Them’s Fightin’ Words

From the Digestive Disease Week, New Orleans.

What had been a semiquiet scuffle emerged into a loud and very public battle for supremacy between the gastroenterology/endoscopy community and the anesthesia community this week when leaders from professional societies for the specialties took pot shots at each other at a well-attended plenary session here.

Via Flickr Creative Commons user mikebaird

For years, gastroenterologists have sedated their colonoscopy patients with a variety of opiates and benzodiazepines. But a few years ago, when it looked like propofol was a better, more cost-effective sedative, many began switching to that agent, which generally had been used only in operating rooms.  Anesthesiologists were not asked to the colonoscopy party, except in some states (like New York), where it was the custom.

Anesthesiologists were not happy about being cut out of a potentially vast new revenue stream. At least, that’s what the endoscopists claim. The anesthesia community has maintained that it’s not safe for other physicians — or nurses — who have not received specific training in airway management to be sedating patients “deeply,” which they claim propofol does.

Dr. Alexander Hannenberg, president of the American Society of Anesthesiologists, told the attendees that his group’s stance might be seen as self-serving, but that it was truly a bid for safety.  Physician offices generally aren’t regulated by state agencies and endoscopists just aren’t capable of multitasking, he said, asking how could they monitor anesthesia and the colon procedure simultaneously?

One can imagine how well that comment sat with the endoscopists.

Dr. Douglas Rex, one of the nation’s most respected colonoscopists, who conducted a review of 600,000 endoscopist-administered cases that showed no safety issues, said Dr. Hannenberg’s contentions were outright baloney.  Dr. Rex accused the ASA of having fabricated the notion of “deep sedation,” which he said the Medicare program adopted, without any scientific evidence to back the idea.

In December, Medicare issued a “clarification” that “deep sedation” should be administered, essentially, only by anesthesiologists or nurse-anesthetists. Another thorn in endoscopists’ side.

Dr. Rex also accused the ASA of having co-opted the FDA and its advisers, helping to defeat approval (read about the FDA’s recent denial here) of an automated sedation device, Sedasys, that endoscopists could use without anesthesiologists’ help. Sedasys maker Johnson & Johnson is appealing.

His conclusion was that gastroenterology, which is fragmented into four different societies, basically had been outspent and outmuscled by a better-organized, deeper-pocketed anesthesiology community.

Should medical societies be so openly warring over what appears to be primarily a turf issue? Let me know what you think.

— Alicia Ault (on Twitter @aliciaault)

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1 Comment

Filed under Anesthesia and Analgesia, Gastroenterology, Health Policy, IMNG, Internal Medicine, Practice Trends

One response to “Them’s Fightin’ Words

  1. ZMD

    Yes there is such a thing as deep sedation. When the GI doc wants the patient so sedated that the patient doesn’t cough or gag when the scope is introduced into the esophagus, that is a deep sedation.
    Or when there are four hands pushing on a patients abdomen as the endoscopist tries to maneuver around the hepatic flexure but GI doesn’t want the patient moaning and groaning in pain, that is deep sedation.

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