Barbarians at the Gate

摘要

Anesthesiology is at a crossroads. In some settings compensation outstrips revenue, supported by stipends to anesthesia groups from hospitals. At the same time, the number of anesthesiologists relative to demand seems to be declining. According to a draft report by the RAND corporation, there is an imminent shortage of anesthesiologists,1 and this will certainly exert further upward pressure on compensation. Meanwhile, government payers are signaling that reimbursements must decline. What will be the outcome of this developing conflict? In this issue of Anesthesia & Analgesia, Kheterpal et al.2 report the results of their most recent survey of workforce and finances in academic anesthesiology programs. Their notable findings are a continuing desire to hire more anesthesiologists into academic practice and another increase in the subsidy from hospitals to anesthesia groups (now $109,000/year per faculty full-time equivalent [FTE]) simply to maintain the status quo in terms of filled faculty positions. The figure represents the difference between revenue per faculty FTE generated by the department and the cost per faculty FTE borne by these same academic departments. One might worry that this subsidy represents the salary support required to keep the departments staffed, although the data of Kheterpal et al. do not prove causation. However, this dismal state of affairs is distressing for obvious reasons; academic departments train the residents who are our future. Academic anesthesia departments do virtually all of the research in anesthesiology, and they provide much of the care for complex cases. In the continuing gap between compensation and revenue, one can discern a concealed but fundamental challenge to anesthesiology, namely a disruptive change that could upend the foundational expectations about how anesthesia care is provided in the United States and perhaps elsewhere. To understand this potential threat, one must understand the notion of the disruptive innovation. Disruptive innovation was described in terms of products and the companies that make and buy them by Clayton Christensen in "The Innovator's Dilemma."3 However, the construct also applies to medical specialties and the services they provide. Generally stated, any product has a range of users who need differing degrees of performance from the product. This is certainly true in anesthesiology, where cardiac surgeons, for example, need more capabilities from their anesthesiologists than surgeons who specialize in minor outpatient procedures. Companies that make the most capable, reliable (i.e., high performance) products meet the needs of the high-end users who demand the most from such products. Such high-end customers are willing to pay high margins for performance, and thus are the company's best customers. Successful companies improve their products by responding to the needs of their high-end customers and seeking the most profitable opportunities. Figure 1 demonstrates, in graphic terms, the general relationship between the performance demanded from products by high-end users and the capabilities achieved by the makers of such products. Required performance of a product, technology (or medical specialty) is shown as two parallel lines on Figure 1. The upper line indicates the capability and performance required to meet the needs of the most demanding users. The lower line represents the capabilities required to meet the most basic needs of the users of a given product. The shaded zone between the lines represents the continuum between the minimum necessary and the highest required performance.Figure 1.: Relationship between the performance demanded from products by high-end users and the capabilities achieved by the makers of such products. Adapted from Ref. 3, with permission from Harper Collins Harvard Business School Press.Through diligence in attending to customer needs and investment in research, products almost always evolve as fast as or a little fa