he creation of critical care units and evolution of critical care medicine (CCM) as a specialty were originally brought about by anesthesiologists. In many countries, anesthesiology has retained a major involvement in CCM. Unfortunately anesthesiology involvement in CCM in the United States has regrettably decreased over the past 40 years, presumably because of the competing pressures of operating room anesthesia and economics. What should be the role of anesthesiology in CCM in the future tertiary care hospital?

In 2004 ASA President-Elect Eugene P. Sinclair, M.D., appointed a Task Force on the Future Paradigms of Anesthesia Practice to address the projected evolution of anesthesiologists’ clinical practices over the next 20 years. A summary of the task force’s deliberations has been presented in several formats, including a presentation at the ASA Board of Directors in August 2005 and in the October 2005 ASA NEWSLETTER. Major emphasis was placed on the future of the tertiary care hospital, surgery and procedures, operating room anesthesia and a possible strategy for the future of our specialty.

The effect of likely changes in the distribution of beds in tertiary care hospitals, as well as other community hospitals, must be evaluated before forecasting the future of anesthesiology. Based on a broad base of information, however, the task force concluded that tertiary care hospitals of the future will be increasingly dominated by seriously ill patients who require procedures (i.e., surgical, imaging, cardiovascular) and monitored and/or critical care beds. Even now the percentage of total beds assigned to CCM has increased from 10 percent as recently as 10 years ago to as much as 40 percent in many tertiary care hospitals today. Critical care physicians are well aware of the critical need for technology to help manage the care of seriously ill patients, including an accelerating push for electronic medical records, the use of data to improve patient safety and error reduction and even the ability to provide care remotely by the use of medical information technology. In fact improved delivery systems and monitoring technology — with “smart” associated information technology and pharmacology — will allow critical care physicians and anesthesiologists to deliver care remotely and for more patients concomitantly than presently exists and to do so in both tertiary care facilities and other community hospitals. While predicting the impact of these advances is difficult, they need to be considered in planning for the future of both CCM and anesthesiology.

Independent of the welfare of the specialty of anesthesiology, the need for critical care is dramatically increasing in the United States. Furthermore many groups, most notably the Leapfrog Group, have strongly recommended that critical care be delivered by individuals especially trained and board-certified in CCM. Clearly the specialty of CCM needs to better define staffing requirements in critical care units and the skill mix, recognizing the wide variation in the acuity of the patients for which care is being provided, including those critically ill patients in postanesthesia care units. Nevertheless there is a tremendous shortage of critical care physicians. This is especially acute in academic medical centers with the advent of work-hour regulations.

With the tertiary care hospital of the future being dominated by surgical-imaging procedures and CCM, physicians with “executive knowledge” will be required to improve patient flow via a systems analysis and outcome approach. Coordination of all materials and personnel needed to achieve optimal efficiencies is required. Also, for patient care, how will the allocation of surgical and medical specialties occur? Who should have responsibility and authority for overall quality and costs? Clearly tertiary care hospitals will need to be structured to provide efficient and effective care in increasingly sicker patients related to surgery and other procedures. The fundamental components of such a hospital are preoperative evaluation, intraoperative anesthesia and postoperative care, including pain management and CCM. Other than the procedure itself, anesthesiology is the only specialty that has the training, skills and experience in all clinical aspects of the tertiary care hospital of the future. Anesthesiology is especially appropriate to coordinate care between the tertiary care hospital components (e.g., CCM and preoperative evaluation) and to assume some of these critical administrative functions.

Major changes are occurring in many specialties, including vascular surgery, cardiac surgery and others. While operating room anesthesia has dominated our specialty for many years, in planning for our future, we would be well served to diversify our value to medicine specifically and society overall. Encouraging additional training in CCM and also encouraging anesthesiology residents to take critical care fellowships would provide a sound basis for our specialty’s role in the future tertiary care hospital. Even if an anesthesiologist who is board-certified in critical care does not work in a critical care unit, the skills learned during that training will ensure that he/she is highly qualified to take care of the increasingly complex surgical cases that confront us intraoperatively. Because of the long lag time between a change in training and an increased output of anesthesiologists in CCM, changes need to be made as soon as possible. Our task force concluded that if the specialty of anesthesiology does not “step up to the plate” with increased involvement in CCM, others will (e.g., pulmonary medicine, hospitalists). The potential for our specialty is enormous in the tertiary care hospital of the future. Significant involvement with CCM is crucial for our specialty’s future and the welfare of CCM overall.

Having been a chair of a major anesthesiology department for 22 years and editor-in-chief of a major journal for 15 years, my personal opinion (independent of the task force) is that the specialty of anesthesiology should be involved with CCM as much as possible. The combined training of anesthesiology and CCM creates the knowledge and skills for the physician leaders of the future tertiary care hospital and potentially with different models of care, the leaders for inpatient care generally. Furthermore such training will provide our specialty with a diversity of options, including operating room anesthesia and the ability to manage our most seriously ill patients, in the tertiary care hospital of the future.

To facilitate such a combination, increased training of CCM in our residencies is essential. The methods to accomplish this goal are numerous, including incorporating more critical care experience in our residency programs, lengthening our residencies, encouraging incentive-based choices of our fellowships or even redesigning some of our residencies to provide a combined anesthesiology and CCM residency for board certification in both specialties.

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