When it comes to safe anesthesia care, there is no substitute for trained physicians

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When it comes to safe anesthesia care, there is no substitute for trained physicians

March 22, 2021
Dr. Jeff Poague
By Dr. Jeff Poague

There was recently an article in this publication that highlighted “the importance of CRNAs to pediatric care.” That statement, and many of the points in the article, are absolutely true. The problem is that the piece is part of a larger campaign to blur the lines between nurses and physicians and promote the independent practice of nurse anesthetists without proper physician oversight.

For the sake of patient safety, we must be clear about who is on the patient care team, and what their training, qualifications, and expertise is.

For low-risk patients undergoing low risk procedures, nurse anesthetists are usually quite qualified and capable of providing anesthesia. But the framework for physician oversight exists and must remain in place because not every case is an easy one. For higher acuity patients and more complex cases, physician expertise not only ensures the best outcome, but may make the difference between life or death. Even the “easy” cases don’t always go as expected. For unexpected complications, a physician who is trained in diagnosing the problem is essential.

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To be clear, the level of compassion and our commitment to patient care does not differ between physicians and nurses.

But the education, skills training, and expertise does.

This difference matters: A physician anesthesiologist has a total of 12-14 years of education after high school, compared to 5-7 years for a nurse anesthetist. Physician anesthesiologists have gone through a 1 year internship and 3 year residency after medical school, and many also pursue an additional 1-2 year fellowship in an anesthesia subspecialty such as cardiac, pediatric, obstetric or neurologic anesthesia. In contrast, a nurse anesthetist goes through a 2 year program to become a CRNA after becoming a basic Registered Nurse. Physician anesthesiologists undergo 12,000-16,000 hours of clinical training, compared to a median of 1,651 hours of clinical training for a nurse anesthetist.

The end result of these vast differences in education and training is that physicians and nurses have a different skillset. Both skillsets are needed for the spectrum of patient care. But we should not lose sight of the fact that they are in fact different. And it is misleading to suggest that research has not found a difference in patient care outcomes between nurse anesthetists and physician anesthesiologists.

Research looking specifically at anesthesiologist direction and patient outcomes found that death rates were 8 percent higher and preventable deaths due to a complication were 10 percent higher among patients whose anesthesia was not provided by a physician anesthesiologist. Additional research that looked at 2.4 million orthopedic ambulatory surgery cased found that an “unexpected disposition” (admission to the hospital or death) was 80 percent higher when a nurse anesthetist provided the care than when a physician anesthesiologist provided the care. Furthermore, four studies have looked at access to anesthesia care in states that choose to be exempt from the Medicare patient safety standard requiring physician supervision of nurse anesthesia. The studies found no evidence that opting out of the physician supervision safety standard increases access to care.

Despite concerns on the patient safety side, and despite the fact that independent nurse anesthetist practice is not proven to increase patient access or reduce costs, we continue to see an irresponsible campaign to encourage nurse anesthetist independence. In fact, attempts have been made to actually blur the lines on labeling and titles between doctors and nurses. We saw this debate play out most recently in New Hampshire, where the state nursing board issued a policy statement authorizing the use of the term "nurse anesthesiologist." Thankfully, the New Hampshire Supreme Court just issued a ruling upholding the state’s Board of Medicine decision that health care professionals using the term “anesthesiologist” must be licensed physicians and meet all of the requirements to practice medicine in the state.

Transparency in labeling and titles, and clear communication with patients about provider training and capabilities is essential for upholding medical ethics, promoting patient understanding of their care, and ensuring patient safety.

No matter how compassionate or well-intentioned, a nurse is not the same as, and cannot replace, a physician anesthesiologist.

About the author: Dr. Jeff Poage is the president of the California Society of Anesthesiologists.

K Bouche

The Difference & The Truth

March 23, 2021 10:31

The author is correct, there is a big difference between Advanced Practice Nurses & Physicians. Most notably, physicians obtain medical degrees & nurses obtain nursing degrees. The author referenced “basic nurses” can go to anesthesia school. Clearly, there was an intent to make nurses look inferior & the verbiage displays the obvious. Additionally, no nurse is “basic” and nurses are not even considered for application to anesthesia school without a 4 year degree and minimum of 2 years in an Intensive care setting (2 years in an ICU setting is an entirely different paragraph) and no anesthesia program is less than 18-36 months - my math shows a minimum - 7 years of education and a minimum - 9 years if you include ICU experience. It’s clear, we have different degrees & different educational paths. It’s clear that CRNAs spend much more time providing direct anesthesia care than the anesthesiologist. What’s not clear, if CRNAs are so inferior to physician anesthesiologist, why would they let Residents spend so much time learning from CRNAs in the OR than having them learn from their own pedigree? My relationship with physician anesthesiologist is great & I respect their input & supervision requirements. What I do not respect is articles with misleading & inaccurate facts.

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Heather Rankin

Who is really blurring the line?

March 24, 2021 11:14

Dr. Poague,
Thank you for reading and referencing my recent article regarding Certified Registered Nurse Anesthetists/Anesthesiologists (CRNAs) who deliver anesthesia to pediatric patients. While your article has some truths, it also has some grossly false statements. Nothing in my article “promoted” independent practice, however I see how you could make that comment as more and more states are supporting this efficient use of safe healthcare providers to increase access to anesthesia services without providing duplicate and more costly care to our patients. In fact, Congresswoman Lauren Underwood recently urged Congress to allow full practice authority in the U.S. Department of Veterans Affairs (VA) system.

You also mention blurring lines between a nurse and a physician – again such concerns are simply unfounded. There are four types of anesthesiologists: nurse, physician, dental and veterinary. Using a descriptor such as nurse or physician in front of the generic term “anesthesiologist” clears any lines you are worried about being blurred. In fact, the American Society of Anesthesiologists (ASA) began this trend with their “physician anesthesiologist” movement almost a decade ago. Any lines currently being blurred result from the ASA use of the term “anesthetist” by calling anesthesiologist assistants “anesthetists.” To set the record straight, in New Hampshire, the board of nursing issued a position statement, not “policy” as you called it, which has not been overturned between the split vote 2-2 from the New Hampshire Supreme Court. CRNAs there may still use the descriptor nurse anesthesiologist.

Your comparison between education hours is flawed. Let us compare apples to apples. You leave out the years of clinical hours a CRNA has in nursing school, the almost three-year average of critical care experience in addition to their clinical hours as a nurse anesthesia resident (an average of more than 9,300). Nurse anesthesia residents only include clinical hours. Yet you include all hours such as on-call hours as well as clinical hours for physician anesthesia residents, which is comparing apples to oranges. And I am not sure what a “basic” registered nurse means, but there was nothing basic about my work in an intensive care unit with critically ill cardiac patients after I passed my nursing board exam.

Overall, your article has some truths, but please do not misrepresent my profession or what I wrote. CRNAs have a long track record of providing safe, quality anesthesia care. We are the main providers of anesthesia in our military overseas and provide access to a wide variety of medically underserved areas across the country where physician anesthesiologists chose not to live. Without CRNAs in these areas, no patients, including children, would have access to anesthesia services. The statistics you cite in your article are out of context and without citations to evoke fear with no evidence. You, sir, are the one blurring the lines. Feel free to contact me with any questions you may have about CRNA practice, and I will provide you fact-based answers.

Heather J. Rankin, DNP, MBA, CRNA

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