ow we as anesthesiologists address perioperative risk will define the future of our profession. In our own clinical research literature, the definitions of anesthesia’s contribution to perioperative risk have expanded from “anesthesia-only” to “anesthesia-contributory” to “anesthesia-related” [Table 1]. Many anesthesiologists fear that others, both within the profession and outside, are assigning us responsibilities that we should not assume or at the very least not shoulder alone. The pro-versus-con discussion of pay for performance in the July 2007 ASA NEWSLETTER reflected this concern. Our acceptance of accountability and liability for the growing number of associations between what we do, can do, or facilitate a surgeon or interventionalist doing, and adverse outcomes range from no to cautious to enthusiastic. The goal of this article is to convince you that it is time to find ways to embrace additional patient care responsibilities in our local practices if we want to secure the future for the next generation of anesthesiologists.

How we construct our practice reflects our view of our contributions to perioperative risk. Currently anesthesiology practice in the United States may be loosely divided into two broad categories: 1) a “limited” practice that confines itself to preoperative assessment on the day of surgery, operating room anesthesia and care in the postanesthesia care unit (PACU) and 2) an “expanded” practice that incorporates all 10 elements in the definition of anesthesiology in the “Booklet of Information” published by the American Board of Anesthesiology (ABA) [Table 2]. Anesthesiologists adhering to a limited practice model may become progressively less essential as the following timeline plays out: standardization of care; reduction in anesthetic requirements associated with the shift from more invasive surgery to minimally invasive surgery or interventional radiology; improvement in the safety profiles of newer sedatives and analgesics; the development of patient-specific anatomically targeted sedatives and analgesics (pharmacogenomics); and the emergence of tele-anesthesia with direction from control rooms. The ASA Task Force on Future Paradigms of Anesthesia Practice in 2005 refers to our current salary expectations as an “anesthesia-operating room economic bubble” that may burst and asks, “Can the current economics be sustained in the long run, especially with the arrival of advanced technology and pharmacology requiring less skill for delivery of intraoperative anesthesia?”¹

Hypothesis #1: The limited practice of anesthesiology will lead to anesthesiologists being viewed as operating room technicians and to the death of the specialty.

ABA uses the adjective “perioperative” in elements 3 and 9 of its definition [Table 2]. Typically the perioperative period is defined based on time and location of care in the hospital or ambulatory care facility, e.g., preoperative evaluation of the patient in the holding area, administration of anesthesia in the operating room, and postoperative care until the patient is discharged from the PACU or from the acute pain service. An alternative is to define the perioperative period as the interval of altered physiology that begins with the onset of the surgical illness and ends with the return to the baseline that was present prior to the surgical illness. Medical comorbidities will have a significant impact on the definition of baseline physiology.

Hypothesis #2: We as anesthesiologists should become the recognized experts in understanding and controlling the altered physiology associated with the perioperative period.

Conceptually an equation describing total perioperative risk (T) may be constructed as T = M + S + (A^C + A), where M is the medical risk, S is the surgical risk, and A and AC are the anesthesia-only and anesthesia-contributory risks defined in Table 1. When studies of perioperative mortality from 2002 are compared with those from 1954, an order of magnitude reduction is found to have occurred in the T and A^C terms of the equation [Table 3]. It is right for us to be proud of this accomplishment. But there is a very uncomfortable reality in these numbers. We have reached the point that additional reductions in anesthesia risk (A^C + A) will help individual patients, and we should certainly strive for them, but they will not significantly lower total perioperative risk. Why? Because M > S > (A^C + A).\

If anesthesia risk is a third order term, then by definition it is not as important or relevant as first and second order ones, especially to health care system leaders and third-party payers. To significantly reduce perioperative mortality and morbidity, the M and S terms must be reduced. But these terms are likely to increase in the next few years as the percent of surgical patients on Medicare increases because of aging baby boomers. In Silber’s study, death within 30 days of surgery occurred in one of every 29 cases among Medicare recipients who had undergone general surgical or orthopedic procedures.² Forty-one percent suffered some perioperative complication.

How can anesthesiologists help to reduce perioperative risk? One way is to take ownership of a portion of the “M” and “S” terms in the risk equation. If we expand our definition of anesthesia complications to include the “anesthesia-related” ones already identified in our own evidence-based literature, and others yet to be identified, we can help to reduce the M and S terms. The resulting total perioperative risk equation becomes T = M* + S* + (AM + AS) + (A^C + A), where AM is the risk resulting from the interaction of an anesthesia activity and a medical comorbidity, AS is the risk resulting from the interaction of an anesthesia activity and a surgical activity, M* = M – AM, and S* = S – AS. The new anesthesia-related risk term (AM + AS) is closer in magnitude to the M* and S* terms than it is the old anesthesia risk term (A^C + A), i.e., M* > S*, (AM + AS) > (A^C + A), and thus its reduction becomes more worthy of attention and funding. An interesting early example of the AM term is the association of postoperative pulmonary complications with the use of long-acting neuromuscular blocking agents.³ An example of the AS term is the recently reviewed association of site infection with intraoperative hypothermia, perioperative hyperglycemia, late antibiotic administration, and perhaps lower oxygen content and blood transfusion.⁴

Hypothesis #3: If we as anesthesiologists want a significant reduction in perioperative mortality and morbidity, we must expand our definition of anesthesia complications to include anything that manifests itself intraoperatively or postoperatively, or anything that is less likely to occur intraoperatively or postoperatively, based on some decision or intervention in our purview.

A limited practice model focuses on just the (A^C + A) term of the total perioperative risk equation. An expanded practice is more open to addressing the (AM + AS) term. The cost of treating perioperative complications is significant. Medicare has already announced that it does not intend to pay for the treatment of certain ones. Demonstrating that we improve the quality of care by reducing perioperative complications is good for the patient and good for the profession. Demonstrating that we reduce the cost of treating complications by reducing their frequency and intensity is good for a hospital’s bottom line and the overall cost of medical care. Protecting a hospital’s operating margin may become a better basis for determining our income in the future than relying on the current inadequate reimbursement from Medicare. How best to quantitate our efforts is part of the challenge we face.

Hypothesis #4: If we as anesthesiologists become experts in controlling the altered physiology in the perioperative period and work to reduce overall perioperative mortality and morbidity, then anesthesiology will not only survive as a specialty, it will grow.

Over the past decade, leaders in our profession have been suggesting that we need to expand our role as physicians:

• “I propose perioperative medicine and pain management (PMPM) as a term that is both unambiguous and describes the totality of what we do (or what we should do).”

Saidman LJ. What I have learned from 9 years and 9,000 papers. Anesthesiology. 1995; 83:191.

• “We propose a series of time-dependent departmental name changes from anesthesiology to anesthesia and perioperative medicine to perioperative medicine and pain management . . . The rate of change will depend on when we can achieve a consensus definition for perioperative medicine and how successful we are in our efforts to convince those outside the profession of the validity of this project.”

Alpert CC, Conroy JM, Roy CA. Anesthesia and perioperative medicine. A department of anesthesiology changes its name. Anesthesiology. 1996; 84:712-715.

• “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 well within our grasp.”

Miller RD. Report from the Task Force on Future Paradigms of Anesthesia Practice. ASA Newsl. 2005; 69(10):20-23.

• “It is premature and counterproductive to content ourselves with the fact that few patients experience intraoperative deaths due solely to anesthetic mishap; we need to take ownership of the substantial perioperative morbidity and mortality that is the reality of modern American surgery.”

Evers AS, Miller RD. Can we get there if we don’t know where we’re going? Anesthesiology. 2007; 106:651-652.

• “Who better than anesthesiologists to lead health care in the coming century?”

Warner MA. Who better than anesthesiologists? The 44th Rovenstine Lecture. Anesthesiology. 2006; 104:1094-1101.

Over the next decade, we need to invest our time and resources to figuring out the right way to expand the scope of anesthetic practice — and do it. Addressing overall perioperative morbidity is a natural extension for us. Success depends on a concerted national effort that is well-organized, demonstrably effective and ultimately reasonably funded.

References:
1. Miller RD. Report from the Task Force on Future Paradigms of Anesthesia Practice. ASA Newsl. 2005; 69(10):20-23.
2. Silber JH, Kennedy SK, Even-Shoshan O, et al. Anesthesiologist direction and patient outcomes. Anesthesiology. 2000; 93:152-163.
3. Berg H, Roed J, Viby-Mogensen J, et al. Residual neuromuscular block is a risk factor for postoperative pulmonary complications. A prospective, randomised, and blinded study of postoperative pulmonary complications after atracurium, vecuronium and pancuronium. Acta Anaesthesiol Scand. 1997; 41:1095-1103.
4. Mauermann WJ, Nemergut EC. The anesthesiologist’s role in the prevention of surgical site infections. Anesthesiology. 2006;105:413-421; quiz 439-440.

Raymond C. Roy, M.D., Ph.D., is Chair, Department of Anesthesiology, Wake Forest University School of Medicine, Winston-Salem, North Carolina.

Randy W. Calicott, M.D., is Vice-Chair for Clinical Affairs, Department of Anesthesiology, Wake Forest University School of Medicine, Winston-Salem, North Carolina.