August 1, 2013 Volume 77, Number 8
It’s a Jungle Out There! Andre Atoian, M.D., M.B.A.

I completed my anesthesiology training less than 18 months ago. During medical school, I had never heard the term “perioperative” and was introduced to this concept late in residency. I have learned that this concept essentially gives the anesthesiologist pre/intra/post-operative responsibility for the surgical patient. Pretty important, really.

Like all new professionals, I am paying my dues as a rookie, but also trying to keep an eye on the future. My conversations with colleagues, both young and experienced, tend to highlight a deep sense of uncertainty about what is coming. There is a lot of grumbling rhetoric with no clear consensus or alternatives, and a palpable anxiety about the future model(s) of anesthesiology. Very few of my colleagues have ever actually practiced with a perioperative tilt, and even fewer are open to the idea of more work with no known reimbursement guidelines. Aside from general concerns about major changes regarding finance and operations, I think we need to ask ourselves the following questions. Does perioperative medicine work? Will it improve patient outcomes? Will it strengthen our position in the marketplace and establish anesthesiologists as irreplaceable physician leaders? The data are scarce, but can we afford to do nothing in these times of rethinking and restructuring?

I am writing this piece in an airplane coming back from a medical mission to the Amazonian jungle of Peru, in the city of Moyobamba. Excited about my first international experience as an attending anesthesiologist, I expected a lack of equipment and medications, primitive resources, and an onslaught of plastics, ortho and general cases. As the only anesthesiologist on the team, I didn’t expect to be required to practice perioperative medicine in essentially the way ASA has proposed it.

On our first day, after an hour or so of confusion, we implemented an evaluation system that mirrored the proposed patient referral and anesthesia evaluation paradigm. Surgeons worked the front line of the triage process. If deemed appropriate for surgical intervention, patients were sent to me for preoperative work-up and medical screening. Not only was I able to control resource expenditure by limiting unnecessary laboratory evaluation, I was able to identify several acute and chronic medical conditions and initiate treatment. I also scheduled follow-up visits for patients whose lab work would determine surgical candidacy. I even sent several parents who were seeking help for their children back to the surgeons because they themselves had issues that had been overlooked.

Administering anesthesia to a patient with whom I had a pre-existing relationship was a novel experience for me. Having already asked me questions a few days earlier, patients seemed emotionally better prepared on the day of surgery. They also felt comfortable asking for clarifi-cation – something the local nurses found rather unusual. And, considering their relatively modest educational backgrounds, many patients engaged in surprisingly sophisticated communication about their procedures. I am convinced that the short time lapse between my consult and the day of surgery gave my patients time to think, prepare and become proactive participants in their care. I also felt that the underlying goal of informed consent was achieved, something that is often lost in our “morning-of” anesthesia rituals at home.

The intraoperative period was a stressful one. Cases were performed without usual monitors (no end tidal gas assessment of any kind, malfunctioning EKG, unreliable pulse oximeter, and no ventilator). I learned to improvise and adapt quickly. In order to facilitate transfer between the OR, PACU and floor, I would plan and initiate postop pain control intraoperatively, allowing for a better overall experience for both patients and ancillary staff charged with their care.

Postoperative daily rounds were an opportunity to assess the efficacy of my anesthetic and monitor for any complications. Teamwork with the surgeons helped me learn about issues from their perspective, which in turn enabled me to adapt and to solve problems as they arose. I learned a lot from the hands-on management of the perioperative period, and I believe it helped me provide better care than if I had strictly stayed in the O.R.

I know that many of our colleagues do not welcome the added responsibilities that perioperative management would impose upon anesthesiologists. Frankly, I too have questions and doubts about the daily practice of this new paradigm. But I can’t deny that I felt I provided better and more effective care because of my perioperative involvement. While it would be impractical to have one anesthesiologist provide all stages of perioperative management in a hospital-based setting, we must begin brainstorming and testing various team-based solutions that we can compare and improve along the way. Doing nothing to evolve will only take us out of the equation as essential physicians. It is a jungle out there, but that’s no reason why we can’t secure our position along the food chain.

Adrian Atoian, M.D., M.B.A. is an independent private practice anesthesiologist and Principal, Perioperative Care Consultants, Inc., Los Angeles, California.