Should physicians be the leaders of anesthesiology?

Not everyone thinks so, especially the AANA.

There was an editorial on this topic in the ASA newsletter by Doug Bacon.

http://www.asahq.org/Newsletters/2007/05-07/crowsNest05_07.html

I had responded to Dr Bacon's comments with a recitation of several articles in the AUA newsletter  which support his musings that the AANA is  actively working to diminish the training programs that are at the core of our specialty.

The ASA newsletter chose not to publish my comments so I post them here.

Letter to the Editor, ASA newsletter

I agree with Dr Bacon’s evaluation of the evidence suggesting that AANA, by its actions, is working aggressively to defeat fixing the anesthesiology teaching payment rule.  As such they are actively hurting our future. With better funding nurse anesthetists have opened 22 new training programs since 2000, whereas 8 anesthesiology residency programs have closed (30 since 1994). The ASA’s efforts at reconciliation with AANA may be for naught.

I refer the interested member to recent issues of the AUA Update, the newsletter of the Association of University Anesthesiologists (http://www.auahq.org/newsletter.html). In the Summer 2006 issue the AUA President Roberta Hines outlined the financial impact of this legislation emphasizing the importance of it to the future of the specialty. In that issue also was a report of a speech by the then ASA President Orin Guidry who presented clear evidence that AANA was effectively undermining efforts of the ASA to promote legislation that would correct the payment reductions for teaching residents. Notably CMS includes AANA as a stakeholder in this physician-related legislation.  One may speculate how this came to be. Indeed the AANA position paper on the topic ends with:

Message to Congress: Oppose teaching rules changes that disrupt fair payment treatment between nurse anesthetists and anesthesiologists. The rules should not unfairly advantage one type of provider over another.

This continues their theme, promulgated to legislators, that nurse anesthetists, despite not having undergone the rigors of premedical education, medical school, and residency, are equivalent to anesthesiologists.

The Fall 2006 issue contained an overview by James Hall of the status of anesthesiology assistants programs, perhaps an alternative that organized anesthesiology could promote to provide alternate members for the anesthesia care team who would be less likely to work against us.  Anesthesiologists should work with their state legislators to develop licensure pathways for AAs and academic programs need to support and develop AA schools. Also in that issue was a report on a NY Times article on the movement of nurses from the third world to the US such that every new nurse anesthetist translates into one less bedside ICU nurse, which in turn further contributes to the nursing shortage in poor countries, despite the fact that there are non-RN alternative anesthesia providers.

The Winter 2006 issue contained a report of Jerry Reve’s Rovenstine lecture with his analysis of problems with anesthesiology research, many of which can be addressed through the financial impact of the teaching rule. The problems he identified may be construed as a symptom of our difficulties providing proper academic support of anesthesiologists in training.

The Summer 2007 issue includes an article by Robert Johnstone, an ASA Director, who describes efforts by the AANA to promote a competing bill that would include direct Medicare funding of student nurse anesthetists. He describes his chagrin, upon talking to his legislators, of learning that the nurse anesthetists had already visited with a competing message. Finally, Johnstone’s article prompted a comment by me:

The following can be found on the Webpage of my state society:
“On May 2nd, the Pennsylvania House Insurance Committee met for testimony on Governor Rendell’s health plan. Representatives from the Pennsylvania  Society of Anesthesiologists (PSA) and the Pennsylvania Association of Nurse Anesthetists (PANA) were present to testify. Dr. Erin Sullivan, President, PSA and Dr. Joseph Answine, President-Elect, PSA, testified that the anesthesia care team is time-proven and safe. Furthermore, they testified that the anesthesiologist is an acute care physician that diagnoses and treats illness during the peri-operative period. Dr. Arthur Zwerling (Doctor of Nursing Practice, DNP), President-Elect, PANA testified that the PANA seeks independent practice for Certified Registered Nurse Anesthetists and that an anesthesiologist is not necessary in most settings.”

The evidence appears compelling that AANA is actively working against the efforts of the ASA to ensure the future viability of Anesthesiology. The AANA is a large society, and most of the nurse anesthetists we work with belong to it and thus can be assumed to support its activities, daily collegiality notwithstanding. Chamberlain is widely thought to have blown it in his disregard of the evidence that he faced. I wonder if we are doing the same?

W Andrew Kofke MD MBA FCCM

Editor AUA Update

Professor University of Pennsylvania

 

Submitted to ASA Newsletter June 25, 2007

 

 

Comments

[Jameson]

"This continues their theme, promulgated to legislators, that nurse anesthetists, despite not having undergone the rigors of premedical education, medical school, and residency, are equivalent to anesthesiologists."

Aaaawwwwwww pooor baby. News flash, those things don't matter as much as you think. Sorry you wasted so much time.

[Ernest]

They don't matter to technicians (CRNAs) but do matter to physician anesthesiologists.

[dontquit]

Here we have both ends of the spectrum in both specialties. A CRNA who resorts to name calling instead of outlining the fundamentals of CRNA's, and a MDA who belittles the training and expertise of CRNA's by calling them technicians. I take offense to that statement as I'm sure most of my collegues do.
As for the original post, I do see merit in what the author says. It is vitally important for the funding to be there to continue on the training for MDA's.
As a side note, I have worked with Dr. Bacon and believe he is a wonderful instructor who has a vast amt of knowledge, teaching CRNA's, SRNA's and residents with kindness and compassion. I do not feel that he would take a position that would hurt CRNA's just for the sake of improving MDA income.
Lets face it, there is a fundamental difference between both specialties. MDA's do have a point that they do go to medical school, residency, and fellowship. They have a vast amt of knowledge that is very beneficial in our profession.
We both provide excellent anesthesia, and one withouth the other would be a shame in our specialty.
I for one would like to see both working together to improve anesthesia as a whole, and move forward.

[Brahms]

CRNAs beleive that the administration of anesthesia does not require a medical degree or four years of residency - its just not that tuff (medical degrees are for real doctors like psychiatrists). And they're right in the majority of cases.
So I'm curious, why not turn over simple surgeries to PAs? Maybe PAs should be doing the inguinal hernia repairs in 20 year old males. Let's start training mid-level practioners in simple surgery with the goal of independent practice - who's with me?
Maybe you haven't heard about the 50 trilion in unfunded liabilites? A PA could do a surgery for half the price. There is a real demand in the rural areas for these mid-level surgeons as well. Surely, after two years of training, a person could learn the ins and outs of a hernia repair. And what about ear tubes? - those poor families in the country wouldn't have to drive three hours for a 5 minute surgery by some overpaid ENT surgeon. Or if that's too radical, think of the advantages that will come with the Surgery Care Team approach - like they say, there is a reason for having two pilots in the airplane.

[kofke]

Brahms' suggestion for an increased role for less well trained providers has some merit in the context of finite resources. However, we have to understand that I think that it does represent a decrement in quality of care and a decision is made to accept this a quality decrement driven by cost containment considerations. The sorts of cases described are low risk patients with low risk surgery so it is likely that most of the time things will be OK. The issue is what happens when an unexpected event arises that requires real medical training to prevent morbidity or mortality. It very well may be that this is an acceptable decrement in quality if the saved resources translate to more people getting medical care or other sorts of things that may in fact save lives in excess of what my be lost.

perhaps the happy medium is to maintain medical assessment and prescription with ongoing MD availability as he /she is multi tasking and ensuring that his/her medical training is optimally used.....