Author: KRAIG S. DE LANZAC, MD
A guest column by the American Society of Anesthesiologists
Daily, and often several times a day, I am asked by patients about my role as a physician anesthesiologist. Occasionally the answer involves reiterating to patients that an anesthesiologist is a physician. Once we get into the discussion, patients are also surprised to learn that as part of an anesthesia care team (ACT), although I am frequently in their operating room and always available, I may not be physically present in their OR throughout the entire procedure. This is usually when confused or frightened faces appear before I explain exactly what the ACT is and how it provides very safe anesthesia care. More intriguing to me is that other medical specialists and health care providers often have the same questions and they don’t always understand the concept and inner workings of the ACT. The anesthesia care team is no different from any other team approach in health care.
Patients are not surprised to encounter various professionals participating in their health care. Nurses administer their medications, a technician or aide takes their blood pressure, or a therapist may assist with specific care needs. But those patients know their physician is ultimately coordinating the overall care. The input of the care team is essential for the physician to make the best decisions about the care of patients and to carry out that care plan. The same concept is true for anesthesia care.
Almost all anesthetics in the U.S. are delivered by physician anesthesiologists or by non-physician anesthesia providers directed by a physician anesthesiologist. The terms “direction” and “supervision” with regard to the role of the physician anesthesiologist are used in the context of billing for anesthesia services and outside the scope of this article. Regardless of the term used, the care of the patient is ultimately the responsibility of the physician anesthesiologist.
As with any team, there has to be a leader. In the ACT, that leader is the physician anesthesiologist, who — with four years of anesthesiology residency and four years of medical school education after completing a pre-medical course of studies in college — brings advanced skills and broad medical knowledge and training to the patient’s bedside. Along with the patient’s surgeon, primary physician or specialists such as cardiologists and pulmonologists, the physician anesthesiologist determines the appropriate degree of patient preparation for surgery.
Using the wide scope of the physician anesthesiologist’s medical training, the patient’s coexisting medical problems and their treatments can be evaluated and a plan for their anesthetic management formulated. Patients carry all of their coexisting medical problems into the OR, and the physician anesthesiologist helps tailor a plan to minimize the effect of the surgery and anesthetic on those conditions, and vice versa. The physician anesthesiologist evaluates and examines patients preoperatively, develops and implements the anesthetic plan, participates in the most demanding portions of the anesthetic, monitors the anesthetic at frequent intervals, remains physically available for diagnosis and treatment of any events, provides postoperative care and performs a postoperative evaluation. In the ACT model, the physician anesthesiologist also must ensure that qualified individuals are delivering the anesthetic and that they are monitored appropriately.
When the physician anesthesiologist is not personally delivering the anesthetic, as in the ACT model, anesthesia is delivered by qualified anesthesia personnel under the direction of an anesthesiologist. Qualified anesthesia personnel include anesthesiology residents and fellows and non-physician anesthetists such as nurse anesthetists and anesthesiologist assistants (AAs). The fellows and residents are physicians undergoing education and training to become physician anesthesiologists. Nurse anesthetists can most applicably be compared to advanced practice nurses with specific training in the delivery of anesthesia, and AAs can most applicably be compared with physician assistants with specific training in the delivery of anesthesia. The physician anesthesiologist, as with any other physician, may delegate appropriate tasks to non-physician providers as long as the physician remains ultimately responsible for the care of the patient.
Now that we know the players on the team, how does the ACT operate? I find it easy for patients to conceptualize the ACT as a “micro” version of the care delivered in intensive care units (ICUs). In the ICU, the intensivist or primary physician is the leader of the team. The ICU nurses, respiratory therapists, nutritionists, physical therapists, technicians and aides provide continual monitoring and input to patient care when the physician is not at the bedside. The intensivist may only come around once or twice during the day, but they provide the direction of the care. The job of the other team members is to carry out the physician’s care plan and vigilantly monitor for any changes, which may necessitate a change in the plan or an immediate intervention by the physician. Anesthesia care is the same within a smaller timeframe.
In fact, in most cases the physician anesthesiologist is present in the OR a higher percentage of time during the anesthesia care than the intensivist in the ICU. Additionally, the physician anesthesiologist is always present and immediately available to respond quickly to any changes in the patient’s condition.
In highly functional teams such as the ACT there must be a clear understanding of the roles of the team members, a commitment to honesty and very effective communication in all directions. The physician anesthesiologist must rely on the expertise of the team members to recognize important developments and relay those events to the physician anesthesiologist. The anesthesiologist must be responsive to the changes and use diagnostic skills to determine if adjustments or treatment is needed. Technology has greatly increased the speed of the communication and hopefully the effectiveness of what is communicated.
In the ACT, the providers have a shared responsibility for the care of the patient and an understanding of the roles each provider plays. When difficulty arises, the ACT allows coordination of efforts through teamwork to allow for the safest outcomes. Given the shared goal of patient safety, the ACT approach is an excellent example of coordinated care among many disciplines, and the safety of modern anesthesia speaks to this achievement.
Whether you are a patient or a family member preparing to undergo an anesthetic, ask to meet your physician anesthesiologist and inquire about how the anesthesia will be delivered to you or your family member. Be informed about the members of the anesthesia care team at your facility. Request that a physician anesthesiologist be involved with your care … because when seconds count, physician anesthesiologists save lives.