Alexander A. Hannenberg, M.D.

ecently I listened to a leading academic anesthesiologist speculate on how completion of an internal medicine or pediatric residency would eventually be a prerequisite for anesthesia training. This view of the specialty’s crystal ball reflected concern that anesthesiology’s dominance in perioperative care requires that we be better trained than internists or pediatricians for this aspect of patient care, which many predict will become a more important part of our practice. While really no more than speculation, the comment was astonishing and reflects an amazing degree of recent self-examination and “out of the box” thinking about our future as a specialty.

What has provoked this recent spate of free-thinking about the transformation of anesthesiology? One might easily attribute this to ASA’s recent centennial and a degree of reflection that traditionally accompanies such an occasion. The reports from the Task Force on Future Paradigms of Anesthesia Practice were intended to make many consider radical alternatives to the current focus of the specialty.

In truth, two phenomena evident to every practicing anesthesiologist are probably responsible for the kind of conversation I witnessed recently. With apologies to Dr. Seuss, let me describe “Thing 1” and “Thing 2.”

Thing 1 is the emergence of “amateur anesthesiologists” in a variety of settings: pediatric intensivists providing procedural sedation for infants and children, emergency physicians employing potent anesthetic drugs for procedures and airway management and, of course, gastroenterologist-supervised nurses sedating patients for huge numbers of endoscopic procedures. Without debating the appropriate strategy for ASA in these controversial intrusions into anesthesiology practice, we must at least contemplate the possibility that the trend will continue (with or without our protests), perhaps stimulated by the future availability of new potent and safer drugs for procedural sedation. If such a possibility is imagined, it is not a large leap to consider the implications for some high-volume operating room procedures such as cataract surgery, breast biopsy, arthroscopy, laparoscopy and cystoscopy, especially as surgical techniques evolve toward less invasive methods. The prospect of lunch disappearing from the table can be expected to stimulate an appetite for creative thinking!

Thing 2 is the past decade’s escalation of the warfare with nurse anesthesia over scope-of-practice issues, precipitated by President Clinton’s 1997 proposed elimination of Medicare’s requirement for physician supervision of nurse anesthesia practice. This and the subsequent and ongoing gubernatorial opt-out battles have been, by any estimate, massively expensive, divisive and distracting. The recent breakdown of Thoughtbridge-facilitated dialog between the American Association of Nurse Anesthetists and ASA discouraged even those most optimistic about a rapprochement. These epic political struggles have taken the spotlight off patient safety, where it belongs, and focused instead on the dissention between our two groups and the polarization that has resulted. This characterization of the anesthesia community handicaps our capacity to advance our most important priorities. Surely policymakers who recognize the presence of nonphysician providers in nearly every area of health care must ask, “Why can’t the anesthesiologists be more like the other medical specialists who rely on nonphysicians in their practice?” If we are smart, we need to ask ourselves the same question. Other medical specialties surely have something to learn from anesthesiology’s experience with physician extenders. But are there are lessons for us to learn from the models of practice among obstetricians and midwives, primary care physicians and nurse practitioners, and surgeons and physician assistants? Just as importantly, nurse anesthesia needs to be contemplating the same comparisons! In these other specialty areas, the nonphysicians practice quasi-independently under general supervision in a limited range of patient acuity and complexity. Do we have comparable means to delineate such patient and procedural characteristics? Can we survive the medicolegal and economic consequences of focusing our surgical anesthesia practice on the most difficult and complex procedures that unambiguously require hands-on physician training and skill?

If anesthesiology evolved into a specialty dominating the medical care of surgical patients and relegating low-intensity procedural care to sedation nurses and other nonphysician providers, what are the implications for the challenges with which we have perennially struggled? Would it then be harder or easier to distinguish ourselves from nurses? Would it be harder or easier to convince government and our physician colleagues of the true value of anesthesiologist services? These are the chronic frustrations of our specialty. If there is a bright side to the prospect of radical transformation of anesthesiology, it may lie in a new and more favorable context for these issues.

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