I think this specialty is on the verge of some dramatic changes, which are necessary in my humble opinion. The notion that we can just provide intraoperative care of surgical patients and survive as a specialty is obsolete. The specialty as a whole needs to expand the scope of practice, and alter the postgraduate educational structure accordingly, such that every graduating anesthesiology resident is viewed as a perioperative physician--i.e., as an expert on the preoperative, intraoperative, and postoperative care of surgical patients. At the very least, I think this will require additional residency training.
This additional training may involve some kind of hybridization of critical care, internal medicine, and anesthesiology training. Perioperative physicians, from my perspective, should be some kind of amalgam of an internist, an intensivist, and an anesthesiologist (with expertise in airway management, lines, regional, etc.). To achieve this goal, we may need to extend the residency training out to 5 or 6 years. This would suck, obviously, but it may be necessary to cement our role in health care as the go-to experts on perioperative medicine.
This is how we can demonstrate value. It's how we can, without any question in my mind, differentiate ourselves from militant CRNAs trying to demonstrate "equivalence" through bs studies. CRNAs will never be able to run an ICU or a stepdown unit. No surgeon would refer their patients to a CRNA for optimization prior to surgery. These things are important and we, as anesthesiologists, are in a unique position to assume a leadership role in these areas.
Pain medicine should probably become a separate residency altogether. It's a different animal entirely.
Just my $0.02
