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The Perioperative Surgical Home: A Panacea or Pandora’s Box for the Specialty of Anesthesiology?

Vetter, Thomas R. MD, MPH; Pittet, Jean-Francois MD

doi: 10.1213/ANE.0000000000000704
Editorials: Editorial

From the Department of Anesthesiology, University of Alabama at Birmingham, Birmingham, Alabama.

Accepted for publication January 23, 2015.

Funding: University of Alabama Department of Anesthesiology internal funds.

The authors declare no conflicts of interest.

Reprints will not be available from the authors.

Address correspondence to Thomas R. Vetter, MD, MPH, Department of Anesthesiology, University of Alabama at Birmingham, JT862, 619 19th St. South, Birmingham, AL 35249. Address e-mail to tvetter@uab.edu.

“I swear by Apollo the physician, and Aesculapius the surgeon, likewise Hygeia and Panacea, and call all the gods and goddesses to witness, that I will observe and keep this underwritten oath, to the utmost of my power and judgment.”

The Classic “Hippocratic Oath” (400 B.C.E)

Panacea was the Greek goddess of healing and the Universal remedy.1 A present-day panacea is a purported remedy or medicine for all diseases or ills or something that will solve all problems.2

In Greek mythology, Pandora was the first woman on Earth. Despite Zeus’ admonishment to the contrary, Pandora opened a box (actually a jar) that she was presented as a gift, releasing all the evils and miseries of the world and forever afflicting mankind (Fig. 1).1 In modern parlance, opening a Pandora’s Box refers to creating a situation that introduces multiple unexpected problems.2

Figure 1

Figure 1

Is the Perioperative Surgical Home a panacea or a Pandora’s Box for the specialty of anesthesiology? We believe that the long-term answer will depend on how effectively academic and community anesthesiologists incorporate the Perioperative Surgical Home into their practice of perioperative medicine.

In this issue of Anesthesia & Analgesia, there are two The Open Mind articles, one by Prielipp et al.3 and the other by Warner and Apfelbaum,4 which offer contrasting perspectives on the current and future state of the specialty of anesthesiology, and the role anesthesiologists in the implementation of the Perioperative Surgical Home. One sees our specialty facing a “burning platform” mandating immediate action, the other calls for continued gradual evolution through “thoughtful expansion.” A third article offers a dialog among these collective authors on specific areas of contention.5

Against the backdrop of these equally engaging articles, we offer our interpretation of the current and future state of anesthesiology, organized along the conventional and, now even more so, interdependent tripartite missions of clinical care, education and training, and research, plus what Dexter and his colleagues6 at the University of Iowa have insightfully identified and aptly called the “fourth mission” of management.

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CLINICAL CARE

Prielipp et al.3 foresee many anesthesiologists in the United States becoming a “commodity” directly employed either by local hospitals/health systems or by large regional and national, multipractice, corporate anesthesiology groups. Examples of this latter phenomenon of for-profit corporate consolidation (mergers and acquisitions funded by private equity firms) include North American Partners in Anesthesia (Moelis Capital Partners), U.S. Anesthesia Partners (Welsh, Carson, Anderson & Stowe), Resolute Anesthesia (Goldman Sachs Private Capital Investing), and NorthStar Anesthesia (TPG Growth). We agree that these new employers (like one’s academic department chair) may not initially support the expanded role of anesthesiologists in the Perioperative Surgical Home. However, as noted by Warner and Apfelbaum,4 only a subset of any group of anesthesiologists will need to practice perioperative medicine. Academic, independently employed private-practice, and hospital or corporately employed anesthesiologists need to incrementally expand their scope of preoperative and postoperative services and then to demonstrate its added value, while remaining fully invested in our core business of intraoperative patient care. Emulating the earlier extensive work of the Institute for Healthcare Improvement on health care collaboratives,a the American Society of Anesthesiologists (ASA) Perioperative Surgical Home Learning Collaborativeb promotes participants’ sharing their practice change experiences and related clinical, operational, and fiscal outcomes data.

Successful innovations must address the needs of multiple stakeholders. That is particularly true in the highly specialized area of heath care, where the deliverable requires many individuals with specialized skills. For the Perioperative Surgical Home to be successful, it must fully embrace surgeons, internists, pediatricians, the myriad of other invested perioperative health care providers, and hospital administrators.7 Local implementation of the Enhanced Recovery after Surgery (ERAS)c protocols8 is an initial, viable Perioperative Surgical Home model. ERAS may be more readily accepted by surgeons given their (European) specialty colleagues’ integral role in developing ERAS protocols.

The anesthesiologist-directed Perioperative Surgical Home model has been hailed by its innovators and early adopters as a positive “disruptive innovation.”9 However, the truly successful disruptive innovation must provide perioperative care more simply, more accessibly, and at lower cost. It must make better care available to more patients.10 In the United States, many anesthesiologists have professionally benefited from the present anesthesia care team model, including medical direction of nurse anesthetists. Prielipp et al.3 predict that more “routine care” will likely in the future be provided by anesthesiologists supervising, not medically directing, a cadre of lower-cost physician extenders (e.g., nurse anesthetists, other advanced practice registered nurses, and anesthesiology assistants), practicing at “the top of their license.” We agree that advanced practice health care providers will be essential to any clinically effective and economically efficient implementation of the Perioperative Surgical Home.

A growing number of academic anesthesiology departments in the United States have renamed themselves to include perioperative medicine. The Society of Academic Anesthesiology Associations is currently working on a resolution for the ASA Board of Directors to change the name of our specialty to Anesthesiology and Perioperative Medicine. More than simple semantics, the goal is to codify the medical role of contemporary fully trained anesthesiologists. However, as astutely noted by Prielipp et al.,3 this new moniker must not be communicated to or interpreted by other key stakeholders and their leadership (e.g., the American College of Surgeons) as laying claim to their clinical turf.

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EDUCATION AND TRAINING

Accreditation Council for Graduate Medical Education: Clinical Learning Environment Review

In 1999, the Accreditation Council for Graduate Medical Education (ACGME) introduced 6 domains of clinical competency: patient care, medical knowledge, practice-based learning and improvement, interpersonal and communication skills, professionalism, and systems-based practice.11 In 2008, these core competencies were adopted by The Joint Commission. They are now mandated in the Focused Professional Practice Evaluation and subsequent Ongoing Professional Practice Evaluation of all credentialed clinicians.12,13

As ACGME program requirements became more prescriptive and their administration burdensome, opportunities for innovation in education have progressively disappeared.11 Recognizing the limitations of its previous system, as of July 2014, the ACGME has fully implemented its Next Accreditation System, including provisions for anesthesiology training. A major component of the ACGME Next Accreditation System is the Clinical Learning Environment Review (CLER) program.14,15

The CLER program will provide United States teaching hospitals, medical centers, health systems, and other clinical settings with periodic feedback in 6 multipathway focus areas (Table 1).16 This feedback will be accomplished via CLER site visits, every 18 to 24 months, which will involve also interviewing the executive leadership of the health care organization (i.e., the “C-Suite”) and visiting patient floors, care units, and service areas to gather input from clinical staff as to how the organization functions as a learning environment.14,15

Table 1

Table 1

With its Next Accreditation System, the 2 ACGME core competencies of practice-based learning and improvement and systems-based practice have been further operationalized through specialty-specific milestones. These require that residents/fellows demonstrate incorporation of patient safety and quality improvement skills into their daily activities.17 Milestones have been generated by the ACGME/American Board of Anesthesiology (ABA)18 for the core anesthesiology residency and the currently accredited fellowships.d

As part and parcel with the educational continuum, the ACGME has recognized the need for faculty development in the CLER focus areas, particularly patient safety and health care quality. In collaboration with other key organizations, the ACGME is committed to developing resources to educate and support faculty (and executive) leadership across the 6 CLER focus areas.19

The specific emphasis of the ACGME CLER program on an academic medical center collectively improving patient safety, health care quality, and transitions in care is consistent with the priorities of the Perioperative Surgical Home. Meeting the educational and training objectives of the CLER program requires a strong alignment with clinical care. The ACGME CLER program could thus be an excellent opportunity for the specialty of anesthesiology, in collaboration with the other major educational and clinical stakeholders from surgery, internal medicine, and pediatrics, along with institutional leadership, to allocate the resources needed to develop, implement, and track a successful, mission-aligned Perioperative Surgical Home model of health care delivery.

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American Board of Anesthesiology (and Perioperative Medicine)

As of July 2013, the American Board of Internal Medicine and the ABA began approving combined training in internal medicine and anesthesiology. The combined training requires 5, not 6, total years of training. To date, 4 combined internal medicine/anesthesiology programs have been approved.c As of July 2010, the American Board of Pediatrics and the ABA began approving combined training in pediatrics and anesthesiology, also requiring 5, not 6, total years of training. To date, 7 combined pediatrics/anesthesiology programs have been approved.e A current participant in the combined pediatrics/anesthesiology residency at the Children’s Hospital Boston and Brigham and Women’s Hospital has offered a series of insightful observations in an Anesthesia & Analgesia The Open Mind article.20

While laudable, these combined primary care/anesthesiology residency training programs will annually produce at most a handful of dual specialty–trained clinicians. Most of them will likely stay on as Department of Anesthesiology and Perioperative Medicine faculty at academic medical centers. Given the staggering median debt of United States medical school graduates (US$170,000 in 2012),21 it is doubtful that many such trainees will elect to pursue an additional sixth year of clinical fellowship training, let alone a seventh year of dedicated research training or a relevant Master in Business Administration, Master in Public Health, Master of Science in Health Administration, or Master of Science in Health Care Informatics.

We wholeheartedly agree with Prielipp et al.3 that a fundamental transformation of anesthesiology residency training is needed, including training a cohort of “super specialists” in either multispecialty adult anesthesiology, pediatric anesthesiology, critical care medicine, pain medicine, or academics/research. To this list, we would add formal training and expertise in management science, reflecting the recently recognized major fourth mission of practice management in any anesthesiology practice.6 Perhaps, the predicted paradigm shift espoused by Prielipp et al. will eventually result in fewer anesthesiology residency programs and graduates. However, we must ensure that we can produce an adequate number of suitably trained anesthesiologists to deliver on the expanded scope of the Perioperative Surgical Home, lest we overpromise and underdeliver.

A more practical and immediately high-impact approach would be to revamp the current anesthesiology residency to provide didactics and training in perioperative medicine throughout the 4-year curriculum. The considerably revised first postgraduate year would provide a more relevant clinical base experience and be fully integrated into the anesthesiology and perioperative medicine residency. The third clinical anesthesia year would be dedicated to subspecialty training (e.g., perioperative medicine), as originally intended by the ABA. The optional fourth clinical anesthesia year would remain devoted to clinical fellowship training.f

The ASA Subcommittee on Perioperative Surgical Home Education has developed a comprehensive inventory of core competencies and skills for the anesthesiology resident. The final product of this taskforce will include a set of recommendations to be submitted to the ASA Vice Presidents of Scientific Affairs and Professional Practice and to be passed along to the ASA Administrative Council for consideration for submission to the ACGME and its Anesthesiology Residency Review Committee.g

Currently, 2 American universities (Stanford University and University of California, Irvine) and 2 Canadian universities (University of Manitoba and University of Toronto) offer postgraduate fellowships in perioperative medicine.22 However, there is a paucity of published literature on what a perioperative medicine fellowship curriculum should include.22 Nevertheless, we believe that fellowships in perioperative medicine should be generally incorporated into anesthesiology training programs, with formal accreditation by the ACGME and a board eligibility/certification pathway through the ABA. Just as currently with critical care medicine and pain medicine, in concert with the American Board of Medical Specialties, the ABA would offer board eligibility to physicians who complete primary residencies in the closely interrelated specialties such as surgery, internal medicine, and pediatrics. A temporary alternate pathway to board certification would be offered to attending physicians actively practicing perioperative medicine.

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RESEARCH

Extramural funding is increasingly scarce for clinician-scientists. Anesthesiologists are at a further disadvantage because, unlike 3-year internal medicine and pediatric subspecialty fellowships that include bona fide research training and mentorship, 1-year anesthesiology fellowships provide strictly clinical training. Because few resources are allocated to research training during this 1 year, graduates of these clinical fellowships have less chance of extramural funding.

It has been estimated that 40 cents of university funds are required for each dollar of external funding (including direct and indirect costs) received.23 This even greater investment is compounded in anesthesiology and surgery, where the current National Institutes of Health (NIH) direct salary funding cap of US$179,700 is not commensurate with academic faculty salaries. This will pose an even greater challenge as operational surpluses and discretionary cash reserves in academic departments dwindle or completely disappear.

Nevertheless, we disagree with the proposal by Prielipp et al.3 that extramurally funded research be limited to a subset of academic programs by coalescing the best scholars to institutions most recognized for research expertise. Like Warner and Apfelbaum,4 we cannot envision how such a consolidation process would be adjudicated. Instead, let grant agencies and their evolving research priorities continue to determine the competitive allocation of extramural funding, and medical school deans and department chairs determine the allocation of locally available cross-subsidies. The fluidity of the annual Blue Ridge Institute for Medical Research NIH funding rankingsh and the recent rapid prominence of the Patient-Centered Outcomes Research Institute support a the free-market approach to extramurally funded research.

The Perioperative Surgical Home must be extensively studied.24 This research will build on the substantial existing corpus of perioperative management research undertaken by Dexter et al.i as well as perioperative health services and outcomes research done by others.25 Dissemination and implementation of research methods will play a major role in studying the population health impact of the Perioperative Surgical Home.26 Such novel practice-based research represents the much needed “Blue Highways” on the NIH research roadmap, which will provide the essential link between bench discoveries, bedside efficacy, and everyday clinical effectiveness.27 This clinical outcomes, health services, and management science research will take anesthesiologists into new methodologies and interdisciplinary collaborations. Such research can thus strengthen alignment with our surgical, medical nursing, and administrative colleagues.

The Vanderbilt University Department of Anesthesiology has initiated a “Clinician Scientist Training in Perioperative Science Fellowship,” which is supported by an NIH T32 funding mechanism. This highly innovative fellowship prepares basic and clinician-scientists for the unique challenges associated with the optimization of perioperative care. Fellows are offered training in 4 research areas: mechanisms and management of pain, pharmacology and pharmacogenomics, perioperative stress biology and outcomes, and health services and translational research.j Ideally, such additional focused research training opportunities will be created soon at other institutions.

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MANAGEMENT AND LEADERSHIP

Dexter et al.6 have validly recognized and documented that academic (and nonacademic) anesthesiology departments have substantial management responsibilities, including directing the operating rooms, coordinating sedation, informatics, ongoing professional performance evaluation, staff scheduling, and workroom inventory management. We suggest a broader scope of what Dexter et al. have called the fourth mission be applied that includes not only operational management, but also administrative and strategic leadership activities.

The combined effects of coverage expansions under the Affordable Care Act, faster economic growth, and an aging population (the “Silver Tsunami”) are expected to result in greater demand for health care goods and services and to fuel health spending growth at 6.0% per year from 2015 to 2023.28 Health care expenses as a fraction of the US gross domestic product are thus expected to increase from 17.2% in 2012 to 19.3% in 2023.28

There has been a seemingly never-ending debate about the Centers for Medicare & Medicaid Services (CMS) sustainable growth rate.29 However, “sustainable growth” is an oxymoron. As documented by recent audits and projections by the Office of the Actuary at CMS,30,31 the growth of federal health care spending is not sustainable.

Prielipp et al.3 suggest that value-based purchasing by CMS and commercial payers is encouraging health care providers to take a broader view of each patient’s clinical experience and provide for the continuum of care into and out of the surgical suite. We daresay that such financial risk sharing by providers mandates that anesthesiologists play a more active and visible role in optimizing the entire perioperative continuum of care, including preoperative optimization (e.g., prerehabilitation), enhanced postoperative recovery (e.g., opioid-sparing multimodal analgesia), and cost-efficient postdischarge care (e.g., reduced hospital readmissions). Furthermore, high-level institutional participation by anesthesiologists in determining clinical productivity, operational efficiency, and pay-for-performance metrics, as well as in developing integrated funds flow models and negotiating bundled payments, all represent vital management and leadership opportunities.

Like virtually all other sectors in health care, anesthesiology is subject to market forces. In a 2011 Anesthesia & Analgesia Special Article, Scurlock et al.32 presented a needs assessment for unsolved problems in anesthesia business strategy (our “industry”) using Porter Five Forces Analysis (Fig. 2).33 Based on a narrative literature review, these authors found little previous investigation for 2 of these 5 forces (threat of new entrants and bargaining power of suppliers), modest understanding for 1 force (threat of substitute products or services), and substantial understanding for 2 forces (bargaining power of customers and jockeying for position among current competitors).32

Figure 2

Figure 2

This narrative review was proposed (at the time) by its authors as likely useful only for markets with anesthesia groups competing and functioning as independent decision-making entities that are distinct from their hospitals.32 However, we believe that their market forces needs assessment is valid in analyzing the emerging Perioperative Surgical Home within a more integrated health care system or a more consolidated anesthesia services market. This needs assessment also provides a roadmap for accomplishing and further researching the fourth mission of operational management and strategic leadership. For example, a very recent study of the relationship between competition and quality in procedural cardiac care observed that hospitals located in more competitive markets did not demonstrate better publicly reported quality metrics or lower costs.34

To continue to adequately fulfill the fourth mission of operational management and strategic leadership, anesthesiologists will need additional formal education. For example, a Leadership Education and Development (LEAD) program has been implemented in the University of Alabama at Birmingham Department of Anesthesiology. This LEAD program offers resident learning tracks in research, quality and patient safety, health care administration, and health care organization and policy. Residents can obtain a Master of Science in Health Administration or Master of Science in Health Care Informatics through affiliated schools at the University of Alabama or Certification in Medical Quality through the American Board of Medical Quality. A LEAD program participant’s costs are offset in part by departmental philanthropic funds, including from our current faculty, residency alumni, and state anesthesiology society, who recognize the importance of such skills in present and future anesthesiologists. The goals and objectives of the University of Alabama at Birmingham LEAD program are also fully aligned with those of the ACGME CLER program (Table 1) and its promulgated milestones for the core anesthesiology residency and the currently accredited fellowships.18

For currently practicing anesthesiologists, Dr. Franklin Dexter in the Division of Management Consulting in the University of Iowa Department of the Anesthesiology offers an intensive and well-established multimedia course, “Education in Operating Room Management.”k Many of the fundamentals and advanced concepts taught in this course, including management research methodology, are directly applicable to the Perioperative Surgical Home.

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CONCLUSIONS

First applied by Socrates and Plato, the dialectic method is a means of inquiring into and arriving at the truth by rational reflection and argument by the exchange of logical and reasoned arguments, usually in the form of questions and answers.35,36 Articulating opposing arguments can lead to greater mutual understanding, an appreciation of the limits of knowledge, and herein to improved health care policy, advocacy, delivery, and economics.37

We respectfully submit that much needed medical dialectic (dialog) has been heretofore lacking on the role of Perioperative Surgical Home model and perioperative medicine in anesthesiology. The myriad of valid questions raised by Prielipp et al.,3 the thoughtful insights provided by Warner and Apfelbaum,4 and their collective dialog5 represent such an important effort.

Prielipp et al.3 start by quoting Yogi Berra. We end by quoting Billy Joel: “They say that these are not the best of times, but they’re the only times I’ve ever known. And I believe there is a time for meditation in cathedrals of our own.”l

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DISCLOSURES

Name: Thomas R. Vetter, MD, MPH.

Contribution: This author helped write the manuscript.

Attestation: Thomas R. Vetter approved the final manuscript.

Name: Jean-Francois Pittet, MD.

Contribution: This author helped write the manuscript.

Attestation: Jean-Francois Pittet approved the final manuscript.

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

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FOOTNOTES

a Institute for Healthcare Improvement: Collaboratives. Available at: http://www.ihi.org/engage/collaboratives/Pages/default.aspx. Accessed December 25, 2014.
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b American Society of Anesthesiologists: Perioperative Surgical Home Learning Collaborative. Available at: http://www.asahq.org/. Accessed December 23, 2014.
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c Enhanced Recovery After Surgery (ERAS®) Society: ERAS Guidelines. Available at: http://www.erassociety.org/. Accessed December 23, 2014.
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d Accreditation Council for Graduate Medical Education, Anesthesiology Milestones. Available at: www.acgme.org/acgmeweb/tabid/128/ProgramandInstitutionalAccreditation/Hospital-BasedSpecialties/Anesthesiology.aspx. Accessed December 25, 2014.
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e American Board of Anesthesiology: Combined Training Programs. Available at: www.theaba.org/Home/AnnouncementLetter. Accessed December 21, 2014.
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f Personal communication: American Society of Anesthesiologists Committee on Future Models of Anesthesia Practice. November 21, 2014.
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g Personal communication: Zeev N. Kain, MD, Chair, American Society of Anesthesiologists Sub-Committee on Education: The Resident Anesthesiologist. December 24, 2014.
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h Blue Ridge Institute for Medical Research: NIH Awards. Available at: www.brimr.org/NIH_Awards/NIH_Awards.htm. Accessed December 25, 2014.
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i Bibliography, Division of Management Consulting, University of Iowa Department of the Anesthesiology. Available at: http://www.franklindexter.net/bibliography_TOC.htm. Accessed January 8, 2015.
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j Vanderbilt University Department of Anesthesiology: T32 Fellowship. Available at: www.mc.vanderbilt.edu/root/vumc.php?site=1anesthesiology&doc=45123. Accessed December 22, 2014.
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k Education in the Operating Room; Division of Management Consulting, University of Iowa Department of the Anesthesiology. Available at: www.franklindexter.net/education.htm. Accessed January 8, 2015.
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l Billy Joel: Summer, Highland Falls. Available at: www.billyjoel.com/music/turnstiles/summer-highland-falls. Accessed January 8, 2015.
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