The Role of Anesthesiologists

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By Michael C. Brody, M.D., and Donald E. Martin, M.D.

Overview
Pennsylvania
"Anesthesia Care Team"
Designing Staffing Models
The Anesthesiologist's Expanding Role
Looking To The Past to See Our Future


Overview

An anesthesiologist is a physician licensed to practice medicine, who has successfully completed a residency training program in anesthesiology accredited by the Accreditation Council on Graduate Medical Education (ACGME) or the American Osteopathic Association. An anesthesiologist receives a minimum of 8 years of medical education after completing their undergraduate college education. 

The American Board of Medical Specialties (ABMS) recognizes the American Board of Anesthesiology as one of its member boards establishing benchmarks of expertise and professionalism for board certified specialists. Many anesthesiologists receive additional accredited subspecialty fellowship training and subspecialty board certification after completion of their residency training. Anesthesiology is the practice of medicine; as such the delivery of anesthesia requires the skills and knowledge that a physician acquires through medical training.

In 2011, the practice of Anesthesiology, and comprehensive training in Anesthesiology, include:

  1. Patient medical care during surgical, obstetric, radiologic, or medical diagnostic and therapeutic procedures
  2. Diagnosis and treatment of acute, chronic and cancer-related pain;
  3. Management of critically ill patients in any surgical or non-surgical setting, including
    1. Clinical management of cardiac and pulmonary resuscitation;
    2. Evaluation of respiratory function and the application of respiratory therapy;
    3. Trauma and emergency care
    4. Management of cardiopulmonary bypass or bridges to care which include but are not limited to management of intra-aortic balloon pumps (IABP) or extra-corporeal membrane oxygenation (ECMO)
    5. Transesophageal echocardiography
    6. Ultrasonography for regional anesthetics, vascular access as well as other patient physical assessments and procedures.
    7. Other specialized diagnostic or therapeutic procedures including but not limited to somatosensory or motor evoked potential monitoring and venovenous bypass
  4. Conduct of clinical, translational, basic science and outcomes/best practice research;
  5. Hospital, Operating Room, Ambulatory Surgical Center, and Medical Group Practice management, including setting standards and policies for the administration of anesthesia and procedural sedation throughout hospitals and ambulatory surgery centers.

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Pennsylvania

The most recent data available from the Pennsylvania Department of Health (2008-2009) indicate that anesthesiologists are on staff at 94.8 percent of Pennsylvania hospitals. These hospitals account for 99.3 percent of cases performed in Pennsylvania. Nationwide, an estimated 40 million anesthetics are administered each year with anesthesiologists providing or participating in more than 90 percent of these anesthetics. (Anesthesia Fast Facts, American Society of Anesthesiologists website) Anesthesiologists may personally administer anesthesia to a patient, or direct anesthesia services as the leader of an Anesthesia Care Team.

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"Anesthesia Care Team"

Most anesthetics administered in Pennsylvania are provided using an "Anesthesia Care Team" model, with the anesthesiologist serving as the "director" of the anesthesia care team. Prior to surgery the anesthesiologist evaluates the patients' current state of health and is responsible for designing the anesthesia plan taking into account the patient's condition and the nature of the surgery. The anesthesia plan includes the choice of medications as well as monitoring requirements to ensure patient safety and optimal surgical conditions.

The anesthesiologist provides frequent reassessments of the patient during surgery with revisions to the anesthetic plan when necessary. The anesthesiologist also provides postoperative medical assessment and care for the patient. Postoperative medical care may take many forms including routine post-surgical pain management and cardiopulmonary resuscitation.

In addition to the anesthesiologist, the Anesthesia Care Team includes an Anesthesia Assistant (AA) or a Certified Registered Nurse Anesthestist (CRNA), and often an Anesthesia Technician. As the team leader, the anesthesiologist is responsible for developing performance and quality measures used to monitor practice patterns and standards. The anesthesiologist is also responsible for the critical evaluation of emerging medical literature and the integration of contemporary advances into daily practice.

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Designing Staffing Models

Many considerations are made when determining the staffing structure for an institution. Patient safety must remain the primary determinant. Patient safety/risk is best assessed by considering both the acuity of the patients served at the facility and the complexity/risks of the procedures performed. Other considerations determining the staffing structure include the number of hours staffed per day, the number of days staffed per week (after hours/weekend coverage), the number of sites operating, and coverage for non-physician (AA/CRNA) break relief.

The Anesthesia Care Team model allows for providing optimal patient safety while realizing enhanced efficiency and access to care for patients. Efficiency can take the form of reduced costs (lowest expense for maximum service provided), reduced delays (wait time to schedule a procedure and "through-put" on the day of the procedure), and improved patient satisfaction.

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The Anesthesiologist's Expanding Role

Traditionally anesthetics were administered only in hospital operating rooms; today anesthetics are delivered in operating rooms and a variety of "off-site" locations including obstetrical suites, gastroenterology suites, cardiac cath/EP labs, outpatient surgery centers, and psychiatric facilities. Anesthesiologists also provide consultation and care for patients in intensive care units, and serve as consultants for inpatient and outpatients requiring advanced pain management and/or palliative care. Anesthesiologists may also serve as teachers and evaluate the performance of medical and paramedical personnel for their institution and community.

The Centers for Medicare and Medicaid Services (CMS) released a January 2011 update to their Interpretive Guidelines for the Anesthesia Services Condition of Participation for Hospitals. These new guidelines mandate that anesthesia services are organized under the direction of a qualified physician. As a result anesthesiologists have assumed a leadership role in developing and implementing medical staff rules and regulations (bylaws) that define the qualifications and supervision requirements for many "categories of practitioners", such as those providers performing "Moderate Sedation", "Deep Sedation" or obstetrical "analgesia" services.

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Looking To The Past to See Our Future

The Anesthesia Patient Safety Foundation was created in 1985 to study and reduce the occurrence of preventable adverse clinical outcomes. Anesthesiologists were among the first physicians to champion the cause of patient safety. In the 1970s mortality related to anesthesia care approached 1-2 per 10,000 anesthetics; fourty years later significant changes in anesthesia practice have lowered anesthesia related mortality to 1 per 200,000 anesthetics.

The contributions of anesthesiologists resulting in the improved medical care provided to surgical patients are widely recognized. Historic contributions to the fields of Critical Care Medicine, Emergency Medicine, Neonatology, Pain Medicine, and Hospice Care have been realized from the work of anesthesiologists such as Peter Safar, Virginia Apgar, and John Bonica.

The evolution of health care mandates and political legislation is changing the landscape of health care. Swelling special interests, such as those seen among advanced practice nurses, are challenging the basic tenets of medical practice. Politicians and agencies may ultimately define the "minimum standards" for medical care delivery.

Medical staffs are nonetheless empowered to define the "highest standards" of medical care and will ultimately define the care provided to the patients they serve. Anesthesiologists will continue to enthusiastically share their unique perspectives and expertise while serving as members of their medical staff. Anesthesiologists are also increasingly getting involved in grassroot movements to impact legislative reform and secure the advancement of anesthesia quality and patient safety.

As an example of this involvement, the American Society of Anesthesiologists has formed and funded the Anesthesia Quality Institute, dedicated to the analysis of anesthesia practice and clinical data to raise the standards of quality and safety in the practice of anesthesiology around the world.

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Physicians

Physicians Protecting Patients