Given the opportunity to expound on the reasons that anesthesiologists are ideally suited to practice critical care, I find myself in an enviable position. I say this for several reasons. The first is that I did not come to my current career position by the most direct route. In fact, I trained initially in internal medicine, followed by an internal medicine-based critical care fellowship and only thereafter entered a residency in anesthesiology. Despite my officially becoming a board-certified intensivist during the first year of my anesthesiology residency, I know now that I was not truly a qualified intensivist until the completion of that residency. While this is a potentially controversial point of view, I will undertake to defend it in the following pages and, at the same time, attempt to outline the reasons why I believe that the training and practice of anesthesiology are optimal for practicing critical care. Further, I will argue that the moment is now ripe as never before for anesthesiology residents to consider careers in critical care medicine. Let me first digress briefly into the history of critical care medicine, whose roots run but some 40 years deep. The initial development of intensive care units occurred in the early 1960s as an extension of the concept of postsurgical recovery units. Not surprisingly, anesthesiologists, with their knowledge of early mechanical ventilation technology, were instrumental in the care delivered in these early intensive care units (ICUs). Over the subsequent decades, however, economic and lifestyle considerations drove anesthesiologists to focus their activities primarily on the operating room (O.R.) environment. The resultant ICU vacuum was repleted primarily by pulmonary medicine specialists with backgrounds in internal medicine. This trend has persisted to the present day, which finds anesthesiologists making up only 12 percent of the 7,800 members of the Society of Critical Care Medicine, with no sign that this percentage is on the rise. While this might appear to portend a bleak outlook for critical care anesthesiologists, I fully believe that we are at a proverbial crossroads and that the moment has arrived for anesthesiologists to begin to populate and direct critical care units nationally, particularly surgical ICUs. Let me begin by enumerating the reasons that I believe support my contention that anesthesiologists are ideally suited for the current challenges of critical care medicine. As hackneyed as it may be, I cannot resist the compulsion to describe those reasons in terms of the “ABCs.” While we all recognize the sequence as representing “Airway, Breathing and Circulation,” I will take a few minor liberties with this paradigm and expand it down the alphabet slightly to make my point. “A,” not surprisingly, still stands for “Airway,” without the security of which patient survival may be seriously jeopardized. There is no residency that provides better and broader training in airway management than anesthesiology. No amount of expertise in critical care physiology and therapeutics can substitute for the ability to confidently and expeditiously control the airway of patients with acute hemodynamic or respiratory compromise. Intensivists without advanced airway management skills poorly serve their patients in these situations. Failure to successfully control the airway promptly in such scenarios can have grave implications for patients in terms of both morbidity and mortality. I only came to recognize the extent of this deficit in my own intensivist skills once I was immersed in the daily airway management activities that characterize the anesthesiology residency. “B” still refers to “Breathing,” though I refer here specifically to the broad experience anesthesiology residents obtain in the realm of mechanical ventilation. While trainees in other specialties learn about mechanical ventilation during several mandatory months in the ICU, anesthesiology residents employ mechanical ventilation during much of their time outside the ICU, caring for the full gamut of patients, from those with normal lungs to those with profound pulmonary impairment. By the end of a three-year residency, the anesthesiology trainee has not only had a minimum of two months in a critical care setting but has employed mechanical ventilation in the O.R. on another several hundred patients. This familiarity with the process and pitfalls of mechanical ventilation cannot be achieved in any other residency and provides an ideal foundation for learning ventilatory care of the critically ill patient. “C” refers, again as is traditional, to “Circulation,” but here I am referring to the facility in the use of vasoactive drugs that is developed in the course of three years’ training in anesthesiology. I use the word “facility” not only to imply that anesthesiologists are knowledgeable about the indications for and effects of vasoactive agents but also that they are singularly trained to use these pharmacologic interventions in a reactive and expeditious manner. One of the more remarkable changes in my own practice as I trained in anesthesiology was the comfort I developed in rapidly and aggressively responding to changes in patients’ physiology in the operative setting. This became an invaluable asset in caring for unstable patients in the ICU as well. No other training focuses on the art of resuscitation as clearly as anesthesiology, and nowhere outside the O.R. is this training more valuable and germane than in the ICU. Continuing in the alphabet, I assign “D” to represent “Drugs.” Anesthesiologists are essentially applied clinical pharmacologists. Our operative practice consists of employing pharmacologic principles to maintain desirable physiologic conditions in the O.R. No other training program fosters knowledge of such concepts as pharmacodynamics, pharmacokinetics and drug interactions so rigorously and regularly as an anesthesiology residency. These are concepts that are applied constantly in the ICU, again making trained anesthesiologists uniquely suited to treating the problems of ICU patients. Finally in my alphabetic construct, “E” stands for two related entities: “Environment” and “Economics.” By “Environment,” I refer to the current health care milieu, and with “Economics,” I am alluding to the manner in which that milieu favors the pursuit of a career in critical care as at no previous time. The overall trend of inpatient care over the last 20 years has been toward keeping only the sickest patients in the hospital. The conjectural description of the hospital of the future as consisting of only emergency room, O.R. and ICU is probably an exaggerated vision, but it is far closer to reality than even a decade ago. The ratio of ICU beds to total hospital beds has been slowly rising, creating a burgeoning demand for qualified intensivists. In addition, the Leapfrog Group initiative, propagated by a consortium of the country’s largest corporations to establish priorities in the characteristics of hospitals at which their employees should be treated, identified the participation of intensivists in the care of ICU patients as one of the three most important features. This mandate, compounded by the inexorable aging of the patient population and the increasing willingness to subject older patients to aggressive and invasive therapies, has further augmented the number of hospitals seeking intensivists. In particular, it is in surgical ICUs that intensivists have been especially under-represented. This is, of course, the ICU environment in which anesthesiologists are most at home given their familiarity with the surgical patient population. To summarize: anesthesiology residency is ideal preparation for further training in critical care medicine. The demand for intensivists, particularly surgical intensivists, is at an unprecedented level, meaning that the job market is favorable and that compensation, long a downside for intensivists, is on the rise. Anesthesiology now has the opportunity to raise its purview and its profile in individual hospitals and in the overall health care delivery structure. While we may have fled the ICUs 30 years ago, let us not make the same mistake twice. Anesthesiology has been a pioneer in patient safety measures leading to improved outcomes in the O.R. Let us put our unique skills to work in ICUs as well as O.R.s where we can make a difference in the outcomes of care of critically ill patients.       Nicholas Sadovnikoff, M.D., is Co-Director, Surgical Intensive Care Unit, and Director, Fellowship in Critical Care Medicine, Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts.

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