…The Future of Anesthesiology: Let’s Act
Now
Ronald D. Miller,
M.D.
Our specialty as a whole appears to be prepared for
the likely future that awaits it, including possible
economic and/or political influences. ASA has wisely
formed foundations such as the Anesthesia Patient
Safety Foundation (ASPF) and the Foundation for Anesthesia
Education and Research (FAER), both of which have
helped to shape the future in response to problems
and/or opportunities. APSF has been a leader in the
marked improvement of operating room anesthetic safety
as recognized by the Institute of Medicine.1
FAER has successfully funded the research of young
academic anesthesiologists, many of whom have evolved
into leadership positions not only in anesthesiology
but also in various other areas of medicine. These
leaders are strengthening the presence of anesthesiology’s
voice in medicine.
While these efforts are to be congratulated and should
be continued, no group in our specialty is attempting
to define the long-range future (i.e., the next 10
to 40 years) of anesthesiology. Specifically, how
should our specialty orient itself to be in a position
of influence and importance in the future?
Because no one can predict the long-range future with
any degree of accuracy, perhaps the attempt to do
so is a trivial exercise. Yet there are many examples
of vision and long-range planning that have resulted
in outstanding accomplishments. For example, the concept
of an “Internet-type of communication”
system was developed in the 1970s, and the National
Aeronautics and Space Administration is planning extended
flights into space, which may take place 15 to 20
years from now.2 In
1983, the use of molecular biology and other basic
science information at the bedside was predicted and
is now a reality that has reactivated the need for
physician-scientists in all areas of medicine. Several
anesthesiology departments have had 10- to 15-year
plans that are just now beginning to materialize.
Even some journals, Anesthesia & Analgesia,
for example, made plans 12 years ago that only now
are being implemented fully. In 1999, Science,
the official journal of the American Association for
the Advancement of Science, recommended that a vision
be developed as to what science would be like 40 or
50 years from now. While long-range plans need constant
revision, a vision for the future cannot be obtained
if it is not sought. Other than a few academic training
programs, are any national organizations such as ASA
seeking a long-range vision of the future of our specialty?
Analysis of our history may provide clues as to how
we should plan our future. This author’s view
is that our intellectual foundation and contributions
to the society’s future medical needs will dictate
the future success and importance of anesthesiology
to medicine and society overall.
Historically and even today, the ability to perform
surgery without pain represents the fundamental basis
of our specialty. During the polio epidemic more than
a generation ago, the problem of paralyzed patients
being unable to sustain their own ventilation led
anesthesiologists to develop mechanical ventilators
and analysis of arterial blood gases. Imagine the
public intrigue when Peter Safar, M.D., an anesthesiologist,
brought people back from the brink of death with the
development of cardiopulmonary resuscitation.
More than 40 years ago, John J. Bonica, M.D., also
an anesthesiologist, changed our attitudes toward
pain by developing a multidisciplinary approach to
its diagnosis and treatment, including creation of
pain clinics. Anesthesiologist John S. Lundy, M.D.,
started the first blood bank, and, certainly, the
marked increase in operating room safety won the appreciation
and admiration of medicine.1
The vision that led to the formation of APSF surely
facilitated the marked increase in safety for which
anesthesiology has become well known. These and may
other visions enhanced the overall growth and importance
of anesthesiology as a major player in medicine.
The need for intellectual growth and vision has been
recognized for years by numerous anesthesiologists.
Thirty years ago, Richard J. Kitz, M.D., and Julien
F. Biebuyck, M.D., stated, “A discipline not
continually engaged in an active and imaginative program
of research is dead, and will not advance and will
probably deteriorate in general standards and efficiency.”3
Despite this advice, there are ominous warnings about
the future. In spite of current examples of research
excellence, several indicators suggest that we may
not be creating new knowledge as rapidly as other
specialties. Our National Institutes of Health (NIH)
funding is less than many other specialties. Compared
to funding granted to other medical specialties, our
funding is about 35 percent of radiology’s,
25 percent of neurology’s and surgery’s
and less than 17 percent of pediatrics’ and
pathology’s. A significant portion of our NIH
funding is related to critical care or pain management,
the subspecialties of which we either have or may
lose. Also, most of the funding is directed to less
than 20 of the more than 100 training programs in
the United States. On a per-capita basis, we again
are considerably less funded than other specialties.
Our contributions to the medical literature are not
growing at the rate of other specialties or anesthesiologists
from other countries. The success we have had is due
partly to the dedication and financial sacrifice by
academic departments and funding from FAER, with strong
financial support from ASA and more recently from
other organizations such as the International Anesthesia
Research Society. Even if the funding is sustained,
however, this level of support still may not enough.
Because of limited personnel and focus on operating
room supervisory and reimbursement issues, will our
retraction from perioperative medicine (critical care,
acute pain, pain clinics, perioperative evaluation,
etc.) to operating room anesthesia only satisfy our
specialty’s place in medicine? Will these retractions
discourage bright, young minds from selecting anesthesiology
as their specialty? As emphasized by Neal H. Cohen,
M.D., in the August 2002 NEWSLETTER, anesthesiology’s
role in critical care medicine has been decreasing
for many years.4 Even
though the importance of pain management has dramatically
increased in the last few years, will our specialty
continue to represent pain specialists? Because critical
care and pain management have become so important
in medicine, anesthesiology’s retraction from
these specialties is of questionable wisdom. Leading
health care experts have predicted that the hospitals
of the future will concentrate mainly on surgery and
critical care medicine. As a result, we are in a position
to be the “hospitalists” of the future.
If we continue to pull away from perioperative medicine,
however, this opportunity will quickly disappear.
While this author humbly acknowledges the daunting
challenge of predicting the future, we should try.
Is it possible for our Society to aggressively analyze
the future of medicine on an ongoing basis and shape
our profession accordingly? Perhaps we should create
a large “think tank” to consult with our
national leaders in medicine, information technology,
biotechnology, politics and commerce to create a vision
of the future on an ongoing basis. Without such an
analysis, we most certainly will be relegated to becoming
more reactive and less creative. In the absence of
such an analysis, will the excellence of our intellectual
foundation specifically and our specialty in general
continue to flourish? Our future should not be left
entirely to fate.
Leroy D. Vandam, M.D.,5
once quoted Alexander Slater, M.D., who stated that:
“Without vision and research, the professions
die.” Our forefathers created a specialty that
increasingly occupied a stronger and stronger position
in medicine through the years. While our intellectual
foundation is a key ingredient, let us dedicate ourselves
to a process that analyzes the future in a scholarly
manner and that ensures our profession’s important
role in the decision-making structure of medicine
for many years to come.
References:
1. Richardson WC. Committee on Quality of Care
in America, Institute of Medicine. In: To
Err Is Human. National Academy Press; 2000:144-145.
2. Ball JR, Evans CH, eds. Safe Passage
— Astronaut Care for Exploration Missions.
Institute of Medicine. Washington, DC: National
Academy Press; 2001.
3. Kitz R, Biebuyck JF. Yet another crisis:
Research funding in anesthesiology. Anesthesiology.
1974; 40:211-214.
4. Cohen NH. Critical care growing at a critical
time. ASA Newsl. 2002; 66(8):27-33.
5. Vandam LD. History of Anesthetic Practice.
In: Miller RD, ed. Anesthesia. 5th
ed. Philadelphia: Churchill-Livingstone; 2000:1-11.
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Ronald
D. Miller, M.D., is Professor and Chair, Department
of Anesthesia and Perioperative Care, and Professor
of Cellular and Molecular Pharmacology, University
of California- San Francisco, San Francisco,
California. |
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