By Frederick L. Greene, MD
Editor’s note: Dr. Greene, clinical professor of surgery, UNC School of Medicine, Chapel Hill, North Carolina, wrote the following commentary for General Surgery News. He does not agree with the notion that anesthesiologists should assume a perioperative managerial role.
A fascinating trend in medicine that has developed during the past decade or two is the expansion of certain specialties and the creation of diverse kinds of specialists in order to fill needs abandoned by other groups of physicians.
“Intensivists” have proliferated as critical care medicine has become more complex and as many physicians have been encouraged to abdicate intensive care unit management to others.
The concept of the “hospitalist” evolved because of the desire of many internal medicine specialists to avoid taking hospital call or making rounds in the inpatient hospital setting.
Radiologists and cardiologists expanded their turf and became “interventionalists” to provide services traditionally offered by cardiac and vascular surgeons.
The “laborist” appeared as obstetricians eschewed traditional call responsibility for deliveries and encouraged hospitals and obstetrical practices to hire physicians who sought hospital-based and shift-based practices.
The “surgicalist” emerged in a similar fashion as the exigencies of acute-care surgery and the presumed burden of unassigned emergency department patients changed the mindset of many surgeons regarding hospital call.
These examples of “specialist” expansion and “turf creep” have generally occurred because of the perceived needs of patients and the medical community or as responses to the unwillingness of certain specialties to continue to provide traditional care.
Recently, I came across a new paradigm of this phenomenon: the “perioperativist.” This new creation emanates from the anesthesiology community as an expression that the anesthesiologist is the most appropriate person to have total oversight over the preoperative, intraoperative and postoperative phases of the care of the surgical patient.
I certainly recognize that the preoperative assessment is improved when coordinated with anesthesia personnel who counsel patients regarding current medications and the potential risks of anesthesia associated with certain comorbidities. The American Society of Anesthesiology (ASA) is now advocating the concept of the “perioperativist” and the Perioperative Surgical Home (PSH; see www.asahq.org) and espouses the concept that in the name of safety, economy and overall efficiency, management of operative patients should be coordinated in a multidisciplinary fashion and that this approach should be led by the anesthesiologist. The “perioperativist,” by definition, is the anesthesiologist who will provide overall support in all phases for the surgical patient.
It appears that some in the anesthesia community believe that surgeons are not capable of or have abdicated their role in the management of the perioperative patient. This includes dispensing information in the preoperative setting as well as providing appropriate post-anesthesia care and other postoperative supervision regarding perioperative drug management, pain control and even recommendations for postoperative activity.
I certainly agree that a coordinated multidisciplinary approach for the patient undergoing an operation is both reasonable and beneficial. The PSH should be a patient-centered, physician-led, multidisciplinary team–based model of coordinated care. The preoperative, intraoperative, immediate postoperative and post-discharge care should be fully coordinated and treated as a continuum of care.
My concern, however, is that in this model, the surgeon is marginalized while the anesthesiologist assumes the role of the “perioperativist” in ensuring that all of these phases are coordinated. The president of the ASA opined that “physician anesthesiologist–led anesthesia care teams are associated with better patient outcomes, fewer complications, less pain, earlier return to functionality and home, and lower costs” (ASA website, December 2014). Our anesthesiology colleagues believe that the best specialty and best specialist to coordinate this overarching activity is the anesthesiology-created “perioperativist.”
The creation of new specialty models and physician genres has generally occurred because of abdication of certain responsibilities and traditional roles previously provided by physicians and specialties. I would certainly not want to see the role of the operating surgeon sequestered solely into the technical phase of an operation while leaving the preparation, education and postoperative management of patients to the nonsurgical “perioperativist.” Although some facets of the PSH are appealing, the overall management of the surgical patient must not transition to nonsurgical specialists because of the presumption that we have undervalued or abdicated our responsibility for coordinating the care of the surgical patient. The operating surgeon should and must remain the captain of the entire ship!