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Introduced in early July 2019 to Congress, H.R. bill 3630—known as the No Surprises Act—is intended to limit out-of-network rates that may be charged to individuals insured by healthcare plans for certain emergency and non-emergency services ^[1]. The bipartisan No Surprises Act (shorthand for ‘preventing surprise medical bills’) was spearheaded by Energy and Commerce Chairman Frank Pallone, Jr. (D-NJ) and Ranking Member Greg Walden (R-OR). The bill saw full passage in the Energy and Commerce Committee on July 17, 2019 and was then integrated into H.R. 2328, the Reauthorizing and Extending America’s Community Health Act ^{[2, 3]}. The impetus for the legislation arose from cases in which plan-holding patients have been surprised with unanticipated medical charges after receiving emergency services. Despite the fact that services are provided at in-network hospitals, patients may still receive care from out-of-network medical professionals—most commonly, unknowingly

Firstly, the proposed legislation addresses this issue by requiring that healthcare coverage plans covering emergency services bill members no more than the median in-network rate for emergency services, regardless of provider network status. Secondly, the bill goes further by prohibiting medical insurers from charging plan holders more than the average in-network cost for non-emergency services administered by out-of-network providers at in-network facilities ^{[1, 3, 4]}. In short, under the No Surprises Act, out-of-network providers are barred from billing patients the difference between in-network and out-of-network rates for emergency services.

Additionally, for non-emergency services, the bill protects plan holders from being charged for the difference in rates for non-emergency medical services rendered at in-network facilities, unless a patient is provided with specific notice and written-consent requirements to ensure that they are aware of the possibility of incurring out-of-network fees prior to receiving treatment ^{[1, 2, 4]}. However, an important caveat regarding the billing of non-emergency services in special cases is built into the legislation. This is that out-of-network providers may not bill plan holders for the difference between the rates for out-of-network and in-network non-emergency services if the provider whose services are required is the only professional available and/or qualified to deliver necessary services or treatments. Still, the provider in question must be based at an in-network facility for the proposed rate-capping to apply 

As part of the No Surprises Act, the Department of Health and Human Services is required to disburse grants to create and manage All Payer Claims Databases intended to make insurance claims and payment data public. Additionally, the bill calls for healthcare insurers to publish provider directories and instructs the Government Accountability Office and the Department of Labor to research and disclose information pertinent to commercial healthcare markets ^{[1, 2, 4]}. With similar aims as those encompassed by the No Surprises Act, the Senate Health, Education, Labor and Pensions (HELP) Committee passed the Lower Health Care Costs Act (S. 1895). Moving forward, leaders of the House Energy and Commerce Committee and Senate Health, Education, Labor and Pensions (HELP) Committee are in conversation over compatible and shared goals in their approaches ^{[2, 3]}. Such collaborations are of utmost importance as there exists significant potential for cost savings; for the No Surprises Act, an estimated $21.9 billion in savings is projected over 10 years ^{[4, 5]}. With impending expiration of health provisions and considerable monetary implications at stake, legislation intended to reduce surprise billing is likely to garner attention as the year closes 

Pallone, and Frank. “H.R.3630 – 116th Congress (2019-2020): No Surprises Act.” Congress.gov, July 11, 2019. https://www.congress.gov/bill/116th-congress/house-bill/3630.

^[2] “House Energy and Commerce Committee Advances Surprise Billing Legislation.” AANS, n.d. https://www.aans.org/AANS-E-News/2019/8-30-E-news/House-Energy-and-Commerce-Committee-Advances-Surprise-Billing-Legislation.

^[3] “Pallone & Walden on Committee Passage of No Surprises Act.” Democrats, Energy and Commerce Committee, July 17, 2019. https://energycommerce.house.gov/newsroom/press-releases/pallone-walden-on-committee-passage-of-no-surprises-act.

^[4] “H.R. 3630: No Surprises Act.” GovTrack.us, July 9, 2019. https://www.govtrack.us/congress/bills/116/hr3630/text.

^[5] “What’s New in Washington – October 2019 – Strategy – United States.” What’s New in Washington – October 2019 – Strategy – United States, October 24, 2019. http://www.mondaq.com/unitedstates/x/856814/Industry Updates Analysis/What’s New in Washington October 2019.^[6] Keisling, Jonathan. “Assessing the Legislative Responses to Surprise Billing and Other Transparency Issues.” AAF, July 10, 2019. https://www.americanactionforum.org/insight/assessing-the-legislative-responses-to-surprise-billing-and-other-transparency-issues/.

Ventilation strategies for infants and children are also important to tailor to each patient as there is greater risk for barotrauma and atelectrauma. The closing capacity of an infant’s lungs may be higher than functional residual capacity, making them prone to atelectasis and desaturation. Ventilation should be monitored continuously using end tidal CO2 monitoring intraoperatively as well as chest-rise and auscultation in the perioperative phases. In children at increased risk of apnea, a portable oxygen saturation monitor can be particularly useful during transport between care areas.

Induction is a very critical phase which can be approached in various ways, but may be dictated by the patient’s age, anxiety level, aspiration risk, or airway anatomy. Infants, toddlers, young children, and adolescents each require slightly different approaches to induction, depending on presence of peripheral access, level of anxiety, willingness to cooperate with mask induction, and reaction to the smell of the mask and sevoflurane. In some instances, nitrous oxide is used to “stun” the patient prior to use of sevoflurane to prevent the need for forceful restraint on induction. In general, children have a higher volume of distribution and thus require increased doses of intravenous anesthetic to achieve induction of anesthesia (the same is true for neuromuscular blockade). Inhalational induction is commonly used unless there is a concerning component to the patient’s status such as a difficult airway or full stomach, in which case rapid sequence intubation is indicated and a pre-induction IV must be placed. Premedication with midazolam or parental presence can be very effective in preventing an uncontrolled induction that may require forceful restraint of the child’s limbs and head.² Such an event can be particularly harmful in patients with a preexisting injury or congenital malformation. The audiovisual environment of the operating room at time of induction must also be managed. Parents, if available, should be readily visible to the child, the OR should be quiet, and nursing staff should not be busy moving in the background. All available staff should be attentive and prepared to assist if needed during this critical phase. A pre-induction checklist is useful to prevent the need to search or ask for equipment during induction. Young children are at increased risk of laryngospasm if depth of anesthesia is lost due to forceful or interrupted mask induction.⁵ Thus, succinylcholine 3mg/kg with an IM needle should be readily available and the provider should already have the dose required in mind prior to induction. The use of succinylcholine must take into account the possibility of an undiagnosed muscular dystrophy in infants, which will present as hyperkalemia, rhabdomyolysis, and possibly renal dysfunction perioperatively. Finally, inhaled induction poses a risk of hypotension if large doses of volatile anesthetic are rapidly delivered to the point of causing bradycardia. This is due to the pediatric heart’s lack of dynamic compliance and its dependence on preload and heart rate for maintenance of cardiac output.

Maintenance of anesthesia in children has its own unique set of considerations. Again, there is a higher volume of distribution, shorter half-life, and quicker clearance for many of the commonly used IV anesthetics; thus their weight-based dose requirements are often higher. The minimum alveolar concentration (MAC) required for general anesthesia is also higher in children, peaking in infants up to around six months old and decreasing thereafter. Propofol, for example, requires administration of twice the adult infusion rate for maintenance of a total intravenous anesthetic and at least 50% increase in bolus doses for induction. Regarding neuromuscular blockade, neonates are actually more sensitive to paralysis and while the required induction dose may be relatively higher, the maintenance dose should be decreased. Children have higher incidence of postoperative nausea and vomiting (PONV) as well as emergence delirium; this must be considered and planned for preoperatively in order to prevent postoperative complications. In fact, children who experience preoperative anxiety are 3.5 times more likely to exhibit negative behavior postoperatively.² Medications such as ondansetron and dexmedetomidine are useful for prophylaxis of PONV and emergence delirium respectively but must be dosed and timed appropriately for optimum effect. Temperature management must also be conducted aggressively It begins preoperatively with warming of the entire OR suite, and includes the use of forced air warmers and under-body blankets placed appropriately to avoid thermal injury. Pediatric patients are more prone to heat loss in the perioperative period due to their relatively larger head and higher surface area to mass ratio but are also more vulnerable to skin burns if warming devices are placed too close to the skin.

Emergence and extubation are just as critical as induction and intubation, given a child’s predisposition to PRAEs. The primary goal during this phase is to ensure adequate spontaneous oxygenation and ventilation, avoid laryngospasm, and to remove the airway either before or after Stage II, as this excitatory period is when children are most prone to PRAEs.³ Choosing between awake and deep extubation can be challenging in complex cases but is typically guided by patient factors such as: type of surgery, presence of difficult/airway, risk of aspiration or obstruction, risk of hematoma or damage to surgical closure with coughing, and risk of bronchospasm. For surgeries about the airway and neck, deep extubation is preferred to avoid hematoma formation which itself can completely obstruct the pediatric airway. If the airway is tenuous for any reason, awake extubation is preferred as this minimizes the potential for obstruction during emergence. Prior to deep extubation, adequate spontaneous ventilation, reversal of paralysis, and depth of anesthesia >1 MAC must be confirmed. Oropharyngeal and/or orogastric suctioning and manipulation of the airway within the trachea are commonly performed to remove any potentially stimulating secretions and assess patient reaction to mucosal stimulation. For awake extubation, confirmation of adequate spontaneous ventilation, reversal of paralysis, and observation for conjugate gaze and grimacing with suctioning should be performed to confirm recovery from anesthesia. Should laryngospasm occur in either setting, delivery of 100% oxygen with positive pressure ventilation via a mask with a tight seal will break mild laryngospasm; however more severe episodes may require increasing the depth of anesthesia with propofol or paralysis with succinylcholine. Thereafter, the patient should be supported with mask ventilation and/or intubation.

In planning the setting of surgery and postoperative care for children, the risk of postoperative apnea must be considered. Those patients with a history of obstructive sleep apnea or prematurity, and infants less than <44 weeks post-menstrual age are at increased risk of this complication and should be strongly considered for postoperative admission.^4,8

In summary, pediatric anesthesiology is a challenging yet rewarding field that incorporates much of what providers have learned from their adult patients, but also requires the addition of several special considerations and a thorough understanding of pediatric anatomy, physiology, and pharmacokinetics. Some of the challenges seen in caring for adult patients, such as preoperative anxiety and adverse respiratory events, are more commonly seen in children and must be anticipated. Every aspect of the anesthesiologist’s approach to a case, from preoperative evaluation to extubation and recovery must be modified to the unique needs and constraints presented by children as they traverse the stages of their development. Success or failure depends heavily on how effective one is at recognizing and either preventing or diagnosing and treating these common anesthetic challenges and complications.

1. Apfelbaum, Caplan, Connis, Epstein, Nickinovich, Warner. Practice guidelines for preoperative fasting and the use of pharmacologic agents to reduce the risk of pulmonary aspiration: Application to healthy patients undergoing elective procedures: An updated report by the american society of anesthesiologists task force on preoperative fasting and the use of pharmacologic agents to reduce the risk of pulmonary aspiration. Anesthesiology. 2011;114(3):495-511. doi: 10.1097/ALN.0b013e3181fcbfd9.

2. Banchs RJ, MD, Lerman, Jerrold, MD, FRCPC, FANZCA. Preoperative anxiety management, emergence delirium, and postoperative behavior. Anesthesiology Clinics. 2014;32(1):1-23. doi: 10.1016/j.anclin.2013.10.011.

3. Butz SF. Pediatric ambulatory anesthesia challenges. Anesthesiol Clin. 2019;37(2):289-300. Accessed Nov 3, 2019. doi: 10.1016/j.anclin.2019.01.002.

4. Coté CJ, Kelly DH. Postoperative apnea in a full-term infant with a demonstrable respiratory pattern abnormality. Anesthesiology. 1990;72(3):559-561. Accessed Nov 4, 2019. doi: 10.1097/00000542-199003000-00027.

5. De Francisci G, Papasidero AE, Spinazzola G, et al. Update on complications in pediatric anesthesia. Pediatric reports. 2013;5(1):e2. doi: 10.4081/pr.2013.e2.

6. Fortier MA, Kain ZN. Treating perioperative anxiety and pain in children: A tailored and innovative approach. Paediatr Anaesth. 2015;25(1):27-35. Accessed Nov 3, 2019. doi: 10.1111/pan.12546.

7. Gálvez JA, Acquah S, Ahumada L, et al. Hypoxemia, bradycardia, and multiple laryngoscopy attempts during anesthetic induction in InfantsA single-center, retrospective study. Anesthes. 2019;131(4):830-839. https://anesthesiology.pubs.asahq.org/article.aspx?articleid=2738236. Accessed Nov 3, 2019. doi: 10.1097/ALN.0000000000002847.

8. Mamie C, Habre W, Delhumeau C, Argiroffo CB, Morabia A. Incidence and risk factors of perioperative respiratory adverse events in children undergoing elective surgery. Paediatr Anaesth. 2004;14(3):218-224. Accessed Nov 3, 2019. doi: 10.1111/j.1460-9592.2004.01169.x.

9. Petroski A, Frisch A, Joseph N, Carlson JN. Predictors of difficult pediatric intravenous access in a community emergency department. J Vasc Access. 2015;16(6):521-526. Accessed Nov 3, 2019. doi: 10.5301/jva.5000411.

10. Santillanes G, Gausche-Hill M. Pediatric airway management. Emerg Med Clin North Am. 2008;26(4):96-975, ix. Accessed Nov 3, 2019. doi: 10.1016/j.emc.2008.08.004.

Providing safe and effective anesthesia for the pediatric population is an undertaking that involves several unique challenges the anesthesiologist must consider. To the untrained, it would seem everything is just smaller, however neonates, infants, and young children all pose differing challenges. In fact, there can be more variation from patient to patient in pediatrics than an adult provider might find in a busy surgical suite. Children are obviously smaller in stature, but their body proportions and organ functionality are also different. Tissues throughout the body change in quality with age, which makes them more vulnerable to injury by forces such as pressure, friction, tension, shear, etc. For the anesthesiologist, every act from mask ventilation to patient positioning must take this into strong consideration as the consequences of unintended injury can be severe, long lasting, and costly. There is no safety net for a lack of attention to detail, as errors like connecting a ventilator with tidal volumes set for a teenager to the airway of an infant can cause harm with the delivery of just a single breath. One can lethally overdose an infant with medication by administering a drug without confirming its concentration within a syringe. Providers must think and act quickly as there are no “standard” doses or “one size fits all” tools or techniques that can be applied uniformly to all pediatric patients, especially in life-threatening situations such as cardiopulmonary arrest. Furthermore, a heightened level of awareness must be exercised as a child’s status can change quickly without warning and can rapidly deteriorate if the problem is not noticed, correctly diagnosed, and intervened upon immediately.

Preoperatively, children are very prone to anxiety as they often have little or no understanding of anesthesia or surgery or may anticipate a painful experience based on their knowledge or prior experience. In addition, several different providers will be involved in perioperative care but will be perceived as strangers by young patients, making compliance during history/physical exam, induction of anesthesia, and awake procedures such as IV placement very challenging. Due to this concern, children are commonly anesthetized using a mask induction with placement of invasive line(s) after induction. Interventions such as midazolam premedication, parental presence, patient education, child life play therapy, distraction with books, toys, etc., are all options to treat and/or prevent preoperative anxiety.^2,6 According to Fortier and Kaplan, 60% of pediatric patients experience preoperative anxiety and 25% of children who receive no prophylaxis experience forceful induction of anesthesia, which can lead to further negative sequelae.⁶ Monitoring in pediatric anesthesia is performed for similar indications to that seen in adults, however EKG leads and non-invasive blood pressure cuff are often placed after induction as they can also precipitate anxiety. Conversely, an oxygen saturation sensor is considered an essential monitor for anesthetic induction in children given their high risk for adverse respiratory events.   

Generally, adolescents are able to tolerate premedication with pills and/or placement of an IV prior to induction of anesthesia but this can be variable, especially in patients with mental or behavioral disorders. If intravenous access is required prior to induction for younger children, eutectic mixture of local anesthetic (EMLA) cream, local anesthetic spray, cold topical spray, or another form of anesthetic may be used, however none of the currently available methods reliably produce ideal conditions for venous cannulation. A significant amount of onset time is required after EMLA application (~60 mins or more) prior to peripheral IV attempt and the local anesthetic may make the vessel more difficult to cannulate.⁹ If the anesthetized vessel infiltrates during or after placement, another site must be anesthetized prior to placement which can cause significant delays in procedural start time.

Regarding preoperative fasting, this is widely recommended in adults to reduce gastric volume, however the risk of aspiration must be weighed against that of hypovolemia and hypoglycemia for children, especially in infants.¹ Fluid management for small children must also be done meticulously as one can easily overload a small child using a standard infusion setup if it is inadvertently left running during the case. Healthy children often tolerate this as their kidney function is substantial enough to handle large increases in circulating volume, however children with neurologic, cardiac, pulmonary, renal, endocrine, or metabolic derangements should have a fluid management plan prior to induction. Fluid management may also be dictated by the nature of the planned surgery. For this reason, a buretrol is often used to control the delivery of IV crystalloid. Buretrol infusers will also minimize the delivery of air into the venous circulation, which can be disastrous in children with patent foramen ovale or septal defects as even small amounts of air can cause cerebral arterial air embolism.

The pediatric airway is different structurally from the mature airway and behaves distinctly during the excitatory stage of anesthesia. Children have a relatively larger tongue and occiput, more collapsible airway, more compliant ribcage tissues, shorter and thinner epiglottis, anteriorly tilted glottis, weaker and less efficient diaphragmatic contraction, and variable primary versus permanent dentition. In addition, the narrowest point in the pediatric airway is at the cricoid cartilage versus the glottis in adults, which can cause difficulty passing ETT distal to glottis and may prompt a post-intubation tube exchange to optimize ventilation. The airway is also more delicate and sensitive to the pressure and micromotion an endotracheal tube cuff can place on the tracheal mucosa.¹⁰ Most of these differences make the pediatric airway potentially more difficult to instrument, which can lead to multiple airway attempts, a known risk factor for oxygen desaturation and bradycardia particularly in infants.

Likewise, children are also much more prone to perioperative respiratory adverse events (PRAEs) such as airway obstruction, laryngospasm, bronchospasm, and desaturation. There is potential for obstruction or laryngospasm to occur prior to placement of IV access after an inhalational induction, in which case the provider must be prepared to abort IV placement and re-establish a patent airway promptly. For this reason, an oxygen saturation probe is placed pre-induction due to the rapid desaturation that occurs during apnea given a child’s relatively high metabolic rate. These patients proceed quickly from apnea to hypoxia, bradycardia, hypotension, and cardiac arrest, which makes recognizing and treating these complications quickly of paramount importance.

1. Apfelbaum, Caplan, Connis, Epstein, Nickinovich, Warner. Practice guidelines for preoperative fasting and the use of pharmacologic agents to reduce the risk of pulmonary aspiration: Application to healthy patients undergoing elective procedures: An updated report by the american society of anesthesiologists task force on preoperative fasting and the use of pharmacologic agents to reduce the risk of pulmonary aspiration. Anesthesiology. 2011;114(3):495-511. doi: 10.1097/ALN.0b013e3181fcbfd9.

2. Banchs RJ, MD, Lerman, Jerrold, MD, FRCPC, FANZCA. Preoperative anxiety management, emergence delirium, and postoperative behavior. Anesthesiology Clinics. 2014;32(1):1-23. doi: 10.1016/j.anclin.2013.10.011.

3. Butz SF. Pediatric ambulatory anesthesia challenges. Anesthesiol Clin. 2019;37(2):289-300. Accessed Nov 3, 2019. doi: 10.1016/j.anclin.2019.01.002.

4. Coté CJ, Kelly DH. Postoperative apnea in a full-term infant with a demonstrable respiratory pattern abnormality. Anesthesiology. 1990;72(3):559-561. Accessed Nov 4, 2019. doi: 10.1097/00000542-199003000-00027.

5. De Francisci G, Papasidero AE, Spinazzola G, et al. Update on complications in pediatric anesthesia. Pediatric reports. 2013;5(1):e2. doi: 10.4081/pr.2013.e2.

6. Fortier MA, Kain ZN. Treating perioperative anxiety and pain in children: A tailored and innovative approach. Paediatr Anaesth. 2015;25(1):27-35. Accessed Nov 3, 2019. doi: 10.1111/pan.12546.

7. Gálvez JA, Acquah S, Ahumada L, et al. Hypoxemia, bradycardia, and multiple laryngoscopy attempts during anesthetic induction in InfantsA single-center, retrospective study. Anesthes. 2019;131(4):830-839. https://anesthesiology.pubs.asahq.org/article.aspx?articleid=2738236. Accessed Nov 3, 2019. doi: 10.1097/ALN.0000000000002847.

8. Mamie C, Habre W, Delhumeau C, Argiroffo CB, Morabia A. Incidence and risk factors of perioperative respiratory adverse events in children undergoing elective surgery. Paediatr Anaesth. 2004;14(3):218-224. Accessed Nov 3, 2019. doi: 10.1111/j.1460-9592.2004.01169.x.

9. Petroski A, Frisch A, Joseph N, Carlson JN. Predictors of difficult pediatric intravenous access in a community emergency department. J Vasc Access. 2015;16(6):521-526. Accessed Nov 3, 2019. doi: 10.5301/jva.5000411.

10. Santillanes G, Gausche-Hill M. Pediatric airway management. Emerg Med Clin North Am. 2008;26(4):96-975, ix. Accessed Nov 3, 2019. doi: 10.1016/j.emc.2008.08.004.

In the modern practice of Anesthesiology, we strive to make clinical decisions based on evidence. Outcomes research is the discipline that focuses on providing this evidence. In short, it tells us what does work, and what does not work.

Typically, outcomes research focuses on an intervention or treatment, and whether it advances patient care. An example would be a study that seeks to determine if using a special type of laryngoscope makes intubating patients in the operating room easier. That study would involve using two different types of laryngoscopes and measuring successful attempts at intubation. Successful intubation would be the outcome in question.

Some of the common types of outcomes studies are cross-sectional studies, meta-analyses, and randomized controlled trials. Cross-sectional studies are a snapshot in time of a large population. They look at the characteristics of given groups to make inferences about outcomes without manipulating variables. A meta-analysis combines the results of multiple studies to find an “average” or “true” outcome of multiple studies. A randomized controlled trial reduces bias in a study by randomly allocating subjects to two groups, a control group without intervention, and an experimental group receiving the intervention in question. Of the three study types mentioned, randomized controlled trials provide the strongest evidence.

In anesthesiology, there are a set of core outcomes that the field evaluates. The Anesthesiology Quality Institute (AQI), a division of The American Society of Anesthesiology, set up a series of “core outcomes” on which anesthesiologists focus [2]. They are chosen because they dramatically impact patients’ lives. These outcomes include things like death, cardiovascular complications, and procedural complications. 

Anesthesiologists are keenly interested in outcomes research as it relates to their patients in the operating room and the intensive care unit. Some of the interesting topics being explored are monitored anesthesia care vs. general anesthesia, use of video laryngoscopy vs. direct laryngoscopy, and the effect of opioid and inhalational anesthesia on cancer risk.

A good demonstration of typical outcomes research in anesthesiology is Park et al.’s paper entitled “Comparison between monitored anesthesia care and general anesthesia in patients undergoing device closure of atrial septal defect [3].” They measured number and severity of lung complications as well as turnover time pertaining to the two types of anesthesia. The study found that patients in the monitored anesthesia care group and the general anesthesia group had an equal number of pulmonary complications. It also found that patients in the monitored anesthesia care group had a faster turnover time. These two outcomes are important to an anesthesiologist and demonstrate the value of outcomes research in the field.

A second excellent example of outcomes research in anesthesiology comes from Griesdale et al. in their study “Video-laryngoscopy versus direct laryngoscopy in critically ill patients: a pilot randomized trial [4].” In their randomized controlled trial, patients were placed in either a video laryngoscopy group or a direct laryngoscopy group. For their outcomes, Griesdale’s team measured successful glottic visualization and level of oxygen desaturation. The initial outcome of the study showed improved glottic visualization in the video laryngoscopy group. This implies there must be some superiority to the video laryngoscopy, but the video laryngoscopy’s oxygen saturation was 86% compared to the direct laryngoscopy group’s 95%. This second outcome, though unexpected, shows the benefits of taking more than one outcome into account.

While it may be intimidating to engage with the material of outcomes research, its results are essential for improving anesthetic care. The above studies show that familiarizing ourselves with its methods and results will help us make better choices for our patients.

Works Cited

1.            Jefford, M., M.R. Stockler, and M.H. Tattersall, Outcomes research: what is it and why does it matter? Intern Med J, 2003. 33(3): p. 110-8.

2.            Whitlock, E.L., J.R. Feiner, and L.L. Chen, Perioperative Mortality, 2010 to 2014: A Retrospective Cohort Study Using the National Anesthesia Clinical Outcomes Registry. Anesthesiology, 2015. 123(6): p. 1312-21.

3.            Park, Y.S., et al., Comparison between monitored anesthesia care and general anesthesia in patients undergoing device closure of atrial septal defect. J Thorac Dis, 2019. 11(4): p. 1421-1427.

4.            Griesdale, D.E., et al., Video-laryngoscopy versus direct laryngoscopy in critically ill patients: a pilot randomized trial. Can J Anaesth, 2012. 59(11): p. 1032-9.

Primary care physicians (PCPs) are instrumental to comprehensive healthcare management, particularly in providing common treatments and tracking patient care across time. Alarmingly, a 2018 study by the American Association of American Medical Colleges reported that the United States will face a shortage of PCPs—between 21,100 and 55,200—by 2032. According to their research, the driving factor behind the increasing demand for medical capacity is the fact that our population is growing and aging—per the census, the country’s population is predicted to grow by over 10% by 2032, with individuals over age 65 increasing by 48% . Another factor worth consideration is the nation’s obesity epidemic, which has seen marked increases in chronic health conditions nationwide. Additionally, recent medical graduates heavily consider monetary (as well as other logistical) incentives in pursuing specialized careers within medicine, as they are typically higher earning than those within primary care fields.

Furthermore, a 2019 article in the Washington Post illuminates the way in which the medical school “match” process facilitates physician specialization (including primary, internal, or family medicine) and plays a complex, yet crucial role in the impending shortage ^[2]. Roughly 13% of U.S. patients currently live in a county experiencing a “primary care shortage”—defined as “having less than one primary care physician per 2,000 patients” ^[3]. Notably, while PCP shortages are predicted to take place across the country, the worst of its effects are felt in rural regions, where communities are five times more likely to be facing a primary care shortage than urban and suburban counterparts .

Luckily, research indicates that nurse-practitioners (NPs) and physician assistants (PAs) are viable and well-positioned members of healthcare teams and providers who may ultimately increase patient access to care in coming years—ideally, helping combat predicted PCP shortages ^{[2, 3, 4]}. However, this is assuming a ‘best-case-scenario’—that is, that NPs and PAs can be effectively integrated in most, if not all, medical settings. Under such hopeful circumstances, the government’s Health Resources & Services Administration (HRSA) Bureau of Health Research predicts that the expected shortage of 20,400 PCPs in 2020 could be reduced to 6,400, thereby considerably reducing public health risks ^[4]. Collective studies indicate that significantly curbing the PCP shortage will require the expansion of state and national regulations necessary for NPs and PAs to be able to practice to the fullest extent of their knowledge, employing their extensive training focused in primary care and prevention. Another avenue presently being explored and employed is the recruitment of foreign-trained medical doctors to assuage healthcare deficits in the U.S. 

In combating this monumental health issue, one must surely employ complex, multi-tiered approaches and strategies necessary for combatting this, literally, life-threatening shortage ^{[3, 4]}. The nation’s healthcare leaders must critically examine viable and timely strategies to confront the unfavorable consequences of PCP shortages nationwide. Indeed, earlier this year, lawmakers introduced to Congress the bipartisan Resident Physician Shortage Reduction Act of 2019 (S. 348, H.R. 1763) to promote Medicare services for an added 3,000 residency positions annually for the next five years ^[1]. In summary, there is no doubt that resolving the U.S.’s PCP shortage will be a complex challenge—but one that is already being collectively and collaboratively tackled.

New Research Shows Increasing Physician Shortages in Both Primary and Specialty Care.” AAMCNews, May 8, 2019. https://news.aamc.org/press-releases/article/workforce_report_shortage_04112018/.

Knight, Victoria. “Numbers of Doctors Choosing Primary Care Declining.” The Washington Post. WP Company, July 15, 2019. https://beta.washingtonpost.com/health/america-to-face-a-shortage-of-primary-care-physicians-within-a-decade-or-so/2019/07/12/0cf144d0-a27d-11e9-bd56-eac6bb02d01d_story.html?noredirect=on#targetText=Despite osteopathic graduates and foreign,primary care physicians by 2032.

Heath, Sara. “NPs, PAs Could Reduce Primary Care Physician Shortage Nearly 70%.” Patient Engagement HIT, September 17, 2018. https://patientengagementhit.com/news/nps-pas-could-reduce-primary-care-physician-shortage-nearly-70.

Projecting the Supply and Demand for Primary Care Practitioners Through 2020.” HRSA Bureau of Health Workforce, October 31, 2016. https://bhw.hrsa.gov/health-workforce-analysis/primary-care-2020.

A shared language, particularly in treatment settings, is of crucial importance to effective communication between medical professionals and their patients. In order for clinicians to obtain an accurate and complete history, patients must convey nuanced information describing relevant history, the medical problem itself, and the context in which it arose through mutual, intelligible means of communication ^[1]. In recent decades, the U.S. has seen a revival of linguistic diversity en masse (with the largest portion of non-English speakers being Spanish speakers) .

Conceivably, this demographic shift has resulted in language barriers that have affected non-English speaking patients’ quality of healthcare, access to care, and health status/outcomes ^[3]. According to a 2016 Brookings Institution report, nearly one in ten Americans aged 16 to 64 is considered limited- or non-English proficient ^[4]. Despite the fact that U.S. is considered by many to be a multicultural country, the healthcare system is primarily geared towards English-speakers ^[3]. Research demonstrates that when a patient does not speak the same language as their medical provider, various detrimental effects to their healthcare may occur ^{[1, 3]}. For instance, lack of comprehension in a discussion of relevant medical education and treatment information can lead to poor patient satisfaction, low treatment-plan compliance, and an underutilization of services ^[3]. Diminished access to preventive care and/or primary care has also been found to be common in populations with low English-fluency skills ^[5]. What’s more, there may be serious legal and financial repercussions if medical providers fail to provide adequate medical services to patients with limited English proficiency.Perhaps the most significant barriers in overcoming language disparities in clinical settings is the dearth of skilled, certified medical interpreters ^{[1, 3, 5]}. Research on the use of translators in emergency room settings revealed that no interpreter was used in nearly half of cases involving a non-English speaking patient ^[6]. Consequently, non-English speaking patients must often rely on bilingual family members and/or healthcare staff who do not have formal training in medical translation services, which may represent potential ethical breaches ^{[1, 3]}. Furthermore, crucial, nuanced details can become lost in mistranslation; and misinterpretation has been shown to precipitate medical and logistical catastrophes. In one case, hospital personnel translating for a nurse practitioner instructed the mother of a seven-year-old to administer oral amoxicillin in her daughter’s ears ^[5]. In another, a resident who relied on partial Spanish skills mistranslated a mother’s description of her two-year-old’s tricycle accident (the literal translation being that she “hit herself” while falling off) and perceived the fracture to have been caused by abuse; the attending contacted social services—without an interpreter—had the mother sign away custody of her two children ^[5]. Evidently, the consequences of language barriers may be severe and not limited to medical outcomes.

Furthermore, language barriers—even when assuaged by the use of interpreters—may represent complex challenges in effective patient-provider communication dynamics ^[5]. For instance, the delivery of subtle non-verbal cues indicative of relevant information may become lost in translation ^[1]. Additionally, a lack of sensitivity towards cross-cultural differences on all sides may hinder the quality and efficacy of healthcare services ^{[1, 3]}. Those who study this issue closely have proposed the notion that all payers be required to reimburse providers for medically skilled interpreter services ^[5]. Without question, the mandated provision of satisfactory language services would significantly aid in producing improved patient resource use, satisfaction, communication, outcomes, and patient safety .

Partida, Yolanda. “Language Barriers and the Patient Encounter.” Journal of Ethics | American Medical Association. American Medical Association, August 1, 2007. https://journalofethics.ama-assn.org/article/language-barriers-and-patient-encounter/2007-08.

Rumbaut, Rubén G, and Douglas S Massey. “Immigration and Language Diversity in the United States.” Daedalus. U.S. National Library of Medicine, 2013. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4092008/.

Timmins, Caraway L. “The Impact of Language Barriers on the Health Care of Latinos in the United States: a Review of the Literature and Guidelines for Practice.” Journal of Midwifery & Womens Health 47, no. 2 (2002): 80–96. https://doi.org/10.1016/s1526-9523(02)00218-0.

Wilson, Jill H. “Investing in English Skills: The Limited English Proficient Workforce in U.S. Metropolitan Areas.” Brookings. Brookings, August 24, 2016.

Flores, Glenn. “Language Barriers to Health Care in the United States.” New England Journal of Medicine 355, no. 3 (2006): 229–31. https://doi.org/10.1056/nejmp058316.

Baker, D W, R M Parker, M V Williams, W C Coates, and K Pitkin. “Use and Effectiveness of Interpreters in an Emergency Department.” JAMA. U.S. National Library of Medicine, March 13, 1996. https://www.ncbi.nlm.nih.gov/pubmed/8598595.

Meuter, Renata F. I., Cindy Gallois, Norman S. Segalowitz, Andrew G. Ryder, and Julia Hocking. “Overcoming Language Barriers in Healthcare: A Protocol for Investigating Safe and Effective Communication When Patients or Clinicians Use a Second Language.” BMC Health Services Research. BioMed Central, September 10, 2015. https://bmchealthservres.biomedcentral.com/articles/10.1186/s12913-015-1024-8.

Evidence-based clinical practice is an approach to health care in which professionals use the best evidence possible—i.e., scientific data and other appropriate information—to make clinical decisions about patient care.¹ Evidence-based practice (EBP) has been on the rise for over 20 years,² and in health care in particular, it involves the combination of scientific evidence, clinical expertise and individual patient needs.¹ EBP is particularly important because it allows health professionals to use data from systematic research in their everyday practices, thus giving individualized purpose to broad studies and keeping health care standard across clinicians.³

EBP not only applies to individual or group health care practices, but also to organizational and national guidelines on medical care. For one, the Japanese Society of Gastroenterology published the Evidence-based Clinical Practice Guidelines for GERD in 2009, and then updated these guidelines in 2015 based on research in GERD epidemiology, pathophysiology and treatment during this period.⁴ These new data informed the society’s suggested practices, including those regarding treatment with proton pump inhibitors (PPIs). Later, in 2017, Farrell et al. used a systematic review of PPI trials and side effects to recommend reducing or stopping treatment with PPIs after a short period of time.⁵ Clearly, the case of gastroenterology’s fast-pace updates to standard practice guidelines demonstrates the influence that systematic evidence can have on individual patient care.

Meanwhile, evaluations of clinical practice quality—aside from simply suggestions or guidelines—are also influenced by scientific evidence. The Centers for Medicare & Medicaid Services (CMS) lists evidence-based care as one of its core competencies in its initiatives for quality health care.⁶ Thus, health professionals’ quality of patient care is assessed based on their individual patients’ outcomes as well as on their ability to integrate scientific evidence into their practices. Indeed, EBP and quality improvement efforts are often linked within health care;⁷ EBP is cited as a critical part of quality improvement⁸ and as a mechanism through which health professionals can improve quality of care.

Nonetheless, EBP has faced challenges throughout the years of its popularity. For example, Hisham et al.’s interviews of various primary care doctors revealed that—despite being aware of and having a positive attitude toward EBP—participants cited heavy workload and lack of training as barriers to implementing EBP in their own clinical practices.¹⁰ Additionally, some doctors were concerned that EBP compromised personalized patient care and did not consider an individual physician’s clinical experience. Meanwhile, De Smedt et al. found that while physicians, nurses and paramedics used forums such as the Internet and textbooks to gather evidence, they claimed that lack of time, the overwhelming mass of literature and difficulties integrating evidence into practice were the most common barriers to EBP.¹¹ Overall, EBP is not universally acknowledged as a panacea, and its general acceptance may not necessarily lead to EBP-friendly workplaces.

In sum, EBP can serve as a method for systematic research to make its way into the everyday lives of patients and health care professionals. EBP helps medicine keep pace with clinical evidence and allows professional organizations to standardize practice.¹² Future researchers must explore if EBP is feasible given health professionals’ heavy workloads, if it encourages personalized solutions for patients and, ultimately, if it can lead to improved quality of health care.

1.         McKibbon KA. Evidence-based practice. Bulletin of the Medical Library Association. 1998;86(3):396–401.

2.         Guyatt G, Cairns J, Churchill D, et al. Evidence-Based Medicine: A New Approach to Teaching the Practice of Medicine. JAMA. 1992;268(17):2420–2425.

3.         Sackett DL, Rosenberg WMC, Gray JAM, Haynes RB, Richardson WS. Evidence based medicine: What it is and what it isn’t. BMJ. 1996;312(7023):71–72.

4.         Iwakiri K, Kinoshita Y, Habu Y, et al. Evidence-based clinical practice guidelines for gastroesophageal reflux disease 2015. Journal of Gastroenterology. 2016;51(8):751-767.

5.         Farrell B, Pottie K, Thompson W, et al. Deprescribing proton pump inhibitors. Evidence-based clinical practice guideline. 2017;63(5):354-364.

6.         Centers for Medicare & Medicaid Services. Quality Initiatives: General Information. April 2018; https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/QualityInitiativesGenInfo/index.html.

7.         Banerjee A, Stanton E, Lemer C, Marshall M. What can quality improvement learn from evidence-based medicine? Journal of the Royal Society of Medicine. 2012;105(2):55–59.

8.         Solomons NM, Spross JA. Evidence-based practice barriers and facilitators from a continuous quality improvement perspective: an integrative review. Journal of nursing management. 2011;19(1):109–120.

9.         Grimshaw J, Eccles M, Thomas R, et al. Toward Evidence-Based Quality Improvement. Journal of General Internal Medicine. 2006;21(S2):S14–S20.

10.       Hisham R, Ng CJ, Liew SM, Hamzah N, Ho GJ. Why is there variation in the practice of evidence-based medicine in primary care? A qualitative study. BMJ Open. 2016;6(3):e010565.

11.       De Smedt A, Buyl R, Nyssen M. Evidence-based practice in primary health care. Studies in Health Technology and Informatics. 2006;124:651–656.

12.       Masic I, Miokovic M, Muhamedagic B. Evidence based medicine – New approaches and challenges. Acta Informatica Medica: Journal of Academy of Medical Sciences of Bosnia and Herzegovina. 2008;16(4):219–225.