n a recent study, approximately 95 percent of anesthesiologists thought community participation, political involvement and collective advocacy by physicians were important.¹ Nonetheless only between 20 percent to 33 percent of anesthesiologists reported participating in these activities. Anesthesiologists were less active in community participation than family practice doctors, internists, pediatricians, cardiologists and general surgeons (on the order of 60 to 100 percent less); but anesthesiologists were similarly active in collective advocacy and were more active politically.

Do these numbers mean anesthesiologists are laggards? I do not think so. Anesthesiologists, as compared to the other specialties in this study, have had to fight for their patients and themselves through political activity. Perhaps it is appropriate, then, that more anesthesiologists than cardiologists and pediatricians rated political involvement as very important. While for a number of reasons it would be nice to have anesthesiologists more active in community participation and collective advocacy, the work of anesthesiologists in the political arena is not only appropriate but fulfills the primary obligations of the specialty of anesthesiology.

Obligations arise from relationships. In medicine’s case, obligations of physicians arise from an implicit social contract. Society has supported us in becoming physicians and specialists through providing opportunities to train, to perform research and, perhaps most importantly, to learn from and with patients. In return, society expects anesthesiologists to provide patient care, research, training and advocacy related to anesthesiology.

Gruen has suggested that an additional implicit obligation for physicians is to manage those issues that “directly influence individuals’ health” in the practitioner’s community.² Note two aspects of this statement. The first is the recognition of community and the idea that there are some specific individuals other than direct patients for whom physicians have obligations. Gruen uses “community” to mean those people who live in physical proximity to where the physician practices, and he argues that this proximity brings forth special obligations. The second is the term “directly influence,” which is used to mean that the obligation to be involved is more relevant when the harm clearly and straightforwardly affects health (such as smoking). Indeed physicians considered “involvement in issues closely connected to individual patients’ health to be very important” as compared to issues less clearly linked. It would be natural, then, for physicians to seek to effect those social, economic and environmental characteristics that shape the health of individuals in the community.

In that regard, Gruen suggested that the single most important factor affecting health — access to health care — is the shared responsibility of all physicians. Past that point, however, physicians should be involved with activities that improve community health that are consistent with each physician’s “expertise, interests and situations.”² For example cardiologists as a whole may have a special obligation to address heart health. Pediatricians may have a special obligation to address child safety. I would suggest that as fiduciaries of the skills, knowledge and practice of anesthesiology, preserving and improving anesthesiology care is a primary and specialty-specific obligation.

I would argue that the profession of anesthesiology has two main obligations and that we do a good job of addressing them. I imagine our community as the community of present and future patients. One factor that has been shown to directly affect health is patient safety. Clearly anesthesiologists have been leaders in this domain. The Anesthesia Patient Safety Foundation is unequaled in improving operating room patient health. The second obligation is the preservation and development of the profession of anesthesiology. In this case, I laud the political action of anesthesiologists in working to preserve a very successful standard of care and training that dramatically sustains public health.

These behaviors are wholly consistent with the view that our fiduciary obligation is to manage “all things anesthesia.” Unlike other specialties such as cardiology, however, anesthesiology does not have a narrow spectrum of diseases for which we are responsible. In terms of diseases, for example, the anesthesiology community has taken ownership of only the rare conditions of malignant hyperthermia and pseudocholinesterase deficiency. We could, however, take our obligations further, particularly if we widen our view to include ownership of matters that include the fitness of our patients as they come to surgery.

Anesthesiologists should be involved in issues that directly affect the health of the community and are relevant to providing anesthesia care. Anesthesiologists interested in participating may want to consider the following areas:

• Participate in antismoking activities.

• Participate in obesity prevention activities.

• Participate in pain management activities, including intervening politically and improving the lay community’s understanding of pain and pain-related diseases.

• Participate in improving preventative health practices and access to care.

Naturally, participation in almost any altruistic activity fulfills our community obligations as physicians. I offer only some suggestions here. Whenever anesthesiologists have worked as patient advocates outside of the operating room, it has increased respect for the specialty. We as anesthesiologists should continue or increase our participation in community health issues that may improve the health of our future patients.

References:
1. Gruen RL, Campbell EG, Blumenthal D. Public roles of US physicians. JAMA. 2006; 296:2467-2475.
2. Gruen RL, Pearson SD, Brennan TA. Physician-citizens — public roles and professional obligations. JAMA. 2004; 291:94-98.

David B. Waisel, M.D., is Associate Professor of Anaesthesia, Harvard Medical School, Boston, Massachusetts.