Scope of Anesthesia Practice

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Surgery preceded the development of anesthesia as a medical specialty, with significant implications. Surgery has been performed for thousands of years. Archaeologists have discovered human skulls from prehistoric times with evidence of trephination, a surgical procedure involving drilling or scraping a hole in the skull to expose the brain. However, the brutality of surgery without anesthesia limited the types of surgery that could be performed and the disease processes that could be treated. Advances in surgery could only be accomplished as a result of improved ability to relieve pain during a procedure and manage the physiologic changes taking place both during surgery and thereafter. The first use of an anesthetic agent occurred in 1842 when the use of ether as a surgical anesthetic was administered by Crawford Long in Georgia. Although acknowledged as the first anesthetic administered to a human, it was not documented until Dr. Long published his experience in 1849. The first public demonstration of administration of ether anesthesia was provided by dentist William T.G. Morton at Massachusetts General Hospital on October 16, 1846. Since this initial administration of an inhaled anesthetic to reduce pain during a surgical procedure, the specialty of anesthesiology has advanced beyond the surgical suite to encompass the entire course of perioperative care in addition to associated subspecialties, including pain medicine, critical care medicine, palliative care, and sleep medicine.

ANESTHESIOLOGY AS A MULTIDISCIPLI­NARY SPECIALTY

Although anesthesia is understood to encompass administration of medications to facilitate surgical procedures, as the specialty has evolved, the scope of practice and expertise expected of an anesthesiologist have been formally defined by the American Board of Anesthesiology (ABA), a member of the American Board of Medical Specialties (ABMS) ( Box 1.1 ). The ABA establishes and maintains criteria for board certification in anesthesiology and for subspecialty certification or special qualifications in the United States. Similar professional certification boards exist in many other countries. Currently, formal subspecialty certification is offered in anesthesiology and a number of subspecialties by the ABA, including critical care medicine (also see Chapter 41 ), pain medicine (also see Chapters 40 and 44 ), hospice and palliative medicine (also see Chapter 47 ), sleep medicine (also see Chapter 48 ), pediatric anesthesiology (also see Chapter 34 ), and neurocritical care (also see Chapter 30 ). Other ABMS boards also provide subspecialty qualifications in some of the same subspecialties, allowing providers to collaborate in the care of complex patients requiring specialized services.

The American Society of Anesthesiologists (ASA), founded in 1905 as the Long Island Society of Anesthetists, is the largest professional society for anesthesiologists. The ASA has over 100 committees and editorial boards dedicated to all anesthesia subspecialties and aspects of anesthesia practice. In addition to supporting the practice of anesthesiology and its subspecialties, the ASA advocates on behalf of anesthesiologists with other organizations, including Centers for Medicare & Medicaid Services (CMS), other medical specialties, hospital organizations, and payors. The International Anesthesia Research Society (IARS) and subspecialty societies also provide support for advancing clinical care and research in anesthesia and its subspecialties, reflecting the multidisciplinary growth of anesthesiology ( Table 1.1 ).

PERIOPERATIVE PATIENT CARE

Although the specialty of anesthesiology began in the operating room, the scope of anesthesia practice has evolved as anesthesiologists and surgeons recognized that management of each patient before, during, and after surgery improved outcomes and quality of care. The preoperative evaluation of patients has become critical to the preparation for anesthesia and surgical management. For selected patients, perioperative management for those with underlying medical conditions has also improved outcomes and quality of care. Similarly, postoperative assessment and management related to sequelae of anesthesia is an important component of perioperative care.

Based on this broader definition of anesthesia care, new drugs, monitoring capabilities, and documented improved outcomes in the surgical suite, anesthesia care has expanded to many locations within the health care system, including hospital-based locations, freestanding ambulatory care centers, and office practices ( Table 1.2 ). Several other factors are contributing to the evolution of anesthesiology practice, including the advances in anesthesia care allowing patients with significant comorbidities to undergo complex procedures; the extremes of age of the surgical patient, including the expanding elderly population (also see Chapter 35 ); increasing importance of quality, safety, and value of health care delivery (also see Chapter 46 ); changing composition and expectations of the anesthesia workforce; increasing fragmentation of perioperative care with multiple handoffs and transitions of care; and changing payment methods for physicians that increasingly emphasize value-based approaches.

In addition to the factors that affect the clinical practice of anesthesiology, anesthesiologists have assumed broader roles in health system leadership, including perioperative medical directors, chief quality officers, and other administrative and leadership positions related to both perioperative care and broader health system management.