Authors: Marc P. Steurer, MD, DESA et al
ASA Monitor 12 2015, Vol.79, 18-20.
There are interesting similarities and differences in clinical anesthesia practice and organization between the U.S. and Europe.A detailed analysis stratified for all European countries and the different regions of the U.S. is beyond the scope of this newsletter. However, since both authors have worked in public hospitals in both Switzerland and San Francisco, the comparison of pertinent practice variances will mainly focus on these two settings.
Scope of Practice
In most western European countries, the clinical anesthesiologist is more longitudinally involved in patient care. It starts with a heavy involvement in prehospital emergency medicine. Anesthesiologists are trained and available to go to the scene of an accident or medical emergency. In some systems, dispatch will activate them with the initial call and the anesthesiologist gets to the scene as part of the crew with the primary ambulance. Another approach has the anesthesiologist on standby with a dedicated emergency physician vehicle and driver that will bring her/him to the patient if called upon by the primary team. While the topic of scoop and run versus stay and play approach remain subjects for debate, the presence of a well-trained physician enables more complex protocols and front-line decision-making. It also provides an early starting point for continued care. Not only do anesthesiologists govern the prehospital portion of emergency medicine, but also once the intrahospital care begins. Together with the primary team, an anesthesiologist is usually involved in the care of the most ill medical and surgical patients in the hospital. Also in those settings, the anesthesiologist stays with the patient for the entire critical period and provides a very helpful continuum of care. In Europe there is also a heavy involvement of anesthesiologists in both medical and surgical ICUs. Additionally, operation room (O.R.) management, preoperative and pain clinics as well as services for palliative care have been a mainstay for even small anesthesia departments for a long time. This contrasts to most U.S. practices, where anesthesiologists have predominantly focused on the intraoperative and critical care period.
The broader and more longitudinal scope of practice positions European colleagues well for the development of the field. The concept of the perioperative surgical home (PSH) is gaining momentum and acceptance on both sides of the Atlantic. The ease of implementation of the PSH may be affected by the current scope of anesthesia practice in the two continents.
With regard to specialization after the residency program, there are many different programs in the U.S. and Europe to become specialized in certain fields of anesthesiology, like cardiac, pediatric, neuro-anesthesia or pain.
The daily care that patients receive on either side of the Atlantic Ocean is overall not very different; the variation from site to site and region to region is sometimes greater than the general diversity between the two continents.
Workflow in anesthesia practice (e.g., dedicated holding areas or induction rooms present to reduce turnover times), depends more on the department than the country. There are some areas, however, where distinct diversity in practice seems to correlate with continent. The staffing per anesthesia differs and most European countries mandate two professionals to provide anesthesia (physician and assistant, e.g., certified registered anesthesia nurse): this means that an anesthesiologist and an assistant are both present during all critical events of the anesthesia (e.g., induction and emergence). In contrast, in the U.S., the anesthesia physician may provide anesthesia alone without a trained assistant. The setup with anesthesia assistants such as nurse anesthetists and anesthesia technicians also differs to some degree. Additionally, the regulatory constraints appear to be rather asymmetrical between the two continents; there are a good number of very influential regulatory bodies in the U.S., where most European countries do not possess the same regulatory mandates yet.
Intraoperative anesthesia practice is very similar between the U.S. and Europe; however, clinical practice may differ slightly: the following two examples are used to illustrate this. The practices around neuromuscular blockade have been the focus of a survey that took place 2008 in both Europe and the U.S. While the availability and choice of neuromuscular blocking agents did not diverge between the two, there were some interesting differences.1 The U.S. colleagues were significantly more likely to routinely administer an anticholinesterase at the end of all procedures and rely on clinical signs as indicators for reliable recovery of the neuromuscular blockade. At the same time, in Europe, anesthesiologists had a much greater availability of quantitative neuromuscular monitors (e.g, train of four stimulation) and were interestingly more likely to not use an anticholinesterase. Another very good example is the field of trauma resuscitation. As summarized by Rick Dutton, M.D. in a recent review article, the U.S. practitioners prefer and practice in a system that favors a rapid transport to definitive care for the injured, uses crystalloid as the initial resuscitation fluid and deploys an empiric 1:1:1 approach for transfusion of red cells, plasma and platelets in massively bleeding patients.2 In contrast, most European practices include a prehospital emergency physician, a lower threshold for the administration of tranexamic acid, the use of sophisticated algorithms and bedside viscoelastic coagulation testing for targeted hemostatic management.3 Thereby, and with the availability of coagulation factor concentrates in Europe, the use of plasma in coagulation management has been decreased dramatically over the last two decades.
Education and Training
After medical school in either Europe or the U.S., physicians are required to complete a residency program that includes many board-required elements and encompasses the full scope of perioperative medicine. Additionally, most programs in Europe require the successful completion of both oral and written exams in order to complete the program; just like their U.S. counterparts. The main difference is that the duration of training in Europe lasts longer, as most residency programs are one year longer than in the U.S. and often include more time in the ICU. Also, while the U.S. offers a number of formal fellowships after the completion of the anesthesia residence, some European countries only present the opportunity to do such training under informal circumstances (e.g., Switzerland). Another difference is the presence of a specific board certification in critical care in some European countries like Switzerland. In the U.S., it requires one additional year of fellowship training after residency. Interestingly, despite the significant longer duration of the anesthesia/critical care program in Europe (two to four additional years), it seems that a larger number of colleagues actually chose that pathway.
There is a noteworthy amount of heterogeneity among European residency programs. Some countries have programs, which are similar to the U.S.; they feature a structured education of the residents within a dedicated network of training hospitals. The candidate completes all necessary training within a given system. Other countries have a less organized approach, where the trainee has to put together her/his curriculum. In those settings, the governing bodies just dictate certain objectives and goals that have to be met within defined periods, but do not do so in a more prescriptive fashion. Working hours also vary between different countries. Over the past decade, many European countries were legally mandated to decrease their weekly working hours to 40-50 hours. The potential impact on education and practical training has to be considered.
Non-M.D. Anesthesia Providers
The two continents do differ in training and deployment of non-M.D. anesthesia personnel. The provision of anesthesia is either directly provided by a physician or supervised by an M.D. in most Western European countries. In contrast, nurse anesthetists in many U.S. states may provide direct care to patients without M.D. medical guidance. Many European countries have similarly trained nurse anesthetists, and while they work very closely and well together with the physicians, their role is less independent than their U.S. counterparts. European nurse anesthetists usually do not consult and consent on patients preoperatively, as they are mainly focused on providing clinical care together with a physician in the O.R.. Anesthesia technician positions do not exist in most European systems. Consequently, nurse anesthetists perform a number of tasks that the technician would do in the U.S. system. However, the current roles and competencies of the European nurse anesthetists have been questioned lately as a result of the increasing economic pressure in health care and the shortage of anesthesiologists. As in the U.S., several European countries have started to consider expanding the competencies of their nurse anesthetists.4
Overall, anesthesia practice is very similar in the U.S. and Europe – the techniques and quality standards being used are comparable in all Western countries. However, each state in the U.S. and each country in Europe is unique. There are specific differences in regulation, training (duration, content and specialization), working hours, the scope of practice, and the personnel with respect to number, composition and competencies.
Naguib M, Kopman AF, Lien CA, Hunter JM, Lopez A, Brull SJ . A survey of current management of neuromuscular block in the United States and Europe.Anesth Analg. 2010;111(1):110–119.
Dutton RP . Management of traumatic haemorrhage – the US perspective.Anaesthesia. 2015;70(suppl 1):108–111.
Steurer MP, Mt, Ganter . Trauma and massive blood transfusions. Curr Anesthesiol Rep. 2014;4(3):200–208.
Egger Halbeis CB, Cvachovec K, Scherpereel P, Mellin-Olsen J, Drobnik L, Sondore A . Anaesthesia workforce in Europe. Eur J Anaesthesiol.