In the last decade, American health care has witnessed the rise of two distinct but equally important phenomena. First we have seen a dramatic increase in “generalism” with an emphasis on primary care. Second, we have witnessed the sweeping reorganization of the inpatient care model into a more time- and cost-efficient, hospital-based care system. Unique among hospital-based physicians are anesthesiologists, experienced at providing direct patient care in both the inpatient and outpatient setting. In the operating room (O.R.), we attend to patients for a discreet period of time; in the intensive care unit, we care for patients over the course of their critical illness. Of course in the pain clinic, we see outpatients with chronic problems, often for multiple visits. Currently anesthesiologists have a wide and ever-expanding range of perioperative patient responsibility. As hospital-based physicians, what role will the anesthesiologist play in this new era of medicine? Will our practice be limited to that of intraoperative providers of anesthesia services, or will we assume more diverse responsibilities and lead the evolution of hospital-based programs as medicine strives for efficient, cost-effective delivery of medical, surgical and perioperative care? Hospitalists Traditionally internists or family practitioners follow their patients in both the outpatient and inpatient settings. Notably over the last decade, increasing demands on time dictated by managed care and then subsequently by the increasing complexity of inpatient medicine have led to the establishment of a new cadre of full-time, hospital-based physicians focused primarily upon the care of inpatients. In 1996, Goldman and Wachter first dubbed this new breed of hospital-based specialists “hospitalists.”1 These physicians often are internists who dedicate the majority of their clinical effort to the care of inpatients. Outpatient responsibilities, if they exist, are negligible. The defining characteristic of the hospitalist is the “hand-off” cycle. This arrangement allows the general internist to provide uninterrupted outpatient care, “handing off” care of hospitalized patients to the hospitalist. The hospitalist would provide inpatient care and then facilitate a seamless transition back to the outpatient setting upon discharge.2,3 Perioperative Physicians The complexity of current inpatient care, with increasing acuity of illness in hospitalized patients, suggests that basic competency in critical care medicine should be an important component of hospitalist training. Supporters of hospital-based medicine debate whether those charged with providing inpatient acute care should be trained classically as internist/intensivists or undergo new and distinct training as “hospitalists.”4 Ironically, anesthesiologists have recently been discussing an almost analogous situation with regard to inpatient care of complex surgical patients, with renewed emphasis upon perioperative medicine.5 It is interesting that the similarities between these two novel ideas, developed in parallel, seem to have been missed by those urging their respective specialties toward increased involvement in hospital-based care. This being the case, should we then be asking whether these two roles could be effectively combined? Training Perioperative Physicians as Hospitalists2 Recognizing the breadth of training and scope of practice required by hospital-based specialists, a comprehensive training program, including components of internal medicine and anesthesiology, would seem to be ideal. General internists believe they are capable of caring for most medically relevant issues in all patients. However, their training is lacking with respect to the perioperative management of complex surgical patients. It is the rare internist who appreciates the subtleties of preoperative testing, intraoperative management, acute postoperative care and pain management. “Anesthesiologists have always possessed the knowledge and skills necessary to function as perioperative physicians. Many work in this capacity already, their expertise recognized by their surgical colleagues.” Anesthesiologists, on the other hand, address these issues on an almost daily basis but lack comprehensive training in the finer points of inpatient care outside the operating room and intensive care unit. Hence, training for physicians interested in pursuing hospital-based care as well as perioperative medicine should sample from both disciplines. Training in anesthesia would fill the internist/hospitalist’s void in surgical critical care (unique from medical critical care) and acute and chronic pain management as well as expand their experience with surgical patients, invasive procedures and perioperative physiology. Training in internal medicine would create an anesthesiologist skilled not only as a hospitalist for medical inpatients but also as the ideal perioperative consultant to surgical colleagues currently forced to rely on multiple medical consultants, often poorly coordinated, for management of acute nonsurgical issues during the perioperative period. One would expect that the overuse and possible abuse of the preoperative and postoperative medical consultant could be obviated by obtaining a perioperative medical consult from an internist/anesthesiologist capable of performing a dual role, consequently coordinating a complete and efficient care plan for a patient’s entire hospital stay. Melding components of internal medicine, anesthesiology, critical care medicine and pain management would create a superb inpatient specialist. Because of this unique training, such physicians would be identified by medical and surgical colleagues, as well as hospital administrators, as the individual best suited to act as an inpatient “gatekeeper.” Anesthesiologists have always possessed the knowledge and skills necessary to function as perioperative physicians. Many work in this capacity already, their expertise recognized by their surgical colleagues. Some anesthesiologists have even completed subspecialty training in pain management or critical care medicine and spend a large percentage of their clinical time outside the O.R. Those currently interested in pursuing hospital-based medicine, however, currently lack an organized subspecialty training program. Until a specific fellowship or subspecialty truly emerges, the ideal method of training individuals with an interest in anesthesiology and perioperative medicine is to use the existing infrastructure and incorporate additional training in internal medicine into the anesthesia continuum, potentially as CA-3 rotations or as a subsequent fellowship year. Just as a special qualification in critical care or pain management now requires an extra year of training, so too might training in perioperative medicine (anesthesia/internal medicine) require a similar commitment. Individuals trained in this fashion will serve to expand the clinical realm of both current and future practitioners as graduates participate in the emergence of anesthesiologists as perioperative physicians and hospitalists across the country. Physicians trained in this manner will be capable, both directly and indirectly through education of future trainees, of expanding the role of anesthesiologists outside the operating room. By taking the lead in clinical research and outcome study design, they will be true hospitalists charting a new course for both medical and surgical inpatients and in academics. It is still possible for anesthesiologists to become leaders in this new, exciting and growing field by formalizing resident training in hospital-based, adult inpatient and perioperative medicine. This is where the future of anesthesiology may, or even should, lie and where our expertise can and will be recognized by our colleagues beyond our current participation in the operative portion of the surgical patient’s hospital experience. Until now, internal medicine has taken the lead in defining the specialty of hospital-based medicine. However, we are in the unique position of possessing a body of knowledge necessary to care for the surgical patient over the perioperative period. It is this knowledge that our surgical colleagues recognize in the O.R. but may not extrapolate fully to the entire perioperative period without additional specialized training and/or fellowship certification. We must remember that it is difficult to regain a presence once it is relinquished. While we as anesthesiologists may view ourselves as capable of managing patients throughout the perioperative period, we will be unable in many instances to convince third-party payers, surgeons and hospital administrators to reimburse us for time and effort unless our skill/training is quantified in some objective fashion. In the coming years, the specialty of hospital-based medicine will evolve as market forces dictate. If we do not actively participate in its evolution, we will be left out as other aggressive specialties strive to extend their spheres of influence. The hospitalist movement is changing the way that physicians care for inpatients. This movement is still in its seminal stages, and the definition of a hospitalist is still in flux. Anesthesiologists have the opportunity to establish themselves as the ultimate inpatient specialist, well versed in inpatient medicine and care of the sickest patients. We have gained the trust of our surgical colleagues, we understand the changes that occur throughout the perioperative period, and we are the only physicians who can care for surgical patients throughout their entire perioperative course. Innovative programs are being developed to train anesthesiologists as hospitalists. Our specialty should seize this opportunity and establish anesthesiologists as the ultimate inpatient specialists. References: 1. Wachter RM, Goldman L. The emerging role of “hospitalists” in the American health care system. N Engl J Med. 1996; 335:514-517. 2. Gropper MA, Lisco SJ. The hospitalist movement: Is there a place for anesthesiologists? Anes Clin N America. 1999; 17:445-452. 3. Shea JA, Wasfi YS, Kovath KJ, et al. The presence of hospitalists in medical education. Acad Med. 2000; 75:S34-S39. 4. Kelley MA. The hospitalist: A new medical specialty? Ann Intern Med. 1999; 130:373-375. 5. Alpert CC, Conroy JM, Roy RC. Anesthesia and perioperative medicine: A department of anesthesiology changes its name. Anesthesiology. 1996; 84:712-715.       Steven J. Lisco, M.D., is Co-Director, Surgical Intensive Care Unit and Burn Trauma Intensive Care Unit, Brigham and Women’s Hospital, Boston, Massachusetts.

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Perioperative Medicine

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