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May 1996
Volume 60 |
Number 5
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RESIDENTS'' REVIEW
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| Our Emerging Role
as Perioperative Physician |
I imagine that my thoughts in the second half of this CA-2 year
are quite different from those of my mentors during their residencies.
The changes in our specialty have been overwhelming at times.
I do not believe that uncertainty and the lack of a clear future
were "hot topics" in the resident lounge five, 10 or
20 years ago. I do not believe either that opportunities for the
advancement of our specialty were as readily afforded to our predecessors
as they are to us at this moment in time.
How do we, as residents about to enter into our careers, prepare
and educate ourselves to effectively direct ourselves and the
course of anesthesiology into the 21st century? A helpful concept
introduced by Nicholas M. Greene, M.D., in 1993 is that of the
evolution of our specialty from "anesthesiology" to
"metesthesiology;" that is, the practice of medicine
concerned with sensation but "transcending a focus on intraoperative
pain to include a collection of separate though related interests,
skills and obligations."1 Dr. Greene encourages us to emphasize
to patients, colleagues and policymakers that members of our specialty
have been and will continue to be capable of attending to far
more than merely the intraoperative and immediate postoperative
needs of our patients.
Exactly where do our opportunities lie? Certainly, the intraoperative
care of patients will be and should be a major focus for many
of us. We can continue to be leaders in the areas of pharmacology,
physiology and monitoring. Hodgins et al. discuss the concepts
of "collaboration, completeness and competence" when
referring to the anesthesiologist's role as cardiac diagnostician
with respect to perioperative transesophageal echocardiography
(TEE).2 As TEE becomes more widely utilized, we must embrace any
opportunity to become proficient in this valuable skill.
When examining our role as managers of acute pain, we can look
to the "Practice Guidelines for Acute Pain Management in
the Perioperative Setting," adopted by the ASA House of Delegates
in October 1994, as an example of the advancement of the specialty
through the development of data-driven recommendations.3 In order
to maintain these standards of excellence, we must acquaint ourselves
with all modalities of pain relief including epidurals, patient-controlled
analgesia, PCEA and various regional techniques. Patients with
chronic pain such as cancer and cancer treatment pain, pancreatitis,
postherpetic neuralgia and myriad other conditions will continue
to benefit from our expertise with varied anesthetic and analgesic
techniques. We must be committed to educating ourselves in these
disease processes if we desire to continue to make advancements
in effective treatments.
Recently, I was involved in the evaluation of a patient with multiple
sclerosis and lower extremity spasticity for the use of an intrathecal
lioresal pump. Our experience with this treatment modality at
Virginia Mason Hospital comprises only a handful of patients;
the development of the pump has been fairly recent. Rather than
accepting the role of mere technicians in the process, however,
the anesthesiology team has become intimately involved in the
entire process - from evaluation of "test doses" by
means of the Ashworth and spasticity scales to the physical implantation
of the pump. This role is a satisfying one for patient and physician
alike.
An editorial in Anesthesiology in August 1993 by Peter L. McDermott,
M.D., then President of ASA, calls attention to the unfortunate
fact that many opportunities that have presented to the field
of anesthesiology in the past have, in effect, been lost.4 He
cites the specialties of pulmonary and critical care medicine
as examples of disciplines that grew out of the practice of anesthesia
but are now expanding mainly from the ranks of internal medicine.
Dr. Greene concurs,1 demonstrating that in 1979, 44 percent of
the members of the Society of Critical Care Medicine (SCCM) were
anesthesiologists. In 1988, anesthesiologists constituted only
24 percent of SCCM's membership. Dr. McDermott warns us that although
the area of pain management seems a natural extension of the anesthesiologist's
expertise, there are many surgeons, neurologists and midlevel
practitioners willing to fill the potential void should we "drop
the ball" and cease to provide leadership in this field.
We must embrace the changes that are occurring around us. In doing
so, we must be prepared to be proactive and not reactive; we must
educate ourselves and look forward for new opportunities to advance
ourselves and our specialty. We must be collaborators and leaders
simultaneously, helping to guide the course of anesthesiology
as it approaches the next bend in the road.
References:
1. Greene NM. The 31st Rovenstine Lecture: The changing horizons
in anesthesiology. Anesthesiology. 1993; 79:164-170.
2. Hodgins L, Kisslo JA, Mark JB. Perioperative transesophageal
echocardiography: The anesthesiologist as cardiac diagnostician.
Anesth Analg. 1995; 80:4-6.
3. American Society of Anesthesiologists Task Force on Pain Management,
Acute Pain Section. Practice guidelines for acute pain management
in the perioperative setting. Anesthesiology. 1995; 82:1071-1081.
4. McDermott PL. Tomorrow. Anesthesiology. 1993; 79:209-210.
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