Caroline G. Kan, M.D., is a CA-3 anesthesiology resident, Cedars-Sinai Medical Center, Los Angeles.

Caroline G. Kan, M.D., is a CA-3 anesthesiology resident, Cedars-Sinai Medical Center, Los Angeles.

One of the most widely known mnemonics in medicine is ABC: Airway, breathing and circulation. This is the cornerstone in cardiopulmonary resuscitation and central to our role as anesthesiologists. Despite this, many physicians still fail to understand the full scope of our practice, often joking that in anesthesia, ABC stands for airway, book and chair. Perhaps anesthesiology is a misunderstood field because anesthesiologists work alone in operating rooms and are not as visible as other physicians in the hospital. While other specialties incorporate oral presentations and discuss clinical plans in large teams, anesthesiologists often work independently and silently. Our anesthetic record is technically part of the medical record but is rarely seen by other physicians. Because anesthesiology is not a mandatory clerkship in most medical schools, it is not hard to imagine why other physicians do not fully understand what we do or the challenges we face. Such misunderstandings can compromise perioperative care as anesthesiologists rely on primary care physicians, subspecialists and surgeons for multidisciplinary management. Some of the biggest challenges anesthesiologists face are inadequate preoperative evaluations of patients and poor communication and coordination with surgeons in the operating room. Anesthesiologists play a vital role in providing airway management, yet basic life saving airway maneuvers such as effective bag mask ventilation should be taught to all physicians. A mandatory clerkship in anesthesiology would aim to inform medical students about the importance of medical optimization, physical and hemodynamic risks of anesthesia, and the skills required to maintain airway patency and successful ventilation.

With approximately 48 million surgical and nonsurgical ambulatory procedures performed annually in the United States, surgeons and anesthesiologists have an increasingly larger role in providing care for our growing population.1  Technological advancements continue to provide new surgical interventions for an increasingly complex patient population, making multidisciplinary communication essential among physicians. Although preoperative clinics staffed by anesthesiologists have gained momentum over the past few years, we still rely heavily on primary care physicians and subspecialists to evaluate and optimize our patients prior to surgeries. Not infrequently, cases are cancelled because patients have violated NPO guidelines, continued inappropriate medications or present with uncontrolled or untreated co-morbidities. Without proper evaluation, these patients are at an even increased risk for adverse outcomes intraoperatively. Thus, communication and coordination between the surgeon and the anesthesiologist are essential. Anesthesiologists are often pressured to forgo precautionary procedures such as central line placement or endotracheal intubation in hopes of expediting operating time. Unfortunately, this can be the difference between a successful operation and a major morbidity or mortality in the face of unanticipated difficulties. Just as anesthesiologists are required to spend time on surgery rotations to understand the steps and challenges surgeons face during different procedures, surgeons would highly benefit from understanding the challenges anesthesiologists face in the operating room. Ultimately, better communication and coordination with our medical and surgical colleagues could reduce potential delays in surgical treatment due to cancellations and lead to better outcomes if patients are thoroughly evaluated and optimized.

Unfortunately, anesthesiology remains an elective rota-tion in most medical schools in the U.S. According to the Association of American Medical Colleges (AAMC) curriculum inventory and reports in 2015-16, anesthesiology is a required clerkship in only 22 percent of medical schools with an average total requirement of 1.7 weeks.2  A mandatory rotation in anesthesia not only allows students to understand the breadth and complexity of anesthesiology but also provides the opportunity to learn life-saving skills. While medical students need not master direct laryngoscopy, the ability to successfully ventilate through effective bag masking is a crucial skill that every physician should be able to perform. Clerkships could also be tailored to fit the particular interest of each medical student. Aspiring surgeons may opt to spend more time learning about regional nerve blocks and acute postoperative pain management. Similarly, aspiring obstetricians could spend more time with OB anesthesiologists understanding neuraxial block placement and management. Future pediatricians, internists, and interventional radiologists may benefit from learning the risks of monitored anesthesia care (MAC) for patients they will encounter in GI, cardiology and radiology suites. The ASA Closed Claims Project database shows that 41 percent of MAC claims involved death or permanent brain damage and were caused primarily by respiratory depression as a result of oversedation.3  A reduction in such outcomes could be achieved if proceduralists had a better understanding of the serious risks of deep sedation in patients with unsecured airways. In addition to mandatory anesthesia clerkships, longitudinal simulation sessions could provide opportunities for medical students to practice their airway skills throughout the year. In summary, medical students can learn crucial airway skills and gain a better understanding of anesthetic challenges that may be relevant to their own practice.

Every year, only 4 percent of graduating medical students will enter the field of anesthesiology.4  The other 96 percent of future physicians will play an integral role in helping us care for patients with surgical needs. Exposure to anesthesia is critical and relevant to other fields of medicine. Having mandatory anesthesia clerkships may provide better awareness into anesthetic considerations and complications and help optimize preoperative evaluation of patients. This may lead to fewer cancellations and surgical delays, better patient outcomes and improved coordination of perioperative management among different teams. There is no other field where airway, breathing and circulation is as fundamental as it is in anesthesiology – perhaps it is time that all medical students learn these essential skills with us.

References:

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