The American Society of Anesthesiologists is supporting an expansion of the role of anesthesiologists in the delivery of perioperative care in hospitals. This proposed model is called the Perioperative Surgical Home. The American Society of Anesthesiologists defines the Perioperative Surgical Home as “a patient centered, innovative model of delivering health care during the entire patient surgical/procedural experience; from the time of the decision for surgery until the patient has recovered and returned to the care of his or her Patient Centered Medical Home or primary care provider.”
It’s a sound idea, and it resembles a model that’s existed for decades outside the hospital. In an outpatient surgery center the Perioperative Surgical Home concept is carried out by an anesthesiologist who is the Medical Director. I can speak to this, as I’ve been the Medical Director at a busy surgery center only minutes from Stanford University in downtown Palo Alto, for the past 12 years.
A surgery center Medical Director is responsible for:
- All preoperative matters, including preoperative medical assessment of patients, scheduling of block times, surgical cases, anesthesia assignments, and creation of protocols,
- All intraoperative matters, including quality issues, efficiency and turnover of cases, and the economics of running a profitable set of operating rooms, and
- All postoperative matters, including overseeing Post Anesthesia Care Unit (PACU) nursing care, post anesthesia medical decisions, and supervision of post-discharge follow up with patients.
All medical problems including complications, hospital transfers, and patient complaints, are routed through the anesthesiologist Medical Director.
A key difference between a surgery center and a hospital is scale. A busy hospital has dozens of operating rooms, hundreds of surgeries per day, and hundreds of inpatient beds. No one Medical Director can oversee all of this every day—it takes a team. At Stanford University Medical Center the anesthesia department is known as the Department of Anesthesia, Perioperative and Pain Medicine. The word “Perioperative” is appropriate, because anesthesia practice involves medical care before, during, and after surgery. A team of anesthesiologists is uniquely qualified to oversee preoperative assessment, intraoperative management, and post-operative pain control and medical care in the hospital setting, just as the solitary Medical Director does in a surgery center setting.
A second key difference between a surgery center and a hospital is that medical care is more complex in a hospital. Patients are sicker, invasive surgeries disturb physiology to a greater degree, and patients stay overnight after surgery, often with significant pain control or intensive care requirements. Again, a team of physicians from a Department of Anesthesia, Perioperative and Pain Medicine is best suited to supervise management of these problems.
The greatest hurdle to instituting the Perioperative Surgical Home model is pre-existing economic reality. In a hospital, other departments such as surgery, internal medicine, radiology, cardiology, pulmonology, and nursing are intimately involved in the perioperative management of surgery patients. Each of these departments has staff, a budget, income, and incentives related to maintaining their current role. Surgeons intake patients through their preoperative clinics, and may regard themselves as captains of the ship for all medical care on their own patients. Internal medicine doctors are called on for preoperative medical clearance on patients, and thus compete with anesthesia preoperative clinics. The internal medicine department includes hospitalists, inpatient doctors who may be involved in the post-operative management of inpatients. Invasive radiologists perform multiple non-invasive surgical procedures. Like their surgical colleagues, they may see themselves as decision makers for all medical care on their own patients. Cardiologists manage coronary care units and intensive care units in some hospitals, and may feel threatened by anesthesiologists intent on taking over their territory. Pulmonologists manage coronary care units and intensive care units in some hospitals, and may feel threatened by anesthesiologists intent on taking over their territory. Nurses are involved in all phases of perioperative care. If the chain of command among physicians changes, nurses must be willing partners of and participants with such change.
Why has the anesthesiology leadership role of a Medical Director evolved naturally at surgery centers while the Perioperative Surgical Home idea has to be sold to hospitals? At surgery centers the competing financial incentives of surgeons, internal medicine doctors, radiologists, pulmonologists, cardiologists, and nurses are minimal. In a freestanding surgery center, surgeons want to be able to depart for their offices following procedures, and welcome the skills that anesthesiologists bring to managing any medical complications that arise. Internal medicine doctors have no significant on-site role in surgery centers, although they are helpful office consultants for the anesthesiologist/Medical Director in assembling preoperative clearance for outpatients. Radiologists have no significant on-site role at most surgery centers—if they do perform invasive radiology procedures on outpatients, they too welcome the skills that anesthesiologists bring to managing medical complications that arise. Because there are no intensive care units at a surgery center, there is no role for pulmonary or cardiology specialists. Nursing leadership at a surgery center works hand-in-hand with the Medical Director to assure optimal nursing care of all patients.
Hospital administrators anticipate penetration of the Accountable Care Organization (ACO) model for payment of medical care by insurers. In the ACO model, a medical center receives a predetermined bundled payment for each surgical procedure. The hospital and all specialties caring for that patient negotiate what percentage of that ACO payment each will receive. A Perioperative Surgical Home may or may not simplify this task. You can bet anesthesiologists see the Perioperative Surgical Home as a means to increase their piece of the pie. Ideally the Perioperative Surgical Home will be a means to streamline medical care, decrease costs, and increase profit for the hospital and all departments. Anesthesiologists are rightly concerned that if they don’t take the lead in this process, some other specialty will.
Establishing the Perioperative Surgical Home is an excellent opportunity for anesthesiologists to facilitate patient care in multiple aspects of hospital medicine. To make this dream a reality across multiple medical centers, anesthesiology leadership must demonstrate excellent public relations skills to convince administrators and chairpeople of the multiple other specialties. I expect data on outcomes improvement or cost-control to be slow and inadequate to proactively provoke this change. It will take significant lobbying, convincing, and promoting. Change will require a leap of faith for a hospital, and such change will only be accomplished by anesthesia leadership that captures the confidence of the hospital CEO and the chairs of multiple other departments.
I’m impressed by the adoption of the Perioperative Surgical Home at the University of California at Irvine. I’ve listened to Zev Kain, MD, Professor and Chairman of the Department of Anesthesia and Perioperative Medicine lecture, and I’ve met him personally. He’s the prototype of the charismatic, intelligent, and convincing physician needed to convince others that the Perioperative Surgical Home is the model of the future.(http://www.anesthesiology.uci.edu/clinical_surgicalhome.shtml)
I expect the transition to the Perioperative Surgical Home to occur more easily in university or HMO hospitals than in community hospitals. It will be easier for academic or HMO chairmen to assign new roles to salaried physicians than it will be for community hospitals to control the behavior of multiple private physicians.
Anesthesiologists were leaders in improving perioperative safety by the discovery and adoption of pulse oximetry and end-tidal carbon dioxide monitoring. Can anesthesiologists lead the way again by championing the adoption of Perioperative Surgical Home on a wide scale? Time will tell. Is the Perioperative Surgical Home an optimal way to take care of surgical patients before, during, and after surgeries? I believe it is, just as the Medical Director is a successful model of how an anesthesiologist can optimally lead an outpatient surgery center. Those lobbying for the Perioperative Surgical Home would be wise to examine the successful role of anesthesiologist Medical Directors who’ve led outpatient surgery centers for years. The stakes are high. As intraoperative care becomes safer and the role of nurse anesthesia in the United States threatens to expand, it’s imperative that physician anesthesiologists assert their expertise outside the operating room.
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Published in September 2017: The second edition of THE DOCTOR AND MR. DYLAN, Dr. Novak’s debut novel, a medical-legal mystery which blends the science and practice of anesthesiology with unforgettable characters, a page-turning plot, and the legacy of Nobel Prize winner Bob Dylan.
In this debut thriller, tragedies strike an anesthesiologist as he tries to start a new life with his son.
Dr. Nico Antone, an anesthesiologist at Stanford University, is married to Alexandra, a high-powered real estate agent obsessed with money. Their son, Johnny, an 11th-grader with immense potential, struggles to get the grades he’ll need to attend an Ivy League college. After a screaming match with Alexandra, Nico moves himself and Johnny from Palo Alto, California, to his frozen childhood home of Hibbing, Minnesota. The move should help Johnny improve his grades and thus seem more attractive to universities, but Nico loves the freedom from his wife, too. Hibbing also happens to be the hometown of music icon Bob Dylan. Joining the hospital staff, Nico runs afoul of a grouchy nurse anesthetist calling himself Bobby Dylan, who plays Dylan songs twice a week in a bar called Heaven’s Door. As Nico and Johnny settle in, their lives turn around; they even start dating the gorgeous mother/daughter pair of Lena and Echo Johnson. However, when Johnny accidentally impregnates Echo, the lives of the Hibbing transplants start to implode. In true page-turner fashion, first-time novelist Novak gets started by killing soulless Alexandra, which accelerates the downfall of his underdog protagonist now accused of murder. Dialogue is pitch-perfect, and the insults hurled between Nico and his wife are as hilarious as they are hurtful: “Are you my husband, Nico? Or my dependent?” The author’s medical expertise proves central to the plot, and there are a few grisly moments, as when “dark blood percolated” from a patient’s nostrils “like coffee grounds.” Bob Dylan details add quirkiness to what might otherwise be a chilly revenge tale; we’re told, for instance, that Dylan taught “every singer with a less-than-perfect voice…how to sneer and twist off syllables.” Courtroom scenes toward the end crackle with energy, though one scene involving a snowmobile ties up a certain plot thread too neatly. By the end, Nico has rolled with a great many punches.
Nuanced characterization and crafty details help this debut soar.
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