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August 1999
Volume 63 |
Number 8
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| Beyond Perioperative
Medicine: The Anesthesiologist as Inpatient Specialist |
Carlos M. Nunez, M.D.
As the face of health care delivery has changed over the past
decade, so has the role of the anesthesiologist within this system.
The concept of the anesthesiologist as a "perioperative physician"
at first represented a defense against the grim forecasts surrounding
the health care reform movement of the early 1990s. Even though
President Clinton's proposed Health Security Act has been dead
for several years now, the practice of perioperative medicine
is alive and well. Furthermore, an anesthesiologist with advanced
training in critical care medicine possesses the knowledge and
skills to take care of patients in a variety of hospital settings.
I am living proof that an anesthesiologist can not only
survive, but also thrive, outside of the operating room. As an
anesthesiologist, I work as an intensivist and hospitalist at
a university-affiliated medical center in North Carolina. Last
year, the hospital administration decided to expand its small
group of hospitalists to include a team of full-time intensivists,
creating a most unique and effective "inpatient service." My primary
responsibility is to provide care to the patients in our new,
state-of-the-art, 20-bed medical-surgical intensive care unit
(MSICU) and to respond to all cardiac arrests/emergencies. As
a part of the hospitalist team, I am also called to see admissions
through the emergency room (E.R.), make consultations on the wards
and perform procedures throughout the hospital.
"The system works so well because its main focus is improving
the quality of patient care. The patients on the wards benefit
from a team of physicians whose only duty is to them during their
hospital stay. Without offices and clinics to tend to, inpatient
specialists have decreased the average length of stay and have
enabled physicians in the community to focus on their outpatient
practices."
The system works so well because its main focus is improving
the quality of patient care. The patients on the wards benefit
from a team of physicians whose only duty is to them during their
hospital stay. Without offices and clinics to tend to, inpatient
specialists have decreased the average length of stay and have
enabled physicians in the community to focus on their outpatient
practices. All hospitalized patients benefit from the 24-hour
presence of full-time intensivists, who not only attend to those
in the MSICU, but to any patient in the hospital who becomes unstable
or needs immediate medical attention. The improvements in patient
care realized by this system have translated into increased patient
satisfaction, increased referring physician satisfaction and increased
revenues for the hospital.
The two halves of the inpatient service (hospitalists
and intensivists) function independently for most of the day,
collaborating only when patients need to move into or out of the
MSICU. In fact, most of the time, I function as a traditional
intensivist. It is an excellent arrangement, which allows the
day-shift intensivist to make rounds on all of the ICU patients,
participate in resident education and take care of most of the
procedures and billing concerns. At 7 p.m., we have our shift
change and the night-shift intensivist takes over for his or her
12-hour stint. At this time, the hospitalist service is still
available and remains so until 10 p.m. This allows for three hours
during which the night-shift intensivist can complete any procedures
left over from the day, re-evaluate any patients that may be unstable
and tie up any other loose ends in the ICU. Then, at 10 p.m.,
the night-shift intensivist also becomes the hospitalist as well.
From 10 p.m. until 6 a.m., the in-house intensivist is
the "go to guy" in the hospital. Our primary responsibility continues
to be the ICU patients, but we are available to evaluate and manage
patients throughout the hospital, a job that would normally be
taken care of by the hospitalist team. We accept telephone calls
from the wards to help with routine management dilemmas ("Doctor,
Mrs. Jones is written for a regular diet, but forgot her teeth
at home..."), we verify that routine admissions through the E.R.
are "tucked in" properly (with the help of the E.R. attendings),
and we complete a full evaluation (history, physical and admission
orders) for any patient who is admitted with serious or complicated
problems.
Some nights can get busy, but we are free to use our judgment
and prioritize as we see fit. This system has now been in place
for one full year and has earned nothing but praise from the hospital
administration, medical staff and nursing staff.
At first, some of the medical staff had reservations when
trying to accept this expanded role for an anesthesiologist, so
I was not initially included in the hospitalist rotation. As those
staff members in question began to work with me in the role of
intensivist, their concerns quickly dissipated. If I can take
care of their patients in septic shock or with respiratory failure,
then I could also handle an exacerbation of pyelonephritis or
a chronic obstructive pulmonary disease. I have also found that
my colleagues appreciate my unique perspectives, based on my core
training in anesthesiology.
This small, ideological victory helped me to value my
critical care training more than ever. I also realized that this
example might help to inspire other anesthesiologists to consider
critical care training as a gateway to a variety of practice models.
Anesthesiologists can work outside of the operating room
and now extend beyond the pain clinic and the intensive care unit.
As more hospital administrators begin to realize the value of
full-time intensivists and dedicated inpatient specialists, more
opportunities like mine should become available. As long as anesthesiologists
continue to pursue advanced training in critical care, we can
take advantage of these new and exciting ways to practice medicine.
Carlos M.Nunez, M.D., is a Staff Intensivist
and Assistant Coordinator - Duke University Educational Affiliation,
Northeast Medical Center, Concord, North Carolina.
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