The field of anaesthesiology has changed
dramatically since its beginnings. It began with the need to produce unconsciousness but then incorporated the critical management of the patient’s homoeostasis and pain control during and after a surgical procedure.
Our changing role has been well described by Dr. Kotur in an editorial in the Indian Journal of Anaesthesia1
From Gasman...to.. Anaesthesiologist... to...Perioperative Physician…to...Hospitalist
Modern anaesthesia for surgical operations was born 160 years back on 16th October and it was on this day that the ‘Gasman’ got transformed into an ‘Anaesthetist’. It took nearly a century for the birth of an independent, autonomous department having a separate existence with definite goals and objectives. Subsequently, the ‘Anaesthetist’ transformed himself into a qualified ‘Anaesthesiologist’ in the next 4-5 decades and got recognized as a frontline specialist not only inside the Operating Room but also in many Critical Care areas outside the Operating Room.
Our expertise in physiology and pharmacology propelled us into the intensive care unit, and our knowledge of neuraxial analgesia and peripheral blocks, in addition to our knowledge in physiology and pharmacology, has taken us into obstetric anaesthesia and pain management. The evolution of day surgery and same-day surgery has taken us to preoperative clinics where we interview patients, perform physical examinations, develop anaesthetic plans, including adjustment in medications before surgery, and answer patients’ questions. Given these dramatic changes in anaesthesiologists’ roles, a few departments across the country changed their names to include words such as “Perioperative Medicine/Perioperative Care”, “Critical Care Medicine”, and “Pain Management”.2,3
But the true fact is that the talents and expertise of an anaesthesiologist are not utilized to the fullest extent, in the present day patient care system.
There has been an on going debate of the Role of Anaesthesiologist as a Preoperative Physician, where do we stand today? Which way do we go?
Concept of Perioperative Physician2
The American Society of Anaesthesiologists defines the anaesthesiologist as the perioperative physician—the “all-around” physician responsible for providing medical care to each patient undergoing surgery at all stages. This includes providing the medical evaluation of the patient before surgery (preoperative), holding consultations with the surgical team, providing pain control and support of life functions during surgery (intraoperative), supervising care after surgery (postoperative), and discharging the patient from the recovery unit.
Specifically, the anaesthesiologist’s role has moved beyond just the operating room and into other areas of care.
After preoperative assessment the anaesthesiologist administers anaesthesia. During a surgical procedure, the anaesthesiologist continually assesses the medical status of the patient, monitoring and controlling vital life functions, as well as managing pain.
Postoperatively the anaesthesiologist determines when a patient can return home following an outpatient procedure and when a patient can be moved to another ward following a procedure that requires hospitalization.
The anaesthesiologist is also involved in postoperative pain management, prescribing the appropriate pain-relieving medication and therapies.
The anaesthesiologist also prescribes individualized drug therapies to patients suffering from acute, chronic, and cancer pain.
During childbirth, the anaesthesiologist must provide pain relief with epidural or spinal blocks for the mother while managing the life functions of both the mother and the baby.
In critical care and trauma medicine, the anaesthesiologist makes immediate diagnoses while supporting respiratory and cardiovascular functions, controlling infection, providing airway management, cardiac and pulmonary resuscitation, advanced life support, and pain control.
The anaesthesiologist is also present during cardiac catheterizations, angioplasties, radiological imaging, gastrointestinal endoscopies, in vitro fertilization, electroshock therapy, and respiratory therapy.
The anaesthesiologist participates in research and clinical studies, as well as medical education programmes and legislative activities
To summarise various roles of a Perioperative Physician have been defined which includes,
1. Pre-op Evaluation
2. Inter-operative management
3. Post operative care - PACU
4. ICU/ surgical ICU
5. Acute pain management
6. Chronic pain management
7. Operating room managers
8. Trauma Specialist
9. In house specialist
In India at the start, the anaesthesiologist was always a perioperative physician, he was a Casualty medical officer plus practiced anaesthesia, until the specialization and the development of anaesthesiology came about. The later day anaesthesiologist [1960’s] practiced anaesthesia, looked after surgical intensive care, did chronic pain management and during the evenings when they had free time from their routine practice, worked as general practitioners, that is like a family physician, as they were best suited for their job by virtue of their training in medicine and pharmacology, understanding of surgical needs, this role also fulfilled the need of direct patient contact and follow up. The family physician was the link of the patient to other specialist.
As times changed, specialization increased, the role of the anaesthesiologist got narrowed down to the OR, and they got busier and neglected to develop outside the OR. Intensivists and Respiratory physicians emerged to share their role in the ICU with their superior knowledge of medicine and respiratory physiology, they also had direct admitting rights to these medical oriented ICU’s and looked after their own patients, and billed for the same.
Various Orthopaedic surgeons, Neuro surgeons and Physicians took care of chronic pain. Also development of big hospitals and hospital based consultants kept many of us away from family practice in major cities.
At this current time there is development of all specialized societies like Cardiac anaesthesia and intensive care, Neuro anaesthesia and intensive care, ITTACS, SCCM, Emergency medicine, like in the West, and anaesthesiologists are forming a big part of the same, along with physicians.
In major cities the trend is gradually going back to the expanding role of anaesthesiologist outside the Operating Room as a Perioperative Physician.
All major institutes have a pre-operative clinic, post-op ICU coverage, special surgical ICU. Acute pain service is emerging, more are now doing Chronic Pain, and some exclusively doing intensive Care management.
At the Training level the scene is not clear, this varies from city to smaller towns.
The need to train in all areas of perioperative medicine is a part of the curriculum, but this does not really happen. The training is not extensive enough today to do justification to truly practice as a peri operative physician. After their basic training in anaesthesiology, individuals with interest in different areas of our growing specialities are visiting separate centres to learn them.
The potentials of an Anaesthesiologist as a Perioperative Physician have to be exposed and made use of in the improvised patient care. We must get accustomed to this new concept. Anaesthesia OPDs need to be established in all the hospitals to evaluate the surgical cases prior to admission. We should review the medical history, perform general physical examination, order the necessary investigations, decide whether to order cross consultations with other specialists and evaluate patient’s fitness for surgery. Other specialists may give feed back to the anaesthesiologists but the final decision about whether to go ahead with an elective operation is always the anaesthesiologist’s, because we are the one who understand the interaction of anaesthetics with the disease processes and the haemodynamic changes and fluid and electrolyte shifts of different surgical operations. We have a specialized training in risk assessment and understand the ‘myths’ of intra-operative period.
The ‘Pre Anaesthetic Evaluation’ of elective patients is generally performed on the previous evening, i.e. about 12 hours prior to surgery. This timing warrants an urgent reconsideration, especially for patients with complex medical problems, who have to be seen by us well in advance at least 48-72 hours prior. This facilitates us, not only to review the patients thoroughly, but also to seek additional information from other specialists and the medical literature - practice of ‘Evidence Based Anaesthesia’.
If an additional workup is necessary we can obtain the same without postponing the operation. We should aim not only at a successful outcome of both surgery and anaesthesia but also at a medically stable patient throughout the stressful peri-operative period. The role of anaesthesiologist as the ‘Perioperative Physician’ should not only be restricted to evaluating and stabilising the associated medical problems of the patient but extend to alleviation of apprehension and anxiety, and discussion regarding anaesthetic and post operative pain management options with the patient and his/her relatives.
With expansion into the area of pain management and perioperative care, we have increased opportunities for direct contact with awake patients. This increased patient contact has led to an attempt to emphasize the importance of communication skills.
Kopp and Shafer4 rightly point out that good communication is as important as the knowledge of pharmacokinetics and pharmacodynamics for professional integrity and patient satisfaction. Because contact with patients is usually brief, good communication is extremely important.4 In a study related to this issue; Fung and Cohen5 emphasized that the information and communication were ranked highest by the patients in expressing what they value most in the anaesthetic care. In the preanaesthetic evaluation, patients appreciated if the anaesthesiologists identify themselves and address their concerns. Unfortunately, the issue was underestimated by the anaesthesiologists. It is quite essential that we the anaesthesiologists as perioperative physicians develop the communication skills. It is not enough if we improvise only on verbal communication skills; nonverbal communication strategies like manners, habits, appearance, dress and inter personal skills, need also to be looked into.5,6
This transformation of an anaesthesiologist into a perioperative physician cannot happen over night; it needs a lot of determination and training on all of our part. New generation of anaesthesiologists have to be trained in this regard; of course a modification is mandatory, in the postgraduate curriculum to expand the educational content to include the subjects outside the operating room.
Concept of a Hospitalist:7,8
With the revolutionary changes occurring in the ‘In-patient Care Model’ in to a more time and cost efficient hospital based care system, lot of avenues are opening up for the anaesthesiologists to take up this new hospital based speciality of “Hospitalists”. Anaesthesiologists have always possessed the knowledge and skills necessary to function as Perioperative Physicians, Critical Care Physicians (Intensivists) and also as Pain Physicians. They are already spending large percentage of their clinical time outside the operation theatre. Those anaesthesiologists who are interested in pursuing their career as ‘Hospitalists’, just need to undergo additional training in the finer points of in-patient care outside the Operating Room. Thus, the transformation into ‘Hospitalist’ is quite easy for an anaesthesiologist than any other specialist.
It is worth reminding ourselves that what happens today, will tomorrow be a part of our history. We should stand back, therefore and view the actions and decisions of today in the light of our past.
References
1. Kotur PF, Editorial: Divine the future. Indian J Anaesth 2002; 46 (6) : 424.
2. David LH. The Anesthesiologist as Perioperative physician: The PCP of the Preoperative period? ASA News Letter 2002; 66 : 11.
3. Alpert CC, Conroy JM, Roy RC. Anesthesia and perioperative medicine: A department of Anesthesiology changes its name. Anesthesiology 1996; 84 : 712-5.
4. Kopp VJ, Shafer A. Anesthesiologists and perioperative communication. Anesthesiology 2000; 93: 548-55.
5. Fung D, Cohen M. What do out patients value most in their anaesthesia care? Can J Anaesth 2001; 48 : 12-9.
6. Smith AF, Shetty MP. Communication skills for the anaesthesiologists. Can J Anaesth 1999; 46 : 1082-8.
7. Gropper MA, Lisco SJ. The hospitalist movement; Is there a place for anesthesiologists? Anes Clin N America 1999; 17 : 445-52.
8. Lisco SJ. The Anesthesiologist as Hospitalist: Covering all the Bases in Perioperative Care. ASA News Letter 2002; 66 : 11.
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