Before making the case for evolving formal fellowships for physician anesthesiologists to conscientiously and systematically object to unnecessary health care, particularly unnecessary procedures, it is worth first exploring what constitutes “necessary.” Only then can we begin to regulate what may be considered “unnecessary.” Can physician anesthesiologists lead such academic and practical regulatory efforts, even amid potential conflicts of interest inherent in their role as anesthesia care providers?
This raises several important questions. Is the necessity of any procedure determined by its ability to protect the safety of the patient, provider, and payer, thereby avoiding the first, second, and third victim phenomena? Or is it guided by economic considerations, aiming to deliver affordable care for patients while sustaining productivity and profitability for providers and payers?
Fundamentally, can anything be labeled “unnecessary” except when resources are entirely unavailable to perform even the necessary, or so scarce that necessary procedures are delayed, potentially inviting litigation? Even with future formal training in conscientious objection, can anesthesiologists effectively question proceduralists and their patients about the necessity of interventions, especially when those procedures are paid for by third-party payers, regardless of value?
Who’s to say the “unnecessary” hasn’t helped health care systems prepare for the “necessary,” building skillsets and infrastructure in anticipation of greater need? Who knows if some “unnecessary” procedures are sustaining the health care economy, while some “necessary” ones are avoided for fear of litigation, with safety becoming an incidental benefit to all parties?
The dilemma is persistent: Necessity often remains subjectively defined, and the balance between tolerating the unnecessary versus safeguarding the necessary remains elusive. Nevertheless, physician anesthesiologists are not powerless. They have already transformed anesthesia care through the safety paradigm. They confidently deliver a contextual “no” when anesthesia settings appear unsafe, thus protecting patients (first victims), providers (second victims), and systems (third victims).
This safety-first approach has paved the way for unprecedented levels of care. It has even enabled elective, preemptive extracorporeal membrane oxygenation when the need for procedures is clearly warranted for patients, providers, and systems alike.
Now the question evolves: Should anesthesiologists also begin saying a clear, contextual “no” to delivering anesthesia for procedures that appear unnecessary, even when they can be done safely? Further, if unnecessary procedures are abandoned, would the resulting cost savings for patients, providers, and systems justify reimbursing anesthesiologists for their gatekeeping?
While anesthesiologists may never gain control over pre-authorizations or reimbursement decisions for unnecessary care, they can develop their role in preventing inadvertent facilitation of such procedures. Until formal fellowship training in conscientious objection becomes a reality, anesthesiologists must self-educate and sharpen their clinical and academic judgment about procedural necessity. Ideally, these determinations should be made in partnership with patients, providers, and payers in pre-procedure clinics. The day of the procedure is simply the wrong time and place to assess necessity.
If inertia in health care economics prevents the establishment of such fellowships, anesthesiologists might even consider pioneering cash-only anesthesia care. This would allow them to assert a necessary “no” to questionable procedures, particularly when linguistic, cultural, or informational gaps between patients, providers, and payers obscure clarity around necessity and consent.
Ironically, cash-only anesthesia care may unburden conscientious anesthesiologists from the ethical weight of enabling unnecessary procedures. This is especially true when well-informed, self-aware patients willingly pay out-of-pocket for both anesthesia and their chosen, albeit seemingly unnecessary, procedures.
Deepak Gupta is an anesthesiologist.
