Does Perioperative Care Represent the Future for Anesthesiology? If so, How Can We Most Successfully Assume this Expanded Role in Patient Care? Perioperative care has been the foundation of the practice of anesthesia. With advances in surgery and anesthesia, introduction of new drugs, monitoring capabilities and surgical approaches to care, the quality and safety of perioperative care have improved. At the same time, the environment has become more complex and challenging to manage. As a result of subspecialization of anesthesiology, extensions of procedural care outside of the operating room, perioperative care is more fragmented and the course of care more convoluted. These realities require us to reconsider the roles anesthesiologists can have in perioperative clinical care and management.

A wide variety of approaches have been undertaken by health systems, physician groups and professional societies to identify and implement strategies to optimize perioperative care. The American Society of Anesthesiologists introduced the Perioperative Surgical Home (PSH). This model was designed to encourage anesthesiologists to assume greater responsibility for the full continuum of care for all surgical patients. The PSH is conceptually a viable approach to improving perioperative care, but has limitations. Many consider the model to be “anesthesia centric”, designed to expand the scope of practice for anesthesiologists rather than as a collaborative approach to improving perioperative care. More important, many anesthesia practices had little interest or thought they had the skill set to manage the PSH. As an alternative more clinically focused approach, Enhanced Recovery After Surgery (ERAS) protocols have been implemented to define specific interventions to improve care and reduce costs. ERAS protocols are intended to be “patient centered”, and many have elements that can be generalized, but most protocols are procedure-specific. As a result, ERAS protocols need to be individualized to each surgical procedure, which is challenging, time consuming and resource intensive. Most recently the concept of “Perioperative Medicine” has been proposed as an approach that builds on the experience with the PSH, ERAS and that is defined as an approach to manage the perioperative continuum to best meet patient needs while also optimizing operating room efficiency. The ASA has implemented the Center for Perioperative Medicine to acknowledge it a distinct specialty. Anesthesiologists have a comprehensive understanding of the entire perioperative environment and organizational structure needed to deliver and optimize care, so perioperative medicine seems a natural extension (perhaps a subspecialty) of anesthesiology.

However, no matter the specific model, perioperative medicine is and must remain multidisciplinary with participation of a diverse group of physicians and nursing and health system leadership. With this background, the issues for us to consider include (1) what role(s) anesthesiologists should have in perioperative care, (2) what knowledge and skills are essential for anesthesiologists to extend their role, and (3) whether perioperative care represents the future for anesthesiology. The discussion will clarify the scope of perioperative care in the current environment, potential opportunities for anesthesiology practices, and provide examples of positive outcomes associated with broadening the focus of anesthesia practice to include perioperative medicine.