By Christine Doyle, MD, FASA
The problem with suggesting that complex issues can be addressed through “absolute” solutions is that, unless used in algebra, absolutes rarely further their intended goal.
This is especially concerning in healthcare delivery, where evidence-based treatment and management protocols coexist with variations in patients’ biological responses and the subtle nuances of human-delivered care. It’s simply not a “black or white” profession.
That’s why recent missives from organizations such as the American Association of Nurse Anesthetists, which suggests nurse anesthetists are “the answer to achieving a safer healthcare environment and more cost-efficient healthcare economy,” are so concerning. Using such definitive language, rather than saying “part of the answer” or “an answer,” does little to advance the dialogue around topics such as patient safety, utilization of scarce healthcare resources, or scope of practice.
In my career as a physician anesthesiologist, I have worked with many nonphysician practitioners, and my patients are better for it. Nurse anesthetists implement care plans, stabilize trauma patients, monitor pain management, and provide high-quality patient care. They are well educated, highly skilled, and an integral part of the care team.
But they alone are not the answer; in some cases, neither am I. There are roles for more practitioners in anesthesia procedures, including serving on a team with a shared vision for a strong, patient-focused model of care. But that care must be led by a physician anesthesiologist.
It’s important to note that the term “physician-led” should not be equated with the medical authoritarianism and paternalism of the past. But because patient safety is and must remain the single most important goal, care teams must be led by the medical professional with the most comprehensive and extensive training. Physician anesthesiologists are the only medical specialty cited as having significantly improved patient safety. In fact, data show physician-led anesthesia care teams experience a 20% reduction in adverse events and 50 times fewer deaths compared to nonphysician-led teams.
In an integrated team culture, the physician’s 12,000–16,000 hours of training is combined with the training, skills, and expertise of the rest of the team to optimize continuous medical assessment and immediate response to the patient’s emergent needs. Surgical environments in the United States are complex and dynamic, and benefit from collective knowledge and holistic care.
Almost 40% of the U.S. adult population, for example, is obese. More than 10% of nonoperative intubations are difficult, and 20% of critical incidents in the ICU are airway related, according to a 2017 study. The essential duties of the anesthesia care team—securing and maintaining the patient’s airway, managing vascular access for infusion of fluids and medications, working with the surgical team, monitoring anesthesia response and vital signs, and prescribing appropriate pain relief—must be assigned by the clinician with the most experience at all of these functions. Issues of scope of practice and labor cannot usurp patient care considerations.
I worry about any movement in healthcare that suggests “the answer” is excluding physicians from care. Obviously, the right clinician should provide the right care at the right time, and we should deploy our resources wisely. But costs do not exist in a vacuum. Expanding nurse anesthetists’ scope of practice without proper physician involvement can lead to increased costs due to overutilization of tests, overprescription of medications, and excess referrals to specialists. In recognition of this, policymakers in West Virginia, Oklahoma, New Mexico, Mississippi, Illinois, Florida, Arkansas, and most recently Alabama have defeated proposals to weaken physician involvement in the last few years.
To my physician colleagues, I offer that we should encourage the model of the anesthesia care team. At the same time, the larger healthcare ecosystem must understand that the expertise of physicians cannot be replicated: #MedSchoolMatters. The public, too, must understand why physicians’ body of education is important as they entrust the care and well-being of their family, friends, and colleagues to our healthcare system.
As a medical specialty, our collective energy should go toward larger, complex challenges affecting our profession and our patients. We have work to do in fighting the opioid crisis, establishing team-based performance measures, addressing clinician shortages, working for more licensure of certified anesthesiologist assistants, and dealing with ongoing shortages of anesthesia drugs. These, rather than turf battles, are the issues that demand “answers.”
Christine Doyle, MD, FASA, is a partner in Vituity and practices primarily at O’Connor Hospital, where she is involved in medical staff leadership. She is president of the California Society of Anesthesiologists, is an active member of the American Society of Anesthesiologists, and has achieved Fellowship in the society (FASA). She is board certified in anesthesiology, with subspecialty training in critical care.