Letters to the Editor: Letter to the Editor
To the Editor
Regarding their provocative article in The Open Mind, “The Future of Anesthesiology: Should the Perioperative Surgical Home Redefine Us?”1 I am deeply troubled by the authors’ proposed changes to anesthesiology residency training. They suggest that residents will need to acquire the “knowledge and expertise to supervise 6–20 anesthetizing sites where direct care is provided by physician extenders.” Also, “An extended period of time…might be spent in the simulation lab, being faced with supervision of multiple anesthetic delivery locations…learning to triage and prioritize anesthetic emergencies.”
In the parlance of the day, “Really?”
Because the American Society of Anesthesiologists has recently been promoting physician anesthesiologist–driven care with the slogan, “When seconds matter…” and the official position of the American Society of Anesthesiologists leadership is in opposition to independent certified registered nurse anesthetist (CRNA) practice, are those 2 items compatible with the above proposal? If a physician is supervising 20 sites, could he or she reliably attend to an emergency in one of those venues in a matter of seconds? In my opinion, serious consideration should be given to this question.
The editorial board asked me if I have any evidence whether 1:4 coverage is less safe than 1:3 or 1:2 coverage of extenders. I know of no such studies having been performed, and I do not suspect they will ever be done. All I have to go on is common sense and 31 years of practice supervising, as well as personally providing, anesthesia care. However, I think that most honest brokers would concur that personally provided anesthesia care by a physician would be the safest delivery method in an ideal world and that 1:6 to 1:20, as proposed in the article, would by definition be less safe (res ipsa loquitur). I would boomerang the question back to the authors and ask, “Where is the evidence that such ratios produce similar outcomes and mortality as lower ratios and even MD anesthesia care?” Again, those studies are not likely to be ever performed, but should not they be before our leadership proposes such a radical change?
Key questions that are not adequately addressed as part of the article are numbers of physician anesthesiologists needed in the new paradigm the authors propose and the education, training, and methods of supervising 20 extenders (what are the nuts and bolts of how to do it?). We must demand more accountability from our extenders to practice in a standardized fashion and not allow the “this is the way I have always done it” attitude to continue to prevail, especially in the proposed model of “drive by” supervision.
The independent CRNA practice model has been repudiated in this austere journal, as well as in Anesthesiology. As a member of the board of the Florida Society of Anesthesiologists, I have been personally involved in the efforts to defeat legislation that was put forth by the AANA (American Association of Nurse Anesthetists) and the Florida Association of Nurse Anesthetists (FANA) to allow independent practice in our state. Have not we (physician anesthesiologists) emphasized the expansive differences in training and education between doctors and nurses to anyone who is listening to make our case that independent CRNA practice would be disastrous for patient safety? And finally, have not all of us who currently supervise extenders rescued patients from events and near events all day long, every day of the week? I see these issues, independent CRNA practice and expansive supervisory ratios, to be inextricably linked together. It is not a far reach for legislators and many in the public who are on the outside looking in to ask why they need a physician anesthesiologist when they see only 1 physician for every 20 nurse anesthetists or anesthesiology assistants.
To summarize, to maintain our relevance as physician anesthesiologists, we must continue to be a noticeable presence in the operating room. We must balance patient safety, economic reality, and the impact of changes in healthcare delivery in a fashion such that we as a society, and as individual physicians, remain relevant in every anesthetic delivered in our hospitals, however that may be accomplished.
J. C. Lydon, MD
Brevard Physicians Associates
1. Prielipp RC, Morell RC, Coursin DB, Brull SJ, Barker SJ, Rice MJ, Vender JS, Cohen NH. The future of anesthesiology: should the perioperative surgical home redefine us? Anesth Analg. 2015;120:1142–8