Discipline of Anesthesiology

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By Donald E. Martin, M.D. 

The Practice of Anesthesiology in Pennsylvania 
Qualifications of an Anesthesiologist 
Development of the Medical Specialty of Anesthesiology 
Patient Safety in Anesthesiology 
Pennsylvanians Value Physician Anesthesiologists 
Anesthesiologists - Reducing Costs of Care 
Continued High Standards of Anesthesia Care in 2010

The Practice of Anesthesiology in Pennsylvania

According to the most recent data we have from the Pennsylvania Department of Health, approximately 1.8 million surgical procedures are performed annually in the 170 general hospitals in Pennsylvania. Of these procedures, 99.7 percent were performed in hospitals staffed by Pennsylvania’s more than 1,800 anesthesiologists.

Anesthesia for these procedures was provided by the anesthesiologists, either alone or with the help of nurse anesthetists. In the Pennsylvania general hospitals not staffed by anesthesiologists and in some physician and dental offices, anesthesia was provided by nurse anesthetists supervised by the operating physician or, for dental procedures, by the operating dentist.

According to these same Department of Health statistics, only four of Pennsylvania’s hospitals were staffed by nurse anesthetists but not anesthesiologists. 

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Qualifications of an Anesthesiologist

Anesthesiologists are medical specialists, licensed physicians who, after graduation from college and then medical school, have completed at least four years of residency training in medicine, surgery and anesthesiology.

At the conclusion of this training, the director of the physician’s residency training program must certify the resident as clinically competent. Then, in order to be a board-certified specialist, he or she must past two national examinations, one written and one oral, given by the independent American Board of Anesthesiology or American Board of Osteopathic Anesthesiology. Both boards are recognized members of the American Board of Medical Specialties. 

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Development of the Medical Specialty of Anesthesiology

The anesthetic nitrous oxide, still in common use today, was first prepared by a Pennsylvanian, Joseph Priestley, in 1773. It was not until more than 70 years later, however, that anesthetics were used to relieve pain during surgical procedures.

The era of anesthesia and modern surgical care began in the 1840s, when ether was first used to provide for the relief of pain during surgery by Dr. William Green Morton, a Boston dentist, and Dr. Crawford W. Long, a Georgia physician and an 1838 graduate of the University of Pennsylvania.

Anesthesiology became a recognized medical specialty in 1941 with the founding of the American Board of Anesthesiology. Additional sub-specialty certification was established for anesthesiologists with special interests in critical care medicine in 1986 and in pain management in 1993. 

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Patient Safety in Anesthesiology

The administration of anesthesia can be a dangerous undertaking, in even the best circumstances. General anesthesia removes a patient’s ability to control his or her most basic life functions, including the ability to move and to breathe.

In addition, the use of some anesthetics requires the anesthesiologist to perform medical procedures, which include placement of needles and plastic catheters in the heart, large blood vessels, and near major nerves.

However, complications from anesthesia have declined dramatically during the last 25 years. Since 1970, the number of anesthesiologists has more than doubled, and the percentage who are fully qualified and board-certified has increased.

At the same time, and at virtually the same rate, patient outcomes have improved. Since 1970, estimates of the frequency of death due to anesthesia have dropped 25 fold, from 1 in 10,000 procedures to 1 in 250,000.

That decrease is even more remarkable considering that, during this time period, surgical procedures have become more complex and are being performed on older and sicker patients who present greater anesthesia risks.

A 1996 review of the literature concludes that this improvement in safety has resulted from the increase in the number of fully qualified physician anesthesiologists and the improvements in anesthesia techniques, technology, and patient monitoring that they have pioneered. (Abenstein JP, Warner MA, Anesth Analg 82:1273, 1996)

Several scientific studies have shown that patient outcomes improve when anesthesiologists provide or direct the care of surgical patients.

Two have been performed by the multidisciplinary group headed by Jeffrey H. Silber, M.D., Ph.D., at the University of Pennsylvania. The first, published in Medical Care 1992:30:615-629, found that success in patient “rescue” (following an adverse perioperative event) increased in direct proportion to the number of board certified anesthesiologists available on the medical staff.

The second and more detailed study was more recently published by Silber and his colleagues (Anesthesiology 2000;93:152-163). This study was based on a sample of Medicare patients cared for in Pennsylvania by nurse anesthetists who were supervised either by anesthesiologists or by physicians of other specialties.

Death rates were higher (2.5 more deaths/1,000 patients) than expected, as were “failure to rescue” rates (6.9 more “failures to rescue”/1,000 patients), in those patients whose care was not directed by anesthesiologists. The total number of complications of all types were not different between groups of patients. Rather, it was the management of these complications, and the patient outcomes, which were improved by anesthesiologist care. 

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Pennsylvanians Value Physician Anesthesiologists

A 1999 Tarrance Group survey reported that of Pennsylvanians over age 18, 79 percent would prefer a physician providing or directing their anesthesia, regardless of cost. Of this 79 percent, two thirds responded that they would “strongly prefer” physician direction.

If the cost of the anesthesia provided by, or directed by, the physician were the same as that provided by a nurse anesthetist alone, as is currently the case, 83 percent would prefer that their care be provided or directed by a physician. 

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Anesthesiologists - Reducing Costs of Care

Though the primary concern of anesthesiologists is patient safety, they must also be conscious of costs when looking at how anesthesia care is delivered. Medicare, Medicaid, and most private insurers currently pay an identical amount for anesthesia services, regardless of whether they are provided by an anesthesiologist, a nurse anesthetist supervised by an anesthesiologist, or a nurse anesthetist supervised by the operating surgeon.

However, the anesthesiologist delivers medical care for the patient before, during, and after surgery (in the recovery room) that is included in this cost when the services are provided by the anesthesiologist, but which must be provided by other physicians, at additional cost, if an anesthesiologist does not provide or supervise the patient’s care.

Further, when an anesthesiologist rather than a surgeon cares for the patient preoperatively, requests for medical consultation are reduced by three quarters, the cancellation of operations for medical reasons is reduced by 88 percent, and the costs of laboratory tests are reduced by 59 percent, or $112 per patient. (Wiklund RA, Rosenbaum SH, N Engl J Med 1997; 337:1132)

With the rising cost of medical care, non-physician health professionals have the potential to reduce the cost of care. For decades, anesthesiologists have trained and worked with nurse anesthetists, just as other physicians have worked with nurse practitioners and physician assistants, in order to reduce the cost of care.

In fact, the most common mode of practice in Pennsylvania is for an anesthesiologist to medically direct nurse anesthetists providing anesthesia care for simultaneous, or overlapping, surgical procedures. This allows the anesthesiologist to personally provide all of the physician services, and the nurse anesthetists to provide nursing services, to all patients most efficiently. 

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Continued High Standards of Anesthesia Care in 2010

Controlling the cost of health care, and access for all Pennsylvanians to health care, are important priorities, and must be achieved while maintaining the quality and safety of care.

Anesthesiologists are in a unique position to maintain the high standards of anesthesia care, while using their training and expertise to allow an increasing number of efficient and cost effective health care providers, including nurse anesthetists, nurse practitioners, physician assistants and registered nurses to work under the direction of anesthesiologists to provide safe and comfortable sedation and anesthesia to more patients at lower cost. 

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Anesthesiologists

Physicians Protecting Patients