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.
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.
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.
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).
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.