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August 2001
Volume 65 |
Number 8
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| Critical Care
and Private Practice: It’s the Right Thing to Do |
Vincent L. Hoellerich, M.D.
Gerald A. Maccioli, M.D.
Douglas B. Coursin, M.D.
In the 21st century, society has come to recognize the benefits
of intensive care. As Michael J. Murray, M.D., Todd Dorman, M.D.,
and others outline in this issue, our specialty must realize our
legacy and potential in this important arena. Major insurers,
governmental agencies and regulatory organizations are increasingly
demanding that medicine provide comprehensive critical care that
meets positive outcome benchmarks at responsible costs. Anesthesiologists
previously recognized and supported the acute and intensive care
paradigm since the inception of the prototypical “respiratory
care units” established during the 1950s’ polio outbreak.
Historically, anesthesiologists played pivotal roles in the establishment
of state-of-the-art neurologic and cardiopulmonary monitoring,
support and resuscitation. Our specialty was also a driving force
in the development of intensive care unit (ICU) organization,
management and the inauguration of the Society of Critical Care
Medicine (SCCM).
Logistical factors, economic forces and clinical preference,
however, resulted in preoperative assessment, intraoperative management
and pain therapy being the predominant modes of contemporary anesthesia
care. Many physicians are of the opinion that critical care is
not worth the time and effort. We beg to differ! As discussed
elsewhere, the need for quality critical care is now recognized,
and reimbursement is improving. In our practices, the benefits
go beyond the monetary by facilitating patient care, enhancing
our practice profile and allowing us a greater role in institutional
policy and politics. Current and future anesthesiologists must
re-establish their natural role as intensivists and acute care
physicians.
Members of ASA, the American Society of Critical Care Anesthesiologists
(ASCCA) and the anesthesiology section of SCCM have called for
the resurgence of training and participation in the care of the
critically ill by anesthesiologists. Such training requires a
recommitment to the provision of an appropriate comprehensive
critical care experience within residency training. Attempts in
the past to unite training programs and the private sector have
fallen short due to the current focus on operating room management
of patients and the lack of well-established perioperative anesthesia
practices that include hospital-based acute care and critical
care.
Recent articles call for well-rounded anesthesiologists with
experience in critical care, ICU and systems management and the
ability to provide acute hospitalist care.1,
2 Such individuals will be able to provide the level of care
required by the Leapfrog Group and others. In the forthcoming
2nd edition of the ASCCA-sponsored textbook, Critical Care Medicine
– Perioperative Management, we provide an outline of our
growing private critical care practice. 3
A template for integrating critical care practice into a community
hospital anesthesiology group is well-established at the Rex Hospital
in Raleigh, North Carolina. The Rex group has wide-ranging expertise
with a significant number of subspecialty-certified intensivists
and pain medicine physicians to provide expertise and consultation
across a number of diverse practitioners. One of the group’s
members is the chief of critical care, another is the past chief
of the hospital system’s medical executive committee, while
other members direct perioperative and acute pain services. The
Rex group applies state-of-the-art information technology to communicate
among themselves and organize their practice, assign cases, manage
pain and critically ill inpatients and provide acute hospitalist
care. The Rex model allows an anesthesiologist to act as a perioperative
physician and perform numerous important tasks within the group
as a preoperative consultant, intraoperative anesthesia director
and postoperative intensivist and pain manager. The physician
is able to enhance hospital-based acute care by interfacing with
emergency department physicians, intervening on behalf of out-of-hospital
primary care doctors and providing a continuity of care from the
operating room through the ICU stay.
Maintaining preoperative interaction between the patient and
anesthesiologist is necessary to preserve the physician-patient
relationship, facilitate patient education, optimize the use of
appropriate laboratory assessment, identify high-risk patients
and provide timely subspecialty evaluation and preparation. Preoperative
meetings assure quality patient management and may prevent medical
complications. Versatile anesthesiologists can eliminate the need
for some specialist consultation by the implementation of practice
guidelines, enumeration of potential problems and proactive management
of high-risk patients.
Members of the Rex anesthesia group assume primary care responsibilities
in the intraoperative setting by providing or directing anesthetic
and analgesic treatment while simultaneously assessing and managing
the patient perioperatively. In the past, anesthesiologists were
thought to have played their most important roles in the intraoperative
setting, but the evolution of medicine and acute and critical
care management demonstrates the need for anesthesia to move into
a comprehensive and perioperative process. Consistent and efficient
pre- and intraoperative preparation and care aid in the successful
transition to postoperative pain management and critical care.
Community hospitals often differ from academic centers, especially
with regard to critical care management. Academic hospitals frequently
have a number of subspecialty units that focus on specific care
of the neurologic, coronary, surgical or cardiac surgical patients.
Their community hospital counterparts, however, are known for
the amalgamation of these units into a larger, more versatile
medical-surgical ICU. Academic centers also more commonly operate
their units in a closed fashion. The primary physician relinquishes
control of his or her patient after admittance by critical care
doctors. Community hospital ICUs, however, are usually open or
semi-open, with voluntary consulting balanced between the primary
physician and the intensivists. At Rex, the critical care physicians
are anesthesiologists who provide the majority of medical direction
or consultative intensive care at the request of the primary physician
or surgeon. This is facilitated by strong physician communication,
timely availability and in-house service, and stratified levels
of care.
Providing physicians with broader experience in acute and critical
care and greater perioperative responsibility allows them to go
beyond the limits of operating room management and increase their
clinical profile and institutional value. This will allow physicians
to be better suited to participate in hospital programs, development,
resource utilization and management.
Comprehensive perioperative care requires a synthesis of classical
operating room techniques with contemporary concepts of acute
hospitalist and intensivist training. Future anesthesiologists
will receive more extensive training that includes broader clinical
instruction in conjunction with lessons in business, computer
science and more specific scientific topics. Physicians in a critical
care setting must evolve with the concepts surrounding management
of ICU and similar environments. It is essential that we anesthesiologists
work to promote a dialogue between the specialized academic center
and the practicing community physician in order to expand our
role and presence in acute and critical care. The Rex model may
be applied or modified to fit various practice paradigms.
References:
1. Coursin DB, Maccioli GA, Murray MJ. Anesthesiologists
as Perioperative Physicians. Problems in Anesthesia. 2000; 12:40-45.
2. Coursin DB, Maccioli GA, Murray MJ. Critical
Care – how goes the flow? Anesth Clin N A. 2000; 18:527-538.
3. Murray MJ, Critical Care Medicine — Perioperative
Management. 2d. Philadelphia: Lippincott-Raven. 1997.
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Vincent L. Hoellerich,
M.D., is a private practitioner at Critical Health Systems,
Inc., Raleigh Practice Center and Vice-Chair, Department of
Anesthesiology and Critical Care Medicine, Rex Hospital, Raleigh,
North Carolina. |
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Gerald A. Maccioli,
M.D., is a private practitioner at Critical Health Systems,
Inc., Director of Critical Care Medicine, Raleigh Practice
Center, and Medical Director, Medical/Surgical ICU, Rex Hospital,
Raleigh, North Carolina. |
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Douglas B. Coursin,
M.D., is Professor of Anesthesiology and Internal Medicine
and Associate Director of the Trauma and Life Support Center,
University of Wisconsin-Madison, Madison, Wisconsin. |
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