centennial provides an irresistible occasion for an organization to undertake some self-examination and strategic thinking. Anesthesiology is no stranger to these tasks — ASA, the four Foundations and the American Board of Anesthesiology have independently and jointly brainstormed the future in recent years. Far more than ASA’s 100th anniversary, however, recent major challenges to the place of anesthesiologists in health care have produced a compelling need to look toward the future of the specialty.

At the turn of the millennium, ASA was engaged in a multiyear and multimillion-dollar dispute over the appropriate degree of independence of nurse anesthetists under federal rules. The rancor, duration and cost of this battle were unmatched in other medical specialties’ dealings with their nonphysician counterparts. Yet this dispute occurred during a period in which the prevalence of physician extenders and the breadth of their practice in numerous specialties had grown dramatically.¹ The contrast between the nature of midwifery practice, as one example, and nurse anesthesia practice, with respect to the degree of direct physician supervision, is striking. With a remarkable degree of safety, midwives manage uncomplicated deliveries under protocols providing for physician consultation as needed.² Is it truly easier to prospectively identify low-risk deliveries than it is to stratify anesthetics by patient and procedural complexity? If not, why does our specialty’s view of the care of low-risk anesthetics differ so dramatically from obstetricians’ views on low-risk deliveries? As the role of nonphysicians in other specialties evolves, we will inevitably need to consider whether there is something we can learn from our colleagues, or vice-versa.

Advances in technology and pharmacology will surely alter the range of services provided by anesthesiologists. Our specialty is currently discussing, with gastroenterologists and others, the appropriateness of sedation by intravenous propofol in the absence of an anesthesia specialist. Anesthesiologists say that the capacity of this anesthetic to produce respiratory and cardiovascular depression demands a trained specialist to manage these potential complications.³ In the (unlikely) event that anesthesiologists prevail in the current dispute, what will the next debate bring if the drug involved is not propofol but a potent analgesic-hypnotic without such side effects? Can anyone doubt that such an anesthetic is in our future? Is it not certain that more sophisticated patient monitors will be available soon to control the delivery of anesthetics? If these advances put sedation for endoscopy or imaging in the hands of nonanesthesiologists, what does it mean for cataract surgery, arthroscopy, herniorraphy or even more complicated forms of surgery.

Hospitals Changing, Too
Hospitals are undergoing as radical a transition as our drugs and technology. We see movement of patients and selected procedures away from the hospital to specialty hospitals, outpatient facilities and physician offices. What will be left in the acute inpatient facility? The growing prevalence of critical care beds relative to general hospital beds in tertiary care facilities provides a clue. Nearly all patients, medical and surgical (and the distinction will blur), in the hospital will require complex therapy requiring a critical care setting. They will need preoperative evaluation and management, invasive procedures and postoperative care, including pain management and sophisticated care for acute, multisystem critical illness. None of the existing medical specialties is fully equipped to provide comprehensive care in all of these areas, but anesthesiology is a strong contender for the best qualified. We will not dominate this role, however, without a major commitment made soon. Others, such as internal medicine hospitalists, are already laying claim to the role of the perioperative physician.⁴ A major part of the commitment required to establish anesthesiology’s role in the hospital of the future is a willingness to re-engineer our residency training programs to provide future generations of anesthesiologists with the necessary skills. Remaining relevant requires anticipating future demands and opportunities; the greatest impact we can have on the future of the specialty lies in the choices we make about educating our successors.

Economic Factors
Economic issues can color our view of what our future role might be in health care. It is obvious that operating room practice, medical direction of nonphysicians, pain management and critical care are not equally lucrative areas of practice. On the one hand, an economically viable specialty is better able to attract trainees and ensure future availability of personnel to provide care. On the other hand, there is great value in assessing our strengths, opportunities and potential contributions to medicine without regard for present-day payment implications. The latter approach must be an important element of our strategic thinking. Fear of the monetary impact of the choices available to the specialty can easily blind us to options offering long-term growth and security.

We should not feel alone when facing dramatic changes in the nature of our profession. For example consider the impact that a pharmacological remedy for atherosclerosis will have on a number of other specialties. Those who image, operate on or dilate and stent carotids and other vessels will have the bulk of their livelihood shift to other specialties or disappear altogether. Radiology, neurosurgery, cardiovascular surgery and others will also need to chart new territory before long.

What Lies Ahead?
The prospect that the “bread and butter” core of anesthesiology, operating room practice, will be minimized is terrifying — but critical care units are today being managed remotely with data and video links, and airplanes fly without pilots. Robots are performing complex surgery and could doubtless manage endotracheal intubation if asked. Our drugs will be more pharmacologic-specific and safer. Our equipment and instruments will increasingly become self-functioning. Considering all this, is it surprising that many news sources predict that anesthesiologists will be unnecessary by 2030? We may ultimately disagree, but the pace of change demands that we consider the question carefully and keep our minds wide open about the future direction of the specialty.



References:
1. Cooper RA, Laud P, Dietrich CL. Current and projected workforce of nonphysician clinicians. JAMA. 1998; 280:788.
2. Oakley D, Murray ME, Murland T, et al. Comparisons of outcomes of maternity care by obstetricians and certified nurse-midwives. Obstet Gynecol. 1996; 88:823.
3. AANA-ASA Joint Statement Regarding Propofol Administration. <www.ASAhq.org/news/asaaanajointstmnt.htm>. Accessed on May 25, 2005.
4. Perioperative Care: A Special Supplement to the Hospitalist. <www.hospitalmedicine.org>. Accessed on June 23, 2005.

Ronald D. Miller, M.D., is Professor and Chair, Department of Anesthesiology and Perioperative Care, and Professor of Cellular and Molecular Pharmacology, University of California-San Francisco, San Francisco, California.

Alexander A. Hannenberg, M.D., is Associate Chair, Department of Anesthesiology, Newton Wellesley Hospital, Newton, Massachusetts, and Associate Clinical Professor, Tufts University School of Medicine, Boston, Massachusetts.

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