If you think about scope-of-practice creep at all, you may think immediately of the advocacy efforts so many physicians have made to preserve physician-led care and discourage independent practice by nurse anesthetists or physician assistants.

You may not have paid as much attention to the current momentum to grant independent practice to nurse practitioners, or NPs, nationwide.

In addition to the District of Columbia, 28 states allow NPs full practice authority to treat and prescribe without formal oversight. Half of these states grant NPs full practice authority as soon as they gain their licenses; the other half allow it after the NP practices with physician oversight for a period of time.

My home state, California, is one of the states that has always required physician oversight. Last fall, however, Governor Newsom signed a bill, Assembly Bill 890, that will allow NPs to practice independently after they have completed a three-year transition period, practicing under physician supervision.

That was when I started to worry.

Preop assessments that make us laugh or cry

No doubt everyone who practices anesthesiology or surgery has encountered preoperative medical assessments, H & Ps, or “clearance” notes that have been so far off the mark they’re laughable. I’m not just talking about the three-word “cleared for surgery” note scrawled on a prescription pad. I recall in particular:

A consultation at a VA hospital that “cleared” my cirrhotic patient with massive ascites and coagulopathy for his inguinal hernia repair under spinal anesthesia but not general.

A cardiologist who opined that my patient needed a permanent pacemaker, but it could wait until after his carotid endarterectomy because “this patient has a low risk of perioperative bradycardia. If he were to develop AV block intraoperatively, a temporary transvenous pacemaker could be placed.” (Wait. What? Carotid procedures are notorious for bradycardia. We’re going to insert a transvenous pacing wire through his open neck incision?)

An H & P from a community internist that “cleared” my patient with lung cancer for lobectomy so long as it could be done under local with sedation.

Then we have to deal with the widespread misconception that “minimally invasive” is synonymous with “trivial” when it comes to surgical procedures. My husband, Steven Haddy, MD, a cardiac anesthesiologist, loves to give a lecture to an internal medicine audience on pulmonary hypertension and anesthesia, and wait for the gasps when he shows the photo of a “minimally invasive” robotic prostatectomy with the robot docked, the abdomen insufflated, and the patient in steep Trendelenburg.

If non-anesthesiologist physicians can do such an inept job with preoperative assessments, what are we to expect from nurse practitioners?

What could go wrong?

I rely with complete confidence on the H & Ps of one experienced nurse practitioner who works in the office of a thoracic surgeon. She understands thoracic surgery procedures and their risks, knows the patients and their history, and orders exactly the right preoperative tests, every time.

What causes me anxiety, as an anesthesiologist, is thinking about the accuracy and thoroughness of a preoperative assessment I might receive from a primary care NP, working in an outpatient clinic with no physician consultation. In a brief H & P, we have no way to know what information may have been omitted. If there is little understanding of the surgery or the anesthetic impact of the patient’s underlying medical problems, how would that person know what’s important to include?

Currently, there are more than 290,000 licensed NPs in the US, and Becker’s Hospital Review reports that the number of FTEs surged 109% in the past decade. More than 30,000 NPs complete their academic programs each year.

Until I read the book, Patients at Risk, by Niran Al-Agba, MD, and Rebekah Bernard, MD, I had no idea how little breadth or depth there might be to a nurse practitioner’s education. “Registered nurses who already have a bachelor’s degree in nursing can become a Family Nurse Practitioner in under two years, with coursework completed entirely online,” the authors report. “Schools are now fiercely competing for students to fill their classrooms. One of the downsides of the increased capacity for students is that the criteria for entry have declined. In fact, at least nine programs boast 100% acceptance rates – every student who applies is guaranteed acceptance.”

Since nurse practitioners can earn higher pay than registered nurses, there is an ongoing exodus of RNs into NP programs. They have the option to select a patient population focus on acute care, either for adults or children. But most students – nearly 90%, according to the American Association of Nurse Practitioners (AANP) – certify in an area of primary care. Their certification exams are specific to primary care, and require no additional education or clinical precepting in perioperative care.

Protecting patients

If you already live in a state with full practice authority for NPs, then the camel – not just the camel’s nose – is already in the tent. There will be little you can do other than to have a low threshold for questioning the information, or lack of it, in a preop H & P generated by a non-physician you don’t know personally.

In California, though AB 890 has already passed, there is work to be done in terms of scrutinizing its language and guiding its implementation.

I find it discouraging that the law’s requirements (Section 4, Article 8.5) “are intended to ensure the new category of licensed nurse practitioners has the least [emphasis mine] restrictive amount of education, training, and testing necessary to ensure competent practice.”

I find it outright alarming that one of the conditions listed that would mandate referral to a physician is “any patient with acute decomposition [sic].” My hope would be that the patient would be referred to a higher level of care before decomposition started, but you never know.

To its credit, the California Medical Association (CMA) has established an AB 890 Task Force to provide “expertise and strategic advice” regarding the implementation of AB 890, and “to make recommendations relating to the education of NPs, patient access to care, and patient safety, among other topics.” I have the honor of representing anesthesiology on this task force, and will do my best to ensure that NP independent practice is never defined to include the practice of anesthesiology, perioperative medicine, or pain medicine.

This underscores the importance of having all physicians become members also of our state and county medical associations. If you don’t join, you won’t have a voice. There is always a need for guardrails and vigilance to ensure that everyone in healthcare – physicians and nurses alike – practices within the safe limits of their knowledge and training.

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An earlier version of this article appears in the April 2021 issue of the ASA Monitor.

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            How the ACGME and ABA are infantilizing resident training

Not long ago, my patient in a complex thoracic case developed progressive bradycardia followed by a malignant-looking multifocal atrial arrhythmia that didn’t generate any blood pressure.

“Get out some epinephrine!” I said to my resident, who was standing closer than I was to the drug cart. The resident quickly drew up a milligram of epi, but then paused. I could almost see the thought bubble overhead: “Should I print out a label? Put a tamper-proof cap on the syringe?”

The resident – perhaps spurred on by the look in my eyes – made the right call, pushing epi immediately into the IV line and not stopping first to clean the injection port with alcohol for 15 seconds. The patient responded right away with return of sinus rhythm and a blood pressure consistent with life.

This brief but intense drama led me to ponder (not for the first time) whether the protocols and rules that infuse our days are improving safety or leading to paralysis when decisions must be made. Sometimes you have to act as you think best, accepting the possibility that your action may be vulnerable to criticism.

Even if you follow the protocol today, tomorrow it may change. Wearing masks all the time at the start of the COVID pandemic was considered a bad idea – until it wasn’t. On average, 20% of the recommendations in clinical practice guidelines don’t survive intact through even one review – on the next updated version, they’re downgraded, reversed, or omitted.

Today’s resident education process isn’t helping residents face the inevitable ambiguity of medical decision-making. No wonder residents get rattled when they find that one attending does things far differently from another. The ACGME and ABA are turning residency training into an infantilizing experience. Residents are used to studying to the test, and on the test there’s only one right answer.

Anesthesiology trivial pursuit

I don’t envy residents today. When I peer over their heads in the OR to see what they’re looking at on the computer screen, it’s often a multiple-choice question in preparation for the ABA basic exam, which looms over their first two years like an executioner’s axe. Never once has the question had any relevance to the patient or the case. The question itself seems to be part of an anxiety-ridden trivia game, geared toward testing the ability to prep for the test, not the gain of medical knowledge with any connection to patient care.

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A must-read article for those who are into anesthesiology. Thanks for sharing your thoughts!

Eduardo

I fully agree with you. Too much screens and too little contact with real things. Thanks!

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Every death related to anesthesia is a tragedy; even more so when a minor procedure such as a colonoscopy leads to a completely unexpected death. Everyone knows that open heart surgery carries a mortality risk, but few of us walk into the hospital for a colonoscopy thinking that death is a plausible outcome.

We know so few facts at this point about what happened on January 21 at Beaumont Royal Oak Hospital in Michigan. The patient who died, sources say, was a 51-year-old man who walked into the hospital for a routine colonoscopy. He was obese, with a BMI of 39, and suffered from obstructive sleep apnea, a common problem, where people snore heavily and their breathing may obstruct intermittently while they’re sleeping. Author Charles Dickens described a portly gentleman’s sleep apnea perfectly in The Pickwick Papers:

“His head was sunk upon his bosom, and perpetual snoring, with a partial choke occasionally, were the only audible indications of the great man’s presence.”

Sleep apnea is a risk factor for anesthesia complications, especially airway obstruction, but every anesthesiologist is taught how to recognize and manage it. With the obesity epidemic in America today, sleep apnea is part of daily reality in anesthesiology practice.

According to recent reports in Deadline Detroit by journalist Eric Starkman, who has reported extensively on problems at Beaumont Health, the patient was intubated by a nurse anesthetist who ordinarily worked at another Beaumont Hospital. At the end of the procedure, the nurse anesthetist removed the breathing tube, and the patient began to “thrash around”. It isn’t clear from reports if he was trying unsuccessfully to breathe or wasn’t breathing at all. The nurse anesthetist called for help from an anesthesiologist, and an emergency back-up team was summoned, but the patient went into cardiac arrest and couldn’t be resuscitated.

How could this happen?

We’re not likely to learn further details any time soon, as NorthStar Anesthesia has refused to comment. NorthStar took over the contract for anesthesiology services at Beaumont in 2020, leading to the resignation of a number of experienced anesthesiologists and nurse anesthetists who had worked there for years. Prominent surgeons, specialists, and nurses also resigned, according to reports, concerned that extreme cost-cutting measures would compromise patient care. Senior cardiologists wrote a letter in September, according to Deadline Detroit, expressing “serious concerns that NorthStar will not be able to provide the quality of cardiac anesthesia services that we have received for several decades.”

“We oppose the concept that any Beaumont physicians can be considered replaceable commodities, or that corporate leadership can assume that we would blindly accept another group of physicians to care for our patients with life-threatening cardiac conditions,” the cardiologists’ letter stated.

In the context of this upheaval at Beaumont, we can ask these questions.

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9 COMMENTS

Philip Snyder, MD

This isn't about anesthesia per se or CRNAs vs MDs. This is about what happens when a private equity-backed group takes over and tries to turn anesthesia into a disincentivized widget factory to save money. And NorthStar is just the beginning. NAPA, USAP, Envision, TeamHealth, Somnia, etc. are completely changing anesthesiology into a CRNA-driven (cheaper) system that fosters mediocrity and guts productivity. Note the reference in the piece to the fact several MDs and CRNAs left when NorthStar entered. ...Read More

Corey Collins

Thx for sharing this sad case. My two cents. Every asc/ office based death or critical event should be reported to a objective, central agency immediately and “ lessons learned” disseminated immediately/ASAP, similar to aircraft events/ near-misses/ crashes. It’s unreasonable not to have a robust data set to prevent patient harm. Only then can competency be established for any clinician and pt safety be the focus of this discussion, not credentials. Closed-claims analysis is far too blunt to reflect what really happens in practice. (I’m ...Read More

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Grief takes no holidays

I originally wrote this column just before Thanksgiving one year, and then updated it in 2012 after the tragic massacre of the Newtown first-graders. Now COVID-19 — and all the losses and grief that 2020 has brought — makes it only too relevant once again. For families who have lost a child, each holiday brings fresh grief, hurdles to face, and mourning for celebrations that will never happen.

The glittering commercialism and noisy cheer of any American holiday can be stressful for most of us. But for the parent who’s lost a child during the past year, facing the first of many holidays with an empty place at the table can make already unbearable grief so much worse.

No one in modern America expects a child to die.  Children only die in nineteenth century novels and third-world countries, or so we’d like to think.

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Very true... it's always hardest around the holidays.
I enjoy how you deftly weave your personal experience and history with valuable insight into clinical treatment expectations and just plain wisdom on being human in your writing here.

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Is it time to unionize?

Remember the dark days of the pandemic in March and April, when the true risk of caring for COVID patients started to become clear?  Remember when you could be censured by a nursing supervisor or administrator for wearing a mask in public areas lest you frighten patients or visitors?

Right around then, a third-year resident at UCLA decided to wear a mask wherever he went in the hospital, as testing wasn’t readily available yet for patients, and visitors still had full access. Someone with a clipboard stopped him and said he couldn’t wear a mask in the hallways. The resident politely responded that yes, he could. Why? Because his union representative said so. The discussion ended there.

The resident enjoyed backup that his attendings lacked because all UCLA residents are members of the Committee on Interns and Residents/SEIU, a local of the Service Employees International Union (SEIU). This union represents more than 17,000 trainees in six states and the District of Columbia.

As CMS threatens further pay cuts for anesthesiology services and other third-party payers are likely to follow suit, many attending anesthesiologists are asking:  Why can’t we form a union? Alternatively, why can’t the ASA function like a union and negotiate on our behalf?

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Thank you, Dr. Sibert, for sharing your ideas. I have spent the last few years fantasizing about a national physicians union. The problem (well one of them anyhow) with our system is that doctors are compartmentalized and isolated from one another in ways that prevent collective action. There is systematized bullying of both physicians and patients by insurance companies, hospital systems, Big Pharma and by our government who is in bed with all of them. It is our duty to stand ...Read More
Short answer - Yes and No. The system needs a change and the agencies that play the "controlling role" need to be systemically audited for fraud. Unfortunately, this is an impossible task, but luckily good docs will always exist and help heal no matter what the challenge. Some great points there by Dr. Obrecht. Thank you!

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