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May 1996
Volume 60 |
Number 5
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PRESIDENT'S PAGE
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| What's in a Name? |
Perioperative Medicine Anesthesia Anesthesiology Anesthesia and
Critical Care Anesthesiology and Pain Management Anesthesia and
Perioperative Medicine Perioperative Medicine and Pain Management
Originally, medical school departments of pharmacology were called
departments of pharmacology and toxicology. As the discipline
of pharmacology evolved, toxicology was dropped from their titles.
Facetiously some years ago, I recommended that departments of
anesthesia should be renamed departments of anesthesiology
and toxicology since what we do in the operating room is deliver
carefully titrated sublethal doses of toxins; remember, both overdoses
of curare (if ventilation is not controlled) and inhalation agents
can be lethal. Perhaps this fact explains why a learned British
high-court judge once said, "It is a fact that to anesthetize
a human being, to deprive him of consciousness outright, is to
take a considerable step along the road to killing him."1
The Name Change
Anesthesia is classically defined as "rendering a patient
insensible to the manipulations of a surgeon." (A more complete
six-point definition can be found on page 406 of the 1996 ASA
Directory of Members in Section I of the "Guidelines for
Patient Care in Anesthesiology.") Just as pharmacology evolved
beyond the study of toxins, anesthesiology has evolved beyond
that narrow classical definition.
In 1994, then ASA President Wilson C. Wilhite, Jr., M.D., stated,
"Anesthesiologists no longer administer anesthesia; we deliver
sophisticated, complex and intensive care in the operating room
and perioperative periods." (Parenthetically, I have always
wondered if there was a difference between departments of anesthesiology
and anesthesia. The suffix "-ology" means "study
of." Does that imply that members of the former departments
are students, and of the latter, doers?)
Several departments are now called departments of anesthesiology
and critical care. Even that name change may be too narrow.
In recent years, at least two academic departments, at the Medical
University of South Carolina (MUSC) and University of Missouri
at Columbia (UMC), have been renamed departments of anesthesia
(MUSC)/anesthesiology (UMC) and perioperative medicine.
Additionally, the department in the University of Texas Southwestern
Medical Center, Dallas, Texas, is now called the department
of anesthesiology and pain management. In the 1994 Rovenstine
Memorial Lecture, Lawrence J. Saidman, M.D., proposed perioperative
medicine and pain management as a more complete and an unambiguous
description of whom we are and what we do.2
The name change at MUSC included changing from the department
of anesthesiology to anesthesia since the latter
refers to everyone who administers anesthesia, including nurses,
physician assistants and physicians who have not received training
in and do not specialize in anesthesia. In contrast, an anesthesiologist
is a physician trained in and specializing in anesthesia. Alpert
et al. agree with Dr. Saidman that pain and perioperative medicine
is a more ideal name; however, they were not prepared to eliminate
anesthesia because of tradition and the fact that anesthesia is
the hub from which the spokes lead to perioperative medicine,
pain management and critical care.3
A name change without a change in mission and responsibility is
merely window-dressing. The addition of critical care to the department
name in the mid-1960s (first at the University of Pittsburgh)
reflected the advent of intensive care units, which in many (most?)
hospitals evolved through an extension of intensive operating
room monitoring into the postanesthesia care unit. The addition
of perioperative medicine reflected further involvement of anesthesiologists
outside the operating room, from pre- through postoperative care,
especially the management of pain.
The Mission Change
Indeed, the ability for patients to undergo major surgical procedures
and leave the hospital experiencing only minimal discomfort and
no severe pain is often cited by patients on postdischarge satisfaction
surveys as our most important contribution. We know the ability
to keep patients alive during the surgical procedure - to experience
that pain-free postoperative period - counts for something. However,
like electricity, our success results in this ability too often
being taken for granted.4
The change in mission implicit in the name change presents an
opportunity for anesthesiologists at a time when health care delivery
and finance are changing radically. That this radical change will
continue to occur is certain, and our specialty can either 1)
obstruct, 2) stand clear or 3) participate.5 The first option
is futile, and the second defeatist, leaving the third the only
viable option.
If managed care does decrease surgical volume, does that mean
more unemployed anesthesiologists? Anesthesiology may be in a
circumstance similar to that of radiology in 1975. In 20 years,
radiology has gone from 90 percent plain film reviewing to 90
percent magnetic resonance imaging, ultrasound, computerized tomography
scan and interventional studies. Radiology has expanded the size
of its pie. More radiology is done by more radiologists to generate
more good for society.5
One way anesthesiologists can respond to the radical change in
health care delivery and finance is by expanding our horizons
and securing a bigger piece of a bigger pie. Longnecker recently
advocated increasing our commitment to "perioperative preparation
of surgical patients (not simply preanesthetic evaluations), postoperative
care of surgical patients, operating room administration and management,
acute and chronic pain management and critical care medicine."6
Perioperative Medicine and Pain Management
While market forces, including managed care, will determine the
directions that health care delivery and finance take into the
21st century, these forces can be channeled potentially. I remain
convinced that quality of care will be a determinant despite the
repeated contention that only cost counts in managed care. For
example, I do not believe American patients will accept long delays
in necessary surgery.
Yes, we must remain firm in our commitment to the concepts that
anesthesiology is the practice of medicine and quality counts
as much as cost-containment. We must also recognize that this
is a time when we can change with the times, get out of the way
or be run over. I advocate that we change by embracing perioperative
medicine and pain management and all that the name implies as
our mission. In this way, anesthesiology will continue to flourish
despite radical changes in health care finance and delivery.
References:
1. Vacanti CJ, Van Houten RJ, Hill RC. Statistical analysis of
the relationship of physical status to postoperative mortality
in 68,388 cases. Anesth Analg. 1970; 49:564-566.
2. Saidman LJ. What I have learned from 9 years and 9,000 papers.
Anesthesiology. 1995; 83:191-197.
3. Alpert CC, Conroy JM, Roy CA. Anesthesia and perioperative
medicine. A department of anesthesiology changes its name. Anesthesiology.
1996; 84:712-715.
4. Ellison N. Practice management conferences, HMOs and managed
care: What ASA has done for you lately. ASA NEWSLETTER.
1996; 60(3):2-4.
5. Erickson JP, Roizen MF. Perioperative medicine. ASA Annual
Meeting Scientific Exhibit Program. American Society of Anesthesiologists;
1995:No. 27.
6. Longnecker DE. Planning the future of anesthesiology. Anesthesiology.
1996; 84:495-497.
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