The concept of the anesthesiologist as a perioperative physician has been considered for much of the past decade. Few departments, and even fewer in the private sector, however, have embraced this concept. Pressures from payers, hospital reorganization and the increasing cost of health care will no doubt reshape many specialties, including our own. Revisiting this concept may help us to understand why the anesthesiologist’s role as a hospital-based physician needs to expand to meet these new challenges.

Perioperative medicine requires the anesthesiologist-intensivist to be the principal patient advocate during the perioperative period. As our patient population ages and the severity of illness increases, many will require critical care interventions and support. The logical progression of care from the operating room (O.R.) to the postanesthesia care unit (PACU) and/or intensive care unit (ICU) calls for the anesthesiologist to be involved.

Can “perioperative medicine” be achieved in the private practice setting? Few anesthesiologists are entering into critical care medicine, and fewer will include the intensive care unit into their private practice. Why? We can think of a few reasons:

• Difficulty understanding the structure and management of the ICU, including the best format for organization: closed, open or hybrid;

• The political ramifications of ICU management;

• Reimbursement issues;

• Scheduling issues;

• Perception of no benefit.

Examining each of these items may shed light on their impact and help our colleagues to see the value in critical care medicine as part of daily practice.

Structure and management: In general, community hospitals have what is referred to as “open” ICUs. Each patient retains his or her own private attending, and the intensivist (assuming the intensivist model has been adopted) may or may not consult on this patient for critical illness management (referral care only). This model works well if the intent is to reduce friction between the medical staff and the intensivist but does little to enhance the standards of care in the ICU. Open units have a high turnover of intensivists and offer limited value to the critically ill patient. A “closed” unit is one where patients admitted to the ICU are on the “intensivist medical service,” and all medical care is provided by the critical care team. The intensivist manages all clinical and nonclinical problems in the ICU. A substantial body of clinical literature supports the “closed” unit model, demonstrating enhanced patient care outcomes, reduced mortality, reduced length of stay and improved resource utilization. The failure for this model to be more broadly adopted is rooted in issues of control, ego and potential revenue loss.

Many community “private practice” ICUs have adopted the so-called “hybrid” model where the care of all admitted patients is performed collaboratively with the private attending and the critical care team. In this model, the intensivist still has the “last word,” but rarely do they need to use it. Rounds are conducted on all patients regardless of consultation, and the benefit to the ICU is a uniform standard of care.

Political ramifications: Perception exists that involvement in critical care leads to many confrontations with our colleagues in medicine and surgery. In fact anesthesiologists represent the best practitioners for the ICU since our specialty is not based on referrals. Without the fear of loss of referrals, adherence to uniform standards makes any ICU function more effectively. Commitment of the anesthesiology department’s leadership to these principles will elevate the image of the group across all aspects of the hospital.

Reimbursement issues: The Centers for Medicare & Medicaid Services’ (CMS) level of reimbursement for surgical anesthesia services has and still remains a contentious issue. Critical care medicine is not far behind with similar reimbursement issues. For private practice anesthesiologists, O.R. revenues are always more attractive than the ICU, a situation analogous to a pain clinic. As more “paying” customers leave the hospital setting for ambulatory centers, O.R. revenues may become less competitive. Working together with hospital administrators and educating them on the need for organized critical care services and the role the anesthesiology department can fill will help to support this endeavor through significant savings to the institution. Large savings to the hospital can be shared as an incentive to the anesthesiologist-intensivists working in the ICU.

Scheduling issues: Which physicians should be in the ICU? When they should be there and who covers them are some of the operational issues that need to be resolved by the department. Those who have formal training in critical care should assume leadership roles; 24/7 coverage is optimal.

The issues above are easily overcome. A conviction that this is an added value and benefit to the private sector department of anesthesiology (and critical care medicine) is an axiom. The added value is found in elevation of the standard of patient care, participation in hospital leadership, improved non-O.R. revenue streams and a substantial financial savings for the hospital. Consistently our challenge has been to maintain our specialty’s presence in ICUs. Few anesthesiologists are being trained in critical care and thus our presence in ICUs may continue to decline.

If more anesthesiology departments managed ICUs (true perioperative medicine), the demand for trained anesthesiologist-intensivists would grow as would the incentive to be trained as one.

Aryeh Shander, M.D., is Associate Clinical Professor of Anesthesiology and Medicine, Mount Sinai School of Medicine, Mount Sinai Hospital, New York, New York.

Gerald A. Maccioli, M.D., is Director of Critical Care Medicine, Critical Health Systems, Inc., Raleigh Practice Center and Medical Director, Medical/Surgical Intensive Care Unit, Nutrition Support and Respiratory Therapy, Rex Healthcare, Raleigh, North Carolina. He also is ASA Alternate Director for North Carolina.