Physician Unionization: Opportunities and Challenges for Anesthesiologists in the United States.

Physician unionization is gaining traction in the United States, with <10% of practicing physicians now members, up from historically weak support. Factors that drive interest in unions include a decreased number of independent practitioners, an increase in workloads, and the erosion of autonomy. Approximately 56% of anesthesiologists are considered employees and may be eligible for union membership. Physician unions may provide higher wages, better working conditions, and legal protection. However, they also raise concerns about patient care and professionalism. This article discusses the legal and regulatory framework governing the unionization of physicians, benefits, challenges, and potential future developments. Continued analysis and debate are necessary to determine the optimal role of physician unions in the health care industry.

Predictive value of the National Institutes of Health Stroke Scale and the Mini-Mental State Examination for neurologic outcome after coronary artery bypass graft surgery.

OBJECTIVE: We intended to define the role of the National Institutes of Health Stroke Scale and the Mini-Mental State Examination in identifying adverse neurologic outcomes in a large international sample of patients undergoing cardiac surgery. METHODS: We evaluated 4707 patients undergoing cardiac surgery with cardiopulmonary bypass at 72 centers in 17 countries between November 1996 and June 2000. Prespecified overt neurologic outcomes were categorized as type I (clinically diagnosed stroke, transient ischemic attack, encephalopathy, or coma) or type II (deterioration of intellectual function). The National Institutes of Health Stroke Scale and Mini-Mental State Examination were administered preoperatively and on postoperative day 3, 4, or 5. Receiver operating characteristic curves were plotted to determine the predictive value of worsening in National Institutes of Health Stroke Scale and Mini-Mental State Examination scores with respect to type I and II outcomes. RESULTS: The receiver operating characteristic area under the curve for changes in National Institutes of Health Stroke Scale score (n = 4620) was 0.89 for type I outcomes and 0.66 for type II outcomes. A 1-point worsening in National Institutes of Health Stroke Scale score provided excellent discrimination (86% specificity; 84% sensitivity) of type I outcomes. The receiver operating characteristic area under the curve for changes in Mini-Mental State Examination score (n = 4707) was 0.75 for type I outcomes and 0.71 for type II outcomes. A 2-point worsening in Mini-Mental State Examination score provided only fair discrimination (73% specificity; 62% sensitivity) of type II outcomes. CONCLUSION: We used baseline controls and postoperative worsening in National Institutes of Health Stroke Scale and Mini-Mental State Examination scores to predict both serious adverse neurologic outcome and deterioration of intellectual function. Our findings provide the only reference for evaluating these tests that are used in cardiac surgical clinical trials.

Effects of modified ultrafiltration on coagulation as measured by the thromboelastograph.

Hemodilution during cardiopulmonary bypass (CPB) continues to be a cause of morbidity associated with coagulation dysfunction, bleeding, and allogeneic blood transfusion. Clot formation and strength have been shown to impact bleeding and transfusions. Strategies to reduce hemodilution may be negated based on the course of the cardiac procedure itself. Modified ultrafiltration (MUF) is commonly used in pediatric cardiac surgery; however, it is not well accepted in adult surgery. This study aimed to evaluate clot formation and strength, bleeding, and transfusions in adult subjects undergoing MUF. Nineteen subjects having primary coronary artery bypass, aortic, or mitral valve surgeries were recruited and randomized to having MUF (n = 10) or no-MUF (n = 9) performed after the termination of CPB. Five time points for data collection were designated: T1, baseline/induction; T2, termination CPB; T3, post-MUF; T4, post-protamine; T5, 24 hours postoperative. Subjects randomized to MUF had 1505 +/- 15.8 mL of effluent removed, and no-MUF subjects had the CPB remnants processed with a cell salvage device. There was no statistical difference seen in 24-hour chest tube output, thromboelastograph values, or allogeneic transfusions at any time point between MUF and no-MUF subjects. There was a significant difference between MUF and no-MUF in the number of autologous cell salvage units processed (1.3 +/- .48 vs. 2.9 +/- .78, p = .0013) and end of procedure net fluid balance (+2003 +/- 1211 vs. +4194 +/- 1276 mL, p = .001), respectively. Estimated plasma loss from the cell salvage device was 477.6 mL greater in the no-MUF group. In primary adult cardiac procedures, MUF did not change coagulation values as measured by thromboelastography, number of allogeneic unit transfusions, or chest tube output at 24 hours postoperatively. There was a significant difference in autologous cell salvage units processed and end of procedure net fluid balance that benefited MUF subjects.

Adverse gastrointestinal complications after cardiopulmonary bypass: can outcome be predicted from preoperative risk factors?

UNLABELLED: Adverse gastrointestinal (GI) outcome after cardiac surgery is an infrequent event but is a clinically important health care problem because of associated increased morbidity and mortality. The ability to identify patients at greatest risk before surgery may be helpful in planning appropriate perioperative management strategies. We examined the pre- and intraoperative characteristics of 2417 patients from 24 diverse United States medical centers enrolled in the Multicenter Study of Perioperative Ischemia Study who were undergoing cardiac surgery using cardiopulmonary bypass as predictors for adverse GI outcome. Resource utilization was evaluated for patients with and without adverse GI outcomes. Adverse GI outcomes occurred in 5.5% of patients (133 of 2417), increased in-hospital mortality 6.5-fold, prolonged the mean intensive care unit length of stay by 1 wk, and more than doubled the mean postoperative hospital stay (P < 0.0001). Predictors of adverse GI outcome included decreased left ventricular function, hyperbilirubinemia, thrombocytopenia, prolonged partial thromboplastin time, prior cardiovascular surgery, combined coronary artery bypass graft surgery and intracardiac or proximal aortic surgery, pharmacological cardiovascular support, and intraoperative transfusion. The literature suggests that adverse GI outcome after cardiac surgery is secondary to poor splanchnic perfusion, which many of these risk factors may predict. Therefore, patients deemed to be at risk before surgery may benefit from tightly controlled hemodynamic management and other strategies that optimize perioperative organ perfusion. IMPLICATIONS: We identified the preoperative and intraoperative predictors associated with an increased incidence of postoperative gastrointestinal complications after cardiac surgery using cardiopulmonary bypass. Because these complications are associated with frequent morbidity and mortality, these predictors may be helpful in identifying patients at increased risk so that risk stratification can be modified and perioperative management can be appropriately adjusted.