre Yapalater as an example, a healthy 60-something.  Putting aside the ridiculous cost for the overall procedure, she was billed $2,400 for anesthesia.  But she didn’t need anesthesia.  There is absolutely no reason for her to have an anesthesiologist involved for that case.  None.

Anesthesia care used to be limited to very sick patients, not because they are harder to sedate (they’re actually often easier) but to monitor them closely because of their tenuous physiologic status.  Now everybody is getting it.  Why did she get anesthesia, why did the anesthesiologist give it, why does insurance pay for it?

Another little story.  About 6 months ago there was a midazolam shortage.  Midazolam is a valium-like drug given intravenously for sedation, often used by nurses and non-anesthesia providers very safely, and frequently used in colonoscopies.  One of my hospital’s affiliates, which does a hundred colonoscopies a day, didn’t want their revenue stream interruped by this. So instead of delaying these completely elective cases they asked my department to come give the anesthesia for all of their cases until the midaz shortage was over.  So we sent 2 or 3 doctors over there everyday for a while to give propofol.  Increased the cost of each case by a couple of thousand bucks.

Why did we have to send fully-trained anesthesiologists over there?  Because the anesthesia lobby has been powerfully persuasive about limiting the use of some drugs to our docs only.  Propfol, the sedative used in the above example in place of midazolam, is a powerful drug but it’s use is not rocket science.  It has been used in other developed countries by non-anesthesia personnel safely for years.

And even without propofol, the vast majority of colonoscopies can be done easily with midazolam and fentanyl.  An anesthesiologist is just not necessary.  Apologies to my colleagues.  Protecting our jobs looks great from our 4 bedroom houses in the suburbs, but not so great for the longevity and integrity of our healthcare system.

Shirie Leng, MD is a practicing anesthesiologist at Beth Israel Deaconess Medical Center in Boston. She blogs regularly at medicine for real, where an earlier version of this post appeared.

14 replies »

  1. Very interesting take here. I think I’d want to compare how other countries handle stuff like propofol use before I’d do any changes to our current system, but I do think change might very well be necessary. Thanks for your insight.

  2. Dr., I’m disappointed that you have not responded to my post regarding anesthesia for colonoscopies.

  3. I have awakened to incredible pain every time I have had a colonoscopy. For me, the ‘usual’ drugs don’t cut it. I agree that ALL medical care in the U.S. is terribly overpriced, but to say definitively that anesthesia is not warranted, or to expect an untrained nurse to adequately administer drugs is a grave error.

  4. Exactly how does an anesthesiologist bill $2400 for a colonoscopy?

    The vast majority of “scopes” I do are billed 10 units or less.

    And the major commercial payer in our practice pays a set fee of about $200 for a colonoscopy.

    So I can’t see how cost is relevant.

    What is relevant is the patient experience and safety.

    Nearly 100% of the patients whom I interview for GI procedures, who have had Midazolam and Fentanyl sedation for a previous EGD or colonoscopy, offer the complaint that they “woke up” during the procedure (and had pain) and don’t want that to happen again. And that they had a “hangover” for the rest of the day.

    Propofol, administered by an anesthesiologist, is the “gold standard” for GI procedures.

    And no one should administer Propofol to any patient unless they have the skill to secure an airway.

    I probably do a few hundred GI “MAC” procedures every year.

    Again, I’d really like to know how I can get $2400 for each of them.

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  6. Dr. Santi,

    Never used Propofol – only Versed and Fentanyl. And I have a record of no (sedation related) complications over many years.

    What safety issue?

  7. Two words.. MICHAEL JACKSON !! He would still be moonwalking if he didn’t get Propofol or if an anesthesiologist was present . This article is not totally accurate, first of all where I practice ( Southwest USA ), not eveyone gets moderate sedation . Since we do a lot of Medicare cases, there are strict indications for MAC. The private patients have a choice, most of them WANT anesthesia, we have them sign a consent after an explanation of risks, benefits. If a patient has multiple medical problems, morbidly obese ( we are getting more and more ), they are an anesthetic challenge . Propofol , Versed, Fentanyl, can easily put a patient into”general anesthesia” and if there’s a problem with the airway, untrained personnel will not be able to rescue that patient.

  8. I introduced IV conscious sedation with Valium and Fentanyl to my hospital in 1984. Had to fight the Administration to get a pulse oximeter, which were expensive in those days.

    I made extensive use of sedation with Valium (more recently Versed) and Fentanyl to do angiography and invasive procedures. I think it really added to the patient’s comfort during these procedures. Pts were monitored by nurse using pulse ox, BP, EKG, etc. Did thousands of cases with no complications.

    Recently, the hospitals have made it harder for Radiologists to give IV conscious sedation by requiring more training, tests, paperwork, etc. Some of my colleagues have given up using sedation – which I think is not in the patient’s interest. (I stopped doing angio/interventional about 5 years ago.

    Not sure where the push to make it harder to give sedation is coming from – Anesthesia?, nurses with clipboards?, the government. In any case it will push us to either not give sedation – which is not in the patient’s interest, or to get Anesthesia involved which will drive up the cost of the procedure substantially.

  9. Shirie, my real point is: why would gastroenterologists perform the same job you do while simulataneously performing an invasive diagnostic procedure and not get reimbursed for it? Why does an anesthesiologist get payed(often more than the cost of the procedure itself) and the proceduralist recieves no compensation for doing the SAME job you do? If you want to see anesthesiologists not invited into the procedure room, give proceduralists an economic incentive to perform their own anesthesia by compensating them a fraction of your fee. Until that happens, nothing is going to change.

  10. Rob: When I argue that anyone can use propofol, I mean that there is no technical or intellectual reason anyone can’t. Anesthesia departments have successfully blocked it’s use.

    I agree the responsibility for sedation falls upon the GI doctor if anesthesia is not there. Very good point.

  11. Dr Leng fails to address a very important point. If a gastroenterologist performs their own conscious sedation for a colonoscopy they now have to perform two jobs, as well as take on the added liability of anesthesia while they perform the procedure. For that extra work and liability they are not compensated one additional penny. Bring in an anesthesiologist and they can perform the procedure, defer the job of sedation and the responsibility that goes with it and be reimbursed exactly the same fee. Under those circumstances what is the incentive to administer sedation? Want to get anesthesiologists out of the colonoscopy procedure room? Compensate gastroenterologists a fraction of the anesthesia fee and I guarantee they will do it themselves! Lastly, it’s disingenuous to argue that anyone can use propofol, when in every single hospital I have ever practiced in, the department of anesthesia has strenuously objected to anyone other than themselves using the drug and demanded a formulary restriction forcing practitioners to consult them to use it.

  12. That’s right. Had doctors force sedation and morphine on me for a freaking needle biopsy (isn’t that a big part of the point of a needle biopsy, that it can be done without any drugs?) not too long ago. Had I not already handed a check to the clerk on my way in (and been strapped to the table) I would have walked out and found a doctor willing to stick me without wasting my money and an anesthesiologist’s time. Still should have demanded to be “freed” in hindsight.