Field grand challenge: beyond putting patients asleep: redefining the mission of anesthesiology

The evolution of modern anesthesia

Modern surgery would not exist without the rise of anesthesiology. The introduction of anesthesiology as a clinical specialty during the 1930s and 1940s transformed medicine by removing pain and consciousness as the principal barriers to surgery. Subsequently, anesthesiology evolved beyond the administration of hypnotic and analgesic drugs; it became the medical specialty dedicated to preserving metabolic and hemodynamic homeostasis during one of the most profound stresses the human body can experience. Advances in pharmacology and technology accelerated this transformation, progressively increasing both precision and quality (Figure 1).

Improved patient safety marked the second transformation of anesthesiology. Anesthesiologists recognized that excellence depended not only on individual expertise, i.e., the practice of anesthesia “as an art”, but also on evidence-based knowledge, effective teamwork, communication, and learning from errors. Standardized monitoring, airway and crisis management algorithms, simulation-based education, human factors engineering, checklists, international safety standards, and continuous quality improvement initiatives have collectively reduced anesthesia-related mortality to historically low levels in many healthcare systems (Figure 1).

Today, artificial intelligence, predictive analytics, closed-loop systems, and sophisticated monitoring technologies promise further improvements in intraoperative decision-making (1). While safety remains an ongoing commitment, the traditional mission of anesthesiology—bringing patients safely through surgery—is approaching a level of maturity unimaginable only a few decades ago (2).

The growing importance of post-operative outcomes

Ironically, this extraordinary success now challenges anesthesiologists to redefine their raison d’être (Figure 1). For most patients exposed to surgery and anesthesia today, survival is an expected outcome. While this objective remains essential, it is not the only meaningful endpoint. A technically flawless anesthetic may still be followed by postoperative disability. Importantly, patients undergo surgical procedures to live longer, preserve their independence, remain cognitively intact, return to their families, resume work, or simply regain the ability to perform the activities that give meaning to their lives. These expectations represent a profound shift in perspective. The greatest challenge facing anesthesiology today is no longer how to safely guide a patient through surgery. It is how to influence what happens afterwards.

Millions of patients each year continue to experience postoperative complications, prolonged disability, persistent pain, cognitive decline, psychological distress, delayed return to work, and loss of independence (3, 4). At the same time, the surgical population has been changing dramatically. Patients are older, frailer, and afflicted by multiple chronic diseases. Furthermore, surgical procedures are becoming increasingly ambitious and complex, while healthcare systems face unprecedented pressure to deliver high-quality care with limited resources. The future of anesthesiology therefore requires a transition from a process-oriented technical specialty to comprehensive outcome-oriented medicine (5).

Improving recovery starts weeks before surgery through optimization of relevant co-morbid conditions, nutrition, and frailty by shared, multidisciplinary decision-making. Anesthetic care continues during surgery by individualized physiological management and evidence-based perioperative measures. It extends beyond discharge through pain management, rehabilitation, functional assessment, complication surveillance, and coordination with primary care and rehabilitation teams. In other words, anesthesiology has evolved from facilitating an operation to managing a trajectory. This broader vision also affects the way we assess patients. Frailty scores, nutritional screening, functional tests, biomarkers, cognitive evaluations, or postoperative patient-reported outcomes only become valuable when they trigger meaningful interventions.

The growing complexity of perioperative care also calls for greater collaboration. Surgeons, intensivists, nurses, physiotherapists, nutrition specialists, psychologists, geriatricians, primary care physicians, engineers, and data scientists all contribute complementary expertise, and places anesthesiologists in a unique leadership role. Their expertise in physiology, pharmacology, pain management, critical care, and risk assessment naturally positions them to coordinate multidisciplinary perioperative pathways and ensure continuity across the patient's surgical journey. Emerging technologies will undoubtedly accelerate this transformation. Artificial intelligence may support risk prediction and real-time decision-making. Wearable devices and digital platforms will enable continuous monitoring beyond hospital walls. Predictive analytics may identify patients who would benefit most from prehabilitation, nutritional interventions, or enhanced postoperative surveillance.

A research agenda for the third transformation

The future of the specialty will not be determined by incremental improvements in techniques and technologies alone, but by our ability to comprehend, predict, and modify the patient's entire perioperative trajectory. This requires a better understanding of recovery itself. Despite decades of advances in perioperative medicine, the biological mechanisms that determine why some patients rapidly regain function while others not, remain incompletely understood. Recovery is a complex and dynamic physiological process involving inflammation, metabolic alterations, resilience, psychological adaptation, and social reintegration. Better characterizing these mechanisms will open opportunities to develop interventions that actively promote recovery rather than merely responding to postoperative complications. At the same time, anesthesiology must move beyond the traditional search for universal perioperative strategies. Future research should focus on identifying which intervention is most appropriate for which patient, under which circumstances, and at which stage of the perioperative journey. Equally important is a reconsideration of how success is measured. Perioperative research has traditionally relied on physiological variables, laboratory parameters, or relatively short-term postoperative complications. Although these outcomes remain important, they often fail to capture what patients themselves hope to gain from surgery. Preserving cognitive function, maintaining independence, returning to work, avoiding persistent pain, recovering physical capacity, and achieving a satisfactory quality of life are frequently more meaningful than many conventional clinical endpoints. Achieving these goals will require moving towards a better understanding of when, in whom, and to what extent perioperative interventions affect outcomes that matter to patients. This includes, but is not limited to, refining the evidence surrounding the relationship between depth of anesthesia and electroencephalographic monitoring and postoperative cognitive outcomes, individualized hemodynamic management and cardiac or neurological outcomes, perioperative glycemic control and infectious complications, and perioperative nutritional interventions to enhance functional recovery and metabolic resilience.

The future of anesthesiology therefore requires systematic integration of patient-reported outcomes, patient experience, disability-free survival, and long-term functional recovery into both clinical research and routine practice. Importantly, these outcomes should not merely be collected; they should inform clinical decision-making and help define individualized care plans (6). Finally, the greatest challenge may not be discovering new interventions, but ensuring that existing evidence consistently reaches patients. Enhanced Recovery After Surgery (ERAS) pathways have demonstrated that coordinated, evidence-based perioperative care can substantially improve recovery, yet implementation remains highly variable across institutions and healthcare systems (7, 8). Closing this evidence-to-practice gap should become a research priority in its own right.

Publishing to shape the future of anesthesiology

As anesthesiology enters its third stage of development as an academic clinical specialty, Frontiers in Anesthesiology has the opportunity to become a catalyst for this transformation by fostering dialogue across traditional disciplinary boundaries and by promoting research that addresses questions that will shape perioperative care over the coming decades. The journal will serve as a multidisciplinary forum where ideas from all disciplines involved in perioperative care converge. Hence, the journal is committed to embrace the full spectrum of perioperative research. Basic and translational science remain essential to understand the mechanisms underlying recovery, while clinical trials, implementation studies, quality improvement initiatives, digital health innovations, and health systems research are indispensable to translate these discoveries into better care. Furthermore, we welcome research addressing contemporary challenges in precision perioperative medicine, artificial intelligence, and patients or relatives empowerment strategies to enhance recovery after surgery. Well-conducted negative studies also deserve visibility, as they refine our understanding of complex clinical research questions, prevent unnecessary interventions, and help redirect research efforts toward more promising strategies. In addition, educational contributions, illustrative clinical cases, and interdisciplinary perspectives that generate discussion or provide practical insights into perioperative care will also be considered.

We hope that Frontiers in Anesthesiology will become the home for research that embraces this broader vision—research that not only explains perioperative physiology, but changes clinical practice, informs healthcare policy, and improves the outcomes that matter most to patients.

Generative AI statement

The author(s) declared that generative AI was used in the creation of this manuscript. Figure created by the authors with assistance from ChatGPT (OpenAI) for graphical design and layout.

Any alternative text (alt text) provided alongside figures in this article has been generated by Frontiers with the support of artificial intelligence and reasonable efforts have been made to ensure accuracy, including review by the authors wherever possible. If you identify any issues, please contact us.

Publisher's note

All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.

Footnotes

Edited and Reviewed by: Matthieu Jabaudon, Université Clermont Auvergne, France

Abbreviations ERAS, enhanced recovery after surgery.