In Reply: Encouraging a Bare Minimum While Striving for the Gold Standard: A Response to the Updated WHO-WFSA Guidelines
Bibliographic record
Abstract
In Response We are thankful for the opportunity to respond to the letter from Dr Hendel et al1 addressing the World Health Organization-World Federation of Societies of Anaesthesiologists (WHO-WFSA) International Standards for a Safe Practice of Anesthesia2,3 reiterating their previously stated concern that such standards set the bar too high.4 The WHO-WFSA workgroup was globally representative and was balanced for sex, geography, and high-, middle-, and low-income country membership. Thus, the advice of representatives from low-income countries in different parts of the world was sought and included. This is in contrast to the authorship group of Hendel et al1 where only a part of Africa was represented among low-income countries. Hendel et al1 seem to have missed the distinction made in our Standards document between emergency surgery to save life or limb and purely elective or semi-elective surgery. Their disconcerting statement “We do a disservice to those who rely on a bare minimum by implying that they should have oxygen, safety monitors, and essential medicines at all times”1 is difficult to reconcile with the setting of standards. Their statement serves to sanction all surgery independent of urgency in the absence of basic requirements. The WHO-WFSA workgroup strongly disagrees with such a sanction. The Standards document accommodates the need for anesthesia in the absence of these minimum standards in exceptional circumstances with an explicit statement that “In some resource-poor settings, even HIGHLY RECOMMENDED (ie, minimum expected standards) may not currently be met. In these settings, the provision of anesthesia should be restricted to procedures that are absolutely essential for the immediate (emergency) saving of life or limb. If HIGHLY RECOMMENDED standards are not met, provision of anesthesia for elective surgical procedures is unsafe and unacceptable.”3 Standards are by definition “A required or agreed level of quality or attainment; something used as a measure, norm, or model in comparative evaluations”.5 They are not intended to “imply” what that level is—they state it explicitly. How they are implemented depends on decisions made locally at a hospital, regional, or national level. We have previously pointed out that the failure of local political processes does not represent the failure of appropriate standards.6 Standards are a tool to be used in the political process of establishing best practices in the interests of patient safety and wellbeing. We wish to assure Hendel et al1 that the WFSA is playing a very active role, together with national societies, in ensuring that anesthesia is an integral part of national surgery-obstetric-anesthesia planning. The WHO-WFSA International Standards for a Safe Practice of Anesthesia are proving to be an invaluable resource during those planning processes. We are concerned that the explicit bare minimum step-wise approach previously promulgated by these authors,4 and now reiterated once again,1 will be interpreted as a de facto alternate set of lower standards by those in a position of power and used to endorse the current inadequacies in anesthesia services in many parts of the world. This would maintain the status quo in many low- and middle-income countries.6 Adrian W. Gelb, MBChB, FRCPCDepartment of Anesthesia & Perioperative CareUniversity of California San FranciscoSan Francisco, California Wayne W. Morriss, MBChBUniversity of OtagoChristchurch HospitalChristchurch, New Zealand Walter Johnson, MDServices Organization and Clinical Interventions Unit (SCI)Service Delivery and Safety Department (SDS)Health Systems and Innovation (HIS)World Health Organization, Switzerland Alan F. Merry, MBChB, FANZCA, FFPMANZCADepartment of AnaesthesiologyUniversity of AucklandDepartment of AnaesthesiaAuckland City HospitalAuckland, New Zealand
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How this classification was reachedexpand
Full frame machine prediction
Teacher imitationNot calibrated prevalence, not ground truth. Human validation pending. The Gemma side is a direct model label for every work in the frame, read from the title-only record. The Codex side is a classifier learned from the 10,348 direct Codex labels and calibrated to design-weighted sample rates; fields without enough sample support carry no Codex call. Candidate is the union of the two sides; consensus is their intersection. These outputs are machine_predicted_unvalidated and are not human labels.
Distilled classifier scores by category (both heads)
| Category | Codex | Gemma |
|---|---|---|
| Metaresearch | 0.010 | 0.076 |
| Meta-epidemiology (narrow) | 0.001 | 0.001 |
| Meta-epidemiology (broad) | 0.002 | 0.002 |
| Bibliometrics | 0.001 | 0.001 |
| Science and technology studies | 0.004 | 0.005 |
| Scholarly communication | 0.005 | 0.008 |
| Open science | 0.004 | 0.004 |
| Research integrity | 0.050 | 0.067 |
| Insufficient payload (model declined to judge) | 0.010 | 0.010 |
Machine scores (provisional)
The two teacher heads of the student model, read on this work. A score orders the frame for review; it never asserts a category, and the validation status ships verbatim with every row.
Baseline scores from an immature model (maturity gate not passed, 7 training rounds). Scores rank; they never assert a category.
score_only:v0-immature-baseline · verbatim from the scoring run: score_only means the number may rank works, and no category label ships from itClassification
machine, unvalidatedMachine predicted; a candidate call from one source (direct Gemma or distilled Codex), not a consensus.
How this classification was reached, model by model and score by score, is at the end of the page under "How this classification was reached".