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May 1999
Volume 63 |
Number 5
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| Perioperative
Medicine - To Be or Not To Be? |
Jeffrey H. Silverstein,
M.D.
Perioperative medicine is all the rage, or was that last year?
In this issue, we explore what is developing in perioperative
medicine. Donald S. Prough, M.D., describes
the landscape and advantages of pursuing perioperative medicine.
To follow is my suggestion that the idea of
the perioperative physician is impractical and unlikely to attract
substantial interest from anesthesiologists. Ronald
G. Angus, Jr., M.D., gives a short description of the developing
hospitalists group. I sincerely hope this introduction spurs an
active dialogue and the development of a new friend in the hospital.
Finally, Lee A. Fleischer, M.D.,
presents an interesting discussion of the anesthesiologist as
gatekeeper. Perioperative care remains on the radar!
Jeffrey H. Silverstein, M.D., is Assistant
Professor of Anesthesiology, Surgery, Geriatrics and Adult Development,
Mount Sinai School of Medicine, New York, New York.
PRO: Perioperative Medicine - A Natural
for Anesthesiologists
Donald S. Prough, M.D.
The thesis of this discussion is simple and direct. The practice
of anesthesiology has evolved progressively into one in which
groups of anesthesiologists should practice perioperative medicine,
although each member of a group may not practice all aspects.
Under the rubric of perioperative medicine, I include preoperative
evaluation and preparation, postoperative critical care and pain
management. The development of the concept of perioperative medicine
is inextricably linked to the growth in prestige of anesthesiologists.
As the century draws to a close, anesthesiologists function as
equal colleagues with other physicians; 30 years ago, only a few
anesthesiologists enjoyed that status. In this brief article,
I will touch on a variety of reasons why the continued evolution
of perioperative medicine is important to the continued professional
standing of anesthesiologists and discuss how that importance
should be expressed.
Why should anesthesiologists maintain an interest in perioperative
medicine? I believe there are five compelling reasons: 1) managed
care, 2) breadth of medical knowledge, 3) interspecialty communication,
4) differentiation of anesthesiologists from nonphysician anesthetists,
and 5) quality of perioperative care.
The importance of managed care in the evolution of all medical
practice is impossible to overstate. For the purposes of this
discussion, the most important development is the proliferation
of procedural and financial obstacles that hinders preoperative
consultation by other specialists. Only a few years ago, virtually
any preoperative patient with an intercurrent medical condition
could be referred without penalty or hassle to an appropriate
specialist for additional evaluation. Aggressive precertification
of consultations severely slows that process, and capitated payment
schemes directly or indirectly penalize additional testing and
referrals. If a patient's insurance plan has assigned a primary
care "gatekeeper," no consultation with a specialist may be possible;
the primary care physician may consider his or her own expertise
to be sufficient to advise anesthesiologists regarding preoperative
preparation. The unavoidable conclusion is that anesthesiologists
must effectively manage complicating medical conditions with far
less input from other physicians. Experience strongly suggests
that a well-designed, anesthesiologist-directed preoperative evaluation
clinic can reduce both the number of requests for consultations
and the number of surgical cancellations attributable to inadequate
preoperative preparation.1
The resulting increased responsibility of anesthesiologists
for preoperative preparation is positive for our specialty. Less
reliance on consultations from other physicians maintains and
increases the breadth of our corporate medical knowledge. Better
understanding of chronic diseases improves management throughout
the continuum of perioperative care. In practice, anesthesiologists
who concentrate on preoperative evaluation and preparation or
postoperative care tend to have more current knowledge about treatment
of intercurrent diseases and, as a consequence, serve as a reservoir
of knowledge and experience for colleagues who practice primarily
in the operating room.
The specialty of anesthesiology also benefits from the visibility
of anesthesiologists outside the operating room. I believe that
there is a fundamental difference in the ways that physicians
interact with each other outside the operating room and the interactions
between anesthesiologists and surgeons within the operating room.
Although no data are available to support the hypothesis, I suspect
that a considerable part of the growth of the prestige of anesthesiology
(and perhaps even of its ability to attract high-quality residency
applicants) is directly attributable to increased collegial contact
between other physicians (including surgeons) and anesthesiologists
involved in preoperative clinics, intensive care units (ICUs)
and pain management.
Those interactions are based on a broad range of medical skills.
Consequently, a realistic definition of anesthesiology that includes
the entire scope of perioperative medicine powerfully emphasizes
the irreducible difference between nurse anesthetists and anesthesiologists.
Anesthesiologists are physicians who have a broad understanding
of the diagnosis and management of human disease and who base
their practice of anesthesiology on that foundation.
One final reason for the involvement of physicians in the postoperative
aspects of perioperative medicine is that such involvement improves
the care of patients. The actual form of that involvement may
vary. Ghorra et al.2 reported a
reduction in mortality and in the incidence of acute renal failure
after conversion of the surgical ICU at Rhode Island Hospital
from an open unit to a closed unit in which care was provided
only by a surgical critical care team headed by a board-certified
intensivist (anesthesiologist or surgeon). A closed surgical ICU,
however, raises legitimate questions regarding continuity of care
and education of surgical residents.3
It is reassuring that a rigidly closed unit may be unnecessary.
Pronovost et al.4 found that daily
rounds by an ICU physician were associated with a two-thirds reduction
of mortality in patients recovering from abdominal aortic surgery
and also with reduced resource utilization. Therefore, organization
of surgical intensive care to include daily rounds by intensivists,
many of whom could and should be anesthesiologists, is likely
to be both clinically and economically beneficial.5
How should our specialty demonstrate our commitment to the concept
of perioperative medicine? The appropriate methods include organizational
involvement, educational emphasis and multidisciplinary research.
Organizations of particular interest include ASA, the American
Society of Critical Care Anesthesiologists (ASCCA), the Society
of Neurosurgical Anesthesia and Critical Care (SNACC), the International
Trauma and Critical Care Society (ITACCS) and the Society of Critical
Care Medicine (SCCM). At its annual meeting, ASA historically
has provided refresher courses and scientific sessions that are
directly relevant to surgical critical care. Anesthesiology
publishes original critical care research, and Anesthesia &
Analgesia devotes a specific section of that journal to critical
care. ASCCA provides a forum for exchange of ideas relating to
clinical, scientific and administrative issues confronted by anesthesiologists
who practice critical care. SNACC and ITACCS address critical
care issues that relate to neurosurgical and trauma patients,
respectively. SCCM and its journal, Critical Care Medicine,
represent particularly important opportunities to explore
clinical, scientific and administrative issues from the perspective
of the multiple disciplines that contribute to intensive care.
The educational emphasis within anesthesiology is substantial.
In addition to fellowships in critical care medicine and the subspecialty
examination in critical care medicine conducted by the American
Board of Anesthesiology (ABA), the ABA also requires rotations
in intensive care for all anesthesiology residents. Of considerable
importance is the recent increase in the content of oral ABA examinations
related to perioperative medicine.
Finally, the growth of perioperative medicine is dependent on
continued development of its intellectual foundations. Most of
the important research issues cross multiple medical and basic
science disciplines, and therefore it is essential that anesthesiologists
develop and maintain cross-disciplinary collaborations. Since
many clinical issues also involve multiple specialties, anesthesiologists
should actively participate in the development of practice guidelines
such as those for the evaluation of cardiac patients undergoing
noncardiac surgery.6
Anesthesiology is a much more diverse and challenging field
with the inclusion of the entire range of perioperative medicine.
While the core of anesthesiology remains intraoperative management,
our corporate expertise in preoperative preparation, pain management
and postoperative care is essential to the continued evolution
and growth of our specialty.
References:
- Fischer SP. Development and effectiveness
of an anesthesia preoperative evaluation clinic in a teaching
hospital. Anesthesiology. 1996; 85:196-206.
- Ghorrah S, Reinert SE, Cioffi W, Buczko
G, Simms HH. Analysis of the effect of conversion from open
to closed surgical intensive care unit. Ann Surg. 1999;
229:163-171.
- Trunkey DD. An unacceptable concept. Ann
Surg. 1999; 229:172-173.
- Pronovost PH, Jenckes MW, Dorman T, et
al. Organizational characteristics of intensive care units related
to outcomes of abdominal aortic surgery. JAMA. 1999;
281:1310-1317.
- Randolph AG. Reorganizing the delivery
of intensive care may improve patient outcomes. JAMA.
1999; 281:1330-1331.
- Eagle KA, Brundage BH, Chaitman BR, et
al. Guidelines for perioperative cardiovascular evaluation for
noncardiac surgery. Report of the American College of Cardiology/American
Heart Association Task Force on Practice Guidelines. Committee
on Perioperative Cardiovascular Evaluation for Noncardiac Surgery.
Circulation. 1996; 93:1278-1317.
CON: Perioperative
Physician Is a Different Job Than Being an Anesthesiologist
Jeffrey H. Silverstein, M.D.
Does your business card read "Your Name, M.D., Perioperative
Physician"? Would such a title be a meaningful change from "Anesthesiologist"?
Typically, perioperative is the adjective used to describe an
indefinite period of time beginning before an operation, including
the operation and anesthesia, and extending once again into an
indefinite period of the postoperative recuperation. As an intellectual
construct, perioperative is a useful word. When we start calling
ourselves perioperative physicians, however, we had better be
ready to meet that challenge. I argue that anesthesiologists are
uniquely unprepared and typically have little enthusiasm for becoming
perioperative physicians. This is not to suggest that we cannot
develop this expertise and, to that extent, this argument should
be seen as a challenge.
To whit, a surgeon and a patient decide to undertake surgery.
The patient can be and, in many cases, is directed to a preoperative
clinic and perhaps seen by the anesthesiologist. Preoperative
clinics have become popular in large institutions. The economic
and institutional implications of preoperative clinics in small
private institutions is less described. The patient may undergo
a complete history and physical examination, a few (unneeded?)
laboratory tests and a discussion of anesthetic care. Few clinics,
however, are prepared to adjust diabetic or antihypertensive medications
and have the patient come back in a week or two for a checkup
and determination as to the advisability of proceeding with surgery.
Most clinics would still refer a patient with an uncontrolled
medical condition back to an internist or primary care physician.
If you do attempt to render such care, how long would it continue?
Certainly, there is the opportunity to improve patient readiness
and patient flow through the use of preoperative clinics. But
we are generally not assuming overall care for that patient during
their preoperative preparation. To do that effectively would require
more extensive primary care training than is typically provided
for anesthesiologists.
Within the operating room and the recovery room, anesthesiologists
function with amazing precision. The intensity of care is unrivaled
in any other part of the hospital. Full-time physician coverage
for anesthesia, records in five-minute intervals and complete
monitoring can be found nowhere else. Anesthesia is not safe in
and of itself; it is our presence that makes anesthesia safe.
In the recovery room, highly trained nurses and anesthesiologists
interact to provide a graded level of care, leading to discharge
to the floor or home. The anesthesia care paradigm is diametrically
opposed to the 10- or 15-minute office practice paradigm, a quick
note and an appointment in two weeks.
Some anesthesiologists practice critical care, but most do not.
For the patient who does not require intensive care and returns
to a surgical ward or for the patient who is discharged home following
surgery, a different practice prevails. Postoperative analgesia
is a major advance and is actively practiced by anesthesiologists.
For the most part, however, our involvement ends there and is
documented by the postoperative note. Do we want to be responsible,
even in a supervisory manner, for nasogastric tubes and fluid
balance? Do we want to decide if the patient needs an
X-ray and arrange to have that executed?
Ronald G. Angus, Jr., M.D., describes a burgeoning field of
physicians who specifically focus on hospitalized but not anesthetized
patients. There is a clear challenge to develop a relationship
with the hospitalists in order to coordinate care. This group
of physicians may well interact with postoperative patients. Perhaps
hospitalists should become part of an anesthesiology and perioperative
care department, much as pain management and intensive care physicians
are incorporated today.
Being a perioperative physician is a different job than being
an anesthesiologist. Like pain management and intensive care,
you can get there from here, but you can also get there from other
medical specialties, particularly internal medicine.
Jeffrey H. Silverstein, M.D., is Assistant
Professor of Anesthesiology, Surgery, Geriatrics and Adult Development,
Mount Sinai School of Medicine, New York, New York.
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