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.

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I give what could be lethal injections for a living.

That’s right. Nearly every day I give someone an injection of midazolam, vecuronium, and an IV solution containing potassium chloride–the three drugs in the “cocktail” that was supposed to kill convicted murderer Clayton Lockett quickly and humanely in Oklahoma.

Here’s the difference between an executioner and me. I use those medications as they are intended to be used, giving anesthesia to my patients, because I’m a physician who specializes in anesthesiology. Midazolam produces sedation and amnesia, vecuronium temporarily paralyzes muscles, and the right amount of potassium chloride is essential for normal heart function. These drugs could be deadly if I didn’t intervene.

My job is to rescue the patient with life support measures, and then to reverse the drugs’ effects when surgery is over. The “rescue” part is critical. When Michael Jackson stopped breathing and Dr. Conrad Murray didn’t rescue him in time, propofol–another anesthesia medication–turned into an inadvertently lethal injection.

When anesthesia medications are used in an execution, of course, no one steps in to rescue the inmate. This gives new meaning to the term “drug abuse”. In my opinion, the whole concept of lethal injection is a perversion of the fundamental ethics of practicing medicine.

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Author’s note — Readers may find these related articles of interest:

The Dark Side of Quality

Evidence-based guidelines won’t prevent malpractice claims

Germs and the Pseudoscience of Quality Improvement

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We hold these truths to be self-evident:

A hospital administrator with a clipboard is in search of a physician who isn’t following “evidence-based guidelines”.

There are fads in medicine just as there are in fashion—today’s “evidence-based medicine” may be tomorrow’s malpractice.

Did your hospital, like so many, abruptly switch from povidone-iodine antiseptic solution to ChloraPrep^® for cleaning a patient’s skin before surgery?  If so, I’m sure the staff was told that ChloraPrep would be more effective and cheaper.  No doubt, they were also warned of the extra precautions that must be taken with ChloraPrep to prevent operating room fires, since ChloraPrep contains highly flammable 70% isopropyl alcohol in addition to chlorhexidine.  Even the fire risk apparently wasn’t enough to make hospitals think twice before switching antiseptics.

You (and your hospital’s staff) may not have heard this news. The US Department of Justice (DOJ) announced last month that CareFusion Corp. would pay the government a $40.1 million settlement to resolve allegations that the company violated the False Claims Act by paying kickbacks to boost sales of ChloraPrep and promoting it for uses that aren’t FDA-approved.

Who received kickbacks?  According to the DOJ’s press release, the complaint alleged that “CareFusion paid $11.6 million in kickbacks to Dr. Charles Denham while Denham served as the co-chair of the Safe Practices Committee at the National Quality Forum, a non-profit organization that reviews, endorses, and recommends standardized health care performance measures and practices.”  Another physician with close ties to CareFusion, Dr. Rabih Darouiche, was the lead investigator on a 2010 NEJM article which concluded (not surprisingly) that Chloraprep was “significantly more protective” than povidone-iodine against surgical site infections.

The Leapfrog Group, launched by the Business Roundtable in 2000, claims that its hospital survey is “the gold standard for comparing hospitals’ performance on the national standards of safety, quality, and efficiency.”  On January 30, Leapfrog announced that it accepted the resignation of Dr. Denham, who had served as chair of Leapfrog’s Safe Practices Committee since 2006, amid concerns that Dr. Denham had failed to reveal his “potentially compromising relationship with CareFusion.” At the same time, Leapfrog said it would undertake “a thorough scientific review of its full slate of endorsed safe practices.”

Are you still feeling good about evidenced-based medicine?

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We guard the privacy of patients in my hospital zealously—we take care of a lot of celebrities since we’re right in the shadow of Beverly Hills.  And of course we live in terror of HIPAA violations, those federally mandated HHS rules that protect individually identifiable healthcare information and could bring down “civil money penalties” upon us if we don’t keep our patients’ medical records strictly confidential.

But for healthcare workers—physicians, nurses, technicians, even medical supply vendors—in LA County, the usual privacy rules don’t apply any more.  Now everybody gets to know at least some of our medical history:  whether or not we’ve been vaccinated against influenza.

How will anyone know whether or not I’ve had this year’s flu vaccine?  Because policy dictates that I must publicly say so, whether I want to “out” that information or not.

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This column was written on behalf of the American Society of Anesthesiologists, and was first published by KevinMD on December 22, 2013.

When you need anesthesia for surgery or a diagnostic procedure, of course you want to know who’ll be giving you anesthesia.  If you live in Texas, Florida, the District of Columbia, or 14 other states, you may be lucky enough to have an anesthesia team taking care of you that includes a physician anesthesiologist and an anesthesiologist assistant, or “AA”.  If you live in many other states–including my own state of California–care from an AA isn’t yet an option.

Many Americans have never heard of anesthesiologist assistants.  Even many physicians are unaware that the profession exists.  But for more than 45 years, AAs have worked alongside physician anesthesiologists in exactly the same way that physician assistants (PAs) work with a surgeon, internist, or pediatrician–using teamwork to deliver the best possible medical care to their patients.

Today, there are more than 1400 certified AAs in the U.S.  Why are they limited to practicing only in certain states?  It’s a complicated question.  The answer involves the fierce opposition of nurse anesthetists to the very existence of the AA profession, our complex American system of state licensure, and the economics of healthcare.

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