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.