December 15, 2008

Greetings from New York City, where we are updating our knowledge and renewing our relationships at the 62nd annual PostGraduate Assembly in Anesthesiology, sponsored by the New York State Society of Anesthesiologists.

Four thought leaders looked at the future of the specialty in a panel discussion—the Robertazzi Memorial Panel—that we believe merits the attention of every anesthesiologist practicing today. The professional managers and strategic planners for anesthesiology groups should also take note of the coming changes.

Mark A. Warner, M.D., Professor of Anesthesiology at the Mayo Medical School and ASA’s First Vice-President began the session with the question “Whom Will Be Anesthetizing for What Procedures?” There are two demographic trends that will result in an increase in the number of patients: (1) the well-known aging of the baby boomers, who are growing older, fatter and sicker and (2) immigration of a youthful population with greater rates of high-risk deliveries and higher numbers of pediatric patients under 2 years of age (for whom the relative safety of specialty care has been demonstrated) leading to consolidation of obstetrical and pediatric surgical care in regional centers. Dr. Warner estimates that there could be as many as 100 million procedures requiring anesthesia per year by 2040, up from about 40 million anesthetics annually today. That projection is tempered, however, by scientific advances in three particular areas that will reduce the need for services provided by anesthesiologists:

1. Nanotechnologies that can deliver medications such as “clot-busters” to targeted areas of the body, image-guided application of external power to destroy uterine fibroids by ultrasound, and other minimally invasive and non-invasive procedures. Dr. Warner showed a fascinating video modeling emerging technology in transgastric appendectomies by which micro-robots enter the abdominal cavity through an endoscope, “crawl” to the area of inflammation, excise the appendix using an argon laser, and return to the endoscope to be retracted through the stomach and ultimately deliver the appendix orally. Patients undergoing transgastric appendectomies rarely require general anesthesia. Young adults can be released to home within hours and return to normal activities the next day.
2. Patient-targeted therapies based on a rapidly-growing understanding of genomics. For example, it may become possible—or even standard practice—to use genetic profiles to distinguish between patients who metabolize codeine to morphine rapidly and those who metabolize it poorly. Tailoring perioperative pain management therapy according to an accurate preoperative assessment of the individual patient’s opioid metabolism could avert opioid-induced respiratory arrests.
3. New, safer anesthetics, sedatives, and analgesics that may potentially reduce the need for the highly-skilled services provided by anesthesiologists.

Other factors besides scientific advances will determine the numbers and types of clinicians that will be working in different institutions, Dr. Warner acknowledged. The most important factor will remain the increase in the population of elderly patients. Even with much safer anesthetic and analgesic agents and less invasive or non-incisional procedures, the annual number of anesthetics will probably grow by 50 percent, from 40 million today to 60 million by 2040 (if not to the 100 million predicted using current utilization statistics). The demand for anesthesiologists may well continue to exceed the supply.

John C. Drummond, M.D., Professor of Anesthesiology at the University of California, San Diego followed Dr. Warner at the podium. Dr. Drummond elaborated on the new anesthetics that will be in use over the next decades and theorized that ongoing investigations into (1) neurotoxicity of anesthetics in prenatal and neonatal individuals and (2) the effect of various classes of anesthetic agents on postoperative cognitive dysfunction will influence anesthetic selection in the coming years.

John P. Abenstein, M.D., Associate Professor of Anesthesiology at the Mayo Medical School addressed the question “How Might Anesthesia Be Delivered” by reference to “Lessons From Outside Medicine.” Given the premise of increased demand for anesthesiologists’ services, for sicker patients, combined with a decrease in supply that is attributable not just to the numbers of new anesthesiologists but also to work/life balance changes, we should respond like industries that reallocate their expert and technological resources.

At least arguably, we have neither the luxury of nor the need for one anesthesiologist taking care of one patient at a time. The quest for “value” (quality/cost) in anesthesiology suggests more leveraging of technology:

1. Greater reliance on central oversight. The anesthesiologist will be working in the “cockpit,” acquiring and monitoring large quantities of dynamic data and directing responses by “operators” on the floor.
2. Electronic decision support. Information systems will quickly alert the cockpit clinician to adverse patient incidents. Technology available today will allow that anesthesiologist to change infusion rates, tidal volumes and other parameters remotely.
3. Closed-loop control. It will be possible to keep parameters such as infusion rates and levels of muscle relaxants within tight acceptable ranges, and to let the highly-trained anesthesiologist provide hands-on care for those patients who fall out of the normal ranges.

Debra A. Schwinn, M.D., Professor and Chair of the Department of Anesthesiology, University of Washington Medical School, gave a more detailed picture of the increasing importance of genomics in her presentation entitled “Practical Applications of Today’s Research 10 Years Down the Line.” Dr. Schwinn described surgery as a stressor that provokes a systemic host response and updated the audience on the NIH concept of the “allostatic load” that unites an individual’s genome, gene expression and life experiences. Rather than scoring patients’ health status on comorbidities, anesthesiologists will be determining and delivering “personalized medicine” based on more sophisticated knowledge of the genetic variability between individuals. We already know, for example, that more than 30 genes are involved in the response to warfarin therapy, and physicians are using commercial gene kits in selecting the initial therapy. Genetic tests allow identification of patients with greater susceptibility to malignant hyperthermia. The redhead phenotype is thought to have a stronger pain response and may require more analgesia. An allostatic load scorecard may some day allow better identification of patients with relatively strong pain responses in the preoperative assessment clinic.

As the specialty’s understanding of genomics and new technologies continues to expand at a rapid rate, specialization and extended training will become more necessary—and more popular. In 1998, 31 percent of anesthesiology residents at Duke University and 20 percent at Columbia entered one-year clinical fellowships. By 2008, those numbers had risen to 82 and 85 percent respectively. The specialty now needs to prepare more residents for research fellowships.

We at ABC would like to thank this stellar panel and its moderator, Stephen J. Thomas, M.D., Professor and Vice-Chair of the Department of Anesthesiology at Weill Cornell Medical College for sharing their insight. We hope that this synopsis will be of some value to our readers who did not have the privilege of hearing Drs. Warner, Drummond, Abenstein and Schwinn give their presentations.