The Perioperative Surgical Home

“I swear by Apollo the physician, and Aesculapius the surgeon, likewise Hygeia and Panacea, and call all the gods and goddesses to witness, that I will observe and keep this underwritten oath, to the utmost of my power and judgment.” The Classic “Hippocratic Oath” (400 B.C.E) Panacea was the Greek goddess of healing and the Universal remedy.1 A present-day panacea is a purported remedy or medicine for all diseases or ills or something that will solve all problems.2 In Greek mythology, Pandora was the first woman on Earth. Despite Zeus’ admonishment to the contrary, Pandora opened a box (actually a jar) that she was presented as a gift, releasing all the evils and miseries of the world and forever afflicting mankind (Fig. 1).1 In modern parlance, opening a Pandora’s Box refers to creating a situation that introduces multiple unexpected problems.2Figure 1: “Pandora” by Charles E. Perugini (1839–1918) (Beryl Peters Collection/Alamy).Is the Perioperative Surgical Home a panacea or a Pandora’s Box for the specialty of anesthesiology? We believe that the long-term answer will depend on how effectively academic and community anesthesiologists incorporate the Perioperative Surgical Home into their practice of perioperative medicine. In this issue of Anesthesia & Analgesia, there are two The Open Mind articles, one by Prielipp et al.3 and the other by Warner and Apfelbaum,4 which offer contrasting perspectives on the current and future state of the specialty of anesthesiology, and the role anesthesiologists in the implementation of the Perioperative Surgical Home. One sees our specialty facing a “burning platform” mandating immediate action, the other calls for continued gradual evolution through “thoughtful expansion.” A third article offers a dialog among these collective authors on specific areas of contention.5 Against the backdrop of these equally engaging articles, we offer our interpretation of the current and future state of anesthesiology, organized along the conventional and, now even more so, interdependent tripartite missions of clinical care, education and training, and research, plus what Dexter and his colleagues6 at the University of Iowa have insightfully identified and aptly called the “fourth mission” of management. CLINICAL CARE Prielipp et al.3 foresee many anesthesiologists in the United States becoming a “commodity” directly employed either by local hospitals/health systems or by large regional and national, multipractice, corporate anesthesiology groups. Examples of this latter phenomenon of for-profit corporate consolidation (mergers and acquisitions funded by private equity firms) include North American Partners in Anesthesia (Moelis Capital Partners), U.S. Anesthesia Partners (Welsh, Carson, Anderson & Stowe), Resolute Anesthesia (Goldman Sachs Private Capital Investing), and NorthStar Anesthesia (TPG Growth). We agree that these new employers (like one’s academic department chair) may not initially support the expanded role of anesthesiologists in the Perioperative Surgical Home. However, as noted by Warner and Apfelbaum,4 only a subset of any group of anesthesiologists will need to practice perioperative medicine. Academic, independently employed private-practice, and hospital or corporately employed anesthesiologists need to incrementally expand their scope of preoperative and postoperative services and then to demonstrate its added value, while remaining fully invested in our core business of intraoperative patient care. Emulating the earlier extensive work of the Institute for Healthcare Improvement on health care collaboratives,a the American Society of Anesthesiologists (ASA) Perioperative Surgical Home Learning Collaborativeb promotes participants’ sharing their practice change experiences and related clinical, operational, and fiscal outcomes data. Successful innovations must address the needs of multiple stakeholders. That is particularly true in the highly specialized area of heath care, where the deliverable requires many individuals with specialized skills. For the Perioperative Surgical Home to be successful, it must fully embrace surgeons, internists, pediatricians, the myriad of other invested perioperative health care providers, and hospital administrators.7 Local implementation of the Enhanced Recovery after Surgery (ERAS)c protocols8 is an initial, viable Perioperative Surgical Home model. ERAS may be more readily accepted by surgeons given their (European) specialty colleagues’ integral role in developing ERAS protocols. The anesthesiologist-directed Perioperative Surgical Home model has been hailed by its innovators and early adopters as a positive “disruptive innovation.”9 However, the truly successful disruptive innovation must provide perioperative care more simply, more accessibly, and at lower cost. It must make better care available to more patients.10 In the United States, many anesthesiologists have professionally benefited from the present anesthesia care team model, including medical direction of nurse anesthetists. Prielipp et al.3 predict that more “routine care” will likely in the future be provided by anesthesiologists supervising, not medically directing, a cadre of lower-cost physician extenders (e.g., nurse anesthetists, other advanced practice registered nurses, and anesthesiology assistants), practicing at “the top of their license.” We agree that advanced practice health care providers will be essential to any clinically effective and economically efficient implementation of the Perioperative Surgical Home. A growing number of academic anesthesiology departments in the United States have renamed themselves to include perioperative medicine. The Society of Academic Anesthesiology Associations is currently working on a resolution for the ASA Board of Directors to change the name of our specialty to Anesthesiology and Perioperative Medicine. More than simple semantics, the goal is to codify the medical role of contemporary fully trained anesthesiologists. However, as astutely noted by Prielipp et al.,3 this new moniker must not be communicated to or interpreted by other key stakeholders and their leadership (e.g., the American College of Surgeons) as laying claim to their clinical turf. EDUCATION AND TRAINING Accreditation Council for Graduate Medical Education: Clinical Learning Environment Review In 1999, the Accreditation Council for Graduate Medical Education (ACGME) introduced 6 domains of clinical competency: patient care, medical knowledge, practice-based learning and improvement, interpersonal and communication skills, professionalism, and systems-based practice.11 In 2008, these core competencies were adopted by The Joint Commission. They are now mandated in the Focused Professional Practice Evaluation and subsequent Ongoing Professional Practice Evaluation of all credentialed clinicians.12,13 As ACGME program requirements became more prescriptive and their administration burdensome, opportunities for innovation in education have progressively disappeared.11 Recognizing the limitations of its previous system, as of July 2014, the ACGME has fully implemented its Next Accreditation System, including provisions for anesthesiology training. A major component of the ACGME Next Accreditation System is the Clinical Learning Environment Review (CLER) program.14,15 The CLER program will provide United States teaching hospitals, medical centers, health systems, and other clinical settings with periodic feedback in 6 multipathway focus areas (Table 1).16 This feedback will be accomplished via CLER site visits, every 18 to 24 months, which will involve also interviewing the executive leadership of the health care organization (i.e., the “C-Suite”) and visiting patient floors, care units, and service areas to gather input from clinical staff as to how the organization functions as a learning environment.14,15Table 1: Accreditation Council for Graduate Medical Education CLER 6 Pathways to Excellence15With its Next Accreditation System, the 2 ACGME core competencies of practice-based learning and improvement and systems-based practice have been further operationalized through specialty-specific milestones. These require that residents/fellows demonstrate incorporation of patient safety and quality improvement skills into their daily activities.17 Milestones have been generated by the ACGME/American Board of Anesthesiology (ABA)18 for the core anesthesiology residency and the currently accredited fellowships.d As part and parcel with the educational continuum, the ACGME has recognized the need for faculty development in the CLER focus areas, particularly patient safety and health care quality. In collaboration with other key organizations, the ACGME is committed to developing resources to educate and support faculty (and executive) leadership across the 6 CLER focus areas.19 The specific emphasis of the ACGME CLER program on an academic medical center collectively improving patient safety, health care quality, and transitions in care is consistent with the priorities of the Perioperative Surgical Home. Meeting the educational and training objectives of the CLER program requires a strong alignment with clinical care. The ACGME CLER program could thus be an excellent opportunity for the specialty of anesthesiology, in collaboration with the other major educational and clinical stakeholders from surgery, internal medicine, and pediatrics, along with institutional leadership, to allocate the resources needed to develop, implement, and track a successful, mission-aligned Perioperative Surgical Home model of health care delivery. American Board of Anesthesiology (and Perioperative Medicine) As of July 2013, the American Board of Internal Medicine and the ABA began approving combined training in internal medicine and anesthesiology. The combined training requires 5, not 6, total years of training. To date, 4 combined internal medicine/anesthesiology programs have been approved.c As of July 2010, the American Board of Pediatrics and the ABA began approving combined training in pediatrics and anesthesiology, also requiring 5, not 6, total years of training. To date, 7 combined pediatrics/anesthesiology programs have been approved.e A current participant in the combined pediatrics/anesthesiology residency at the Children’s Hospital Boston and Brigham and Women’s Hospital has offered a series of insightful observations in an Anesthesia & Analgesia The Open Mind article.20 While laudable, these combined primary care/anesthesiology residency training programs will annually produce at most a handful of dual specialty–trained clinicians. Most of them will likely stay on as Department of Anesthesiology and Perioperative Medicine faculty at academic medical centers. Given the staggering median debt of United States medical school graduates (US$170,000 in 2012),21 it is doubtful that many such trainees will elect to pursue an additional sixth year of clinical fellowship training, let alone a seventh year of dedicated research training or a relevant Master in Business Administration, Master in Public Health, Master of Science in Health Administration, or Master of Science in Health Care Informatics. We wholeheartedly agree with Prielipp et al.3 that a fundamental transformation of anesthesiology residency training is needed, including training a cohort of “super specialists” in either multispecialty adult anesthesiology, pediatric anesthesiology, critical care medicine, pain medicine, or academics/research. To this list, we would add formal training and expertise in management science, reflecting the recently recognized major fourth mission of practice management in any anesthesiology practice.6 Perhaps, the predicted paradigm shift espoused by Prielipp et al. will eventually result in fewer anesthesiology residency programs and graduates. However, we must ensure that we can produce an adequate number of suitably trained anesthesiologists to deliver on the expanded scope of the Perioperative Surgical Home, lest we overpromise and underdeliver. A more practical and immediately high-impact approach would be to revamp the current anesthesiology residency to provide didactics and training in perioperative medicine throughout the 4-year curriculum. The considerably revised first postgraduate year would provide a more relevant clinical base experience and be fully integrated into the anesthesiology and perioperative medicine residency. The third clinical anesthesia year would be dedicated to subspecialty training (e.g., perioperative medicine), as originally intended by the ABA. The optional fourth clinical anesthesia year would remain devoted to clinical fellowship training.f The ASA Subcommittee on Perioperative Surgical Home Education has developed a comprehensive inventory of core competencies and skills for the anesthesiology resident. The final product of this taskforce will include a set of recommendations to be submitted to the ASA Vice Presidents of Scientific Affairs and Professional Practice and to be passed along to the ASA Administrative Council for consideration for submission to the ACGME and its Anesthesiology Residency Review Committee.g Currently, 2 American universities (Stanford University and University of California, Irvine) and 2 Canadian universities (University of Manitoba and University of Toronto) offer postgraduate fellowships in perioperative medicine.22 However, there is a paucity of published literature on what a perioperative medicine fellowship curriculum should include.22 Nevertheless, we believe that fellowships in perioperative medicine should be generally incorporated into anesthesiology training programs, with formal accreditation by the ACGME and a board eligibility/certification pathway through the ABA. Just as currently with critical care medicine and pain medicine, in concert with the American Board of Medical Specialties, the ABA would offer board eligibility to physicians who complete primary residencies in the closely interrelated specialties such as surgery, internal medicine, and pediatrics. A temporary alternate pathway to board certification would be offered to attending physicians actively practicing perioperative medicine. RESEARCH Extramural funding is increasingly scarce for clinician-scientists. Anesthesiologists are at a further disadvantage because, unlike 3-year internal medicine and pediatric subspecialty fellowships that include bona fide research training and mentorship, 1-year anesthesiology fellowships provide strictly clinical training. Because few resources are allocated to research training during this 1 year, graduates of these clinical fellowships have less chance of extramural funding. It has been estimated that 40 cents of university funds are required for each dollar of external funding (including direct and indirect costs) received.23 This even greater investment is compounded in anesthesiology and surgery, where the current National Institutes of Health (NIH) direct salary funding cap of US$179,700 is not commensurate with academic faculty salaries. This will pose an even greater challenge as operational surpluses and discretionary cash reserves in academic departments dwindle or completely disappear. Nevertheless, we disagree with the proposal by Prielipp et al.3 that extramurally funded research be limited to a subset of academic programs by coalescing the best scholars to institutions most recognized for research expertise. Like Warner and Apfelbaum,4 we cannot envision how such a consolidation process would be adjudicated. Instead, let grant agencies and their evolving research priorities continue to determine the competitive allocation of extramural funding, and medical school deans and department chairs determine the allocation of locally available cross-subsidies. The fluidity of the annual Blue Ridge Institute for Medical Research NIH funding rankingsh and the recent rapid prominence of the Patient-Centered Outcomes Research Institute support a the free-market approach to extramurally funded research. The Perioperative Surgical Home must be extensively studied.24 This research will build on the substantial existing corpus of perioperative management research undertaken by Dexter et al.i as well as perioperative health services and outcomes research done by others.25 Dissemination and implementation of research methods will play a major role in studying the population health impact of the Perioperative Surgical Home.26 Such novel practice-based research represents the much needed “Blue Highways” on the NIH research roadmap, which will provide the essential link between bench discoveries, bedside efficacy, and everyday clinical effectiveness.27 This clinical outcomes, health services, and management science research will take anesthesiologists into new methodologies and interdisciplinary collaborations. Such research can thus strengthen alignment with our surgical, medical nursing, and administrative colleagues. The Vanderbilt University Department of Anesthesiology has initiated a “Clinician Scientist Training in Perioperative Science Fellowship,” which is supported by an NIH T32 funding mechanism. This highly innovative fellowship prepares basic and clinician-scientists for the unique challenges associated with the optimization of perioperative care. Fellows are offered training in 4 research areas: mechanisms and management of pain, pharmacology and pharmacogenomics, perioperative stress biology and outcomes, and health services and translational research.j Ideally, such additional focused research training opportunities will be created soon at other institutions. MANAGEMENT AND LEADERSHIP Dexter et al.6 have validly recognized and documented that academic (and nonacademic) anesthesiology departments have substantial management responsibilities, including directing the operating rooms, coordinating sedation, informatics, ongoing professional performance evaluation, staff scheduling, and workroom inventory management. We suggest a broader scope of what Dexter et al. have called the fourth mission be applied that includes not only operational management, but also administrative and strategic leadership activities. The combined of the Care and an population are to result in greater for health care and services and to health at year from to Health care as a of the product are thus to from in to in has been a the for & However, is an As documented by recent and by the of the at the of health care is not Prielipp et al.3 suggest that by and is health care providers to take a broader of each clinical experience and provide for the of care into and of the We that such sharing by providers that anesthesiologists play a more and role in the perioperative of care, including preoperative optimization (e.g., postoperative (e.g., and care (e.g., hospital institutional by anesthesiologists in clinical operational and as well as in developing integrated funds and all management and leadership Like all other in health care, anesthesiology is to In a Anesthesia & Analgesia et presented a needs for in anesthesia business (Fig. on a literature these authors previous for 2 of these of new and power of for 1 of or and substantial for 2 power of and for among current competitive that any was the by its authors as likely only for with anesthesia and as that are from their However, we believe that their needs is in the Perioperative Surgical Home a more integrated health care or a more anesthesia services This needs also a for and further the fourth mission of operational management and strategic For a recent of the between and quality in care that in more competitive not demonstrate better quality or lower To continue to the fourth mission of operational management and strategic leadership, anesthesiologists will need additional formal For a Education and program has been implemented in the University of at Department of This program offers learning in research, quality and patient safety, health care and health care organization and can a Master of Science in Health or Master of Science in Health Care through at the University of or in Medical through the American Board of Medical A program are in part by including from our current residency and state anesthesiology who the of such skills in present and future anesthesiologists. The and objectives of the University of at program are also fully with of the ACGME CLER program (Table and its for the core anesthesiology residency and the currently accredited For currently practicing Dexter in the of in the University of Iowa Department of the Anesthesiology offers an and in of the and advanced in this including management research are directly to the Perioperative Surgical Home. applied by and the is a of into and at the by and by the of and in the of and can to greater an of the of knowledge, and to health care and We that much needed medical has been on the role of Perioperative Surgical Home model and perioperative medicine in anesthesiology. The myriad of by Prielipp et al.,3 the provided by Warner and Apfelbaum,4 and their collective such an Prielipp et al.3 by We by that these are not the best of but the only I believe there is a for in of our This the the final This the the final This was

Fetched live from OpenAlex and de-inverted. Abstracts are not stored in this database: the inverted indexes are 8.6 GB of the frame’s 9.3 GB of text, and the host has 13 GB free.