What are the key aspects of social responsibility and dedication in the practice of anesthesiology?

Social Responsibility and Dedication in Anesthesiology

Anesthesiologists must expand their role beyond the operating room to serve as clinical leaders driving value-based perioperative care, focusing on proactive patient optimization, reducing preventable complications and mortality, and addressing health equity to fulfill their social contract with patients and society. 1

Expanding the Scope of Anesthesiology Practice

The American Society of Anesthesiologists has recognized that anesthesiologists can no longer be confined to episodic, hospital-based care but must leverage their expertise across the entire perioperative continuum. 1 This transformation involves:

• Using the surgical experience as the first touchpoint to reengage patients in their own healthcare, shifting from reactive medicine to preventative medicine. 1
• Establishing comprehensive preoperative care centers that address modifiable risk factors including malnutrition, anemia, diabetes, and pain before surgery, as demonstrated by institutions like Duke University and Brigham and Women's Hospital. 1
• Implementing proactive engagement strategies that reduce long-term morbidity by focusing on the longitudinal cycle of care (weeks to months) rather than just the operative episode. 1

The evidence is clear: once the decision for surgery is made, the patient's reduction in body mass index and optimization of chronic conditions matters far more for long-term outcomes than intraoperative anesthetic choices. 1

Leading Value-Based Care Transformation

Anesthesiologists are uniquely positioned to impact perioperative healthcare through their multitude of interactions across the perioperative domain, consolidating their role as clinical leaders in value-based care. 1

Key interventions being effectively instituted include:

• Personalizing and standardizing care delivery by segmenting patients based on complexity and risk, using standardized protocols for low-complexity cases while employing complex adaptive system approaches for high-risk patients. 1
• Implementing data-driven, evidence-based best practices that allow patients to return to optimal functional, cognitive, and psychological health. 1
• Establishing collaborative relationships with surgeons, primary care providers, and multidisciplinary teams to reset patient expectations and reduce mortality through shared decision-making. 1

The COVID-19 pandemic has further highlighted the urgency for anesthesiologists to expand their roles in perioperative care and impact system improvement. 1

Addressing Health Equity and Disparities

Anesthesiologists have a tremendous opportunity and responsibility to eliminate health disparities and achieve health equity by considering social identity and social determinants of health throughout the perioperative period. 2

This requires:

• Ensuring patient safety by incorporating patient-specific social factors that affect clinical outcomes, which could substantially reduce health disparities. 2
• Utilizing clinical informatics and valid data collection on race and ethnicity as foundational tools for achieving health equity. 2
• Working at multiple interdependent levels—patient, clinician, department, health system, and professional societies—to mitigate healthcare disparities. 2

Ethical Obligations and Goals of Care

Anesthesiologists have both an ethical and practical imperative to share responsibility for goals of care discussions, despite the temptation to defer to surgical or primary care colleagues. 3

The American Society of Anesthesiologists, American College of Surgeons, and Association of Perioperative Registered Nurses have mandated "required reconsideration" of do-not-resuscitate orders, based on:

• Respect for patient autonomy, beneficence, and nonmaleficence as guiding ethical principles. 3
• Understanding patients both biologically and biographically—what gives meaning to their life subjectively and what quality of life would be compatible with their level of functioning. 4
• Ensuring interventions are both clinically appropriate and ethically proportionate, offering meaningful benefit within the context of the patient's own life narrative. 4

Professional Identity and Patient Trust

Professionalism plays a central role in the balance between physician autonomy and social contract, with significant impact on patient safety and medicolegal outcomes. 5

Critical aspects include:

• Addressing the credibility gap: 35% of the general public did not believe anesthesiologists were medically qualified doctors in surveys, necessitating patient education efforts. 1
• Providing empathetic, personal, and forthright communication in simple terms without jargon, as patients inherently believe their doctors are competent but need reassurance about loss of control during anesthesia. 1
• Recognizing that the anaesthetist's presence and information delivery has the greatest impact on alleviating patient anxiety compared to nursing staff. 1

Quality Improvement as Ongoing Obligation

Continuous improvement of quality and safety is a professional obligation of anesthesiologists, representing an infinite process that evolves in response to emerging threats to patient safety. 6

This involves:

• Recognizing that human factors contributed to airway complications in 40% of cases, with a median of 4.5 human factors per case in follow-up studies. 1
• Implementing non-technical skills training and graded assertiveness communication tools like PACE (Probe, Alert, Challenge, Emergency) to avert catastrophes. 1
• Acknowledging that events leading to harm often result from omission of key planning steps, such as failure to anticipate and plan for difficult airways. 1

Common Pitfalls to Avoid

• Failing to convince hospital administration that healthier patients undergoing surgery result in cost avoidance and reduced readmissions, even if it reduces revenue in fee-for-service systems. 1
• Not recognizing that pay-for-performance programs can penalize physicians for caring for the poorest and sickest patients, requiring careful implementation. 1
• Overlooking the psychology of surrendering control that causes patient anxiety about never waking up, dying during surgery, or waking up during the procedure. 1