Introduction

Annals News and Perspective explores topics relevantto emergency medicine, in particular those in whichour specialty interacts with the political, ethical,sociologic, legal and business spheres of our society.Discussion of specific clinical problems and their

management will be rare. By design, it will not be a‘‘breaking news’’ section with the latest (andundigested) developments, but instead a reflectiveinvestigation of recent and emerging trends. If youhave any feedback about this section, please forwardit to us at annalsnews@acep.org.

0196-0644/$-see front matterCopyright © 2007 by the American College of Emergency Physicians.

“POACHERS AND DABBLERS?”: ASA PRESIDENT’S INCAUTIOUS COMMENT RILESEMERGENCY PHYSICIANS

George FlynnSpecial Contributor to Annals News & Perspective

Salaries and sedation were a central theme of the “21st

Century Anesthesiology – Preparing for the Future Paradigm”presentation at the Practice Management Conference of theAmerican Society of Anesthesiologists (ASA) last January.

Slide illustrations reflected the warnings ASA president MarkJ. Lema issued to his colleagues. “What are the Current IssuesChallenging the Status Quo?” one slide asked, followed by thislist of answers:

“Provider Shortage/Aging Population”;“Salary/Payment Problems”; and“Poachers and Dabblers.”Elaborating on the final point, another slide named the

perpetrators eroding the anesthesiologists’ profession byadministering propofol sedation. “Dabblers” were theendoscopists, dentists and cosmetic surgeons.

But what group topped Lema’s “Poacher” list?“ER MDs (emergency surgery).”Other “Poachers” were hospitalists and critical care

physicians. Emergency physicians have been aware of the long-running ASA disputes with elective surgery specialties, and evendentists, over who should be administering propofol and underwhat conditions.

Emergency physicians, though, did not expect to findthemselves as the new top target in the campaigns by theASA and related groups to make propofol sedation the exclusivedomain of anesthesiologists.

EMERGENCY PHYSICIANS FIRE BACKDr. Linda Lawrence, president of the American College of

Emergency Physicians (ACEP), said the ASA leader’s allegationwas unfair and unjustified: “Emergency physicians are trained intheir residencies to do procedural sedation. We’re trainedappropriately and have the experience to deal with the potential

risks and complications,” Lawrence said. “It is wrong to thinkotherwise.”

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

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

Yealy noted that the ASA recognizes a shortage ofanesthesiologists, particularly those who provide services inemergency departments (EDs). That has led emergencyphysicians to assume the responsibilities of propofol sedation, hesaid. 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 isthat the (sedation) service couldn’t be provided in a timely andefficient manner. And we’re not asking to provide it in a lessefficient and less safe manner. We have the skill set–we have thetraining and the experience.”

The reference is more troubling, he said, because ACEP hasproceeded cautiously in condoning administration of propofolin EDs. While emergency physicians have largely stayed out ofthe debate on the proper circumstances for its use in officesettings or for elective surgeries, ACEP’s call for safety standardsgenerally parallels the ASA positions on the issue.

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

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

ASA PRESIDENT DEFENDS COMMENTASA president Lema indicated in a recent interview that he

believes his “famous poacher comment” may have beenmisinterpreted.

Lema, professor and chair of anesthesiology at StateUniversity of New York’s Buffalo University and Rosewell ParkCancer Institute, now says he was not necessarily speaking ofemergency physicians as “poachers” in classic cases of emergencytreatment.

“I still use that term,” he said. “And I point out every time Iuse it that I’m not referring to . . . ICU physicians andemergency physicians who truly respond to an emergency wherethere is no one (else) available. I’m responding to those who arelooking to expand; to expand their privileges into an area whichmight involve elective procedures or semi-elective procedures.”

In elaborating on his selection of words, Lema indicates thathe still believes that administering anesthetics is best left up toanesthesiologists, even if emergency physicians are trained andexperienced in intubation and other propofol-related emergencyprocedures.

“What that (poacher comment) was referring to was not anemergency room physician who comes to the aid ofanesthesiologists or surgeons in an emergency,” he said. “It isthose anesthesiologists that tell me . . . that there are emergencyroom physicians looking to get credentialed to provideanesthetics in their hospitals without having undergoneadequate training for anesthesiology. It denigrates a specialty toan anyone-can-do-it mentality. That would be the same as forme to say that I think any anesthesiologist is capable of walkinginto any emergency department in the US and being a fullycapable emergency room physician without emergency medicalresidency.”

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

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

In discussing the emergency physician propofol issue, hecited 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 sayingthat “anesthesiologists are not looking for work. So for us to feelchallenged, let’s say, by emergency physicians wanting to beanesthesiologists, is less of an issue than for us to be concernedthat emergency physicians believe it takes no special training tobe an anesthesiologist, and that they can simply get credentialsin a particular hospital. And that’s what that’s all about.”

Some emergency physicians are skeptical about Lema’sexplanation that he was referring to those who may try tomoonlight by getting credentialed to administer sedation suchas propofol in non-urgent cases.

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

Green said it is correct that emergency physicians who careprimarily for adults are not branching out into non-urgentsedation services. However, Green, a professor of emergencymedicine and pediatrics for Loma Linda University MedicalCenter and Children’s Hospital, said that many pediatricemergency physicians and ICU physicians are expanding theirsedation services for children outside EDs.

Coupled with the moonlighting issue was Lema’s continuedinsistence that EDs use anesthesiologists exclusively for propofolsedation.

Green disputed that notion. “Anesthesiologists used tosimilarly insist that they were the only ones qualified to performemergency intubation in the ED,” he said. “However, whenthey found this personally inconvenient, their criticismdisappeared, and they decided that we were competent at thisprocedure after all.

“Deep sedation with propofol is a much less difficult task tomaster than rapid sequence intubation, and the proficiency oftrained EPs to perform this procedure is now beyond reasonabledispute. Propofol administration has now effectively evolvedinto an essential EP skill.”

LACK OF ALTERNATIVESLema was asked about the widespread concerns by

emergency physicians about the difficulties in gettinganesthesiologists to respond quickly enough to be available toadminister propofol in emergency cases. The alternative–full-timestaffing of an anesthesiologist in the department–was viewed asimpractical because of the relative infrequency of those cases.

“That’s a local issue that would need to be addressed by ahospital CEO or a medical board,” Lema said. “. . . That’s notsomething we advocate for the ASA. We’re a profession thatlooks to improve patient care. So we would hope that anyarrangement that could be made for safe patient care isdeveloped among all parties. And they should take patient careas the priority and work from there.”

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

“There clearly is a shortage nationwide of anesthesiologyproviders to meet the current OR-based needs,” Yealy said. “Soit is not likely anytime soon they are going to be able to serviceanother underserved area, like the emergency department.”

Yealy said that, “The truth of the matter is that virtually allthe people in the emergency department getting proceduralsedation need an emergency, time-sensitive procedure. Thecurrent state of the anesthesiology services and providers, theyare not able at the vast majority of settings to provide that.”

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

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

Eight years ago, Green authored an article for AcademicEmergency Medicine titled, “Propofol for emergency departmentprocedural sedation: not yet ready for prime time.” In January2007, he concluded in an article for Annals of EmergencyMedicine 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 thetheoretical dangers and limited published data, any change inclinical practice should be thoroughly evidence based. In theensuing 7-year period, the amassed evidence has now proven myinitial admonitions obsolete. These agents are indeed ‘ready forprime time’ in emergency medicine.”

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

“ED deep sedation using ultra-short-acting agents is here to stayand now effectively evolved into an essential emergency physicianskill. Any remaining restrictions to this practice by medical staffs orhospital-wide sedation committees represent unfamiliarity with theliterature at best and turf-based decisionmaking at worst.”

MANAGING THE RISKSGreen and other emergency medicine authorities advised

that only personnel trained in propofol’s use and the necessarymonitoring use the drug. They agreed that sedation carriesseveral risks, although emergency physicians have the trainingand experience to deal with them.

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

Yealy estimated that busy EDs would typically have anarrival with airway problems on a daily basis. So unlike otherspecialties, emergency physicians also have the basic trainingand experience to deal with the complications from propofol,

he said. Yealy also pointed out that EDs have the kind ofsupporting equipment to provide effective monitoring ofsedated patients to further ensure safety.

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

Dr. Marc E. Koch, an anesthesiologist and MBA, overseesthe site, the home of ASAP—Anesthetists for the SafeAdministration of Propofol. He is also chief executive officer ofSomnia, Inc. Anesthesia Service, which bills itself as a nationalprovider 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 goto the Somnia Web site for detailed information about thepropofol issue.

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

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

Despite the spirited defenses, the trend seems to be easingaway from restricting propofol administration toanesthesiologists. The insurance giant Aetna issued a directive,effective in February 2007, that it would only consideranesthesia services necessary for gastrointestinal endoscopypatients who had sedation risk factors. That included those 18years of age or younger, or 65 or older, or pregnant, or havingspecial conditions or complications that made them more proneto the potential problems of propofol.

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

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

He advocates including all “stakeholders” in the developmentof a hospital policy, but points out that at his hospital, the chief

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of emergency services, rather than the anesthesiology chief, isthe one ultimately responsible for ED procedural safety.

PRIMARY TARGETS AND COLLATERALDAMAGE

Yealy cautions that the issue is squarely on the use ofpropofol in the ED, rather than any wider controversies overother specialties administering the drug. ASA president Lemaconcurs that, despite his presentations, the organization doesnot view EDs as their primary target in the propofol campaign.

“Clearly, our concerns are more with office-based usethan . . . emergency rooms or ICU usage, because those aregenerally located in hospitals, where there is a number ofsupport personnel. That is opposed to an office, where the onlydoctor may be the proceduralist.”

He believes ASA and ACEP have a good workingrelationship, and notes that ASA has been allied with

emergency physicians on other key issues, such as the timelierplacement of psychiatric patients.

“In general, I think that anesthesiologists and anesthesiologyas a specialty fully support emergency physicians and thedifficult task that they have to care for America’s acutely illpatients,” Lema said. “Hopefully, we can play our role tofacilitate their role.”

Even though his presentations carry a heavy emphasis on theeconomic impacts for ASA members, Lema insists that theconcerns are based on what is best for patients. “We havebasically drawn a line in the sand and asked for the safe use of adrug 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 acrossto the country to let them know that we are a fully maturespecialty” now subject to inter-specialty rivalries, Lema said.

doi:10.1016/j.annemergmed.2007.07.016

THE COST OF KOI: EVIDENCE-BASED DESIGN IN EMERGENCY MEDICAL FACILITIESWilliam B. Millard, PhD

Special Contributor to Annals News & Perspective

The cost and benefits of koi, Japanese gardens and tree-linedvistas may not strike many emergency department (ED)directors as a topic of interest, but an emerging body ofliterature is suggesting these and many other components of“evidence-based design” have direct relevance for everythingfrom patient outcomes to staff productivity.

“The environment counts,” says Mark S. Smith, MD,chairman of emergency medicine at Washington HospitalCenter and Georgetown University School of Medicineand director of ER One, a federally funded project todesign a prototype ED capable of handling disastersranging from emerging diseases to terrorism. “It has aprofound effect on people’s ability to work . . . Architecturematters, design matters, materials matter, sound and lightmatter.”

As clinicians and others have gained knowledge about thenonmedical variables affecting patients’ experiences, includingphysical and procedural components of hospitals, an empiricaldesign philosophy has arisen in parallel to evidence-basedmedicine (EBM). In recent years, evidence-based design (EBD)has been an increasingly influential component of hospitalarchitecture and planning.1 Interest in EBD is driven in part byrelated concerns about sustainable construction, in part byrecognition of the medical error problem in the wake of theInstitute of Medicine’s relevant studies,2 and in part by theadministrative axiom that “you can’t manage what you can’tmeasure”; the movement is beginning to receive attention in thenonspecialist media.3

Since the ED is so often patients’ primary portal of entryinto a hospital, and since inefficiencies anywhere in the

institution can affect the performance of the ED, emergencymedicine and EBD potentially have much to gain from eachother.

COMMON SENSE PLUS UNCOMMON RIGORWith both EBM and EBD, the practice predates the formal

term. “Evidence-based medicine has been around since thescientific revolution,” says D. Kirk Hamilton, FAIA, FACHA,one of the movement’s chief practitioners and theorists, “but theterm hasn’t really been defined until [David] Sackett and peoplelike that started writing about it in the ‘90s. The Center forHealth Design (CHD) has existed since the ‘80s.” Thisorganization, the EBD movement’s rough equivalent of theCentre for Evidence-Based Medicine at Oxford University,promotes the use of research to guide health care architectureand planning. The CHD’s Pebble Project, a series of researchcollaborations with 43 health care organizations and 4corporations, has been facilitating studies of design outcomerelationships in the US since 2000. Other institutions that havebecome prominent in EBD include Texas A&M University’sCenter for Health Systems and Design, Sweden’s KarolinskaInstitute, and the Academy of Architecture for Health, acomponent of the American Institute of Architects.

EBD adds an objective dimension to subjective ideas aboutenvironmental influences on patients’ well-being, includinglight, space, noise, air quality, materials, traffic flow, triageprocedures, infection control, ergonomics, aesthetics,navigation, and access to specialty services. As this form ofthinking has spread among architects and hospital officials, ithas also extended attention to the experiences of medical staffand patients’ family members. Surprisingly clear benefits, EBD

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