 |
|
|
|
 |
 |
 |
|
 |
|
||
|
|||||||||||
Home About SPA Join SPA Education Newsletter Jobs & Fellowships Volunteer Service Abroad Links of Interest
|
SPA Newsletter.
It was Sir William Osler who said that "Errors in judgment must occur in the practice of an art which consists largely in balancing probabilities." This sentiment has special meaning for those of us in anesthesiology. Our profession is not an exact science, but a discipline that balances very detailed scientific knowledge with clinical conditions in which there is significant uncertainty. Although our depth of scientific understanding of developmental biology, physiology, and pharmacology increases every year, the human organism continues to be a mystery to us. Children continue to be the great wonder in our lives who are unceasingly changing. In this setting of increasing, but incomplete, knowledge, how do we decide what we need to know to provide the best practice with the fewest errors? It has been common in our profession to take the complexity of patient evaluation, preparation, monitoring, and management and reduce our clinical practice to a single comment. As John Relton loved to say, "The keys to pediatric anaesthesia are a first class i.v. and a first call airway." Other maxims include "Always keep a finger on the pulse," "The best monitor is still a precordial stethoscope," or, even, "It's hard to kill a spontaneously breathing patient." Please excuse this last example, but it is typical of our tendency to reduce complex issues to a single, universal truth. However, the big issue that I see is related to our assimilating simple truths, as well as more complex information, concepts, and experience. As there is a general increase in knowledge and sophistication, what is our responsibility to ensure that we have progressed in our capabilities to keep pace with what is known and the current "state-of-the-art" for anesthesiology and pediatric anesthesiology? Very few pediatric anesthesiologists would admit that they were not "current". Instead, we often brag that not only are we knowledgeable about the latest concepts and advances, but that we have also incorporated the "correct" ones into our practice and rejected others, based on our experience and good sense. However, how do we ensure that we and our peers are keeping up on the knowledge necessary to practice good care? There is the important issue of being able to judge that we not only have the minimum levels of knowledge to practice anesthesiology, but the higher level that one would expect of a consultant or expert in pediatric anesthesiology. But knowledge is only part of the equation. How we practice, how much we practice, and how our practices are critically evaluated vary dramatically from individual to individual and hospital to hospital. There are several national organizations that are trying to address these issues. Some take a limited focus, such as minimizing errors in clinical practice. There has been a lot of publicity on this issue, especially after the Institute of Medicine report on errors in medicine. Because of all the accompanying publicity, every institution seems to now have task forces on safety and error prevention. This focus, however, is limited to avoiding identified problems, though hopefully with changes in the way systems are managed. The American Society of Anesthesiologists (ASA), through a variety of committees, is looking at several issues, including performance-based credentialing. Performance-based credentialing has the appeal of basing evaluations of physicians based on their normal practice in their normal setting for each individual. The concept is proving difficult to put into a universal program that is easy and simple to administer. The primary question is that if we find a way of collecting meaningful performance information on anesthesiologists, what do we compare it to? If there aren't national performance standards that the profession agrees to, the comparison would have to be to some sort of national norm based on a large database of performance measures. Neither performance standards or a database are in place at the moment. The American Board of Anesthesiology (ABA) is working in collaboration with the American Board of Medical Specialties (ABMS) to enact what could be a revolutionary change in the way we look at the ongoing performance and competence of physicians. The ABA and other ABMS constituent boards have agreed to move to changing the concept of recertification (an event that occurs every 7-10 years, depending on the specialty) to maintenance of certification (a series of processes that occur yearly). Airline pilots have to participate in a maintenance program involving requalifying every year. The proposed systems use a similar model, with a focus on identifying four basic components of demonstrating a maintenance of professional competence and certification. They are evidence of:
How these key competencies of a specialist will be evaluated is now being actively discussed by each specialty. The revolutionary element is that each board is committed to having physicians actively participate in an ongoing evaluation of their knowledge and practice, not focused on passing a single written exam every 7-10 years. This is exciting because it allows renewal of our claim that we are true professionals who are committed to our specialty and to not only providing the best of care, but also continually improving ourselves and our capabilities. It should be stressed that this work on the part of the ABA and ABMS boards is just starting, with implementation probably several years off. What is the role of the SPA in this? The Society has multiple missions, but one of our strongest and most successful to date has been education. The primary educational focus of our organization fits very well with the concept of lifelong learning. We have tried to mix the latest in scientific advances and practical experiences across the spectrum of pediatric anesthesia in our offerings. The Society is always planning a variety of new educational activities, and is now considering tools for periodic self-assessment. Watch the newsletter and website for coming announcements. This is clearly a time where the definition of who we are is changing. Regulatory agencies are becoming more intrusive and demanding. Hospitals are increasingly interested in controlling how we practice. SPA needs to continually look for ways to fulfill its missions and help our members become better educated in the multiple aspects of providing anesthesia services for children. It is, then, appropriate to mention at this point that Dr. Peter Davis is becoming your new President at our October meeting. Please give him your enthusiastic support. I would also like to stress that tremendous thanks are owed to all who helped the Society for the last two years, especially Past President Mark Rockoff and all those who are leaving the Board and its committees this October. Best wishes and thanks. Steven C. Hall, MD |
