VOLUME 35, ISSUE 1

The 2022 TSA Annual Meeting included both economic and scientific news for obstetrical anesthesiologists.

For starters, the House of Delegates received a briefing on the “No Surprises Act.” A victory for patient rights when it was passed by Congress last December, the Act has been twisted by commercial insurance companies in its implementation. The final regulations have allowed payors to create erroneously deflated qualifying payment amounts as the basis for arbitration, leaving physicians without adequate payment and patients without in-network access to quality care. A battle we thought was won is still raging, with the next major skirmish to take place in the Court of Appeals, right here in Texas, in response to a lawsuit brought by the Texas Medical Association and vigorously supported by the TSA and ASA.

The scientific program made it clear that anesthesia safety is a reality, and major negative outcomes are rare enough to be negligible. Paradoxically, this has not improved outcomes; gains in safety are instead ‘reinvested’ in sicker patients and more complex cases. As Dr. Richard Dutton underscored in his lecture “Anesthesiology and Patient Safety: Shifting from Mortality to Health”, we anesthesiologists are victims of our own success. We have enabled our surgical (and procedural) colleagues to push the limits of clinical safety on a daily basis. It could be called the “JFK Syndrome”, alluding to the famous speech by our past president launching the Apollo Program: “We don’t do these things because they are easy, but because they are hard.” This describes our work every day as anesthesiologists.

The session on obstetrical anesthesia and the Betty P. Stephenson Lectureship by Dr. Joy Hawkins of the University of Colorado (and formerly of the Baylor College of Medicine and the inaugural class of the Texas A&M College of Medicine) made similar points for that subspecialty: general anesthesia for cesarean section is safer than ever, but high-risk patients are ever more common, while disparities in access and resources for pregnant patients contribute to adverse outcomes and will require deliberate efforts to resolve.

General anesthesia is not ideal in labor and delivery; we wish for patients to enjoy the delivery of a healthy baby in the safest, most comfortable, and natural conditions. Yet, this is not the case all the time, especially in units caring for the most complex patients. The anesthesia team is often estranged from the planning and communication process for complex patients and may be ‘invited to the party’ too late to provide constructive input. Patient education, expectations, and concerns are often primed by other staff members that are not anesthesia trained, especially when considering the safety and quality of care during and after general anesthesia. Dr. Girish Joshi addressed this in his lecture on “Print to Practice: Recent Publications that May Influence the Future of Anesthesia Care”. We should not let anyone demonize general anesthesia. While continuing to stress the importance of neuraxial anesthesia, we should be equally positive regarding the benefits of general anesthesia. Good anesthesia is good anesthesia, by whatever route.

Healthcare in the United States is complicated by geography, social and ethnic diversity, a wealth gap, and the intricacies of insurance coverage. All of these factors contribute to adverse outcomes in obstetrical care, often with striking amplification: 50% of maternal mortality is in African American patients, who collectively have higher rates of contributing comorbidities. Dr. Hawkins presented more than a few studies that link the latest reports of maternal mortality to poor health conditions in predominantly African American communities. We, as anesthesiologists, are challenged to intervene in the earlier stages of medical optimization but must be aware of population risks. We must recognize that risks associated with race and ethnicity may be due to both the inherent risk for disease and to social disparities caused by poverty, food insecurity, and lack of access to preventative care. Conditions such as pre-eclampsia are created by both genetic circumstances, such as risk for obesity and hypertension, and socioeconomic conditions such as lack of early prenatal care, inability to fill expensive prescriptions, and even limited access to fresh fruit and vegetables. A society that cannot work with their own members to respect individual identities, while still recognizing the risk associated with certain human customs, is not a healthy society in a broader sense and meaning.