The Daily Dose • Saturday, March 19, 2022

Anesthesiologists as Patient-Centered, Perioperative Physicians in the Post-Pandemic Era

Jane S. Moon, MD

This year’s eagerly anticipated T.H. Seldon Memorial Lecture provided a sweeping overview of the past, present, and future of anesthesiology as seen through the lens of patient-centered, perioperative care. The invited speaker was Dr. S. Ramani Moonesinghe, Professor of Perioperative Medicine and Consultant Anaesthetist at University College London; National Clinical Director for Critical and Perioperative Care, NHS England; and Director of the NIAA Health Services Research Centre of the Royal College of Anaesthetists. In her presentation, “Harder, Better, Faster, Stronger: The Beneficial Legacy of COVID-19 for Perioperative Healthcare,” held Saturday, March 19 at the IARS 2022 Annual Meeting, Dr. Moonesinghe cohesively tied together all points in time to illustrate how anesthesiologists can improve patient care as perioperative and public health physicians.

Professor S. Ramani Moonesinghe MD, FRCP, FRCA, FFICM, argued that technological advances in anesthesiology have improved patient safety to the point of essentially fixing the historical problem of anesthetic mortality. However, longer patient lifespans today have ushered in a new epidemic of perioperative morbidity. The COVID-19 pandemic, by increasing wait times for medical appointments, has opened a unique window for anesthesiologists to intervene earlier in patients’ lives to optimize their overall condition and to prevent postsurgical complications.

Prof. Moonesinghe began her talk with a brief historical overview of our profession since 1846, the year of the first public demonstration of ether anesthesia. She emphasized the technological developments that have improved patient safety and have allowed us to broaden our focus from intraoperative to perioperative care. She referenced the original motto of the Royal College of Anaesthetists — divinum sedare dolorem (“It is divine to alleviate pain”) — to highlight the initial focus on the short-term duty of anaesthetists to keep their patients alive and to relieve discomfort. She referenced a 2005 study (Khuri 2005) to emphasize the association between postoperative complications and long-term survival, highlighting the power and responsibility of anesthesiologists to affect patients’ perioperative morbidity and thus their long-term quality of life.

In this day and age, Prof. Moonesinghe explained that the process of improving patients’ postoperative outcomes should ideally begin long before they enter the operating room. She accentuated the unique historical moment that we are in two years after the start of the COVID-19 pandemic. As COVID-19 has led to longer wait times for both medical consultation and surgical treatment, anesthesiologists can now begin communicating with patients about their overall health condition and perioperative options much earlier than before. With plenty of patients now deconditioned, malnourished, and dealing with unmanaged comorbidities due to the lack of medical care during the pandemic, there is plenty of work for us perioperative physicians to do.

As the same comorbidities that compromise patients’ overall health also increase their surgical risk, the perioperative physician naturally serves as public health physician as well. Anesthesiologists can thus help improve patients’ quality of life by encouraging the care of various components of health like fitness, nutrition, blood pressure, blood glucose, and the use of tobacco, alcohol, or drugs. We can also help enhance the overall patient experience by increasing patient “activation,” or engagement with their own care. Patients can be presented with all of their healthcare options and can be given the opportunity to ask questions and make choices in an informed and unpressured setting.

According to Prof. Moonesinghe, our job as perioperative physicians should also continue postoperatively, with the aim to get patients safely home from the hospital as soon as we can. The British parallel to enhanced recovery after surgery (ERAS) protocols in the U.S. is to strive for the goal of the patient “DrEaMing” (drinking, eating, mobilizing) within 24 hours of surgery. Optimal postoperative analgesia can be a significant factor in facilitating patient DrEaMing.

Prof. Moonesinghe then concluded her talk with a vision for the future — one increasingly characterized by automation, artificial intelligence, and the gradual takeover of intraoperative patient management by machines. She cited two studies that showed success with closed-loop systems in achieving targeted sedation and goal-directed fluid therapy, respectively (Hemmerling 2013, Joosten 2015).

The session concluded with an energetic Q&A discussion led by Michael Avidan, MBBCh, FCA SA, the Dr. Seymour and Rose T. Brown Professor of Anesthesiology and Head of the Department of Anesthesiology at the Washington University School of Medicine in St. Louis.

During the Q&A session, a flurry of questions surrounded Prof. Moonesinghe’s belief in a largely automated future. Several attendees voiced their concerns with technology and artificial intelligence removing the creative and humane aspects of patient care and exaggerating health care disparities, especially for patients with limited technological access. Prof. Moonesinghe responded to these concerns by encouraging physicians to embrace change and the inexorable movement toward “technological singularity”— the point at which machines will become better than humans at most tasks. At the same time, she urged the audience to see the technological evolution as an opportunity to make our care even more patient-centered. In her view, the future is bright. Machines will ultimately give us more time to have meaningful conversations with patients about their values, choices, and wishes.

When prompted by Dr. Avidan to summarize the key takeaways from her talk, Prof. Moonesinghe reiterated her great hope that anesthesiologists will embrace our role as perioperative, or public health, physicians and view the surgical period as a “teachable moment” for patients. At this point in time, we can do our part to reduce perioperative morbidity by dedicating ourselves to the following aspects of patient care: preoperative optimization, high-quality intraoperative management, enhanced recovery principles in the immediate postoperative period, and close patient follow-up in the longer term.