January 25, 2016

There are more nearly 50,000 hospitalists practicing in the U.S. today and the specialty continues to grow rapidly.  A recent American Society of Anesthesiologists (ASA) Health Policy Research paper entitled “Prevalence of Hospitalists in U.S. Community Hospitals” found that between 2012 and 2013, 34 out of 50 states showed an increase in the percentage of hospitals using hospitalists and that the percentage of community hospitals using hospitalists increased by almost five percent during that period.

Hospitalists in general are trained as internists.  (The American Board of Medical Specialties does not include a “hospital medicine” board nor offer subspecialty certificates.)  Their roles encompass the following, according to the Society of Hospital Medicine's (SHM's) website for residents and medical students, Future of Hospital Medicine:

• Care of patients who do not have primary care physicians (ED unassigned)
• Coordination of care: improving hospital throughput, decreasing length of stay and discharge planning
• Cost-effective, resource utilization
• Surgical co-management
• 24 hour in-house coverage: can assist with rapid response teams, code blues and cross covering
• Hospital leadership: can assist with quality improvement initiatives
• Staff education
• JCAHO/CMS hospital accreditation
• Medical directorships/committee service

In 2005, the SHM stated that perioperative care is “a fundamental facet of [the hospitalist’s] identity” as a “perioperative expert.”  The SHM also has published practice guidelines for perioperative care.  In their 2007 article, Hospitalists and anesthesiologists as perioperative physicians:  Are their roles complementary? (Proc (Bayl Univ Med Cent). 2007 Apr; 20(2): 140–142), Adesanya and Goshi observed that “The hospitalists are filling a void left by office-based internists, surgeons, and anesthesiologists.  As a result, hospitalists have emerged as leaders of perioperative medicine and significant members of the perioperative care team.”

In the nine years since the publication of the Adesanya and Goshi study, however, anesthesiologists have assumed greater perioperative medicine responsibilities, concomitant with if not as a result of, the development of the Perioperative Surgical Home model, spurred on by the growing importance of demonstrating enhanced value to health systems and payers.  As Adesanya and Goshi note, “By virtue of training and experience, anesthesiologists are perioperative physicians; the scope of their practice includes preoperative evaluation and preparation, intraoperative anesthetic and medical management, and acute postoperative care.  Many anesthesiologists are also trained in the management of critically ill patients in the ICU.  In addition, some anesthesiologists also work as key members of the multidisciplinary acute and chronic pain management teams.”

Taking charge of the perioperative continuum goes well beyond the requirements of traditional  anesthesiology.  Members of ASA’s Committee on Future Models of Anesthesia Practice published an article in the April 2015 ASA NEWSLETTER (Alem N. et al, Perioperative Medicine and the Future of Anesthesiology Training.  ASA Newsl. 2015; 79(4)) citing capabilities extending more deeply into the preoperative, postoperative and even post-acute phases of care:

Prior studies have demonstrated that medical consultation during the surgical episode may result in fewer complication rates and decreased length of stay. Intuitively, detailed preoperative evaluation and “pre-habilitation” provide the opportunity to risk-stratify and meticulously optimize a patient prior to surgery.  Likewise, patients with postoperative complications consume considerable resources and have increased morbidity and mortality.  Well-recognized and potentially avoidable postoperative complications include pneumonia, venous thromboembolism, acute myocardial infarction, decompensated heart failure and wound infection.  Should they occur, prompt diagnosis and intervention for such critical events are essential.  Moreover, an even more resourceful prospect exists for the perioperative specialist to be the ultimate patient liaison who coordinates the longitudinal “care transitions” between the hospital episode and the community.  [Footnotes omitted.]

There is, then, considerable overlap between the roles of hospitalists and anesthesiologists in perioperative medicine—and there are also differences.  As surgical inpatients become older, more frail and have more co-morbidities, and as surgical procedures become more challenging, anesthesiologists’ “specific training” and “adequate exposure in managing complex surgical patients” may become indispensable.  (Vetter TR et al., The Perioperative Surgical Home: how can it make the case so everyone wins?  BMC Anesthesiol. 2013; 13: 6.)  At the same time, “it will be necessary to expand the core knowledge, skills, and experience expected of the perioperative anesthesiologist.  Anesthesiologists will need to view this movement toward becoming anesthesia perioperativists as an expansion of the specialty, rather than an abdication of their traditional intraoperative role.” (Footnotes omitted). 

Vetter et al. conclude that “The expansion of the perioperative care team—especially with anesthesiologists who communicate effectively with surgeons and possess an underlying familiarity with the patient and their medical and surgical history—will thus be critical to providing high value healthcare services in the future.”  The unmet needs of surgical inpatients are great enough, however, that anesthesiologists, hospitalists and other specialists will need to collaborate to develop evidence-based perioperative pathways of care that improve outcomes and reduce overused, underused and misused care.  “Standardized, evidence-informed perioperative care plans, designed in a multidisciplinary and cooperative team-based approach, will likely improve outcomes.” 

The SHM has foreseen the need to delineate the scope of practice and respective responsibilities of the various specialists involved in inpatient care in its publication The Key Principles and Characteristics of an Effective Hospital Medicine Group:  An Assessment Guide for Hospitals and Hospitalists.  Principle 8 provides:

The HMG takes a thoughtful and rational approach to its scope of clinical activities.
• Characteristic 8.1: The HMG has a well-defined, annually reviewed plan for evolving the scope of hospitalist clinical activities to meet the changing needs of its institution.
• Characteristic 8.2: The respective roles of hospitalists and physicians in other specialties in treating patients, including patients that are co-managed, are clearly defined with a clear mechanism to address disagreements about scope and responsibilities.
• Characteristic 8.3: The HMG uses appropriate references to define the clinical responsibilities of hospitalists.

Anesthesiologists working with hospitalists—or indeed other perioperative physicians—should consider Characteristic 8.2 in particular and seek to be a key part of the ongoing process of defining and coordinating roles.  As the “Rationale” for Characteristic 8.2 states in part, “Failure to proactively define roles and responsibilities may jeopardize patient safety, degrade efficiency and promote needless confusion and complexity that adversely affects patients and families, hospital staff and colleagues.” In fact, anesthesiologists who are thinking of leading a perioperative program at their hospitals might benefit from considering the Key Principles as an overall guide to establishing an effective and well-received new paradigm of care.

We agree with Adesanya and Goshi, who concluded their article thus:

Clearly, there is a role for both anesthesiologists and hospitalists in perioperative medicine.  If each specialty brings its expertise to the care of the perioperative patient, care is likely to improve.  An example of cooperative medical care is the referral by the anesthesiologist to the hospitalist for a cardiac evaluation of a patient who presents to the preanesthetic screening clinic with a significantly abnormal electrocardiogram.  The specialty of anesthesiology will become much more diverse and challenging with the inclusion of perioperative medicine.

With best wishes,

Tony Mira
President and CEO