Pain Management

Pain management is required in the perioperative setting ( Chapter 40 ) as well as for chronic pain conditions ( Chapter 44 ). The management of perioperative pain has become more complex as the relationship between postoperative pain control and functional outcomes (e.g., mobility after joint replacement surgery) has become more tightly linked. In addition, the increasing use of neuraxial and regional anesthesia techniques ( Chapter 17, Chapter 18 ) for postoperative pain management has led to increasingly specialized acute pain management services usually managed by anesthesiology.

An outpatient-based pain management center typically takes care of patients with chronic pain on an outpatient basis with occasional consultations in the hospital itself (e.g., for patients with chronic pain who require surgery that leads to acute and chronic pain). Many specialties are involved in chronic pain management, including neurology, neurosurgery, medicine, psychiatry, physical medicine, and physical therapy.

Critical Care Medicine

Critical care medicine has significantly increased in complexity over the 30 years it has been recognized as a distinct subspecialty of anesthesiology (see Chapter 41 ). Increasingly, data from large randomized clinical trials are used to develop patient care protocols. The categorization of ICU patients is most often arranged by one or more specialties (e.g., medical, surgical, neurosurgical, cardiac). Because so many specialties can or need to be involved, the critical care medicine specialist may have his or her initial residency training in several different specialties, including anesthesiology, medicine, surgery, neurology, pulmonary medicine, nephrology, or emergency medicine. In many institutions, anesthesiologists are in local leadership roles in critical care medicine.

Pediatric Anesthesia

Since the 1980s, anesthesia residency training has included rotations in pediatric anesthesia (see Chapter 34 ), and separate pediatric anesthesia fellowships have been offered for many years. However, subspecialty certification by the ABA has only been issued since 2013. In 2009, the ABA and the American Board of Pediatrics launched a combined integrated training program in both pediatrics and anesthesiology that would take 5 years instead of the traditional 6 years. In pediatric hospitals, the role of pediatric anesthesiologists is very clear. However, the practice (and staffing challenges) becomes more complex when pediatric and adult surgeries are performed in the same hospital. Typical questions include how young must a patient be when only pediatric anesthesiologists deliver anesthesia (i.e., instead of anesthesiologists whose practice is mostly adult patients)? How should anesthesia be covered when there are no pediatric anesthesiologists? In a few hospitals, pediatric anesthesiologists also manage patients in the pediatric ICUs.

Cardiac Anesthesia

Cardiac anesthesia rotations have been required in residency for many years, and elective cardiac anesthesia fellowships have been available for at least as long (see Chapter 25, Chapter 26 ). In 2006, the ACGME began to accredit adult cardiothoracic anesthesia fellowships, which led to increasing structure and standardization of the fellowships, including the requirement for echocardiography training. Anesthesiologists can obtain certification from the National Board of Echocardiography for perioperative transesophageal echocardiography as well as adult echocardiography. This certification is commonly achieved by cardiac anesthesiologists.

Obstetric Anesthesia

Because of the unique physiology and patient care issues, and the painful nature of childbirth, obstetric anesthesia experiences have always been an essential component of anesthesia training programs (see Chapter 33 ). Similarly, anesthesia fellowship training in obstetric anesthesia has been offered for decades. In 2012, the ACGME began to accredit obstetric anesthesiology fellowships. Similar to the evolution of other ACGME anesthesia fellowships (i.e., critical care, pain medicine, pediatric anesthesia, and adult cardiothoracic anesthesia), this has resulted in standardized and structured training to develop future leaders in obstetric anesthesia. Currently, the ABA does not offer subspecialty certification in this area.

Other Surgical Areas of Anesthesia

Anesthesia for the remaining surgical specialties is not associated with another certification process, although non-ACGME fellowship training may be available. These subspecialties include cardiothoracic ( Chapter 27 ), colon and rectal ( Chapter 28, Chapter 29 ), general surgery, neurological ( Chapter 30 ), ophthalmic ( Chapter 31 ), oral and maxillofacial, urology, vascular, as well as hospice and palliative ( Chapter 35 ). Anesthesia for the remaining surgical subspecialties is frequently delivered by anesthesiologists without additional special training other than that provided by a standard anesthesiology residency. Often, institutional patient volume dictates whether specialized anesthesia teams can deliver anesthesia. For example, institutions with large outpatient or neurosurgical surgery may have separate specialized teams.

Preoperative Evaluation

Perioperative care includes preoperative evaluation, preparation in the immediate preoperative period, intraoperative care, PACU, acute postoperative pain management ( Chapter 40 ), and possibly ICU care. Beginning in the late 1990s to early 2000s, most surgical patients were required to arrive the morning of surgery rather than the night before. This change frequently dictated that the anesthesia preoperative evaluation be performed during the morning of surgery. However, with complex patient medical risks and surgical procedures, many institutions created a preoperative clinic that allowed patients to be evaluated one or more days before the day of surgery. These clinics have become quite sophisticated (see Chapter 13 ) and are often managed by anesthesiologists. Patients may be evaluated directly by anesthesiologists, or the anesthesiologist may oversee care provided by nurses or nurse practitioners. Periodically, a patient will need additional evaluation by the primary care physician or other specialists for specific patient care issues.

Operating Room Theaters

Operating room theaters are increasingly becoming management challenges (see Chapter 46 ). Matching operating room available time with predicted surgical complexity and length is an intellectual challenge in its own right. “Throughput” is the term used to describe the efficiency of each patient’s experience. For decades, surgical teams have been allowed to operate in two to three operating rooms at the same time. For the first time in decades, the risks of concurrent surgeries are being questioned. Sometimes the throughput is delayed not because of the operating room availability but because of insufficient beds in the PACU. There are numerous steps in the perioperative pathway (e.g., preoperative evaluation, the accuracy of predicting length and complexity of surgical care, and patient flow in and out of PACUs) that can delay a patient’s progress as scheduled. For example, patients may need to wait in the operating room when surgery is complete awaiting a bed in the PACU. Institutions are increasingly appointing perioperative or operating room directors who either manage the operating rooms or coordinate the entire perioperative process starting from the preoperative clinic until exit from the PACU. These positions can be administratively challenging and require considerable skill and clinical savvy. Such jobs are frequently held by an anesthesiologist, although sometimes the director might be a surgeon, nurse, or hospital administrator.

Postanesthesia Care Unit

In a tertiary care hospital, the role of the PACU is pivotal (see Chapter 39 ). Not only are patients recovering from anesthesia and surgery, they also are receiving direction for appropriate care after their PACU time that spans from ICU to discharge. Even now, insufficient PACU beds are often a cause of delayed throughput in operating room theaters. There are many scenarios that illustrate this basic problem. If the routine hospital beds are completely occupied, there is no place to transfer fully recovered patients in the PACU. If those patients stay in the PACU, there will then be no beds for patients who need recovery from operating room–based surgery and anesthesia. When this problem is anticipated, then surgery start times are delayed. In the future, as anesthesiologists take care of patients with more complex medical risks, more PACU beds will be required in hospitals. In addition to the quality of care, patient logistical management is key to the quality and efficiency of care in the perioperative period.

Postgraduate (Residency) Training in Anesthesiology

Postgraduate training in anesthesiology in the United States consists of 4 years of supervised experience in an approved program after the degree of doctor of medicine or doctor of osteopathy has been obtained. The first year of postgraduate training in anesthesiology consists of education in the fundamental clinical skills of medicine. The second, third, and fourth postgraduate years (clinical anesthesia years 1 to 3) are spent learning all aspects of clinical anesthesia, including subspecialty experience in obstetric anesthesia, pediatric anesthesia, cardiothoracic anesthesia, neuroanesthesia, anesthesia for outpatient surgery, recovery room care, regional anesthesia, and pain management. In addition to these subspecialty experiences, 4 months of training in critical care medicine is required. The duration and structure of anesthesiology education differ in countries around the world. Nevertheless, there is generalized international agreement on what constitutes adequate training in anesthesiology and its perioperative responsibilities.

The content of the educational experience during the clinical anesthesia years reflects the wide-ranging scope of anesthesiology as a medical specialty. Indeed, the anesthesiologist should function as the clinical pharmacologist and internist or pediatrician in the operating room. Furthermore, the scope of anesthesiology extends beyond the operating room to include acute and chronic pain management (see Chapter 40, Chapter 44 ), critical care medicine (see Chapter 41 ), cardiopulmonary resuscitation (see Chapter 45 ), and research. More recently, anesthesia training programs have been given increasingly more flexibility. Programs can offer integrated residency and fellowship training, including options for significant research time. These more specialized training programs have the opportunity to produce leaders in subspecialty clinical areas and research. In addition, the ABA has supported the development of combined residency programs in anesthesia and internal medicine, anesthesia and pediatrics, and, most recently, anesthesia and emergency medicine. Clearly, anesthesia training programs are being encouraged to train anesthesiologists who can meet the challenges of the future.

Approximately 131 postgraduate training programs in anesthesiology are approved by the ACGME in the United States. Approved programs are reviewed annually by the Residency Review Committee (RRC) for Anesthesiology to ensure continued compliance with the published program requirements. The RRC for Anesthesiology consists of members appointed by the American Medical Association, the American Society of Anesthesiologists, and the ABA.

American Board of Anesthesiology

The ABA was incorporated as an affiliate of the American Board of Surgery in 1938. After the first voluntary examination, 87 physicians were certified as diplomates of the ABA. The ABA was recognized as an independent board by the American Board of Medical Specialties in 1941. To date, more than 30,000 anesthesiologists have been certified as diplomates of the ABA based on completing an accredited postgraduate training program, passing a written and oral examination, and meeting licensure and credentialing requirements. These diplomates are referred to as “board-certified anesthesiologists,” and the certificate granted by the ABA is characterized as the primary certificate. Starting on January 1, 2000, the ABA, like most other specialty boards, began to issue time-limited certificates (10-year limit). To recertify, all diplomates must participate in a program designated Maintenance of Certification in Anesthesiology (MOCA). In 2016, this program was newly redesigned as MOCA 2.0. Diplomates whose certificates are not time limited (any certificate issued before January 1, 2000) may participate voluntarily in MOCA. The MOCA program emphasizes continuous self-improvement (cornerstone of professional excellence) and evaluation of clinical skills and practice performance to ensure quality, as well as public accountability. The components include (1) professionalism and professional standing (unrestricted state license), (2) lifelong learning and self-assessment (formal and informal continuing medical education [CME], including patient safety), (3) assessment of knowledge, judgment, and skills (completing 30 MOCA minute pilot questions per calendar quarter), and (4) improvement in medical practice. This final component may include a variety of self-directed activities including simulation, quality improvement projects, or clinical pathway development. Along with several other specialties, the ABA also issues certificates in pain medicine, critical care medicine, hospice and palliative medicine, sleep medicine, and pediatric anesthesiology to diplomates who complete 1 year of additional postgraduate training in the respective subspecialty, meet licensure and credentialing requirements, and pass a written examination. These certificates also have a 10-year time limit. Recertification requirements are continuing to evolve as part of the ABA transition to Maintenance of Certification in Anesthesiology for Subspecialties Program (MOCA-SUBS).

Credentialing and Privileging

After completing residency and joining the medical staff of a hospital, the anesthesiologist must undergo the credentialing and privileging process, which allows appropriate institutions to collect, verify, and evaluate all data regarding a clinician’s professional performance. Recently, three new concepts were developed on a joint basis by the ACGME and the American Board of Medical Specialties. General competencies (i.e., patient care, medical/clinical knowledge, practiced-based learning and improvement, interpersonal and communication skills, professionalism, and systems-based practice) are used by the medical staff to evaluate clinicians. Also, focused professional practice evaluation can be used to provide more thorough information about an individual clinician. The last new concept is ongoing professional practice evaluation. In essence, processes need to be developed to identify a problem as soon as possible.