While anesthesiologists play a vital role in ASC operations, they are rarely at the helm.
Christina Menor, MD, president of the California Society of Anesthesiologists, joined Becker’s to discuss the barriers keeping anesthesiologists out of leadership roles in ASCs, and how their expertise could drive efficiency, safety and patient satisfaction.
Editor’s note: This interview was edited lightly for clarity and length.
Q: What barriers do you see to anesthesiologists stepping into the role of ASC medical director, and what opportunities do you see for both the ASCs and anesthesiologists to benefit from that dynamic?
Dr. Christina Menor: The biggest barrier is that most ASCs are either partially or fully owned by surgeons. The traditional model was surgeons opening their own surgery centers to increase their financial investments and take their own cases there. Most are still privately owned by surgeons, and most of those have one of the primary owners, a surgeon, as the medical director.
Surgeons are often not fully aware of everything going on in a surgery center or hospital operating room services. Anesthesiologists are in the OR and perioperative space all the time so we see and manage interactions between specialties, pre- and postop care, pain management, nurses, surgical technologists, laboratory, interventional radiology, gastroenterology, etc.
We could improve throughput and efficiency, and significantly decrease same-day cancellation rates, especially by participating more fully in pre-op assessments. Nonprofit ASCs have demonstrated success in this. They have a preop clinic. Most ASCs do not, because of the cost to maintain staff and anesthesiologists typically are not compensated for these services outside of the anesthesia service fees. Preop assessments are currently nurse-led in most ASCs via phone interviews and chart review, and we don’t see the patient until the day of surgery. This is acceptable for many patients. However, our expertise in assessing patients for readiness for anesthesia is superior to most primary care and cardiologist physicians as they are typically stating “clearance” for a patient. “Clearing” a patient for anesthesia. Or surgery is not a useful term nor helps to risk stratify and plan for a safe anesthetic. Unfortunately this myth of needing “clearance” persists in most settings and physicians involved. This lack of understanding of the information we need to safely provide anesthesia for patients can result in same-day cancellations, especially in the ASC setting, where care may not be appropriate for this patient with their medical problems.
Anesthesiologists could help set up enhanced recovery protocols, pain optimization, better scheduling and increased efficiency in the ASC setting. We generally know how long surgeons’ cases last and how long turnover takes better than surgeons do. That could increase patient satisfaction, efficiency and throughput.
The largest barrier is still surgeon ownership. Traditionally, anesthesiologists haven’t been allowed to be owners — not legally prohibited, but surgeons generally don’t want anesthesiologist partners.
Another issue is authority. For example, with GI cases, anesthesiologists oversee nurse administered sedation. If a GI doctor gives unsafe doses, the anesthesiologist can raise concerns, but ultimately the surgeon medical director decides what happens. And often they won’t push back because they want the business. So there’s a tension between safety and finances.
You have to build trust and show you won’t cancel cases frivolously. If you say a case should go to the hospital, it has to be for a really good reason. That trust is key for an efficient and functional partnership.
Also, site neutrality might change everything. If reimbursements become the same in hospitals and ASCs, hospitals might try to push more cases to ASCs, which will continue to change the ASC environment, for which we as anesthesiologists are experts at planning, preparing and carrying out the full spectrum of perioperative services.
