“Poachers and Dabblers?”: ASA President’s Incautious Comment Riles Emergency Physicians

Emergency Physicians Fire Back 

Dr. Linda Lawrence, president of the American College of Emergency Physicians (ACEP), said the ASA leader’s allegation was unfair and unjustified: “Emergency physicians are trained in their residencies to do procedural sedation. We’re trained appropriately and have the experience to deal with the potential risks and complications,” Lawrence said. “It is wrong to think otherwise.”

Emergency physician, Dr. Steven Green, who has authored studies on the propofol issue, said “Historically, anesthesiologists criticizing the administration of propofol by emergency physicians have carefully centered their arguments on patient safety. This recent unusual candor by Dr. Lema, however, makes it clear that for many or most such critics their greatest underlying concern is instead economic.”

One emergency physician surprised by the reference is Dr. Donald Yealy. He is professor and vice-chair of the department of emergency medicine at the University of Pittsburgh School of Medicine and the Pittsburgh Medical Center.

Yealy noted that the ASA recognizes a shortage of anesthesiologists, particularly those who provide services in emergency departments (EDs). That has led emergency physicians to assume the responsibilities of propofol sedation, he said. In light of that, he finds the “poacher” label unwarranted.

The Absent Farmer 

“You can’t ‘poach’ off of a farm unless the farmer is not paying attention,” Yealy said. “The reason this came to be is that the (sedation) service couldn’t be provided in a timely and efficient manner. And we’re not asking to provide it in a less efficient and less safe manner. We have the skill set–we have the training and the experience.”

The reference is more troubling, he said, because ACEP has proceeded cautiously in condoning administration of propofol in EDs. While emergency physicians have largely stayed out of the debate on the proper circumstances for its use in office settings or for elective surgeries, ACEP’s call for safety standards generally parallels the ASA positions on the issue.

“My point is that the ASA seems worried about the gastroenterologists and the dentists doing this (sedation),” Yealy said. “That’s a whole separate issue.” The ASA and its allied groups have cited ACEP and emergency medicine position papers positively in arguing for safeguards on propofol sedation, he said.

“So, their own organization seems to recognize that if there is a need, you should create similar training, safety and monitoring capabilities (as recommended by ACEP), which is what we have always embraced,” Yealy said.

ASA President Defends Comment 

ASA president Lema indicated in a recent interview that he believes his “famous poacher comment” may have been misinterpreted.

Lema, professor and chair of anesthesiology at State University of New York’s Buffalo University and Rosewell Park Cancer Institute, now says he was not necessarily speaking of emergency physicians as “poachers” in classic cases of emergency treatment.

“I still use that term,” he said. “And I point out every time I use it that I’m not referring to…ICU physicians and emergency physicians who truly respond to an emergency where there is no one (else) available. I’m responding to those who are looking to expand; to expand their privileges into an area which might involve elective procedures or semi-elective procedures.”

In elaborating on his selection of words, Lema indicates that he still believes that administering anesthetics is best left up to anesthesiologists, even if emergency physicians are trained and experienced in intubation and other propofol-related emergency procedures.

“What that (poacher comment) was referring to was not an emergency room physician who comes to the aid of anesthesiologists or surgeons in an emergency,” he said. “It is those anesthesiologists that tell me…that there are emergency room physicians looking to get credentialed to provide anesthetics in their hospitals without having undergone adequate training for anesthesiology. It denigrates a specialty to an anyone-can-do-it mentality. That would be the same as for me to say that I think any anesthesiologist is capable of walking into any emergency department in the US and being a fully capable emergency room physician without emergency medical residency.”

Lema said, “I don’t have a problem with anything that I say,” and that if he had meant to “draw attention to the American College of Emergency Physicians, I would have addressed it directly. It was a response, basically, to tell them (ASA members) we are no longer a specialty that’s in development, but we’re fully mature. And just like every other specialty, there are inter-specialty rivalries.

“Now, that could be inter-specialty rivalry which is a euphemistic term for poachers and dabblers,” he said. Lema gave the example of cardiac surgeons and interventional cardiologists who may view each other as “a poacher and dabbler.”

In discussing the emergency physician propofol issue, he cited economic impacts for anesthesiologists even as he said that “everyone believes it is a patient safety issue.”

Lema referred to the shortage of anesthesiologists in saying that “anesthesiologists are not looking for work. So for us to feel challenged, let’s say, by emergency physicians wanting to be anesthesiologists, is less of an issue than for us to be concerned that emergency physicians believe it takes no special training to be an anesthesiologist, and that they can simply get credentials in a particular hospital. And that’s what that’s all about.”

Some emergency physicians are skeptical about Lema’s explanation that he was referring to those who may try to moonlight by getting credentialed to administer sedation such as propofol in non-urgent cases.

The slide he used in his presentation, especially the explanatory words in parentheses clearly stated “ER MDs (emergency surgery)” as one of the poacher groups.

Green said it is correct that emergency physicians who care primarily for adults are not branching out into non-urgent sedation services. However, Green, a professor of emergency medicine and pediatrics for Loma Linda University Medical Center and Children’s Hospital, said that many pediatric emergency physicians and ICU physicians are expanding their sedation services for children outside EDs.

Coupled with the moonlighting issue was Lema’s continued insistence that EDs use anesthesiologists exclusively for propofol sedation.

Green disputed that notion. “Anesthesiologists used to similarly insist that they were the only ones qualified to perform emergency intubation in the ED,” he said. “However, when they found this personally inconvenient, their criticism disappeared, and they decided that we were competent at this procedure after all.

“Deep sedation with propofol is a much less difficult task to master than rapid sequence intubation, and the proficiency of trained EPs to perform this procedure is now beyond reasonable dispute. Propofol administration has now effectively evolved into an essential EP skill.”

Lack of Alternatives 

Lema was asked about the widespread concerns by emergency physicians about the difficulties in getting anesthesiologists to respond quickly enough to be available to administer propofol in emergency cases. The alternative–full-time staffing of an anesthesiologist in the department–was viewed as impractical because of the relative infrequency of those cases.

“That’s a local issue that would need to be addressed by a hospital CEO or a medical board,” Lema said. “…That’s not something we advocate for the ASA. We’re a profession that looks to improve patient care. So we would hope that any arrangement that could be made for safe patient care is developed among all parties. And they should take patient care as the priority and work from there.”

Yealy said the ASA president’s references about leaving the staffing dilemma up to local control means that he doesn’t really have an answer to that key issue.

“There clearly is a shortage nationwide of anesthesiology providers to meet the current OR-based needs,” Yealy said. “So it is not likely anytime soon they are going to be able to service another underserved area, like the emergency department.”

Yealy said that, “The truth of the matter is that virtually all the people in the emergency department getting procedural sedation need an emergency, time-sensitive procedure. The current state of the anesthesiology services and providers, they are not able at the vast majority of settings to provide that.”

The situation, Yealy said, leaves only basic choices for the ED: “Either delay a procedure that is best done quickly, do it with a great deal of pain, or have these skilled providers–emergency physicians–follow similar training and safety requirements and provide the comfort. And that’s really what’s happening right now.”

Propofol, marketed as Diprovan by AstraZeneca, has been available for more than a decade. It has been prompting inter-specialty disputes for almost that long.

Eight years ago, Green authored an article for Academic Emergency Medicine titled, “Propofol for emergency department procedural sedation: not yet ready for prime time.” In January 2007, he concluded in an article for Annals of Emergency Medicine that it was safe and effective:

“In 1999, I editorialized caution in the adoption of ultra-short acting sedatives in the ED, arguing that, given the theoretical dangers and limited published data, any change in clinical practice should be thoroughly evidence based. In the ensuing 7-year period, the amassed evidence has now proven my initial admonitions obsolete. These agents are indeed ‘ready for prime time’ in emergency medicine.”

The closing of the introduction to Green’s latest article summarized his findings:

“ED deep sedation using ultra-short-acting agents is here to stay and now effectively evolved into an essential emergency physician skill. Any remaining restrictions to this practice by medical staffs or hospital-wide sedation committees represent unfamiliarity with the literature at best and turf-based decisionmaking at worst.”

Managing the Risks 

Green and other emergency medicine authorities advised that only personnel trained in propofol’s use and the necessary monitoring use the drug. They agreed that sedation carries several risks, although emergency physicians have the training and experience to deal with them.

“We are used to seeing people who need airway assessment, need management, and need close monitoring,” Yealy said. “All the tools and skills are common to the practice of emergency medicine.”

Yealy estimated that busy EDs would typically have an arrival with airway problems on a daily basis. So unlike other specialties, emergency physicians also have the basic training and experience to deal with the complications from propofol, he said. Yealy also pointed out that EDs have the kind of supporting equipment to provide effective monitoring of sedated patients to further ensure safety.

The campaign to limit the administration of propofol has spawned various new Web sites and special interest groups to press the message on behalf of the primary sponsors, anesthesiologists. However, they appear to have stayed largely clear of the dispute about emergency physicians, and Lema’s “poaching” allegations.

Dr. Marc E. Koch, an anesthesiologist and MBA, oversees the site, the home of ASAP—Anesthetists for the Safe Administration of Propofol. He is also chief executive officer of Somnia, Inc. Anesthesia Service, which bills itself as a national provider of anesthesia services to office-based surgical facilities, ambulatory surgery centers and hospitals.

A telephone call to the ASAP number was answered as “Somnia.” Koch advised that interested persons soon should go to the Somnia Web site for detailed information about the propofol issue.

Koch also explained that the group has not even “evaluated that concept” of controversies over ED use of propofol. Instead, the site is primarily geared to issues over sedation for patients undergoing colonoscopies. Insurance limitations on payments for anesthesiologists for procedures discriminate against many patients, he said.

“To the extent that anesthetic agents are being administered, ideally you want to have it done by somebody with specific training, experience and expertise in those medications,” Koch said. “That person should also have the right skills, qualifications and experience to deal with expected, or unexpected, adverse outcomes from the administration of that medication.”

Despite the spirited defenses, the trend seems to be easing away from restricting propofol administration to anesthesiologists. The insurance giant Aetna issued a directive, effective in February 2007, that it would only consider anesthesia services necessary for gastrointestinal endoscopy patients who had sedation risk factors. That included those 18 years of age or younger, or 65 or older, or pregnant, or having special conditions or complications that made them more prone to the potential problems of propofol.

Yealy noted that the controversies have created misconceptions in some quarters, such as the debate over the standards set out by the Joint Commission (TJC, formerly JCAHO).

“One of the common misstatements you’ll hear is that the joint commission…insists on the anesthesiologists supervising the care and they have ‘responsibility’,” Yealy said. Instead, the commission guidelines state local anesthesiology leaders must be part of any hospital-based policy and quality assessment that is developed–which is far different from stating anesthesiologists are personally responsible or that they personally be on hand, Yealy said.

He advocates including all “stakeholders” in the development of a hospital policy, but points out that at his hospital, the chief of emergency services, rather than the anesthesiology chief, is the one ultimately responsible for ED procedural safety.

Primary Targets and Collateral Damage 

Yealy cautions that the issue is squarely on the use of propofol in the ED, rather than any wider controversies over other specialties administering the drug. ASA president Lema concurs that, despite his presentations, the organization does not view EDs as their primary target in the propofol campaign.

“Clearly, our concerns are more with office-based use than…emergency rooms or ICU usage, because those are generally located in hospitals, where there is a number of support personnel. That is opposed to an office, where the only doctor may be the proceduralist.”

He believes ASA and ACEP have a good working relationship, and notes that ASA has been allied with emergency physicians on other key issues, such as the timelier placement of psychiatric patients.

“In general, I think that anesthesiologists and anesthesiology as a specialty fully support emergency physicians and the difficult task that they have to care for America’s acutely ill patients,” Lema said. “Hopefully, we can play our role to facilitate their role.”

Even though his presentations carry a heavy emphasis on the economic impacts for ASA members, Lema insists that the concerns are based on what is best for patients. “We have basically drawn a line in the sand and asked for the safe use of a drug that has no reversal agent to it….,” he said.

Calling emergency physicians “poachers” is just part of a “lecture that I had designed to awaken anesthesiologists across to the country to let them know that we are a fully mature specialty” now subject to inter-specialty rivalries, Lema said.