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Time Has Come for the Acute Care Anesthesiologist

Murray, Michael J. MD, PhD*; Murray, Teresa M. MD; Miller, Ronald D. MD

doi: 10.1213/ANE.0000000000001032
Editorials: Editorial

From the *Grand Canyon Anesthesiology Consultants, Phoenix, Arizona; Department of Anesthesiology, Washington University School of Medicine, St. Louis, Missouri; and Department of Anesthesiology, University of California–San Francisco, San Francisco, California.

Funding: None.

The authors declare no conflicts of interest.

Reprints will not be available from the authors.

Address correspondence to Michael J. Murray, MD, PhD, Grand Canyon Anesthesiology Consultants, 24311 N 121st Pl., Scottsdale, AZ 85255. Address e-mail to mjmurray3@gmail.com.

The future of our specialty of anesthesiology is appropriately and persistently debated and analyzed. One current focus is the perioperative surgical home (PSH). There are other models for how anesthesiologists can advance health care. Divining the future is never easy, but, as Prielipp et al.1 have suggested, we should have a dialogue and perhaps even a debate before we, as a field, commit to a strategy that will ostensibly protect the relevance of our specialty for generations of anesthesiologists but is, as yet, unproven. In this issue of Anesthesia & Analgesia, McCunn et al.2 suggest that we learn from our surgical colleagues’ experience with the acute care surgery model and develop an acute care anesthesiologist (ACA) model. As McCunn et al. pointed out, the ACA concept complements our involvement in the PSH.

The concept of the PSH was borrowed from other specialties, most clearly from the hospitalist model that grew out of internal medicine in the 1980s. The term hospitalist was not formally used until 1996, when Kaiser Permanente in California and Park Nicolett in Minnesota assigned groups of internists to manage hospitalized patients’ medical conditions.3 The next year, the National Association of Inpatient Physicians (now the Society of Hospital Medicine) was founded. One of the current tenets of the Society of Hospital Medicine is the involvement of hospitalists in the perioperative care of the surgical patient.4 In 2005, 6 years before the concept of the PSH was born, Phy et al.5 at the Mayo Clinic in Rochester, Minnesota, published the results of a historical cohort study demonstrating that the involvement of hospitalists in the perioperative care of 466 patients 65 years or older admitted for repair of a hip fracture decreased time to surgery, time from surgery to dismissal, and the overall length of stay. There was no difference in inpatient mortality and no difference in 30-day readmission rates.5 Other studies have shown almost identical results.6,7

The involvement of anesthesiologists in the PSH will bring additional expertise to the full continuum of perioperative care, creating roles for both hospitalists and anesthesiologists in the perioperative care of patients.8 The 2005 report of the American Society of Anesthesiologists Task Force on Future Paradigms of Anesthesia Practice highlighted the necessity of anesthesiologists diversifying their scope of practice into perioperative medicine along with increasing their care of critically ill patients.9 Murray et al.10 concluded that this diversification should include business and healthcare management, development and incorporation of new technologies, pharmacogenomics, and novel information management systems.

Despite the existing shortage of anesthesiologists, diversification requires anesthesiologists to spend more time outside the operating room. There are more programs to train nonphysician anesthesia providers than to train anesthesiologists. There are 117 anesthesiology residencies,a 116 certified registered nurse anesthetist schools,b and 10 anesthesiologist assistant programs.c Because of the increasing number of surgical interventions, it is mathematically impossible for anesthesiologists to administer every anesthetic in the United States.11 The role of nonphysician providers is expanding. Published literature suggests that the care provided by certified registered nurse anesthetists is equivalent to that delivered by an anesthesiologist for some outpatient procedures,12 as well as in simulated emergencies.13 As anesthesiologists, we must continue to demonstrate our value for the surgical patients who require our advanced skills and training as well as establish our role in the medical management of patients before and after surgery. Just as the PSH has established our value within the healthcare system based on our increased involvement in the pre- and postoperative management of the patient, so too should we continue to demonstrate our value within operating room suites by improving the outcomes of critically ill patients who require life-saving operations.

Hospitalists have been proclaiming their value in the perioperative care of patients for 2 decades. We can apply their approach to define our role in the perioperative care of patients. Surgeons historically faced challenges similar to ours. General surgeons not only were seeing an increasing number of acute trauma cases (because of an overall increase in the size of the population and improved survival of transported patients) and more patients were requiring acute emergency operations (because of the increased number of patients >65 years),14 but fewer general surgeons were available to perform these operations (as of 2008, 80% of physicians who completed a general surgery residency went on to subspecialize).15 Several groups of surgeons met in 2003 to address these challenges.16 The outcome was a commitment to the development of an acute care surgery fellowship that would incorporate training in the management of patients who had sustained trauma, patients who required emergency operations, and patients who were critically ill.17 Several studies have demonstrated that acute care operations improve patient outcomes.18 The most recent and largest study included 131, 410 patients undergoing emergency general surgery. Outcomes were improved when care was provided by acute care surgeons in a trauma center compared with patients who received their care in a trauma center or nontrauma center without the involvement of an acute care surgeon.19 As McCunn et al.2 suggest, the acute care surgical fellowship that has been developed could serve as a model for the ACA fellowship.

Prielipp et al.1 propose an analogy for the current state of affairs for anesthesiology, a burning oil platform in the North Sea. Although that representation may be overly dramatic, we can all agree that we face significant challenges.20 A different analogy can be made to events occurring in Japan at the end of World War II. Their economy in shambles, the Japanese knew that they had to innovate and revamp their economy. The Japanese turned to an American, W. Edwards Deming, who advised them that their goals would be very difficult to achieve, but were doable, as long as they focused on quality.21 We know the results.

Demings’ 14 principles of quality improvement (Table 1) can just as easily be applied to the PSH and to the concept of the ACA. We must focus on quality, the quality of care that patients receive who are critically ill and who require emergency operations. As McCunn et al. point out, trauma is the leading cause of death in patients 45 years of age and younger and the third leading cause of death overall. Given these statistics, if anesthesiology offers subspecialty training in sleep medicine, palliative medicine, and ambulatory anesthesiology, then how can we not similarly value subspecialty training in acute care anesthesiology? As Khalil et al.22 document in their study of >31,000 patients, physicians who are experienced in acute care surgery improve outcome.

Table 1

Table 1

Many anesthesiologists who have contributed greatly to our specialty began their careers caring for trauma patients. Ronald Miller at the University of California–San Francisco studied resuscitation of soldiers in Vietnam.23 Warren Zapol at Harvard studied acute respiratory distress syndrome in soldiers in Thailand.24 As Warner and Apfelbaum have argued, not every anesthesiologist has to be a “fully trained perioperative specialist”; they assert that departments “will recruit a subset of members who have specific training” to work in the PSH, just as departments recruit a subset of members who have pediatric cardiac surgical training.25 Their argument is just as valid for the ACA. The concept of an ACA fellowship is one that warrants further discussion, planning, and implementation.

Several authors have commented on the “costs” of the PSH and the ACA.1,26 In today’s environment, Deming’s advice to the Japanese, focus on quality and the rest will follow, is not necessarily a given. However, several hospitals have demonstrated the value of the PSH.27–29 The same is true for trauma centers.30,31 These programs have demonstrated sufficient value that either the hospital or the third-party payers should be willing to cover for the associated costs. These institutions might well serve as models for other programs to follow.

The “big picture” for the future of our specialty is the PSH. The ACA represents an integral component of this big picture of the future of our specialty.

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DISCLOSURES

Name: Michael J. Murray, MD, PhD.

Contribution: This author helped design the study, conduct the study, analyze the data, and write the manuscript.

Attestation: Michael J. Murray approved the final manuscript.

Name: Teresa M. Murray, MD.

Contribution: This author helped design the study, conduct the study, analyze the data, and write the manuscript.

Attestation: Teresa M. Murray approved the final manuscript.

Name: Ronald D. Miller, MD.

Contribution: This author helped design the study, conduct the study, analyze the data, and write the manuscript.

Attestation: Ronald D. Miller approved the final manuscript.

This manuscript was handled by: Steven L. Shafer, MD.

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FOOTNOTES

a Available at: http://www.nrmp.org/wp-content/uploads/2014/04/Main-Match-Results-and-Data-2014.pdf. Accessed July 23, 2015.
Cited Here...

b Available at: http://home.coa.us.com/accredited-programs/Documents/February%202015.pdf. Accessed July 23, 2015.
Cited Here...

c Available at: http://www.anesthetist.org/faqs#educationprograms. Accessed July 23, 2015.
Cited Here...

d Adapted from: https://en.wikipedia.org/wiki/W._Edwards_Deming. Accessed August 10, 2015. Originally from eming, WE Out of the Crisis. Boston, MA: MIT Press 1986.

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