The Future of Anesthesia Education: Developing Frameworks for Perioperative Medicine and Population Health

Value-based health care and population health management are emerging initiatives that will shape the future of medicine in the United States and worldwide. To meet the challenges and demands raised by these changes, anesthesiology training in the United States must undergo significant change. Traditional educational paradigms may not be well suited to these needs. Incorporating directives from oversight agencies and learning from individual institutional initiatives aimed at providing appropriate skillsets will foster a workforce of anesthesiologists that is better prepared to successfully meet the demands of the future health care as perioperative physicians. ANESTHESIOLOGY, VALUE-BASED CARE, AND POPULATION HEALTH: WHAT ARE THE DRIVERS OF CHANGE? Every health care system worldwide is facing an unsustainable increase in health care spending. Multitudinous attempts to contain costs have thus far largely failed.1 As health care spending continues to increase, new delivery and payment models are being implemented.2 Currently, providers work under multiple payment models and therefore face varying exposure to risk. In the United States, the Center for Medicare and Medicaid (CMS) insures a large percentage of patients. Therefore, bundled payments introduced by CMS have a widespread impact on provider reimbursement, and the effects are more widely studied.3 Bundled payments now include dozens of surgical interventions and medical conditions managed in more than 1000 institutions in the United States. A recent review by the Leonard Davis Institute of Health Economics concludes that the evidence so far points to favorable results for surgical conditions such as joint replacements.4 Since its beginnings, the scope of practice of anesthesiology has included the perioperative period. For several decades, the major focus of research and improvements was in the immediate perioperative setting, but recent findings are leading to major shifts that now expand that period well into the preoperative and postoperative care arc. As population health management and value-based care are introduced into the perioperative care setting, anesthesiologists are uniquely suited to play a significant role. Anesthesiologists differ from internists and hospitalists as they are innately aware of physiologic impact of surgery and anesthesia. In addition, several anesthesiology departments have implemented perioperative care pathways that include preoperative medical optimization and postdischarge care for high-risk patients. Examples of program components and implementation are available from several institutions.2,5 In this evolving perioperative care model, collaboration among anesthesiologists, surgeons, and other clinicians will be critical in developing and implementing needed integrated care pathways based on the latest evidence to improve patient experience and outcomes as well as health care economics. Accreditation Council for Graduate Medical Education (ACGME) requirements have been changed to reflect this, as described below (2019 ACGME Program Requirement IV.B.1.c.1.c). Specific to knowledge and skills in perioperative medicine, the residency program requirements state that “the residents must demonstrate medical knowledge in the topics related to the anesthetic care of patients, including: … care of the patient in the continuum of the perioperative period, to include collaboration with medical and surgical colleagues to optimize preoperative patient condition and optimize recovery.” PROFESSIONAL CULTURE: NEED FOR CHANGE TO ADDRESS THESE DRIVERS Anesthesiologists have significant experience in streamlining perioperative care delivery and improving patient safety, and they frequently function as leaders in the perioperative environment. However, there are concerns that anesthesiologists are either unprepared or unwilling to manage patients or systems of care outside of the immediate perioperative setting.6 As Davis writes, “Even with 4 years of medical school education and 4 years of residency training, most anesthesiologists are not (not want to be) trained to deal with issues outside the immediate perioperative area…. This will be a significant culture change for young physicians entering our specialty.”6 If anesthesiologists are to be members of the core leadership team to improve value-based care delivery throughout the entire perioperative care arc, the specialty needs to rethink education for residency training programs as well as for its faculty.7 Both trainees and practicing anesthesiologists will need to be familiar with principles of population health management, process and outcome improvement, team leadership, evidence-based perioperative medicine, operations management, and health system finances. Essentially, the future anesthesiologist as a perioperative physician will need to be able to care for the sickest patients and sick systems of care from the decision to operate until well after discharge from the hospital.5 Several anesthesiology departments have made progress in developing these educational frameworks, and those detailed below may serve as examples for other departments that seek to develop these new core competencies in their staff and trainees. Furthermore, faculty from many departments participate in the programs held by the Society of Perioperative Assessment and Quality Improvement (www.spaqi.org) and the American Society for Enhanced Recovery (ASER; www.aserhq.org). These multidisciplinary societies were formed in 2006 and 2014, respectively, because of the needs expressed by a number of institutions to promote education and collaboration in perioperative medicine. CURRENT TRAINING REQUIREMENTS IN ANESTHESIOLOGY IN THE UNITED STATES Anesthesiology residency training is now a highly regulated model with specific program requirements, the latest of which make specific mention of population health. Over the last few years, training guidelines set forth by the American Board of Anesthesiology (ABA) and the ACGME have added some requirements. The ABA successfully added the Objective Structured Clinical Examination (OSCE) to board requirements with 1 goal being to test perioperative communication skills of graduates. The OSCE assesses perioperative communication skills of the graduates. Communication skills have always been an important aspect of being a consultant anesthesiologist. However, as the scope of our practice is expanding, these skills are increasingly important as they are used in shared decision-making between the patient and physicians, often used in risk/benefit discussions during preoperative risk assessment and prescribing of plans for medical optimization before surgery.8 The increased focus on value reflects population health management applied in the perioperative care setting, and communication is a key component needed to provide optimal care. The ACGME added patient safety and quality improvement as training program requirements for all types of residency programs in 2015. In addition, the ACGME has increased expectations about the training on point of care ultrasound throughout the perioperative period. While subtle, the changes suggest increased expectations of graduates to act as consultant perioperative physicians. However, more is needed. As most of the 4 years of current anesthesiology training is spent on various clinical rotations—without training content offered in the areas identified as missing by the American Society of Anesthesiologists (ASA) task force in 20157—anesthesiologists are typically not well prepared to provide optimal value-based care to surgical patients in the perioperative care setting. SUGGESTED EDUCATIONAL REFORMS AT THE NATIONAL LEVEL While the ABA and ACGME have made some updates to the training requirements, the suggested educational reforms discussed within the specialty of anesthesiology and perioperative medicine are more far-reaching. To address missing educational components and thus to prepare anesthesiologists for practice in the perioperative care model, in 2015, the ASA created an educational task force, which identified at least 57 elements in 6 domains that need to be enhanced or added to the traditional anesthesiology residency curriculum and training requirements.7 In particular, this ASA task force identified that residency education needs to include an understanding of the principles of developing and implementing multidisciplinary perioperative care pathways. This requires education in preoperative risk stratification and optimization for multiple medical conditions. In 2018, the International Board of Perioperative Medicine (www.internationalboardpom.org) was formed at the annual ASA meeting and further defined learning objectives for the perioperative physician. Publications in relevant specialty journals have described knowledge and skills relevant for a physician practicing in a value-based care model.5 LEADERSHIP SKILLS AND ADMINISTRATIVE SKILLS Besides medical knowledge, the acquisition of leadership skills and the understanding of organizational processes have explicitly been stated as an essential skillset to become a successful perioperative physician9 (ACGME Program Requirement IV B.1.c.1.a). Proposals were made to recognize and incorporate health care management as the “fourth mission” of faculty in academic anesthesiology departments—in addition to the conventional missions of patient care, education, and research.10 This analysis of time spent by academic anesthesia faculty reported that faculty time in managerial activities was greater than time spent in education, research, and other professional activities. Administrative activities may constitute a hidden “fourth mission,” yet academic faculty are generally trained and evaluated based only on metrics related to clinical care, education, and research. Examples of such managerial activities include medical directorships of surgical and perioperative areas, supervising the operating room and postoperative care units, and strategic planning for both departmental and hospital initiatives. Emphasis on managerial skills at both the resident and faculty level appears essential to ensure success in both current and future financial and clinical environments. To obtain these needed skills, there is an increasing number of physicians pursuing advanced degrees in health care management (MPH, MBA, etc). In addition, the ASA own program for leadership and business development is evidence of this fourth mission as distinct from the traditional tripartite mission. INSTITUTIONAL INITIATIVES AT THE FOREFRONT OF EDUCATIONAL INNOVATION While publications concerning the proposed skills for developing perioperative physicians are important, most skills and knowledge thought to be pertinent for anesthesiologists to function effectively in the perioperative setting are not yet specifically incorporated into training requirements. This is a global problem, as residency board certification requirements not only in anesthesiology but also in related specialties dealing with surgical patients such as internal medicine and surgery also lack specific curriculum requirements in these perioperative domains.11 A recent survey of anesthesia program directors reported an increasing understanding of the value of including training in perioperative medicine and management in residency curricula.12 Of the 55 programs that responded, 34% had incorporated additional training in these competencies in the previous 3 years, and 32% had plans to integrate more such training in the next 3 years. This survey did not include data on the successful impact on resident education; research in this area needs to be conducted. Individual anesthesiology residency programs have made efforts to innovate curricula and add opportunities for their trainees to develop skills critical to the shifting health care environment, while also fulfilling the current training requirements set forth by the ABA and ACGME. At this time, ACGME accreditation is one definition of success, as outcomes related to the learning of these skills have not formally been demonstrated. There are opportunities to include innovative curricula during the internship year as well as during the subsequent 3 years of the anesthesiology residency. There has been a significant increase in the number of postgraduate year (PGY)-1 positions in categorical tracks within the same institution as the PGY-2 to PGY-4 years. This allows residency programs to incorporate innovative curricula right from the start of training by shaping the content of the clinical base year. For example, University of California Irvine Health has restructured existing rotations and previous elective blocks to incorporate competencies fundamental to the Perioperative Surgical Home (PSH) from the internship year and throughout their anesthesiology graduate medical education. This curriculum has been published and shared with the anesthesiology community, providing a detailed example of how elements of perioperative care can be incorporated into an existing residency curriculum.13 The Vanderbilt University Medical Center training program has created an Anesthesia Perioperative Consult Service (APCS) for postoperative management and High-Risk Surgical Encounter (Hi-RiSE) preoperative management clinic, which provide a 4-year longitudinal training curriculum containing experiences necessary for residents to learn concepts that prepare them to lead care redesign in perioperative medicine throughout their careers.14 Standardized operating room management curricula15 and training in nonoperating room anesthesia (NORA) have been described.16 Residency programs, such as the one at Brigham and Women’s Hospital, customize resident schedules to support their individual development and build electives into the rotation schedule that advance resident skills and knowledge in areas of interest. An example at Brigham and Women’s Hospital is the senior preadmission test center elective rotation, a month-long elective, which focuses on research in the development of perioperative systems and multidisciplinary pathways. Cooperations with other institutional entities like business schools and schools of public health can also teach cross-disciplinary skills during residency training, as shown in the example of process mapping in endoscopy, which developed from a relationship between Harvard Business School and the anesthesia residents at Brigham and Women’s Hospital, with mentors from both departments.17 COMBINED PROGRAMS TO TRAIN LEADERS IN PATIENT-CENTERED HEALTH CARE ENVIRONMENT During the past decade, combined residency programs have been created to meet the educational and training needs of the future physicians seeking to deliver patient care outside the traditional silos of each specialty. Trainees in combined residency programs undertake training in 2 specialties simultaneously with eligibility for dual board certification at the completion of the program. Thus far, specialty boards have approved 7 combined programs in pediatric-anesthesiology, 5 combined medicine-anesthesiology, and 1 combined emergency medicine-anesthesiology program. In each of the combined programs, only 1–3 positions are available each year. Therefore, only a small number of trainees currently graduate from combined programs each year. The graduates are extremely well-positioned to assume leadership roles in a patient-centered health care environment where patient care, rather than departmental divides, determines the care provided. EXAMPLE OF PEDIATRIC ANESTHESIOLOGY AND THE POTENTIAL BENEFIT OF A COMBINED PROGRAM Care coordination for children remains one of the least understood yet widespread practice and policy interventions in pediatrics.18 It is estimated that 95% of pediatric medical expense is allocated to children with complex or chronic disease and only 5% on healthy children. Unlike the adult population where surgical procedures are procedure based, the indication for surgery in children is often disease based (eg, neuromuscular scoliosis or cyanotic congenital heart disease). The American Board of Pediatrics (ABP) and the ABA launched a combined training program in pediatrics and anesthesiology in 2009 that enables physicians to fulfill the training requirements for certification in pediatrics and anesthesiology. It is anticipated that many trainees will develop careers focused on caring for children with complex medical and surgical conditions who are hospitalized and/or require perioperative/periprocedural management. The strengths of both a pediatric and anesthesiology residency complement each other to provide the optimal educational experience and potentially develop leaders in the field. There are currently only 7 approved combined pediatrics/anesthesiology training programs in the United States. Every combined training program in anesthesiology and pediatrics must be approved by both the ABA and ABP before residents can be recruited. The curriculum assures a cohesive, planned integrated educational experience and not simply a series of rotations between the 2 specialties. As a general principle, the training of residents in pediatrics is the responsibility of the pediatric faculty, and the training of residents in anesthesiology is the responsibility of the anesthesiology faculty. Unfortunately, for now, graduates of combined programs, while well qualified to bridge patient care across different specialties, are still confronted with the strict separation of different specialties and departments when seeking postgraduation employment. They are often forced to pursue their career in one or the other specialty. Practice in both specialties is hindered by the traditional financial and organizational separation of departments within the same institution and by maintenance in certification set forth separately for each specialty. CREATION OF FELLOWSHIPS IN PERIOPERATIVE MEDICINE At Loma Linda University, the Departments of Anesthesiology and Urology implemented a perioperative service led by anesthesiology-trained physicians to comanage patients for their entire perioperative course. Reductions in complications and costs were achieved.19 At Vanderbilt University Medical Center, anesthesiologists and surgeons collaborated to create clinical pathways for a wide spectrum of surgical patients in line with the Enhanced Recovery After Surgery (ERAS) approach.14 To manage these efforts, a new clinical service led by anesthesiologists was created called the Perioperative Consult Service. Along with this, new curricula were built into the anesthesiology residency program reflecting the need to expose trainees to the clinical pathway and to orient trainees to the emerging specialty of perioperative medicine.6 Ultimately, this led to the creation of a fellowship in perioperative medicine at Vanderbilt University. Similar initiatives led to the creation of perioperative medicine fellowships at University of California Los Angeles, University California San Diego, Duke, Brigham and Women’s Hospital, and several other academic anesthesiology departments throughout the United States. These perioperative medicine fellowships are 1-year-long, non-ACGME accredited fellowships. The year is divided into rotations and educational experiences designed to provide fellows with the opportunity to learn from a clinical and administrative perspective about perioperative medicine, with an emphasis on the PSH, ERAS, perioperative management of comorbid conditions, goals of care discussions, and complex coordination of care. Detailed examples include the curriculum for the Perioperative Medicine Fellowship at Brigham and Women’s Hospital20 and those proposed by the International Board of Perioperative Medicine. FUTURE OF FACULTY DEVELOPMENT: TRAINING THE DOERS AND THE TRAINERS A focus on coordinating surgical care to increase value (defined as outcomes/cost) has created new opportunities for anesthesiologists to become leaders in the perioperative care environment of the future. This has already led to a new work-related focus of anesthesiology faculty, in which many academic anesthesiology faculty spend significant time in leadership roles to improve the organizational structure of clinical care delivered. This frequently leads to less productivity in traditional academic activities like research.10 This type of work is not part of the traditional tripartite mission of academic medical centers (patient care, education, and research). As noted earlier, faculty time and effort devoted to organizational improvements is not captured by traditional measures of professional productivity, such as hours billed, numbers of trainees, hours of lectures, papers published, and grants received. It appears logical to recognize and advocate for health care management as the so-called “fourth academic mission.” Department chairs should realign incentives and rewards to the desired outcome of anesthesiologists as health care leaders. Continuing education activities and, in some of degrees to knowledge and skills in health care management should be by chairs and institutions to create anesthesiology leaders in the new health care delivery the of these competencies may be the key to the future success of the specialty. Continuing professional development should be the for our specialty to anesthesiologists to in the new opportunities available to our specialty in the health care environment. 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