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August 2002
Volume 66 |
Number 8
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SUBSPECIALTY NEWS
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| Critical Care
Growing at a Critical Time |
Neal H. Cohen, M.D., President
American Society of Critical Care Anesthesiologists
Anesthesiology is at a critical threshold. A number of events,
some of our own making, some out of our control, are having enormous
impact on the specialty. Clinical, political and environmental
factors are affecting medicine in general and anesthesiology in
particular. Leaders of academic departments, community providers,
ASA and subspecialty societies will decide how to respond to these
challenges, and I hope that they will work cooperatively, think
strategically and be willing to take some risks. The potential
opportunities for anesthesiology are enormous, if only we are
willing to acknowledge and take advantage of them.
The practice of anesthesiology continues to evolve in major ways.
Although managed care was predicted to reduce the number of surgical
procedures and anesthetics, it has had the opposite effect. The
aging population in particular has increased the demand for surgery.
We are now able to safely anesthetize patients who would not have
been candidates for surgery in the past. The demand for anesthesia
services also has increased in response to the needs of patients
undergoing procedures in settings other than the operating room,
including radiology suites and endoscopy units.
At the same time, our clinical capabilities have improved. Most
of the drugs we use on a daily basis did not exist as recently
as 10 years ago. The drugs are safer and patient response more
predictable. The availability of these drugs has improved quality
of care and patient safety. The monitors we rely on to safeguard
our patients have become more sophisticated and, in some respects,
challenge our understanding of the patient's response to intraoperative
events. The preoperative and postoperative management of our patients
also has changed dramatically. Gone are the days when we could
leisurely evaluate our patients preoperatively since they were
hospitalized for days prior to undergoing a surgical procedure.
The preoperative evaluation is more commonly provided in an office
setting. Postoperative care for most routine cases is provided
in the outpatient setting; only critically ill patients remain
hospitalized for postoperative care. This change in inpatient
acuity has created the need for more critical care providers as
has the mandate by the Leapfrog Group and others for dedicated
critical care physicians. Subspecialty training has improved our
understanding of the needs of specific patient populations and
improved patient care. As our knowledge of mechanisms of pain
and treatment modalities for pain has improved, new practice opportunities
have been created for anesthesiologists trained in pain management.
All of these changes seem to bode well for the future of the
specialty. Practice opportunities currently outpace supply, so
recruitment efforts are challenging, and interest in anesthesiology
has improved as a result. The recruitment of outstanding residents
into the specialty is encouraging, particularly after the recent
shortfall in trainees. At the same time, the creation of accredited
subspecialties has expanded career options for anesthesiologists.
Unfortunately, the future is not necessarily secure. The shortage
of providers has created a different challenge: how to fill the
need for anesthesia services in operating rooms and, at the same
time, take advantage of all of the other opportunities created
by the changing health care environment.
The experience of the past few years emphasizes the risk of defining
our specialty too narrowly. We have not taken a sufficiently broad
view of the possibilities or defined ways to take advantage of
them. Over the past two years, ASA and the specialty as a whole
have spent the majority of time, effort and resources on protecting
our role as supervisor of anesthesia services when not personally
providing those services in the operating room. It was important
for us to do so if we are to ensure the safe delivery of anesthesia
to our patients. At the same time, the effort spent in clarifying
the roles of anesthesiologists and nurse anesthetists has distracted
us from a broader challenge: redefining the specialty as the health
care environment changes. While we have been distracted, many
things have threatened the specialty. For example, as the shortage
of anesthesiologists has worsened, patients requiring anesthesia
services for procedures performed outside of the operating room
are receiving sedation and analgesia delivered by a nurse or nurse
practitioner with minimal training. The role of the critical care
anesthesiologist is being undermined. The increased need for anesthesiologists
in the operating room has caused a dramatic reduction in the number
of trainees entering anesthesia-based critical care training programs.
Critical care anesthesiologists are finding it necessary to spend
more and more of their time in the operating room, delegating
their critical care responsibilities to others. Many intensive
care units previously directed by an anesthesiologist are now
managed by a pulmonary medicine physician or surgeon.
Finally, the subspecialization of anesthesia has caused rifts
in relationships between anesthesia providers, potentially threatening
the specialty. Pain management anesthesiologists in many cases
have differentiated themselves from the specialty; some no longer
belong to ASA or feel that ASA is not able or willing to represent
their interests. Most are members of pain specialty organizations
that they think represent their interests more effectively. The
rift is exacerbated by the fact that most patients are unaware
that their pain physician is an anesthesiologist. Clearly, if
anesthesiology is to survive as a medical specialty and attract
outstanding trainees, we must begin to focus our energies on addressing
these broad issues and take advantage of the diverse opportunities
available to us.
The value of the critical care anesthesiologist to the specialty
provides a clear example of how embracing diverse practice opportunities
can benefit the specialty and ensure its future. Although the
concept of the anesthesiologist as perioperative physician has
not won many advocates, some of us have been functioning in that
role for a number of years. A dedicated though small group of
anesthesiologists has assumed responsibility for care in both
the intensive care unit and operating room. This dual role has
provided a challenging and interesting practice for the individuals
who have assumed it, but more importantly, has significantly benefited
the specialty. The model has been successful not only in academic
settings but also in community practices. It has provided a chance
to extend the clinical skills developed in the operating room
to other clinical settings. By doing so, I think it has helped
clarify for our colleagues and our patients what differentiates
anesthesiologists from other anesthesia providers and why anesthesiology
is the practice of medicine. It also has facilitated the transition
of new technologies to the operating room. The pulmonary artery
catheter and transesophageal echocardiography are examples of
such a transfer of technology and demonstrate how new opportunities
for the specialty are created by assuming an expanded perspective.
In addition, and perhaps of greatest concern to most anesthesia
groups, is the lack of understanding that critical care anesthesiologists
do not detract from but rather augment clinical staffing. Most
critical care anesthesiologists spend the majority of their time
providing anesthesia services in the operating room or elsewhere,
thereby increasing the pool of providers for the department and
potentially attracting a different group of physicians to the
specialty. Finally, the extended role of the anesthesiologist
outside of the operating room gives the department more exposure
and broader representation in medical staff activities. In the
competitive health care environment, this representation is critical.
Unfortunately, the value of critical care to the specialty is
not acknowledged in some settings. The list of excuses for ignoring
the benefits of critical care to an anesthesia practice is long.
Most anesthesiologists do not understand critical care or have
an interest in it, but operating room needs remain critical. Chairs
of departments do not lose their jobs if the intensive care unit
is not staffed by anesthesiologists, but they do if the operating
room needs are not met. Finances also dictate decisions about
allocation of anesthesia personnel and for critical care, and
finances have had a major impact. The same is true for other opportunities
such as delivery of nonoperating room anesthesia, office-based
care and pain management. We cannot ignore the financial realities
of our decisions but must also define ways to take advantage of
new opportunities and address the financial consequences. We can
do both. Other specialties have done so and have demonstrated
that they not only can survive but prosper. For example, the hospitalist
programs continue to expand even though most hospitalists cannot
generate enough clinical income to support themselves. They have
done so by demonstrating the value of the services they provide
to both patients and the institution and obtaining financial support
from both sources. Anesthesia and critical care services that
improve outcome and reduce costs will similarly be compensated
if we will document their value.
Using the critical care situation is one example of an opportunity
not adequately pursued by the specialty. It is time we take a
much broader view of what the specialty of anesthesiology is and
can be. We should not lose sight of our responsibilities in the
operating room; to do so would be irresponsible. As we try to
address the shortage of anesthesia providers, we must consider
alternative models of care and define ways in which technology
can assist us in fulfilling an increasing need. We should evaluate
ways to utilize anesthesiologist assistants and alternative care
team approaches to address the diverse settings in which anesthesia
is now required.
Most importantly, we must be willing to look beyond the immediate
needs and take a long-term perspective. We must identify ways
to introduce new information management tools into our practices
and consider the role telemedicine might have in improving the
delivery of anesthesia services. As a highly technical specialty,
we have the skills necessary to take a leadership role in developing
ways to utilize robotics and alternative drug delivery systems
to safely and effectively provide care to patients in a variety
of settings and to fulfill the changing needs of surgeons and
patients. It is important for the future of the specialty that
we not overlook opportunities outside of the operating room in
spite of the current shortage of providers and the challenges
that creates.
The future is bright for anesthesiology, in large part because
of the changing health care environment and the dramatic improvements
in technology, pharmacology and information management. No specialty
is in a better position to take advantage of these opportunities
if we are willing to look beyond tradition, think strategically
and be creative. I challenge the specialty as a whole and each
of us individually to do so.
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Neal
H. Cohen, M.D., is Professor and Vice-Dean of Anesthesia and
Medicine, University of California-San Francisco, San Francisco,
California. |
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