Eugene P. Sinclair, M.D.

t the beginning of my term as ASA President, I pointed out that the Administrative Council is the official planning body for ASA. It must look beyond the next year or two and have the vision and resolve to look over the horizon in charting the future direction of our specialty.

The accelerating rate of dynamic change in coming years will have profound effects on our practices and our patients. To assist the officers in studying the multiple issues that will influence and shape our profession and our future practices, I appointed a Task Force on Future Paradigms of Anesthesia Practice, chaired by Ronald D. Miller, M.D., of the University of California-San Francisco.

Dr. Miller has presented well-received summaries of the task force report to the August 2005 Board of Directors and the Administrative Council. He has prepared a written summary that follows this preface.

The full report will serve as a valuable resource to the Administrative Council in its work as the official planning body of the Society. Clearly future Administrative Councils will have to revisit and update this work from time to time to keep it current.

I. Introduction
n 2004, ASA formed a task force to identify possible anesthesia paradigms in 2025. Hopefully the findings of this task force may facilitate ASA’s strategic planning. In planning the task force, several concomitant questions emerged.

For example:

• What are the factors that could influence our future practice?

• Is the specialty of anesthesiology ready for the future?

• What are the changes in American medicine and its hospital structure that may promulgate future anesthesia pathways?

• How will variables such as innovations, demographics and economics influence the specialty?

• How can anesthesiology be positioned as a specialty that is the best value for improved health care delivery systems?

Considerable thought and discussion preceded the development of this task force, including three Foundation for Anesthesia Education and Research retreats, academic anesthesiology committee discussions and many informal discussions. In addition, the task force analyzed the interviews of more than 20 leaders in American medicine outside the specialty of anesthesiology. Despite a diversity of responsibility in health care, these leaders often provided similar views regarding the future of medicine and the possible role anesthesiology may have. This consistency certainly added strength to our conclusions.

II. Current Trends and the Future
Tertiary care-oriented hospitals will persistently increase the percentage of critical care and monitored beds to as many as 50 percent of the total beds. Information technology is rapidly becoming installed in many of our nation’s hospitals, creating more opportunities for national databases from which both quality and quantity of clinical care can be assessed. Operating rooms will increasingly have information-intensive layouts with more robotics and voice-activated technologies. Increasing numbers of invasive procedures will be delegated to nonphysicians or mid-level technicians. Credentialing will be based more on demonstrated competence rather than academic degree or board-certification. Turf wars will increasingly occur, with traditional boundaries for scope of practice being severely challenged. For example, at least four specialties are currently competing for control of the “carotid artery.”

Traditional surgical approaches will be challenged by imaging and invasive catheters approaches. Furthermore, medical substitutes will be developed for some surgical interventions. For example, 50 percent to 70 percent of vascular surgery is by imaging and catheter approaches rather than traditional surgery. How is the risk of anesthesia influenced by sicker patients but less invasive procedures? In some cases, some surgical procedures will actually disappear or be markedly modified by genetic-molecular medicine and/or imaging.

The institution of genetic-molecular medicine has already started and will only continue to increase over the next 20 years. New drug development will be based on pharmacogenomics. Molecular studies for individualized analysis of drug responses, including our ability to project a patient’s susceptibility to adverse events, will occur. And, lastly, drugs will be developed that will have little risk or will not require marked skill necessary to administer them.

Evaluation of our interviews inevitably created many questions. For example:

• With the advances in technology and pharmacology, how qualified will the future intraoperative anesthesia provider need to be?

• What will the role of the anesthesiologist be with advanced technology and pharmacology (e.g., safer and more precise drugs)?

• How many anesthesia providers (e.g., technicians?) should an anesthesiologist supervise at once?

Even though many anesthesiologists think that compensation is currently inadequate, some of our interviews reflected that some day the “anesthesia-operating room economic bubble” may burst. Can the current economics be sustained in the long run, especially with the arrival of advanced technology and pharmacology requiring less skill for the delivery of intraoperative anesthesia? Because of perceived inadequate third-party reimbursement, many academic medical centers and even a few private practice situations are providing additional financial support to augment the financial package of anesthesia health care providers. Will such institutional support continue, especially in large academic anesthesia medical centers?

III. Opportunities of the Future
With the tertiary care hospital increasingly dominated by a combination of monitored and critical care beds (i.e., at the exclusion of general medical beds), in addition to procedural suites and operating rooms, opportunities for our specialty presently exist. Most inpatients will be procedurally oriented but of higher acuity than now exists.

• Who will perform the preoperative evaluation?


• Who will prepare patients for these procedures and surgery?

• Who will manage their intraoperative course, both logistically and medically in the postanesthetic care units (i.e., many intensive care units)?

• Who will manage these?

• Who will take care of the patient’s postoperative care (including pain)?

• Who will provide their critical care?

• On a broader scale, what type of physician should lead all of these areas of inpatient care in an organizationally and medically sound coordinated basis?

Increasingly this type of medical care must be based on systems analysis and measures of outcome. In fact, one of the leaders we interviewed suggested that this represents a medical specialty that currently does not exist.

Although inpatient care has been emphasized, our specialty has the opportunity to be more involved with interventional pain management, including acute and chronic pain care and palliative care on an outpatient basis.

IV. Conclusions
Anesthesia could be the dominant leader in tertiary care hospitals, both clinically and administratively, with emphasis on “through-put” and “outcomes.” Furthermore the leaders we interviewed frequently stated that anesthesiology, in many respects, is the preferred specialty for this type of change. Yet they also questioned whether the specialty of anesthesiology would seek or accept broader perioperative responsibilities. Their perception is that the current comfortableness with operating room anesthesia and its economics (i.e., anesthesiologists are highly paid specialists) was the basis of this concern.

Will the specialty be able to adapt to the hospitals of the future? Even with substantial changes in training programs, new graduates with contemporary training will not manifest themselves for six to 10 years. For example, anesthesia’s increased role in perioperative medicine probably requires additional involvement in critical care. Specifically, were a change in our residency to augment the amount of critical care training, the residency would not be changed until 2008, which means that graduates will not appear until 2012, seven years from now. Yet other specialties are ready to act now. For example, medical hospitalists have been actively discussing and publishing a projected vision of their future role in perioperative medicine. Other specialties, including surgery, emergency room and trauma physicians, are discussing an augmented role in inpatient medicine. Some of these specialties (especially medicine) are ready to respond now, and even more so in the next two or three years.

Those who favor retaining the status quo may argue that our task force’s vision of operating room anesthesia and perioperative care in 2025 could be wrong. They may even predict that because operating room anesthesia has been essentially the same for the last 30 years, it will remain similar for the next 20 years (i.e., until 2025). However, a widespread consensus among the interviewed leaders was that there would be more change in the next 10 years than in the last 30 years put together. Close examination of current economics and scope of practice indicates that this scene of rapid change is already taking place.

Should the future of our specialty be nearly entirely based on operating room anesthesia? If the status quo persists, the answer is possibly yes. If the predicted changes in technology and pharmacology allow a lesser-trained individual to deliver anesthesia, then the answer is no. If the later prediction is correct, then diversification of practice paradigms is a more fundamentally sound basis for the future of anesthesiology. Our traditional and current practices may be more assured if we complement them with future focused alternatives (e.g., perioperative medicine, critical care, pain). Most certainly science and technology are creating more ways to both use and not use the anesthesiologist’s skills. No doubt, health care delivery systems, and hospitals in particular, will favor the specialty that provides more overall value and diversity of practice paradigms.

V. Recommendations

A. Our specialty should have a mechanism in place to automatically revise our vision of the future every one to two years. This disciplined approach will automatically force us to consider new clinical, scientific and administrative approaches in the overall framework of what our specialty should be. It was inspiring to hear that while the specialty of anesthesiology could and should have a major role in the future of American medicine, especially its hospitals, the opinion, however, is that most (but not all) anesthesiologists are relatively comfortable with their current role in operating room anesthesia and probably will not be willing to adapt themselves to the future.

B. Our specialty should initiate research programs to guide appropriate diversification, including the scientific determination of best practices and clinical benchmarks, management studies to determine the approach to clinical excellence and the performance of high-quality research that contributes not only to the welfare of our specialty but also medicine overall.

C. Despite the considerable lag time between changing our training programs and the resultant contemporary graduates appearing on the clinical scene, there are some changes than can be made in the next two to four years.

1. Our vision for the future is severely hampered by a lack of substantial anesthesiology-trained critical care physicians. Even though our specialty has historically been the one that started and developed critical care medicine, it has gradually been given away to other specialties in the last 30 years. Anesthesiology needs to reverse that trend. Currently our specialty has substantial critical care fellowship capacity. With the help of ASA, perhaps a large effort should be made to encourage anesthesia residents to take critical care fellowships.

2. About 15-20 anesthesia programs are now ready to train anesthesiologists of the future. Furthermore there may be other programs that wish to make this transition. Perhaps measures can be taken now to unleash these programs to make this vision well-known to medical students so that the appropriate individuals can be recruited into our specialty. How can these programs be stimulated to move forward? Furthermore our trainees and existing physician practitioners must maintain a high degree of general medical knowledge and experience if we are to provide the value-added care and leadership for the full scope of perioperative care. As it is likely that the physician role in operative anesthesia will more likely involve the supervision of nurses and technicians in multiple locations, trainees should be educated for this role as they become senior housestaff.

In conclusion our specialty needs to diversify its practice paradigms in order to ensure its future leadership position in medicine. To have an increasingly dominant role in perioperative management, including critical care, seems to be within our grasp. We must act immediately to create the intellectual environment that will actualize the profession’s full and diverse potential by 2025 because change takes time. In some respects, we are already behind, but we have opportunities that can be implemented in the next two to four years.

Ronald D. Miller, M.D., is Professor and Chair, Department of Anesthesia and Perioperative Care, University of California-San Francisco.

Orin F. Guidry, M.D.

ene Sinclair’s action to create this task force was far-sighted, and the task force has done an excellent job in laying out the future as far as it can be discerned. We have to continue the effort on dual tracks. The first is to continuously look into the future as far as we can see. The second effort is to prepare the specialty to meet coming challenges.

This preparation for the future includes not just the ASA’s organizational preparation but also preparing individuals, groups and residents to care for the patients of the future.