In this issue of Anesthesia & Analgesia, 2 articles focus on future roles for anesthesiologists and the future of anesthesiology as a specialty. The first, “Anesthesiologists as Health System Leaders: Why It Works,”1 discusses why anesthesiologists are uniquely well suited to leadership positions and how the anesthesiology mindset and skills can contribute to efficient integrated health care delivery. The second, “Opportunities Beyond the Anesthesiology Department: Broader Impact Through Broader Thinking,”2 advocates that anesthesiology adjust its traditional missions to broader and more longitudinal aspects of population health, focusing less on episodes of care and prioritizing professional development of leaders in multiple aspects of health care. Both articles cite many valuable aspects of anesthesiology culture and practice that could be of great value to population health: team orientation; operational organization and reliability; intolerance for error; rapid response and problem solving; flexibility.
Needless to say, physicians in other specialties also have leadership and technical skills, sometimes overlapping with those of anesthesiologists. As Mathis et al2 suggest, cooperation rather than competition with these other specialties will integrate health care and improve outcomes. Future health care systems directed at improved population health are likely to blur specialty boundaries, and deemphasize specialty hegemony (turf) and competition. Clearly, the current era of guilds of superspecialists has produced amazing outcomes for select patients, but mediocre outcomes for the population at large. In considering the future of anesthesiology and health care writ large, we found the words of Prikel Avot (Ethics of our Fathers 1:14) to be particularly pertinent: “If I am not for myself, who is for me? And if I am only for myself, what am I? And if not now, when?”
Discussions about the future of anesthesiology are often overly focused on what would be best for anesthesiologists. The call for new and bigger leadership roles for anesthesiologists may not promote integration of health care and may not be well received by other specialties or the population at large. This call for a leadership role is understandable, but as suggested in the aphorism above, a contribution to a larger purpose has to be part of our mission. The critical question should be “What can anesthesiologists do to improve the health of our population?”
ANESTHESIOLOGY EXCELLENCE IN ACUTE EPISODES OF CARE ALREADY CONTRIBUTES ENORMOUSLY TO POPULATION HEALTH
Continuous advances in anesthesiology practice over 175 years have made surgeries and procedures safe and pain-free, transforming societal acceptance and enthusiasm for interventional care and dramatically improving public health. The real-time physiological monitoring and interventions that anesthesiology has developed for surgery have been widely applied to critical care medicine, producing dramatic life-saving effects, particularly in the current (and past) pandemics. Is there opportunity for additional major impact in our current arena? Mathis et al2 have recommended several specific ways in which the horizons of current anesthesiology practice can be expanded to enhance public health. We suggest generalizing some of their recommendations (see no. 2 below), with some additional suggestions:
- The benefits of safe and pain-free surgeries and procedures have been preferentially distributed to economically prosperous communities and nations. Anesthesiology should prioritize increased access to safe surgical care by reducing costs and changing practice models.
- We should better protect our patients from the delayed and persistent adverse effects of surgical trauma. Anesthesiology has made death in the operating room a rare event, but 30-day perioperative death remains a leading cause of mortality in the world.3,4 The physiological stresses of an episode of surgical trauma clearly alter a patient’s health trajectory, leading to delayed strokes, myocardial infarction, and blood clots, as well as long-lasting changes in multisystem organ function, notably cognitive and renal function. Clearly, there is enormous opportunity to anticipate and prevent these complications.
- The skills and knowledge that anesthesiology brings to physiologic monitoring and interventions should be applied to all acute care. Abundant evidence indicates that handoffs and transitions of care are major contributors to morbidity and mortality in the acute care setting.5 Anesthesiology, critical care medicine, emergency medicine, and acute care surgery need to partner to make acute care seamless and safe.
WE CAN ALSO USE OUR CURRENT PLATFORM TO IMPROVE THE SAFETY AND OUTCOMES OF TRANSITIONS BETWEEN PREVENTATIVE/CHRONIC CARE AND ACUTE CARE
Preoperative evaluation provides unique opportunities to review patient health status and treatment at a critical moment in their lives. Unfortunately, this remains a largely unrealized opportunity, likely due to high costs and limited revenue opportunities. Many patients interact with the health care system only at the time of a surgery or procedure, providing an opportunity to identify and rectify long-term medical issues. For other patients, preoperative evaluation serves as a critical interface between preventative and chronic care and acute care. Preoperative evaluation provides substantial opportunities to improve surgical outcomes, including the following:
- Identify risks and inform patients. For patients who cannot make their own decisions or have multiple comorbidities, anesthesiologists need to be part of the perioperative establishment of goals, including the plans for resuscitation during or after anesthesia.
- Adjust chronic therapy for safety during an episode of surgical care. Many outpatient treatments are hazardous or require adjustment to accommodate the circumstances and stresses of a major procedure. For example, acute interventions, such as stopping sodium-glucose transport protein 2 (SGLT2)-inhibitors 3 to 4 days before surgery or other procedures can prevent postoperative ketoacidosis.6
- Identify problems that may require modification to ensure optimal health. For example, recognition of severe pulmonary hypertension can lead to using open abdominal surgery rather than insufflation of the abdomen, thus preventing heart failure. A major surgery can also be an emotional pivot point for patients, allowing interventions to alter unhealthy behaviors, such as smoking, substance abuse, and poor nutrition. Furthermore, for patients with poor functional status, prehabilitation may provide a more systematic approach to exercise, nutrition, and psychological issues and help to improve perioperative outcomes and general health for frail preoperative patients.
In this age of superspecialization, many groups in health care have become siloed. As elegantly outlined in these 2 articles in the current issue of Anesthesia & Analgesia,1,2 we need to resist that model. We as anesthesiologists will have a great future if we use our unique skills in acute care to work with other health care professionals to create seamless care both within an acute care setting and at the interface between chronic and acute medical care. A bright future for anesthesiology is likely to result from cooperation with colleagues and an altruistic focus on population health, rather than a competitive drive to expand our turf. What anesthesiologists do is essential and valuable. We agree with Conroy et al1 that anesthesiologists have unique leadership attributes and should be leaders in health care. However, first and foremost we should be leading the integration of medical care by partnering with our colleagues in all specialties and disciplines. Our leadership should be the product of these efforts.
2. Mathis RM, Schonberger RB, Whitlock EL, et al. Opportunities beyond the anesthesiology department: broader impact through broader thinking. Anesth Analg. 2022:134:242–252.
3. Nepogodiev D, Martin J, Biccard B, Makupe A, Bhangu A; National Institute for Health Research Global Health Research Unit on Global Surgery. Global burden of postoperative death. Lancet. 2019;393:401.
5. Jones PM, Cherry RA, Allen BN, et al. Association between handover of anesthesia care and adverse postoperative outcomes among patients undergoing major surgery. JAMA. 2018;319:143–153.