The Scope and Future of Anesthesia Practice

Anesthesiology arose as a medical specialty because the dangers associated with anesthetic drugs and techniques demanded that they be administered by skilled and knowledgeable physicians. As safer drugs were developed and physiologic monitoring improved, the need for anesthesiologists was propelled by increasing surgical complexity and severity of patient illness, as well as by increasing expectations for patient safety. Whereas the original raisondêtre for the specialty remains today, a variety of professional and economic factors have challenged anesthesiology and produced large “swings of fortune” during the past few decades. During the 1970s and 1980s the emergence of critical care attracted many talented medical students to American anesthesiology training programs. However, these were halcyon days for anesthesiologists practicing in the operating room, where professional income was high, job opportunities were ample and increasing surgical complexity demanded an increasing level of medical knowledge and skills. Thus there was little incentive for anesthesiologists to expand their roles beyond the confines of the operating suites and most of the trainees who were initially attracted by critical care subsequently practiced operating room anesthesia only. In contrast, during this same period, anesthesiologists in Europe and Canada were consolidating

their positions in the burgeoning sub specialties of pain, intensive care, and resuscitation. In the mid 1990s, gloom beset anesthesiology in the United States as predictions, widely reported in lay press such as the Wall Street Journal, suggested that the need for anesthesiologists would decrease dramatically in an anticipated managed care environment.

Medical graduates were discouraged from pursuing careers in anesthesiology, and residency programs contracted dramatically. Anesthesiologists in other parts of the world have also experienced fluctuating fortunes. Currently there is a shortage of doctors in general, and of anesthesiologists in particular, in many countries. The future of anesthesiology depends on several factors, including changes in surgery and inter ventional medical practice, technological advances in anesthesiology, the evolving scope of anesthesia practice, and the role of non physicians (e.g., nurse anesthetists and anesthesia physician assistants) and physicians trained in other specialties in the provision of anesthesia care; healthcare financing will also influence trends in anesthesia practice. This Article briefly reviews the current scope of anesthetic practice and offers some possible scenarios for future directions of the specialty.

OPERATING ROOM ANESTHESIA

The operating room remains the primary focus for the vast majority of anesthesiologists. The anesthesiologist’s primary responsibility in this arena is to ensure the patients’ comfort and safety when they are exposed to the trespass of surgery; this includes protecting the patient from pain, undesired awareness and organ system injury, and fostering full recovery from the surgical and anesthetic interventions. Over the past decades it has become increasingly clear that the intra operative conduct of anesthesia has a profound effect on patient safety and comfort in the postoperative period. For example, modest intra operative hypothermia can either decrease the incidence of wound infection 1 or provide neuro protection, 2 depending on the clinical situation. Anesthesiologists are increasingly sophisticated in their understanding of patient safety and they are focusing on such issues as appropriate peri operative medications, antibiotic prophylaxis and infection control, multi modal analgesia, maintenance of normothermia and normoglycemia, and appropriate fluid and electrolyte therapy. Recent findings raise the intriguing possibility that anesthetic management may contribute to postoperative cognitive decline and to long-term outcomes.3 This growing responsibility for overall postoperative outcomes raises new expectations for knowledge and skills of the practicing anesthesiologist and challenges our previously narrower definitions of anesthetic outcome.

Despite the demands imposed by increasing severity of illness in surgical patients, growing surgical complexity and more comprehensive postoperative considerations, anesthesiology is often viewed as a victim of its own perceived success. One widely cited study from the United Kingdom, the Confidential Enquiry into Peri operative Deaths (CEPOD) study, reports that patients undergoing general anesthesia have a 1 in 185,000 chance of dying as a consequence of anesthetic misadventure.4–6 This finding was highlighted in the Institute of Medicine report on medical errors 7 and anesthesiology was cited as the specialty that had best addressed safety issues (see Chap. 3 for a more comprehensive review of quality and safety in anesthesia practice). Unfortunately, this widely publicized perception that anesthesia is “safe” has encouraged nonp hysician anesthesia providers to advocate for independent practice and has suggested to insurers that anesthetic care by an anesthesiologist is needlessly expensive.

However, studies from other countries have reported much higher rates of death attributable to anesthesia than those reported in the CEPOD study.8 In a large French study, the peri operative mortality directly attributable to anesthesia was found to be 1 in 13,000.9 In studies reported from Australia,10 Denmark, 11 Finland,12 and the Netherlands, 13 perioperative death attributable to anesthesia ranged from 1 in 250011 to 1 in 67,000.12 The mortality attributable to anesthesia is probably much greater in developing countries. For example, a 1992 study from a Zimbabwean teaching hospital reported an alarming incidence of death or coma— 1 in 388—attributable to anesthesia.14 Whereas the bulk of evidence suggests that anesthesia is not nearly as safe as publicized,15 it is undoubtedly true that advances in anesthetic practice in developed countries have rendered the care of healthy patients undergoing low- or intermediate-risk surgery much safer than in the past (see Chap. 24 for a more detailed review of anesthesia risk).

The challenges to anesthesiology are exacerbated by the massive expansion in demand for anesthesia services for a variety of nonoperative procedures, ranging from cerebral aneurysm coiling to general anesthesia for screening colonoscopy, and by the introduction of freestanding ambulatory surgery centers and office-based surgical suites where anesthesia is administered. The demands for safe anesthesia care provided in numerous remote locations, present significant challenges to the workforce, and to the financing and practice of anesthesiology. Current practice models vary widely both in the United States and worldwide. In the United States, some anesthesiologists (or practice groups) personally provide all anesthetic care regardless of complexity, an approach that is also common in the United Kingdom, Canada, and Australia. In other practices, anesthesiologists supervise ancillary providers (e.g., nurse anesthetists, residents, or anesthesia assistants) in more than one operating room; a practice model that is also common in the Netherlands. The provision of safe anesthetic care across geographically dispersed practice sites and encompassing wide ranges of severity of patient illness, in an economically responsible manner, is a major challenge that anesthesiologists need to address proactively.

The expectations for operating room anesthesia can be simply stated: we need to provide an ever increasing quality of peri operative care for a lower cost. In turn, these expectations and predictions require that the anesthesiologist community consider who will, or should, provide each component of anesthesia care, what levels of knowledge and skill will be required of each provider, and how the responsibility for care will be organized, managed, and rewarded. Currently, at least 50% of anesthesia care in the United States involves nurse anesthetists; in several states, physician supervision is not mandatory. Worldwide, anesthesia practice often includes some form of non physician provider, or a physician provider who is not a fully trained anesthesiologist. For example, staff-grade non certified anesthetists provide a significant proportion of anesthesia care in the United Kingdom. One report asserts that non anesthesiologists can safely provide anesthesia for selected procedures (e.g., colonoscopy) and patients.16 It is also clear that patients with minimal physiologic reserve, those undergoing major interventions, and those with complex medical problems require the direct involvement of a skilled anesthesiologist to enhance patient safety.17,18 Unfortunately, practitioner skill and experience are often not matched to these factors, but determined by availability of providers, or a fixed model of care delivery, rather than one that is tailored to the specific clinical situation. This is a fruitful area for further work by anesthesiologists to assure proper matching of resources to the clinical needs.

It is arithmetically impossible to provide a fully trained anesthesiologist for every anesthetic procedure. Furthermore, the increasing demands for anesthesia services (aging population, proliferation of ambulatory surgery centers, escalating demand for nonsurgical anesthesia and sedation) will outstrip even the most aggressive output of anesthesiologists. Medical schools simply do not have the capacity to train sufficient numbers of doctors to feed exponentially increasing anesthesia programs. For reasons of both anesthesiologist availability and cost, it is apparent that the future of anesthesia practice will involve an increasing role for non physician providers. How can this be made compatible with the demands for increasing safety and quality? By involving skilled anesthesiologists in the cognitive aspects of every anesthetic. This will require coordination and cooperation with non physician providers, allowing them to perform at the highest levels their training allows, while ensuring that a fully trained specialist is involved in planning and managing care for high risk cases and is readily available for complex diagnostic and therapeutic decision making. Techno logic developments in monitoring and information systems should facilitate these changes. The development of tele medicine could make this model of care feasible even in communities where an anesthesiologist is not physically present.19 Meeting the manpower, safety and cost demands of the future will require that we overcome the political infighting between organized anesthesiology and nurse anesthesia. Furthermore, the training of anesthesiologists will increasingly need to encompass the development of skills in supervising other anesthesia providers. It is in the interests of public safety and healthcare delivery that unity be forged among anesthesia providers under the leadership of specialist anesthesiologists, whose medical training and education is required for complex medical decision making, supplemented by the skills and abilities of non physician providers who enhance this team approach.