TRAINING PERIOPERATIVE PHYSICIANS

It has been widely suggested that the specialty of anesthesiology should alter its traditional focus on the technical aspects of intraoperative care toward an expansion of its responsibilities and promotion of the profession as the practice of perioperative medicine. Greene 2 and Saidman 6 used the American Society of Anesthesiologists (ASA) annual Rovenstine lectures to recommend changing the name of the specialty to reflect such a new approach. This concept has been relevant over the last few years, especially in America, because there has been an apparent oversupply of anesthesiology practitioners. Events of the past 18 months have shown this condition to be transient, but during its most intense period, expansion into other areas seemed appropriate. Presentations and panels at major national meetings on perioperative medicine were commonplace (e.g., ASA1996, ASA1998). Leaders of the profession were championing the concept, including the Chairman of a major West Coast anesthesia department who remarked, "I'm afraid we're going to recover too soon." By this statement, he meant that the job shortage crisis seemed to be the motivating factor for causing the re-evaluation and revision of training and programmatic activities and that, as soon as the shortage resolved, enthusiasm would drain from the perioperative medicine initiative. He may have been right. There are many reasons for believing that properly trained and motivated anesthesiologists could provide added value to the care of hospitalized surgical patients. Before, during, and after surgery, aspects of patient management are fragmented, nonstandardized, and are conducted by multiple groups with various degrees of communication. Anesthesiologists practicing perioperative medicine may be better able to integrate preoperative evaluation and testing; risk assessment and optimization of patient status; intraoperative techniques and monitoring; and principles of postoperative management, which affect morbidity and mortality, timely convalescence, and satisfaction. 1 At Vanderbilt University School of Medicine (Nashville, TN), a program and a practice of perioperative medicine is being developed that reflects the expectation that such activity constitutes appropriate evolution of the profession, improves patient care, improves specialty image, and increases the ability to attract high-quality house-staff. The following points are proposed: •The future of anesthesiology does not rest on the development of better agents, delivery devices, or monitors •Appropriately trained and motivated anesthesiologists are better able to assess and modify perioperative risk •Principles of perioperative management not yet established can reduce morbidity, facilitate recovery, and lead to earlier discharge •Enlightened subgroups in the profession have the resolve to pursue the practice of perioperative medicine, whereas training programs include a program of instruction