ith significant growth in ambulatory surgery (performed mainly in ambulatory surgery centers and surgeons’ offices), patients hospitalized after surgical procedures are generally sicker with significant coexisting medical conditions and require complex and extensive surgery. Therefore, even anesthesiologists who confine their practice primarily to the operating room are commonly faced with patients who require preoperative optimization as well as intensive intraoperative and postoperative care to ensure major organ function and improve outcome. It is clear that anesthesiologists have the opportunity to be involved in all aspects of the perioperative process and assume the role of perioperative physician. This is even more important as physicians, including anesthesiologists, are asked to increase the value of their services to patients, other physicians and hospitals.

Furthermore, the increased emphasis on improving perioperative efficiency and reducing hospital stays, as well as health care costs, provide us an opportunity to contribute to this multidisciplinary process and extend our role as perioperative physicians. This could be achieved through perioperative rehabilitation programs that should result in improved perioperative outcome and early resumption of normal activities of daily living.¹ Anesthesiologists, as perioperative physicians, play a major role in this process through preoperative evaluation and optimization that should reduce requests for consultations and prevent surgical cancellations and delays.² Preoperative optimization should also reduce perioperative complications and improve outcome. In addition, preoperative information and communication is crucial for improving patient satisfaction. Although the aim of preoperative clinics is not to assume overall care of chronic medical conditions, there is an enormous potential to influence patient behavior (e.g., smoking cessation and rehabilitation programs consisting of physical training preoperatively) and educate them as well as allow early identification of debilitating conditions such as obstructive sleep apnea and diabetes. In fact, the benefits of such clinics are boundless and limited only by our vision.

Importantly, anesthesiologists can influence perioperative outcome through appropriate choice of anesthetic technique and intraoperative initiation of preventative measures to reduce postoperative side effects. In contrary to the conventional belief, decisions made in the intraoperative period (e.g., fluid management, ventilatory management, temperature management, glycemic management, depth of hypnosis management and pain management) can influence postoperative outcome. Of note, anesthesiologists practicing as perioperative physicians have contributed to this realization through their involvement in the postoperative period, particularly in the intensive care unit and organized acute pain services. Thus, anesthesiologists can improve patient care and safety throughout the continuum of the perioperative period.

A new group of primary care physicians, known as “hospitalists,” has emerged and established roles as perioperative physicians.³ This group works closely with surgeons to care for the medical aspects of preoperative and postoperative management.^4,5 However, hospitalists may have different approaches to management of perioperative care due to differences in their training. A survey comparing the knowledge of preoperative evaluation and preparation — as well as perioperative changes during anesthesia and surgery between primary care and anesthesiology resident physicians — identified some deficiencies in primary care physicians, emphasizing that their education differs from that of anesthesiology residents.⁶ Thus, anesthesiologists, through their knowledge, training and experience with the pathophysiologic changes accompanying anesthesia and surgery, are best-suited as perioperative physicians. Nevertheless, as hospitalists play a more significant role in perioperative care, anesthesiologists as perioperative physicians will need to work closely with this group to further improve perioperative care. Specialty societies that provide perioperative care (e.g., anesthesiologists, surgeons and hospitalists) can collaborate in developing evidence-based guidelines and comprehensive clinical pathways that will ensure uniformity of practice and continued improvement in the quality of care. Because of our niche, we can play a leadership role in this process.

It is imperative that anesthesiologists diversify their practice paradigms in order to ensure a future leadership position in medicine. Although anesthesiologists are involved in operative suite management, we need to expand our administrative roles to participate as directors and members of hospital committees (e.g., operating room, intensive care unit, quality improvement). This will make us the leaders in perioperative care and further enhance our ability to influence patient care and perioperative outcome. In addition, this would change the attitude of our surgical and medical colleagues, as well as our patients, toward anesthesiologists.

Of note, ambulatory anesthesiologists have been practicing as perioperative physicians for decades and play a vital role in outpatient facilities. In fact, the role of the ambulatory anesthesiologist now expands after discharge home (e.g., pain control). Anesthesiologists are medical directors of the majority of ambulatory surgery centers in the United States and are thus providing both clinical and managerial services.

The time is right for anesthesiologists to take a more active role as perioperative physicians. I submit that because most academic anesthesiology departments are involved in perioperative care, including intensive care and pain management, consideration should be given to changing their names to “Department of Anesthesiology and Perioperative Medicine.” Expanding the scope of our specialty would require groups of anesthesiologists practicing in different areas of perioperative care (e.g., preoperative clinic, intraoperative period, acute pain service and intensive care unit) to work toward the same goals. Of note, a cost-effective approach would be anesthesiologist-directed and supervised, nurse practitioner-based, and/or physician assistant-based preoperative clinics as well as acute pain services.⁷

The articles included in this issue of our NEWSLETTER reflect involvement of anesthesiologists as perioperative physicians. ASA and the American Board of Anesthesiology have shown a commitment to redefine the practice of anesthesiology and expand the role of anesthesiologists as perioperative physicians. It is now up to individual anesthesia practitioners to embrace this concept and elevate the practice of anesthesiology as well as to contribute to the growth of our specialty.

References:
1. White PF, Kehlet H, Neal JM, Schricker T, Carr DB. The role of the anesthesiologist in fast-track surgery: From multimodal analgesia to perioperative medical care. Anesth Analg. 2007; 104:1380-1396.
2. Correll DJ, Bader AM, Hull MW, et al. Value of preoperative clinic visits in identifying issues with potential impact on operating room efficiency. Anesthesiology. 2006; 105:1254-1259.
3. Watchter RM, Goldman L. The emerging role of “hospitalists” in the American health care system. N Engl J Med. 1996; 335:514-517.
4. Merli GJ. The hospitalist joins the surgical team. Ann Intern Med. 2004; 141:67-69.
5. Huddleston JM, Long KH, Naessens JM, et al. Hospitalist-Orthopedic Team Trial Investigators medical and surgical comanagement after elective hip and knee arthroplasty: A randomized, controlled trial. Ann Intern Med. 2004; 141:28-38.
6. Adesanya AO, Joshi GP. Comparison of knowledge of perioperative care in primary care residents versus anesthesiology residents. Proc Bayl Univ Med Cent. 2006; 19:216-220.
7. Rawal N. Organization, function, and implementation of acute pain service. Anesthesiol Clin N Am. 2005; 23:211-225.

Girish P. Joshi, M.D., F.F.A.R.C.S.I., is Professor of Anesthesiology and Pain Management, and Director, Perioperative Medicine and Ambulatory Anesthesia, University of Texas Southwestern Medical Center, Dallas.