Chapter 2. The Scope and Future of Anesthesia Practice

1. The operating room remains the primary focus for the vast majority of anesthesiologists.

2. The anesthesiologist's primary responsibility is to ensure patients' comfort and safety when they are exposed to the trespass of surgery.

3. The intraoperative conduct of anesthesia has effects on patient safety and comfort in the postoperative period.

4. The provision of safe anesthetic care across geographically dispersed sites and encompassing wide ranges of patient health, in an economically responsible manner, is a challenge that anesthesiologists need to address proactively.

5. It is arithmetically impossible to provide a fully trained individual anesthesiologist for every anesthetic procedure.

6. Meeting the labor, safety, and cost demands of the future will require that we overcome the political infighting between organized anesthesiology and nurse anesthesia.

7. Many believe it is important for the future of the specialty that anesthesiologists increase their commitment to critical care medicine.

8. Recent advances in knowledge and technology create an enormous opportunity for anesthesiologists to address the scientific questions at the core of the specialty as well as a variety of important clinical problems.

9. Apart from traditional areas of involvement, such as operating room anesthesia, critical care, pain medicine, teaching, research, and resuscitation, there will be future opportunities for anesthesiologists in pharmacogenomics, health care systems management, and new technologies.

Anesthesiology arose as a medical specialty because the dangers associated with anesthetic drugs and techniques demanded that they be administered by skilled and knowledgeable physicians. As safer drugs were developed and physiologic monitoring improved, the need for anesthesiologists was propelled by increasing surgical complexity and severity of patient illness, as well as by increasing expectations for patient safety. Whereas the original raison d'être for the specialty remains today, a variety of professional and economic factors have challenged anesthesiology and produced large "swings of fortune" during the past few decades.

During the 1970s and 1980s, the emergence of critical care attracted many talented medical students to American anesthesiology training programs. However, these were halcyon days for anesthesiologists practicing in the operating room, where professional income was high, job opportunities were ample, and increasing surgical complexity demanded an increasing level of medical knowledge and skills. Thus there was little incentive for anesthesiologists to expand their roles beyond the confines of the operating suites, and most of the trainees who were initially attracted by critical care subsequently practiced operating room anesthesia only. In contrast, anesthesiologists in Europe and Canada were consolidating their positions during this same period in the burgeoning subspecialties of pain, intensive care, and resuscitation.

In the mid-1990s, gloom beset anesthesiology in the United States as predictions, widely reported in lay press such as the Wall Street Journal, suggested that the need for anesthesiologists would decrease dramatically in an anticipated managed care environment. Medical graduates were discouraged from pursuing careers in anesthesiology, and residency programs contracted dramatically. In the last 10 years, US anesthesiology programs have enjoyed a revival, and many talented medical graduates have chosen to enter the specialty. Another encouraging recent trend has been the marked increase in the proportion of US graduating residents who are choosing to pursue fellowships to bolster their specialist knowledge and refine their clinical skills. All anesthesiology subspecialties (eg, pain medicine, critical care, pediatrics, clinical scientist) are benefiting from this growing cadre of subspecialists. Anesthesiologists in the other parts of the world have also experienced fluctuating fortunes. Currently there is a shortage of doctors, in general, and anesthesiologists, in particular, in many countries. The future of anesthesiology depends on several factors, including changes in surgery and interventional medical practice, technological advances in anesthesiology, the evolving scope of anesthesia practice, and the role of nonphysicians (eg, nurse anesthetists and anesthesia physician assistants) and physicians trained in other specialties, in the provision of anesthesia care; health care financing will also influence trends in anesthesia practice. This chapter briefly reviews the current scope of anesthetic practice and offers some possible scenarios for future directions of the specialty.

The operating room remains the primary focus for the vast majority of anesthesiologists. The anesthesiologist's primary responsibility in this arena is to ensure the patients' comfort and safety when they are exposed to the trespass of surgery; this includes protecting the patient from pain, undesired awareness, and organ system injury, and fostering full recovery from the surgical and anesthetic interventions. Over the past decades it has become increasingly clear that the intraoperative conduct of anesthesia has profound effects on patient safety and comfort in the postoperative period. For example, modest intraoperative hypothermia can either decrease the incidence of wound infection1 or provide neuroprotection2 depending on the clinical situation. Anesthesiologists are increasingly sophisticated in their understanding of patient safety, and they are focusing on such issues as appropriate perioperative medications, antibiotic prophylaxis and infection control, multimodal analgesia, maintenance of normothermia and normoglycemia, and appropriate fluid and electrolyte therapy. Recent research shows that an estimated 1.85% of adult patients die within 30 days of undergoing operations across the entire surgical spectrum, with some operations having much higher mortality (eg, vascular surgery: 5.97%) and others having lower mortality (eg, breast surgery: 0.07%).3 It is likely that, with appropriate interventions, many of these deaths could be prevented. This growing responsibility for overall postoperative outcomes raises new expectations for knowledge and skills of the practicing anesthesiologist and challenges our previously narrower definitions of anesthetic outcome.4

Despite the demands imposed by increasing severity of illness in surgical patients, growing surgical complexity and more comprehensive postoperative considerations, anesthesiology is often viewed as a victim of its own perceived success. One widely cited study from the United Kingdom, the Confidential Enquiry Into Perioperative Deaths (CEPOD), reports that patients undergoing general anesthesia have a 1 in 185000 chance of dying as a consequence of anesthetic misadventure.5-7 This finding was highlighted in the Institute of Medicine report on medical errors,8 and anesthesiology was cited as the specialty that had best addressed safety issues (see Chapter 3 for a more comprehensive review of quality and safety in anesthesia practice). Unfortunately, this widely publicized perception that anesthesia is "safe" has encouraged nonphysician anesthesia providers to advocate for independent practice and has suggested to insurers that anesthesia care by an anesthesiologist is needlessly expensive. However, studies from other countries have reported much higher rates of death attributable to anesthesia than those reported in the CEPOD study.9 In a large French study, the perioperative mortality directly attributable to anesthesia was found to be 1 in 13,000.10 In studies reported from Australia,11 Denmark,12 Finland,13 and the Netherlands,14 perioperative death attributable to anesthesia ranged from 1 in 250012 to 1 in 67,000.13 The mortality attributable to anesthesia is probably much greater in underdeveloped countries. For example, a 1992 study from a Zimbabwean teaching hospital reported an alarming incidence of death or coma attributable to anesthesia of 1 in 388.15 Whereas the bulk of evidence suggests that anesthesia is not nearly as safe as publicized,16 it is undoubtedly true that advances in anesthetic practice in developed countries have rendered the care of healthy patients undergoing low- or intermediate-risk surgery much safer than in the past (see Chapter 25 for a more detailed review of anesthesia risk).

The challenges to anesthesiology are exacerbated by the massive expansion in demand for anesthesia services for a variety of nonoperative procedures ranging from cerebral aneurysm coiling to general anesthesia for screening colonoscopy, and by the introduction of free-standing ambulatory surgery centers and office-based surgical suites where anesthesia is administered. The demands for safe anesthesia care provided in numerous remote locations present significant challenges to the workforce, financing, and practice of anesthesiology.

Current practice models vary widely both in the United States and worldwide. In the United States, some anesthesiologists (or practice groups) personally provide all anesthetic care regardless of complexity, an approach that is also common in the United Kingdom, Canada, and Australia. In other practices, anesthesiologists supervise ancillary providers (eg, nurse anesthetists, residents, or anesthesia assistants) in more than one operating room, a practice model that is also common in the Netherlands. The provision of safe anesthetic care across geographically dispersed practice sites and encompassing wide ranges of severity of patient illness, in an economically responsible manner, is a major challenge that anesthesiologists need to address proactively.

The expectations for operating room anesthesia can be simply stated: We will need to provide an ever-increasing quality of perioperative care for a lower cost. In turn, these expectations and predictions require that the anesthesiology community consider who will, or should provide each component of anesthesia care, what levels of knowledge and skill will be required of each provider, and how the responsibility for care will be organized, managed, and rewarded.

Currently, at least 50% of anesthesia care in the United States involves nurse anesthetists; in several states, physician supervision is not mandatory. Worldwide, anesthesia practice often includes some form of nonphysician provider or physician provider who is not a fully trained anesthesiologist. For example, staff-grade noncertified anesthetists provide a significant proportion of anesthesia care in the United Kingdom. There is one report asserting that nonanesthesiologists can safely provide anesthesia for selected procedures (eg, colonoscopy) and patients.17 It is also clear that patients with minimal physiologic reserve, those undergoing major interventions, and those with complex medical problems require the direct involvement of a skilled anesthesiologist to enhance patient safety.18,19 Unfortunately, practitioner skill and experience are often not matched to these factors but determined by the availability of providers or a fixed model of care delivery rather than one tailored to the specific clinical situation. This is a fruitful area for further work by anesthesiologists to ensure proper matching of resources to clinical needs.

It is arithmetically impossible to provide a fully trained individual anesthesiologist for every anesthetic procedure. Further, the increasing demands for anesthesia services (aging population, proliferation of ambulatory surgery centers, escalating demand for nonsurgical anesthesia and sedation) will outstrip even the most aggressive output of anesthesiologists. Medical schools simply do not have the capacity to train sufficient doctors to feed exponentially increasing anesthesia programs. For reasons of both anesthesiologist availability and cost, it is thus apparent that the future of anesthesia practice will involve an increasing role for nonphysician providers. How can this be made compatible with the demands for increasing safety and quality? This can be accomplished by involving skilled anesthesiologists in the cognitive aspects of every anesthetic. This will require coordination and cooperation with nonphysician providers, allowing them to perform at the highest levels their training allows while ensuring that a fully trained specialist is involved in planning and managing care for high-risk cases and is readily available for complex diagnostic and therapeutic decision making. Technological developments in monitoring and information systems should facilitate these changes. The development of telemedicine could make this model of care feasible even in communities where an anesthesiologist is not physically present.20 Meeting the labor, safety, and cost demands of the future will require that we overcome the political infighting between organized anesthesiology and nurse anesthesia. Further, the training of anesthesiologists will increasingly need to encompass the development of skills in supervising other anesthesia providers. It is in the interests of public safety and health care delivery that unity be forged among anesthesia providers under the leadership of specialist anesthesiologists, whose medical training and education is required for complex medical decision making, supplemented by the skills and abilities of nonphysician providers who enhance this team approach.

Preoperative Care

Perioperative morbidity is frequently attributable to poor preoperative patient assessment and optimization. These roles have always been integral to the anesthesiologist's practice. However, as patients increasingly present to the hospital on the day of surgery, it has become necessary to ensure that patients are properly evaluated well before the immediate preoperative interval. Recognizing this need has led to burgeoning preoperative assessment clinics, where problems such as ischemic heart disease, pulmonary disease, or sleep apnea may be evaluated and appropriate perioperative interventions may be planned (see Chapter 4 for a more detailed discussion of the benefits and operation of preoperative clinics). In some practice settings, preoperative assessment of complicated patients has been largely relegated to non–anesthesiology-trained physicians or physician extenders. In other settings, the challenge of same-day surgery admission has left preoperative assessment as a day-of-surgery activity; neither of these approaches is optimal. From the standpoint of continuity of care and so that anesthesiologists can implement best practices that contribute to the continuum of care and long-term outcomes, it is essential that anesthesiologists continue to play an integral role in preoperative assessment clinics. This should also be a key component of anesthesia resident training programs, for it represents an important aspect of future anesthesia practice.

Pain Medicine

Doctors cannot always cure disease, but they should always try to alleviate suffering. Physical pain is among the most unpleasant of human experiences. Anesthesiologists are often involved in the management of severe pain associated with surgery, and the perioperative use of analgesics constitutes an important component of anesthetic care. Anesthesiologists are more comfortable with opiate administration than many other physicians, both because of their knowledge of pharmacology (especially opioid pharmacology) and their skill and experience in managing side effects such as respiratory depression. Anesthesiologists have pioneered regional anesthetic techniques, many of which are applicable to the treatment of chronic intractable pain. Increasing numbers of anesthesiologists are specializing in pain management, and the effective relief of pain will remain an important component of the anesthesiologist's role even for those who do not subspecialize specifically in pain medicine.

Critical Care Medicine

Anesthesiologists pioneered the development of critical care medicine.21 In many countries, anesthesiologists constitute the bulk of the physician workforce in critical care. In most of Europe, full training in critical care is an integral component of an anesthesia residency, and critical care anesthesiologists are responsible for organizing and staffing most hospital critical care units. In contrast, US anesthesia residents receive only a few months of critical care training, and anesthesiologists constitute a minority of the nation's critical care physicians. Many believe it is important for the future of the specialty that anesthesiologists increase their commitment to critical care medicine. To achieve this, leading academic programs must expand their critical care fellowships and promote critical care as a financially viable and intellectually rewarding subspecialty for talented graduating residents.

Clinical Services Administration

The operating suite is a complex environment, one that often has not been efficiently managed. Anesthesiologists are an integral component of this important but unwieldy organization. The need for effective management and administration is being increasingly recognized, and anesthesiologists are often sought for this management function. In many countries, including in Europe and North America, anesthesiologists are acquiring formal training in management and business administration. Today's doctors, even in academic institutions and national health services, cannot afford to isolate themselves from the realities of reimbursement, cost, efficiency, patient satisfaction, and overall system performance. There appears to be a bright future for physician leaders in health care organizations; anesthesiologists are, and will continue to be, an important part of this management evolution.

Patient Safety

Anesthesiologists have been at the forefront of pioneering patient safety. The improvements have been so dramatic that liability insurance for anesthesia practice has decreased while that for most other specialties has steadily increased (some dramatically). The Anesthesia Patient Safety Foundation was founded in the United States in 1984 with the expressed purpose of ensuring "that no patient shall be harmed by the effects of anesthesia." Since 1985 the Committee on Professional Liability of the American Society of Anesthesiologists (ASA) has been studying records of closed malpractice claims files for anesthesia-related patient injuries.22 More than 5000 claims have been studied. Subsequently, the Australian Patient Safety Foundation was established in 1987 and the Australian Incident Monitoring Study was initiated.23 More than 4000 critical incidents have been reported to date. Analysis of these incidents has reinforced the value of technological advances, such as capnography and oximetry, in improving patient safety. The results also confirm the value of structured algorithms in anesthesia care, by documenting favorable outcomes in a range of life-threatening crises during anesthesia. CEPOD was started in the United Kingdom in 1989. Changes in consultant practice, increase in medical audits, improvement in physiologic monitoring, appropriate matching of specialist experience to patient's medical conditions, and increased awareness of the need for critical care services are believed to have been influenced by this inquiry.24

Critical events occur within the context of complex system failures, and anesthesiologists have been developing safeguards to decrease the likelihood that human error may result in patient harm. Examples include written "checklists," audible alarm settings, and automated anesthesia machine checks. A seminal study showed how the routine implementation in hospitals around the world of a simple 19-item surgical safety checklist designed to improve team communication and consistency of care markedly reduced 30-day complications (from 11% to 7%) and deaths (from 1.5% to 0.8%) associated with surgery.25 Expertise in patient safety should be developed and translated into the broader medical context, including application in areas not historically viewed as the purview of anesthesia practice (such as diagnostic and treatment suites, obstetric suites, intensive care units, and intermediate care units).

Research

Anesthesiology has a vibrant history of research and intellectual contributions to clinical medicine. Historically, anesthesia research has focused on laboratory investigations in physiology and pharmacology and their application to patient care. These contributions have improved the safety of anesthesia and surgery, and they constituted pioneering efforts in the initial application of scientific principles to individual patient care. Until recently many of the scientific questions at the core of anesthesiology have been relatively inaccessible to investigation; this stems from the absence of tools to study the mechanisms of the complex behaviors (eg, consciousness, memory, pain) that anesthesiologists manipulate. Recent advances in cellular physiology (ie, patch clamp recording), molecular biology, genetics, functional imaging, and behavioral sciences have enabled serious investigation of these complex behaviors. It is thus now possible that the fundamental mysteries of anesthesia (including the molecular mechanism of the hypnotic, amnestic, and analgesic effects of anesthetics agents) will be solved. These same new scientific tools also make it feasible to define the mechanisms of hyperalgesia and chronic pain and to design effective treatments. Finally, advances in the understanding and manipulation of inflammation and the immune response provide a new opportunity to delineate how organ system injury occurs in the perioperative period and to identify strategies for protection of the brain, heart, kidneys, and other organs. Collectively, recent advances in knowledge and technology create an enormous opportunity for anesthesiology to address the scientific questions at the core of the specialty, as well as a variety of important clinical problems. Innovative anesthesiology training programs are offering integrated scholarship tracks to the most academically competitive residency applicants, and several graduates are pursuing fellowships in clinical and translational research.

The application of information technology and epidemiologic techniques (often referred to as outcomes research) to the perioperative period has also created new research opportunities for anesthesiology. These approaches quantify and describe perioperative morbidity and mortality, facilitating recognition of patterns and causes of adverse patient outcomes. The broad application of information technology coupled to epidemiologic analysis will provide the opportunity to define and monitor "best practices" and to evaluate systematically the efficacy of new technologies, techniques, and approaches. Recognizing the need for detailed perioperative clinical data, the American Society of Anesthesiologists established the Anesthesia Quality Institute in 2008, which will house the National Anesthesia Clinical Outcomes Registry, a patient data registry that will be combined with other data sources to enable provider benchmarking, quality improvement, research, public reporting, credentialing, and maintenance of certification. The National Anesthesia Clinical Outcomes Registry will contain anesthesia-specific data elements that are essential for comprehensive perioperative clinical research.26

Academic anesthesia has been challenged in recent years, with decreased academic funding of some departments, a decreasing share of extramural grant funds,27 and a contraction in the number of young anesthesiologists embarking on rigorous research training and careers. One of the reasons put forward for reduced funding for anesthesia research is that the current safety of anesthesia implies that anesthesia research is not a pressing public health concern. As noted earlier, this may be a misconception; although intraoperative mortality is rare, postoperative mortality and major morbidity still occur commonly, and anesthesia care has been shown to contribute to this process, both positively and negatively. There is much room for improvement before any field can conclude that we have overcome the hurdles in surgical care that challenge the extremes of age, those with significant comorbidities, or those undergoing extensive surgical procedures. Many of the advances in these areas will come from improved perioperative care, built on evidence-based techniques that are confirmed by careful clinical investigation and innovation. One of the priorities for research, as identified by the National Institutes of Health, is for investigators to embark on more multidisciplinary and multicenter research initiatives. It is also crucial to foster translational research where advances in the basic sciences, including genetics, can lead to progress in the clinical arena. A strong commitment to research will be necessary to ensure the continued advance of the specialty and to ensure that anesthesiology remains a mainstream medical discipline that contributes to the overall good of society.

Clearly, the future of the specialty requires a robust commitment to education and training at all levels, from undergraduate medical education through the most advanced subspecialty levels. Strong training programs depend on an excellent teaching faculty, ample and diverse clinical cases, a well-organized teaching program, and an emphasis on the knowledge required for future as well as current practice. Adequate funding for anesthesiology education by the federal government, by teaching hospitals, and by our specialty societies is an imperative if the specialty is to flourish in future decades. The current shortfall in anesthesiologists (particularly in teaching hospitals) creates a temptation to increase training numbers and churn out many more anesthesiologists; this may be particularly true in training programs that need to use residents primarily as the workforce. The danger is that this approach will decrease the selectivity of training programs and downgrade the quality of anesthesiologists. Training must be broadened as well; if the next generation of anesthesiologists is to be prepared for the future, anesthesiology training programs must emphasize preoperative assessment, critical care, pain management, supervision of nonphysician providers, and operating room administration, among others. Also important will be an increased emphasis on fellowship programs, with formal recognition of fellowships in areas such as regional anesthesia, transplant anesthesia, and obstetric anesthesia.

To attract high-caliber applicants to anesthesiology, medical students must continue to receive adequate exposure to the specialty. In addition to perioperative medicine and pain medicine, anesthesiologists are well placed to teach medical students applied respiratory and cardiovascular physiology, several aspects of neuroscience, and numerous aspects of pharmacology, in addition to their more traditional educational roles in resuscitation and emergency airway management. The model of academic anesthesia care facilitates excellent learning, with medical students able to spend high-quality one-on-one time with experienced anesthesiologists.

Simulation

The aerospace industry has long appreciated the value of simulation in increasing safety and decreasing errors. Within the medical profession, anesthesiologists have been among the first to recognize the potential role of simulation in improving both education and patient safety. Anesthesiologists established simulation facilities to train anesthesiologists in the management of infrequent but life-threatening problems that arise in the operating room. It rapidly became apparent that simulation might be useful for teaching other topics that are not unique to anesthesia practice (eg, diagnosis and management of pneumothorax, hemorrhagic shock, myocardial infarction, and insertion of central vascular catheters). Computer modeling can be used in research as well. Speculation is rife about a role for simulation in credentialing and recredentialing in various medical specialties. Increasingly, physician and nursing professionals, including those in critical care and emergency medicine, are seeking time in simulation facilities for purposes of training and honing their skills in crisis management. Simulation centers are mushrooming internationally and are also being embraced by medical schools. Anesthesiologists have led this initiative, and it is important that we continue to lead innovation in this field of evolving technology. Maintenance of certification is increasingly emphasized for specialist medical practice and is particularly valued by the public.28 Simulation offers a practical and potentially objective method to assess anesthesiologists and other practicing clinicians, and to ensure uniform methodological rigor in complementing both initial certification and maintenance of certification programs.29-31

Anesthesiology is one of the largest physician-based specialties, but few mainstream medical specialties are as poorly understood by members of the public and by other health professionals.32 Many patients do not realize that anesthesiologists are doctors or that they have responsibilities outside the operating room.32 In Swiss and Austrian studies, 93% to 99% of patients knew that anesthesiologists are qualified physicians. In addition, many of the patients were aware that the anesthesiologists are engaged in activities outside the operating room. However, many patients also thought that the anesthesiologists played a subservient role to the surgical team.33,34 In studies from Singapore, Pakistan, and the West Indies, only 56% to 66% of patients were aware that anesthesiologists are physicians, and most patients had a limited knowledge of the anesthesiologists' roles.35-37 In contrast to these findings, a Finnish study reported that anesthesiologists were generally recognized as specialist physicians and were held in high esteem.38 In the United Kingdom, the organizations representing anesthesiologists initiated National Anaesthesia Day in an attempt to increase the profile of anesthesiologists. Clearly there is variation among countries in the way anesthesiologists are perceived. Heightening public awareness and improving public perception about anesthesiologists and their many essential functions may be important to the future of the specialty in several respects, including allocation of research funding, quality of applicants to residencies, and the future role of anesthesiologists within health care in general.

A recent Scandinavian study explored perceptions of the anesthesiologist's role. The study was titled "Professional Artist, Good Samaritan, Servant and Co-coordinator: Four Ways of Understanding the Anaesthetist's Work."39 According to these authors, the current scope of anesthesia practice encompasses the following:

1. The provision of safe anesthesia while controlling patients' vital functions.

2. Helping patients including the alleviation of pain and anxiety.

3. Providing service to the whole hospital including support to other doctors and nurses who are caring for severely ill patients.

4. Participation in the organization and direction of the operating suites to ensure that lists run smoothly.

Whereas these are essential and important components of the specialty, even collectively they do not encompass the spectrum of anesthesiology as we view it currently or as we look to the future, which seems particularly attractive if we maintain a comprehensive view of the opportunities for our discipline.

The future of the specialty depends on several key drivers: (1) The vision and actions of organized anesthesiology, (2) technological changes in surgery and anesthesiology, and (3) the directions chosen by academic institutions, the trainers of future practitioners. These drivers will influence the attractiveness of anesthesiology as a specialty choice for medical students, the career paths of young anesthesiologists, and the scope and organization of anesthetic practice.

There will be tough choices faced by future anesthesiologists. New drugs and increasingly sophisticated monitoring will facilitate safer anesthesia. Such technological advances will allow more effective remote supervision of anesthesia providers. There is likely to be a steady growth in the demand for anesthesia. Anesthesiologists will have to decide whether to try to expand their ranks at all costs and to defend their turf or whether to refine their training according to future conditions. It is highly unlikely that anesthesiologists alone will be able to meet all the demands for anesthesia.

Anesthesiology faces many challenges in the years ahead. To meet these challenges, perioperative medicine, which includes the spectrum of care from preoperative assessment to postoperative care, may offer the best chance for the specialty to survive and prosper.40 Although there is a vision that future anesthesiologists will practice as much outside as inside operating rooms,41 the expansion of anesthesiologists' activities could lead to dilution of the specialty's identity, endangering the vitality of anesthesiology in an era of sweeping changes in health care delivery systems.42 An expansion of anesthesiology practice into nonoperative domains of perioperative medicine may also be challenged by other specialties. The role of perioperative physician may fall to hospitalists, the role of critical care physicians to intensivists, and the role of pain management to pain specialists. Anesthesia may grow and acquire new tentacles or it may have its subspecialties amputated, leaving it as a restricted operating room–bound specialty (Fig. 2-1).

As an academic specialty, anesthesiology evolved out of fundamental contributions to health care, including the prevention of pain from surgery and the development of critical care medicine, cardiopulmonary resuscitation, and pain medicine.43 In recent years, many advances have occurred in the basic science of anesthesiology; these include mechanisms of pain, receptor physiology, modes of action of anesthetic agents, and cellular responses to sepsis. If anesthesiology is to flourish as an academic specialty, it is crucial that research is pursued and encouraged. Without intellectual advances, anesthesiology is in danger of becoming a sterile technical discipline.43 University departments of anesthesiology are increasingly experiencing pressure to emphasize clinical delivery at the expense of academic pursuits. If they succumb to these pressures, this will threaten undergraduate perioperative medicine teaching, development of critical appraisal skills among anesthesiologists, and the future of research programs.44 The irony would be that by immersing themselves entirely in the clinical arena, anesthesiologists would neglect the education of medical students and trainees, thus jeopardizing the future of clinical anesthesiology practice.

Although it is easy to teach others as we were taught, or as we practice today, focus on the future is an essential element of education. Long-term success for the specialty will depend on our efforts in undergraduate and graduate medical education, whereas short-term success will depend on our efforts in the continuing medical education of current practitioners.45 A different approach may be required to redefine the scope of the practice with broadened training to provide increased expertise in the evolving medical marketplace. This approach could include solid training in business, informatics, data management, and critical thinking on outcomes. This paradigm shift may be challenging, and it requires redirection, reallocation of assets, reeducation, and a new mindset. If successfully applied, however, it presents a means to strengthen the respected position of the specialty and to promote the medical care and practice of perioperative specialists in the rapidly changing landscape of modern medicine.46

Scenario 1: To Each Patient a Dedicated Anesthesiologist

This is the current model of anesthesia care in much of the developed world, and many in the United States are adherents to this model. Most American residency programs are structured to train anesthesiologists to practice in this model. As discussed earlier in this chapter, it is unlikely that this model of anesthesia care will be sustainable given the mismatch between surgical demand and the anesthesiology workforce and the inevitable pressure to reduce the cost of anesthesia.

Scenario 2: Physicians for the Perioperative Period

Many advocate that anesthesiologists should play a greater role in perioperative care. This is an appealing option but fraught with difficulties. An expansion of anesthesiologists' roles will mean that even more anesthesiologists must be trained. There is simply a limited capacity to achieve this. It is also not clear whether anesthesiologists are prepared to compete financially in many perioperative roles. Anesthesiologists are accustomed to high remuneration for their procedure-driven roles, whereas hospitalists are willing to accept lower compensation. Thus far anesthesiologists have not shown enthusiasm in adopting the mantle of perioperative physicians. Tremendous inertia will have to be overcome for this to become a possibility.

Scenario 3: Process Managers and Perioperative Care Directors

To achieve this, anesthesiologists will require formal training in business, management, and finance. They will also need to broaden their medical knowledge and experience. Perhaps most importantly, anesthesiologists would have to be trained to supervise others effectively and to use physician extenders throughout the perioperative period. Certified registered nurse anesthetists are also expensive, and other physician extender roles should be explored too. This model runs counter to the current training process. There are anesthesia programs that are offering novel fellowships, such as operating room management. The philosophy behind this model is that anesthesiologists would receive broader training, where operating room anesthesia would be only a component. Fellowships and academic tracks would also increase. If this model is to succeed, residencies will have to undergo major paradigm shifts.

Meeting the Challenge of Change

At the ASA's 2005 Rovenstein Lecture, Mark Warner opined that as long as anesthesiologists remain steadfast in their commitment to the specialty's core values, the specialty would continue to develop as a vibrant academic medical specialty.47 Warner identified two quintessential values of anesthesiology47:

1. Commitment to the care of critically ill patients as well as those experiencing acute and chronic pain.

2. Promoting and improving patient safety in the operating room and in the perioperative period.

Change will be driven by several imperatives, including shifting demographics, technological advances, patterns of surgery, and economic realities. There will be an increasing number of elderly people, high-risk obstetric patients, and children with complex medical problems requiring surgery. It is important to further increase the safety of surgical, anesthetic, and perioperative care to minimize both short-term morbidity and long-term deterioration when vulnerable patients undergo surgery and anesthesia.

Improved monitoring, safer drugs, less invasive surgery, and sophisticated communication networks may allow anesthesiologists and other anesthesia providers to extend their roles without compromising patient safety. Intensive care units may serve as a useful model. Typically 1 nurse attends to 1 or 2 critically ill patients. Usually a small number of physicians, with one experienced intensivist, regularly assess all the patients and modify treatment plans over the course of the day. A derivative of this model could be conceptualized for future operating room anesthesia care. As individual patients present with their genetic profiles, it may become possible to tailor anesthetic and analgesic therapy with increased efficacy and decreased side effects. This pharmacogenomics model would represent a major advance in patient safety.

Health care systems are evolving at a rapid rate. Anesthesiology as a specialty must adapt to the changes in order that anesthesiologists remain valuable and essential members of the health care team. Anesthesiologists must extend their physician skills and increasingly pursue subspecialty fellowships. Anesthesiologists should have a meaningful presence in all areas of medicine. Apart from traditional areas of involvement, such as operating room anesthesia, critical care, pain medicine, teaching, research and resuscitation, there will be future opportunities for anesthesiologists in pharmacogenomics, health care systems management, and new technologies.

• Brennan TA, Horwitz RI, Duffy FD, Cassel CK, Goode LD, Lipner RS. The role of physician specialty board certification status in the quality movement. JAMA. 2004;292(9):1038-1043.
• Haynes AB, Weiser TG, Berry WR, et al. A surgical safety checklist to reduce morbidity and mortality in a global population. N Engl J Med. 2009;360(5):491-499.
• Lagasse RS. Anesthesia safety: model or myth? A review of the published literature and analysis of current original data. Anesthesiology. 2002;97(6):1609-1617.
• Larsson J, Holmstrom I, Rosenqvist U. Professional artist, good Samaritan, servant and co-ordinator: four ways of understanding the anaesthetist's work. Acta Anaesthesiol Scand. 2003;47(7):787-793.
• Noordzij PG, Poldermans D, Schouten O, Bax JJ, Schreiner FA, Boersma E. Postoperative mortality in the Netherlands: a population-based analysis of surgery-specific risk in adults. Anesthesiology. 2010;112(5):1105-1115.
• Schwinn DA, Balser JR. Anesthesiology physician scientists in academic medicine: a wake-up call. Anesthesiology. 2006;104(1):170-178.
• Warner MA. Who better than anesthesiologists? The 44th Rovenstine lecture. Anesthesiology. 2006;104(5):1094-1101.