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September 1999
Volume 63 |
Number 9
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LETTERS TO THE EDITOR
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| Is Perioperative
Medicine Our Future? It Depends ... |
Roger W. Litwiller,
M.D., Chair
I read the debate [about "Perioperative
Medicine for Anesthesiologists"] between Donald S. Prough,
M.D., and Jeffrey H. Silverstein, M.D., (ASA NEWSLETTER,
May 1999) with great interest. I would like to share with you
some thoughts concerning the essence of the controversy. Forces
external to us -- economic, political and social -- are transforming
the world of medicine, compelling us to be proactive. The future
of our specialty is critically dependent upon our ability to grow
and evolve, and perioperative medicine provides the ideal avenue
for the advancement of anesthesiology. Because of what we already
do, we are uniquely suited to excel in this field. As we mature
as perioperative physicians, we will ensure the future of our
specialty and afford ourselves greater roles as stewards of the
resources needed to provide our patients with the highest quality
of care throughout the perioperative period.
We should not miss this opportunity. Historically, we
started cardiopulmonary resuscitation and critical care, and to
a great extent, we lost these areas to other specialties. The
reasons for these losses were multiple and included lack of financial
incentives. At that time, some of us sacrificed the future
for the well-being (as it was perceived) of the present. Many
could not do it for local political reasons, but some leaders,
however, understood the need for the specialty to develop an intellectual
base and maintain our presence in those areas. In many institutions,
critical care is provided by or with anesthesiologists. In many
places however, this is not the case.
I'm afraid that similar things will occur with the concept
of perioperative medicine. In some centers, perioperative medicine
will develop, and the anesthesiologists will be responsible for
and will effectively manage the preoperative, intraoperative and
all aspects of postoperative period of our patients. On the other
hand, many departments would not be willing or able to develop
and provide the full spectrum of perioperative medicine in their
institutions. I would argue that anesthesiologists would play
a more important role and would be more respected in the institutions
where perioperative medicine will be developed, compared to the
institutions where it would not occur.
I believe that much of the concern about our endeavor
into perioperative medicine stems from the notion that many will
be required to work in areas that we do not enjoy. Dr. Silverstein
emphasized this point. In my mind, this will not be the case.
Due to the discoveries and innovations that will inevitably occur
in anesthesiology, perioperative and pain medicine will increase
the range of opportunities for us. Because our knowledge base
will grow dramatically and become increasingly complex, it will
be undesirable -- even impossible -- for perioperative physicians
to work in all of the department's clinical arenas. Moreover,
I envision departments of perioperative medicine successfully
recruiting many highly-qualified physicians who, in the past,
would not have considered our specialty appealing. Perioperative
medicine will be recognized as a discipline that affords clinicians
a spectrum of rewarding professional career choices, well-suited
to a multitude of interests, abilities and natures.
It is my dream to be able to tell medical students contemplating
their career options:
"Choose anesthesiology and perioperative medicine as your
specialty. As you progress through your residency training, you
will figure out who you are and what you really enjoy doing. You
will see that our specialty offers an abundance of professional
opportunities that are well-suited to a diverse range of clinical
and academic interests and personality types. For example, if
intense and complex operative cases interest you, consider specializing
in cardiac or thoracic anesthesia. Alternatively, you might pursue
ambulatory anesthesia if you enjoy high-volume, brief and rapid-paced
clinical cases. Chronic pain management might be a good choice
if you prefer to have ongoing relationships with patients. Critical
care medicine offers other types of opportunities. If being a
medical consultant and managing resources appeals to you, you
might strive to become the director of a pre-admitting center,
an intensive care unit or a hospital's operating rooms. The possibilities
are vast."
Dr. Silverstein says: "When we start calling ourselves
perioperative physicians, we better be ready to meet that challenge."
But we cannot be ready unless we start doing this. The complete
transformation from a department of anesthesiologists to a department
of perioperative physicians will take time, possibly even a generation
of physicians; it will also take special efforts -- the work of
pioneers is never easy, is always frustrating and exciting. Our
educational programs will have to be expanded in order to achieve
this goal. Ultimately, the expansive and diverse knowledge base
of a faculty of perioperative physicians will foster a
deeper understanding of the clinical challenges that confront
us.
The anesthesiologists of the future, whether choosing
to work exclusively in operating rooms or in other settings, will
think and perform as consummate medical practitioners caring for
perioperative patients regardless of whether such perioperative
physicians will work in an academic medical center or in a community
hospital. The future depends on us.
Simon Gelman, M.D., Ph.D.
Boston, Massachusetts
Trauma Anesthesiologist as Perioperative Physician
I found your discussion of the perioperative physician
in the May 1999 ASA NEWSLETTER
most interesting and relevant. As a former trauma anesthesia fellow
(1997-98) at the R. Adams Cowley Shock Trauma Center in Baltimore,
Maryland, I have seen no better example of the anesthesiologist
as the true "perioperative physician" than here. At the Shock
Trauma Center, anesthesiologists are involved in the training
of pre-hospital personnel in the management of airways in the
field as well as providing anesthesia for situations such as difficult
extrications or amputations in the field. Anesthesiologists also
assist in helicopter transports of critically ill patients from
outlying medical centers. Upon arrival to the Shock Trauma Center,
anesthesiologists are present for every admission and resuscitation,
and they assume the care of the operative patient from the admitting
area to the O.R., postoperative care unit and intensive care unit,
and often to the ward with pain management services. Due to our
unique skills and areas of expertise, I believe that trauma anesthesia
is one subspecialty where anesthesiologists have much to offer
the "perioperative patient."
Brent Lee, M.D.
Boston, Massachusetts
Make Your Voices Heard
It is time for the anesthesiologists in all medical facilities
to make their voices heard against the traditional and ancient
view of the department of anesthesiology as "an ancillary service."
Times have changed and we must change with the times. We should
all insist that the department of anesthesiology be recognized
as a clinical department, just as surgery, ob-gyn, pediatrics
and medicine are.
Years ago, the term "ancillary service" was changed in some hospitals
to "associated service," but even this is not be acceptable at
the present time when the anesthesiologist should be considered
a perioperative physician.
I have no doubt that if we all insist and give the appropriate
reasons and behave like all other physicians, anesthesiology will
be, in the near future, considered a clinical department in every
hospital in the United States.
Miguel Colón-Morales, M.D.
San Juan, Puerto Rico
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