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Section II - Scientific Principles

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Chapter 2 - Scope of Modern Anesthetic Practice

Fredrick K. Orkin

Stephen J. Thomas

Since we last opined on the scope of anesthetic practice in the previous edition of this book, published in 1999, the specialty is experiencing a most welcome renewed interest among medical students and a spectacular increase in the demand for services. Nevertheless, many questions about our future, in terms of clinical practices and the best method for the delivery of anesthetic care and the education and research base for that practice have arisen. Politically the world, where now terrorism is feared in every land (see Chapter 64 ), has changed dramatically. The United States has endured September 11 and its aftermath. We have achieved remarkable military success, invading both Afghanistan and Iraq, toppling and finally capturing Sadaam Hussein. The future plans for these countries remain somewhat vague, manifestly controversial, and incredibly costly. Medically, a crucial issue continues to be medical expenditures. The economy is recovering as the United States has plunged into record-setting deficits from equally impressive surpluses. The impact on federal expenditures to hospitals and clinicians as well as to scientists (the first rumors about the 2005 budget mention reductions in NIH funding) cannot be good. Scientifically, anesthesiology has joined other areas of medicine in the emphasis on outcome studies and on the potential of the new genomic treatment paradigm that promises to treat human disease according to the given patient's genetic individuality.^[1]

The organization, financing, and delivery of health care continue to follow the whims of the marketplace. The defeat of the Clinton Health Plan a decade ago ushered in managed care—a cost-containment method of funding and delivering the "commodity" known as health care.^[2] Despite spending almost 15% of the gross domestic product (GDP) on health care, we still managed to leave 15.2% of the population uninsured in 2004. Employer-supplied health care coverage is now undergoing erosion; employee benefits decrease while simultaneously premium contributions increase.^[3] Medicare struggles to become more efficient, but efforts to enhance its weak and complicated underlying financing languish.^[4] The Medicare bill passed in 2003, supported by most of organized medicine, turns a projected 3.6% decrease in Medicare payment to anesthesiologists into a 1.5% increase for each of the next 2 fiscal years. It also offers a drug benefit, the true effects of which are unclear. What is clear is that the $400 billion price tag when the bill was passed is currently estimated to be $530 billion, a price that would have most likely precluded passage! A mandated push to privatize Medicare (completely unsuccessful to date) and a prohibition on the government from using its incredible purchasing power to negotiate lower drug prices from pharmaceutical companies are further issues. Major legislative, rather than market-based, reform of health care financing in the United States, must await public recognition of an emerging national health care crisis.

The term scope of practice has many meanings. Medically, the buzzwords of the day, when referring to anesthesiologists, are "perioperative physician." Anesthesiology seeks to encompass the entire perioperative experience, from preoperative evaluation to intraoperative regional or general anesthesia (given almost anywhere—hospital, ambulatory care center, procedure room, doctor's office) to the post-anesthesia care unit (PACU), intensive care

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Scientifically, we are still trying to develop new faster-acting drugs of shorter duration, as well as novel approaches to reversing the effects of the drugs that we do have. Other research frontiers include molecular biologic techniques investigating issues ranging from the adrenergic system to mechanisms of anesthesia to outcome studies of the clinical and economic results of our actions. It is significant that the journals Anesthesia and Analgesia and Anesthesiology both now have separate sections devoted to economics and health services research. This is important not only because of physicians' concerns about their future but also because the economics of our specialty—or at least the perceived economics—resulted in a precipitous decline in interest by American medical students in the latter half of the 1990s, interest which is rebounding as original perceptions and assumptions proved exaggerated (and, perhaps, because the initial zeal for primary care on the part of managed care organizations and deans of medical schools proved misguided). This renewed interest, a boon to all program directors and to practitioners awaiting fresh, well-trained recruits for their expanding practices, appears to be driven by economics (good job, good salary) and by concerns for a "controllable lifestyle." ^[6]

To better understand the scope of the specialty, it is useful to review how the American Board of Anesthesiology (ABA) defines anesthesiology^[7] :

Anesthesiology and perioperative management is defined as a continuity of patient care involving preoperative evaluation, intraoperative and postoperative care and the management of systems and personnel that support these activities.

The ABA exists in order to maintain the highest standards of practice by fostering educational facilities and training in anesthesiology, which the ABA defines as the practice of medicine dealing with but not limited to:

1. Assessment of, consultation for, and preparation of, patients for anesthesia.
2. Relief and prevention of pain during and following surgical, obtetric, therapeutic, and diagnostic procedures.
3. Monitoring and maintenance of normal physiology during the perioperative period.
4. Management of critically ill patients.
5. Diagnosis and treatment of acute, chronic, and cancer-related pain.
6. Clinical management and teaching of cardiac and pulmonary resuscitation.
7. Evaluation of respiratory function and application of respiratory therapy.
8. Conduct of clinical, translational, and basic science research.
9. Supervision, teaching, and evaluation of performance of both medical and paramedical personnel involved in perioperative care.
10. Administrative involvement in health care facilities and organizations and medical schools necessary to implement these responsibilities.

"Scope of practice" also has a distinct political interpretation, encompassing the questions of who can practice anesthesiology and under whose direction. The traditional approaches to delivery of anesthesia care, either by the anesthesiologist alone or as part of an anesthesia care team^[8] —including residents and/or Certified Registered Nurse Anesthetists (CRNAs) and/or anesthesia assistants (AAs)—are under increasing political pressure as CRNAs join other advance-practice nurses in seeking independent privileges to practice.^[9] The governors of many states have signed "opt-out" requests, under a new rule from the Center for Medicare and Medicaid Services (CMS) that permits CRNAs in those states to administer anesthesia without any physician supervision (and not endanger Medicare reimbursement to their hospitals). This was vigorously opposed by both the American Society of Anesthesiologists (ASA) and individual state societies.

It will not be long before additional data will be available (albeit not prospectively designed and collected) comparing outcomes between physician-directed and CRNA-independent anesthetics to complement recent articles on the subject.^{[10] [11] [12]} Many other countries have different types of non-OR specialties, such as emergency medicine in Germany.