Anesthesiologist

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An anesthesiologist (US English) or anaesthetist (British English) is a physician trained in anesthesia and perioperative medicine.

In the United States, the term anesthesiologist refers to a physician who completed an accredited residency program in anesthesiology, usually four years following medical school either with M.D. or D.O. degree. In contrast, the term anesthetist is used for anesthesia providers without the qualification of a physician.

In the United Kingdom and in Europe the term anaesthetist refers only to physicians (university graduates in medicine) specialised in anaesthetics. In a very few UK hospitals some duties are performed by non-physicians, but only under close physician anaesthetist supervision, and this has effectively ceased. In several European countries (e.g. Germany, Austria) anaesthesia is exclusively provided by physicians (1:1 ratio anaesthetist:patient), while anaesthesia nurses (or anaesthesia technicians) assist the anaesthetist.

Role in healthcare delivery
Anesthesiologists (anaesthetists in the UK) are physicians who provide medical care to patients in a wide variety of (usually acute) situations. This includes a preoperative evaluation, consultation with the surgical team, creation of a plan for the anaesthesia tailored to each individual patient, airway management, intraoperative life support and provision of pain control, intraoperative diagnostic stabilisation, and proper post-operative management of patients. For anesthesiologists/anaesthetists, preparation of patients for emergency surgery is mandatory and essential. Because anesthesiologists/anaesthetists are physicians, in contrast to other anesthesia providers, they are able to utilize their extensive knowledge of physiology, pharmacology and diseases to guide their decision making. Nevertheless, in many areas of the United States this function is fulfilled by Certified Registered Nurse Anesthetists who are authorized by state and federal authorities to function in the same capacity as their physician counterparts.

In the USA, there has been a shortage of anesthesiologists historically. In order to better serve the population, residency positions in anesthesiology for physicians have been steadily increasing the past several years. In addition, US physicians supervise ACTs, or Anesthesia Care Teams, which are composed of a supervising physician with several certified registered nurse anesthetists (CRNAs) or anesthesiologist assistants (AAs). In other areas of the USA, anesthesiologists work in what is deemed a "solo" or "MD/DO only" practice, during which they provide anesthesia in a "one on one" relationship with the patient.

A consultant anaesthetist in the UK is a fully qualified doctor, who has spent at least 9 years (7 of which should be in anaesthesia) after graduation as a trainee, and is appointed as a consultant. Trainee anaesthetists in the UK are fully qualified doctors on their way to become consultants; they could be two years or even 10 years post graduation.

Anesthesiologists/Anaesthetists and patient-informed consent
Patient-informed consent is a fundamental ethical and legal principle and is considered essential to patient autonomy. The American Society of Anesthesiologists, the American Osteopathic College of Anesthesiologists, and other professional organizations, such as the American Association of Nurse Anesthetists, support the principle that patients should be fully informed regarding the manner in which their anesthetic will be administered. In Germany, the law requires that prior to anaesthesia informed consent of the patient must be obtained by the anaesthetist.

Due to medications given before, during, and after surgery, a patient may sometimes not remember interacting with the anesthesiologist/anaesthetist, nurse anesthetist, or anesthesiologist assistant involved in their anaesthesia care. The anaesthetic plan, as well as alternatives, risks, and benefits of the chosen anaesthetic techniques, should be discussed with the patient prior to surgery (This can be difficult or impossible in some situations, such as with unconscious patients, confused patients, or extremely urgent cases).

Training by country
Physician training in anaesthesiology in developed countries is quite similar.

Argentina
In Argentina, anaesthetists are physicians who have specialized in the medical field of anaesthesia. Residency is 5 years long.

Australia and New Zealand
In Australia and New Zealand, anaesthetists are physicians (with the degree of Bachelor of Medicine and Bachelor of Surgery i.e. MB ChB or MB BS) who have specialized in the medical field of anaesthesia.

In Australia and New Zealand, anaesthetists are represented by the Australian Society of Anaesthetists and the New Zealand Society of Anesthetists. Training is overseen by the Australian and New Zealand College of Anaesthetists. The ANZCA approved training sequence encompasses an initial two-year Pre-vocational Medical Education and Training (PMET) period and the five-year period of ANZCA Approved Training (two years Basic Training and three years Advanced Training).

In the course of Approved Training, Trainees are required to successfully complete:

- Five years of supervised clinical training at Approved Training Sites

- Both the Primary and Final Examinations which consist of both written (multiple choice questions and short answer questions) and, if successful at the written component, oral examinations

In the final examination, there are many stations of clinical scenarios (including interpretation of radiological exams, EKGs and other special investigations). There is also two stations of real patients with complex medical conditions - for clinical examination and a following discussion. - A program of 12 modules such as obstetric anaesthesia, pediatric anaesthesia, cardiothoracic and vascular anaesthesia, neurosurgical anaesthesia and pain management.

- Completion of an advanced project, such as a research publication or paper.

- An EMAC (Effective Management of Anaesthetic Crises) or EMST (Early Management of Severe Trauma) course.

On completion of all Training Program requirements the Trainee will be awarded the Diploma of Fellowship and be entitled to use the qualification of FANZCA – Fellow of the Australian and New Zealand College of Anaesthetists.

Canada
In Canada anaesthesiologists are physicians (with the degree MD - Medicinae Doctorem or MDCM - Medicinae Doctorem et Chirurgiae Magistrum) who have specialized in the medical field of anaesthesiology.

Training is overseen by 16 universities approved by the Royal College of Physicians and Surgeons of Canada. Upon completion of a residency program, (typically five years) the candidate is required to pass a comprehensive objective examination consisting of a written component (two three-hour papers: one featuring 'multiple choice' questions, and the other featuring 'short-answer' questions) and an oral component (a two-hour session made up of stations on the clinical aspects of anaesthesiology). The examination of a patient is not required.

Upon completion of all training requirements, the anaesthesiology graduate is then entitled to become a "Fellow of the Royal College of Physicians of Canada" and to use the post-nominal letters "FRCPC".

Germany
In Germany, anaesthetists (German: Anaesthesist or Facharzt für Anaesthesiologie) are the only anaesthesia providers as German law does not allow anyone but a physician to practice medicine - physician centered medicine (German: Arztvorbehalt). After earning the right to practice medicine (German: Approbation), German physicians who want to become anaesthetists have to go through a 5-year training, ending with a board examination, held by the state chamber of physicians (German: Landesärztekammer). German Anaesthetists are trained in all aspects of anaesthesia, including ECG and pulmonary function testing, critical care and pain medicine as well as palliative care medicine. The training includes rotations serving in the operating theatre to perform anaesthesia on a variety of patients being treated by every kind of surgical sub-specialty (i.e. general surgery, neurosurgery or invasive urological and gynecological procedures), followed by a rotation through various intensive-care units. Many German anaesthetists choose to complete a curriculum in emergency medicine, which once completed, enables them to be referred to as Notarzt, an emergency physician working pre-clinically with the Emergency Medical Service. In the pre-clinical setting the emergency physician is assisted by paramedics.

The Netherlands
Anaesthetists in The Netherlands must have completed medical school, which takes six years on average. After successfully completing medical school they start a five year residency training in anaesthesiology. In their fifth year they can choose to spend the year doing research, or to specialize in a certain area, including regular anaesthesia, critical care medicine, pain and palliative medicine, paediatric anaesthesiology, cardiothoracic anaesthesiology, neuro anaesthesiology, obstetric anaesthesiology.

Guatemala
To specialize in Anesthesiology in Guatemala, a student with a medical degree (he or she must have a Surgeon and General Medicine skills by law) completes a residency of six years (five years in residency and one year of practice with an expert anesthesiologist). After residency, students then go to a board examination overseen by the College Of Medicine of Guatemala, the Universidade De San Carlos De Guatemala (Medicine Faculty Examination Board), and a Chief Physician who represents the Healthcare Ministry Of The Government Of Guatemala. The examination includes a written section, an oral section, and a special examination of skills and knowledge in Anesthesia Instruments, Emergency Treatment, Pre-Operative Care, Post-Operative Care, ICU -Intensive Care Unit-, and pain medicine.

After passing the examination, the College Of Medicine Of Guatemala, Universidad De San Carlos De Guatemala and the Healthcare Ministry Of The Government Of Guatemala grants the new anesthesiologist a special license to practice anesthesiology as well as a Diploma issued by the Universidad De San Carlos De Guatemala granting the degree of Physician with specialization in anesthesiology. Anesthesiologists in Guatemala are also subject to yearly examinations and mandatory participation in a yearly seminary on the latest developments in anesthesiology.

Hong Kong
To be qualified as a specialist anaesthetist in Hong Kong, medical practitioners must undergo a minimum of six years of postgraduate training and pass three professional examinations. Upon completion of training, the Fellowship of Hong Kong College of Anaesthesiologists and subsequently the Fellowship of Hong Kong Academy of Medicine would be awarded. Practicing specialist anaesthetists are required to register in the Specialist Register of the Medical Council of Hong Kong and hence are under the regulation of the Medical Council.

Italy
In Italy, the Anaesthesiologist-Intensive Care is a doctor who, after graduation from Medical School (6.5 years), has completed a residency of four years (five years starting in 2008). They can work in Operating Rooms, ICUs, PACUs, Pain Units, Hyperbaric Units and Emergency Departments.

Scandinavia
In Denmark, Finland, Iceland, Norway, and Sweden, anaesthetist training is overseen by the respective national societies of anaesthesiology as well as the Scandinavian Society of Anesthesiology and Intensive Care Medicine (SSAI). In Scandinavia, anaesthesiology is the medical specialty that is engaged in the fields anaesthesia, intensive care medicine, pain medicine, and pre- and in-hospital emergency medicine.

Anaesthesiologist in the Scandinavian countries are doctors who have completed a six-year undergraduate training program (from Medical School), a twelve-month internship, and a five-year residency program. SSAI currently hosts five training programs for anaesthesiologists in Scandinavia. These are Intensive Care, Pediatric Anesthesia and Intensive Care, Advanced Pain Medicine, Critical Care Medicine, Advanced Obstetric Anesthesia.

United Kingdom
In England, Northern Ireland, Scotland, and Wales, training is overseen by the Royal College of Anaesthetists. Anaesthetists in the United Kingdom are doctors who have completed either a five-year or six-year undergraduate training program or a four-year program open only to open to post graduates.

Following the completion of medical school, doctors enter the two-year Foundation Program which consists of at least six, four-month rotations in various medical specialties. It is mandatory for all doctors to complete a minimum of three months of general medical and general surgical training in this time.

Following the Foundation Programme, doctors compete for specialist training in anaesthetics. The training program in the United Kingdom currently consists of two years of Core Training and five years of Higher Training. Trainees wishing to hold dual accreditation in Anaesthetics and Intensive Care Medicine may enter anaesthesia training via the Acute Care Common Stem (ACCS) program which lasts three years and consists of experience in anaesthesia, emergency medicine, acute medicine and intensive care. Trainees in anaesthesia are called Specialty Registrars (StR) or Specialist Registrars (SpR).

Before the end of Core Training, all anaesthetic trainees must have passed the primary examination of the diploma of Fellowship of the Royal College of Anaesthetists (FRCA).

The CCT (Certificate of Completion of Training) program in anaesthetics is divided into three levels: basic, intermediate and advanced. During this time, doctors experience anaesthesia as applicable to all surgical specialties. The curriculum focuses on a modular format, with trainees primarily working in one specialist area during the module, for example: cardiac anaesthesia, neuroanaesthesia, ENT, maxillofacial, pain medicine, intensive care, trauma.

Traditionally (before the advent of the Foundation Programme) trainees have entered anaesthetics from other specialties, such as medicine or accident and emergency. Specialist training then takes at least seven years.

On completion of specialist training, doctors are awarded the Certificate of Completion of Training (CCT) and are eligible for entry on the GMC Specialist Register and are able to work as Consultant Anaesthetists. A new consultant in anaesthetics will have completed a minimum of 14 years of training (including: five to six years of medical school; two years of foundation training; and seven years of anesthesia training). It is this level of training that confers the credibility to a CCT holder, referred to as a Consultant in the NHS, and is respected throughout the World.

Those wishing for dual accredit in intensive care are required to undertake an additional year of training and normally complete the Diploma in Intensive Care Medicine (DICM). Pain specialists sit the Fellowship of the Faculty of Pain Medicine of the Royal College of Anaesthetists (FFPMRCA) examination.

United States
Anesthesiologists are the most extensively trained anesthesia providers in the United States. Anesthesiologists are physicians (M.D. or D.O.) who have chosen to specialize in anesthesiology. Anesthesiologists in the United States must have completed an undergraduate college degree (that includes pre-medical requirements) and, like all other physicians, four years of medical school. Anesthesiology residency programs in the United States, without exception, require successful completion of four years of residency training for board certification eligibility in the specialty of anesthesiology. An anesthesiology residency requires a one year medical or surgical internship followed by three years of anesthesiology training. Anesthesiology residents face multiple examinations during their second, third, and fourth years of residency, including exams encompassing physiology, pathophysiology, pharmacology, and other medical sciences addressed in medical school, along with multiple anesthesia knowledge tests which assess progress during residency. Successful completion of a board exam after completion of residency is required for board certification.

Anesthesiology residency training in the U.S. encompasses the full scope of perioperative medicine, including pre-operative medical evaluation, management of pre-existing disease in the surgical patient, intraoperative life support, intraoperative pain control, post-operative recovery, intensive care medicine, and chronic and acute pain management. After residency, many anesthesiologists complete an additional fellowship year of subspecialty training in areas such as pain management, sleep medicine, cardiothoracic anesthesiology, pediatric anesthesiology, neuro anesthesiology, regional anesthesiology/ambulatory anesthesiology, obstetric anesthesiology or critical care medicine.

The majority of anesthesiologists in the United States are board-certified by a specialty medical board; either the American Board of Anesthesiology (ABA) or the American Osteopathic Board of Anesthesiology (AOBA). It should be noted that D.O. anesthesiologists can be certified by the ABA. The ABA is a member of the American Board of Medical Specialties, while the AOBA falls under the auspices of the American Osteopathic Association. Both Boards are recognized by the major insurance underwriters in the U.S. as well as by all branches of the U.S. Uniformed Services. Board certification by the ABA involves both a written and an oral examination. AOBA certification requires the same exams, in addition to a practical examination with examining physicians observing the applicant actually administering anesthetics in the operating room.