The Future of Anesthesiology

摘要

“You’ve got to be very careful if you don’t know where you are going because you might not get there.”—Yogi Berra Anesthesiology is at a crossroads. The “Burning Platform” allegory highlights the dilemma facing clinical care and anesthesiology today. We are the workers trapped 150 feet above a stormy, cold ocean on a burning oil platform.a Balanced on that burning stage, our options are limited. None are attractive. For the oil rig worker, death is certain if he stays, and almost certain if he jumps. This metaphor emphasizes that in the face of uncertainty about the future, radical action is required of all of us. This analogy is particularly relevant to the practice of medicine in an unsustainable and rapidly evolving health care environment. Survival instincts (e.g., jumping 150 feet into icy water) trumps one’s instinct to hesitate and hope the current situation fades. For years, the flames of change have been nipping at the heels of the medical practice of anesthesiology. Some think we are “crying wolf.” But most health care experts and even the lay public acknowledge that we must change how we approach our patients and practice. We must adapt to new models of care. We must address some of the most vexing problems that compromise the patient-provider relationship and its impact on quality, safety, and health outcomes. As Dr. Karen Domino opined in her 2014 American Society of Anesthesiologists (ASA) Rovenstine Lecture, “This is no time for business as usual. The forces driving change are enormous, but they can be guided. The clock is ticking. The time to act is now.” EVOLVING ROLES We acknowledge that the traditional practice of anesthesiology has been undergoing change for many years, expanding some of the opportunities outside of the traditional operating room (OR) environment to include perioperative care. At the same time, even these expansions of our roles and responsibilities may not be sufficient to sustain our specialty. The future options for anesthesia practice are less clear as we confront challenges at many levels. We need to assess our current practice, build on successful initiatives, and most importantly address deficiencies in current practice and the relationship of these items to quality, safety, and costs of care to address the needs of our patients and the overall health care system. A number of changes in our scope of practice have been demonstrated to address some of these challenges. None of these changes should be undervalued nor the implications ignored. Subspecialization has created new opportunities for some of our colleagues to focus their clinical skills and practice on a subset of what has been the focus of anesthesia practice for decades. These include the specialty disciplines of obstetrical anesthesia, pediatric anesthesia, and cardiothoracic anesthesia. In addition, we have expanded our scope of practice to include critical care medicine, pain medicine, palliative care, and, for a modicum of clinicians, sleep medicine. However, in each of these areas, other medical specialists and other providers are competing for the same roles and responsibilities. Many have been formidable competitors with or without data to support their positions. Perhaps, most importantly for our specialty, anesthesiologists have taken on new administrative and clinical roles in perioperative care. We have demonstrated our ability to effectively manage patients preoperatively rather than simply assess them and provide improved care in the postanesthesia care unit and during their hospitalization. Our expanded perioperative role has occurred in parallel with the changes in the roles and expectations for surgical specialties. Surgeons are rewarded and incented to operate. As a result, our surgical colleagues have requested assistance in the management of some aspects of perioperative care. This assistance is often provided by hospitalists, nurse practitioners, and physician assistants. Finally, we have been encouraged